Impact on costs of a case management intervention for emergency department frequent users

Background: In most of the emergency departments (ED) in developed countries, a subset of patients visits the ED frequently. Despite their small numbers, these patients are the source of a disproportionally high number of all ED visits, and use a significant proportion of healthcare resources. They place a heavy economic burden on hospital and healthcare system budgets overall. In order to improve the management of these patients, the University hospital of Lausanne, Switzerland implemented a case management intervention (CM) between May 2012 and July 2013. In this randomized controlled trial, 250 frequent ED users (visits>5 during previous 12 months) were allocated to either the CM group or the standard ED care (SC) group and followed up for 12 months. The first result of the CM was to reduce significantly the ED visits. The present study examined whether the CM intervention also reduced the costs generated by the ED frequent users not only from the hospital perspective, but also from the healthcare system perspective. Methods: Cost data were obtained from the hospital's analytical accounting system and from health insurances. Multivariate linear models including a fixed effect "group" and socio-demographic characteristics and health-related variables were run.

Análisis de la motivación al cambio en sujetos que han realizado un programa formativo en violencia doméstica

Esta investigación consiste en la evaluación de la motivación al cambio en un grupo de 116 agresores que realizan un programa formativo en materia de violencia doméstica (VIDO) como medida penal alternativa. El objetivo principal de esta investigación es determinar en qué grado se produce un cambio motivacional como consecuencia de la participación en el programa formativo. Con este propósito, se evalúa el riesgo de los individuos (mediante la evaluación de riesgo realizada por los delegados judiciales), sus necesidades criminògenas (mediante datos sociodemográficos y de carrera criminal), las características clínicas de personalidad medidas con el Inventario de evaluación de la Personalidad (PAI) y su motivación para el cambio (a través de la Escala de Estadios de cambio). Los resultados indican que los cambios en el nivel de motivación de los sujetos no se deben a los efectos del programa formativo. Sin embargo, se encuentran cambios significativos cuando la motivación se analiza en relación a las características del PAI. Estos resultados sugieren la existencia de diferentes perfiles de maltratadores de pareja que se deben tener en cuenta a la hora de planificar el programa formativo para conseguir la máxima eficacia de las intervenciones y el cambio terapéutico de los individuos.

Primary care in Switzerland: evolution of physicians' profile and activities in twenty years (1993-2012).

BACKGROUND: According to the Organization for Economic Cooperation and Development, the Swiss healthcare system is one of the most effective in the world. Yet, as other occidental countries, it has to face the increase of chronic diseases frequency and its resulting cost, particularly for primary care (PC). However very few consistent data are available to describe PC features and its evolution over time. The aim of this study is to describe the evolution of the Swiss PC physicians' (PCPs) profile and activities between 1993 and 2012. METHODS: The date come from two independent European surveys carried out in Switzerland respectively in 1993 and 2012. Both surveys were cross-sectional ones and based on representative samples of 200 PCPs, interviewed by questionnaire. RESULTS: In 20 years, PCPs became older (median age 46 vs 56, p < 0.001) and more feminized (7 % vs 22 %, p < 0.001). Nowadays, they more often work in group practices (28 % vs 52 % in 2012, p < 0.001) and are more involved in other paid activities (28 % vs 66 % in 2012, p < 0.001). All the PCPs have a computer in 2012 (78 % in 1993, p < 0.001) and it is mostly used for keeping records of consultations (47 %). The number of daily face-to-face contacts with patients decreased from 31 to 24 but the average length rose from 15 to 20 min (p < 0.001). PCPs provide fewer pediatric and gynecological services but their activity remains globally unchanged in other domains. The frequency of meetings with other disciplines decreased significantly (e.g. once/month face-to-face meets with ambulatory specialists: 78 % vs 23 % in 2012, p < 0.001). The involvement of PCPs in follow-up and treatment of chronic disease globally little differed. In 2012, 8.5 % of the PCPs never performed any chirurgical acts (vs 0 % in 1993, p < 0.001). CONCLUSION: This study showed a substantial evolution of Swiss PC over the last twenty years in terms of socio-demographic, organizational and service provided. The main changes include: feminization and ageing, lower diversity in services provided, fewer but longer consultations. These changes may have important implications for patients' management and will need to be considered for health planning purposes.

Cannabis use and other predictors of the onset of daily cigarette use in young men: what matters most? Results from a longitudinal study.

BACKGROUND: According to the gateway hypothesis, tobacco use is a gateway of cannabis use. However, there is increasing evidence that cannabis use also predicts the progression of tobacco use (reverse gateway hypothesis). Unfortunately, the importance of cannabis use compared to other predictors of tobacco use is less clear. The aim of this study was to examine which variables, in addition to cannabis use, best predict the onset of daily cigarette smoking in young men. METHODS: A total of 5,590 young Swiss men (mean age = 19.4 years, SD = 1.2) provided data on their substance use, socio-demographic background, religion, health, social context, and personality at baseline and after 18 months. We modelled the predictors of progression to daily cigarette smoking using logistic regression analyses (n = 4,230). RESULTS: In the multivariate overall model, use of cannabis remained among the strongest predictors for the onset of daily cigarette use. Daily cigarette use was also predicted by a lifetime use of at least 50 cigarettes, occasional cigarette use, educational level, religious affiliation, parental situation, peers with psychiatric problems, and sociability. CONCLUSIONS: Our results highlight the relevance of cannabis use compared to other potential predictors of the progression of tobacco use and thereby support the reverse gateway hypothesis.

Impact of geographical and cultural factors on clinical trials in acute mania: lessons from a ziprasidone and haloperidol placebo-controlled study

Clinical trials today are conducted in multiple countries to enhance patient recruitment and improve efficiency of trials. However, the demographic and cultural diversity may contribute to variations in study outcomes. Here we conducted post-hoc analyses for a placebo-controlled study with ziprasidone and haloperidol for the treatment of acute mania to address the demographic, dosing, and outcome disparities in India, Russia and the USA. We compared the baseline characteristics, outcomes and discontinuations in patients and explored the relationship between the outcome measures across these countries. We found substantial differences in baseline characteristics of subjects, administered dosage and disease severity in India compared to the USA and Russia. Conversely, US subjects had a higher placebo response compared to subjects in Russia and India. These results are probably due to demographic differences in patient populations and psychiatric clinical practice across countries. While we offer initial ideas to address the disparities identified in this analysis, it is clear that further research to improve our understanding of geographical differences is essential to ensure globally applicable results for clinical trials in psychiatry.

Characteristics of non-responders to self-reported questionnaires in a large inflammatory bowel disease cohort study.

BACKGROUND: A major threat to the validity of longitudinal cohort studies is non-response to follow-up, which can lead to erroneous conclusions. The objective of this study was to evaluate the profile of non-responders to self-reported questionnaires in the Swiss inflammatory bowel disease (IBD) Cohort. METHODS: We used data from adult patients enrolled between November 2006 and June 2011. Responders versus non-responders were compared according to socio-demographic, clinical and psychosocial characteristics. Odds ratio for non-response to initial patient questionnaire (IPQ) compared to 1-year follow-up questionnaire (FPQ) were calculated. RESULTS: A total of 1943 patients received IPQ, in which 331 (17%) did not respond. Factors inversely associated with non-response to IPQ were age >50 and female gender (OR = 0.37; p < 0.001 respectively OR = 0.63; p = 0.003) among Crohn's disease (CD) patients, and disease duration >16 years (OR = 0.48; p = 0.025) among patients with ulcerative colitis (UC). FPQ was sent to 1586 patients who had completed the IPQ; 263 (17%) did not respond. Risk factors of non-response to FPQ were mild depression (OR = 2.17; p = 0.003) for CD, and mild anxiety (OR = 1.83; p = 0.024) for UC. Factors inversely associated with non-response to FPQ were: age >30 years, colonic only disease location, higher education and higher IBD-related quality of life for CD, and age >50 years or having a positive social support for UC. CONCLUSIONS: Characteristics of non-responders differed between UC and CD. The risk of non-response to repetitive solicitations (longitudinal versus transversal study) seemed to decrease with age. Assessing non-respondents' characteristics is important to document potential bias in longitudinal studies.

Clinical and course characteristics of depression and all-cause mortality: A prospective population-based study.

BACKGROUND: Given the large heterogeneity of depressive disorders (DD), studying depression characteristics according to clinical manifestations and course is a more promising approach than studying depression as a whole. The purpose of this study was to determine the association between clinical and course characteristics of DD and incident all-cause mortality. METHODS: CoLaus|PsyCoLaus is a prospective cohort study (mean follow-up duration=5.2 years) including 35-66 year-old randomly selected residents of an urban area in Switzerland. A total of 3668 subjects (mean age 50.9 years, 53.0% women) underwent physical and psychiatric baseline evaluations and had a known vital status at follow-up (98.8% of the baseline sample). Clinical (diagnostic severity, atypical features) and course characteristics (recency, recurrence, duration, onset) of DD according to the DSM-5 were elicited using a semi-structured interview. RESULTS: Compared to participants who had never experienced DD, participants with current but not remitted DD were more than three times as likely to die (Hazard Ratio: 3.2, 95% CI: 1.1-10.0) after adjustment for socio-demographic and lifestyle characteristics, comorbid anxiety disorders, antidepressant use, and cardiovascular risk factors and diseases. There was no evidence for associations between other depression characteristics and all-cause mortality. LIMITATIONS: The small proportion of deceased subjects impeded statistical analyses of cause-specific mortality. CONCLUSIONS: A current but not remitted DD is a strong predictor of all-cause mortality, independently of cardiovascular or lifestyle factors, which suggests that the effect of depression on mortality diminishes after remission and further emphasizes the need to adequately treat current depressive episodes.

Identifying Pertinent Variables for Nonresponse Follow-Up Surveys : Lessons Learned from 4 Cases in Switzerland

All social surveys suffer from different types of errors, of which one of the most studied is non-response bias. Non-response bias is a systematic error that occurs because individuals differ in their accessibility and propensity to participate in a survey according to their own characteristics as well as those from the survey itself. The extent of the problem heavily depends on the correlation between response mechanisms and key survey variables. However, non-response bias is difficult to measure or to correct for due to the lack of relevant data about the whole target population or sample. In this paper, non-response follow-up surveys are considered as a possible source of information about non-respondents. Non-response follow-ups, however, suffer from two methodological issues: they themselves operate through a response mechanism that can cause potential non-response bias, and they pose a problem of comparability of measure, mostly because the survey design differs between main survey and non-response follow-up. In order to detect possible bias, the survey variables included in non-response surveys have to be related to the mechanism of participation, but not be sensitive to measurement effects due to the different designs. Based on accumulated experience of four similar non-response follow-ups, we studied the survey variables that fulfill these conditions. We differentiated socio-demographic variables that are measurement-invariant but have a lower correlation with non-response and variables that measure attitudes, such as trust, social participation, or integration in the public sphere, which are more sensitive to measurement effects but potentially more appropriate to account for the non-response mechanism. Our results show that education level, work status, and living alone, as well as political interest, satisfaction with democracy, and trust in institutions are pertinent variables to include in non-response follow-ups of general social surveys. - See more at: https://ojs.ub.uni-konstanz.de/srm/article/view/6138#sthash.u87EeaNG.dpuf

Evolución de la enfermería y aparición de nuevos roles: Rol de la enfermera de Cuidados Paliativos

El papel de la enfermería se ha visto sometido a muchos cambios desde sus inicios hasta la actualidad. Cambios que han ayudado a que la profesión crezca y a que se fundamente en un cuerpo de conocimientos propios. Las enfermeras, inicialmente supeditadas al estamento médico, se encuentran actualmente con un nivel de formación que les permite desarrollar su rol autónomo. Las nuevas necesidades de cuidados, generadas por los cambios socio-demográficos, epidemiológicos y políticos, y la necesidad de dar respuesta a la demanda de la población, han generado una nueva perspectiva de los sistemas de salud. Los sistemas sanitarios tratan de adaptarse a las nuevas circunstancias generando modelos sanitarios eficaces y económicamente sostenibles, donde la enfermera tiene un papel primordial. Para poder dar la atención necesaria y profesional a todo este nuevo modelo asistencial se está procediendo cada vez más y de manera más activa, a la implantación de nuevos roles enfermeros (enfermera/o gestora/or de casos, enfermera de Enlace, etc.). Dentro de estos roles, destaca el de enfermera/o en Cuidados Paliativos (CP) por su gran complejidad e incluso desconocimiento, debido a que es un rol relativamente reciente. Dada la importancia para el colectivo enfermero de conocer y comprender los cambios que ha experimentado la enfermería, el presente trabajo pretende obtener una visión general de la evolución histórica de la enfermería y la aparición de nuevos roles, profundizando en el rol de CP. Para ello se realiza una revisión de la literatura. Palabras clave: Roles enfermería, cuidado, historia enfermería, evolución enfermería, cuidados paliativos, enfermería paliativa.

Characterizing the vulnerability of frequent emergency department users by applying a conceptual framework: a controlled, cross-sectional study.

BACKGROUND: Frequent emergency department (ED) users meet several of the criteria of vulnerability, but this needs to be further examined taking into consideration all vulnerability's different dimensions. This study aimed to characterize frequent ED users and to define risk factors of frequent ED use within a universal health care coverage system, applying a conceptual framework of vulnerability. METHODS: A controlled, cross-sectional study comparing frequent ED users to a control group of non-frequent users was conducted at the Lausanne University Hospital, Switzerland. Frequent users were defined as patients with five or more visits to the ED in the previous 12 months. The two groups were compared using validated scales for each one of the five dimensions of an innovative conceptual framework: socio-demographic characteristics; somatic, mental, and risk-behavior indicators; and use of health care services. Independent t-tests, Wilcoxon rank-sum tests, Pearson's Chi-squared test and Fisher's exact test were used for the comparison. To examine the -related to vulnerability- risk factors for being a frequent ED user, univariate and multivariate logistic regression models were used. RESULTS: We compared 226 frequent users and 173 controls. Frequent users had more vulnerabilities in all five dimensions of the conceptual framework. They were younger, and more often immigrants from low/middle-income countries or unemployed, had more somatic and psychiatric comorbidities, were more often tobacco users, and had more primary care physician (PCP) visits. The most significant frequent ED use risk factors were a history of more than three hospital admissions in the previous 12 months (adj OR:23.2, 95%CI = 9.1-59.2), the absence of a PCP (adj OR:8.4, 95%CI = 2.1-32.7), living less than 5 km from an ED (adj OR:4.4, 95%CI = 2.1-9.0), and household income lower than USD 2,800/month (adj OR:4.3, 95%CI = 2.0-9.2). CONCLUSIONS: Frequent ED users within a universal health coverage system form a highly vulnerable population, when taking into account all five dimensions of a conceptual framework of vulnerability. The predictive factors identified could be useful in the early detection of future frequent users, in order to address their specific needs and decrease vulnerability, a key priority for health care policy makers. Application of the conceptual framework in future research is warranted.

Attitudes and burden in relatives of patients with schizophrenia in a middle income country

BACKGROUND: Most studies of family attitudes and burden have been conducted in developed countries. Thus it is important to test the generalizability of this research in other contexts where social conditions and extended family involvement may be different. The aim of this study was to assess the relationship between the attitudes of caregivers and the burden they experience in such a context, namely Arica, a town located in the northernmost region of Chile, close to the border with Peru and Bolivia. METHODS: We assessed attitudes towards schizophrenia (including affective, cognitive and behavioural components) and burden (including subjective distress, rejection and competence) in 41 main caregivers of patients with schizophrenia, all of whom were users of Public Mental Health Services in Arica. RESULTS: Attitude measures differed significantly according to socio-demographic variables, with parents (mainly mothers) exhibiting a more negative attitude towards the environment than the rest of the family (t = 4.04; p = 0.000).This was also the case for caregivers with a low educational level (t = 3.27; p < 0.003), for the oldest caregivers (r = 0.546; p = 0.000) and for those who had spent more time with the patient (r = 0.377; p = 0.015). Although attitudes had significant association with burden, their explanatory power was modest (R2 = .104, F = 4,55; p = .039). CONCLUSIONS: Similar to finding developed countries, the current study revealed a positive and significant relationship between the attitudes of caregivers and their burden. These findings emphasize the need to support the families of patients with schizophrenia in this social context.

Explaining vineyard specialization in the province of Barcelona (Spain) in the mid-19th century

[cat] Presentem un model estadístic de l’especialització vitícola a la província de Barcelona cap el 1860 que combina la pressió boserupiana de l’augment de població, l’atracció de la demanda induïda per un creixement de tipus smithià (mesurada per les distancies horàries al port més proper), i l’adequació dels sòls disponibles per sembrar gra o plantar ceps (mesurada per l’estès hídric, el pendent i el risc de glaçades). L’assoliment global d’uns nivells de R2 ajustats que oscil·len entre 0,608 i 0,826 poden considerar-se força bons. Creiem que la desigualtat en la propietat de la terra també va jugar un paper molt important, però l’hem hagut d’ometre de moment per manca de dades estadístiques. També cal aprofundir en el tractament del problema de possible endogeneïtat derivat de l’ús de variables socio-demogràfiques.

Explaining vineyard specialization in the province of Barcelona (Spain) in the mid-19th century

[cat] Presentem un model estadístic de l’especialització vitícola a la província de Barcelona cap el 1860 que combina la pressió boserupiana de l’augment de població, l’atracció de la demanda induïda per un creixement de tipus smithià (mesurada per les distancies horàries al port més proper), i l’adequació dels sòls disponibles per sembrar gra o plantar ceps (mesurada per l’estès hídric, el pendent i el risc de glaçades). L’assoliment global d’uns nivells de R2 ajustats que oscil·len entre 0,608 i 0,826 poden considerar-se força bons. Creiem que la desigualtat en la propietat de la terra també va jugar un paper molt important, però l’hem hagut d’ometre de moment per manca de dades estadístiques. També cal aprofundir en el tractament del problema de possible endogeneïtat derivat de l’ús de variables socio-demogràfiques.

Improving interMediAte Risk management. MARK study

Background: Cardiovascular risk functions fail to identify more than 50% of patients who develop cardiovascular disease. This is especially evident in the intermediate-risk patients in which clinical management becomes difficult. Our purpose is to analyze if ankle-brachial index (ABI), measures of arterial stiffness, postprandial glucose, glycosylated hemoglobin, self-measured blood pressure and presence of comorbidity are independently associated to incidence of vascular events and whether they can improve the predictive capacity of current risk equations in the intermediate-risk population. Methods/Design: This project involves 3 groups belonging to REDIAPP (RETICS RD06/0018) from 3 Spanish regions. We will recruit a multicenter cohort of 2688 patients at intermediate risk (coronary risk between 5 and 15% or vascular death risk between 3-5% over 10 years) and no history of atherosclerotic disease, selected at random. We will record socio-demographic data, information on diet, physical activity, comorbidity and intermittent claudication. We will measure ABI, pulse wave velocity and cardio ankle vascular index at rest and after a light intensity exercise. Blood pressure and anthropometric data will be also recorded. We will also quantify lipids, glucose and glycosylated hemoglobin in a fasting blood sample and postprandial capillary glucose. Eighteen months after the recruitment, patients will be followed up to determine the incidence of vascular events (later follow-ups are planned at 5 and 10 years). We will analyze whether the new proposed risk factors contribute to improve the risk functions based on classic risk factors. Discussion: Primary prevention of cardiovascular diseases is a priority in public health policy of developed and developing countries. The fundamental strategy consists in identifying people in a high risk situation in which preventive measures are effective and efficient. Improvement of these predictions in our country will have an immediate, clinical and welfare impact and a short term public health effect

Data mining and mall users profile

Marketing scholars have suggested a need for more empirical research on consumer response to malls, in order to have a better understanding of the variables that explain the behavior of the consumers. The segmentation methodology CHAID (Chi-square automatic interaction detection) was used in order to identify the profiles of consumers with regard to their activities at malls, on the basis of socio-demographic variables and behavioral variables (how and with whom they go to the malls). A sample of 790 subjects answered an online questionnaire. The CHAID analysis of the results was used to identify the profiles of consumers with regard to their activities at malls. In the set of variables analyzed the transport used in order to go shopping and the frequency of visits to centers are the main predictors of behavior in malls. The results provide guidelines for the development of effective strategies to attract consumers to malls and retain them there.