Health technology assessment in Switzerland.

Switzerland has a mixed public and private healthcare system. All citizens are enrolled in compulsory basic health insurance. A 1996 law allows people to choose among different sickness funds and managed care plans. The federal government is empowered to act on important health issues, but the 26 cantons have prime responsibility in health care and social welfare. They have their own laws on health care, hygiene, hospitals, and social welfare. These laws are not harmonized. The system is complex, with a mix of public (mainly hospitals) and private (mainly doctors' offices) providers. The health services are decentralized. Ambulatory care was traditionally provided in doctors' offices, but the last decade has seen the development of centers for day surgery, group practices, and managed care plans. Decisions on placement, location, and extension of services are decentralized. The payment system is very complex. Current trends include global budgets, cost analyses, and prices related to patient categories. However, coverage policy is developed centrally and includes both traditionally established services and new technologies. New technologies are added to the list only after evaluation by the Federal Coverage Committee. The coverage process integrates health technology assessment (HTA). Coverage can be granted in stages, including limited coverage and temporary coverage. Technologies and coverage can be reevaluated on the basis of registries or assessment information. The structure of the Swiss healthcare system does not lend itself to the establishment of a national HTA program. However, recent moves include the development of a coordinating mechanism for HTA in Switzerland.

[Preventive medicine: costs and responsibilities of insurance companies]. / Präventionsmedizin: Kosten und Leistungen der Versicherer.

Under the provisions of the Health Insurance Law (KVG), the costs of preventive medicine are to be borne by the mandatory health insurance. Although it has been defined who shall be responsible for taking the necessary measures, concrete objectives have yet to be established. This is giving rise to difficulties in the implementation of the law. The author discusses basic questions relating to this situation: The nature of the preventive measures (GENOME Analysis), and the economic efficiency. An insight is also given into the work of the Preventive Medicine Services Subcommittee of the Federal Service-Providing Committee (Subkommission Präventive Leistungen der Eidgenössischen Leistungskommission) and the criteria adopted.

Indoor Rn levels in different geological areas in Switzerland.

The distribution of indoor Rn concentrations in different geological areas in Switzerland was studied using passive alpha-track detectors. Measurements involving a sample of 400 single-family homes were made in the cellar, on the ground floor and the first floor, respectively. On the basis of a pilot survey, the country was divided into four zones in which the Rn distribution in houses was analyzed separately. The indoor exposure to Rn and Rn decay products is quite variable from region to region. The geology of the different areas was found to be an important factor in determining the mean value Rn levels. In the basin north of the Alps, where the population centers are located, a median Rn gas level of 47 Bq m-3 for the living area was found. The arithmetic mean value of 60 Bq m-3 in this region leads to an annual effective dose equivalent of about 1.8 mSv. For the population living in alpine areas, an arithmetic mean value exceeding 200 Bq m-3 will lead to an annual effective dose equivalent in the range of 6 mSv. The estimated exposure to Rn and Rn decay products for the upper one-percentile of the homes in the most affected alpine region even exceeds the annual limit of 50 mSv effective dose equivalent for occupational exposure.

[Health policy aspects: role of the government in the prevention of tobacco abuse]. / Gesundheitspolitische Aspekte: die Rolle des Staates in der Prävention des Tabakmissbrauchs.

Possible instruments for control of tobacco-abuse available in a liberal and democratic country are discussed. Prohibition-strategies including bans on advertisement and non smoking areas, reduction of insurance benefits and modifications of liability rules are valued with reservation. Emphasis is placed on fiscal measures and on support of preventive measures exerted by family physicians.

[Effect of droperidol on the creatine phosphokinase activity in acute myocardial infarct]. / Beeinflussung der Aktivität des Kreatin-phosphokinase-Isoenzyms durch Droperidol beim akuten Myokardinfarkt.

In 141 patients with acute myocardial infarction, creatine phosphokinase isoenzyme (CPK-MB) was determined by the activation method with dithiothreitol (RAO et al.: Clin. Chim. Acta 21, 1612 [1975]). 15 out of 16 patients with atypical negative CPK-MB values within the first 3 days after infarction had been treated with 5-10 mg droperidol, a neuroleptic drug dispensed for its antiemetic effect. In a prospective study in 7 patients, CPK-MB determined serially showed a decrease or persistently low or negative values within 1 minute after injection of 5 mg droperidol and lasting 24-36 hours after injection. In contrast, CPK-MB determined by immunoprecipitation did not change its typical pattern after use of droperidol. Hence, negative or low values of CPK-MB in acute myocardial infarction must be expected after droperidol if determination is by the activation method with dithiothreitol.

Changes in phasic femoral artery flow induced by various stimuli: a study with percutaneous pulsed Doppler ultrasound.

Transcutaneous blood flow measurements were performed by means of pulsed Doppler ultrasound flowmeter in the femoral artery of healthy subjects. The pulsatile flow pattern was changed characteristically from resting state by postocclusive reactive hyperaemia, by the application of amyl nitrite, xanthinol nicotinate, and angiotensin amide. During reactive hyperaemia systolic flow was increased, diastolic reverse flow was abolished, and the forward flow continued throughout diastole. Amyl nitrite augmented thenegative flow phase and reduced mean flow, while xanthinol nicotinate decreased the negative component and augmented mean flow. Angiotensin amide produced enhancement of the average flow by elevating systolic and diastolic flow equally over the base line. In each of these interventions the changes in flow were determined mainly by variations during the diastolic flow phase.

Left ventricular contractile function in aortic stenosis evaluated by isovolumic and ejection phase indexes.

This study is to reappraise the usefulness of isovolumic as compared to ejection phase indexes for detecting abnormal left ventricular contractile function patients with a common hemodynamic abnormality, namely, chronic left ventricular pressure overload. In 41 subjects with pure or predominant aortic stenosis left ventricular pressure measurements were performed by micromanometry. Single-plane left ventricular cineangiograms were carried out in the right anterior oblique (RAO) and the A-P position. The isovolumic contractile indexes we used in this study were peak measured velocity of shortening of the contractile elements (Vpm) and Vmax obtained from linear extrapolation of total pressure-velocity curves. The end-diastolic and end-systolic RAO cineventriculograms served for the calculation of the ejection phase parameters mean velocity of circumferential fiber shortening (VCF) and mean normalized systolic ejection rate (MNSER). Of the 41 patients, Vpm was depressed in 16 (39 per cent), Vmax in 17 (42 per cent), VCF in 12 (29 per cent), and MNSER in 14 (34 per cent). When the isovolumic and the ejection phase parameters were combined, 24 patients (59 per cent) were found to have at least one of the four contractile indexes below normal. In 26 of the 41 patients the isovolumic and the ejection phase indexes provided the same conclusions as to normality of left ventricular function. In contrast, 15 patients showed discordant isovolumic and ejection phase indexes. An increased left ventricular end-diastolic pressure was only inconsistently related to an abnormal left ventricular function because in 7 of 28 patients with an end-diastolic pressure above 14 mm. Hg all contractile indexes were normal. Furthermore, a normal end-diastolic pressure was present in three of 24 patients with depressed myocardial function. It is concluded that in chronic left ventricular pressure overload from aortic stenosis neither the isovolumic nor the ejection phase indexes are superior in sensitivity for assessing contractile function. In this clinical setting the combination of both types of indexes appears to be the most reliable way for identifying patients with depressed contractile function of theleft ventricle in the basal state.

The influence of hypertrophy on myocardial function.

In patients with hypertrophy from long-standing left ventricle pressure (PL) and volume overload (VL) as well as in a group of controls basal left ventricular contractility was assessed by peak measured isovolumic velocity of shortening (Vpm), mean velocity of circumferential fiber shortening (mean VCF) and mean normalized systolic ejection rate (MNSER). The angiographically determined left ventricular muscle mass was elevated to a similar extent in PL and VL. As compared to the control group both hypertrophy had decreased contractile indexes. No significant differences of contractility existed between the groups with PL and VL. Hence it appears that in chronic mechanical overloading the extent of hypertrophy is probably more important for the decrease of contractility than the nature of the stimulis to hypertrophy. In 15 patients with aortic stenosis left ventricular muscle mass and isovolumic and ejection phase contractile indexes were determined preoperatively and 13.5 months after successful valve replacement by a tilting disc prosthesis. Postoperatively there was a significant (P less than 0.001) decrease of muscle mass from 182 to 114 g/m2. Mean VCF increased from 1.07 to 1.52 circ/sec (P less than 0.01); MNSER from 1.92 to 2.59 enddiastolic volumes/sec (P less than 0.01); Vpm from 1.17 to 1.60 ML/sec (P less than 0.001) and total pressure Vmax from 1.61 to 2.09 ML/sec (P less than 0.01). In 9 of 13 patients an abnormal or pathologic response to handgrip at the preoperative study became normal postoperatively. It is concluded that in aortic stenosis removal of the chronic pressure burden leads to regression of left ventricular hypertrophy associated with an improvement of resting and exercise contractile function. Pressure-deprived contractile indexes; ejection phase contractile indexes; chronic pressure load; chronic volume load; aortic valve replacement; postoperative hemodynamics.

[Proceedings: The ankle arterial pressure during reactive hyperemia in healthy patients and patients with arterial occlusive disease]. / Der Knöchelarteriendruck während reaktiver Hyperämie bei Gefässgesunden und Patienten mit arterieller Verschlusskrankheit

In 8 healthy subjects and in 16 patients with arterial occlusions in the iliac or ilio-femoral region ankle blood pressure and blood flow velocity were measured by Doppler ultrasound during postocclusive reactive hyperemia. In the normal subjects the ankle blood pressure decreased significantly within the initial 30 sec after release of the occlusion. The pressure values showed a negative relation to the simultaneous increases in flow velocity (r = 0.67). In the patients the pressure decreased further and the reduction was prolonged with the protracted course of the reactive hyperemia.

[Proceedings: Determination of the severity of aortic insufficiency with pulsed Doppler-ultrasound in the common carotid artery]. / Bestimmung des Schweregrades von Aorteninsuffizienzen mit gepulstem Doppler-Ultraschall an der A. carotis communis

The severity of aortic incompetence can be assessed by quantifying the alteration of blood flow in the common carotid artery. The use of a pulsed multichannel ultrasonic Doppler device in 41 patients with aortic valve disease yielded a satisfactory correlation between the ultrasonic parameters and the maximal aortic regurgitation distance. Correlations between Doppler parameters and regurgitation (thermodilution) were less strict.

[Proceedings: Left ventricular cineangiography and echocardiography in patients with the mesosystolic click-telesystolic sound syndrome]. / Linksventrikuläre Cineangiographie und Echokardiographie bei Patienten mit dem Symdrom mesosystolischer Klick-telesystolisches Geräusch

Twenty-three patients with the syndrome of midsystolic click--late systolic murmur were investigated by right and left heart catheterization, cineangiography and echocardiography. Most of the patients had symptoms such as atypical chest pain and arrhythmias. Except in one patient, slight to moderate mitral incompetence was found at rest or during stress testing by infusion of aramine or rapid atrial pacing (2 patients). In all cases, an abnormal systolic mitral valve motion was found in left ventricular cineangiography. In 14 of 15 technically satisfactory echocardiograms a systolic prolapse of one or both mitral leaflets was observed. A minority of the patients had localized abnormal wall motion in the postero-basal area or moderate generalized hypokinesis.

[Left ventricular cineangiography and echocardiography in patients with the mesosystolic click-telesystolic murmur syndrome]. / Linksventrikuläre Cineangiographie und Echokardiographie bei Patienten mit dem Syndrom mesosystolischer Klick - telesystolisches Geräusch

Twenty-three patients with the midsystolic click - late systolic murmur syndrome were investigated by right and left heart catheterization, cineangiography and echocardiography. Most had symptoms such as atypical chest pain and arrhythmias. Except in one patient, slight to moderate mitral incompetence was present at rest (20 patients) or during stress testing by the infusion of aramine or rapid atrial pacing (2 patients). In all cases, an abnormal systolic mitral valve motion was found by left ventricular cineangiography. In 14 of 15 technically satisfactory echocardiograms a systolic prolapse of one or both mitral leaflets was observed. A minority of the patients had localized abnormal wall motion in the posterobasal area or moderate generalized hypokinesis.