Improving collaboration between specialists and general practitioners in services for individuals with chronic spinal cord injury living in rural areas of Switzerland: Baseline results from the SCI-Co study

CONTEXT/OBJECTIVE

Strategies to combine primary and specialized care are crucial to meet the needs of individuals with spinal cord injury (SCI) located in rural areas. We explored the collaboration between general practitioners (GPs) and SCI specialists who will participate in an intervention study to improve their collaboration.

DESIGN

A questionnaire survey from August to October 2020.

SETTING

Primary Care, Specialized SCI care.

PARTICIPANTS

Eight GPs and 13 SCI specialists.

INTERVENTIONS

Baseline results from the SCI-Co study.

OUTCOME MEASURES

N/A.

RESULTS

Overall, satisfaction ratings for the collaboration between GPs and SCI specialists were high, and all physicians agreed that they work together well. Especially, SCI specialists were satisfied in collaborating with GPs. Despite Switzerland's fragmented primary and secondary care system, only a few physicians reported about issues with delays and waiting lists. While GPs wanted to improve the quality of their referral, most SCI specialists reported being content with it. GPs were also discontent about discharge organization by specialists.

CONCLUSION

Satisfaction with collaboration was high, both in GPs and specialists. Areas for improvement include discharge and referral processes.

Comparison of quality and interpretation of newborn ultrasound screening examinations for developmental dysplasia of the hip by basically trained nurses and junior physicians with no previous ultrasound experience

BACKGROUND

We are obliged to give babies the chance to profit from a nationwide screening of developmental dysplasia of the hip in very rural areas of Mongolia, where trained physicians are scarce. This study aimed to compare the quality and interpretation of hip ultrasound screening examinations performed by nurses and junior physicians.

METHODS

A group of 6 nurses and 6 junior physician volunteers with no previous ultrasound experience underwent Graf's standard training in hands-on practice. Newborns were examined before discharge from the hospital, according to the national guideline. Two standard documentation images of each hip were saved digitally. The groups were compared on the proportion of good quality of sonograms and correct interpretation. Two Swiss supervisors' agreed diagnosis according to Graf was considered the final reference for the study purposes.

RESULTS

A total of 201 newborns (402 hips or 804 sonograms) were examined in the study, with a mean age of 1.3±0.8 days at examination. Junior physicians examined 100 newborns (200 hips or 400 sonograms), while nurses examined 101 newborns (202 hips or 404 sonograms). The study subjects of the two groups were well balanced for the distribution of baseline characteristics. The study observed no statistically significant difference in the quality of Graf's standard plane images between the providers. Eventually, 92.0% (92) of the physician group and 89.1% (90) of the nurse group were correctly diagnosed as "Group A" (Graf's Type 1 hip) or "Non-Group A" hips (p = 0.484). The most common errors among the groups were a missing lower limb, wrong measurement lines, and technical problems.

CONCLUSION

Our study provides evidence that while there might be a trend of slightly more technical mistakes in the nurse group, the overall diagnosis accuracy is similar to junior physicians after receiving standard training in Graf's hip ultrasound method. However, after basic training, regular quality control is a must and all participants should receive refresher trainings. More specifically, nurses need training in the identification of anatomical structures.

Validation of self-reported cardiovascular problems in childhood cancer survivors by contacting general practitioners: feasibility and results

BACKGROUND

Epidemiological studies often rely on self-reported health problems and validation greatly improves study quality. In a study of late effects after childhood cancer, we validated self-reported cardiovascular problems by contacting general practitioners (GPs). This paper describes: (a) the feasibility of this approach; and (b) the agreement between survivor-reports and reports from their GP.

METHODS

The Swiss Childhood Cancer Survivor Study (SCCSS) contacts all childhood cancer survivors registered in the Swiss Childhood Cancer Registry since 1976 who survived at least 5 years from cancer diagnosis. We validated answers of all survivors who reported a cardiovascular problem in the questionnaire. Reported cardiovascular problems were hypertension, arrhythmia, congestive heart failure, myocardial infarction, angina pectoris, stroke, thrombosis, and valvular problems. In the questionnaire, we further asked survivors to provide a valid address of their GP and a consent for contact. We sent case-report forms to survivors' GPs and requested information on cardiovascular diagnoses of their patients. To determine agreement between information reported by survivors and GPs, we calculated Cohen's kappa (κ) coefficients for each category of cardiovascular problems.

RESULTS

We used questionnaires from 2172 respondents of the SCCSS. Of 290 survivors (13% of 2172) who reported cardiovascular problems, 166 gave consent to contact their GP and provided a valid address. Of those, 135 GPs (81%) replied, and 128 returned the completed case-report form. Survivor-reports were confirmed by 54/128 GPs (42%). Of the 54 GPs, 36 (28% of 128) confirmed the problems as reported by the survivors; 11 (9% of 128) confirmed the reported problem(s) and gave additional information on more cardiovascular outcomes; and seven GPs (5% of 128) confirmed some, but not all cardiovascular problems. Agreement between GPs and survivors was good for stroke (κ = 0.79), moderate for hypertension (κ = 0.51), arrhythmias (κ = 0.41), valvular problems (κ = 0.41) and thrombosis (κ = 0.56), and poor for coronary heart disease (κ = 0.15) and heart failure (κ = 0.32).

CONCLUSIONS

Despite excellent GP compliance, it was found unfeasible to validate self-reported cardiovascular problems via GPs because they do not serve as gatekeepers in the Swiss health care system. It is thus necessary to develop other validation methods to improve the quality of patient-reported outcomes.

Impact of primary care physicians working part-time on patient care: A scoping review

BACKGROUND

Increasing numbers of primary care physicians (PCPs) are reducing their working hours. This decline may affect the workforce and the care provided to patients.

OBJECTIVES

This scoping review aims to determine the impact of PCPs working part-time on quality of patient care.

METHODS

A systematic search was conducted using the databases PubMed, CINAHL, Embase, and the Cochrane Library. Peer-reviewed, original articles with either quantitative, qualitative or mixed methods designs, published after 2000 and written in any language were considered. The search strings combined the two concepts: part-time work and primary care. Studies were included if they examined any effect of PCPs working part-time on quality of patient care.

RESULTS

The initial search resulted in 2,323 unique studies. Abstracts were screened, and information from full texts on the study design, part-time and quality of patient care was extracted. The final dataset included 14 studies utilising data from 1996 onward. The studies suggest that PCPs working part-time may negatively affect patient care, particularly the access and continuity of care domains. Clinical outcomes and patient satisfaction seem mostly unaffected or even improved.

CONCLUSION

There is evidence of both negative and positive effects of PCPs working part-time on quality of patient care. Approaches that mitigate negative effects of part-time work while maintaining positive effects should be implemented.

The Role of Wearable Sensors in the Future Primary Healthcare - Preferences of the Adult Swiss Population: A Mixed Methods Approach

Wearable sensors have the potential to increase continuity of care and reduce healthcare expenditure. The user concerns and preferences regarding wearable sensors are the least addressed topic in related literature. Therefore, this study aimed first, to examine the preferences of the adult Swiss population regarding the use of wearable sensors in primary healthcare. Second, the study aimed to explain and learn more about these preferences and why such wearable sensors would or would not be used. An explanatory sequential design was used to reach the two aims. In the initial quantitative phase preferences of a nationwide survey were analyzed descriptively and a multivariable ordered logistic regression was used to identify key characteristics, that influence the preferences. In the second phase, eight semi-structured interviews were conducted. The cleaned study sample of the survey included 687 participants, 46% of whom gave a positive rating regarding the use of wearable sensors. In contrast, 44% gave a negative rating and 10% were neutral. The interviews showed that sensors should be small, not flashy and be compatible with everyday activities. Individuals without a current health risk or existing chronic disease showed lower preferences for using wearable sensors, particularly because they fear losing control over their own body. In contrast, individuals with increased risk or with an existing chronic disease were more likely to use wearable sensors as they can increase the personal safety and provide real-time health information to physicians. Therefore, an important deciding factor for and against the use of wearable sensors seems to be the perceived personal susceptibility for potential health problems.

The effect of the general practitioner as the first point of contact for care on the satisfaction with health care services in persons living with chronic spinal cord injury: A cross-sectional study

OBJECTIVE

The primary objective of this study was to investigate the effect of having a general practitioner (GP) as a first point of contact for care on the satisfaction with care services in persons with spinal cord injury (SCI), and how this effect is related to socio-demographic and health-related factors.

METHODS

This is a cross-sectional survey conducted within the framework of the Swiss Spinal Cord Injury Cohort Study Community Survey 2017. Outcome measures comprised three aspects of care (treatment with respect, understandability of explanations, and involvement in decision-making) and satisfaction with GP care and SCI centres. Information was grouped by first contact of care (GP or SCI specialist) and compared using the Mann-Whitney U test and logistic regression analysis.

RESULTS

Out of 3,959 invitees, 1,294 participants (33%) completed the survey. No significant association was found between the three aspects of care and the first contact of care. Persons who first contacted a GP and lived within a 10-minute travel distance to the GP practice were significantly less likely to be satisfied with their GP care (-5.7 percentage points, CI 95% = -10.7, -0.7), as compared to those living farther away. Persons who first contacted a GP rather than an SCI specialist were more likely to be satisfied with their GP care if married (7.1 percentage points, CI 95% = 1.4, 12.7), employed (6.6 percentage points, CI 95% = 0.9, 12.3), had a high social status (11.0 percentage points, CI 95% = 2.0, 20.1), or had tetraplegia (10.8 percentage points, CI 95% = 3.6, 18.1). For the same group, satisfaction with SCI centres was significantly higher in persons with good (10.1 percentage points, CI 95% = 0.1, 20.1) or very good health (8.2 percentage points, CI 95% = 1.0, 15.4), as compared to those with poor health.

CONCLUSION

The majority of participants were satisfied with the services offered by their first contact point for care, with variations due to factors endogenous to the participants. Socio-demographic and health-related factors should be integrated into health care planning strategies and improvement initiatives to ensure equitable access and better quality of health care services.

How time consuming are general practitioners' home visits? Insights from a cross-sectional study in Switzerland

BACKGROUND

Worldwide, the number of home visits has been decreasing over past decades. Lack of time and long journeys have been reported to hinder general practitioners (GPs) from conducting home visits. In Switzerland also, home visits have declined. Time constraints in a busy GP practice could be one reason. Therefore, the aim of this study was to analyse the time requirements of home visits in Switzerland.

METHODS

A one-year cross-sectional study involving GPs from the Swiss Sentinel Surveillance System (Sentinella) was conducted in 2019. GPs provided basic information on all home visits performed throughout the year and additionally detailed reports of up to 20 consecutive home visits. Univariable and multivariable logistic regression analyses were run to identify factors affecting journey and consultation duration.

RESULTS

In total, 95 GPs conducted 8489 home visits in Switzerland, 1139 of which have been characterised in detail. On average, GPs made 3.4 home visits per week. Average journey and consultation duration were 11.8 and 23.9 minutes, respectively. Prolonged consultations were provided by GPs working part-time (25.1 minutes), in group practice (24.9 minutes) or in urban regions (24.7 minutes). Rural environments and short journey to patient's home were both found to lower the odds of performing a long consultation compared to a short consultation (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.16-0.44 and OR 0.60, 95% CI 0.46-0.77, respectively). Emergency visits (OR 2.20, 95% CI 1.21-4.01), out-of-hours appointments (OR 3.06, 95% CI 2.36-3.97) and day care involvement (OR 2.78, 95% CI 2.13-3.62) increased the odds of having a long consultation. Finally, patients in their 60s had markedly higher odds of receiving long consultations than patients in their 90s (OR 4.13, 95% CI 2.27-7.62), whereas lack of chronic conditions lowered the odds of a long consultation (OR 0.09, 95% CI 0.00-0.43).

CONCLUSION

GPs perform rather few but long home visits, especially for multimorbid patients. GPs working part-time, in group practice or in urban regions devote more time to home visits.

Role distribution and collaboration between specialists and rural general practitioners in long-term chronic care: a qualitative study in Switzerland

INTRODUCTION

This study explores general practitioners' (GPs') and medical specialists' perceptions of role distribution and collaboration in the care of patients with chronic conditions, exemplified by spinal cord injury.

METHODS

Semi-structured interviews with GPs and medical specialists caring for individuals with spinal cord injury in Switzerland. The physicians we interviewed were recruited as part of an intervention study. We used a hybrid framework of inductive and deductive coding to analyse the qualitative data.

RESULTS

Six GPs and six medical specialists agreed to be interviewed. GPs and specialists perceived the role of specialists similarly, namely as an expert and support role for GPs in the case of specialised questions. Specialists' expectations of GP services and what GPs provide differed. Specialists saw the GPs' role as complementary to their own responsibilities, namely as the first contact for patients and gatekeepers to specialised services. GPs saw themselves as care managers and guides with a holistic view of patients, connecting several healthcare professionals. GPs were looking for relations and recognition by getting to know specialists better. Specialists viewed collaboration as somewhat distant and focused on processes and patient pathways. Challenges in collaboration were related to unclear roles and responsibilities in patient care.

CONCLUSION

The expectations for role distribution and responsibilities differ among physicians. Different goals of GPs and specialists for collaboration may jeopardise shared care models. The role distribution should be aligned according to patients' holistic needs to improve collaboration and provide appropriate patient care.

Accuracy of Trained Physicians is Inferior to Deep Learning-Based Algorithm for Determining Angles in Ultrasound of the Newborn Hip

PURPOSE

 Sonographic diagnosis of developmental dysplasia of the hip allows treatment with a flexion-abduction orthosis preventing hip luxation. Accurate determination of alpha and beta angles according to Graf is crucial for correct diagnosis. It is unclear if algorithms could predict the angles. We aimed to compare the accuracy for users and automation reporting root mean squared errors (RMSE).

MATERIALS AND METHODS

 We used 303 306 ultrasound images of newborn hips collected between 2009 and 2016 in screening consultations. Trained physicians labelled every second image with alpha and beta angles during the consultations. A random subset of images was labeled with time and precision under lab conditions as ground truth. Automation predicted the two angles using a convolutional neural network (CNN). The analysis was focused on the alpha angle.

RESULTS

 Three methods were implemented, each with a different abstraction of the problem: (1) CNNs that directly learn the angles without any post-processing steps; (2) CNNs that return the relevant landmarks in the image to identify the angles; (3) CNNs that return the base line, bony roof line, and the cartilage roof line which are necessary to calculate the angles. The RMSE between physicians and ground truth were found to be 7.1° for alpha. The best CNN architecture was (2) landmark detection. The RMSE between landmark detection and ground truth was 3.9° for alpha.

CONCLUSION

 The accuracy of physicians in their daily routine is inferior to deep learning-based algorithms for determining angles in ultrasound of the newborn hip. Similar methods could be used to support physicians.

Why Do Community-Dwelling Persons with Spinal Cord Injury Visit General Practitioners: A Cross-Sectional Study of Reasons for Encounter in Swiss General Practice

Purpose

In a country of free selection of providers, general practitioners (GPs) remain the most visited health-care professionals by the vast majority of persons with spinal cord injury (SCI) in Switzerland; yet, little is known about these contacts. The study aims to explore reasons for encounters (RFEs) in general practice, and their relationships to first-contact of care (GP or specialist) and GP’s competence in managing SCI-specific problems.

Patients and Methods

Cross-sectional study from baseline data of non-randomized controlled trial. Persons with SCI in the chronic phase and living in Swiss rural communities were invited. Participants were asked about RFEs (reasons and health problems) of their last visit to a GP. RFEs were coded according to the International Classification of Primary Care (ICPC-2), and analyzed according to first-contact and participants’ ratings of GPs’ competence in managing SCI-specific problems.

Results

Out of 395, 226 (57%) persons participated, of which 89% have reported 2.1 (SD ±1.4) RFEs and 2.4 (±1.7) health problems per GP visit, on average. Participants visited GPs for medications (49%), urgent medical problems (33%) and follow-up (30%). Most RFEs were related to general/unspecified problems (65%). Persons whose first contact was a specialist were more likely to visit GPs for medications (Specialist = 60% vs GP = 42%). There were no associations between RFEs and the perceived GP’s competence at P < 0.05.

Conclusion

Irrespective of first contact of care, persons with SCI visit GPs for medication, urgent issues, and follow-up care, and more often for general problems than for secondary health conditions. Strengthening collaboration between GPs in rural communities and specialized centers is recommended; promoting such a connection potentially aids GPs in meeting their information needs for managing secondary health conditions and improving the quality of SCI care for this population.

Shared responsibility between general practitioners and highly specialized physicians in chronic spinal cord injury: Study protocol for a nationwide pragmatic nonrandomized interventional study

Introduction

To improve the continuity of care for persons with spinal cord injury (SCI) living in peripheral areas, collaboration between general practitioners (GPs) and specialists is needed. This pragmatic non-randomized interventional study assesses feasibility and effectiveness of a new primary care model based on this collaboration.

Methods

The intervention is medical education on SCI related topics offered by specialists to GPs practicing in rural areas. Outcomes are assessed and analyzed in physicians and patients. Group allocation of persons with SCI follows intention-to-treat principle with intervention group being those in close proximity to a participating GP.

Results

It is expected that ten GPs and sixteen specialists will take part in the study's intervention. An average difference in “Doctor's opinion on collaboration questionnaire” score (mean 44; SD ± 12) from baseline after two years post-intervention in the group of participating GPs is hypothesized at P-value level <0.05; meanwhile, the control group remains at an average score of 56. Of persons with SCI (n = 395), 230 are expected to take part in the study at baseline. An average modified “Spinal Cord Injury-Secondary Conditions Scale” change in score from baseline to 24 months post intervention is expected to fall from 12.0 to 9.0 in the intervention group and to stay at 12.0 in the control group.

Conclusion

The study aims to improve patients' outcomes and providers’ experience with delivery of care for persons with SCI, as compared to current best practice.

Trial registration

ClinicalTrials.gov, NCT04071938. Registered August 28, 2018, https://www.clinicaltrials.gov/ct2/show/NCT04071938.

Traditional Mongolian swaddling and developmental dysplasia of the hip: a randomized controlled trial

BACKGROUND

Mongolian traditional swaddling of infants, where arms and legs are extended with a tight wrapping and hips are in adduction position, may lead to abnormal maturation and formation of the hip joint; and is a contributing factor for developmental dysplasia of the hip (DDH). This hypothesis was tested in this randomized controlled trial.

METHODS

Eighty newborns with one or two hips at risk of worsening to DDH (Graf Type 2a; physiologically immature hips) at birth were randomized into 2 groups at a tertiary hospital in Ulaanbaatar. The "swaddling" group (n = 40) was swaddled in the common traditional Mongolian method for a month while the "non-swaddling" group (n = 40) was instructed not to swaddle at all. All enrollees were followed up on monthly basis by hip ultrasound and treated with an abduction-flexion splint if necessary. The groups were compared on the rate of Graf's "non-Type 1" hips at follow-up controls as the primary outcome. Secondary outcomes were rate of DDH and time to discharge (Graf Type 1; healthy hips). In addition, correlation between the primary outcome and swaddling length in days and frequency of swaddling in hours per day were calculated.

RESULTS

Recruitment continued from September 2019 to March 2020 and follow-up data were completed in June 2020. We collected final outcome data in all 80 enrollees. Percentages of cases with non-Type 1 hip at any follow-up examination were 7.5% (3/40) in the non-swaddling group and 40% (16/40) in the swaddling group (p = 0.001). There was no DDH case in the non-swaddling group while there were 8 cases of DDH in the swaddling group. The mean time to discharge was 5.1 ± 0.3 weeks in the non-swaddling group and 8.4 ± 0.89 weeks in the swaddling group (p = 0.001). There is a correlation between the primary outcome and the swaddling frequency in hours per day (r = 0.81) and swaddling length in days (r = 0.43).

CONCLUSIONS

Mongolian traditional swaddling where legs are extended and hips are in extension and adduction position increases the risk for DDH.

TRIAL REGISTRATION

Retrospectively registered, ISRCTN11228572 .

First contact of care for persons with spinal cord injury: a general practitioner or a spinal cord injury specialist?

Background

Although general practitioners (GPs) are generally considered as the first point of contact for care, this may be different for persons with complex conditions, such as those with spinal cord injury (SCI). The objective of this study is to understand the differences in long-term care provision by GPs and SCI-specialists, by examining (1) the first contact of care for SCI health problems, (2) the morbidity profile and use of health-care services in relation to first contact, and (3) the factors associated with the choice of first contact.

Methods

In this cross-sectional study based on data derived from the Swiss Spinal Cord Injury Cohort Study Community Survey 2017, the main outcome measure was the reported first contact for SCI-specific care. This information was analysed using the chi-square test and logistic regression analysis of groups based on patient characteristics, use of health-care services and secondary health conditions assessed using the Spinal Cord Injury Secondary Conditions Scale (SCI-SCS).

Results

Out of 1294 respondents, 1095 reported their first contact for SCI-specific care; 56% indicated SCI-specialists and 44% specified GPs. On average, participants who first contacted a GP reported higher number of GP consultations (5.1 ± 5.2 vs. 3.9 ± 7.2), planned visits to ambulatory clinics (3.7 ± 7.3 vs. 3.6 ± 6.7) and hospital admissions (GP, 1.9 ± 1.7 vs. 1.5 ± 1.3), but lower number of visits to SCI-specialists (1.7 ± 1.8 vs. 2.6 ± 1.7) and of hospital days (22.8 ± 43.2 vs. 31.0 ± 42.8). The likelihood to contact a GP first was significantly higher in persons ≥75 years old (OR = 4.44, 95% CI = 1.85–10.69), Italian speakers (OR = 5.06, 95% CI = 2.44–10.47), had incomplete lesions (OR = 2.39, 95% CI = 1.71–3.35), experiencing pain (OR = 1.47, 95% CI = 1.04–2.09) or diabetes mellitus (OR = 1.85, 95% CI = 1.05–3.27), but lower for those situated closer to SCI centres (OR = 0.69, 95% CI = 0.51–0.93) or had higher SCI-SCS scores (OR = 0.92, 95% CI = 0.86–0.99).

Conclusion

Age, language region, travel distance to SCI centres, lesion completeness, and occurrence of secondary conditions play a significant role in determining the choice of first contact of care, however there is still some unwarranted variation that remains unclear and requires further research.

Frequency of home visits where general practitioners are exposed to a problem different from that foreseen - a Swiss cross-sectional study

BACKGROUND

When a home visit is considered, patients' suspected health problems are important for correct triage, the decision for or against the visit and allocation of the visit to a general practitioner (GP) or a nurse practitioner. Misjudgment might lead to suboptimal patient outcomes.

OBJECTIVE

We aimed to evaluate the accuracy of suspected health problems (based on pre-visit assessments) by comparing them with the actual health problems (post-visit assessments) and investigating associated factors.

METHODS

GPs of the Swiss Sentinel Surveillance Network (Sentinella) reported pre-visit and post-visit assessments and patient characteristics for up to 20 consecutive home visits, which they conducted in 2019. Using multivariable logistic regressions, we investigated associations between patient and clinical factors and unconfirmed suspected health problems from pre-visit assessments and unforeseen actual health problems from post-visit assessments.

RESULTS

Overall, 114 GP practices participated. The GPs reported 1496 patient visits with a total of 1789 and 1762 health problems from pre-visit and post-visit assessments, respectively, that were included in the analysis. Musculoskeletal and circulatory problems were the most common in patients receiving home visits. The health problems from pre-visit and post-visit assessments were unconfirmed and unforeseen in15% and 13% of the cases, respectively. Older age (odds ratio [OR] 1.1 in 10-year steps; 95% confidence interval [95% CI] 1.0-1.3) and urgent visits (OR 1.7 compared with regular visits; 95% CI 1.1-2.6) showed a trend for more unforeseen health problems.

CONCLUSION

When home visits were conducted, about one out of seven health problems from pre-visit and post-visit assessments were unconfirmed and unforeseen. Particularly when patients were older or visits were urgent, there were higher odds of unconfirmed and unforeseen health problems.These results should be considered when triaging patients.

Nurse Practitioners in Swiss Family Practices as Potentially Autonomous Providers of Home Visits: An Exploratory Study of Two Cases

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.

Delivery of mobile dental services to dependent elderly people: results from a pilot study in rural Switzerland

The objective of this pilot study was to provide data on the oral health status and oral health behaviour of care-dependent elderly people in the canton of Uri. The study aimed at assessing whether age and duration of living in a nursing home is associated with dental attendance, whether there is a relationship between age and the DMF-T index, and how high the risk was for participants to develop oral health problems. The study offered mobile dental services to people residing in nursing homes (NHG) and to community dwellers (CDG). Data was collected on demographics, medical history, presence of pain, ability to eat and oral health behaviour by means of a questionnaire. A clinical examination was performed and data on the oral status was collected. Statistical methods were: median tests, linear regressions and descriptive statistics. Uptake of the programme was low. 56 participants were examined. 47 participants (24 females, 23 males, average age 86.3 ± 7.36 years) resided in nursing home, nine participants (seven females, two males, average age 76 ± 12.8 years) were community dwellers. No significant differences were found between frequency of dental attendance and age (p = 0.35) or duration of stay in a nursing home (p = 0.55). The number of decayed teeth (p=0.005), missing teeth (p=0.01), and the DMF-T index (average in NHG = 26.5, CDG = 20.2, p < 0.001) increased, the number of filled teeth (p=0.02) decreased as age increased. Upon calculation of the 'Teamwerk-index', which takes into account oral health behaviour, dental caries, periodontal status, the majority of participants had a medium risk of developing oral health problems. Our pilot study in rural Switzerland provides first results of the oral health status in dependent elderly people. As people age, oral health deteriorates. More attention should be given in order to achieve better oral hygiene maintenance and more regular dental visits, to ensure a better oral health status in dependent elderly people.

Potentially inappropriate testing for vitamin D deficiency: a cross-sectional study in Switzerland

Background

There is consensus that vitamin D supplementation is often indicated but population-based screening by laboratory testing for vitamin D deficiency is inadequate. Testing should be restricted to people at high risk of severe deficiency. This study describes the current lab testing for vitamin D deficiency in the adult population of Switzerland.

Methods

We assessed Swiss health insurance data (SWICA) for incidence of lab testing for vitamin D levels, comparing the years 2015 and 2018. Claims were analyzed for associations between lab testing and age, sex, medical indications, insurance status and geographic location in multivariable regression analyses. We also estimated the costs of vitamin D testing.

Results

Data from 200,043 and 200,046 persons for 2015 and 2018, respectively, were analyzed. Vitamin D level was tested in 14% of the sample population in 2015 and 20% in 2018. Testing increased by 69% for individuals aged 26–30. Testing was associated with being middle-aged to young senior citizens, female, medical indications (pregnancy, renal disease, osteoporosis, hyperparathyroidism, HIV, glucocorticoid intake), more chronic conditions, having a mandatory insurance with a low deductible, additional insurance coverage, and living in urban areas. We estimate that the total laboratory cost to mandatory insurance was about 90 million Swiss francs in 2018.

Conclusions

Despite recommendations for routine vitamin D supplementation, vitamin D testing of low risk individuals is common and increasing in Switzerland.

Oral corticosteroids for post-infectious cough in adults: study protocol for a double-blind randomized placebo-controlled trial in Swiss family practices (OSPIC trial)

BACKGROUND

Cough is a common reason for patients to visit general practices. So-called post-infectious cough is defined as lasting 3 to 8 weeks after an upper respiratory tract infection. It can be disabling in daily activities, with substantial impact on physical and psychosocial health, leading to impaired quality of life and increased health care costs. Recommendations for the management of post-infectious cough in primary care are scarce and incoherent. A systematic review and meta-analysis of randomized clinical trials (RCT) assessing patient-relevant benefits and potential harms of available treatments identified six eligible RCTs assessing different treatment regimens (i.e. inhaled fluticasone propionate, inhaled budesonide, salbutamol plus ipratropium-bromide, montelukast, nociception-opioid-1-receptor agonist, codeine, gelatine). No RCT found clear patient-relevant benefits and most had an unclear or high risk of bias. Post-infectious cough is thought to be mediated by inflammatory processes that are also present in exacerbations of asthma or chronic obstructive pulmonary diseases for which there is strong evidence that oral corticosteroids provide patient-relevant benefit without relevant harm. We therefore plan to conduct the first RCT evaluating the effectiveness of oral corticosteroids for post-infectious cough.

METHODS

We are conducting a triple-blinded randomized-controlled and multicentred superiority trial in primary health care practices in Switzerland. We will include 204 adult patients who consult their general practitioner (GP) for a cough lasting 3 to 8 weeks following an upper respiratory tract infection. Participants will be randomly allocated to either the 5-day treatment with oral corticosteroids or placebo. The primary outcome is cough-related quality of life assessed by the Leicester Cough Questionnaire score 14 days after randomization. Secondary outcomes include cough-related quality of life at several time points, overall cessation of cough and adverse events.

DISCUSSION

This RCT will provide evidence on whether oral corticosteroids are beneficial and safe in patients with post-infectious cough. Results can have a substantial impact on the well-being and management of these patients in Switzerland and beyond. An evidence-based treatment for this condition may reduce re-consultations with GPs and spending for antitussive drugs, thus possibly having an impact on health care spending.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04232449 . Prospectively registered on 18 January 2020.

Effect of a patient-centred deprescribing procedure in older multimorbid patients in Swiss primary care - A cluster-randomised clinical trial

Background

Management of patients with polypharmacy is challenging, and evidence for beneficial effects of deprescribing interventions is mixed. This study aimed to investigate whether a patient-centred deprescribing intervention of PCPs results in a reduction of polypharmacy, without increasing the number of adverse disease events and reducing the quality of life, among their older multimorbid patients.

Methods

This is a cluster-randomised clinical study among 46 primary care physicians (PCPs) with a 12 months follow-up. We randomised PCPs into an intervention and a control group. They recruited 128 and 206 patients if ≥60 years and taking ≥five drugs for ≥6 months. The intervention consisted of a 2-h training of PCPs, encouraging the use of a validated deprescribing-algorithm including shared-decision-making, in comparison to usual care. The primary outcome was the mean difference in the number of drugs per patient (dpp) between baseline and after 12 months. Additional outcomes focused on patient safety and quality of life (QoL) measures.

Results

Three hundred thirty-four patients, mean [SD] age of 76.2 [8.5] years participated. The mean difference in the number of dpp between baseline and after 12 months was 0.379 in the intervention group (8.02 and 7.64; p = 0.059) and 0.374 in the control group (8.05 and 7.68; p = 0.065). The between-group comparison showed no significant difference at all time points, except for immediately after the intervention (p = 0.002). There were no significant differences concerning patient safety nor QoL measures.

Conclusion

Our straight-forward and patient-centred deprescribing procedure is effective immediately after the intervention, but not after 6 and 12 months. Further research needs to determine the optimal interval of repeated deprescribing interventions for a sustainable effect on polypharmacy at mid- and long-term. Integrating SDM in the deprescribing process is a key factor for success.

Trial registration

Current Controlled Trials, prospectively registered ISRCTN16560559 Date assigned 31/10/2014.

The Prevention of Polypharmacy in Primary Care Patients Trial (4P-RCT).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01870-8.

Patients' experiences with the advanced practice nurse role in Swiss family practices: a qualitative study

Background

Considering shortages of general practitioners (GP) and strategies for improving the quality of health care provision, many countries have implemented interprofessional care models with advanced practice nurses (APN). International evidence suggests that APN care results in high patient satisfaction. In Switzerland, the role is still new, and the patient perspective has not yet been researched. Our aim was therefore to explore patients’ experiences with the APN role in Swiss family practices.

Methods

We conducted 22 semi-structured interviews in four different family practices with patients aged 18 to 97 suffering from minor acute to multiple chronic diseases, and who had at least one consultation with an APN. All interviews were audiotaped, transcribed verbatim, and analysed using qualitative content analysis.

Results

The analysis resulted in five themes: Despite the unfamiliarity, all patients were willing to be consulted by an APN because it was recommended by their GP (1); after several encounters, most participants perceived differences between the APN and the GP consultation in terms of the length and style of the consultations as well as the complexity of their tasks (2); the interviewees emphasised coaching, guidance, care coordination, and GP-assisting tasks as APN core competencies and attributed the characteristics empathetic, trustworthy, and competent to the APN role (3); most patients especially valued home visits and the holistic approach of the APNs, but they also noticed that in certain cases GP supervision was required (4); and due to the close collaboration between the APN and the GP, patients felt safe, well cared for and experienced improvements in physical and psychological well-being as well as in daily activities (5).

Conclusion

Our results suggested that patients value the APNs’ competencies, despite their initial lack of role knowledge. Trust in the GP seemed to be the most important factor for patients’ receptiveness toward the APN role. Overall, patients perceived an added value due to the enlargement of the scope of practice offered by APNs. The patient perspective might provide valuable insights for further APN role implementation in Swiss family practices.

Treating insomnia in Swiss primary care practices: A survey study based on case vignettes

Guidelines recommend cognitive behavioural therapy for insomnia (CBT-I) as first-line treatment for chronic insomnia, but it is not clear how many primary care physicians (PCPs) in Switzerland prescribe this treatment. We created a survey that asked PCPs how they would treat chronic insomnia and how much they knew about CBT-I. The survey included two case vignettes that described patients with chronic insomnia, one with and one without comorbid depression. PCPs also answered general questions about treating chronic insomnia and about CBT-I and CBT-I providers. Of the 820 Swiss PCPs we invited, 395 (48%) completed the survey (mean age 54 years; 70% male); 87% of PCPs prescribed sleep hygiene and 65% phytopharmaceuticals for the patient who had only chronic insomnia; 95% prescribed antidepressants for the patient who had comorbid depression. In each case, 20% of PCPs prescribed benzodiazepines or benzodiazepine receptor agonists, 8% prescribed CBT-I, 68% said they knew little about CBT-I, and 78% did not know a CBT-I provider. In the clinical case vignettes, most PCPs treated chronic insomnia with phytopharmaceuticals and sleep hygiene despite their lack of efficacy, but PCPs rarely prescribed CBT-I, felt they knew little about it, and usually knew no CBT-I providers. PCPs need more information about the benefits of CBT-I and local CBT-I providers and dedicated initiatives to implement CBT-I in order to reduce the number of patients who are prescribed ineffective or potentially harmful medications.

Differences in patient population and service provision between nurse practitioner and general practitioner consultations in Swiss primary care: a case study

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 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 5210 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. 1613 (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 < 0.001) and polypharmaceutical (OR 1.28; 95%-CI 1.15–1.42; p < 0.001) in comparison to GP consultations. In NP consultations, vital signs (OR 3.05; 95%-CI 2.72–3.42; p < 0.001) and anthropometric data (OR 1.33; 95%-CI 1.09–1.63; p 0.005) were measured more frequently, and lab tests (OR 1.16; 95%-CI 1.04–1.30; p 0.008) were ordered more often compared to GP consultations, independent of patient characteristics. By contrast, medications (OR 0.35; 95%-CI 0.30–0.41; p < 0.001) were prescribed or changed less frequently in NP consultations.

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.

The provision of mobile dental services to dependent elderly people in Switzerland

OBJECTIVE

This work aimed at describing mobile dental services provided by both the private sector and the universities in Switzerland to dependent elderly people. It also aimed at presenting the views of both sectors on the current status of these services.

BACKGROUND

As people age and become more care-dependent, their oral health requirements increase, as access to dental care decreases.

METHOD

A survey was sent to practitioners who potentially provided a mobile dental service (n = 253). Five interviews were conducted with six individuals who have a leading role in Geriatric dentistry in the four universities in Switzerland that provide dental training.

RESULTS

The private sector provides a mobile dental service to the elderly mainly through the use of portable equipment, while university services are provided by different models. The interviewees discussed the reasons as to why these services were set up. They discussed the challenges associated with treating dependent elderly patients, which often makes work in this field hard and unattractive. Both sectors see the need for better collaboration with other professionals.

CONCLUSION

The private sector in Switzerland provides a mobile dental service to elderly people mostly through the use of portable equipment, while university services are provided in a variable configuration of models. Better collaboration is required to improve dental care and service delivery to dependent elders. There is a potential for improvement of these services, in order to meet the demand of an ageing population, catering for both the institutionalised elders and those living at home.

Implementation of a nationwide universal ultrasound screening programme for developmental dysplasia of the neonatal hip in Mongolia

PURPOSE

Mongolia is the first Asian country to launch universal ultrasound screening for newborns with developmental dysplasia of the hip (DDH). The aims of this study were to determine the coverage and treatment rate of this programme.

METHODS

Data from birth statistics and ultrasound hip screening from 29 hospitals were retrospectively reviewed (2010 to 2016, pre-nationwide phase; and 2017 to 2019, nationwide programme). DDH was diagnosed using the Graf-technique and treated according to 'ABCD', a modified Graf classification (Group A: Graf Type 1, mature; B: 2a, physiologically immature; C: 2c to 3, early DDH; D: 4, dislocated). Group B children were followed with monthly ultrasound. Group C and D children were treated with a flexion and abduction orthosis (Tübingen). Screeners used a web-based platform to upload images for quality surveillance.

RESULTS

Between 2017 and 2019, 230 079 live births were registered and 176 388 newborns screened. The nationwide screening coverage rate in newborns increased from 73.6% in 2017 to 82.1% in 2019. Group A (148 510 children, 84.2%) was discharged, while Group B (25 820, 14.6%) was followed. Among children in Group B, 284 cases worsened to Group C and were, therefore, treated with a Tübingen orthosis. The remaining 2058 (1.2%) of newborns with DDH were treated with a Tübingen orthosis, including 1999 newborns in Group C and 59 in Group D. Since 2017, a total of 142 860 (81.0%) hip sonograms were uploaded to the platform.

CONCLUSION

A simplified diagnostic and therapeutic framework for ultrasound DDH screening for newborns was successfully deployed in Mongolia, a developing country, providing high surveillance coverage and appropriate treatment.Level of evidence: IV.

The use of ultrasound in primary care: longitudinal billing and cross-sectional survey study in Switzerland

Background

Ultrasound imaging is utilized in Swiss primary care; however, little is known regarding the extent to which it is performed. With this study, we aim to (1) provide an overview of ultrasound use by general practitioners (GPs), and (2) determine the clinical indications of ultrasound in Swiss general practice.

Methods

This is a quantitative study, analyzing 15 years of billing data from 213 GPs in Central Switzerland, and cross-sectional survey data completed by 61 GPs attending 26 certification and refresher courses offered by the Swiss Society of Ultrasound in Medicine (SGUM).

Results

According to billing data, 49% of the GPs used ultrasound and provided 130,245 exams to 67,180 patients between 2004 and 2018. Over the years, ultrasound use became more frequent among GPs. Male GPs provide more ultrasound exams than female GPs. Patients that are female, ≥65 years, and multi-morbid had more ultrasound exams compared to males, patients < 65 years, and those with only one morbidity, respectively. GPs provided a mean of 129 ultrasound exams per physician-year. Abdominal ultrasound comprised almost 69% of all exams. According to survey data, indications covered many organ systems and clinical conditions, with abdominal indications being most frequent among them.

Conclusions

The use of ultrasound is high among general practitioners and it covers a wide range of clinical indications. Ultrasound is utilized primarily in the diagnosis of clinical indications of the abdomen, and more often for female than male patients.

Complexity as a factor for task allocation among general practitioners and nurse practitioners: a narrative review

BACKGROUND

General practitioner (GP) shortages and increasing demand for care led to the introduction of nurse practitioners (NPs) to primary care. Many concepts for task sharing among health professionals feature complexity. The aim of this narrative review was to examine how complexity is used as a factor for task allocation between GPs and NPs.

METHODS

According to the PRISMA statement, PubMed and CINAHL were searched systematically, and eligibility criteria were applied to detect literature concerning GPs and NPs in primary care and complexity in the context of task allocation. Relevant information was extracted, and a narrative analysis was performed.

RESULTS

Thirty-seven studies from seven countries were included, comprising quantitative, qualitative, and mixed methods. Complexity was used to describe patients, their needs, and health professionals' tasks. The understanding of the use of complexity as a factor for task allocation between NPs and GPs was based on the patient population (specific vs. unspecific), the setting (specific vs. unspecific), the numbers of health professionals involved (two vs. more than two), and the NP role (distinct model of care vs. no model). Despite similarities in these areas, the tasks which NPs perform range from providing minor to complex care. However, there is a slight trend towards NPs treating socially complex patients and GPs focusing on medically complex cases.

CONCLUSION

Complexity as a concept is prominent in primary care but remains broad and inconsistent as a factor for task allocation between NPs and GPs. This review can be used as a point of reference when practitioners are seeking methods for task allocation in a collaborative primary care setting.

Satisfaction with access and quality of healthcare services for people with spinal cord injury living in the community

Objective: To identify barriers to access healthcare services and reveal determinants of satisfaction with healthcare services in people with chronic spinal cord injury (SCI).Design: Cross-sectional survey.Setting: Community setting in Switzerland.Participants: People with chronic SCI.Interventions: Non-applicable.Outcome Measures: Questionnaire-based evaluation of availability and quality of healthcare services for secondary health conditions, satisfaction with fulfillment of healthcare needs, and preference for care from a hypothetical service provider with limited specialized SCI care expertise but in close proximity over comprehensive care from an existing specialized SCI center located at a greater distance.Results: Close to three-quarter of participants (70%) indicated satisfaction with healthcare services received for SCI related health conditions. Elderly individuals (61+ years old) rated the availability and quality of healthcare 6% to 11% higher than younger individuals. The perceived fulfillment of healthcare needs was lower in people with incomplete paraplegia (odds ratio (OR) 2.11, 95%-credibility interval (CI) 1.18-3.84), chronic pain (OR 1.85, CI 1.12-3.08), insufficient access to long distance transportation (OR 5.81, CI 2.74-12.82), and longer travel distances to specialized SCI centers.Conclusion: Perceived inadequateness of access to healthcare services was partly related to transportation barriers, suggesting that outreach services or support with transportation are possible solutions. People with incomplete paralysis and pain consistently rated the fulfillment of care needs associated with SCI less favorably, pointing to the need for enhanced advocacy for this vulnerable groups.

Reduction of corticosteroid use in outpatient treatment of exacerbated COPD - Study protocol for a randomized, double-blind, non-inferiority study, (The RECUT-trial)

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.

Advanced practice nurses' and general practitioners' first experiences with introducing the advanced practice nurse role to Swiss primary care: a qualitative study

BACKGROUND

Primary care is facing a multimorbid, ageing population and a lack of general practitioners (GPs), especially in rural areas. In many countries, advanced practice nurses (APNs) may be a potential solution for these challenges. Switzerland, however, is in the early stages of APN role development with a handful of pilot projects that are unresearched. Our aim was to explore the experiences of APNs and GPs involved in introducing the APN role to Swiss primary care.

METHODS

We organised two focus group discussions with APNs (n = 9) engaged in primary care across German-speaking Switzerland and individual interviews with APNs (n = 2) and GPs (n = 4) from two pilot projects in remote areas. Data analysis followed an exploratory hybrid approach of thematic analysis and was guided by the PEPPA Plus framework.

RESULTS

The analysis resulted in five main themes: The participants considered themselves pioneers developing a new model in primary care, seeking to shape and improve future health care ((1) pioneering spirit). Both nurses and doctors agreed on the additional value of the APN role, a role seen as having more time for and a different approach to patient care, bringing higher quality of care and flexibility to the practice ((2) added value from the APN role). Participants also emphasized the importance of asking for advice when unsure about diagnostic steps or appropriate treatment ((3) awareness of limited knowledge and skills). The main barriers identified included the impression that Swiss doctors have little knowledge about nurses in advanced roles ((4) GP's lack of knowledge regarding the APN role), and that further regulations will be important to foster role clarity and accountability ((5) political and legal obstacles in introducing the APN role).

CONCLUSIONS

The early phase of introducing APNs to Swiss primary care is characterised by heterogeneous, small-scale projects of pioneering GPs and APNs recognising the added value and limits of APNs despite a lack of governance and knowledge regarding the APN role among GPs. Experiences gained from ongoing projects provide elements of good practice for political discussions and regulations.

Communicating "cure" to pediatric oncology patients: A mixed-methods study

BACKGROUND

Uncertainty about cure puts childhood cancer survivors at risk of mental distress. We asked survivors if they had been told they had been cured and investigated associated factors.

PROCEDURE

We used nationwide registry data and a questionnaire survey for ≥five-year survivors of childhood cancer (n = 301), followed by online focus groups with a purposive sample of Swiss pediatric oncologists (n = 17). Discussions were coded by investigators using thematic analysis.

RESULTS

Overall, 235 among 301 survivors (78%; 95% confidence interval, 73%-83%) reported having been told they were cured. The proportion was 89% (81%-97%) among lymphoma and 84% (77%-91%) among leukemia survivors, but only 49% (33%-65%) among central nervous system tumor survivors. Pediatric oncologists acknowledged that telling survivors they are cured may reassure them that their cancer lies behind them. However, many refrained from telling all patients. Reasons included the possibility of late effects (cure disrupted by a continued need for follow-up care) or late relapse (uncertainty of biological cure), case-by-case strategies (use of "cure" according to individual factors), and reluctance (substitution of noncommittal terms for "cure"; waiting for the patient to raise the topic).

CONCLUSIONS

Not all physicians tell survivors they have been cured; their choices depend on the cancer type and risk of late effects.

General practitioners' attitudes towards early diagnosis of dementia: a cross-sectional survey

BACKGROUND

Dementia is often underdiagnosed in general practice, which may be based on general practitioners' (GPs') knowledge and emotional factors as well as external problems. This study aimed to describe GPs' attitudes toward early diagnosis of dementia.

METHODS

Cross-sectional postal survey in Switzerland in 2017. Members of the Swiss Association of General Practitioners (N = 4460) were asked to participate in the survey. The questionnaire assessed attitudes, enablers and barriers to early dementia diagnosis and post-diagnostic intervention strategies. Exploratory factor analysis and linear regression were used.

RESULTS

The survey response rate was 21%. 85% of GPs agreed with enablers of early dementia recognition (e.g. "Plan for the future, organize support and care", "Minimize the strain and insecurity of patients and their informal family caregivers"). On the other hand, 15% of respondents perceived barriers towards early dementia recognition (e.g. "Time constraints in carrying out the necessary procedures to diagnose dementia"). GPs who were more likely to agree with barriers would less often counsel family members (β = - 0.05, 95% CI = - 0.09 - -0.02) or test fitness to drive (β = - 0.05, 95% CI = - 0.09 - -0.02), and more often choose a watchful waiting strategy (β = 0.05, 95% CI = 0.02-0.09).

CONCLUSIONS

The attitude of the majority of GPs is not characterized by diagnostic and therapeutic nihilism. However, negative attitudes were associated with sub-optimal management after the diagnosis. Thus, health systems are required to critically examine the use of available resources allowing GPs to look after patients and their relatives in a holistic way.

Communication Skills Training for Professionals Working with Adolescent Patients with Cancer Based on Participants' Needs: A Pilot

Purpose: We aimed to pilot and evaluate communication skills training (CST) for health care professionals (HCPs) interacting with adolescent patients with cancer and their parents based on participants' needs. Methods: We developed and piloted a 2-day CST with physicians and nurses in adolescent oncology. The CST's agenda was determined by the critical incidents reported by the participants. Training consisted of experiential learning based on role-play between HCPs and simulated patients and parents. Whenever suited, short lectures were given on specific communication techniques. Skills were self-assessed by questionnaires before, immediately after, and 6 months after training. We compared the proportion of participants who felt confident in 19 predefined areas of difficult communication before and 6 months after training. Responses to open-ended questions were analyzed qualitatively by thematic analysis. Results: Twenty-six physicians and 24 nurses participated in 6 CSTs. The proportion of participants who felt confident increased significantly in 6 of 19 communication items (p < 0.05). Positive feedback outweighed negative in quantity and quality. Predominant themes immediately after training were the training's practical orientation and intensity, and 6 months later, increased self-confidence and applied communication techniques. Participants noted that the effect diminishes with time, and expressed their need for booster trainings. Conclusion: The results of CST tailored to the specific needs of HCPs in adolescent oncology were promising. We suggest that similar training opportunities are implemented elsewhere.

Early diagnosis and management of dementia in general practice - how do Swiss GPs meet the challenge?

INTRODUCTION

In general practice, the diagnosis of dementia is often delayed. Therefore, the Swiss National Dementia Strategy 2014 concluded that action was needed to improve patient care. Little is known about GPs&rsquo; confidence in and approach to the diagnosis, disclosure and post-diagnostic management of individuals with dementia in Switzerland. The aim of this survey is to assess these elements of dementia care and GPs&rsquo; views on the adequacy of health care services regarding dementia.

MATERIALS AND METHODS

Cross-sectional postal survey in Switzerland in 2017 supported by all academic institutes of general practice in Swiss universities. Members of the Swiss Association of General Practitioners (n = 4460) were asked to participate in the survey. In addition to the GPs&rsquo; demographic characteristics, the survey addressed the following issues: GPs&rsquo; views on the adequacy of health care services, clinical approach and confidence in the management of dementia.

RESULTS

The survey response rate was 21%. The majority of GPs (64%) felt confident diagnosing dementia, but not in patients with a migration background (15%). For neuropsychological testing, three-quarters of GPs collaborated with memory clinics and were satisfied with the access to diagnostic services. At the time of first diagnosis, 62% of GPs diagnosed the majority of their patients with a mild stage of dementia, and 31% with a mild cognitive impairment. The most frequent actions taken by GPs after the diagnosis of mild dementia were giving advice to relatives (71%), testing fitness-to-drive (66%) and minimising cardiovascular risk factors (63%). While 65% of GPs felt confident taking care of patients with dementia, fewer (53%) felt confident in pharmacological treatment, coping with suicidal ideation (44%) or caring for patients with a migration background (16%). Half of GPs preferred to delegate the assessment of fitness-to-drive to an official authority. One in four GPs was not satisfied with the local provision of care and support facilities for patients with dementia.

CONCLUSIONS

Overall, GPs reported confidence in establishing a diagnosis of dementia and sufficient access to diagnostic services. Post-diagnostic management primarily focused on counselling and harm reduction rather than pharmacological treatment. Future educational support for GPs should be developed, concentrating on coping with their patients&rsquo; suicidal ideation and caring for patients with a migration background.

Improving Communication in Adolescent Cancer Care: A Multiperspective Study

BACKGROUND

Professionals treating adolescents with cancer must communicate well with them and their parents. Evidence suggests that the communication needs of this population are rarely met. Skills training can improve professional communication, but has been criticized for not being based on the experience of the participants in the clinical encounter. We took a multiperspective approach, drawing on perspectives of former adolescents with cancer, patients' parents, physicians, and nurses with the aim to provide suggestions for improvement in communication in adolescent cancer care.

METHODS

Adolescent cancer survivors (n = 16), parents (n = 8), pediatric oncologists (n = 12), and pediatric oncology nurses (n = 18) participated in 11 focus groups. They discussed their experiences communicating with each other. Transcripts were analyzed by thematic analysis.

RESULTS

We identified themes within the following sections: (1) The framework in which professionals communicate with adolescents with cancer (regression in a time of detachment, adolescents' perception and knowledge of illness, cognitive versus legal maturity, "lost in transition" between pediatric and adult oncology); (2) communication difficulties between professionals and patients and parents (professionals and patients/parents identified the other party as the source of difficulties), and (3) effective professional communication (there was some overlap on how doctors and nurses should communicate, along with substantially different expectations for the two professions).

CONCLUSIONS

The framework within which professionals communicate, the different perspectives on the factors that make communication difficult, and the different expectations regarding good communication by doctors and nurses should be considered when communication skills training courses are developed for professionals who work in adolescent oncology.

Vitamin D Deficiency in Unselected Patients from Swiss Primary Care: A Cross-Sectional Study in Two Seasons

Background

As published data on 25-hydroxy-cholecalciferol (25(OH)D) deficiency in primary care settings is scarce, we assessed the prevalence of hypovitaminosis D, potential associations with clinical symptoms, body mass index, age, Vitamin D intake, and skin type in unselected patients from primary care, and the extent of seasonal variations of serum 25(OH)D concentrations.

Methodology/Principal Findings

25(OH)D was measured at the end of summer and/or winter in 1682 consecutive patients from primary care using an enzyme-linked immunosorbant assay. Clinical symptoms were assessed by self-report (visual analogue scale 0 to 10), and vitamin D deficiency was defined as 25(OH)D concentrations < 50 nmol/l. 25(OH)D deficiency was present in 995 (59.2%) patients. 25(OH)D deficient patients reported more intense muscle weakness (visual analogue scale 2.7, 95% confidence interval 2.5 to 2.9) and had a higher body mass index (25.9kg/m², 25.5 to 26.2) than non-deficient patients (2.5, 2.3 to 2.7; and 24.2, 23.9 to 24.5, respectively). 25(OH)D concentrations also weakly correlated with muscle weakness (Spearman’s rho -0.059, 95% confidence interval -0.107 to -0.011) and body mass index (-0.156, -0.202 to -0.108). Self-reported musculoskeletal pain, fatigue, and age were not associated with deficiency, nor with concentrations. Mean 25(OH)D concentrations in patients with vitamin D containing medication were higher (60.6 ± 22.2 nmol/l) than in patients without medication (44.8 ± 19.2 nmol/l, p < 0.0001) but still below the targeted level of 75 nmol/l. Summer and winter 25(OH)D concentrations differed (53.4 ± 19.9 vs. 41.6 ± 19.3nmol/l, p < 0.0001), which was confirmed in a subgroup of 93 patients who were tested in both seasons (p = 0.01).

Conclusion/Significance

Nearly 60% of unselected patients from primary care met the criteria for 25(OH)D deficiency. Self-reported muscle weakness and high body mass index were associated with lower 25(OH)D levels. As expected 25(OH)D concentrations were lower in winter compared to summer.

Risk Behavior and Reciprocity of Organ Donation Attitudes in Young Men

BACKGROUND

Lack of donor organs remains a major obstacle in organ transplantation. Our aim was to evaluate (1) the association between engaging in high-risk recreational activities and attitudes toward organ donation and (2) the degree of reciprocity between organ acceptance and donation willingness in young men.

METHODS

A 17-item, close-ended survey was offered to male conscripts ages 18 to 26 years in all Swiss military conscription centers. Predictors of organ donation attitudes were assessed in bivariate analyses and multiple logistic regression. Reciprocity of the intentions to accept and to donate organs was assessed by means of donor card status.

RESULTS

In 1559 responses analyzed, neither motorcycling nor practicing extreme sports reached significant association with donor card holder status. Family communication about organ donation, student, or academic profession and living in a Latin linguistic region were predictors of positive organ donation attitudes, whereas residence in a German-speaking region and practicing any religion predicted reluctance. Significantly more respondents were willing to accept than to donate organs, especially among those without family communication concerning organ donation.

CONCLUSIONS

For the first time, it was shown that high-risk recreational activities do not influence organ donation attitudes. Second, a considerable discrepancy in organ donation reciprocity was identified. We propose that increasing this reciprocity could eventually increase organ donation rates.

Survivorship after childhood cancer: PanCare: a European Network to promote optimal long-term care

Survival after childhood cancer has improved substantially over recent decades. Although cancer in childhood is rare increasingly effective treatments have led to a growing number of long-term survivors. It is estimated that there are between 300,000 and 500,000 childhood cancer survivors in Europe. Such good survival prospects raise important questions relating to late effects of treatment for cancer. Research has shown that the majority will suffer adverse health outcomes and premature mortality compared with the general population. While chronic health conditions are common among childhood cancer survivors, each specific type of late effect is very rare. Long-term effects must be considered particularly when addressing complex multimodality treatments, and taking into account the interaction between aspects of treatment and genotype. The PanCare Network was set up across Europe in order to effectively answer many of these questions and thereby improve the care and quality of life of survivors. The need for a structured long-term follow-up system after childhood cancer has been recognised for some time and strategies for implementation have been developed, first nationally and then trans-nationally, across Europe. Since its first meeting in Lund in 2008, the goal of the PanCare Network has been to coordinate and implement these strategies to ensure that every European survivor of childhood and adolescent cancer receives optimal long-term care. This paper will outline the structure and work of the PanCare Network, including the results of several European surveys, the start of two EU-funded projects and interactions with relevant stakeholders and related projects.

Concentration, working speed and memory: cognitive problems in young childhood cancer survivors and their siblings

BACKGROUND

Cognitive problems can have a negative effect on a person's education, but little is known about cognitive problems in young childhood cancer survivors (survivors). This study compared cognitive problems between survivors and their siblings, determined if cognitive problems decreased during recent treatment periods and identified characteristics associated with the presence of a cognitive problem in survivors.

METHODS

As part of the Swiss Childhood Cancer Survivor Study, a questionnaire was sent to all survivors, aged 8-20 years, registered in the Swiss Childhood Cancer Registry, diagnosed at age <16 years, who had survived ≥ 5 years. Parent-reported (aged 8-15 years) and self-reported (aged 16-20 years) cognitive problems (concentration, working speed, memory) were compared between survivors and siblings. Multivariable logistic regression was used to identify characteristics associated with cognitive problems in survivors.

RESULTS

Data from 840 survivors and 247 siblings were analyzed. More often than their siblings, survivors reported problems with concentration (12% vs. 6%; P = 0.020), slow working speed (20% vs. 8%; P = 0.001) or memory (33% vs. 15%; P < 0.001). Survivors from all treatment periods were more likely to report a cognitive problem than were siblings. Survivors of CNS tumors (OR = 2.82 compared to leukemia survivors, P < 0.001) and those who had received cranial irradiation (OR = 2.10, P = 0.010) were most severely affected.

CONCLUSION

Childhood cancer survivors, even those treated recently (2001-2005), remain at risk to develop cognitive problems, suggesting a need to improve therapies. Survivors with cognitive problems should be given the opportunity to enter special education programs.

Risk of late effects of treatment in children newly diagnosed with standard-risk acute lymphoblastic leukaemia: a report from the Childhood Cancer Survivor Study cohort

BACKGROUND

Treatment of patients with paediatric acute lymphoblastic leukaemia has evolved such that the risk of late effects in survivors treated in accordance with contemporary protocols could be different from that noted in those treated decades ago. We aimed to estimate the risk of late effects in children with standard-risk acute lymphoblastic leukaemia treated with contemporary protocols.

METHODS

We used data from similarly treated members of the Childhood Cancer Survivor Study cohort. The Childhood Cancer Survivor Study is a multicentre, North American study of 5-year survivors of childhood cancer diagnosed between 1970 and 1986. We included cohort members if they were aged 1·0-9·9 years at the time of diagnosis of acute lymphoblastic leukaemia and had received treatment consistent with contemporary standard-risk protocols for acute lymphoblastic leukaemia. We calculated mortality rates and standardised mortality ratios, stratified by sex and survival time, after diagnosis of acute lymphoblastic leukaemia. We calculated standardised incidence ratios and absolute excess risk for subsequent neoplasms with age-specific, sex-specific, and calendar-year-specific rates from the Surveillance, Epidemiology and End Results Program. Outcomes were compared with a sibling cohort and the general US population.

FINDINGS

We included 556 (13%) of 4329 cohort members treated for acute lymphoblastic leukaemia. Median follow-up of the survivors from 5 years after diagnosis was 18·4 years (range 0·0-33·0). 28 (5%) of 556 participants had died (standardised mortality ratio 3·5, 95% CI 2·3-5·0). 16 (57%) deaths were due to causes other than recurrence of acute lymphoblastic leukaemia. Six (1%) survivors developed a subsequent malignant neoplasm (standardised incidence ratio 2·6, 95% CI 1·0-5·7). 107 participants (95% CI 81-193) in each group would need to be followed-up for 1 year to observe one extra chronic health disorder in the survivor group compared with the sibling group. 415 participants (376-939) in each group would need to be followed-up for 1 year to observe one extra severe, life-threatening, or fatal disorder in the group of survivors. Survivors did not differ from siblings in their educational attainment, rate of marriage, or independent living.

INTERPRETATION

The prevalence of adverse long-term outcomes in children treated for standard risk acute lymphoblastic leukaemia according to contemporary protocols is low, but regular care from a knowledgeable primary-care practitioner is warranted.

FUNDING

National Cancer Institute, American Lebanese-Syrian Associated Charities, Swiss Cancer Research.

Life partnerships in childhood cancer survivors, their siblings, and the general population

BACKGROUND

Life partnerships other than marriage are rarely studied in childhood cancer survivors (CCS). We aimed (1) to describe life partnership and marriage in CCS and compare them to life partnerships in siblings and the general population; and (2) to identify socio-demographic and cancer-related factors associated with life partnership and marriage.

METHODS

As part of the Swiss Childhood Cancer Survivor Study (SCCSS), a questionnaire was sent to all CCS (aged 20-40 years) registered in the Swiss Childhood Cancer Registry (SCCR), aged <16 years at diagnosis, who had survived ≥ 5 years. The proportion with life partner or married was compared between CSS and siblings and participants in the Swiss Health Survey (SHS). Multivariable logistic regression was used to identify factors associated with life partnership or marriage.

RESULTS

We included 1,096 CCS of the SCCSS, 500 siblings and 5,593 participants of the SHS. Fewer CCS (47%) than siblings (61%, P < 0.001) had life partners, and fewer CCS were married (16%) than among the SHS population (26%, P > 0.001). Older (OR = 1.14, P < 0.001) and female CCS (OR = 1.85, <0.001) were more likely to have life partners. CCS who had undergone radiotherapy, bone marrow transplants (global P Treatment = 0.018) or who had a CNS diagnosis (global P Diagnosis < 0.001) were less likely to have life partners.

CONCLUSION

CCS are less likely to have life partners than their peers. Most CCS with a life partner were not married. Future research should focus on the effect of these disparities on the quality of life of CCS.

Information provision and information needs in adult survivors of childhood cancer

BACKGROUND

Knowledge about their past medical history is central for childhood cancer survivors to ensure informed decisions in their health management. Knowledge about information provision and information needs in this population is still scarce. We thus aimed to assess: (1) the information survivors reported to have received on disease, treatment, follow-up, and late effects; (2) their information needs in these four domains and the format in which they would like it provided; (3) the association with psychological distress and quality of life (QoL).

PROCEDURE

As part of the Follow-up survey of the Swiss Childhood Cancer Survivor Study, we sent a questionnaire to all survivors (≥18 years) who previously participated to the baseline survey, were diagnosed with cancer after 1990 at an age of <16 years.

RESULTS

Most survivors had received oral information only (on illness: oral: 82%, written: 38%, treatment: oral: 79%, written: 36%; follow-up: oral: 77%, written: 23%; late effects: oral: 68%, written: 14%). Most survivors who had not previously received any information rated it as important, especially information on late effects (71%). A large proportion of survivors reported current information needs and would like to receive personalized information especially on late effects (44%). Survivors with higher information needs reported higher psychological distress and lower QoL.

CONCLUSIONS

Survivors want to be more informed especially on possible late effects, and want to receive personalized information. Improving information provision, both qualitatively and quantitatively, will allow survivors to have better control of their health and to become better decision makers.

Incidence and treatment of developmental hip dysplasia in Mongolia: a prospective cohort study

Background

In Mongolia, adequate early diagnosis and treatment of developmental hip dysplasia (DDH) have been unavailable and its incidence was unknown. We determined the incidence of ultrasonographic DDH in newborns and established adequate procedures for diagnosis and treatment of DDH at the largest maternity hospital in Ulaanbaatar, Mongolia.

Methodology/Principal Findings

During one year (Sept 2010 – Aug 2011) we assessed the hips newborns using ultrasound and Graf’s classification of DDH. 8,356 newborns were screened; median age at screening was 1 day. We identified 14,873 Type 1 (89.0%), 1715 Type 2a (10.3%), 36 Type 2c (0.2%), 70 Type D (0.4%), 14 Type 3 (0.08%), and 4 Type 4 hips (0.02%). Children with Type 1 hips (normal) were discharged. Children with Type 2a hips (physiologically immature) received follow-up ultrasounds at monthly intervals. Children with Type 2c to 4 (DDH; deformed or misaligned hip joint) hips were treated with a Tubingen hip flexion splint and also followed up. The hip abnormalities resolved to mature hips in all children who were followed up. There was no evidence for severe treatment related complications.

Conclusion/Significance

This study suggests that the incidence of DDH in Mongolian neonates is comparable to that in neonates in Europe. Early ultrasound-based assessment and splinting treatment of DDH led to mature hips in all children followed up. Procedures are feasible and will be continued.

Estimated long-term outcomes in children newly diagnosed with standard risk acute lymphoblastic leukemia (ALL) based on similarly treated members of the childhood cancer survivor study (CCSS) cohort

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Background: Therapy for ALL has evolved such that the risk for late effects in children treated in early eras is likely different from those that will occur in children treated today. In order to estimate future risks for late effects in newly diagnosed children with standard risk ALL, we examined the long-term outcomes in a cohort of patients enrolled in the CCSS who were treated in a manner analogous to contemporary ALL therapies. Methods: We assessed outcomes that occurred ≥5 years from diagnosis in survivors of ALL enrolled in the CCSS who were aged 1-9.9 years at diagnosis, treated with 0-120 mg/m2 of anthracyclines and 0-1000 mg/m2 of alkylating agents, and no radiotherapy. We compared their risks for death, second malignant neoplasms (SMN), chronic physical health conditions and decreased health status with the general population (death and SMN) and the CCSS sibling cohort (remaining outcomes). Results: 556 survivors were eligible. At last assessment, they were a median of 27.8 years old (range 9.1 to 45.7) and 23.4 years (range 5.0-38.0) from diagnosis. 29/556 (5.2%) died (standardized mortality ratio 3.6, 95% CI 2.4-5.2); 12 of these deaths were due to ALL recurrence. Compared to siblings, the rate ratio for ≥1 chronic condition was 1.4 (95% CI 1.3-1.6), and for a severe/life threatening chronic condition was 1.7 (95% CI 1.3-2.3). Four survivors (0.7%) developed a SMN (standardized incidence ratio 1.7, 95% CI 0.5-4.5), 114 were obese (odds ratio (OR) 1.2, 95% CI 1.0-1.5), and 2 (0.4%) reported a stroke. No survivors reported symptomatic congestive heart failure. The OR for reporting adverse general health was 1.2 (95% CI 0.8-1.8), poor mental health 1.3 (95% CI 1.0-1.8), decreased functional status 2.1 (95% CI 1.4-3.0), and activity limitations 1.4 (95% CI 1.1-1.8). Conclusions: Children treated for standard risk ALL on contemporary protocols are at increased risk for future chronic health conditions and decreased health status. Despite excellent survival after leukemia therapy, such survivors will likely benefit from life-long medical care focused on the long-term risks stemming from their therapy.

Health-related quality of life in long-term survivors of relapsed childhood acute lymphoblastic leukemia

BACKGROUND

Relapses occur in about 20% of children with acute lymphoblastic leukemia (ALL). Approximately one-third of these children can be cured. Their risk for late effects is high because of intensified treatment, but their health-related quality of life (HRQOL) was largely unmeasured. Our aim was to compare HRQOL of ALL survivors with the general population, and of relapsed with non-relapsed ALL survivors.

METHODOLOGY/PRINCIPAL FINDINGS

As part of the Swiss Childhood Cancer Survivor Study (SCCSS) we sent a questionnaire to all ALL survivors in Switzerland who had been diagnosed between 1976-2003 at age <16 years, survived ≥5 years, and were currently aged ≥16 years. HRQOL was assessed with the Short Form-36 (SF-36), which measures four aspects of physical health and four aspects of mental health. A score of 50 corresponded to the mean of a healthy reference population. We analyzed data from 457 ALL survivors (response: 79%). Sixty-one survivors had suffered a relapse. Compared to the general population, ALL survivors reported similar or higher HRQOL scores on all scales. Survivors with a relapse scored lower in general health perceptions (51.6) compared to those without (55.8;p=0.005), but after adjusting for self-reported late effects, this difference disappeared.

CONCLUSION/SIGNIFICANCE

Compared to population norms, ALL survivors reported good HRQOL, even after a relapse. However, relapsed ALL survivors reported poorer general health than non-relapsed. Therefore, we encourage specialists to screen for poor general health in survivors after a relapse and, when appropriate, specifically seek and treat underlying late effects. This will help to improve patients' HRQOL.

Waveguides in three-dimensional photonic-bandgap materials by direct laser writing and silicon double inversion

Three-dimensional complete photonic-bandgap materials offer unique opportunities regarding the integration of optical waveguide architectures in three dimensions. However, corresponding experimental realizations are truly sparse. Here, we fabricate such waveguides using direct laser writing and a silicon double-inversion procedure. The optical characterization is in good agreement with theoretical calculations, raising hopes that even more complex architectures may soon come into reach.