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Background and aims Sex differences in cardiovascular prevention have been reported, yet the role of sex with regard to different modifiable risk factors such as low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (BP), and glycated hemoglobin (HbA1c) in primary care settings is unclear. Therefore, we studied sex differences in assessment and measured values of LDL-C, BP, and HbA1c in primary and secondary cardiovascular prevention delivered by general practitioners. Methods This cross-sectional study was based on electronic medical records of 59,092 primary care patients (51.9% women) aged 40–79 years in Switzerland. Multilevel regression was used to model associations of sex with assessment and measured values of LDL-C, BP, and HbA1c in 2018. Results In both primary and secondary prevention, women had lower LDL-C assessment rates (age-adjusted odds ratio (aOR) 0.71 [95% confidence interval (CI) 0.67 to 0.75] and 0.70 [CI 0.51 to 0.95]), and higher measured LDL-C values than men (age-adjusted difference 0.30 mmol/L [CI 0.25 to 0.35] and 0.28 mmol/L [CI 0.07 to 0.48]). Compared with men, women in primary prevention displayed lower BP and HbA1c assessment frequencies (aOR 0.77 [CI 0.73 to 0.81] and 0.76 [CI 0.71 to 0.80]) and measured values (age-adjusted difference -2.49 mmHg [CI -2.99 to -1.79] and -0.19% [CI -0.24 to -0.14]), while there was no sex difference in secondary prevention. Age-dependent increases in measured values of LDL-C, BP, and HbA1c were greater in women than men. Conclusions Control of LDL-C in women in primary care should be improved to reduce sex-based inequalities in prevention of cardiovascular disease.

Background Medication safety in patients with polypharmacy at transitions of care is a focus of the current Third WHO Global Patient Safety Challenge. Medication review and communication between health care professionals are key targets to reduce medication-related harm. Objective To study whether a hospital discharge intervention combining medication review with enhanced information transfer between hospital and primary care physicians can delay hospital readmission and impact health care utilization or other health-related outcomes of older inpatients with polypharmacy. Design Cluster-randomized controlled trial in 21 Swiss hospitals between January 2019 and September 2020, with 6 months follow-up. Participants Sixty-eight senior physicians and their blinded junior physicians included 609 patients ≥ 60 years taking ≥ 5 drugs. Interventions Participating hospitals were randomized to either integrate a checklist-guided medication review and communication stimulus into their discharge processes, or follow usual discharge routines. Main Measures Primary outcome was time-to-first-readmission to any hospital within 6 months, analyzed using a shared frailty model. Secondary outcomes covered readmission rates, emergency department visits, other medical consultations, mortality, drug numbers, proportions of patients with potentially inappropriate medication, and the patients’ quality of life. Key Results At admission, 609 patients (mean age 77.5 (SD 8.6) years, 49.4% female) took a mean of 9.6 (4.2) drugs per patient. Time-to-first-readmission did not differ significantly between study arms (adjusted hazard ratio 1.14 (intervention vs. control arm), 95% CI [0.75–1.71], p = 0.54), nor did the 30-day hospital readmission rates (6.7% [3.3–10.1%] vs. 7.0% [3.6–10.3%]). Overall, there were no clinically relevant differences between study arms at 1, 3, and 6 months after discharge. Conclusions The combination of a structured medication review with enhanced information transfer neither delayed hospital readmission nor improved other health-related outcomes of older inpatients with polypharmacy. Our results may help researchers in balancing practicality versus stringency of similar hospital discharge interventions. Study Registration ISRCTN18427377, https://doi.org/10.1186/ISRCTN18427377

Summary Background Increasing cancer drug prices are a challenge for patients and health systems in the USA and Europe. By contrast with the USA, national authorities in European countries often directly negotiate drug prices with manufacturers. The American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO) developed frameworks to evaluate the clinical value of cancer therapies: the ASCO-Value Framework (ASCO-VF) and the ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS). We aimed to assess the association between the clinical benefit of approved cancer drugs based on these frameworks and their drug prices in the USA and four European countries (England, Switzerland, Germany, and France). Methods For this cost–benefit analysis, we identified all new drugs with initial indications for adult cancers that were approved by the US Food and Drug Administration between Jan 1, 2009, and Dec 31, 2017, and by the European Medicines Agency up until Sept 1, 2019. For drugs indicated for solid tumours, we assessed clinical benefit using ASCO-VF and ESMO-MCBS. We compared monthly drug treatment costs between benefit levels using hierarchical linear regression models, and calculated Spearman's correlation coefficients between costs and benefit levels for individual countries. Findings Our cohort included 65 drugs: 47 (72%) drugs were approved for solid tumours and 18 (28%) were approved for haematological malignancies. The monthly drug treatment costs in the USA were a median of 2·31 times (IQR 1·79–3·17) as high as in the assessed European countries. There were no significant associations between monthly treatment costs for solid tumours and clinical benefit in all assessed countries, using the ESMO-MCBS (p=0·16 for the USA, p=0·98 for England, p=0·54 for Switzerland, p=0·52 for Germany, and p=0·40 for France), and for all assessed countries except France using ASCO-VF (p=0·56 for the USA, p=0·47 for England, p=0·26 for Switzerland, p=0·23 for Germany, and p=0·037 for France). Interpretation Cancer drugs with low or uncertain clinical benefit might be prioritised for price negotiations. Value frameworks could help identify therapies providing high clinical benefit that should be made rapidly available across countries. Funding Swiss Cancer Research Foundation (Krebsforschung Schweiz).

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.

Increasing oncological treatment costs are a major global concern with the risk of entailing two-tiered health care. Among cost determining factors is the price of individual drugs. In recognition of the central role of this factor, we present a comprehensive overview of the development of monthly prices of oncological drugs introduced over the last 15 years in Switzerland. We identified all oncological drugs newly reimbursed by mandatory health insurance in 2005–2019, and searched public repositories for their package prices, indications with approval dates, and treatment regimens for the calculation of (indication-specific) monthly prices. We found 81 products covering 77 different substances (39.5% protein kinase inhibitors, 21.0% monoclonal antibodies). Most indications related to the topography “blood”, followed by “lung and thorax” and “digestive tract”. From 2005–2009 to 2015–2019, the median monthly product price over all distinct indications of all products decreased by 7.56% (CHF 5,699 [interquartile range 4,483–7,321] to CHF 5,268 [4,19–6,967]), whereas it increased by 73.7% for monoclonal antibodies. In December 2019, six products had monthly prices over CHF 10,000, all approved for hematological or dermatological cancers. Our analysis suggests that individual price developments of oncological drugs are presently not the major driver of rising cancer treatment costs. However, rising launch prices of some new, mostly hematological drugs are of concern and require continued monitoring.

Background: The severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) pandemic forced hospitals to redistribute resources for the treatment of patients with coronavirus disease 2019 (COVID-19), yet the impact on elective and emergency inpatient procedure volumes is unclear. Methods: We analyzed anonymized data on 234 921 hospitalizations in 2017-2020 (55.9% elective) from a big Swiss health insurer. We used linear regression models to predict, based on pre-pandemic data, the expected weekly numbers of procedures in 2020 in the absence of a pandemic and compared these to the observed numbers in 2020. Compensation effects were investigated by discretely integrating the difference between the two numbers over time. Results: During the first COVID-19 wave in spring 2020, elective procedure numbers decreased by 52.9% (95% confidence interval -64.5% to -42.5%), with cardiovascular and orthopedic elective procedure numbers specifically decreasing by 45.5% and 72.4%. Elective procedure numbers normalized during summer with some compensation of postponed procedures, leaving a deficit of -9.9% (-15.8% to -4.5%) for the whole year 2020. Emergency procedure numbers also decreased by 17.1% (-23.7% to -9.8%) during the first wave, but over the whole year 2020, net emergency procedure volumes were similar to control years. Conclusion: Inpatient procedure volumes in Switzerland decreased considerably in the beginning of the pandemic but recovered quickly after the first wave. Still, there was a net deficit in procedures at the end of the year. Health system leaders must work to ensure that adequate access to non-COVID-19 related care is maintained during future pandemic phases in order to prevent negative health consequences.

IMPORTANCE The high cost of cancer medicines is a public health challenge. Policy makers in the US and Europe are debating reforms to drug pricing that would cover both the prices of new medicines when entering the market and price increases after they are launched. OBJECTIVE To assess launch prices, postlaunch price changes, and clinical benefit of cancer drugs in the US compared with 3 European countries (England, Germany, and Switzerland). DESIGN, SETTING, AND PARTICIPANTS This economic evaluation identified all new drugs that were approved for use in the US, England, Germany, and Switzerland with initial indications for treatment of adult solid tumor and hematologic cancers. Analysis included drugs approved by the US Food and Drug Administration between January 1, 2009, and December 31, 2019, and by the European Medicines Agency and Swissmedic until December 31, 2019. Prices were adjusted for currency and inflation. Clinical benefit of drugs indicated for solid tumors was assessed using the American Society of Clinical Oncology Value Framework and European Society for Medical OncologyMagnitude of Clinical Benefit Scale. Using Spearman rank correlation coefficients, correlations between clinical benefit and launch prices and postlaunch price changes for each country were evaluated. MAIN OUTCOMES AND MEASURES Launch prices, postlaunch price changes, and clinical benefit of cancer drugs. RESULTS The cohort included 65 drugs: 47 (72%) approved for solid tumors and 18 (28%) for hematologic cancers. In all countries, the lowest median monthly treatment costs at launch were greater in 2018-2019 vs 2009-2010: $14 580 vs $5790 in the US, $5888 vs $4289 in Germany, $6593 vs $5784 in Switzerland, and $6867 vs $3939 in England. Between 2009 and 2019, 48 of 65 (74%) cancer drugs had price increases in the US that were greater than inflation. Only 1 of 62 (2%) drugs in England, 0 of 60 drugs in Germany, and 7 of 56 drugs (13%) in Switzerland had a median price increase greater than inflation. There were no associations between launch prices or postlaunch price changes and clinical benefit in any assessed country. CONCLUSIONS AND RELEVANCE During this economic evaluation study period, launch prices of cancer drugs were substantially higher in the US than in the assessed similar high-income European countries, a gap that increased in the years after approval. Cancer drug prices frequently increased faster than inflation in the US but decreased on inflation-adjusted terms in Europe. Price changes were not associated with clinical benefit in any country.

Sample size calculations for trials with time-to-event outcomes are usually based on the assumption that an event – prototypically death in survival analysis – occurs only once per sample unit. However, events like changes in disease status or switches between treatment modalities may repeat over time. In trials with such outcomes, standard sample size formulae derived from the classical survival time models are not applicable. Instead, modeling the repeating transition events must precede the actual sample size calculation. Markov chains are an obvious choice to model transitions. Accordingly, in order to determine the sample size for a one-arm feasibility and acceptability study of a new drug intake route, we model switches of administration routes by a homogeneous finite-state, higher-order Markov chain. Assumptions about its transition matrix translate into multinomial distributions of the preferred administration routes at given points in time. From these distributions, the required sample size can then be calculated according to the study’s specific question. In this manuscript, we first introduce the method for the case of drug intake preferences, before we briefly discuss how the proposed method can also be used for power-based sample size calculation in multi-arm trials.

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.

Digitalization and patient empowerment result in new requirements and challenges. In response, the module "Clinical Telemedicine/e-Health" was implemented by the Faculty of Medicine of Zurich in 2008. The module was systematically evaluated to determine if the students would benefit from this course. In 2011, 2015, and 2016 further evaluations were performed.In 2008 and 2009, students evaluated 16 statements. We calculated the combined mean value and medians for both evaluations. In 2011, the same evaluation was conducted, and the results were compared through U-test. In 2015, students were asked about the application and benefits of telemedicine; the answers were analyzed qualitatively and quantitatively. In 2016, the University of Zurich created an online survey which integrated three of the statements from the original evaluations.Every mean value of the combined evaluations of 2008/2009, 2011, and 2016 achieved a score of over 4 on a 6-point scale. In 2011, and also again in 2016, the overall satisfaction and understanding of telemedicine as a supplement in traditional medical consultations increased as follows: 4.71 ± 0.74 versus 4.86 ± 0.93 versus 5.1 ± 1.5 and, respectively, 5.02 ± 0.96 versus 5.25 ± 0.81 versus 5.7 ± 0.6. In the 2015 evaluation, 93% of students indicated that they would use telemedicine for chronically ill and elderly patients.The positive assessment of the module indicates the successful introduction of the topics of telemedicine and e-health to medical students at the University of Zurich. Throughout the course, the students gained confidence and basic skills.

Background Tobacco abuse is a frequent issue in general practitioners' (GPs') offices, with doctors playing a key role in promoting smoking cessation to their patients. However, not all smokers are ready and willing to give up smoking. Thus, a GP focusing on smoking cessation alone might waste the opportunity to improve his patient’s health by supporting a change in another harmful behaviour pattern. The aim of this study is to determine whether multi-thematic coaching will lead to higher overall health benefits without resulting in a reduced rate of successful smoking cessations, compared with a monothematic smoking cessation approach. Methods The study is designed as a two-armed, double-blinded, cluster-randomised trial. GPs will be randomly assigned to the intervention or control group. In the intervention group, GPs will undergo training in patient-centred coaching, shared decision-making and motivational interviewing. The control group will be trained in a state-of-the-art smoking cessation algorithm. GPs will approach adult cigarette-smoking patients and advise those included according to the GP’s group affiliation. The primary outcome is the between-group difference in the proportion of participants who achieve a beneficial change in at least one of seven different health-related behavioural dimensions, 12 months post baseline. Secondary outcomes include smoking cessation rates and the patients’ self-perceived smoking-related motivation, self-efficacy and planning behaviour. Additionally, covariates describing both GPs and patients will be collected before the start of the intervention, and process outcome measures in compliance with the RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework will be recorded during the ongoing study. Discussion Tobacco consumption is still highly prevalent in the general population and often goes hand in hand with other behaviour patterns with adverse health effects. This study will add to the literature regarding effective strategies available to GPs to address unhealthy behaviour among their smoking patients beyond mere smoking cessation counselling. The study will also establish a basis for decisions about further promotion and dissemination of the coaching under study. Trial registration ISRCTN, ISRCTN38129107. Registered on 2 October 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-3071-z) contains supplementary material, which is available to authorized users.

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.

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 To estimate the prevalence of chronic obstructive pulmonary disease (COPD) and related risk factors in persons in opioid agonist treatment (OAT), to compare airflow limitation severity and age-specific COPD prevalence rates with those in the general population, and to assess the OAT patients' willingness to adopt lifestyle changes and to use therapeutic offers for COPD management. DESIGN Cross-sectional study in a random sample of OAT patients. SETTING Outpatient centres for substance addiction medicine in Zurich, Switzerland. PARTICIPANTS A total of 125 participants, recruited from November 2016 to April 2017 through invitation letters followed by phone or personal contact. MEASUREMENTS Standardised questionnaires about drug use, smoking habits, and medical history, filled in during face-to-face interviews or from medical records. Spirometry without and-depending on the result-with bronchodilation. FINDINGS Almost one third (30.3%; 95% CI: 22.6%-39.0%) of the 119 participants with valid spirometry tests were diagnosed with COPD. Among males of 30-59 years, the age-adjusted prevalence of at least moderate airflow limitation (GOLD grade ≥ 2) was 2.4 (95% CI: 1.3-4.4) times as high as in the ever-smoking Swiss population in the same age group. Smoking tobacco (92.0%) and substance inhalation (cannabis: 97.6%, cocaine: 69.6%, heroin: 68.0%) were highly prevalent among all participants. The participants expressed considerable interest in lifestyle changes and use of therapeutic offers for COPD management, with smoking cessation being least (20.2% of tobacco smokers interested), and pharmacological treatment to alleviate COPD symptoms most popular. CONCLUSIONS In Switzerland, chronic obstructive pulmonary disease (COPD) and multiple risk factors for COPD appear to be high among people in opioid agonist treatment (OAT) compared with the general population. OAT patients appear to develop COPD at a younger average age compared with the general population and are open to lifestyle changes and other COPD management approaches.

Background: Since 1999, the University Hospital Zurich (Switzerland) offers an e-mail based online consultation where patients can ask online doctors anonymous questions about individual health concerns. This study aimed at the characterization of the patient, the content of the question and the recommendations given specifically in the field of gastroenterology. Methods: In total, 3,489 inquiries were asked from July 2010 to December 2015. Based on the International Classification of Diseases ICD-10 and the Primary Care Code ICPC-2 252 (7.2%) inquiries were included in the retrospective qualitative study. The content of the requests was qualitatively evaluated by inductive categorization using a professional text analysis program (MAXQDA). Results: Of the users, 49.2% were male, 49.6% female. The mean age was 47.9 years. Main topics of the questions were bowel diseases in 29.8% (infectious in 6%, non-infectious in 7.1%, other bowel diseases in 16.7%). Most often patients suffered from abdominal pain (32.7%), diarrhea (22.7%), general weakness (22.7%) or epigastric pain (17.1%). Half (48.8%) of the questioners inquired about a second opinion while 25% asked for medical advice. The online doctors responded with detailed information about therapy (73.4%), explained a specific disease (63.9%) or provided decision support (13.9%). Most patients rated the clarity of the answer as good or very good (95.2%). Conclusion: An e-mail based teleconsultation in the field of gastroenterology can provide individual advice and empowers patients by improving their health literacy. Patients with bowel diseases have high expectations to obtain professional medical advice and need support in their decision-making process.