The ecology of medical care in Switzerland: prevalence of illness in the community and healthcare utilisation in Switzerland.

INTRODUCTION: The allocation and equal distribution of healthcare resources is one of the major challenges of today. Therefore, a framework to analyse the prevalence of illness in the community and the use of various sources of healthcare is crucial. The aim of the study was to evaluate the health-seeking behaviour of 1025 individuals in Switzerland in a 2-month period in 2018. METHODS: Population-based, cross-sectional health survey with a multistage, stratified cluster design. The LINK Institute (Luzern, Switzerland, https://www.link.ch/) interviewed a representative sample of the adult Swiss population (age ≥18 years, stratified by language region: German-, French- and Italian-speaking, 70, 25 and 5%, respectively) by telephone. There were two interview rounds to account for potential seasonal variations, in May (n = 506) and November 2018 (n = 516). The health-seeking behaviour of these individuals during the previous 2 months was analysed. RESULTS: In total, data of 1025 individuals were analysed: 51% females, median age 52 years (range 1885). During the preceding 2 months, per 1000 adults, 546 had at least one symptom, 184 reported several symptoms, 243 sought medical advice, 164 first contacted their general practitioner, 81 directly contacted a specialist in a private practice, 16 were self-admitted to an accident and emergency department, 17 firstly contacted a pharmacy and 6 contacted an alternative medicine healthcare provider. In total, 21 persons were admitted to a hospital, of whom 8 underwent surgical procedures, 18 were at first transferred to a regular ward and 3 required intensive care unit services. Because of their current health problem, 387 individuals took medication and 259 bought their medication themselves. The vast majority (95%) of subjects was registered with a general practitioner. CONCLUSIONS: This study represented an attempt to map the healthcare utilisation of the Swiss population. These results may be useful for further delineation of healthcare policies and medical education to meet the demand and needs of people in Switzerland. They indicate that general practitioners are the most important healthcare resource in Switzerland. Compared with specialists, they provide twice as much health advice at less costs. To optimise the health care system in Switzerland, we suggest to allocate resources where they are most needed.

Polypharmacy and drug-drug interactions among older and younger male prisoners in Switzerland.

PURPOSE: The purpose of this paper is to determine the prevalence of polypharmacy and drug-drug interactions (DDIs) in older and younger prisoners, and compared if age group is associated with risks of polypharmacy and DDIs. DESIGN/METHODOLOGY/APPROACH: For 380 prisoners from Switzerland (190 were 49 years and younger; 190 were 50 years and older), data concerning their medication use were gathered. MediQ identified if interactions of two or more substances could lead to potentially adverse DDI. Data were analysed using descriptive statistics and generalised linear mixed models. FINDINGS: On average, older prisoners took 3.8 medications, while younger prisoners took 2.1 medications. Number of medications taken on one reference day was higher by a factor of 2.4 for older prisoners when compared to younger prisoners (p = 0.002). The odds of polypharmacy was significantly higher for older than for younger prisoners (>=5 medications: odds ratio = 5.52, p = 0.035). Age group analysis indicated that for potentially adverse DDI there was no significant difference (odds ratio = 0.94; p = 0.879). However, when controlling for the number of medication, the risk of adverse DDI was higher in younger than older prisoners, but the result was not significant. ORIGINALITY/VALUE: Older prisoners are at a higher risk of polypharmacy but their risk for potentially adverse DDI is not significantly different from that of younger prisoners. Special clinical attention must be given to older prisoners who are at risk for polypharmacy. Careful medication management is also important for younger prisoners who are at risk of very complex drug therapies.

Aging Prisoners' Views on Healthcare Services in Swiss Prisons.

OBJECTIVE: Due to the higher morbidity prevalent in the increasing older population, prisons are facing new challenges on a structural, ethical, and financial level. This study's goal was to explore older prisoners' views and experiences regarding the quality of medical services. METHOD: In this qualitative study, 35 semi-structured interviews were conducted with older inmates aged 50 years and above in 12 different prisons in the German-speaking (23 interviews) and the French-speaking parts (12 interviews) of Switzerland. RESULTS: The majority of older prisoners in this sample expressed concerns about quality of treatment throughout incarceration. Topics addressed reached from quality of the entrance to routine examinations, quality of the treatment received, and delays in care and services provided. CONCLUSION: This study's findings suggest that healthcare in prison is often perceived as insufficient and inadequate by older inmates.

Improving the Health of Older Prisoners: Nutrition and Exercise in Correctional Institutions.

This qualitative article presents and compares the views of older prisoners and expert stakeholders on the topic of nutrition and exercise. The study highlights measures for improving the health of older prisoners. Older prisoners report the need to improve quality of meals provided in prison. They note that prison food is of poor quality and not adapted to their needs. With regard to exercise, they point out the lack of proper opportunities to engage in exercise and sports, and describe several factors that make physical activities either unsuitable or unfeasible. Expert stakeholders see prison as an opportunity to improve the health of those convicted of crimes. In light of the increasing number of older prisoners, age-appropriate nutritional and exercise interventions should take priority in prisons.

Prescription of pain medication in prisons: A comparative analysis of younger and older male prisoners.

PURPOSE: In prison populations, treating pain is particularly challenging, especially for the growing number of older prisoners. The objective was to find out about prevalence, frequency, and types of pain medications prescribed to older prisoners (≥50 years) in comparison with younger prisoners (<50 years). METHODS: Data were collected in Switzerland as part of a study on ageing prisoners' health. Fifteen prisons (out of 26 of the total eligible population) agreed to take part, and data from medical records of 190 older and 190 younger male prisoners were analysed. Descriptive statistics on pain medication prescriptions (excluding drugs used in opioid dependence) were carried out and differences between the 2 age groups tested for statistical significance. RESULTS: More than half of younger and older prisoners were prescribed pain medication during the past 180 days, while 10% of younger and 15% of older prisoners were prescribed pain medication on a daily basis. Nonsteroidal anti-inflammatory drugs and "other analgesics and antipyretics" were most frequently prescribed. Significantly (P < .05), more younger than older prisoners were prescribed NSAIDs and drugs to treat muscle skeletal pain. Tramadol was the opioid most often prescribed. CONCLUSIONS: This is the first empirical study investigating prescriptions of pain medication in Swiss prisoners on a national level. It shows that nonopioid pain medication is an important part of health care provision inside prison, while there are only few prescriptions of strong opioids. Research is needed to investigate whether the standard set by the principle of equivalence is met regarding treatment of pain in prison.

Can routine data from prisoners' files be used to estimate prevalence rates of illicit drug use among prisoners?

OBJECTIVES: The paper examines whether routine data from prisoners' files is a useful basis to estimate prevalence rates of illicit drug use among prisoners. METHODS: Medico-legal files of 190 younger (20-49 years) and 190 older (50-75 years) male prisoners from 13 prisons in Switzerland were analysed. Indications of illicit drug use were extracted based on recorded legal measures, notes from health care professionals, diagnoses related to the use of illicit substances, prescribed medications, other treatment indicators, and results from mandatory drug tests in prison. RESULTS: Estimated lifetime prevalence of illicit drug use based on those indicators is 50.0% for younger and 24.2% for older prisoners. Current cannabis use is an estimated 10.0% and current cocaine, opioids, or other drug use 4.7% for younger prisoners. Among older prisoners, prevalence of current cannabis use is an estimated 3.2% and of other drug use 0.5%. CONCLUSIONS: The paper concludes that analysing routine data is a reasonable alternative to surveys if prisoners' files are kept more complete and concise and if data is collected for no other purpose than to benefit prisoners' health.

Aging Prisoners in Switzerland: An analysis of Their Health Care Utilization.

OBJECTIVE: This study assessed health care utilization of aging prisoners and compared it with that of younger prisoners. METHOD: Health care utilization comprised visits to general practitioners (GPs), nurses, and mental health professionals (MHPs) for a period of 6 months. Using retrospective study design, data were extracted from medical records of 190 older prisoners (50 years and older) and 190 younger inmates (18-49 years). Age group was a dichotomous predictor variable with type of sentencing and time spent in prison as covariates. Descriptive statistics and generalized linear mixed models (GLMMs) were performed. RESULTS: For each of the three outcome variables, two GLMMs were constructed. The first model only included age group as the predictor variable (3 × Unadjusted models). The second included the two covariates in addition to the predictor variable (3 × Adjusted model). Results from the adjusted model indicate that visits to GPs significantly differed between the two age groups (p = .022). Older prisoners visited GPs 1.43 times more often than younger prisoners over the 6-month period (adjusted risk ratio [RR] = 1.43, 95% confidence interval [CI] = [1.05, 1.94]). The finding for visits to nurses was not statistically significant (p = .080). However, older prisoners visited nurses 1.36 times more frequently (adjusted RR = 1.36, 95% CI = [0.96, 1.91]). Finally, older prisoners visited MHPs 1.24 times more often than younger prisoners (adjusted RR = 1.24, 95% CI = [.95, 1.61]) and this finding was also not statistically significant (p = .11). DISCUSSION: Study findings underline that older prisoners utilized health care more often than younger prisoners although in most models the finding did not reach statistical significance. The prison system must develop solutions to address the needs of an aging population, particularly those with physical and mental health problems.

Easily forgotten: elderly female prisoners.

Women form a growing minority within the worldwide prison population and have special needs and distinct characteristics. Within this group exists a smaller sub-group: elderly female prisoners (EFPs) who require tailored social and health interventions that address their unique needs. Data collected from two prisons in Switzerland housing women prisoners were studied. Overall 26 medical records were analyzed, 13 from EFPs (50+ years) and for comparison 13 from young female prisoners (YFPs, 49 years and younger). Additionally, five semi-structured interviews were conducted with EFPs. Using the layer model of vulnerability, three layers of vulnerability were identified: the "prisoner" layer; followed by the layer of "woman"; both of which are encompassed by the layer of "old age." The analysis of these layers resulted in three main areas where EFPs are particularly vulnerable: their status of "double-minority," health and health-care access, and their social relations. Prison administration and policy-makers need to be more sensitive to gender and age related issues in order to remedy these vulnerabilities.

Ageing prisoners' disease burden: is being old a better predictor than time served in prison?

BACKGROUND: The number of older prisoners entering and ageing in prison has increased in the last few decades. Ageing prisoners pose unique challenges to the prison administration as they have differentiated social, custodial and healthcare needs than prisoners who are younger and relatively healthier. OBJECTIVE: The goal of this study was to explore and compare the somatic disease burden of old and young prisoners, and to examine whether it can be explained by age group and/or time served in prison. METHODS: Access to prisoner medical records was granted to extract disease and demographic information of older (>50 years) and younger (≤ 49 years) prisoners in different Swiss prisons. Predictor variables included the age group and the time spent in prison. The dependent variable was the total number of somatic diseases as reported in the medical records. RESULTS were analysed using descriptive statistics and a negative binomial model. RESULTS: Data of 380 male prisoners from 13 different prisons in Switzerland reveal that the mean ages of older and younger prisoners were 58.78 and 34.26 years, respectively. On average, older prisoners have lived in prison for 5.17 years and younger prisoners for 2.49 years. The average total number of somatic diseases reported by older prisoners was 2.26 times higher than that of prisoners below 50 years of age (95% CI 1.77-2.87, p < 0.001). CONCLUSION: This study is the first of its kind to capture national disease data of prisoners with a goal of comparing the disease burden of older and younger prisoners. Study findings indicate that older inmates suffer from more somatic diseases and that the number of diseases increases with age group. RESULTS clearly illustrate the poorer health conditions of those who are older, their higher healthcare burden, and raises questions related to the provision of healthcare for inmates growing old in prison.

Will I stay or can I go? Assisted suicide in prison.

Assisted suicide (AS) is a controversial practice with which physicians and nurses are confronted more and more often. In Switzerland, it is available for Swiss residents and in certain cases for foreigners. Prisoners meet the same prerequisites for AS as the general population and should therefore be eligible for it. Ethical issues, such as informed choice and the autonomy of prisoners, and organizational questions need to be addressed. They must not lead to a denial of this practice. Even though prisons constitute a special area of work for medical staff, it is important to address the possibility of AS in prison openly. This can raise awareness of the difficulties health-care professionals face working in closed institutions.

Expert perspectives on Western European prison health services: do ageing prisoners receive equivalent care?

Health care in prison and particularly the health care of older prisoners are increasingly important topics due to the growth of the ageing prisoner population. The aim of this paper is to gain insight into the approaches used in the provision of equivalent health care to ageing prisoners and to confront the intuitive definition of equivalent care and the practical and ethical challenges that have been experienced by individuals working in this field. Forty interviews took place with experts working in the prison setting from three Western European countries to discover their views on prison health care. Experts indicated that the provision of equivalent care in prison is difficult mostly due to four factors: variability of care in different prisons, gatekeeper systems, lack of personnel, and delays in providing access. This lack of equivalence can be fixed by allocating adequate budgets and developing standards for health care in prison.

Ageing prisoners' health care: analysing the legal settings in Europe and the United States.

BACKGROUND: Relatively little is known about the current health care situation and the legal rights of ageing prisoners worldwide. To date, only a few studies have investigated their rights to health care. However, elderly prisoners need special attention. OBJECTIVE: The aim of this article is to critically review the health care situation of older prisoners by analysing the relevant national and international legal frameworks with a particular focus on Switzerland, England and Wales, and the United States (U.S.). METHODS: Publications on legal frameworks were searched using Web of Science, PubMed, MEDLINE, HeinOnline, and the National Criminal Justice Reference Service. Searches utilizing combinations of keywords relating to ageing prisoners were performed. Relevant reports and policy documents were obtained in order to understand the legal settings in Switzerland, England and Wales, and the U.S. All articles, reports, and policy documents published in English and German between 1774 to June 2012 were included for analysis. Using a comparative approach, an outline was completed to distinguish positive policies in this area. Regulatory approaches were investigated through evaluations of soft laws applicable in Europe and U.S. Supreme Court judgements. RESULTS: Even though several documents could be interpreted as guaranteeing adequate health care for ageing prisoners, there is no specific regulation that addresses this issue completely. The Vienna International Plan of Action on Ageing contributes the most by providing an in-depth analysis of the health care needs of older persons. Still, critical analysis of retrieved documents reveals the lack of specific legislation regarding the health care for ageing prisoners. CONCLUSION: No consistent regulation delineates the provision of health care for ageing prisoners. Neither national nor international institutions have enforceable laws that secure the precarious situation of older adults in prisons. To initiate a change, this work presents critical issues that must be addressed to protect the right to health care and well-being of ageing prisoners. Additionally, it is important to design legal structures and guidelines which acknowledge and accommodate the needs of ageing prisoners.