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Background Financial incentives are often used to improve quality of care in chronic care patients. However, the evidence concerning the effect of financial incentives is still inconclusive. Objective To test the effect of financial incentives on quality measures (QMs) in the treatment of patients with diabetes mellitus in primary care. We incentivized a clinical QM and a process QM to test the effect of financial incentives on different types of QMs and to investigate the spill-over effect on non-incentivized QMs. Design/Participants Parallel cluster randomized controlled trial based on electronic medical records database involving Swiss general practitioners (GPs). Practices were randomly allocated. Intervention All participants received a bimonthly feedback report. The intervention group additionally received potential financial incentives on GP level depending on their performance. Main Measures Between-group differences in proportions of patients fulfilling incentivized QM (process QM of annual HbA1c measurement and clinical QM of blood pressure level below 140/95 mmHg) after 12 months. Key Results Seventy-one GPs (median age 52 years, 72% male) from 43 different practices and subsequently 3838 patients with diabetes mellitus (median age 70 years, 57% male) were included. Proportions of patients with annual HbA1c measurements remained unchanged (intervention group decreased from 79.0 to 78.3%, control group from 81.5 to 81.0%, OR 1.09, 95% CI 0.90–1.32, p = 0.39). Proportions of patients with blood pressure below 140/95 improved from 49.9 to 52.5% in the intervention group and decreased from 51.2 to 49.0% in the control group (OR 1.16, 95% CI 0.99–1.36, p = 0.06). Proportions of non-incentivized process QMs increased significantly in the intervention group. Conclusion GP level financial incentives did not result in more frequent HbA1c measurements or in improved blood pressure control. Interestingly, we could confirm a spill-over effect on non-incentivized process QMs. Yet, the mechanism of spill-over effects of financial incentives is largely unclear. Trial Registration ISRCTN13305645

To investigate if a trochleoplasty increases knee flexion angles and extensor moments in the gait of patients with patellar instability and to compare postoperative gait to a healthy control group. A bilateral dislocation group (6 patients) and a unilateral dislocation group (14 patients) were treated with bilateral and unilateral trochleoplasty, respectively. Kinematics and kinetics of the lower extremity were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, plug-in-gait, two force plates). The mean of six trials was computed. The gait cycles were compared pre to postoperatively for each group. The gait of the two groups was compared to each other and the gait of a healthy population (54 knees). After trochleoplasty, the knee flexion angles and knee extensor moments only increased in the bilateral dislocation group, whereas the gait pattern of the unilateral dislocation group remained unchanged. Compared to the healthy population, the postoperative gait pattern of the bilateral dislocation group did not differ. In contrast, knee flexion angles and extensor moments of the unilateral dislocation group were still lower. In adolescents with bilateral recurrent patellar dislocations, trochleoplasty of both knees increases knee flexion angles and knee extensor moments comparable to normal gait. Unilateral symptomatic patients undergoing a unilateral trochleoplasty did not achieve normal walking. These findings point out that patellar instability should be considered as a bilateral problem, even in patients with unilateral dislocations. III.

To evaluate the kinematics/kinetics of the ankle, knee, hip in the sagittal plane in adolescents with recurrent patellar dislocation in comparison to a healthy control. Case–control study. Eighty-eight knees (67 patients) with recurrent patellar dislocation (mean age 14.8 years ± 2.8 SD) were compared to 54 healthy knees (27 individuals, 14.9 years ± 2.4 SD). Kinematics/kinetics of ankle, knee, hip, and pelvis were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, Plug-in-Gait, two force plates). One cycle (100%) consisted of 51 data-points. The mean of six trials was computed. The loading-response increased by 0.02 s ± 0.01SE (10.8%) with dislocations (0.98% of total gait, P

INTRODUCTION Finger proximal interphalangeal joint (PIP) reconstruction after the destruction of parts of the joint remains challenging. Surgical techniques include implant arthroplasty, arthrodesis, free vascularized joint transfer, and non-vascularized bone and joint transfer. This study analyzes our experience after non-vascularized transfer in terms of range of motion, postoperative rehabilitation, and patient satisfaction. MATERIALS AND METHODS Between 2009 and 2014, ten patients underwent non-vascularized partial joint transfer for PIP joint reconstruction. One of them was lost to follow-up. Included patients had osteochondral partial joint transplants of 25-50% of the toes (n = 4) and the hand (n = 5). Range of motion (ROM), grip-, and pinch-strength were measured at the last follow-up control and compared to the healthy side. Patients were asked to score the pain at rest/ on load on a visual scale (VAS: 0 = no pain; 10 = excruciating pain). Satisfaction self-assessment was evaluated by asking the patients to grade their postoperative result as excellent, very good, good or poor. RESULTS Mean follow-up period was 4.0 years (range 1.2-7.9 years). Mean PIP joint flexion was 93 ± 26° at the last follow-up control. Mean grip- and pinch-strength of the operated side at the last control were, respectively, 43 ± 18 kg and 8 ± 5 kg, close to the healthy side values (45 ± 15 kg and 9 ± 4 kg). Mean pain at rest/on load measured on a visual scale was, respectively, 0.3 ± 1 and 1.8 ± 2. Eight patients (89%) rated their operation as excellent, and one as poor. CONCLUSION In this study, non-vascularized partial joint transfer provides a mobile and stable PIP joint 4 years after reconstruction. The surgical technique presented herein is complex depending on additional injuries but results in great patient satisfaction.

Introduction Quality indicators and pay-for-performance schemes aim to improve processes and outcomes in clinical practice. However, general practitioner and patient characteristics influence quality indicator performance. In Switzerland, no data on the pay-for-performance approach exists and the use of quality indicators has been marginal. The aim of this study was to describe quality indicator performance in diabetes care in Swiss primary care and to analyze associations of practice, general practitioner and patient covariates with quality indicator performance. Methods For this cross-sectional study, we used medical routine data from an electronic medical record database. Data from 71 general practitioners and all their patients with diabetes were included. Starting in July 2018, we retrieved 12-month retrospective data about practice, general practitioner and patient characteristics, laboratory values, comorbidities and co-medication. Based on this data, we assessed quality indicator performance of process and intermediate outcomes for glycated hemoglobin, blood pressure, cholesterol and associations of practice, general practitioner and patient characteristics with individual and cumulative quality indicator performance. We calculated odds ratios (OR) and 95% confidence intervals (CI) using regression methods. Results We assessed 3,383 patients with diabetes (57% male, mean age 68.3 years). On average, patients fulfilled 3.56 (standard deviation: 1.89) quality indicators, whereas 17.2% of the patients fulfilled all six quality indicators. On practice and general practitioner level, we found no associations with cumulative quality indicator performance. On patient level, gender (ref = male) (OR: 0.83, CI: 0.78–0.88), number of treating general practitioners (OR: 0.94, CI: 0.91–0.97), number of comorbidities (OR: 1.43, CI: 1.38–1.47) and number of consultations (OR: 1.02, CI: 1.02–1.02) were associated with cumulative quality indicator performance. Conclusion The influence of practice, general practitioner and patient characteristics on quality indicator performance was surprisingly small and room for improvement in quality indicator performance of Swiss general practitioners seems to exist in diabetes care.

The aim of this study was to assess the impact of the 2019 published European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guideline on cardiovascular (CV) risk management compared with its predecessor from 2016 in a cohort in general practice. We performed a cross-sectional retrospective study with data from electronic medical records. The study cohort included 103,351 patients with known CV risk. We assessed changes in CV risk classification and low-density lipoprotein cholesterol (LDL-C) target values, the impact on LDL-C achievement rates, and the current lipid-lowering treatments. Under the 2019 ESC guideline, CV risk categories changed in 27.5% of patients, LDL-C target levels decreased in 71.4% of patients, and LDL-C target achievement rate dropped from 31.1% to 16.5%. Among non-achievers according to the 2019 guideline, 52.2% lacked lipid-lowering drugs entirely, and 41.5% had conventional drugs at a submaximal intensity. Of patients in the high-risk and very high-risk categories, at least 5% failed to achieve the LDL-C target level despite treatment at maximal intensity with conventional lipid-lowering drugs, making them eligible for PCSK-9 inhibitors. In conclusion, the 2019 ESC/EAS guideline lowered LDL-C target values for the majority of patients in general practice and halved LDL-C target achievement rates. There is still a large undeveloped potential to lower CV risk by introducing conventional lipid-lowering drugs, particularly in patients at high or very high CV risk. A substantial proportion of the patients can only achieve their LDL-C targets using PCSK-9 inhibitors, which would currently require an at least 10-fold increase in prescribing of these drugs.

Metacarpal neck fractures with severe displacement are commonly treated surgically with intramedullary Kirschner wires. We present the results of treatment of fifth metacarpal neck fractures using a light curable intramedullary photodynamic polymer (IlluminOss™, IlluminOss Medical Inc., East Providence, RI, USA). Twenty-nine patients with isolated displaced fifth metacarpal neck fractures were included and followed up for 12–24 weeks. All fractures had radiologically healed after 3 months. In two cases, a secondary loss of reduction was seen, which did not require further correction. During the follow-up period, range of motion of the metacarpophalangeal joint was 89% after 6 weeks and increased to 100% after 3 months compared with the uninjured side. Grip strength improved over time from 61% to 85%. No implant removal was necessary. We conclude that osteosynthesis using an intramedullary photodynamic polymer is a reliable treatment option for displaced fractures of the fifth metacarpal neck. Level of evidence: IV

Aims Heart failure is one of the leading causes of morbidity and mortality worldwide, but little is known on heart failure epidemiology and treatment in primary care. This study described patients with heart failure treated by general practitioners, with focus on drug prescriptions and especially on the only specific treatment for heart failure with reduced ejection fraction, namely sacubitril/valsartan. Methods and results This was a retrospective cross‐sectional study using data from an electronic medical record database of Swiss general practitioners from 2016 to 2019. Multilevel logistic regression was used to find determinants of sacubitril/valsartan prescription; odds ratios (ORs) and 95% confidence intervals (CIs) were reported. We identified 1288 heart failure patients (48.5% women; age: median 85 years, interquartile range 77–90 years) by means of diagnosis code, representing 0.5% of patients consulting a general practitioner during the observation period. About 73.6% received a renin–angiotensin–aldosterone system inhibitor, 67.8% a beta‐blocker, 34.6% a calcium channel blocker, 86.1% a diuretic, and 40.1% another cardiac drug. Sacubitril/valsartan was prescribed in 6% predominantly male patients (OR 2.10, CI 1.25–3.84), of younger age (OR 0.59 per increase in 10 years, CI 0.49–0.71), with diabetes mellitus (OR 1.76, CI 1.07–2.90). The recommended starting dose for sacubitril/valsartan was achieved in 67.1% and the target dose in 28.6% of patients. Conclusions Prevalence of heart failure among patients treated by general practitioners was low. Considering the disease burden and association with multimorbidity, awareness of heart failure in primary care should be increased, with the aim to optimize heart failure therapy.

Aims In some healthcare systems, physicians are allowed to dispense drugs; in others, drug-dispensing is restricted to pharmacists. Whether physician-dispensing affects patient health is unknown. Thus, we aimed to investigate associations between physician-dispensing and clinical and process measurements in patients with selected long-term conditions indicating increased cardiovascular risk. Methods Retrospective cross-sectional study in 2018 based on data from electronic medical records of 22405 patients (73.6% physician-dispensing) in Switzerland with medications for diabetes mellitus, arterial hypertension, or lipid-related disorders. We used multilevel regression models to determine the associations between physician-dispensing and clinical measurements (glycated hemoglobin [HbA1c], systolic blood pressure [sBP], low-density lipoprotein cholesterol [LDL-C]) or process measurements (number of annual clinical measurements, consultations, and drug prescriptions). Results Median (interquartile range) HbA1c value was 6.8% (6.3-7.5) both for the physician-dispensing and pharmacist-dispensing group, sBP was 137 (126-150) and 136 mmHg (126-149), and LDL-C was 2.3 (1.8-3.0) and 2.5 mmol/L (1.9-3.2). After adjustments, the physician-dispensing group had 4% lower LDL-C levels (p = 0.041), 12% more frequent HbA1c measurements (p = 0001), 16% higher annual consultation rates (p < 0.05 for all conditions), and equal number of different drugs, compared to the pharmacist-dispensing group. Conclusions We found no relevant differences in selected clinical measurements between physician- and pharmacist-dispensing, and mixed results in process measurements. Our results do not indicate that one drug-dispensing channel is superior to the other.

Guidelines recommend initiation of statins depending on cardiovascular risk and low-density lipoprotein cholesterol (LDL-C) levels. In this retrospective cohort study, we aimed to assess guideline concordance of statin treatment decisions and to find determinants of undertreatment in Swiss primary care in the period 2016&ndash, 2019. We drew on electronic medical records of 8060 statin-naive patients (50.0% female, median age 59 years) with available LDL-C levels and cardiovascular risk. Guideline concordance was assessed based on the recommendations of the European Society of Cardiology, and multilevel logistic regression was performed to find determinants of undertreatment. We found that statin treatment was initiated in 10.2% of patients (50.0% female, median age 59 years) during one year of follow up. Treatment decisions were classified as guideline-concordant in 63.0%, as undertreatment in 35.8% and as overtreatment in 1.2%. Among determinants of undertreatment were small deviation from LDL-C treatment thresholds (odds ratio per decrease by 1 mmol/L: 2.09 [95% confidence interval 1.87&ndash, 2.35]), high compared with very high cardiovascular risk (1.64 [1.30&ndash, 2.05]), female sex (1.31 [1.05&ndash, 1.64]), and being treated by older general practitioners (per 10 year decrease: 0.74 [0.61&ndash, 0.90]). In conclusion, undertreatment of patients at high or very high cardiovascular risk was common, but general practitioners considered cardiovascular risk and LDL-C in their treatment decisions.

Background Primary care systems around the world have implemented nurse practitioners (NPs) to ensure access to high quality care in times of general practitioner (GP) shortages and changing health care needs of a multimorbid, ageing population. In Switzerland, NPs are currently being introduced, and their exact role is yet to be determined. The aim of this study was to get insight into patient characteristics and services provided in NP consultations compared to GP consultations in order to appraise whether the NP role meets the political and demographic demands in Swiss primary care.Methods This case study used retrospective observational data from electronic medical records of a family practice with one NP and two GPs. Data on patient-provider encounters were collected between August 2017 and December 2018. We used logistic regression to assess associations between the assignment of the patients to the NP or GP and patient characteristics and delivered services respectively.Results Data from 5,210 patients participating in 27,811 consultations were analyzed. The average patient age was 44.3 years (SD 22.6), 47.1% of the patients were female and 19.4% multimorbid. 1,613 (5.8%) consultations were with the NP, and 26,198 (94.2%) with the two GPs. Patients in NP consultations were more often aged 85+ (OR 3.43; 95%-CI 2.70-4.36), multimorbid (OR 1.37; 95%-CI 1.24-1.51; p Conclusions Quantitative data from pilot projects provide valuable insights into NP tasks and activities in Swiss primary care. Our results provide first indications that NPs might have a focus on and could offer care to the growing number of multimorbid, polypharmaceutical elderly in Swiss primary care. NPs could offer care to the growing number of multimorbid, polypharmaceutical elderly, and might relieve work pressure from the GPs. Hence, the NP role has the potential to meet the current political and demographic demands in Swiss primary care. An extended scope of practice, especially prescription rights, could foster further professional practice and role implementation.

AIMS Statins decrease the risk of fatal CVD by lowering low-density lipoprotein (LDL) levels. Guidelines suggest that statin treatment strategies should be guided by CV risk, but little is known about statin treatment in Swiss general practice. In this study, we aimed to investigate statin treatment and LDL target achievement rates, including their predictors, in patients treated by Swiss general practitioners (GPs). METHODS Retrospective observational study of statin-treated patients in 2018 using a general practice electronic medical records database. CV risk categories were defined according to the ESC guidelines published in 2016. We used multilevel logistic regression models to find associations between patient and GP demographic factors and LDL target achievement. RESULTS We analysed 11,779 statin-treated patients, of whom 59% were at a high or very high risk of fatal CVD. High-intensity statin treatment was used in 39% of patients, and LDL measurement was performed at least once in 54% of patients. Achievement of LDL target levels across CV risk categories was 36% in very high-risk, 56% in high-risk, and 66% in low-/moderate-risk patients, and generally higher for male patients. CONCLUSIONS Although over half of patients were at a high or very high risk of fatal CVD, the majority did not receive high-intensity statin treatment. Only a third of very high-risk patients achieved LDL target values, and there was a gender gap in LDL target achievement disadvantaging female patients. Results from this study suggest that current treatment may warrant reconsideration in a large proportion of patients treated with statins in Swiss general practice.

Background Gout is the most common form of inflammatory arthritis worldwide and its prevalence is rising. In Switzerland, there are no data available on the characteristics and treatment of gout patients. In this study, we aimed to describe numbers of patients affected by gout and hyperuricaemia and unveil approaches Swiss primary care physicians (PCPs) use for the management. Methods This was a retrospective observational study using electronic medical routine ndata provided from 242 Swiss PCPs. Included were all their patients receiving urate-lowering therapy (ULT), with a diagnostic code for gout or who had a serum uric acid (SUA) measurement. According to their disease status, patients were classified into four subgroups (normal urate, hyperuricaemia, untreated gout, treated gout). For treatment analysis, patients with SUA measurements before and after ULT initiation were included. Comorbidities and risk factors for secondary causes relevant in the context of gout were collected. Outcomes were prevalence of gout and hyperuricaemia, characteristics of patients according to subgroup, number of SUA measurements, levels of SUA and patients who reached the treatment goal of a SUA level l360 mmol/l. Results We assessed 15,808 patients and classified them into the subgroups. This yielded a prevalence of 1.0% for gout and 1.2% for hyperuricaemia. 2642 patients were diagnosed with gout of whom 2420 (91.6%) received a ULT. Overall; 41.3% of patients with a gout treatment had at least one SUA measurement; 15.0% of patients with treated gout had a record of SUA measurements before and after ULT initiation; and 57.5% reached the treatment goal of l360 mmol/l after allopurinol treatment. Conclusion Swiss gout patients received comprehensive treatment, which is reflected in a high number of patients treated with ULT, laboratory tests per person and a high treatment success rate, although there is no systematic approach to the treatment of gout.

In Swiss primary care, general practitioner (GP) home visits have decreased due to impending GP shortages particularly in rural areas. Nurse practitioners (NP) are newly introduced in family practices and could potentially offer home visits to the increasing number of multimorbid elderly. We analysed consultation data from two pilot projects (Practice A and Practice B) with the goal to measure the frequency and patient characteristics of NP consultations both in the practice and on home visits, and to determine the NPs’ autonomy based on the required GP supervision. In Practice A, 17% of all NP consultations were home visits, in Practice B 51%. In both practices, the NPs saw older patients and reported higher autonomy on home visits compared to consultations in the practice. In Practice A, the NP encountered a higher share of multimorbid patients on home visits than in the practice, and the NP’s proportion of autonomously conducted consultations increased from 0% in the first month to 19% after 13 months of GP supervision. In Practice B, the NP was autonomous in about three-quarters of consultations after 2 years on the job. These first cases provide some evidence that NPs could reach a relatively high degree of autonomy and might pose a potential solution for the decreasing numbers of GP home visits to multimorbid elderly in Swiss primary care.

Introduction There is only limited and conflicting evidence on the effectiveness of Pay-for-Performance (P4P) programmes, although they might have the potential to improve guideline adherence and quality of care. We therefore aim to test a P4P intervention in Swiss primary care practices focusing on quality indicators (QI) achievement in the treatment of patients with diabetes. Methods and analysis This is a cluster-randomised, two-armed intervention study with the primary care practice as unit of randomisation. The control group will receive bimonthly feedback reports containing last data of blood pressure and glycated haemoglobin (HbA1c) measurements. The intervention group will additionally be informed about a financial incentive for each percentage point improved in QI achievement. Primary outcomes are differences in process (measurement of HbA1c) and clinical QI (blood pressure control) between the two groups. Furthermore, we investigate the effect on non-incentivised QIs and on sustainability of the financial incentives. Swiss primary care practices participating in the FIRE (Family Medicine ICPC Research using Electronic Medical Record) research network are eligible for participation. The FIRE database consists of anonymised structured medical routine data from Swiss primary care practices. According to power calculations, 70 of the general practitioners contributing to the database will be randomised in either of the groups. Ethics and dissemination According to the Local Ethics Committee of the Canton of Zurich, the project does not fall under the scope of the law on human research and therefore no ethical consent is necessary. Results will be published in a peer-reviewed journal. Trial registration number ISRCTN13305645; Pre-results.

Zur Daumenrekonstruktion nach traumatischer Amputation hat sich auch die Kallusdistraktion mittels Distraktionsfixateur etabliert. Die Wahl des geeigneten Verfahrens hangt von der Amputationshohe, dem Alter, Beruf und vom funktionellen Anspruch des Patienten ab. Wir berichten uber unsere Erfahrungen bei 5 Patienten, welche nach traumatischen Daumenamputationen auf Hohe der Basis der Grundphalanx mit einem in unserer Klinik in Zusammenarbeit mit einer spezialisierten Firma (Rotomed AG, Allmenstrasse 4, CH-4512 Bellach, www.rotomed.ch ) entwickelten semi-zirkularen Ringfixateur System behandelt wurden. Bei allen Patienten konnte eine zufriedenstellende Verlangerung von durchschnittlich 26,2 mm erreicht werden. Es traten keine Achsenabweichung oder revisionsbedurftigen Komplikationen auf. Der Hand Michigan Outcome Score betrug durchschnittlich 82,2%.

Background Little guidance is currently available for standardized diagnostic protocols and therapeutic recommendations for bone and joint infections (BJIs) of the hand. Objectives To summarize the available data in the scientific English-language literature on the diagnosis and treatment of native BJIs of the hand. To illustrate these concepts from a narrative point of view in areas where there is lack of evidence. Sources We performed a systematic PubMed and Internet search of studies that investigated hand BJIs in adult patients. Content Few studies have systematically investigated and validated diagnostic concepts, classifications or surgical treatment protocols. Most concepts derive from traditional intra-institutional experience, expert opinions and extrapolations from infections in large joints and long bones. Similarly, there is no uniformly accepted infection definition of BJIs of the hand. The best-documented literature is available for microbiological findings and antibiotic treatment duration in uncomplicated native joint arthritis of the fingers. Retrospective studies and one prospective randomized trial suggest that post-surgical targeted antibiotic therapy of 2 weeks results in a microbiological cure rate of ≥88%. Implications Studies on diagnostic workup and infection definition and classification are urgently needed to compare inter-institutional outcome results and generate guidelines for the best patient care. For uncomplicated pyogenic arthritis of native joints, current evidence suggests that a 2-week course of antibiotic therapy following surgery cures the infection.

Background Intravenous iron supplementation (IVIS) is increasing in Swiss general practice. This is controversial because of higher costs and risks compared with oral iron supplementation (OIS). In this study, we aimed to investigate indications for OIS and IVIS in Swiss general practice and test which factors are associated with prescribing IVIS instead of OIS. Methods This was a retrospective observational study using data from electronic medical records of 279 Swiss general practitioners (GPs), including all their patients at their first OIS and IVIS administration who were at least 14 years old and with available pretreatment serum ferritin and haemoglobin measurements. We also collected data about the following comorbidities: chronic kidney disease (CKD) stage 3b or higher, inflammatory bowel disease (IBD), chronic heart failure and restless legs syndrome. Outcomes were proportions of cases treated with IVIS or OIS by assumed indication (anaemic or non-anaemic iron deficiency [NAID]) or the abovementioned comorbidities. We evaluated associations with IVIS prescription using regression models adjusting for patient and GP variables. Results We assessed 1282 IVIS and 3003 OIS cases (median age 44 and 40 years, female in 86.7 and 88.6%, respectively). The most important indication for both IVIS and OIS was NAID (59.4 and 74.7%, respectively). Significant associations with prescribing IVIS instead of OIS were the severity of iron deficiency (reflected by serum ferritin levels and the presence of anaemia), the presence of advanced CKD, IBD and male sex of the GP. There was a time trend towards increasing serum ferritin levels associated with initiation of IVIS in NAID. Conclusion When preferring IVIS to OIS, Swiss GPs seem to consider severity of iron deficiency and comorbid conditions. However, pretreatment serum ferritin levels in IVIS for NAID are increasing, suggesting an ongoing indication extension and potential overuse.

BACKGROUND Research on individual general practitioner (GP) workload, e.g. in terms of consultation counts, is scarce. Accurate measures are desirable because GPs' consultation counts might be related to their work satisfaction and arguably, there is a limit to the number of consultations a GP can hold per day without jeopardizing quality of care. Moreover, understanding the association of consultation counts with GP characteristics is crucial given current trends in general practice, such as the increasing proportion of female GPs, part-time work and group practices. AIM The aim of this study was to describe GPs' consultation counts and efficiency and to assess associations with GP and practice variables. METHODS In this retrospective observational study we used routine data in electronic medical records obtained from 245 Swiss GPs in 2018. We described GPs' daily consultation counts as well as their efficiencies (i.e. total consultation counts adjusted for part-time work) and used hierarchical linear models to find associations of the GPs' total consultation counts in 2018 with GP- and practice-level variables. RESULTS The median daily consultation count was 28 over all GPs and 33 for full-time working GPs. Total consultation counts increased non-linearly with part-time status, with high part-time working GPs (60%-90% of full-time) being equally or more efficient than full-time workers. Excluding part-time status in the regression resulted in higher consultation counts for male GPs working in single practices and with older patients, whereas part-time adjusted consultation counts were unaffected by GP gender and practice type. CONCLUSION Female gender, part-time work in the range of 60%-90% of full-time, and working in group practices do not decrease GP efficiency. However, the challenge of recruiting sufficient numbers of GPs remains.

IntroductionFollowing years of controversy regarding screening for prostate cancer using prostate-specific antigen, evidence evolves towards a more restrained and preference-based use. This study reports the impact of landmark trials and updated recommendations on the incidence rate of prostate cancer screening by Swiss general practitioners.MethodsWe performed a retrospective analysis of primary care data, separated in 3 time periods based on dates of publications of important prostate-specific antigen screening recommendations. 1: 2010-mid 2012 including 2 updates; 2: mid 2012-mid 2014 including a Smarter Medicine recommendation; 3: mid-2014-mid-2017 maintenance period. Period 2 including the Smarter Medicine recommendation was defined as reference period. We further assessed the influence of patient's age and the number of prostate-specific-antigen (PSA) tests, by the patient and within each time period, on the mean PSA concentration. Uni- and multivariable analyses were used as needed.Results36,800 men aged 55 to 75 years were included. 14.6% had ≥ 2 chronic conditions, 11.7% had ≥ 1 prostate-specific antigen test, (mean 2.60 ng/ml [SD 12.3]). 113,921 patient-years were covered. Data derived from 221 general practitioners, 33.5% of GP were women, mean age was 49.4 years (SD 10.0), 67.9% used prostate-specific antigen testing. Adjusted incidence rate-ratio (95%-CI) dropped significantly over time periods: Reference Period 2: incidence rate-ratio 1.00; Period 1: incidence rate-ratio 1.74 (1.59-1.90); Period 3: incidence rate-ratio 0.61 (0.56-0.67). A higher number of chronic conditions and a patient age between 60-69 years were significantly associated with higher screening rate. Increasing numbers of PSA testing per patient, as well as increasing age, were independently and significantly associated with an increase in the PSA value.ConclusionSwiss general practitioners adapted screening behavior as early as evidence of a limited health benefit evolved, while using a risk-adapted approach whenever performing multiple testing. Updated recommendations might have helped to maintain this decrease. Further recommendations and campaigns should aimed at older patients with multimorbidity, to sustain a further decline in prostate-specific antigen screening practices.

Preoperative discontinuation of aspirin (acetylsalicylic acid) can reduce bleeding risk but may increase the risk of perioperative cardiovascular events. We retrospectively assessed the impact of preoperative continuation versus discontinuation of aspirin compared with a control group in a cohort of 739 consecutive patients undergoing total hip (THA) (n = 396) or knee arthroplasty (TKA) (n = 343) at a tertiary hospital. Bleeding risk, local complications, orthopaedic outcome, and cardiac and cerebral complications were assessed. Four hundred and sixty-five patients did not receive antithrombotic or full-dose anticoagulant medication, 175 patients were taking low-dose aspirin, 99 vitamin K antagonists, clopidogrel, or a combination of these drugs. Of the patients taking aspirin, 139 discontinued and 36 continued aspirin. Blood loss and local bleeding complications were comparable in these two groups. TKA patients who continued aspirin more frequently showed marked knee swelling after 1 week than those discontinuing aspirin (35.1 vs. 81.3 %; p = 0.001). However, orthopaedic outcome did not differ significantly between the two groups. There was a trend towards an increased risk of cardiac complications in patients who discontinued aspirin (6.5 vs. 0.0 %; p = 0.107). Continuation or discontinuation of aspirin did not show a statistically significant difference in the risk of relevant perioperative bleeding complications in our study. Continuation of aspirin was associated with a transitory increase in knee swelling, but had no effect on orthopaedic outcome. Continuation of aspirin may be associated with a favourable perioperative cardiac outcome. Our data support perioperative continuation of aspirin intake in patients undergoing THA or TKA.

Implant-related infections in hand surgery are dreaded complications, potentially leading to loss of finger joint function or amputation. Knowledge about the clinical presentation and treatment concepts of these infections is limited. The aim of this study is to present a consecutive series of patients with implant-related infections of the finger joints and wrist.We identified 25 patients with 29 implant-related infections. Infections were categorized as osteosynthesis-related infections (ORIs) or arthroplasty-related infections (ARIs). Further categorization included early and late post-operative (four weeks or less or more than four weeks after implantation) and exogenous and hematogenous infection.Compared with patients with ARIs (n = 11), those with ORIs (n = 14) were predominantly male (n = 11), were younger (mean 43 vs. 65 years, p = 0.0023), had few or no comorbidities, and had an exogenous source of infection. Patients with ARIs were predominantly female with rheumatoid arthritis (n = 8) and had a hematogenous pathogenesis. Infections occurred late in 22 (88%) patients. The most commonly isolated micro-organism was Staphylococcus aureus (n = 12; 48%). All ORIs were treated with implant removal and a median antimicrobial treatment duration of 39 days (interquartile range [IQR] 28-50 days). In the ARI group, the implant was removed in three patients and exchanged in three patients (one-stage exchange in one patient, two-stage exchange in two patients). In five individuals, debridement and implant retention was performed. The median antimicrobial treatment duration for ARIs was 42 days (IQR 30-75 days). The median follow-up time was 96 days (IQR 42-258 days) and infection was cured or presumably cured in 22 patients (88%).Our series shows distinct host and clinical patterns in ORIs and ARIs, supporting this categorization. The infection prognosis in ORIs is excellent with implant removal and antimicrobial treatment. Treatment concepts in ARIs are often derived from algorithms for periprosthetic joint infections of larger joints and need to be further elucidated.

Rubber band syndrome is a rare entity seen in younger children mainly in communities where rubber bands are worn around the wrist for decorative purposes. When the band is worn for a long duration, it burrows through the skin and soft tissues resulting in distal edema, loss of function, and even damage to the neurovascular structures. These symptoms are difficult to relate to this rare but typical condition. We report a case of a 2¾-year-old girl with the history of a linear circumferential scar at the right wrist combined with the limited use of a swollen hand for several weeks. The child was taken to surgery with the purpose to release the red, indurated scar and eliminate the lymphatic congestion. A rubber band was found lying in a plane superficial to the flexor tendons but had cut through the superficial branch of the radial nerve and partially through the abductor pollicis longus tendon. The band was removed and the lacerated structures were repaired. The child had excellent recovery postoperatively. The cardinal features of a linear constricting scar around the wrist in the presence of a swollen hand should always alert the clinician to the possibility of a forgotten band around the wrist, which might have burrowed into the soft tissues for a period. Early recognition may be important to prevent further damage of essential structures.

Due to incipient HELLP syndrome and no progression in labour, a caesarean was performed on a 33-year-old para I gravida I. During the operation she suffered a heavy blood loss as a result of uterine inertia. In the postoperative stage she developed an acute idiopathic colonic pseudo-obstruction, also known as Ogilvie's syndrome. Only 6 days after the operation did she slowly recover. Additional factors that could have led to Ogilvie's syndrome are the caesarean, the HELLP syndrome and the postpartal haemorrhage. Due to her reduced physical health, the mobilization of the patient was restricted, which further prolonged the recovery. However, an early initiation of supportive treatment, the timely diagnosis of Ogilvie's syndrome and two colonoscopic decompressions prevented a caecal rupture. After 3 weeks of hospitalization, the patient was discharged in good general health.

Human orf should be considered based on a typical presentation with erythematous papule/nodule to avoid unnecessary over-treatment.