A randomized experiment of the effects of including alternative medicine in the mandatory benefit package of health insurance funds in Switzerland.

OBJECTIVES: The present investigation focuses on the following questions: 1. Are complementary medical services paid for by a health insurer used in addition to orthodox medical services, or as substitute for them?; 2. If health insurers include complementary medical services in the basic cover, what will be the effect on costs?; 3. If complementary medical services as included in the basic cover, what will be the effect on the policyholders' subjective state of health? STUDY DESIGN: A randomized experiment was set up in which 7500 members of Switzerland's biggest health insurance fund, Helvetia, were offered free supplementary insurance for alternative medicine for 3 years. This simulated a situation in which the experimental group had access to the full range of complementary medical treatments under their health insurance policies. The remaining members in the scheme (670,000) people) formed the control group. To evaluate the effect on costs, we analysed the health insurer's cost and benefits data. In addition, a survey was carried out among random samples of subjects from the experimental group and from the control group using the 36-Item Short-Form Health Survey (SF-36) to examine the effects of including complementary medicine on subjective state of health. RESULTS: The analysis of the cost data shown that subjects used alternative in addition to orthodox medical services. It is also clear that alternative medical treatments are given in combination with orthodox medicine; less than 1% of the experimental group used exclusively alternative medical services. However, as only a very small percentage of experimental subjects (6.6%) took advantage of complementary medicine, no significant impact on overall health costs can be inferred. On the other hand, multiple regressions show that use of complementary medicine has a greater effect on treatment costs than sex, age or language region. Neither at the beginning nor the end of the experiment were any significant differences noted in the scales of the SF-36 between the experimental and the control group. Nor did multiple regressions reveal any effects on subjects' state of health due to the inclusion of complementary medicine in the basic insurance cover.

[Health economic analysis of the effects of including complementary medicine in the benefit package of health insurance]. / Gesundheitsökonomische Analyse der Wirkungen des Angebots komplementärmedizinischer Leistungen der Krankenkassen.

A randomized experiment was set up in which 7,500 policyholders of Switzerland's largest health insurance fund, Helvetia, were offered free supplementary insurance for complementary medicine for 3 years. This was meant to simulate a situation in which the experimental group had access to the full range of complementary medical treatments under their health insurance policies. The remaining policyholders in the scheme (670,000 people) formed the control group. A third group of policyholders who had taken out additional insurance for complementary medical services at their own expense is mentioned only in passing. The health insurer's cost and benefit data were analyzed to evaluate the effect of the offered free supplementary insurance for complementary medicine. In addition, a survey was carried out among random samples of subjects from the experimental group and from the control group using the 36-Item Short-Form Health Survey (SF-36) to examine the effects of including complementary medicine on people's subjective state of health. The analysis of the cost data showed that subjects in the experimental group used complementary medicine in addition to mainstream medical services. It became also clear that alternative medical treatments were given in combination with orthodox medicine; less than 1% of the experimental group used exclusively alternative medical services. However, as only a very small percentage of the experimental subjects (6.6%) took advantage of complementary medicine, no significant impact on overall health cost could be inferred. On the other hand, multiple regressions showed that the use of complementary medicine had a greater effect on the treatment costs than sex, age or language region. Neither at the beginning nor the end of the experiment were any significant differences noted in the scales of the SF-36 between the experimental and the control group; nor did multiple regressions reveal any effects on subjects' state of health due to the inclusion of complementary medicine in the basic insurance cover. This study was presented in the media and at a public hearing of the Swiss National Science Foundation. It triggered numerous valuable discussions. The study design and the conclusions were not left uncontested.

[Does the new Health Insurance Legislation lead to more competition? Consequences for physicians]. / Führt das neue KVG zu mehr Wettbewerb? Konsequenzen für die Arzte.

One of the goals of the new Swiss Health Insurance Law, which will be effective as of January 1, 1996, is to strengthen the market forces in the Swiss health care system. Although under the new law several barriers to competition will continue to exist, competition between physicians in private practice and between hospitals will have profound effects. In future physicians will have to accept responsibility not only for medical aspects but also for the financial consequences of their action. They will be confronted with new forms of reimbursement, utilization and cost reviews. Therefore, doctors will require training for their new role in a market-oriented health care system.

[Health economic analysis of the effects of offered complementary medical procedures on health insurance]. / Gesundheitsökonomische Analyse der Wirkungen des Angebotes komplementärmedizinischer Leistungen der Krankenkassen.

A randomized trial is being conducted to determine whether the offer of unconventional medicine as a health benefit by the health insurance funds has a substitutional or additional effect on the use of conventional medicine. For this purpose, a stratified random sample of 5000 enrollees of the largest Swiss health insurance fund is receiving, as an experiment group, an insurance supplement for unconventional medicine during the next three years free of charge. The rest of the insured population with comparable health insurance but without coverage of unconventional medicine is the control group. The third group to be examined are insured persons who have already chosen the unconventional health insurance supplement on their own account. Data of inpatient and outpatient costs and use of conventional and unconventional health services will be collected and analyzed. The third group with self-selected insurance supplement for unconventional medicine will be compared systematically with the other two groups. A further random sample of persons from each of the three groups will be interviewed at different points of time about their health perceptions.

[Hyperlactacidemia in intestinal ischemia. II. Experimental principles]. / Hyperlactatämie bei Darmischämie. II. Experimentelle Grundlagen.

Looking for an early laboratory parameter in diagnosis of acute bowel ischemia, we caused an acute ischemia of the rabbit bowel by clamping the superior mesenteric artery. The blood tests showed a significant increase of lactate during 80 min of ischemia. This lactate excess continued nearly 40 min after revascularization of the bowel, but disappeared nearly completely after 90 min. Neither the laparotomy without clamping the superior mesenteric artery, nor the experimental clamping of the a. femoralis communis led to a lactacidemia. The lactacidemia in our experiments is compared with clinical observations in acute bowel diseases and vascular surgery with clamping of the aorta. The reasons of the specific high lactate excess of bowel ischemia are discussed. The fast increase of the lactate following mesenteric vascular occlusion and the rapid normalisation of lactate after recovery demonstrate a sensitive method in the diagnosis and controlling the treatment of acute bowel diseases with an insufficient blood supply.

Fluorescence polarization decay of tyrosine in lima bean trypsin inhibitor.

The fluorescence of lima bean trypsin inhibitor is due to a single tyrosine residue at position 69. The lifetime of this tyrosine fluorescence is 620 +/- 50 ps (mean +/- SD) and is little affected by addition of 0.88 M citrate, an efficient quencher of tyrosine fluorescence. The steady-state emission intensity is also only weakly reduced by the quencher. The tyrosine is thus not accessible to the citrate and is probably located in the interior of the protein. The high pK of the tyrosine supports this conclusion. The fluorescence anisotropy decay of the inhibitor's tyrosine can be fitted to a double exponential form, with time constants of about 40 ps and greater than or equal to 3 ns. The anisotropy at time zero is 0.19 +/- 0.015 (mean +/- SD), the same as for N-acetyl-L-tyrosinamide in viscous glycerol solution. The nanosecond component of the decay is consistent with rotation of the entire protein molecule. The 40-ps component demonstrates that the tyrosine has considerable freedom to move independently of the protein as a whole. This rotational correlation time is approximately what is observed for free tyrosine in aqueous solution. Since the polypeptide chain near tyrosine-69 is anchored by several disulfide bonds, the data argue that this interior portion of the protein consists of a rigid, immobile backbone embedded in fluid, mobile amino acid side chains.

Geminate recombination of n-butyl isocyanide to myoglobin.

Transient optical absorption spectra of myoglobin were measured following photolysis of the n-butyl isocyanide complex with 10-ns laser pulses at room temperature. The data were analyzed by using singular value decomposition to give the kinetics of ligand rebinding and spectral changes. Geminate recombination phases were observed at 30 ns and 1 microsecond following photodissociation. These processes were accompanied by simultaneous changes in the shape of the Soret band which indicate changes in protein conformation. These spectral changes are not present in the geminate recombination of photolyzed complexes of myoglobin with the diatomic ligands oxygen and carbon monoxide. This difference in behavior, as well as the slower overall association rate of n-butyl isocyanide to myoglobin, can be rationalized as arising from distortion of the protein structure by the larger isocyanide ligand along the binding pathway.

Nanosecond optical spectra of iron-cobalt hybrid hemoglobins: geminate recombination, conformational changes, and intersubunit communication.

Hybrid hemoglobins were prepared in which cobalt was substituted for the heme iron in either the alpha or beta subunits. Transient optical absorption spectra were measured at room temperature for these hybrids at time intervals between 0 and 50 ms following photodissociation of the carbon monoxide complex with 10-ns laser pulses. The cobalt porphyrins do not bind carbon monoxide, making it possible to investigate the time-resolved response of the cobalt-containing subunits to photodissociation of carbon monoxide in the iron-containing subunits. At the same time the response of the iron-containing subunits to the photolysis event can be studied, permitting an independent determination of the kinetics of ligand rebinding and conformational changes in the alpha and beta subunits of an intact tetramer. The data were analyzed by using singular-value decomposition to obtain the kinetic progress curve for ligand rebinding, the deoxyheme and cobalt porphyrin spectral changes, and the time course of these spectral changes. The geminate rebinding kinetics following photodissociation of alpha(Co)2 beta(Fe-CO)2 were very similar to those found unsubstituted hemoglobin, alpha(Fe-CO)2 beta(Fe-CO)2, indicating equivalence of the geminate kinetics for alpha and beta subunits within the R-state tetramer. The results for alpha(Fe-CO)2 beta(Co)2 were consistent with this conclusion, even though the analysis was complicated by the presence of comparable populations of R- and T-state species. Comparison of the deoxyheme spectral changes and relaxation times among the three molecules indicated that both alpha and beta subunits contribute to the deoxyheme spectral changes that signal tertiary and quaternary conformational changes in the unsubstituted tetramer. The response of the cobalt porphyrins to photodissociation was similar in the two hybrids. No structural changes were detected in the cobalt-containing subunits until the second tertiary conformational change in the iron-containing subunits observed at 1-2 microseconds. Much larger structural changes, as judged by the amplitude of the spectral changes, occurred in the cobalt-containing subunits concomitant with the R----T quaternary change at about 20 microseconds.

Geminate recombination of carbon monoxide to myoglobin.

Transient absorption spectra of myoglobin, following photolysis of the carbon monoxide complex at room temperature, were measured using a newly developed, sensitive nanosecond absorption spectrometer. The Soret spectrum of the immediate photoproduct is almost identical to that of deoxymyoglobin at equilibrium, suggesting that the heme group has changed from a planar to a domed structure in less than about 3 ns. About 4% of the photodissociated carbon monoxide molecules rebind to the hemes to which they were initially bound, with a relaxation time of 180 ns. Duddell et al. (1980) observed a geminate yield of 27% and a relaxation time of approximately 55 ns for the photolysis of oxymyoglobin. Comparison of the two results using the simplest kinetic model suggests that the 30-fold more rapid overall association rate for the reaction of oxygen with myoglobin compared to carbon monoxide results mainly from faster binding at the heme, with a small contribution from more rapid entry of oxygen into the protein from the solvent. The data on carbon monoxide are also compared with predictions from low-temperature studies of Frauenfelder and co-workers. This comparison points to the need for further experiments to demonstrate the correspondence between the ligand rebinding processes observed at high and low temperatures.

Nanosecond absorption spectroscopy of hemoglobin: elementary processes in kinetic cooperativity.

A nanosecond absorption spectrometer has been used to measure the optical spectra of hemoglobin between 3 ns and 100 ms after photolysis of the CO complex. The data from a single experiment comprise a surface, defined by the time-ordered set of 50-100 spectra. Singular value decomposition is used to represent the observed spectra in terms of a minimal set of basis spectra and the time course of their amplitudes. Both CO rebinding and conformational changes are found to be multiphasic. Prior to the quaternary structural change, two relaxations are observed that are assigned to geminate recombination followed by a tertiary structural change. These relaxations are interpreted in terms of a kinetic model that points out their potential role in kinetic cooperativity. The rapid escape of CO from the heme pocket compared with the rate of rebinding observed for both R and T quaternary states shows that the quaternary structure controls the overall dissociation rate by changing the rate at which the Fe--CO bond is broken. A comparable description of the control of the overall association rates must await a more complete experimental description of the kinetics of the quaternary T state.

[Nursing care cases and acute-care hospital beds: results of a one-day census]. / Pflegefälle und Akutbetten: Ergebnisse eines Tageszensus.

For the purposes of an analysis of the hospital capacities of the canton of Basel-Stadt, a one-day census was conducted on April 20, 1983. On that day, the physicians in charge identified every fifth patient out of 2920 hospitalized patients as misplaced. "Misplaced" means that, from a medical point of view, mostly elderly patients could be treated and cared for as well (and cheaper) in other institutions (e.g., nursing homes) or in community settings if adequate home care services were available.