Taking care of the most vulnerable : a descriptive study of patients with 12 attendances or more at a Swiss university hospital emergency department in 2009

Introduction: Patients who repeatedly attend the Emergency Department (ED) often have a distinct and complex vulnerability profile that includes poor somatic, psychological, and social indicators. This profile has an impact on the patients' well-being as well as on hospital costs. The objective of the study was to specify the characteristics of hyper users (HU) and explore the connection with ED care and hospital costs. Methods: The study sample comprised all adult patients with 12 or more attendances at the ED of the Lausanne University Hospital in 2009. The data were collected by retrospectively searching internal databases to identify the patients concerned and then analysing the profiles of these patients. Information gathered included demographic, somatic, psychological, at-risk behaviour, and social indicators, and health system consumption including costs. Results: In 2009, 23 patients (0.1%) attended 12 times or more (425 attendances, 0.8%). The average age was about 43 years, 60.9% were female, and 47.8% single. Of these 95.7% had basic insurance, 87.0% had a general practitioner, and 30.4% were under legal guardianship. The majority attended in the evening or at night (67.1%), and almost one quarter of these attendances resulted in inpatient treatment (24.0%). Most HU had attended the ED in previous years too (95.7% in 2008). The most prevalent diagnoses concerned 'mental disorders' (87.0%). About 30.4% of patients had attempted suicide (all were female patients). Other frequent diagnoses concerned 'trauma' (65.2%), and the 'digestive' and the 'nervous system' (each 56.5%). At-risk behaviour such as severe alcohol consumption (34.8%), or excessive use of medicines (26.1%) was very frequent, and some patients used illicit drugs (21.7%). There was only a weak association between the number of ED attendances and the resulting costs. However, a reduction of one outpatient visit per patient would have decreased ED outpatient costs by 8.5%. Conclusions: HU often have a particularly vulnerable profile. Mental problems are prevalent among them, as are at-risk behaviour and severe somatic conditions. The complexity of the patients' profiles demands specific care that cannot be guaranteed within an everyday ED routine. The use of an interdisciplinary case management team might be a promising approach in diminishing the number of attendances and the associated costs, although the profiles of HU are such that they probably cannot completely give up ED attendance.

Comparability of health care responsiveness in Europe

The aim of this paper is to measure and to correct for the potential incomparability of responses to the SHARE survey on health care responsiveness. A parametric approach based on the use of anchoring vignettes is applied to cross-sectional data (2006-2007) in eleven European countries. More than 7,000 respondents aged 50 years old and over were asked to assess the quality of health care responsiveness in three domains: waiting time for medical treatment, quality of the conditions in visited health facilities, and communication and involvement in decisions about the treatment. Our results suggest that there is reporting heterogeneity across countries and across individuals within countries, and the degree of heterogeneity varies with the health care domain. Although leading countries in terms of health care responsiveness remain among the most successful even after correction for reporting heterogeneity, one may acknowledge many shifts in the ranking of the other countries.

SocialPosition : Social Position Indicators Construction Toolbox

This R package provides to sociologists (and related scientists) a toolbox to facilitate the construction of social position indicators from survey data. Social position indicators refer to what is commonly known as social class and social status. There exists in the sociological literature many theoretical conceptualisation and empirical operationalization of social class and social status. This first version of the package offers tools to construct the International Socio-Economic Index of Occupational Status (ISEI) and the Oesch social class schema. It also provides tools to convert several occupational classifications (PCS82, PCS03, and ISCO08) into a common one (ISCO88) to facilitate data harmonisation work, and tools to collapse (i.e. group) modalities of social position indicators.

Socioeconomic status, structural and functional measures of social support, and mortality: The British Whitehall II Cohort Study, 1985-2009.

The authors examined the associations of social support with socioeconomic status (SES) and with mortality, as well as how SES differences in social support might account for SES differences in mortality. Analyses were based on 9,333 participants from the British Whitehall II Study cohort, a longitudinal cohort established in 1985 among London-based civil servants who were 35-55 years of age at baseline. SES was assessed using participant's employment grades at baseline. Social support was assessed 3 times in the 24.4-year period during which participants were monitored for death. In men, marital status, and to a lesser extent network score (but not low perceived support or high negative aspects of close relationships), predicted both all-cause and cardiovascular mortality. Measures of social support were not associated with cancer mortality. Men in the lowest SES category had an increased risk of death compared with those in the highest category (for all-cause mortality, hazard ratio = 1.59, 95% confidence interval: 1.21, 2.08; for cardiovascular mortality, hazard ratio = 2.48, 95% confidence interval: 1.55, 3.92). Network score and marital status combined explained 27% (95% confidence interval: 14, 43) and 29% (95% confidence interval: 17, 52) of the associations between SES and all-cause and cardiovascular mortality, respectively. In women, there was no consistent association between social support indicators and mortality. The present study suggests that in men, social isolation is not only an important risk factor for mortality but is also likely to contribute to differences in mortality by SES.

When Cooperation Stumbles: the effects of grades on indicators of cooperation

(English Abstract) In western societies, grades are to date the most widespread means by which achievement and performance are assessed in educational contexts. Grades are used for their capacity to provide individuals with a clear indicator of success or failure, in particular in comparison to others; in this respect, we study their impact on particular work contexts requiring cooperation. Indeed, students are often exhorted to cooperate and work in groups, while at the same time assessed with grades and focused on inter-individual comparison. However, to the best of our knowledge, no work has investigated the effects of grades on cooperation and on indicators of cooperation, a central question to be addressed given its significance for educational trends encouraging cooperative practices, and which we propose to explore in the experimental parts of this thesis. The first experimental chapter, Chapter 4, investigates the effect of grades with regards to their capacity to highlight individual visibility and at the same time social comparison. It tries to disentangle which of these facets could affect a motivated bias likely to reduce cooperation, namely individuals' preference for information confirming their own choice. In two experiments, results showed that a graded-cooperative situation increased this preference effect in comparison to other conditions where only individual visibility was manipulated, and furthermore increased individuals' perception of a competitive atmosphere. Chapter 5 investigates the effect of grades on direct cooperative inter- individual interactions, namely on group information sharing. Two experiments showed that grades hindered informational communication between individuals, leading them to withhold crucial task-information. Finally, Chapter 6 investigates the effects of grades on another indicator of group cooperation, namely inter-individual coordination. Results indicated that showcasing grades at the onset of a cooperative task necessitating inter-individual coordination decreased group performance and elicited more negative dominant behaviours amongst participants. Together these results provide evidence that grades hamper group cooperation. We conclude by discussing implications for the practice of grading in Education. ------------------------------------------------------- (Résumé en langue française) Dans la plupart des pays occidentaux, les notes sont majoritairement utilisées pour évaluer la performance et rendre compte de la réussite scolaire des individus. Dans cette perspective, elles sont non seulement un indicateur de succès ou d'échec, mais aussi de la valeur comparative des individus. Dans cette thèse nous proposons de tester l'effet des notes lorsque celles-ci sont utilisées dans des contextes bien spécifiques de coopération. En effet, si les notes et la comparaison sociale sont pratique courante, les étudiants sont souvent encouragés et amenés à coopérer en groupe. Cependant, à notre connaissance, point d'études ont testé l'effet des notes sur la coopération; études qui seraient pourtant légitimes étant donné la tendance existante en milieu éducatif à encourager les pratiques coopératives. C'est précisément ce que proposent de faire les chapitres expérimentaux de cette thèse. Le premier (Chapitre 4) teste l'effet des notes au regard de leur capacité à accentuer à la fois la visibilité et la comparaison sociale. Deux expériences investiguent l'effet des notes et tentent de démêler ce qui, de la visibilité individuelle, de la comparaison sociale ou des deux, pourrait affecter un biais motivationnel qui réduit la propension à coopérer: la propension à préférer les informations qui confirment les choix de l'individu. Les résultats montrent qu'en situation coopérative, les notes accroissent ce biais comparativement à des situations où seule la visibilité individuelle est soulignée, suggérant de plus que les notes produisent une focalisation des individus sur une comparaison sociale compétitive. Le second (Chapitre 5) teste l'effet des notes sur les interactions coopératives des individus, précisément sur le partage d'information. Deux expériences montrent que dans un contexte de travail en groupe coopératif, les notes entravent le bon partage des informations entre individus, les amenant à faire de la rétention d'information. Enfin, le troisième (Chapitre 6) investigue l'effet des notes sur un autre indicateur de coopération en groupe: la coordination interindividuelle. Les résultats montrent que les notes réduisent la coordination des individus et les mènent à avoir des comportements de dominance négative entre eux. En somme, les notes entravent la coopération et réduisent les comportements coopératifs entre individus. Enfin, nous discutons des implications pour le milieu éducatif.

The impact of social relationships on the maintenance of independence in advanced old age: findings of a Swiss Longitudinal Study .

The impact of social relationships on the maintenance of independence over periods of 12-18 months in a group of 306 octogenarians is assessed in this study. The study is based on the results of the Swilsoo (Swiss Interdisciplinary Longitudinal Study on the Oldest Old). Participants (80-84 years old at baseline) were interviewed five times between 1994 and 1999. Independence was defined as the capacity to perform without assistance eight activities of daily living. We distinguished in our analyses kinship and friendship networks and evaluated social relationships with the help of a series of variables serving as indicators of network composition and contact frequency. Logistic regression models were used to identify the short-term effects of social relationships on independence, after controlling for sociodemographic and health-related variables; independence at a given wave of interviews was interpreted in the light of social factors measured at the previous wave. Our analyses indicate that the existence of a close friend has a significant impact on the maintenance of independence (OR=1.58, p<0.05), which is not the case with the other variables concerning network composition. Kinship contacts were also observed to have a positive impact on independence (OR=1.12, p<0.01).

Alcohol consumption and social inequality at the individual and country levels--results from an international study.

BACKGROUND: International comparisons of social inequalities in alcohol use have not been extensively investigated. The purpose of this study was to examine the relationship of country-level characteristics and individual socio-economic status (SES) on individual alcohol consumption in 33 countries. METHODS: Data on 101,525 men and women collected by cross-sectional surveys in 33 countries of the GENACIS study were used. Individual SES was measured by highest attained educational level. Alcohol use measures included drinking status and monthly risky single occasion drinking (RSOD). The relationship between individuals' education and drinking indicators was examined by meta-analysis. In a second step the individual level data and country data were combined and tested in multilevel models. As country level indicators we used the Purchasing Power Parity of the gross national income, the Gini coefficient and the Gender Gap Index. RESULTS: For both genders and all countries higher individual SES was positively associated with drinking status. Also higher country level SES was associated with higher proportions of drinkers. Lower SES was associated with RSOD among men. Women of higher SES in low income countries were more often RSO drinkers than women of lower SES. The opposite was true in higher income countries. CONCLUSION: For the most part, findings regarding SES and drinking in higher income countries were as expected. However, women of higher SES in low and middle income countries appear at higher risk of engaging in RSOD. This finding should be kept in mind when developing new policy and prevention initiatives.

Assessment of youth-friendly health care: a systematic review of indicators drawn from young people's perspectives.

PURPOSE: To review the literature on young people's perspectives on health care with a view to defining domains and indicators of youth-friendly care. METHODS: Three bibliographic databases were searched to identify studies that purportedly measured young people's perspectives on health care. Each study was assessed to identify the constructs, domains, and indicators of adolescent-friendly health care. RESULTS: Twenty-two studies were identified: 15 used quantitative methods, six used qualitative methods and one used mixed methodology. Eight domains stood out as central to young people's positive experience of care. These were: accessibility of health care; staff attitude; communication; medical competency; guideline-driven care; age appropriate environments; youth involvement in health care; and health outcomes. Staff attitudes, which included notions of respect and friendliness, appeared universally applicable, whereas other domains, such as an appropriate environment including cleanliness, were more specific to particular contexts. CONCLUSION: These eight domains provide a practical framework for assessing how well services are engaging young people. Measures of youth-friendly health care should address universally applicable indicators of youth-friendly care and may benefit from additional questions that are specific to the local health setting.

Toward a Statistically Robust Assessment of Social and Solidarity Economy Actors. Conceptual Development and Empirical Validation

Many definitions and debates exist about the core characteristics of social and solidarity economy (SSE) and its actors. Among others, legal forms, profit, geographical scope, and size as criteria for identifying SSE actors often reveal dissents among SSE scholars. Instead of using a dichotomous, either-in-or-out definition of SSE actors, this paper presents an assessment tool that takes into account multiple dimensions to offer a more comprehensive and nuanced view of the field. We first define the core dimensions of the assessment tool by synthesizing the multiple indicators found in the literature. We then empirically test these dimensions and their interrelatedness and seek to identify potential clusters of actors. Finally we discuss the practical implications of our model.

Trends in the association between height and socioeconomic indicators in France, 1970-2003

Average physical stature has increased dramatically during the 20th century in many populations across the world with few exceptions. It remains unclear if social inequalities in height persist despite improvements in living standards in the welfare economies of Western Europe. We examined trends in the association between height and socioeconomic indicators in adults over three decades in France. The data were drawn from the French Decennial Health Surveys: a multistage, stratified, random survey of households, representative of the population, conducted in 1970, 1980, 1991, and 2003. We categorised age into 10-year bands, 25-34, 35-44, 45-54 and 55-64 years. Education and income were the two socioeconomic measures used. The slope index of inequality (SII) was used as a summary index of absolute social inequalities in height. The results show that average height increased over this period; men and women aged 25-34 years were 171.9 and 161.2 cm tall in 1970 and 177.0 and 164.0 cm in 2003, respectively. However, education-related inequalities in height remained unchanged over this period and in men were 4.48 cm (1970), 4.71 cm (1980), 5.58 cm (1991) and 4.69 cm (2003), the corresponding figures in women were 2.41, 2.37, 3.14 and 2.96 cm. Income-related inequalities in height were smaller and much attenuated after adjustment for education. These results suggest that in France, social inequalities in adult height in absolute terms have remained unchanged across the three decades under examination.

Social inequalities of functioning and perceived health in Switzerland: a representative cross-sectional analysis.

Many people worldwide live with a disability, i.e. limitations in functioning. The prevalence is expected to increase due to demographic change and the growing importance of non-communicable disease and injury. To date, many epidemiological studies have used simple dichotomous measures of disability, even though the WHO's International Classification of Functioning, Disability, and Health (ICF) provides a multi-dimensional framework of functioning. We aimed to examine associations of socio-economic status (SES) and social integration in 3 core domains of functioning (impairment, pain, limitations in activity and participation) and perceived health. We conducted a secondary analysis of representative cross-sectional data of the Swiss Health Survey 2007 including 10,336 female and 8,424 male Swiss residents aged 15 or more. Guided by a theoretical ICF-based model, 4 mixed effects Poisson regressions were fitted in order to explain functioning and perceived health by indicators of SES and social integration. Analyses were stratified by age groups (15-30, 31-54, ≥55 years). In all age groups, SES and social integration were significantly associated with functional and perceived health. Among the functional domains, impairment and pain were closely related, and both were associated with limitations in activity and participation. SES, social integration and functioning were related to perceived health. We found pronounced social inequalities in functioning and perceived health, supporting our theoretical model. Social factors play a significant role in the experience of health, even in a wealthy country such as Switzerland. These findings await confirmation in other, particularly lower resourced settings.

Multidimensional Deprivation in Contemporary Switzerland Across Social Groups and Time

We have investigated the phenomenon of deprivation in contemporary Switzerland through the adoption of a multidimensional, dynamic approach. By applying Self Organizing Maps (SOM) to a set of 33 non-monetary indicators from the 2009 wave of the Swiss Household Panel (SHP), we identified 13 prototypical forms (or clusters) of well-being, financial vulnerability, psycho-physiological fragility and deprivation within a topological dimensional space. Then new data from the previous waves (2003 to 2008) were classified by the SOM model, making it possible to estimate the weight of the different clusters in time and reconstruct the dynamics of stability and mobility of individuals within the map. Looking at the transition probabilities between year t and year t+1, we observed that the paths of mobility which catalyze the largest number of observations are those connecting clusters that are adjacent on the topological space.

Social trust : a public good?

Combining theories on social trust and social capital with sociopsychological approaches and applying contextual analyses to Swiss and European survey data, this thesis examines under what circumstances generalised trust, often understood as public good, may not benefit everyone, but instead amplify inequality. The empirical investigation focuses on the Swiss context, but considers different scales of analysis. Two broader questions are addressed. First, might generalised trust imply more or less narrow visions of community and solidarity in different contexts? Applying nonlinear principal component analysis to aggregate indicators, Study 1 explores inclusive and exclusive types of social capital in Europe, measured as regional configurations of generalised trust, civic participation and attitudes towards diversity. Study 2 employs multilevel models to examine how generalised trust, as an individual predisposition and an aggregate climate at the level of Swiss cantons, is linked to equality- directed collective action intention versus radical right support. Second, might high-trust climates impact negatively on disadvantaged members of society, precisely because they reflect a normative discourse of social harmony that impedes recognition of inequality? Study 3 compares how climates of generalised trust at the level of Swiss micro-regions and subjective perceptions of neighbourhood cohesion moderate the negative relationship between socio-economic disadvantage and mental health. Overall, demonstrating beneficial, as well as counterintuitive effects of social trust, this thesis proposes a critical and contextualised approach to the sources and dynamics of social cohesion in democratic societies. -- Cette thèse combine des théories sur le capital social et la confiance sociale avec des approches psychosociales et s'appuie sur des analyses contextuelles de données d'enquêtes suisses et européennes, afin d'étudier dans quelles circonstances la confiance généralisée, souvent présentée comme un bien public, pourrait ne pas bénéficier à tout le monde, mais amplifier les inégalités. Les études empiriques, centrées sur le contexte suisse, intègrent différentes échelles d'analyse et investiguent deux questions principales. Premièrement, la confiance généralisée implique-t-elle des visions plus ou moins restrictives de la communauté et de la solidarité selon le contexte? Dans l'étude 1, une analyse à composantes principales non-linéaire sur des indicateurs agrégés permet d'explorer des types de capital social inclusif et exclusif en Europe, mesurés par des configurations régionales de confiance généralisée, de participation civique, et d'attitudes envers la diversité. L'étude 2 utilise des modèles multiniveaux afin d'analyser comment la confiance généralisée, en tant que prédisposition individuelle et climat agrégé au niveau des cantons suisses, est associée à l'intention de participer à des actions collectives en faveur de l'égalité ou, au contraire, à l'intention de voter pour la droite radicale. Deuxièmement, des climats de haute confiance peuvent-ils avoir un impact négatif sur des membres désavantagés de la société, précisément parce qu'ils reflètent un discours normatif d'harmonie sociale qui empêche la reconnaissance des inégalités? L'étude 3 analyse comment des climats de confiance au niveau des micro-régions suisses et la perception subjective de faire partie d'un environnement cohésif modèrent la relation négative entre le désavantage socio-économique et la santé mentale. En démontrant des effets bénéfiques mais aussi contre-intuitifs de la confiance sociale, cette thèse propose une approche critique et contextualisée des sources et dynamiques de la cohésion sociale dans les sociétés démocratiques.

Les déterminants de la prolongation des séjours en SSRG et les indicateurs du devenir des patients après leur sortie : Étude rétrospective au CHRU de Strasbourg [Determinants of prolonged stays in geriatric rehabilitation department and indicators of patient outcome after discharge: A retrospective study in Strasbourg university hospital]

Objectif. Analyser les déterminants de la prolongation des séjours hospitaliers en service de soins de suite et réadaptation gériatrique (SSRG) et identifier les indicateurs du devenir des patients après leur sortie. Méthode. Étude rétrospective au CHRU de Strasbourg de l'ensemble des séjours de durée supérieure à 90 jours entre le 1 janvier 2012 et le 30 septembre 2013. L'ensemble des données sociodémographiques, descriptives des séjours et de l'état de santé des patients ont été analysées. Les patients ont été suivis 9 mois après leur sortie. Les réhospitalisations, l'admission en institution et le décès ont été informés par un contact téléphonique auprès du médecin traitant ou de la famille. Résultats. Quarante-six séjours ont été analysés. Les patients étaient à 68,0 % des femmes. La moyenne d'âge était de 82,9 ± 5,8 ans. Quatre-vingt-dix-huit pour cent d'entre eux vivaient à domicile avant l'admission en milieu hospitalier. Les raisons justifiant la prolongation étaient d'ordre médical (60,8 %), psychique (45,6 %), social (65,2 %) et liées à la difficulté de trouver une solution d'aval (58,7 %). À la fin de leur séjour, 9 patients ont pu regagner leur domicile et 37 ont été admis directement en institution. Durant la période de suivi, 17 patients ont été réhospitalisés au moins une fois et 3 jusqu'à trois fois. Au 9e mois, 9 patients étaient décédés dans un délai moyen de 75 jours après la sortie du SSRG. Les résultats des analyses unifactorielles et multivariées ont permis d'identifier des indicateurs d'évolution défavorable (décès et/ou réhospitalisation). Aucune des variables sociodémographiques ou de syndrome gériatrique n'a été identifiée. Par contre un « motif d'hospitalisation pour une maladie infectieuse », ou pour « un trouble de la marche ou une chute », une « prolongation du séjour en SSRG pour raison médicale » et un « séjour prolongé en court séjour » étaient les facteurs identifiés. Conclusion. Dans la tendance actuelle à améliorer la rentabilité de l'utilisation des ressources de santé, ces résultats rappellent qu'il est important de maintenir un juste équilibre entre utilisation raisonnée des ressources et les besoins spécifiques des patients âgés.