[Clinical itinerary for heart failure: a program designed by primary care practitioners in Geneva]. / Itinéraire clinique pour l'insuffisance cardiaque: un programme conçu par des médecins de premier recours genevois.

Episodes of heart failure impact on patients' quality of life as well as their morbidity and mortality. This article describes a series of interventions designed by a group of primary care practitioners in Geneva. Some interventions aim to improve patients' autonomy in identifying the first signs of heart failure to act immediately. Others focus on patients' motivation to adopt appropriate behaviours (physical activity, etc.). And finally others have the objective to improve coordination between ambulatory and hospital care, as well as the transmission of clinical information. The implementation of these interventions highlights the need for individualised objectives of care in complex cases where patients have several co-morbidities and/or complicated social situations. In these situations an interdisciplinary approach is also essential.

[Scientific research in family medicine: practitioners' experience, barriers and needs]. / Recherche scientifique en médecine de famille: expériences, barrières et besoins des praticiens.

Scientific data from family medicine are relevant for the majority of the population. They are therefore essential from an ethical and public health perspective. We need to promote quality research in family medicine despite methodological, financial and logistic barriers. To highlight the strengths and weaknesses of research in family medicine in the French-speaking part of Switzerland we asked practitioners from this region to share their experience, critics and needs in relation to research. This article summarizes their contribution in light of the international literature.

[Quality in ambulatory medicine]. / La qualité en medecine ambulatoire.

The perspectives of the insurance companies, medical associations and practitioners about quality in outpatient care are different. After a brief discussion of each of these views, a proposal for quality improvement through continuous medical education is presented. It applies to the doctor-patient relationship, the diagnostic and therapeutic strategies and the handling of uncertainty. Practically, simulations can help the physicians to understand the theory behind continuous quality improvement and apply it to the process of outpatient care.

[Continuing education, motivation for cost control, a Swiss experiment]. / Weiterbildung, Antrieb zur Kostendämpfung, ein schweizerisches Experiment.

The article reviews the prospective, controlled experience of the introduction of a physician network service (health maintenance organisation 5000 insured persons). There was a reduction of cost (26%-33%) compared with the control group, without loss of quality. This reduction still holds good after four years. Risk selection explains only a small part of the reduction in cost. The only interventions consisted of gatekeeping plus continuing medical education (CME). Diagnosis and financial data were not available and profiling was not used to control the experience. CME was provided by a quality circle once a week. In these meetings, the subjective and objective features particular to outpatient medicine were addressed.

[Quality of care: from theory to practice]. / Qualité des soins: de la théorie à la pratique.

Quality of care is growing concern among health care professionals and managers. As a multidimensional concept, it cannot be reduced to simple customer satisfaction. Taking into account the views of the three major players in the health care system-patients, providers and payers-quality can be defined as the capacity to satisfy patients' needs according to professional knowledge and within available resources. Efficacy, efficiency, appropriateness, acceptability, legitimacy and equity are dimensions of health care quality. Contrary to popular belief, quality is neither maximum performance, nor satisfaction at all costs, nor punishment or elimination of "bad apples". In ambulatory medicine, quality implies first of all the ability to master the processes occurring during an office visit. However, although history taking and physical examination are the cornerstones of medical practice, they have not been well studied. Improving quality of care in the ambulatory sector will require better knowledge about medical decision-making processes, in particular identification of the most relevant information required for a decision and the optimal way of obtaining it in any specific clinical situation.

Comparison of patient satisfaction with ambulatory visits in competing health care delivery settings in Geneva, Switzerland.

OBJECTIVES: To measure satisfaction with medical visits in various health care settings and to assess the extent to which differences in satisfaction scores between health care settings can be attributed to patients' characteristics. DESIGN: This was a cross sectional survey to measure seven dimensions of patient satisfaction. SETTINGS: Ambulatory visits to 'gatekeepers' or specialists in a newly established managed care organisation, a private group practice, or a university hospital outpatient clinic in Geneva, Switzerland. PATIENTS: There were altogether 1027 adult patients (81% participation rate). RESULTS: Patients who consulted physicians in the private group practice reported higher levels of satisfaction (overall mean 83.2 on a scale between 0 and 100) than university clinic patients (79.7), patients of independent specialists within the managed plan (78.5), and patients of managed plan gatekeepers (69.8, intergroup differences p < 0.001). Differences between settings were reduced after adjustment for sex, age, country of origin, general practitioner versus specialist visit, and scheduled versus urgent visit (adjusted scores: 80.8, 78.8, 77.6, and 72.7 in the four settings, p < 0.001). Intergroup differences were largest for general satisfaction, but small and non-significant for satisfaction with explanations given by the physician and for time spent with the patient. CONCLUSIONS: Patient satisfaction varied widely between health care settings. Differences in satisfaction ratings could be ascribed only partly to disparities in patient populations. Patients of managed plan gatekeepers were least satisfied, presumably because they could not choose their physician freely. Comparison of patient satisfaction across health care settings can provide a basis for targeted quality improvement initiatives.

[Patient satisfaction in the ambulatory setting: validation of a scale and identification of associated factors]. / Satisfaction des patients en milieu ambulatoire: validation d'une échelle et identification de facteurs associés.

BACKGROUND: Patient satisfaction is increasingly used to evaluate the performance of health services. Validated French-language instruments to measure satisfaction are currently lacking. This study was designed to validate a questionnaire of this kind and to identify factors associated with patient satisfaction. METHODS: Mail survey of 1027 patients who consulted at 4 different ambulatory health care settings in Geneva, Switzerland. The participation rate was 81%. The questionnaire measured 7 dimensions of satisfaction using 16 items adapted from other sources. RESULTS: The questionnaire was easy to respond to (scores were available for 95 to 99% of respondents, depending on the scale). The internal consistency of the scales was satisfactory (Cronbach alpha between 0.65 and 0.82) for 5 of 6 multi-item scales; it was lower for the scale which measures satisfaction with access to care. Factor analysis identified two principal components corresponding roughly to the "process" and to the "organization" of care. Open comments also confirmed the validity of the multi-item scales. Several patient or visit characteristics were independently associated with the level of satisfaction: older patients, those who were born in Switzerland, who had a visit appointment, who consulted a specialist, and those who saw the same physician as at their previous visit were more satisfied than other patients. CONCLUSIONS: The brief satisfaction questionnaire described in this paper is easy to use, and its reliability and validity are good. Its use can be recommended in ambulatory health care settings. Several variables associated with the level of satisfaction were identified; they should be measured in satisfaction surveys to allow correct appraisal of the results.

[Current models in health insurance and health care delivery]. / Nouveaux modèles d'assurance-maladie et gestion des soins.

Health care organizations similar to American HMOs have recently appeared in Switzerland. They elicit many reactions, both in the general public and among the medical profession. In contrast to traditional health insurance, HMOs organize and actively manage health care delivered to their members. This paper reviews the historical background of similar organizations in Europe and in the United States, and focuses in particular on the recent evolution and fragmentation of the concept of "managed care". Follows a discussion of the mechanisms and the side-effects of various tools used to manage care, both in managed care settings and by traditional health insurance plans. It appears that all of health care is managed, that all management tools have potential side effects, and that use of some management tools implies a redistribution of the respective roles of plan members, administrators, and physicians. The authors suggest that the complexity of health care management requires a more active implication of the health professions in that process.