Impact of the COVID-19 pandemic on the quality of diabetes care: Insights from longitudinal data in Switzerland.

In this population-based cohort study on diabetes care, self-reported quality indicators measured just before (2019) and during (2021) the COVID-19 pandemic were comparable, apart from a modest increase in seasonal influenza immunization and a small decline in patient-centeredness of care in 2021.

Ambulatory Healthcare Use Profiles of Patients With Diabetes and Their Association With Quality of Care: A Cross-Sectional Study.

Background: Despite the growing burden of diabetes worldwide, evidence regarding the optimal models of care to improve the quality of diabetes care remains equivocal. This study aimed to identify profiles of patients with distinct ambulatory care use patterns and to examine the association of these profiles with the quality of diabetes care. Methods: We performed a cross-sectional study of the baseline data of 550 non-institutionalized adults included in a prospective, community-based, cohort study on diabetes care conducted in Switzerland. Clusters of participants with distinct patterns of ambulatory healthcare use were identified using discrete mixture models. To measure the quality of diabetes care, we used both processes of care indicators (eye and foot examination, microalbuminuria screening, blood cholesterol and glycated hemoglobin measurement [HbA1c], influenza immunization, blood pressure measurement, physical activity and diet advice) and outcome indicators (12-Item Short-Form Health Survey [SF-12], Audit of Diabetes-Dependent Quality of Life [ADDQoL], Patient Assessment of Chronic Illness Care [PACIC], Diabetes Self-Efficacy Scale, HbA1c value, and blood pressure <140/90 mmHg). For each profile of ambulatory healthcare use, we calculated adjusted probabilities of receiving processes of care and estimated adjusted outcomes of care using logistic and linear regression models, respectively. Results: Four profiles of ambulatory healthcare use were identified: participants with more visits to the general practitioner [GP] than to the diabetologist and receiving concomitant podiatry care ("GP & podiatrist", n=86); participants visiting almost exclusively their GP ("GP only", n=195); participants with a substantially higher use of all ambulatory services ("High users", n=96); and participants reporting more visits to the diabetologist and less visits to the GP than other profiles ("Diabetologist first", n=173). Whereas participants belonging to the "GP only" profile were less likely to report most processes related to the quality of diabetes care, outcomes of care were relatively comparable across all ambulatory healthcare use profiles. Conclusions: Slight differences in quality of diabetes care appear across the four ambulatory healthcare use profiles identified in this study. Overall, however, results suggest that room for improvement exists in all profiles, and further investigation is necessary to determine whether individual characteristics (like diabetes-related factors) and/or healthcare factors contribute to the differences observed between profiles.

Interest in and use of person-centred pharmacy services - a Swiss study of people with diabetes.

BACKGROUND: Diabetes is one of the most important chronic diseases and affects 9% of the world's population. To support these people in the day-to-day management of their treatments, pharmacies can offer professional pharmacy services. These are defined as one or more actions organized or provided in a pharmacy to optimize the process of care, with the goal of improving health outcomes and the value of healthcare. Such services have to be tailored to the needs and interests of patients. This study aimed to evaluate interest in and use of pharmacy services among people with diabetes in the canton of Vaud, Switzerland. METHODS: This cross-sectional study analysed self-reported data from 790 people with diabetes included in the CoDiab-VD cohort. Questions focused on sociodemographic and economic characteristics, diabetes and its management, and interest in and use of pharmacy services related to (1) medication intake and adherence and (2) diabetes and general health. Descriptive analyses were first conducted. Logistic regression analyses were then performed for pharmacy services that were of interest to ≥50% of respondents. RESULTS: The mean age of participants was 66 years, and the sample included more males (59%) than females. The pharmacy services that interested the most respondents were individual interview, pill boxes or weekly pill boxes, treatment plans, checks of all medications, first medical opinions from pharmacists and counselling on devices. Factors significantly associated with interest in pharmacy services were being older, having a lower self-efficacy score, taking more than three medications and having a positive opinion about pharmacists. CONCLUSIONS: This study provides key information on interest in and use of pharmacy services among patients with diabetes in Switzerland; it should help pharmacists individualize their services for patients.

Feasibility, acceptability and effectiveness of integrated care for COPD patients: a mixed methods evaluation of a pilot community-based programme.

QUESTION UNDER STUDY: The aim of this study was to assess the feasibility, acceptability and effectiveness of a pilot COPD integrated care programme implemented in Valais, Switzerland. METHODS: The programme was adapted from the self-management programme Living Well with COPD, and included the following elements: self-management patient-education group sessions, telephone and medical follow-ups, multidisciplinary teams, training of healthcare professionals, and evidence-based COPD care. A process and outcome evaluation of the pilot phase of the programme was conducted by means of qualitative and quantitative methods. Reach (coverage, participation rates), dosage (interventions carried out), fidelity (delivered as intended) and stakeholders' acceptance of the programme were evaluated through data monitoring and conduct of focus groups with patients and healthcare professionals. Effectiveness was assessed with pre-post analyses (before and after the intervention). The primary outcome measures were; (1) generic and disease-specific quality of life (36-Item Short Form Health Survey, Chronic Respiratory Questionnaire); and (2) hospitalisations (all-cause and for acute exacerbations) in the past 12 months. Secondary outcomes included self-efficacy, number of exacerbations and exercise capacity. Finally, controlled pre-post comparisons were also made with patients from the Swiss COPD Cohort for three common outcome measures (dyspnoea [mMRC score], number of exacerbations and smoking status). RESULTS: During the first 2 years of the programme, eight series of group-based education sessions were delivered to 57 patients with COPD in three different locations of the canton of Valais. Coverage objectives were achieved and attendance rate at the education sessions was high (83.6%). Patients' and healthcare professionals' reported a high degree of satisfaction, except for multidisciplinarity and transfer of information. Exploration of the effectiveness of this pilot programme suggested positive pre-post results at 12 months, with improvements in terms of health-related quality of life, self-efficacy, exercise capacity, immunisation coverage and Patient Assessment of Chronic Illness Care score. No other outcome, including the number of hospital admissions, differed significantly after 12 months. We observed no differences from the control group. CONCLUSIONS: The evaluation demonstrated the feasibility and acceptability of the programme and confirmed the relevance of mixed method process evaluation to adjust and improve programme implementation. The introduction of multidisciplinary teams in a context characterised by fragmentation of care was identified as the main challenge in the programme implementation and could not be achieved as expected. Despite this area for improvement, patients' feedback and early effectiveness results confirmed the benefits of COPD integrated care programmes emphasising self-management education.

Awareness and practices regarding eye diseases among patients with diabetes: a cross sectional analysis of the CoDiab-VD cohort.

BACKGROUND: The increasing prevalence of diabetes is leading to a rise of eye diseases, augmenting the risk of sight-threatening complications. The aim of this study was to evaluate prevalence, awareness and practices regarding eye diseases among patients with diabetes in the canton of Vaud, Switzerland. METHODS: A cohort of 323 patients with diabetes completed a self-administered questionnaire assessing prevalence, awareness and practices regarding eye diseases, besides health status and quality of care measures. Descriptive analyses followed by exploratory subgroup analyses and linear regressions were performed to investigate factors associated with awareness and practices. RESULTS: While diabetic retinopathy was reported by 40.9% of patients with type 1 diabetes and 9.8% of patients with type 2 diabetes, 35.8% and 12.6% of all participants reported cataract and glaucoma, respectively. Awareness that diabetes could damage the eyes was reported by almost all participants; the majority was also aware of the importance of glycemic control and regular eye examination in preventing eye diseases. In contrast, only 70.5% of participants underwent an eye examination by an ophthalmologist during the past year. Eye examination was associated with better patients' awareness. Barriers mentioned by patients revealed a lack of knowledge about screening guidelines, in particular regarding the preventive nature of eye examinations. CONCLUSIONS: Despite high levels of awareness regarding diabetic eye diseases, a significant proportion of patients with diabetes did not report annual eye examination. Both healthcare strategic efforts targeting the promotion of regular eye examination and initiatives aiming at improving knowledge of screening guidelines should be encouraged. TRIAL REGISTRATION: ClinicalTrials.gov on 9th July 2013, identifier NCT01902043 (retrospectively registered).

Health literacy and quality of care of patients with diabetes: A cross-sectional analysis.

BACKGROUND: Limited health literacy (HL) may lead to poor health outcomes and inappropriate healthcare use, particularly in patients with chronic diseases. We aimed to assess the association between functional HL (FHL) and quality of care, as measured by process- and outcome-of-care indicators, in patients with diabetes. METHODS: This cross-sectional study used data from the 2013 CoDiab-VD cohort follow-up, which included non-institutionalised adults with diabetes from canton of Vaud, Switzerland. Using self-administered questionnaires, we collected patients' characteristics, processes [annual HbA1C check, lipid profile, urine test, foot examination, influenza vaccination, eye examination (24 months), physical activity and diet recommendations] and outcomes of care (HbA1C knowledge, HbA1C value, SF-12, ADDQoL, PACIC, self-efficacy). A single validated screening question assessed FHL. Unadjusted and adjusted regression analyses were performed. RESULTS: Of 381 patients 52.5% (95%CI: 47.5%-57.5%), 40.7% (95%CI: 35.7%-45.6%) and 6.8% (95%CI: 4.3%-9.4%) reported high, medium and poor FHL, respectively. Significant associations were found for two out of seven outcomes of care; lower self-efficacy scores associated with medium and poor FHL (adjusted: ß -0.6, 95%CI -0.9 to -0.2 and ß -1.8, 95%CI -2.5 to -1.2, respectively), lower SF-12 mental scores associated with poor FHL (adjusted: ß -8.4, 95%CI -12.5 to -4.2). CONCLUSIONS: This study found few outcomes of care associated with FHL. Further exploration of the impact of limited HL on quality of care indicators will help tailor initiatives - both on patients' and providers' side - to improve diabetes care.

CoDiab-VD: protocol of a prospective population-based cohort study on diabetes care in Switzerland.

BACKGROUND: Diabetes represents an increasing health burden worldwide. In 2010, the Public Health Department of the canton of Vaud (Switzerland) launched a regional diabetes programme entitled "Programme cantonal Diabète" (PcD), with the objectives to both decrease the incidence of diabetes and improve care for patients with diabetes. The cohort entitled CoDiab-VD emerged from that programme. It specifically aimed at following quality of diabetes care over time, at evaluating the coverage of the PcD within this canton and at assessing the impact of the PcD on care of patients with diabetes. METHODS/DESIGN: The cohort CoDiab-VD is a prospective population-based cohort study. Patients with diabetes were recruited in two waves (autumn 2011--summer 2012) through community pharmacies. Eligible participants were non-institutionalised adult patients (≥ 18 years) with diabetes diagnosed for at least one year, residing in the canton of Vaud and coming to a participating pharmacy with a diabetes-related prescription. Women with gestational diabetes, people with obvious cognitive impairment or insufficient command of French were not eligible. Self-reported data collected, included the following primary outcomes: processes-of-care indicators (annual checks) and outcomes of care such as HbA1C, (health-related) quality of life measures (Short Form-12 Health Survey--SF-12, Audit of Diabetes-Dependent Quality of Life 19--ADDQoL) and Patient Assessment of Chronic Illness Care (PACIC). Data on diabetes, health status, healthcare utilisation, health behaviour, self-management activities and support, knowledge of, or participation to, campaigns/activities proposed by the PcD, and socio-demographics were also obtained. For consenting participants, physicians provided few additional pieces of information about processes and laboratory results. Participants will be followed once a year, via a mailed self-report questionnaire. The core of the follow-up questionnaires will be similar to the baseline one, with the addition of thematic modules adapting to the development of the PcD. Physicians will be contacted every 2 years. DISCUSSION: CoDiab-VD will allow obtaining a broad picture of the care of patients with diabetes, as well as their needs regarding their chronic condition. The data will be used to evaluate the PcD and help prioritise targeted actions. TRIAL REGISTRATION: This study is registered with ClinicalTrials.gov, identifier NCT01902043, July 9, 2013.

Prevalence and Diagnostic Approach to Sleep Apnea in Hemodialysis Patients: A Population Study.

BACKGROUND: Previous observations found a high prevalence of obstructive sleep apnea (OSA) in the hemodialysis population, but the best diagnostic approach remains undefined. We assessed OSA prevalence and performance of available screening tools to propose a specific diagnostic algorithm. METHODS: 104 patients from 6 Swiss hemodialysis centers underwent polygraphy and completed 3 OSA screening scores: STOP-BANG, Berlin's Questionnaire, and Adjusted Neck Circumference. The OSA predictors were identified on a derivation population and used to develop the diagnostic algorithm, which was validated on an independent population. RESULTS: We found 56% OSA prevalence (AHI ≥ 15/h), which was largely underdiagnosed. Screening scores showed poor performance for OSA screening (ROC areas 0.538 [SE 0.093] to 0.655 [SE 0.083]). Age, neck circumference, and time on renal replacement therapy were the best predictors of OSA and were used to develop a screening algorithm, with higher discriminatory performance than classical screening tools (ROC area 0.831 [0.066]). CONCLUSIONS: Our study confirms the high OSA prevalence and highlights the low diagnosis rate of this treatable cardiovascular risk factor in the hemodialysis population. Considering the poor performance of OSA screening tools, we propose and validate a specific algorithm to identify hemodialysis patients at risk for OSA for whom further sleep investigations should be considered.

Association between education and quality of diabetes care in Switzerland.

PURPOSE: Low socioeconomic status is associated with higher prevalence of diabetes, worse outcomes, and worse quality of care. We explored the relationship between education, as a measure of socioeconomic status, and quality of care in the Swiss context. PATIENTS AND METHODS: Data were drawn from a population-based survey of 519 adults with diabetes during fall 2011 and summer 2012 in a canton of Switzerland. We assessed patients and diabetes characteristics. Eleven indicators of quality of care were considered (six of process and five of outcomes of care). After bivariate analyses, regression analyses adjusted for age, sex, and diabetic complications were performed to assess the relationship between education and quality of care. RESULTS: Of 11 quality-of-care indicators, three were significantly associated with education: funduscopy (patients with tertiary versus primary education were more likely to get the exam: odds ratio, 1.8; 95% confidence interval [CI], 1.004-3.3) and two indicators of health-related quality of life (patients with tertiary versus primary education reported better health-related quality of life: Audit of Diabetes-Dependent Quality of Life: ß=0.6 [95% CI, 0.2-0.97]; SF-12 mean physical component summary score: ß=3.6 [95% CI, 0.9-6.4]). CONCLUSION: Our results suggest the presence of educational inequalities in quality of diabetes care. These findings may help health professionals focus on individuals with increased needs to decrease health inequalities.

A new technique with high reproducibility to estimate renal oxygenation using BOLD-MRI in chronic kidney disease.

OBJECTIVES: To assess inter-observer variability of renal blood oxygenation level-dependent MRI (BOLD-MRI) using a new method of analysis, called the concentric objects (CO) technique, in comparison with the classical ROI (region of interest)-based technique. METHODS: MR imaging (3T) was performed before and after furosemide in 10 chronic kidney disease (CKD) patients (mean eGFR 43±24ml/min/1.73m(2)) and 10 healthy volunteers (eGFR 101±28ml/min1.73m(2)), and R2* maps were determined on four coronal slices. In the CO-technique, R2* values were based on a semi-automatic procedure that divided each kidney in six equal layers, whereas in the ROI-technique, all circles (ROIs) were placed manually in the cortex and medulla. The mean R2*values as assessed by two independent investigators were compared. RESULTS: With the CO-technique, inter-observer variability was 0.7%-1.9% across all layers in non-CKD, versus 1.6%-3.8% in CKD. With the ROI-technique, median variability for cortical and medullary R2* values was 3.6 and 6.8% in non-CKD, versus 4.7 and 12.5% in CKD; similar results were observed after furosemide. CONCLUSION: The CO-technique offers a new, investigator-independent, highly reproducible alternative to the ROI-based technique to estimate renal tissue oxygenation in CKD.

Baseline data of a population-based cohort of patients with diabetes in Switzerland (CoDiab-VD).

QUESTIONS UNDER STUDY: To describe a population-based sample of patients with diabetes and the quality of their care in the canton of Vaud, Switzerland, as a baseline measure for the evaluation of the "Programme cantonal Diabète". METHODS: We conducted a self-administered paper-based questionnaire survey. Non-institutionalised adult (aged ≥18 years) patients with diabetes diagnosed for at least 1 year and residing in the canton of Vaud were recruited by community pharmacies. Women with gestational diabetes, people with obvious cognitive impairment or people not sufficiently fluent in French were excluded. Primary outcomes were recommended processes-of-care and outcomes of care (glycosylated haemoglobin [HbA1c], generic and disease-specific health-related quality of life (HRQoL), overall care score in relation to the Chronic Care Model). Other measures included diabetes education, self-management support and self-efficacy, health status, health behaviour and demographics. RESULTS: A total of 519 patients with diabetes were included. Whereas the mean HbA1c level was 7.3% (n = 177, 95% confidence interval 7.1-7.5), diabetes-specific processes-of-care and influenza vaccination were reported by less than two-thirds of the patients. Physical activity and diet recommendations results mirrored patients' difficulties with their management in daily life and diabetes-specific HRQoL was worst in the dimensions relative to diet (eating and drinking) and sex life. A minority of patients reported ever having participated in diabetes education courses (32.8%). Overall, patients were satisfied with their care and the support they received. CONCLUSIONS: This study provides a broad picture of the experiences of people living with diabetes in the canton of Vaud. It shall guide the development of targeted interventions within the "Programme cantonal Diabète".

Genetic diversity of EBV-encoded LMP1 in the Swiss HIV Cohort Study and implication for NF-Κb activation.

Epstein-Barr virus (EBV) is associated with several types of cancers including Hodgkin's lymphoma (HL) and nasopharyngeal carcinoma (NPC). EBV-encoded latent membrane protein 1 (LMP1), a multifunctional oncoprotein, is a powerful activator of the transcription factor NF-κB, a property that is essential for EBV-transformed lymphoblastoid cell survival. Previous studies reported LMP1 sequence variations and induction of higher NF-κB activation levels compared to the prototype B95-8 LMP1 by some variants. Here we used biopsies of EBV-associated cancers and blood of individuals included in the Swiss HIV Cohort Study (SHCS) to analyze LMP1 genetic diversity and impact of sequence variations on LMP1-mediated NF-κB activation potential. We found that a number of variants mediate higher NF-κB activation levels when compared to B95-8 LMP1 and mapped three single polymorphisms responsible for this phenotype: F106Y, I124V and F144I. F106Y was present in all LMP1 isolated in this study and its effect was variant dependent, suggesting that it was modulated by other polymorphisms. The two polymorphisms I124V and F144I were present in distinct phylogenetic groups and were linked with other specific polymorphisms nearby, I152L and D150A/L151I, respectively. The two sets of polymorphisms, I124V/I152L and F144I/D150A/L151I, which were markers of increased NF-κB activation in vitro, were not associated with EBV-associated HL in the SHCS. Taken together these results highlighted the importance of single polymorphisms for the modulation of LMP1 signaling activity and demonstrated that several groups of LMP1 variants, through distinct mutational paths, mediated enhanced NF-κB activation levels compared to B95-8 LMP1.