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Abstract Background Diagnoses entered by general practitioners into electronic medical records have great potential for research and practice, but unfortunately, diagnoses are often in uncoded format, making them of little use. Natural language processing (NLP) could assist in coding free-text diagnoses, but NLP models require local training data to unlock their potential. The aim of this study was to develop a framework of research-relevant diagnostic codes, to test the framework using free-text diagnoses from a Swiss primary care database and to generate training data for NLP modelling. Methods The framework of diagnostic codes was developed based on input from local stakeholders and consideration of epidemiological data. After pre-testing, the framework contained 105 diagnostic codes, which were then applied by two raters who independently coded randomly drawn lines of free text (LoFT) from diagnosis lists extracted from the electronic medical records of 3000 patients of 27 general practitioners. Coding frequency and mean occurrence rates (n and %) and inter-rater reliability (IRR) of coding were calculated using Cohen’s kappa (Κ). Results The sample consisted of 26,980 LoFT and in 56.3% no code could be assigned because it was not a specific diagnosis. The most common diagnostic codes were, ‘dorsopathies’ (3.9%, a code covering all types of back problems, including non-specific lower back pain, scoliosis, and others) and ‘other diseases of the circulatory system’ (3.1%). Raters were in almost perfect agreement (Κ ≥ 0.81) for 69 of the 105 diagnostic codes, and 28 codes showed a substantial agreement (K between 0.61 and 0.80). Both high coding frequency and almost perfect agreement were found in 37 codes, including codes that are particularly difficult to identify from components of the electronic medical record, such as musculoskeletal conditions, cancer or tobacco use. Conclusion The coding framework was characterised by a subset of very frequent and highly reliable diagnostic codes, which will be the most valuable targets for training NLP models for automated disease classification based on free-text diagnoses from Swiss general practice.

Abstract Background Monitoring the career intentions of medical students during their undergraduate studies could help to address the shortage of physicians, particularly in general practice. This study aimed to investigate changes in medical students' career openness, attractiveness and determinants of medical career choice during their bachelor’s studies. Methods The design was cross-sectional, recruiting all medical students who started a bachelor’s program in one of the four different educational tracks in Zurich, Switzerland, in the fall of 2019 (first survey) and completed it in the summer of 2022 (second survey). Students’ perceptions of the attractiveness and determinants of different medical career options were assessed using a structured online questionnaire. Absolute changes between the two-time points were reported in percentage points overall and by educational track. Regression analysis was used to examine the association of student characteristics and determinants of career options with the attractiveness of each option. Results We surveyed 354 medical students at the beginning and 433 at the end of the bachelor’s program (participation rate: 71.1% and 86.9%, respectively). Overall, the proportion of students open to all proposed medical career options decreased (from 52.8% to 43.8%, p = 0.004). The attractiveness of outpatient gynecology or pediatrics increased (from 27.4% to 43.4%, p

BACKGROUND: Primary care databases collect electronic medical records with routine data from primary care patients. The identification of chronic diseases in primary care databases often integrates information from various electronic medical record components (EMR-Cs) used by primary care providers. This study aimed to estimate the prevalence of selected chronic conditions using a large Swiss primary care database and to examine the importance of different EMR-Cs for case identification. METHODS: Cross-sectional study with 120,608 patients of 128 general practitioners in the Swiss FIRE (“Family Medicine Research using Electronic Medical Records”) primary care database in 2019. Sufficient criteria on three individual EMR-Cs, namely medication, clinical or laboratory parameters and reasons for encounters, were combined by logical disjunction into definitions of 49 chronic conditions; then prevalence estimates and measures of importance of the individual EMR-Cs for case identification were calculated. RESULTS: A total of 185,535 cases (i.e. patients with a specific chronic condition) were identified. Prevalence estimates were 27.5% (95% CI: 27.3–27.8%) for hypertension, 13.5% (13.3–13.7%) for dyslipidaemia and 6.6% (6.4–6.7%) for diabetes mellitus. Of all cases, 87.1% (87.0–87.3%) were identified via medication, 22.1% (21.9–22.3%) via clinical or laboratory parameters and 19.3% (19.1–19.5%) via reasons for encounters. The majority (65.4%) of cases were identifiable solely through medication. Of the two other EMR-Cs, clinical or laboratory parameters was most important for identifying cases of chronic kidney disease, anorexia/bulimia nervosa and obesity whereas reasons for encounters was crucial for identifying many low-prevalence diseases as well as cancer, heart disease and osteoarthritis. CONCLUSIONS: The EMR-C medication was most important for chronic disease identification overall, but identification varied strongly by disease. The analysis of the importance of different EMR-Cs for estimating prevalence revealed strengths and weaknesses of the disease definitions used within the FIRE primary care database. Although prioritising specificity over sensitivity in the EMR-C criteria may have led to underestimation of most prevalences, their sex- and age-specific patterns were consistent with published figures for Swiss general practice.

BackgroundThe pallidum has been the preferred DBS target for dystonia, but recent studies have shown equal or greater improvement in patients implanted in the STN.1 Transient stimulation-induced dyskinesia (SID) is frequently observed when stimulating this novel target, and there are no previously published video case reports of this phenomenon.CasesWe describe in detail the SID phenomenology experienced by 4 patients who had been implanted with STN DBS for isolated dystonia.ConclusionsSID can occur in focal, segmental, axial, or generalized distribution, can resemble levodopa-induced dyskinesia choreiform or dystonic movements observed in Parkinson's disease, and is generally transient and resolves with customized DBS programming. Providers should be aware that SID can occur after STN DBS when treating isolated dystonia and not assume movements are the result of worsening or spread of the underlying dystonia.

Abstract Background As most countries, Switzerland is experiencing a shortage of physicians especially in general practice and new medical education tracks with respective focusses have been started in response. This study investigated Swiss medical students’ career openness and attractiveness of different medical disciplines as well as the concordance of students’ career intentions with assigned medical education tracks. Methods Cross-sectional study surveying first year medical students assigned to four different Swiss medical education tracks with distinctive additional education focuses (ETH Zurich: medical technology and engineering, University of St. Gallen and University of Lucerne: primary healthcare and University of Zurich: no distinctive focus). Results We surveyed 354 medical students (response rate across all included medical education tracks 71.1%), 64.8% female, mean age 20 years. Regarding career openness, we found that 52.8% of medical students had neither a strong commitment nor a strong reservation for any of the proposed career options and 17.0% had a strong commitment. Among medical disciplines, medical subspecialties were attractive to the largest part of students (inpatient subspecialties attractive for 71%, outpatient for 58%), attractiveness of general practice was moderate (30%), academic (22%) and industrial sector (17%) careers were least attractive. Proportions of medical students attracted to general practice were similar at medical education tracks with focus on primary healthcare compared to other medical education tracks (32.2% vs. 25.8%, p = 0.391). Conversely, proportions of medical students attracted to academic or industry careers were significantly higher at the ETH Zurich compared to other medical education tracks (37.2%, vs. 13.1%, p

Carola A Huber,1,2 Michael Nagler,3 Thomas Rosemann,2 Eva Blozik,1,2 Markus Näpflin,1 Stefan Markun2 1Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland; 2Institute of Primary Care, University of Zürich, University Hospital Zürich, Zürich, Switzerland; 3University Institute of Clinical Chemistry, Inselspital Bern University Hospital, University of Bern, Bern, SwitzerlandCorrespondence: Carola A HuberDepartment of Health Sciences, Helsana Insurance Group, P.O. Box, 8081, Zürich, SwitzerlandTel +41 43 340 6341Fax +41 43 340 0434Email carola.huber@helsana.chBackground: Micronutrient laboratory tests (MLT) are increasing in many healthcare systems. This study assessed time trends of annual MLT incidence in the Swiss population and examined the frequency of specific MLT, defined as the number of yearly tests performed in individual persons.Methods: For annual time trends, we used a longitudinal design with a seven-year observation period (2012– 2018) and for yearly testing frequency we used a cross-sectional design (2018 only). The database consisted of nationwide insurance claims from adult persons.Results: Persons with MLT compared to persons without were older (mean age 57.1 years vs 48.6 years) and to a higher proportion female (65.1% vs 45.5%). Between 2012 and 2018, we included 6.7 million person years and found an increase in the proportion of persons receiving any MLT from 24.5% to 35.0%. Tests with strongest absolute increase during the observation period were vitamin D (from 7.4% of persons to 20.4%), vitamin B12 (from 9.0% to 17.6%) and ferritin (from 17.4% to 26.6%). In 2018, vitamin D and vitamin B12 tests were performed more than once in 4.5% and 3.3% of the population, respectively.Conclusion: We found that the Swiss population undergoes MLT with high and increasing frequency. Testing for vitamin D, vitamin B12 and ferritin is very common and of questionable appropriateness.Keywords: laboratory testing, micronutrient, claims data, trend

Stefania Di Gangi, Stefan Markun, Thomas Rosemann, Andreas Plate Institute of Primary Care, University and University Hospital of Zürich, Zürich, SwitzerlandCorrespondence: Stefania Di GangiInstitute of Primary Care, University of Zurich, Pestalozzistrasse 24, Zürich 8091, SwitzerlandTel +41 44 255 75 02Fax +41 44 255 90 97Email stefania.digangi@usz.chPurpose: Sleeping disturbances are highly prevalent in the general population, and pharmacological drug treatment harbours the risk of serious side effects. Many affected persons use dietary supplements for self-treating their symptoms, but little is known about the specific characteristics and preferences of these patients. Even less evidence exists about the consequences of a specific dietary supplement usage on health care utilization. The aim of this study was to explore characteristics, preferences and the impact on health care utilization in patients using a specific over-the-counter dietary supplement, which is promoted for improving sleeping disturbances.Patients and Methods: We conducted a structured survey and invited a sample of 297 customers of a specific dietary supplement to participate. The survey was open between June and September 2020. Participants were invited by email. All participants accepted an informed consent.Results: A total of 127 customers participated in the survey (participation rate: 42.8%). Of them, 87.7% were female and the mean age 50.5 years. Participants reported an overall good improvement of symptoms (7.66 on a ten-point Likert-scale) and showed a strong belief in the effectiveness of supplements in general; 67% of participants reported that the intake led to fever physician encounters, and 48.3% reported that they could stop the intake of other pharmaceutical sleeping drugs.Conclusion: A significant proportion of participants reported a substantial reduction in pharmaceutical drug use and health care utilization. While these self-reports lack an adequate control, they are still real consumer experiences, and the large beneficial effects – whether placebo or not – explain the popularity of such supplements and their therapeutic potential in sleeping disorders.Keywords: supplement use, sleeping disorders, usage patterns, drugs, health care utilization

Purpose: The frequency of medication prescribing and polypharmacy has increased in recent years in different settings, including Swiss general practice. We aimed to describe patient age- and sex-specific rates of polypharmacy and of prescriptions of the most frequent medication classes, and to explore practitioner variability in prescribing.Methods: Retrospective cross-sectional study based on anonymized electronic medical records data of 111 811 adult patients presenting to 116 Swiss general practitioners in 2019. We used mixed-effects regression analyses to assess the association of patient age and sex with polypharmacy (≥5 medications) and with the prescription of specific medication classes (second level of the Anatomical Therapeutic Chemical Classification System). Practitioner variability was quantified in terms of the random effects distributions.Results: The prevalence of polypharmacy increased with age from 6.4% among patients aged 18–40 years to 19.7% (41–64 years), 45.3% (65–80 years), and 64.6% (81–92 years), and was higher in women than in men, particularly at younger ages. The most frequently prescribed medication classes were antiinflammatory and antirheumatic products (21.6% of patients), agents acting on the renin-angiotensin system (19.9%), analgesics (18.7%), and drugs for acid related disorders (18.3%). Men were more often prescribed agents targeting the cardiovascular system, whereas most other medications were more often prescribed to women. The highest practitioner variabilities were observed for vitamins, for antiinflammatory and antirheumatic products, and for mineral supplements.Conclusion: Based on practitioner variability, prevalence, and risk potential, antiinflammatory drugs and polypharmacy in older patients appear to be the most pressing issues in current drug prescribing routines.

BackgroundChronic kidney disease (CKD) is a common condition in general practice. Data about quality and physician-level variation of CKD care provided by general practitioners is scarce. In this study, we evaluated determinants and variation of achievement of 14 quality indicators for CKD care using electronic medical records data from Swiss general practice during 2013-2019.MethodsWe defined two patient cohorts from 483 general practitioners, one to address renal function assessment in patients with predisposing conditions (n = 47,201, median age 68 years, 48.7% female) and one to address care of patients with laboratory-confirmed CKD (n = 14,654, median age 80 years, 57.5% female). We investigated quality indicator achievement with mixed-effect logistic regression and expressed physician-level variation as intraclass correlation coefficients (ICCs) and range odds ratios (rORs).ResultsWe observed the highest quality indicator achievement rate for withholding non-steroidal anti-inflammatory drug prescription in patients with CKD staged G2-3b within 12 months of follow-up (82.6%), the lowest for albuminuria assessment within 18 months of follow-up (18.1%). Highest physician-level variation was found for renal function assessment during 18 months of follow-up in patients with predisposing conditions (diabetes: ICC 0.31, rOR 26.5; cardiovascular disease: ICC 0.28, rOR 17.4; hypertension: ICC 0.24, rOR 17.2).ConclusionThis study suggests potentially unwarranted variation in general practice concerning RF assessment in patients affected by conditions predisposing for CKD. We further identified potential gaps in quality of CKD monitoring as well as lower quality of CKD care for female patients and patients not affected by comorbidities.

Abstract Background Chronic obstructive pulmonary disease (COPD) is a major public health issue affecting approximately 4% to 7% of the Swiss population. According to current inpatient guidelines, systemic corticosteroids are important in the treatment of acute COPD exacerbations and should be given for 5 to 7 days. Several studies suggest that corticosteroids accelerate the recovery of FEV1 (forced expiratory volume in 1 second), enhance oxygenation, decrease the duration of hospitalization, and improve clinical outcomes. However, the additional therapeutic benefit regarding FEV1 recovery appears to be most apparent in the first 3 to 5 days. No data are available on the optimum duration of corticosteroid treatment in primary-care patients with acute COPD exacerbations. Given that many COPD patients are treated as outpatients, there is an urgent need to improve the evidence base on COPD management in this setting. The aim of this study is to investigate whether a 3-day treatment with orally administered corticosteroids is non-inferior to a 5-day treatment in acute exacerbations of COPD in a primary-care setting. Methods/design This study is a prospective double-blind randomized controlled trial conducted in a primary-care setting. It is anticipated that 470 patients with acutely exacerbated COPD will be recruited. Participants are randomized to receive systemic corticosteroid treatment of 40 mg prednisone daily for 5 days (conventional arm, n = 235) or for 3 days followed by 2 days of placebo (experimental arm, n = 235). Antibiotic treatment for 7 days is given to all patients with CRP ≥ 50 mg/l, those with a known diagnosis of bronchiectasis, or those presenting with Anthonisen type I exacerbation. Additional treatment after inclusion is left at the discretion of the treating general practitioner. Follow-up visits are performed on days 3 and 7, followed by telephone interviews on days 30, 90, and 180 after inclusion in the study. The primary endpoint is the time to next exacerbation during the 6-month follow-up period. Discussion The study is designed to assess whether a 3-day course of corticosteroid treatment is not inferior to the conventional 5-day treatment course in outpatients with exacerbated COPD regarding time to next exacerbation. Depending on the results, this trial may lead to a reduction in the cumulative corticosteroid dose in COPD patients. Trial registration ClinicalTrials.gov, NCT02386735. Registered on 12 March 2015.

ObjectiveSubthalamic nucleus (STN) deep brain stimulation (DBS) can improve motor complications of Parkinson's disease (PD) but may worsen specific cognitive functions. The effect of STN DBS on cognitive function in dystonia patients is less clear. Previous reports indicate that bilateral STN stimulation in patients with PD amplifies the decrement in cognitive-motor dual-task performance seen when moving from a single-task to dual-task paradigm. We aimed to determine if the effect of bilateral STN DBS on dual-task performance in isolated patients with dystonia, who have less cognitive impairment and no dementia, is similar to that seen in PD.MethodsEight isolated predominantly cervical patients with dystonia treated with bilateral STN DBS, with average dystonia duration of 10.5 years and Montreal Cognitive Assessment score of 26.5, completed working memory (n-back) and motor (forced-maintenance) tests under single-task and dual-task conditions while on and off DBS.ResultsA multivariate, repeated-measures analysis of variance showed no effect of stimulation status (On vs Off) on working memory (F=0.75, p=0.39) or motor function (F=0.22, p=0.69) when performed under single-task conditions, though as working memory task difficulty increased, stimulation disrupted the accuracy of force-tracking. There was a very small worsening in working memory performance (F=9.14, p=0.019) when moving from single-task to dual-tasks when using the 'dual-task loss' analysis.ConclusionsThis study suggests the effect of STN DBS on working memory and attention may be much less consequential in patients with dystonia than has been reported in PD.

Nahara Anani Martínez-González, Andreas Plate, Stefan Markun, Oliver Senn, Thomas Rosemann, Stefan Neuner-JehleInstitute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich CH-8091, SwitzerlandAims: To synthesize the empirical evidence on the effectiveness of shared decision making (SDM) compared to usual care for prostate cancer (PC) treatment.Methods and results: A systematic review of academic (MEDLINE, EMBASE, Cochrane Library, CINHAL, PsychINFO, and Scopus) and grey (clinicaltrials.gov, WHO trial search, meta-Register ISRCTN, Google Scholar, opengrey, and ohri.ca) literature, also identified from contacting authors and hand-searching bibliographies. We included randomized controlled trials (RCTs): 1) comparing SDM to usual care for decisions about PC treatment, 2) conducted in primary or specialized care, 3) fulfilling the key SDM features, and 4) reporting quantitative outcome data. Four RCTs from Canada (n=3) and the USA were included and comprised 1,065 randomized men, most (89.8%) of whom were in PC stage T1-T2. The studies reported 24 outcome measures. In 62.5% study estimates, SDM was similar to usual care at improving patient satisfaction and mood, and at reducing decisional conflict and decisional regret. In 37.5% study estimates, SDM significantly improved knowledge, perception of being informed and patient-perceived quality of life (QoL) at four weeks. There was a dearth of outcome data, particularly on the adherence to treatment and on patient-important and clinically relevant health outcomes such as symptoms and mortality.Conclusion: SDM may positively influence men’s knowledge and may have a positive but short-term effect on patient-perceived QoL. The (long-term) effects of SDM on patient-related outcomes for decisions about PC treatment are unclear. Future research needs consensus about the interventions and outcomes needed to evaluate SDM and should address the absence of evidence on health outcomes.Keywords: systematic review, shared decision making, prostate cancer, treatment, controlled clinical trials, urology

The development of technology has been significantly given the implication towards consumer’s behaviour in having the online purchase intention via mobile app that has been developed by the e-commerce company to serve better and deliver a better service to the consumers; especially when internet has connected people through their smartphones. The insignificant growth in doing the online purchase via mobile app which does not go along with the growth of internet mobile users in Indonesia and Singapore will deliver this study in order to evaluate and validate the implication of ease of use, usefulness, system quality, information quality, and service quality towards consumer’s behaviour in having the online purchase intention via mobile app. Data was gathered with survey by spreading 100 questionnaires randomly to the respondents who had the experience in doing the online purchase via mobile app in the last 6 months in Indonesia and Singapore. The methodology in doing this study is the quantitative approach by considering the connection amongst the independent variables and the dependent variables. This research found that usefulness and information quality significantly affect the online purchase intention through mobile app in Indonesia while in Singapore ease of use, usefulness, and service quality significantly affect the online purchase intention through mobile app.

Abstract Background Inappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients. At hospital discharge of elderly patients, polypharmacy is often even more pronounced than at admission. However, the optimal discharge strategy in view of sustained medication appropriateness remains unclear. In particular, unreflectingly switching back to the pre-hospitalisation medication must be avoided. Therefore, both the patients and the follow-up physicians should be involved in the discharge process. In this study, we aim to test whether a brief medication review which takes the patients’ priorities into account, combined with a standardised communication strategy at hospital discharge, leads to sustained medication appropriateness and extends readmission times among elderly multimorbid patients. Methods The study is designed as a two-armed, double-blinded, cluster-randomised trial, involving 42 senior hospital physicians (HPs) with their junior HPs and 2100 multimorbid patients aged 60 years or older. Using a randomised minimisation strategy, senior HPs will be assigned to either intervention or control group. Following instructions of the study team, the senior HPs in the intervention group will teach their junior HPs how to integrate a simple medication review tool combined with a defined communication strategy into their ward’s discharge procedure. The untrained HPs in the control group will provide data on usual care, and their patients will be discharged following usual local routines. Primary outcome is the time until readmission within 6 months after discharge, and secondary outcomes cover readmission rates, number of emergency and GP visits, classes and numbers of drugs prescribed, proportions of potentially inappropriate medications, and the patients’ quality of life after discharge. Additionally, the characteristics of both the HPs as well as the patients will be collected before the intervention. Process evaluation outcomes will be assessed parallel to the ongoing core study using qualitative research methods. Discussion So far, interventions to reduce polypharmacy are still scarce at the crucial interface between HPs and GPs. To our knowledge, this trial is the first to analyse the combination of a brief deprescribing intervention with a standardised communication strategy at hospital discharge and in the early post-discharge period. Trial registration ISRCTN, ISRCTN18427377. Registered 11 January 2018

Background: Proton-pump inhibitors (PPI) are among the most prescribed drugs worldwide, and a large body of evidence raises concerns about their inappropriate use. Previous estimates of inappropriate use varied due to different definitions and study populations. Aims: We aimed to measure the population-based incidence and time trends of PPI and potentially inappropriate PPI prescriptions (PIPPI) with a novel method, continuously assessing excessive cumulative doses based on clinical practice guidelines. We also assessed association of patient characteristics with PPI prescriptions and PIPPI. Methods: This was an observational study based on a large insurance claims database of persons aged >18 years with continuous claims records of ⩾12 months. The observation period was January 2012 to December 2017. We assessed the incidence and time trends of PPI prescriptions and PIPPI based on doses prescribed, defining ⩾11.5 g of pantoprazole dose equivalents during any consecutive 365 days (average daily dose >31 mg) as inappropriate. Results: Among 1,726,491 eligible persons, the annual incidence of PPI prescriptions increased from 19.7% (2012) to 23.0% (2017), ( p =

ObjectiveRecently, an iMRI-guided technique for implanting DBS electrodes without MER was developed at our center. Here we report the clinical outcomes of PD patients undergoing STN DBS surgery using this surgical approach.MethodsConsecutive PD patients undergoing bilateral STN DBS using this method were prospectively studied. Severity of PD was determined using the UPDRS scores, Hoehn and Yahr staging score, stand-sit-walk testing, and the dyskinesia rating scale. The primary outcome measure was the change in UPDRS III off medication score at 6 months. DBS stimulation parameters, adverse events, levodopa equivalent daily dose (LEDD), and DBS lead locations were also recorded. Seventeen advanced PD patients (9M/8F) were enrolled from 2007 to 2009.ResultsThe mean UPDRS III off medication score improved from 44.5 to 22.5 (49.4%) at 6 months (p=0.001). Other secondary outcome measures (UPDRS II, III on medication, and IV) significantly improved as well (p

BACKGROUND To address low-value interventions in healthcare, “Choosing Wisely” campaigns provide recommendations of interventions to avoid (RIAs). These are usually developed by expert panels rather than general practitioners (GPs). The aim of our study was to develop RIAs for ambulatory general medicine based on the suggestions of GPs, with their involvement from the very beginning. METHODS This was a nationwide online Delphi survey among Swiss Society of General Internal Medicine members. In round one, each participant suggested two interventions perceived as particularly inappropriate. In round two, the 16 most frequent RIAs were rated by importance on a 0–100 scale and compared with “Choosing Wisely” lists. We calculated descriptive statistics for suggestions and importance ratings, and used regression models to search for associations with GP characteristics. RESULTS Response rates were 7.4% (538/7318) for round one and 18.2% (1357/7468) for round two. GPs provided 1074 suggestions. Out of the 16 most frequent RIAs, 13 corresponded to existing “Choosing Wisely” lists. The RIAs rated most important were: antibiotics in viral infections, unnecessarily duplicated tests and imaging in unspecific low back pain (means 88.5–91.7, standard deviations 18.6–19.9). None of the GPs’ characteristics were associated with any of the five highest rated RIAs except for working in a hospital setting. CONCLUSION Most RIA suggestions from GPs were concordant with previously published recommendations of interventions to avoid, independently of GPs knowledge of these and reflecting their high clinical relevance. In addition, our study revealed some more relevant topics and may help to develop future “Choosing Wisely” recommendations, with the final goal to reduce low-value care.

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.

Testing and prescribing vitamin B12 (also known as cobalamin) is increasing in Switzerland but substantial variation among general practitioners (GPs) with respect to testing has been noted. In this study, we aimed at exploring GPs’ mindsets regarding vitamin B12 testing and prescribing. A cross-sectional study was conducted using an online survey distributed by e-mail to Swiss GPs. The questionnaire explored mindsets related to testing and prescribing vitamin B12 in specific clinical situations, as well as testing and prescribing strategies. The questionnaire was sent to 876 GPs and 390 GPs responded (44.5%). The most controversial domains for testing and prescribing vitamin B12 were idiopathic fatigue (57.4% and 43.4% of GPs agreed, respectively) and depressive symptoms (53.0% and 35.4% of GPs agreed, respectively). There was substantial variation among GPs with regard to testing strategies (89.5% of GPS used a serum cobalamin test, 71.3% of GPS used holotranscobalamin, and 27.6% of GPs used homocysteine or methylmalonic acid). Intramuscular injection was the predominantly prescribed route of application (median of 87.5% of the prescriptions). In this study, we focus on discordant mindsets that can be specifically targeted by using educational interventions, and research questions that still need answering specifically about the effectiveness of vitamin B12 for idiopathic fatigue.

Stefan Markun,1,* Daniel P Franzen,2,* Kaba Dalla Lana,1 Swantje Beyer,3 Stephan Wieser,4 Thomas Hess,3 Malcolm Kohler,2 Thomas Rosemann,1 Oliver Senn,1 Claudia Steurer-Stey1,5 1Institute of Primary Care, 2Department of Pneumology, University Hospital Zurich, University of Zurich, Zurich, 3Department of Pneumology, Cantonal Hospital of Winterthur, Winterthur, 4Department of Pneumology, City Hospital Waid, 5MediX Group Practice Ltd, Zurich, Switzerland *These authors contributed equally to this work Introduction: Hospitalizations because of acute exacerbated COPD (AECOPD) are a major burden to patients and the health care system. Interventions during acute and post-acute hospital care exist not only to improve short-term outcomes but also to prevent future exacerbations and disease progression. We aimed at measuring the implementation rates of acute and post-acute hospital care interventions for AECOPD.Methods: We performed 24 months (January 1, 2012, to December 31, 2013) retrospective medical chart review of consecutive cases hospitalized to one of three public hospitals in the canton of Zurich due to AECOPD. Implementation rates of five acute care and seven post-acute care interventions were assessed.Results: Data from 263 hospitalizations (61% male, mean age 68.5 years, 47% active smokers) were analyzed. The median length of stay was 9 days (interquartile range [IQR] 6–12 days). In all, 32% of hospitalizations were caused by individuals with previous hospitalizations because of AECOPD. Implementation rates of four acute care interventions were >75% (lowest was appropriate antibiotic therapy with 56%). Compared to this, implementation rates of five post-acute care interventions were

Sima Djalali, Ryan Tandjung, Thomas Rosemann, Stefan Markun Institute of Primary Care, University of Zurich, University Hospital Zurich, Zurich, Switzerland Background: Facing the upcoming shortage of primary care physicians (PCPs), medical and governmental organizations have recently made major investments to foster vocational training programs in Switzerland, designed to provide context-specific training for trainees in primary care practices. Less is known about the impact of these programs on the skills and specific knowledge of trainees. We aimed to evaluate the Cantonal program for vocational primary care training in the Canton of Zurich, Switzerland’s largest Canton.Methods: We undertook a pretest–posttest study and surveyed physicians before and after participating in the Cantonal program for vocational primary care training in the Swiss Canton of Zurich. All trainees who participated in the program from 2013 until the end of 2015 were eligible. Primary outcome was the proportion of trainees being confident about their professional, organizational, examination and management skills before and after completing vocational training. Secondary outcomes were the proportion of trainees stating knowledge gain in entrepreneurship and the proportion of trainees being motivated to pursue a career as PCP.Results: Data of 47 trainees participating in the vocational training between 2013 and 2015 were eligible. In total, 35 (74.5%) participated in the T1 survey and 34 (72.3%) in the T2 survey. At T2, significantly more trainees (T1: 11%−89%, T2: 79%−100%) stated to be at least “slightly confident” about their skills (p

Abstract Background Swiss primary care (PC) is facing workforce shortage. Up to 2011 this workforce was supplied by two board certifications: general medicine and internal medicine. To strengthen them against subspecialties, they were unified into one: general internal medicine. However, since unification general practitioners’ career options are no longer restrained by early commitment to PC. This may lead to a decrease of future primary care physicians (PCPs). Methods To gain insights in timing and factors influencing career choice of internists, we addressed a cross sectional survey to all board certified internists in the years 2000–2010 (n = 1462). Main measures were: final career choice (PCPs, hospital internists or subspecialists), timing and factors influencing career choice, and attractiveness of PCP career during medical school and residency. Results Response rate was 53.2%, 44.8% were female and median age was 45 years old. Final career choice was PCP for 39.1% of participants, 15.0% chose to become hospital internists, 41.8% became subspecialists and 4.0% other. Timing of career choice significantly differed between groups. Most of the subspecialists have chosen their career during residency (65.3%), while only 21.9% of the PCPs chose during residency. Work experience in an academic hospital was negatively associated with becoming PCP (P

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.

Vitamin B12 is often used to improve cognitive function, depressive symptoms, and fatigue. In most cases, such complaints are not associated with overt vitamin B12 deficiency or advanced neurological disorders and the effectiveness of vitamin B12 supplementation in such cases is uncertain. The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) is to assess the effects of vitamin B12 alone (B12 alone), in addition to vitamin B12 and folic acid with or without vitamin B6 (B complex) on cognitive function, depressive symptoms, and idiopathic fatigue in patients without advanced neurological disorders or overt vitamin B12 deficiency. Medline, Embase, PsycInfo, Cochrane Library, and Scopus were searched. A total of 16 RCTs with 6276 participants were included. Regarding cognitive function outcomes, we found no evidence for an effect of B12 alone or B complex supplementation on any subdomain of cognitive function outcomes. Further, meta-regression showed no significant associations of treatment effects with any of the potential predictors. We also found no overall effect of vitamin supplementation on measures of depression. Further, only one study reported effects on idiopathic fatigue, and therefore, no analysis was possible. Vitamin B12 supplementation is likely ineffective for improving cognitive function and depressive symptoms in patients without advanced neurological disorders.

INTRODUCTION Men facing prostate cancer screening and treatment need to make critical and highly preference-sensitive decisions that involve a variety of potential benefits and risks. Shared decision-making (SDM) is considered fundamental for “preference-sensitive” medical decisions and it is guideline-recommended. There is no single definition of SDM however. We systematically reviewed the extent of SDM implementation in interventions to facilitate SDM for prostate cancer screening and treatment. METHODS We searched Medline Ovid, Embase (Elsevier), CINHAL (EBSCOHost), The Cochrane Library (Wiley), PsychINFO (EBSCOHost), Scopus, clinicaltrials.gov, ISRCTN registry, the WHO search portal, ohri.ca, opengrey.eu, Google Scholar, and the reference lists of included studies, clinical guidelines and relevant reviews. We also contacted the authors of relevant abstracts without available full text. We included primary peer-reviewed and grey literature of randomised controlled trials (RCTs) reported in English, conducted in primary and specialised care, addressing interventions aiming to facilitate SDM for prostate cancer screening and treatment. Two reviewers independently selected studies, appraised interventions and assessed the extent of SDM implementation based on the key features of SDM, namely information exchange, deliberation and implementation. We considered bi-directional deliberation as a central and mandatory component of SDM. We performed a narrative synthesis. RESULTS Thirty-six RCTs including 19 196 randomised patients met the eligibility criteria; they were mainly conducted in North America (n = 28). The median year of publication was 2008 (1997–2015). Twenty-three RCTs addressed decision-making for screening, twelve for treatment and one for both screening and treatment for prostate cancer. Bi-directional interactions between healthcare providers and patients were verified in 31 RCTs, but only 14 fulfilled the three key SDM features, 14 had at least “deliberation”, one had “unclear deliberation” and two had no signs of deliberation. CONCLUSIONS There is significant variation in the extent of SDM implementation among studies addressing SDM for prostate cancer screening and treatment. Further evaluation of these results on patient outcomes, a standardised SDM definition and guidance for an effective implementation in several clinical settings are needed.

BACKGROUND Explanation models for the effectiveness of homeopathy are not supported by natural sciences and the aggregated evidence from clinical trials is unconvincing. From this standpoint, placebo effects seem the most obvious explanation for the therapeutic effects experienced in homeopathy. Still, many physicians continue to prescribe homeopathic treatments. OBJECTIVES Whether physicians who prescribe homeopathic treatments aim to achieve placebo effects or actually believe in specific effects is poorly understood. However, this distinction has important educational and ethical implications. Therefore, we aimed to describe the use of homeopathy among physicians working in outpatient care, factors associated with prescribing homeopathy, and the therapeutic intentions and attitudes involved. METHODS All physicians working in outpatient care in the Swiss Canton of Zurich in the year 2015 (n = 4072) were approached. Outcomes of the study were: association of prescribing homeopathy with medical specialties (odds ratios [OR] and 95% confidence intervals [95% CI] from multivariable logistic regression); intentions behind prescriptions (to induce specific or nonspecific/placebo effects); level of agreement with specific attitudes; and views towards homeopathy including explanatory models, rating of homeopathy’s evidence base, the endorsement of indications, and reimbursement of homeopathic treatment by statutory health insurance providers. RESULTS The participation rate was 38%, mean age 54 years, 61% male, and 40% specialised in general internal medicine. Homeopathy was prescribed at least once a year by 23% of the respondents. Medical specialisations associated with prescribing homeopathy were: no medical specialisation (OR 3.9; 95% CI 1.7-9.0), specialisation in paediatrics (OR 3.8 95% CI 1.8-8.0) and gynaecology/obstetrics (OR 3.1 95% CI 1.5-6.7). Among prescribers, only 50% clearly intended to induce specific homeopathic effects, only 27% strongly adhered to homeopathic prescription doctrines, and only 23% thought there was scientific evidence to prove homeopathy’s effectiveness. Seeing homeopathy as a way to induce placebo effects had the strongest endorsement among prescribers and non-prescribers of homeopathy (63% and 74% endorsement respectively). Reimbursement of homeopathic remedies by statutory health insurance was rejected by 61% of all respondents. CONCLUSION Medical specialties use homeopathy with significantly varying frequency and only half of the prescribers clearly intend to achieve specific effects. Moreover, the majority of prescribers acknowledge that effectiveness is unproven and give little importance to traditional principles behind homeopathy. Medical specialties and associated patient demands but also physicians’ openness towards placebo interventions may play a role in homeopathy prescriptions. Education should therefore address not only the evidence base of homeopathy, but also ethical dilemmas with placebo interventions.

In real life, outcomes in wet age related macular degeneration (W-AMD) continue to fall behind the results from randomized controlled trials. The aim of this trial was to assess if outcomes can be improved by an intervention in healthcare organization following recommendations of the Chronic Care Model (CCM).Multi-centered randomized controlled clinical trial. The multifaceted intervention consisted in reorganization of care (delivery by trained chronic care coaches, using reminder systems, performing structured follow-up, empowering patients in self-monitoring and giving decision-support). In the control usual care was continued. Main outcome measures were changes in ETDRS visual acuity, optical coherence tomography (OCT) macular retinal thickness and quality of life (NEI VFQ-25 questionnaire).169 consecutive patients in Swiss ophthalmology centers were included. Mean ETDRS baseline visual acuity of eyes with W-AMD was 57.8 (± 18.7). After 12 months, the between-group difference in mean change of ETDRS visual acuity was -4.8 (95%CI: -10.8 to +1.2, p = 0.15); difference in mean change of OCT was +14.0 (95% CI -39.6 to 67.6, p = 0.60); difference in mean change of NEI VFQ-25 composite score mean change was +2.1(95%CI: -1.3 to +5.5, p = 0.19).The intervention aiming at improving chronic care was not associated with favorable outcomes within 12 months. Other approaches need to be tested to close the evidence-performance gap in W-AMD.Controlled-Trials.com ISRCTN32507927.

AIMS: The aim of the study was to assess the concordance of care for age related macular degeneration with the evidence-based framework for care for chronic medical conditions known as the chronic care model. Furthermore we aimed to identify factors associated with the concordance of care with the chronic care model. METHODS: Multi-centered cross-sectional study. 169 patients beginning medical treatment for age related macular degeneration were recruited and analyzed. Patients completed the Patient Assessment of Chronic Illness Care (PACIC) questionnaire, reflecting accordance to the chronic care model from a patient's perspective, the National Eye Institute Visual Functioning Questionnaire-25 (NEI-VFQ-25) and Patient Health Questionnaire (PHQ-9). Visual acuity and chronic medical conditions were assessed. Nonparametric tests and correlation analyses were performed, also multivariable regression analysis. RESULTS: The median PACIC summary score was 2.4 (interquartile range 1.75 to 3.25), the lowest PACIC subscale score was "follow-up/coordination" with a median of 1.8 (interquartile range 1.00 to 2.60). In multivariable regression analysis the presence of diabetes type 2 was strongly associated with low PACIC scores (coefficient = -0.85, p = 0.007). CONCLUSION: Generally, care for patients with age related macular degeneration by ophthalmologists is in moderate concordance with the chronic care model. Concerning follow-up and coordination of health service, large improvements are possible. Future research should answer the question how healthcare delivery can be improved effecting relevant benefits to patients with AMD.

Patients with multimorbidity are an increasing concern in healthcare. Clinical practice guidelines, however, do not take into account potential therapeutic conflicts caused by co-occurring medical conditions. This makes therapeutic decisions complex, especially in emergency situations.The aim of this study was to identify and quantify therapeutic conflicts in emergency department patients with multimorbidity.We reviewed electronic records of all patients ≥18 years with two or more concurrent active medical conditions, admitted from the emergency department to the hospital ward of the University Hospital Zurich in January 2009. We cross-tabulated all active diagnoses with treatments recommended by guidelines for each diagnosis. Then, we identified potential therapeutic conflicts and classified them as either major or minor conflicts according to their clinical significance.166 emergency inpatients with multimorbidity were included. The mean number of active diagnoses per patient was 6.6 (SD±3.4). We identified a total of 239 therapeutic conflicts in 49% of the of the study population. In 29% of the study population major therapeutic conflicts, in 41% of the patients minor therapeutic conflicts occurred.Therapeutic conflicts are common among multimorbid patients, with one out of two experiencing minor, and one out of three experiencing major therapeutic conflicts. Clinical practice guidelines need to address frequent therapeutic conflicts in patients with co-morbid medical conditions.

BACKGROUND: Physicians' shortage in many countries and demands of high-quality and affordable care make physician-nurse substitution an appealing workforce strategy. The objective of this study is to conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the impact of physician-nurse substitution in primary care on clinical parameters. METHODS: We systematically searched OVID Medline and Embase, The Cochrane Library and CINAHL, up to August 2012; selected peer-reviewed RCTs comparing physician-led care with nurse-led care on changes in clinical parameters. Study selection and data extraction were performed in duplicate by independent reviewers. We assessed the individual study risk of bias; calculated the study-specific and pooled relative risks (RR) or weighted mean differences (WMD); and performed fixed-effects meta-analyses. RESULTS: 11 RCTs (N = 30,247) were included; most were from Europe, generally small with higher risk of bias. In all studies, nurses provided care for complex conditions including HIV, hypertension, heart failure, cerebrovascular diseases, diabetes, asthma, Parkinson's disease and incontinence. Meta-analyses showed greater reductions in systolic blood pressure (SBP) in favour of nurse-led care (WMD -4.27 mmHg, 95% CI -6.31 to -2.23) but no statistically significant differences between groups in the reduction of diastolic blood pressure (DBP) (WMD -1.48 mmHg, 95%CI -3.05 to -0.09), total cholesterol (TC) (WMD -0.08 mmol/l, 95%CI -0.22 to 0.07) or glycosylated haemoglobin (WMD 0.12%HbAc1, 95%CI -0.13 to 0.37). Of other 32 clinical parameters identified, less than a fifth favoured nurse-led care while 25 showed no significant differences between groups. LIMITATIONS: disease-specific interventions from a small selection of healthcare systems, insufficient quantity and quality of studies, many different parameters. CONCLUSIONS: trained nurses appeared to be better than physicians at lowering SBP but similar at lowering DBP, TC or HbA1c. There is insufficient evidence that nurse-led care leads to better outcomes of other clinical parameters than physician-led care.

Background: Cervical dystonia (CD) is characterized by sustained, involuntary contraction of head and neck muscles. Botulinum toxin injections are established as safe and effective, but unfortunately 15–25% of patients fail to respond. The aim of this study was to examine whether multichannel electromyogaphic mapping improved outcomes in a cohort of antibody-negative onabotulinumtoxinA non-responders by more precisely identifying which muscles were involved in the dystonia.Methods: Patients with cervical dystonia who had “failed chemodenervation therapy” administered by an outside provider were enrolled in a single-blind, randomized, crossover design study. Patients received either a multichannel electromyographic mapping study prior to the first botulinum toxin injection, which was followed by use of only a single-lead injection 16 weeks later (injected by an alternate and blinded movement disorders specialist) or vice versa. The primary outcome measure was change in total Toronto Western Spasmodic Torticollis Rating Scale score 4 weeks after each injection compared with each pre-injection baseline score.Results: Nine subjects completed this study. Mean percentage improvement in Total Toronto Western Spasmodic Torticollis Rating Scale was 23.5% using multichannel electromyography compared with 9% using the single-channel technique (p = 0.11).Discussion: This pilot study suggests that multichannel electromyographic mapping may result in improved efficacy in the treatment of antibody-negative onabotulinumtoxinA refractory CD.