Development of pharmaceutical care services in nursing homes: practice and research in a Swiss canton.

OBJECTIVE: The aim of this study was to assess the implementation process and economic impact of a new pharmaceutical care service provided since 2002 by pharmacists in Swiss nursing homes. SETTING: The setting was 42 nursing homes located in the canton of Fribourg, Switzerland under the responsibility of 22 pharmacists. METHOD: We developed different facilitators, such as a monitoring system, a coaching program, and a research project, to help pharmacists change their practice and to improve implementation of this new service. We evaluated the implementation rate of the service delivered in nursing homes. We assessed the economic impact of the service since its start in 2002 using statistical evaluation (Chow test) with retrospective analysis of the annual drug costs per resident over an 8-year period (1998-2005). MAIN OUTCOME MEASURES: The description of the facilitators and their implications in implementation of the service; the economic impact of the service since its start in 2002. RESULTS: In 2005, after a 4-year implementation period supported by the introduction of facilitators of practice change, all 42 nursing homes (2,214 residents) had implemented the pharmaceutical care service. The annual drug costs per resident decreased by about 16.4% between 2002 and 2005; this change proved to be highly significant. The performance of the pharmacists continuously improved using a specific coaching program including an annual expert comparative report, working groups, interdisciplinary continuing education symposia, and individual feedback. This research project also determined priorities to develop practice guidelines to prevent drug-related problems in nursing homes, especially in relation to the use of psychotropic drugs. CONCLUSION: The pharmaceutical care service was fully and successfully implemented in Fribourg's nursing homes within a period of 4 years. These findings highlight the importance of facilitators designed to assist pharmacists in the implementation of practice changes. The economic impact was confirmed on a large scale, and priorities for clinical and pharmacoeconomic research were identified in order to continue to improve the quality of integrated care for the elderly.

Hour of birth as a prognostic factor for perinatal death.

The analysis of the 220,540 births and 2152 perinatal deaths recorded in Switzerland between 1979 and 1981 showed a variation of perinatal mortality rates (PMR) according to the hour of birth. The PMR for babies born between 4 pm and 2 am was 12 per 1000, contrasting with a figure of 8.4 per 1000 for babies born between 2 am and 4 pm. This pattern, which was fairly constant throughout the week, was characterised by a slow and steady increase from the very early morning, reaching a maximum in the late evening. There was also an hour-to-hour variation in the proportion of babies born weighing less than 2500 g, with a maximum in the evening and a less pronounced peak in the morning: the mortality rates by birthweight were raised only in the evening. Since the availability of hospital staff and equipment also follows a circadian rhythm, the variation in PMR may be related to a circadian rhythm of quality of care or possibly to chronobiological or selection factors.

Health care workers' influenza vaccination: motivations and mandatory mask policy

BACKGROUND: Vaccination of health care workers (HCW) against seasonal influenza (SI) is recommended but vaccination rate rarely reach >30%. Vaccination coverage against 2009 pandemic influenza (PI) was 52% in our hospital, whilst a new policy requiring unvaccinated HCW to wear a mask during patient care duties was enforced. AIMS: To investigate the determinants of this higher vaccination acceptance for PI and to look for an association with the new mask-wearing policy. METHODS: A retrospective cohort study, involving HCW of three critical departments of a 1023-bed, tertiary-care university hospital in Switzerland. Self-reported 2009-10 SI and 2009 PI vaccination statuses, reasons and demographic data were collected through a literature-based questionnaire. Descriptive statistics, uni- and multivariate analyses were then performed. RESULTS: There were 472 respondents with a response rate of 54%. Self-reported vaccination acceptance was 64% for PI and 53% for SI. PI vaccination acceptance was associated with being vaccinated against SI (OR 9.5; 95% CI 5.5-16.4), being a physician (OR 7.7; 95% CI 3.1-19.1) and feeling uncomfortable wearing a mask (OR 1.7; 95% CI 1.0-2.8). Main motives for refusing vaccination were: preference for wearing a surgical mask (80% for PI, not applicable for SI) and concerns about vaccine safety (64%, 50%) and efficacy (44%, 35%). CONCLUSIONS: The new mask-wearing policy was a motivation for vaccination but also offered an alternative to non-compliant HCW. Concerns about vaccine safety and efficiency and self-interest of health care workers are still main determinants for influenza vaccination acceptance. Better incentives are needed to encourage vaccination amongst non-physician HCW.

Etendue des prestations de l'assurance-maladie sociale : le catalogue des prestations est- il suffisant pour que tous accèdent à des soins de qualité ?

Le projet "prestations de l'assurance-maladie sociale" est l'un des projets partiels élaborés par l'Office fédéral des assurances sociales (OFAS) dans le cadre de l'analyse des effets de la LAMal. Deux approches complémentaires sont adoptées pour répondre à la question du caractère suffisant du "catalogue" suisse des prestations à charge de l'assurance-maladie sociale: d'une part, la comparaison des "catalogues" des prestations remboursées en Suisse et à l'étranger et, d'autre part, l'examen de la couverture par le "catalogue" des prestations de problèmes de santé utilisés comme traceurs. [Table des matières] 1.1. Contexte. 1.2. Définition et limites du mandat. 1.3. Le "catalogue" des prestations : composition actuelle, participation d'autres assurances sociales et des pouvoirs publics. 1.4. Approches méthodologiques : comparaison internationale, étude de conditions-traceurs. 2. Analyse par comparaison internationale. 2.1. Recherche de documentation et collaborations. 2.2. Résultats : Suisse, France, Allemagne, Israël, Pays-Bas, Luxembourg, comparaison internationale des prestations générales, par catégorie, et des prestations spéciales. 3. Analyse par conditions traceurs. 3.1. Stratégie de la recherche documentaire. 3.2. Critères de choix des documents. 3.3. Variations méthodologiques et particularités. 3.4. Résultats : Accident vasculaire cérébral (ischémique), fracture de hanche, obésité, leucémie aigüe (LA), grossesse normale et nouveau-né en bonne santé. 3.5. Discussion.

Donner la parole aux médecins traitants [Letting the treating physicians speak].

OBJECTIVE: Quality assessment in consultation and liaison psychiatry (CLP) is extremely difficult and must take into account numerous factors. The general practitioner (GP) of the patients seen by CL psychiatrists seems an essential factor to be considered in evaluating CL work. However, as far as we know, no study is doing so. Therefore, we have implied the GP to assess our CL work at the hospital St-Loup-Orbe. METHOD: We put up a qualitative study consisting of semi-structured interviews with 18 GPs caring for 45 patients having been submitted to a psychiatric CL intervention. Furthermore, we invited the GPs to assesses CLP as a specialization as well as CLP practiced at St-Loup-Orbe hospital. RESULTS: Impact is judged by the GPs with regard to the total number as: highly favorable> favorable> indifferent> negative. The GPs' critiques, whether positive or negative, are highly informative. CONCLUSIONS: GPs accept favorably CLP interventions and consider them on the whole as constructive. On the other hand, they are not sufficiently considered as partners during their patients' hospital stay. Furthermore, CLP must evaluate its impact at distance from the consultation and take into account the GPs' assessments to improve CL quality.

Que faire d'un stagiaire dans votre consultation [Tips for hosting a medical student in a PC consultation].

Hosting a medical student in one's primary care consultation challenges the practitioner to be a clinical teacher as well as providing high-quality patient care. A few tips can make this double task easier. Before the consultation it is possible to define the student's learning objectives and to plan the consultation. During the consultation itself some teaching models exist (One minute preceptor, SNAPP) that facilitate the teaching by maximising the teaching moments for each student-patient encounter. And finally after the consultation a time of reflection where both student and clinical teacher can think about what went well and what could be done better.

L'erreur en médecine ambulatoire: comment l'aborder. [Error in ambulatory medicine: how to deal with it?]

Medical errors compromise patient safety in ambulatory practice. These errors must be faced in a framework that reduces to a minimum their consequences for the patients. This approach relies on the implementation of a new culture without stigmatization and where errors are disclosed to the patients; this culture implies the build up of a system for reporting errors associated to an in-depth analysis of the system, looking for root causes and insufficient barriers with the aim to fix them. A useful education tool is the "critical situations" meeting during which physicians are encouraged to openly present adverse events and "near misses". Their analysis, with supportive attitude towards involved staff members, allows to reveal systems failures within the institution or the private practice.

Coronary artery disease screening in diabetic patients: how good is guideline adherence?

INTRODUCTION: Diabetic patients are at high risk for coronary artery disease (CAD), which is the leading cause of death in this population. The Swiss Society of Endocrinology-Diabetology (SSED) recommends CAD screening for diabetic patients with > or = 2 additional cardiovascular risk factors (CVRF), by stress echocardiography (SE) or myocardial perfusion imaging (MPI). The aim of this study was to assess the application of these guidelines and the treatment of CVRF in the diabetes outpatient clinics of the five Swiss University Hospitals. METHODS: The study was initiated in Lausanne and the study questionnaires were circulated to the endocrinologists of the five Swiss University Hospitals. Practitioners were asked to include consecutive patients attending the diabetes outpatient clinics over one month. Prevalence of CAD, screening methods for CAD, prevalence of CVRF, biological analyses over the last 6 months and medical therapy were recorded. RESULTS: A total of 302 subjects were included. The mean age was 53 +/- 14 years, 68% had type 2 diabetes, 27% type 1 and 5% other types. Among T2DM with > or = 2 CVRF, 45% were screened for CAD according to SSED guidelines. In T2DM 25% had blood pressure < or = 130/80 mm Hg, 15% a lipid profile within target, 23% HbA1c < or = 7.0%. Overall, 2% achieved all 3 targets. CONCLUSIONS: Only 45% of T2DM with > or = 2 CVRF were screened for CAD according to SSED guidelines and 2% of T2DM had proper control over all CVRF. Efforts are still necessary to improve CAD prevention and screening of diabetic patients in Swiss University Hospitals.

Mis à l'écart et laissé-pour-compte: l'adéquation dans l'article 32 de la LAMal (commentaire de l'article de Georg Marckmann: "Marktorientierung und Gerechtigkeit: Prinzipen im Widerspruch?")

Commentaire de: Marckmann G. Marktorientierung und Gerechtigkeit: Prinzipen im Widerspruch? SGBEbulletinSSEB 2010;(61):5-12.

Qualité et DRG : mariage impossible ?

Les DRG, Diagnosis Related Groups, sont une classification permettant de regrouper les hospitalisations de soins aigus en fonction des affections traitées et des coûts engendrés. Ils ont été développes dans les années 70 à l'université de Yale aux Etats-Unis par le professeur Robert Fetter dans le but de standardiser les clientèles hospitalières dans un objectif de contrôle qualité. En Suisse, le financement en APDRG a commencé comme un projet pilote à Lausanne en 2002. Ce dernier a été repris du système déjà introduit aux Etat-Unis. Le 18 janvier 2008, la Suisse a décidé de passer à un financement en DRG au niveau national. La société anonyme SwissDRG a ainsi vu le jour en se basant sur Les G-DRG (=DRG allemand). Le coeur de ce mémoire consiste à déterminer si l'introduction des DRG ne causera pas une perte de qualité dans le système de soins. Afin de répondre à cette question, nous nous sommes basés sur l'expérience des autres pays notamment celle des Etats-Unis. L'étude réalisée par Kahn va être souvent prise en exemple. Les points forts qui en ressortent sont une augmentation de la sévérité des admissions, une baisse de la durée moyenne de séjour, une mortalité inchangée, ainsi que l'augmentation de l'état de santé instable à la sortie de l'hôpital. Ce qui ressort également dans l'ensemble des études documentées dans ce travail, c'est l'augmentation de l'efficience des hôpitaux et le risque qu'il y ait une sélection inverse des patients. [Auteur, p. 10]

Assessment of needs, health-related quality of life, and satisfaction with care in breast cancer patients to better target supportive care.

BACKGROUND: This study assessed whether breast cancer (BC) patients express similar levels of needs for equivalent severity of symptoms, functioning difficulties, or degrees of satisfaction with care aspects. BC patients who did (or not) report needs in spite of similar difficulties were identified among their sociodemographic or clinical characteristics. PATIENTS AND METHODS: Three hundred and eighty-four (73% response rate) BC patients recruited in ambulatory or surgery hospital services completed the European Organisation for Research and Treatment of Cancer Quality of Life questionnaire (EORTC QLQ)-C30 quality of life [health-related quality of life (HRQOL)], the EORTC IN-PATSAT32 (in-patient) or OUT-PATSAT35 (out-patient) satisfaction with care, and the supportive care needs survey short form 34-item (SCNS-SF34) measures. RESULTS: HRQOL or satisfaction with care scale scores explained 41%, 45%, 40% and 22% of variance in, respectively, psychological, physical/daily living needs, information/health system, and care/support needs (P < 0.001). BC patients' education level, having children, hospital service attendance, and anxiety/depression levels significantly predicted differences in psychological needs relative to corresponding difficulties (adjusted R(2) = 0.11). Medical history and anxiety/depression levels significantly predicted differences in information/health system needs relative to degrees of satisfaction with doctors, nurses, or radiotherapy technicians and general satisfaction (adjusted R(2) = 0.12). Unmet needs were most prevalent in the psychological domains across hospital services. CONCLUSIONS: Assessment of needs, HRQOL, and satisfaction with care highlights the subgroups of BC patients requiring better supportive care targeting.