[Evaluation of the impact of guidelines for rationalizing the prescription of preop tests for patients ASA 1 and 2 undergoing elective surgery]. / Valutazione dell'impatto di linee-guida per la razionalizzazione della prescrizione degli esami preoperatori a pazienti ASA 1 e 2 sottoposti a chirurgia elettiva.

OBJECTIVES: To evaluate the impact of implementation of guidelines aimed at reducing the use of laboratory and diagnostic preoperative tests in patients with low anesthesiologic risk, admitted to six public hospital of Ente Ospedaliero Cantonale in Cantone Ticino (Switzerland). DESIGN: Observational study. METHODS: Time series analysis of patterns of use of preoperative tests, on 14,585 patients admitted to public hospitals form March 1996 to June 1998. PRINCIPAL OUTCOME MEASURE: Proportion of patients undergoing a laboratory or other diagnostic tests during three six months periods before guidelines implementation (baseline), during the six months of the implementation phase and during the following four months of adoption of the guidelines in the participating centres. RESULTS: During the four months following the implementation, we observed a reduction of 15% (95% CI: 1%-27%) in the use of azotemia, and a reduction of 34% (95% CI: 18%-50%) for coagulation tests. Corresponding figures for glycemia and chest x-ray indicated a reduction of 44% (95% CI: 32%-54%) and of 22% (95% CI: 8%-34%), respectively. As for other tests (creatinine, ECG), no statistically significant reduction was observed. Most of the observed effect was explained by a reduction in use in patients at a low risk (ASA 1 and 2). In addition, guidelines appeared to have a greater impact in the four small (i.e. < 200 beds) hospitals, as compared with the two centres of greater size. CONCLUSIONS: Consistently with the empirical evidence available in this area, this study suggests that guidelines can change clinical practice, when they are implemented through a strategy taking into account adaptation of the recommendations to local circumstances and involvement of health professionals.

[Educational strategies and tools in a public health program at the University of Geneva]. / Stratégies et outils pédagogiques dans le cadre d'un Diplôme de Santé publique: une expérience à l'Université de Genève.

In the Swiss context, the newly developed MPH programme at the University of Geneva is experimental in educational matters. Indeed the programme is fully learner-centered and community-oriented. Throughout the curriculum students plan, implement and evaluate intervention programmes or/and research projects related to health problems of the communities they are in charge of. In this article, we describe the educational strategies and tools used in this MPH curriculum (professional profile, mind-mapping procedures, field-work either on research projects or on intervention programmes, group work and evaluation procedures). These strategies and tools might assist some educational experimentation in MPH programmes in search of public health relevance and pedagogic efficacy.

[Effect of occupation on health behavior and biological cardiovascular risk factors]. / Einfluss des Berufs auf das Gesundheitsverhalten und die biologischen kardiovaskulären Risikofaktoren.

Within the framework of the second survey of MONICA-Switzerland (cantons of Vaud and Fribourg; canton of Tessin), the data of 683 working men were analysed to examine the relation between occupation and cardiovascular risk factors. For this purpose, lifestyle factors (smoking, nutritional habits, physical activity, alcohol intake) as well as blood pressure and serum lipoprotein concentrations were compared among 17 different occupational groups. Furthermore, every occupational group was ranked, based on the medians of the mentioned dependent variables. A strong relationship between socioeconomic status (recorded as number of years of schooling completed) and an index for healthy lifestyle was found. However, in some occupational groups a major discrepancy between socioeconomic status respectively lifestyle and measured cardiovascular risk factors (blood pressure, lipoprotein concentrations) was observed. It is therefore hypothesized that unknown occupational factors adversely affect blood pressure and serum lipoproteins for example in physicians, managers and executives whereas the contrary--beneficial effect of unknown occupational factors--is true for example for drivers and bricklayers.

[Social class and cardiovascular risk factors in Italian-speaking Switzerland: results of the first Swiss population study MONIKA Project 1985-1986]. / Soziale Schicht und kardiovaskuläre Risikofaktoren in der italienisch-sprachigen Schweiz: Ergebnisse der ersten Bevölkerungsstudie des Schweizer MONICA-Projektes 1985-1986.

The relationship of social class and prevalence of risk factors for cardiovascular diseases was investigated within the Swiss MONICA-project, a cross sectional study of the Swiss-Italian population started in 1985/1986. A representative sample of 984 men and 1014 women ages 35 to 64 was selected, the response rate was 78%. Social class was measured by two indicators, occupational status and education. A significant trend was found in age standardized analysis with higher mean blood pressure and body mass index in lower social classes (p < 0.001). When other confounders for cardiovascular diseases were considered in a multiple regression model, the predictive power of social class was moderate. A significant inverse relationship of cardiovascular risk factors and social class was only found for body mass index (both sexes) and exercise in women which was directly related to higher social class and education. No relationship was found for lipids (cholesterol, HDL-cholesterol), blood pressure and smoking in both sexes. Risk factors for cardiovascular diseases beside obesity do not seem to cluster in lower social classes within the Swiss-Italian population.

[Outcome and analysis of participation in the 2d MONICA survey (1988-1989) of cardiovascular risk factors]. / Echantillonnage et analyse de la participation pour la deuxième enquête MONICA (1988-1989) sur les facteurs de risque cardiovasculaires.

Two Swiss regions, the cantons of Vaud and Fribourg (VD-FR) and the canton of Ticino (TI), take part in the international research project MONICA (MONItoring trends and determinants in CArdiovascular disease). In this framework, two surveys were respectively carried out in 1984-86 and in 1988/89 to determine the distribution of the major cardiovascular risk factors in the adult population. This article presents the outcome of the sampling procedure and participation for the second survey. A two-stage sampling procedure was performed by randomly drawing first communes (51 in VD-FR region; 25 in TI region) and then individuals out of the communal registry offices (3300 in VD-FR; 2000 in TI). In the two regions, 2011 and 1458 persons respectively attended the medical examination, leading to overall participation rates of 61% and 73%. As the sex and age distribution of the sample and of the participants is very close to that of the population, a major selection bias is unlikely. For the VD-FR region, the improvement in the participation (57% in the first survey) is due mainly to a better response from foreign nationals and older persons, whereas in the TI region the drop in recruitment (78% in the first survey) may reflect a saturation point reached by the population after several years of an intensive prevention programme against coronary heart disease initiated in 1984. In both regions, unmarried people represent the only population group in which the participation rate has decreased. On the basis of a questionnaire proposed to the non participants, unmarried status, sedentary leisure activities and a previous cholesterol check appear as factors significantly associated with a higher refusal rate.

[Regular assessment of cardiovascular risk factors and diseases: a valuable tool or not? (The MONICA experience)]. / Regelmässige Erfassung von Herz-Kreislauf-Risiken und -Krankheiten: sinnvoll oder nicht? (Die MONICA-Erfahrung).

An important aspect of public health policy is the information system through which the health of the whole population and of particular groups at risk can be monitored. In Switzerland, a first national health survey (SOMIPOPS) was carried out in 1981-1982 by questionnaire and interview and paved the way for implementation of the Swiss Health Survey, whose first test run is currently ongoing. Periodic health examination surveys including measurements of physical characteristics have been conducted only at a regional level in the framework of the WHO project MONICA (MONItoring of trends and determinants in CArdiovascular disease). The mainly French-speaking cantons of Vaud and Fribourg and the Italian-speaking canton of Ticino take part in this project and the levels of the major cardiovascular risk factors were measured on representative samples of the population in 1984-86 and in 1988-89. A similar survey was conducted in the German-speaking city of Basel in 1989/89. These studies allow time trend and geographical analysis, and some comparisons are presented in terms of age-standardized prevalence rates of the risk factors. The discussion focuses on the desirability of implementing a periodic health examination survey at the national level. One main advantage of such surveys is that variables of particular interest at a given time can be added to the usual set of measurements, as was the case for blood lead, vitamin D and apolipoproteins in the MONICA surveys.

[Blood lipids in the Swiss population: MONICA study 1988-89]. / Lipides sanguins dans la population suisse: enquête MONICA 1988-89.

The second population survey of the Swiss MONICA project took place in 1988-89 in the cantons of Vaud, Fribourg and Ticino. Blood lipids (total, LDL, and HDL cholesterol as well as apolipoproteins A-I and B) were measured in 3341 individuals aged 25-74 years belonging to a representative sample of the three cantons' population. Total and LDL cholesterol values were high on average, especially among patients aged 45 and over: total cholesterol was > 6.5 mmol/l in 27% (age 25-34) to 58% (age 45-54) and in 15% (age 25-34) to 64% (age 65-74) of men and women, respectively. HDL cholesterol values were relatively stable with age, at a higher level in women (median 1.5 mmol/l) than in men (median 1.2 mmol/l). To summarize, about 1 out of 5 people had cholesterol values placing them at low risk for the development of coronary heart disease, whereas 1 out of 4 were at increased risk. Apolipoprotein B, a component of LDL cholesterol, and apolipoprotein A-I, a component of HDL cholesterol, were measured for the first time in a large representative sample of the Swiss population. The distribution of both apolipoproteins was, in the aggregate, very similar to the distribution of the corresponding LDL and HDL cholesterol. A comparison of cholesterol values measured in 1988-89 with values previously measured in the same population (MONICA population survey 1984-85) did not show any reduction with time.

[Incidence of use of various myocardial infarct treatments in 2 Swiss regions]. / Fréquence d'utilisation des différents traitements de l'infarctus du myocarde dans deux régions suisses.

Two regions in Switzerland (Vaud-Fribourg and Ticino) participate in the WHO MONICA project (MONItoring of trends and determinants in CArdiovascular disease). Within this context, all hospitalizations of men for ischemic heart disease will be recorded during a period of ten years. All cases are classified according to uniform criteria, in three categories: definite myocardial infarction, possible myocardial infarction or no myocardial infarction. In 1986, the records were completed with a summary of treatments. The treatment of 334 patients with definite myocardial infarction, aged between 25 and 64 years, surviving after 27 days are analyzed (VD-FR: 217; TI: 117). Results show that anticoagulants were administered in a routine fashion (in 97% of the cases), whilst thrombolysis, applied in 1986 by only one hospital in each area, concerned only 9% of the patients. As compared to Ticino, VD-FR distinguished itself by its significantly higher use of anti-arrhythmia drugs (69% versus 47%; p less than 0.005), nitrates (97% versus 86%; p less than 0.005) and beta-blockers (57% versus 43%; p less than 0.05). Furthermore, patients from VD-FR spent more time in the intensive care unit (6.4 versus 3.7 days; p less than 0.005) and participated more frequently in rehabilitation programmes (47% versus 12%; p less than 0.005). The discussion compares the observed therapy with results published in the literature.

[Total cholesterol, HDL-cholesterol and blood pressure in relation to life style: results of the first population screening of the Swiss MONIKA Project]. / Gesamtcholesterin, HDL-Cholesterin und Blutdruck in Abhängigkeit vom Lebensstil: Ergebnisse der ersten Bevölkerungsstudie des Schweizer MONICA-Projekts.

To evaluate the association of individual health habits with levels of cardiovascular risk factors such as serum cholesterol and blood pressure, data from a representative population sample of 860 men and 788 women, aged 25 to 64 years and residing in Western Switzerland, were analyzed cross-sectionally. The data had been collected during 1984/85 as a part of the WHO MONICA project, an international research project on the epidemiology of cardiovascular diseases. In age-adjusted analysis, a score of prudent diet was a reasonably strong inverse correlate of total cholesterol in men (p less than 0.001) but less so in women (p = 0.11); the diet score was unrelated to HDL cholesterol. In both genders, alcohol consumption was associated with elevated levels of systolic and diastolic blood pressure (men: both p less than 0.001; women: p = 0.05 and 0.01 respectively) and of HDL cholesterol (men and women: p less than 0.001). Coffee consumption was unrelated to either blood lipids or blood pressure. In both men and women, leisure-time exercise was a predictor of a low-risk lipid profile, i.e. a low total cholesterol/HDL ratio (both p less than 0.001). Better educated persons, especially women, revealed consistently lower levels of cardiovascular risk factors. The independent character of these lifestyle-risk factor-associations was largely confirmed in a multivariate analysis, with cigarette smoking emerging as another significant predictor of a deteriorated lipid profile, while education was not an independent determinant of biological risk factors. Lifestyle variables, including body mass index, explained 9 to 19% of variance in cardiovascular risk factors, with relative weight being the strongest of the predictors related to behaviour. Entering age and sex into the regression models enhanced the predictive power of the equations to 16 to 26% explained risk factor variance. We conclude from this population-based, cross-sectional study that personal health habits such as diet, exercise, alcohol consumption and smoking, as well as body weight are significantly and independently related to blood lipid and blood pressure levels; the apparent size of effect of these behavioural traits on biological risk factors for cardiovascular diseases was only modest, but it may nevertheless be relevant to prevention.

[The medical team and the campaign for primary prevention of cardiovascular diseases in the Tessin canton]. / Corps médical et campagne de prévention primaire des maladies cardio-vasculaires dans le canton du Tessin.

This study presents the results of a questionnaire research into the subjective perception of the free-practicing doctors in Ticino concerning the primary prevention programme against cardiovascular risk factors, directed to the whole cantonal population by the Social Welfare Department. 93% of the doctors (82% of the population) are aware of the programme and 82% of those interviewed judged it to be useful or very useful. Furthermore, the single initiatives of the programme (TV-advertisements and information-Leaflets) were also evaluated, as well as the frequency of preventive practices during medical visits (information on tobacco risks, blood pressure measurement, treatment of hypercholesterolemia). This study was also analyzed on the basis of questionnaire received before (response rate 41%) and after having sent out a further reminder (final response rate 61%). The results and conclusions did not differ with an increase in the reply rate.