Implications of diagnosis related groups (DRGs) for the management of hospitals.

Although tremendous advances have been made in the diagnosis and treatment of patients, hospital administrative systems have progressed relatively slowly. The types of information available to managers in industrial sectors are not available in the health sector. For this reason, many phenomena, such as the variations of average costs and lengths of stay between different hospitals, have remained poorly explained.The DRG system defines groups of patients that consume relatively homogeneous quantities of hospital resources. On the basis, it is possible to standardize average lengths of stay and average hospital costs in terms of the differences in case mix treated. Thus DRGs can serve as an explanation of variations in these factors between different hospitals, and also (but not only) for prospective reimbursement schems. As in a number of other European countries, a project has been set up in Switzerland to examine the possibilities of using DRGs in hospital management, planning and financing.

The future of longevity: background and perspectives

In many developed countries, including Switzerland, the ongoing increase in life expectancy is driven by the mortality decline among older persons. This has important consequences for both the provision of health care and the management of pension funds. In this context, the Swiss Federal Office of Statistics mandated a small group of experts to provide a critical review on the future evolution of mortality in developed countries. The report starts with an analysis of the past trends in life expectancy. Longevity is defined here as the duration (or the length) of life as observed in population or in individuals. The oldest and still most used indicators of longevity are life expectancy at birth (LE0) at a population level, and maximum life span (MLS) at the individual level (page 9) and in healthy life expectancy (page 19). A discussion on the future evolution of mortality and health is then presented (page 27). A set of recommendations is finally proposed (page 39).

Prevalence of cardiovascular risk factors in a middle-income country and estimated cost of a treatment strategy.

BACKGROUND: We assessed the prevalence of risk factors for cardiovascular disease (CVD) in a middle-income country in rapid epidemiological transition and estimated direct costs for treating all individuals at increased cardiovascular risk, i.e. following the so-called "high risk strategy". METHODS: Survey of risk factors using an age- and sex-stratified random sample of the population of Seychelles aged 25-64 in 2004. Assessment of CVD risk and treatment modalities were in line with international guidelines. Costs are expressed as USD per capita per year. RESULTS: 1255 persons took part in the survey (participation rate of 80.2%). Prevalence of main risk factors was: 39.6% for high blood pressure (> or =140/90 mmHg or treatment) of which 59% were under treatment; 24.2% for high cholesterol (> or =6.2 mmol/l); 20.8% for low HDL-cholesterol (<1.0 mmol/l); 9.3% for diabetes (fasting glucose > or =7.0 mmol/l); 17.5% for smoking; 25.1% for obesity (body mass index > or =30 kg/m2) and 22.1% for the metabolic syndrome. Overall, 43% had HBP, high cholesterol or diabetes and substantially increased CVD risk. The cost for medications needed to treat all high-risk individuals amounted to USD 45.6, i.e. 11.2 dollars for high blood pressure, 3.8 dollars for diabetes, and 30.6 dollars for dyslipidemia (using generic drugs except for hypercholesterolemia). Cost for minimal follow-up medical care and laboratory tests amounted to 22.6 dollars. CONCLUSION: High prevalence of major risk factors was found in a rapidly developing country and costs for treatment needed to reduce risk factors in all high-risk individuals exceeded resources generally available in low or middle income countries. Our findings emphasize the need for affordable cost-effective treatment strategies and the critical importance of population strategies aimed at reducing risk factors in the entire population.

Prévention des maladies et promotion de la santé: propositions pour une stratégie vaudoise

Ce document présente un plan de prévention pour le Canton de Vaud (version octobre 2007). Ce plan concentre ses efforts sur la prévention de quelques maladies (infarctus du myocarde, accident vasculaire cérébral, diabète, cancer colorectal, cancer du sein, cancer du poumon, dépression, fracture ostéoporotique), à l'aide d'un nombre restreint d'interventions (améliorer l'alimentation et augmenter l'activité physique, lutte contre le tabagisme, prévention primaire et secondaire de la maladie athéromateuse, prévention secondaire du cancer colorectal, prévention secondaire du cancer du sein, prévention secondaire de la dépression). Après la présentation de quelques enjeux de ce plan, le rapport conclut sur trois recommandations portant sur les structures de la prévention des maladies et de promotion de la santé, le monitorage des activités de prévention des maladies et de promotion de la santé et enfin sur le mandat et l'organisation de la Commission cantonale de prévention.

Opinions on smoking policies in Switzerland

Purpose: to assess the opinions regarding smoking ban policies in Switzerland. Methods: cross sectional study on 2,601 women and 2,398 men, aged 35-75 years, living in Lausanne, Switzerland. Nine questions on smoking policies (restrictions, advertising, taxes and prevention) were applied. Results: 95% of responders supported policies that would help smokers to quit, 92% supported no selling of tobacco to subjects aged less than 16 years, 87% a smoking ban in public places and 86% a national campaign against smoking. A further 77% supported a total ban on tobacco advertising, 74% the reimbursement of nicotine replacement therapies and 70% increasing the price of cigarettes. Conversely, a lower support was found for a total ban of tobacco sales (35%) or the promotion of light cigarettes (22%). Multivariate analysis showed that women, lower educational level, older age, being physically active or non-smoker were associated with tougher policies against tobacco, whereas current drinking or smoking and higher educational level were associated with lower levels of support. Conclusion: opinions regarding smoking poli ci es vary considerably according to the policy type considered and also the characteristics of the subjects. Those findings provide interesting data regarding which anti-smoking policies would be more acceptable by the lay public, as well as the subjects who might oppose them.

Recensement des patients dans les hôpitaux, cliniques, établissements spécialisés et homes valaisans : résultats d'une enquête en 1985

Sur mandat du Conseil d'Etat valaisan, l'Institut universitaire de médecine sociale et préventive a réalisé une étude sur les patients hospitalisés dans les établissements de soins valaisans en automne 1985. L'objectif de cette étude, organisée sous forme d'un recensement, était principalement d'étudier l'adéquation du lieu d'hospitalisation par rapport à l'état du patient; cette question a été directement posée au médecin traitant. Plusieurs autres renseignements démographiques et médicaux ont été relevés lors de cette enquête. Celle-ci a porté sur 26 établissements fournissant des prestations de soins aigus, chroniques et d'hébergement (lits d'infirmerie des homes); il s'agissait des soins somatiques aussi bien que psychiatriques. Cela représente un total de 2771 lits... [Auteurs]

Not all inflammatory markers are linked to kidney function: results from a population-based study.

BACKGROUND: Several studies have reported increased levels of inflammatory biomarkers in chronic kidney disease (CKD), but data from the general population are sparse. In this study, we assessed levels of the inflammatory markers C-reactive protein (hsCRP), tumor necrosis factor α (TNF-α), interleukin (IL)-1β and IL-6 across all ranges of renal function. METHODS: We conducted a cross-sectional study in a random sample of 6,184 Caucasian subjects aged 35-75 years in Lausanne, Switzerland. Serum levels of hsCRP, TNF-α, IL-6, and IL-1β were measured in 6,067 participants (98.1%); serum creatinine-based estimated glomerular filtration rate (eGFR(creat), CKD-EPI formula) was used to assess renal function, and albumin/creatinine ratio on spot morning urine to assess microalbuminuria (MAU). RESULTS: Higher serum levels of IL-6, TNF-α and hsCRP and lower levels of IL-1β were associated with a lower renal function, CKD (eGFR(creat) <60 ml/min/1.73 m(2); n = 283), and MAU (n = 583). In multivariate linear regression analysis adjusted for age, sex, hypertension, smoking, diabetes, body mass index, lipids, antihypertensive and hypolipemic therapy, only log-transformed TNF-α remained independently associated with lower renal function (β -0.54 ±0.19). In multivariate logistic regression analysis, higher TNF-α levels were associated with CKD (OR 1.17; 95% CI 1.01-1.35), whereas higher levels of IL-6 (OR 1.09; 95% CI 1.02-1.16) and hsCRP (OR 1.21; 95% CI 1.10-1.32) were associated with MAU. CONCLUSION: We did not confirm a significant association between renal function and IL-6, IL-1β and hsCRP in the general population. However, our results demonstrate a significant association between TNF-α and renal function, suggesting a potential link between inflammation and the development of CKD. These data also confirm the association between MAU and inflammation.

Is the obesity epidemic exaggerated? Clues from a developing country

Rapid response to: Patrick Basham and John Luik. Is the obesity epidemic exaggerated? Yes. BMJ 2008; 336: 244. doi: 10.1136/bmj.39458.495127.AD

Risk factors of stroke mortality in the African region: a cohort study

Background: Population-based cohort studies of risk factors of stroke are scarce in developing countries and none has been done in the African region. We conducted a longitudinal study in the Seychelles (Indian Ocean, east of Kenya), a middle-income island state where the majority of the population is of African descent. Such data in Africa are important for international comparison and for advocacy in the region. Methods: Three examination surveys of cardiovascular risk factors were performed in independent samples representative of the general population aged 25-64 in 1989, 1994 and 2004 (n=1081, 1067, and 1255, respectively). Baseline risk factors data were linked with cause-specific mortality from vital statistics up to May 2007 (all deaths are medically certified in the Seychelles and kept in an electronic database). We considered stroke (any type) as a cause of death if the diagnosis was reported in any of the 4 fields in the death certificates for underlying and concomitant causes of death. Results. Among the 2479 persons aged 35-64 at baseline, 280 died including 56 with stroke during follow up (maximum: 18.2 years; mean: 10.2 years). In this age range, age-adjusted mortality rates (/100'000/year) were 969 for all cause and 187 for stroke; age-adjusted prevalence of high blood pressure (≥140/90 mmHg) was 48%. In multivariate Cox survival time regression, stroke mortality was increased by 18% and 35% for a 10-mmHg increase in systolic, respectively diastolic BP (p<0.001). Stroke mortality was also associated with age, smoking ≥5 cigarettes vs. no smoking (HR: 2.4; 95% CI: 1.2-4.8) and diabetes (HR: 1.9; 1.02-3.6) but not with sex, LDL-cholesterol intake, alcohol intake and professional occupation. Conclusion. This first population-based cohort study in the African region demonstrates high mortality rates from stroke in middle-aged adults and confirms associations with high BP and other risk factors. This emphasizes the importance of reducing BP and other modifiable risk factors in high risk individuals and in the general population as a main strategy to reduce the burden of stroke.