Primary care physician supply and other key determinants of health care utilisation: The case of Switzerland

Background The Swiss government decided to freeze new accreditations for physicians in private practice in Switzerland based on the assumption that demand-induced health care spending may be cut by limiting care offers. This legislation initiated an ongoing controversial public debate in Switzerland. The aim of this study is therefore the determination of socio-demographic and health system-related factors of per capita consultation rates with primary care physicians in the multicultural population of Switzerland. Methods The data were derived from the complete claims data of Swiss health insurers for 2004 and included 21.4 million consultations provided by 6564 Swiss primary care physicians on a fee-for-service basis. Socio-demographic data were obtained from the Swiss Federal Statistical Office. Utilisation-based health service areas were created and were used as observational units for statistical procedures. Multivariate and hierarchical models were applied to analyze the data. Results Models within the study allowed the definition of 1018 primary care service areas with a median population of 3754 and an average per capita consultation rate of 2.95 per year. Statistical models yielded significant effects for various geographical, socio-demographic and cultural factors. The regional density of physicians in independent practice was also significantly associated with annual consultation rates and indicated an associated increase 0.10 for each additional primary care physician in a population of 10,000 inhabitants. Considerable differences across Swiss language regions were observed with reference to the supply of ambulatory health resources provided either by primary care physicians, specialists, or hospital-based ambulatory care. Conclusion The study documents a large small-area variation in utilisation and provision of health care resources in Switzerland. Effects of physician density appeared to be strongly related to Swiss language regions and may be rooted in the different cultural backgrounds of the served populations.

Comparison of lactated Ringer's, gelatine and blood resuscitation on intestinal oxygen supply and mucosal tissue oxygen tension in haemorrhagic shock

OBJECTIVES: To evaluate the effects on intestinal oxygen supply, and mucosal tissue oxygen tension during haemorrhage and after fluid resuscitation with either blood (B; n=7), gelatine (G; n=8), or lactated Ringer's solution (R; n=8) in an autoperfused, innervated jejunal segment in anaesthetized pigs. METHODS: To induce haemorrhagic shock, 50% of calculated blood volume was withdrawn. Systemic haemodynamics, mesenteric venous and systemic acid-base and blood gas variables, and lactate measurements were recorded. A flowmeter was used for measuring mesenteric arterial blood flow. Mucosal tissue oxygen tension (PO(2)muc), jejunal microvascular haemoglobin oxygen saturation (HbO(2)) and microvascular blood flow were measured. Measurements were performed at baseline, after haemorrhage and at four 20 min intervals after fluid resuscitation. After haemorrhage, animals were retransfused with blood, gelatine or lactated Ringer's solution until baseline pulmonary capillary wedge pressure was reached. RESULTS: After resuscitation, no significant differences in macrohaemodynamic parameters were observed between groups. Systemic and intestinal lactate concentration was significantly increased in animals receiving lactated Ringer's solution [5.6 (1.1) vs 3.3 (1.1) mmol litre(-1); 5.6 (1.1) vs 3.3 (1.2) mmol litre(-1)]. Oxygen supply to the intestine was impaired in animals receiving lactated Ringer's solution when compared with animals receiving blood. Blood and gelatine resuscitation resulted in higher HbO(2) than with lactated Ringer's resuscitation after haemorrhagic shock [B, 43.8 (10.4)%; G, 34.6 (9.4)%; R, 28.0 (9.3)%]. PO(2)muc was better preserved with gelatine resuscitation when compared with lactated Ringer's or blood resuscitation [20.0 (8.8) vs 13.8 (7.1) mm Hg, 15.2 (7.2) mm Hg, respectively]. CONCLUSION: Blood or gelatine infusion improves mucosal tissue oxygenation of the porcine jejunum after severe haemorrhage when compared with lactated Ringer's solution.

Preference of dairy cows for ryegrass, white clover and red clover, and its effects on nutrient supply and milk quality

Two experiments were conducted with 30 dairy cows each, to study the preference for fresh (Experiment 1) and ensiled (Experiment 2) ryegrass, white and red clover. Both experiments consisted of three choice diets with white or red clover or both, offered with ryegrass, and two diets with ryegrass mixed with white or red clover (40% clover). Cows consumed diets with 37.7% fresh white and 45.9% red clover, and no preference was observed when the cows were offered all three forages. By contrast, cows preferred white and red clover silage (73.0 and 69.2%, respectively) over ryegrass silage (of lower nutritive quality). When offered three forages, cows preferred white (59.8%) over red clover (17.5%) and ryegrass (22.7%). Choice diets resulted in diets similar (fresh forages) or higher in nutrient content and digestibility (silages). Treatments did not affect feed intake and performance. Choices compared to mixed diets with red clover silage were preferable regarding the fatty acid composition of the milk fat. Obviously, only large differences in nutrient and energy concentration facilitate preferences for clovers over ryegrass, which could, depending on clover type, be beneficial in terms of the milk's fatty acid composition.

Avoidable hospitalizations in Switzerland: a small area analysis on regional variation, density of physicians, hospital supply and rurality.

BACKGROUND Avoidable hospitalizations (AH) are hospital admissions for diseases and conditions that could have been prevented by appropriate ambulatory care. We examine regional variation of AH in Switzerland and the factors that determine AH. METHODS We used hospital service areas, and data from 2008-2010 hospital discharges in Switzerland to examine regional variation in AH. Age and sex standardized AH were the outcome variable, and year of admission, primary care physician density, medical specialist density, rurality, hospital bed density and type of hospital reimbursement system were explanatory variables in our multilevel poisson regression. RESULTS Regional differences in AH were as high as 12-fold. Poisson regression showed significant increase of all AH over time. There was a significantly lower rate of all AH in areas with more primary care physicians. Rates increased in areas with more specialists. Rates of all AH also increased where the proportion of residences in rural communities increased. Regional hospital capacity and type of hospital reimbursement did not have significant associations. Inconsistent patterns of significant determinants were found for disease specific analyses. CONCLUSION The identification of regions with high and low AH rates is a starting point for future studies on unwarranted medical procedures, and may help to reduce their incidence. AH have complex multifactorial origins and this study demonstrates that rurality and physician density are relevant determinants. The results are helpful to improve the performance of the outpatient sector with emphasis on local context. Rural and urban differences in health care delivery remain a cause of concern in Switzerland.

Hospital use of young children in Switzerland: a nation-wide study based on a complete survey over 4 years

Background Young children are known to be the most frequent hospital users compared to older children and young adults. Therefore, they are an important population from economic and policy perspectives of health care delivery. In Switzerland complete hospitalization discharge records for children [<5 years] of four consecutive years [2002–2005] were evaluated in order to analyze variation in patterns of hospital use. Methods Stationary and outpatient hospitalization rates on aggregated ZIP code level were calculated based on census data provided by the Swiss federal statistical office (BfS). Thirty-seven hospital service areas for children [HSAP] were created with the method of "small area analysis", reflecting user-based health markets. Descriptive statistics and general linear models were applied to analyze the data. Results The mean stationary hospitalization rate over four years was 66.1 discharges per 1000 children. Hospitalizations for respiratory problem are most dominant in young children (25.9%) and highest hospitalization rates are associated with geographical factors of urban areas and specific language regions. Statistical models yielded significant effect estimates for these factors and a significant association between ambulatory/outpatient and stationary hospitalization rates. Conclusion The utilization-based approach, using HSAP as spatial representation of user-based health markets, is a valid instrument and allows assessing the supply and demand of children's health care services. The study provides for the first time estimates for several factors associated with the large variation in the utilization and provision of paediatric health care resources in Switzerland.

Increased splanchnic oxygen extraction because of routine nursing procedures

OBJECTIVE: Multiple organ failure is a common complication of acute circulatory and respiratory failure. We hypothesized that therapeutic interventions used routinely in intensive care can interfere with the perfusion of the gut and the liver, and thereby increase the risk of mismatch between oxygen supply and demand. DESIGN: Prospective, observational study. SETTING: Interdisciplinary intensive care unit (ICU) of a university hospital. PATIENTS: Thirty-six patients on mechanical ventilation with acute respiratory or circulatory failure or severe infection were included. INTERVENTIONS: Insertion of a hepatic venous catheter. MEASUREMENTS AND MAIN RESULTS: Daily nursing procedures were recorded. A decrease of >or=5% in hepatic venous oxygen saturation (Sho2) was considered relevant. Observation time was 64 (29-104) hours (median [interquartile range]). The ICU stay was 11 (8-15) days, and hospital mortality was 35%. The number of periods with procedures/patient was 170 (98-268), the number of procedure-related decreases in Sho2 was 29 (13-41), and the number of decreases in Sho2 unrelated to procedures was 9 (4-19). Accordingly, procedure-related Sho2 decreases occurred 11 (7-17) times per day. Median Sho2 decrease during the procedures was 7 (5-10)%, and median increase in the gradient between mixed and hepatic venous oxygen saturation was 6 (4-9)%. Procedures that caused most Sho2 decreases were airway suctioning, assessment of level of sedation, and changing patients' position. Sho2 decreases were associated with small but significant increases in heart rate and intravascular pressures. Maximal Sequential Organ Failure Assessment scores in the ICU correlated with the number of Sho2 decreases (r: .56; p < 0.001) and with the number of procedure-related Sho2 decreases (r: .60; p < 0.001). CONCLUSIONS: Patients are exposed to repeated episodes of impaired splanchnic perfusion during routine nursing procedures. More research is needed to examine the correlation, if any, between nursing procedures and hepatic venous desaturation.

Capability of E-Bike Tourism in Switzerland

AIM OF PAPER AND RESEARCH QUESTIONS The primary aim of this investigation was to examine, if tourism in Switzerland can be stimulated by focusing on e-bike offers. Switzerland is an attractive and manifold country for bike tourism. However, there are plenty of hilly and steep areas, where the topography is quite demanding and cycling is predestined to ambitious sportsperson. Less performance-oriented bike tourists are possibly discouraged by the challenges of the landscape. E-bikes seem to be a reasonable alterna-tive to enable less trained person to attend bike tours in steeper regions as well as to keep heterogeneous groups together. E-bikes are already popular in Switzerland for daily routes as the journey to work, but they are not very common in the tour-istic context. The presented investigation evaluates the current standing of supply and demand for e-bike tourism and asks for opportunities and threats in the future development. LITERTURE REVIEW The existing frameworks to analyse capability in the field of sport tourism are limited, because of the broad variation of sports and tourism types. Still several conceptions are valuable to evaluate the opportunities of e-bike tourism in Switzer-land. According to Higham and Hinch (2009) the potential of touristic products and destinations always depends on the interaction among the factors place, people and activity. Standeven and de Knop (1999) support this position by identify-ing the experience of place as a key component of the sport tourism experience. Bull (2005) assumes that place not only affects experience. In his opinion, the specific spatially located resources are even crucial for the existence of nature sports. He identifies four factors determining the attraction of touristic products or destination, as physical characteristics, accessibility and infrastructural arrangements, political and economic resources as well as cultural and perceptual aspects. Concerning the demand side (people) the contemporary research is guided by an individual psychological focus delivering mainly results about motives and the decision making process (e.g. Görtz & Hürten, 2011). RESEARCH DESIGN AND DATA ANALYSIS The presented study is based on a between method triangulation, consisting of qualitative interviews with important stake-holders on the supply side and a cross sectional survey on the demand side. Qualitative interviews were conducted with the first provider of touristic e-bike routes and with the manager of the leading e-bike rental company in Switzerland. The interviews were evaluated by qualitative content analysis according to Mayring (2008). The survey covered a randomized sample of 748 adult persons and focused on interests and needs of potential consumers. The concluding potentials analy-sis combined the results of the interviews and the survey with the findings of literature research. As central outcome the strengths, weaknesses, opportunities and threats were evaluated and presented by SWOT-analysis. RESULTS Results showed that the development of e-bike tourism in Switzerland was not initiated by tourism promoter, but by an innovative e-bike producer. However, also for the manufacturer the fit between landscape (place), product (activity) and visitors (people) was the crucial criterion. The first e-bike tours were offered in a demanding and rural region, in order that the experience of place was able to promote a positive overall experience. Due to the success of the first touristic e-bike products, several tourism regions started to extend their portfolio with e-bike offers. To date a nationwide network for signalised e-bike tours, rental stations and changing stations for rechargeable batteries is established. Despite the attractive offer, the demand is only moderate. The obtained results of the consumer survey pointed at a certain barrier to use e-bikes for tourism activities. The most substantial barrier is the missing affinity for bike tourism in general. Another notable group considering themselves as “fit enough for normal bike tourism”. Nevertheless 55% of the respondent are interested in tour-istic e-bike products. Looking only at people with e-bike tourism experience, even 92% are interested in further activities. DISCUSSION AN CONCLUSION The current study findings are encouraging because they suggest a superior suitability and an attractive level of e-bike tourism products in Switzerland. The results of the consumer survey indicate an increasing demand for e-bike tourism. The investigation also points at some risks, as the rivalry for bike tourism or the raised safety hazard because of the increased driving speed. Summing up, the results support the conclusion, that e-bike tourism will become more important in the com-ing years. However, to reach the goal relevant trends as the requirement for customised offers must be considered and marketing activities are supposed to be extended. REFERENCES Bull, C. (2005). Sport tourism resource analysis. In J. Higham (Ed.), Sport tourism destination: Issues, opportunities and analysis (pp. 25-38). Amsterdam: Elsevier Butterworth-Heinemann. Görtz, M., & D. Hürten (2011). Motive der Radurlauber, psychografische Merkmale und Reiseverhalten. In A. Dreyer, E. Miglbauer & R. Mühlnickel (Hrsg.), Radtourismus. Entwicklungen, Potenziale, Perspektiven (S. 36-43). München: Olden-bourg. Higham, J., & Hinch, T. (2009). Sport and Tourism. Globalization, Mobility and Identity. Amsterdam: Butterworth-Heinemann. Mayring, P. (2008). Qualitative Inhaltsanalyse. Grundlagen und Techniken (10. Aufl.). Weinheim: Beltz Verlag. Standeven, J., & De Knop, P. (1999). Sport Tourism. Campaign: Human Kinetics.

Qualifikationsnachfrage und Arbeitsmarkteintritt in der Schweiz: Arbeit im erlernten Beruf, Berufswechsel oder Arbeitslosigkeit

Berufsorientierte Bildungssysteme sind auf die Vermittlung von spezialisierten beruflichen Qualifikationen ausgelegt. Werden diese nach Abschluss einer beruflichen Grundbildung auf dem Arbeitsmarkt wenig nachgefragt, riskieren die Absolventen, die erworbenen berufsspezifischen Qualifikationen nicht verwerten zu können. Dies trifft nicht nur zu, wenn Arbeitsmarkteinsteiger arbeitslos werden, sondern auch, wenn sie den Beruf wechseln müssen. Für die drei verschiedenen Optionen des Arbeitsmarkteinstiegs – Arbeit im erlernten Beruf, Berufswechsel und Arbeitslosigkeit – wird erstens untersucht, welche Bedeutung das individuell passende und das fachfremde Stellenangebot hat. Zweitens wird analysiert, wie eine unterschiedlich ausgeprägte Nachfrage nach fachspezifischen Qualifikationen die Bedeutung ausbildungsbezogener und individueller Merkmale für den Berufseinstieg verändert. Die Schweiz mit ihrem berufsorientierten Bildungssystem und berufsfachlich segmentieren Arbeitsmarkt dient als empirische Referenz. Die multinominalen logistischen Regressionsmodelle basieren auf den Daten des Schweizer Jugendpanels PISA2000/TREE. Die Individualdaten von Lehrabgänger werden auf Berufsebene, zeitpunkt- und regionsspezifisch mit dem individuell passenden und fachfremden Stellenangebot verknüpft, das auf den Stelleninseratendaten des Stellenmarktmonitors Schweiz (SMM) beruht. Dank dieser Verknüpfung von Angebot und Nachfrage nach beruflichen Qualifikationen auf der Mikroebene kann zum ersten Mal die grundlegende Bedeutung der Personalnachfrage für den Berufseinstieg nachgewiesen werden.

[Complementary and alternative medicine in primary care in Switzerland]

OBJECTIVE: This study investigated the current supply of complementary and alternative medicine (CAM) in Swiss primary care. Information was collected on physicians' qualifications in CAM, frequency of patients' demand for CAM, physicians' supply and temporal resources for CAM as well as physicians' referrals to CAM. MATERIAL AND METHODS: 750 (500 German-speaking and 250 French-speaking) randomly selected Swiss female and male primary care physicians were asked to complete a questionnaire (response rate 50.4%). Sociodemographic data on professional training, place of residence, and sex were used to calculate a weighting factor to correct the responders' data in the analysis accordingly. RESULTS: 14.2% of the physicians were qualified in at least one CAM discipline. Around 30% (95% confidence interval 25.4-34.6%) of the physicians were asked for CAM by their patients more than once a week. Homeopathy and phytotherapy were the most frequently offered therapies, followed by traditional Chinese medicine (TCM)/acupuncture. 62.5% (57.6-67.4%) of the physicians refer their patients to CAM. Most patients were referred to TCM/acupuncture. Of the 37.2% (32.6-42.4%) of the physicians who do not refer their patients to CAM, around 40% (35.1-44.9%) offer it themselves. CONCLUSION: About three quarters of the physicians offer CAM themselves or refer their patients to CAM treatments. CAM is very important in primary medical care in Switzerland. Clear regulations for CAM are required in order to ensure a high quality in care.

Development and in-vitro characterization of an implantable flow sensing transducer for hydrocephalus

An implantable transducer for monitoring the flow of Cerebrospinal fluid (CSF) for the treatment of hydrocephalus has been developed which is based on measuring the heat dissipation of a local thermal source. The transducer uses passive telemetry at 13.56 MHz for power supply and read out of the measured flow rate. The in vitro performance of the transducer has been characterized using artificial Cerebrospinal Fluid (CSF) with increased protein concentration and artificial CSF with 10\% fresh blood. After fresh blood was added to the artificial CSF a reduction of flow rate has been observed in case that the sensitive surface of the flow sensor is close to the sedimented erythrocytes. An increase of flow rate has been observed in case that the sensitive surface is in contact with the remaining plasma/artificial CSF mix above the sediment which can be explained by an asymmetric flow profile caused by the sedimentation of erythrocythes having increased viscosity compared to artificial CSF. After removal of blood from artificial CSF, no drift could be observed in the transducer measurement which could be associated to a deposition of proteins at the sensitive surface walls of the packaged flow transducer. The flow sensor specification requirement of +-10\% for a flow range between 2 ml/h and 40 ml/h. could be confirmed at test conditions of 37 degrees C.

Climate Change and International Law. Exploring the Linkages Between Human Rights, Environment, Trade and Investment

Mapping the relevant principles and norms of international law, the paper discusses scientific evidence and identifies current legal foundations of climate change mitigation adaptation and communication in international environmental law, human rights protection and international trade regulation in WTO law. It briefly discusses the evolution and architecture of relevant multilateral environmental agreements, in particular the UN Framework Convention on Climate Change. It discusses the potential role of human rights in identifying pertinent goals and values of mitigation and adaptation and eventually turns to principles and rules of international trade regulation and investment protection which are likely to be of crucial importance should the advent of a new multilateral agreement fail to materialize. The economic and legal relevance of rules on tariffs, border tax adjustment and subsidies, services and intellectual property and investment law are discussed in relation to the production, supply and use of energy. Moreover, lessons from trade negotiations may be drawn for negotiations of future environmental instruments. The paper offers a survey of the main interacting areas of public international law and discusses the intricate interaction of all these components informing climate change mitigation, adaptation and communication in international law in light of an emerging doctrine of multilayered governance. It seeks to contribute to greater coherence of what today is highly fragmented and rarely discussed in an overall context. The paper argues that trade regulation will be of critical importance in assessing domestic policies and potential trade remedies offer powerful incentives for all nations alike to participate in a multilateral framework defining appropriate goals and principles.

The sodium-dependent ascorbic acid transporter family SLC23

Transporters for vitamin C and its oxidized form dehydroascorbic acid (DHA) are crucial to maintain physiological concentrations of this important vitamin that is used in a variety of biochemical processes. The human SLC23 family consists of the Na(+)-dependent vitamin C transporters SVCT1 (encoded by the SLC23A1 gene) and SVCT2 (SLC23A2) as well as an orphan transporter SVCT3 (SLC23A3). Phylogenetically, the SLC23 family belongs to the nucleobase-ascorbate transporter (NAT) family, although no nucleobase transport has yet been demonstrated for the human members of this family. The SVCT1 and SVCT2 transporters are rather specific for ascorbic acid, which is an important antioxidant and plays a crucial role in a many metal-containing enzymes. SVCT1 is expressed predominantly in epithelial tissues such as intestine where it contributes to the supply and maintenance of whole-body ascorbic acid levels. In contrast to various other mammals, humans are not capable of synthesizing ascorbic acid from glucose and therefore the uptake of ascorbic acid from the diet via SVCT1 is essential for maintaining appropriate concentrations of vitamin C in the human body. The expression of SVCT2 is relatively widespread, where it serves to either deliver ascorbic acid to tissues with high demand of the vitamin for enzymatic reactions or to protect metabolically highly active cells or specialized tissues from oxidative stress. The murine Slc23a3 gene encoding the orphan transporter SVCT3 was originally cloned from mouse yolk sac, and subsequent studies showed that it is expressed in the kidney. However, the function of SVCT3 has not been reported and it remains speculative as to whether SVCT3 is a nucleobase transporter.

Uterine fibroid embolization: the utility of aortography in detecting ovarian artery collateral supply

PURPOSE: To retrospectively determine the sensitivity of ovarian artery (OA) visualization at aortography performed after uterine fibroid embolization (UFE) and, using OA arteriography as the reference standard, compare the extent of arterial flow to the uterus at aortography with selective ovarian arteriography, to establish the utility of aortography and ovarian arteriography in the routine practice of UFE. MATERIALS AND METHODS: This study received institutional review board approval with waiver of informed consent and was HIPAA compliant. Retrospective review of 1129 consecutive UFE patients (1072 with aortograms, 57 excluded; mean age, 44 years; range, 21-60 years) was performed to identify all visible OAs. Visible OAs were independently graded by two interventional radiologists according to extent of pelvic arterial flow. If selective arteriography was performed, a second grade was assigned based on assessment of the selective study. Descriptive and summary statistics were used for assessment by the senior observer, and interobserver variability was determined. RESULTS: Of 1072 UFE patients, 184 (17.2%) had at least one visible OA. Ten (0.8%) patients were identified at aortography with collateral OA supply to more than 10% of the uterus. In total, 251 OAs were visualized, and 157 of these were further evaluated with selective study. Sixty-two (5.8%) patients were identified at selective arteriography as having collateral OA supply. The sensitivity of aortography was approximately 18%. Interobserver concordance was high (kappa values of 0.81 and 0.90 for aortography and selective study, respectively), but not perfect. CONCLUSION: Aortography rarely helps identify patients with substantial residual OA supply to the uterus and is a poor predictor of the extent of that supply, and thus may be of limited utility in routine UFE.