[Swiss healthcare system: a bulimic machine]. / Système de santé suisse : une machine boulimique.

Healthcare costs are a sensitive issue in Switzerland, in particular because of the financial burden of insurance premiums on households. The amount of resources allocated and their significant and regular increase seem to be out of control. But what do these costs really represent? How do we fuel our "machine" and what is the combustion mechanism behind it? At a time when debates are often very much focused on individual interests, this article attempts to answer these questions and to examine the sustainability of a health policy that focuses above all on illness and the cost of care.

Les coûts de la santé sont un sujet sensible en Suisse, notamment du fait du poids financier des primes d'assurance qui pèse sur les ménages. Le montant des ressources allouées et leur augmentation significative et régulière semble non maîtrisable. Mais que représentent réellement ces coûts ? Comment alimente-t-on notre « machine ¼ et quelle est la mécanique de combustion qui se cache derrière ? À l'heure où les débats sont souvent très orientés autour des intérêts de chacun, cet article tente de répondre à ces questions et interroge la durabilité d'une politique de santé focalisée avant tout sur la maladie et le coût des soins.

[Risk assessment and management: between epidemiology and social acceptability]. / Évaluation et gestion des risques : entre épidémiologie et acceptabilité sociale.

Risk is a well-known concept in medicine and in epidemiology and its approach intend to be rational and measurable. Risk measurement makes it possible to communicate with a patient or a population the risk of occurrence of an event. However, it is often difficult to estimate accurately the probability of occurrence of an adverse event and there is therefore uncertainty. In addition, the notion of risk is not easy to grasp for most people. The same risk can be perceived very differently from one individual to another and this perception and understanding depends on psychological, social, cultural, historical and political factors. Understanding this social dimension of risk in clinical practice or in public health is essential to implement efficient risk management.

La notion de risque est bien connue en médecine et en épidémiologie et son approche se veut rationnelle et mesurable. Cette mesure du risque permet de communiquer à un patient ou à une population le risque de survenue d'un événement. Mais il est souvent difficile d'estimer avec précision la probabilité de survenue d'un événement et il existe donc de l'incertitude. De plus, la notion de risque n'est pas facile à appréhender pour la plupart des personnes. Un même risque pourra être perçu très différemment d'un individu à l'autre et ces perception et compréhension des risques dépendent de facteurs psychologiques, sociaux, culturels, historiques et politiques. Bien comprendre cette dimension sociale du risque est essentiel pour appréhender une gestion des risques, que ce soit en clinique ou en santé publique.

Wish to Die Among Residents of Swiss Long-Term Care Facilities: A Multisite Cross-Sectional Study.

OBJECTIVES: The wish to die (WTD) in persons near the end of life is a clinically important, ethically and practically complex phenomenon as demonstrated by the intense debates on assisted dying legislation around the world. Despite global aging and increasing institutionalization in old age, WTD among residents of long-term care facilities (LTCF) is underexplored. We aimed to assess the prevalence of WTD and identify its predictors in older LTCF residents. DESIGN: Multisite cross-sectional observational study. SETTING AND PARTICIPANTS: 31 LTCF in the 3 major linguistic regions of Switzerland, including residents 75 years or older, admitted to the LTCF 4 to 10 months before the study, without severe cognitive impairment. METHODS: Between February 2013 and June 2017, trained research staff interviewed residents to assess WTD using 2 validated instruments and collected information on potential predictors, including depressive symptoms, anxiety, demoralization, feeling to be a burden, spiritual distress, symptom burden, multimorbidity, and drug use. Demographic data were obtained by chart review. Descriptive statistics as well as univariate and multivariate regression analyses were performed. RESULTS: From 427 eligible residents, 101 were excluded, 46 refused, and 280 were included in the study (acceptance rate 85.9%). In general, residents readily and openly addressed the topic of WTD. The prevalence of WTD was 16.0% and 16.2% according to the 2 instruments, with all but 1 of the residents expressing a passive WTD. The strongest independent predictors for a WTD were depressive symptoms (OR 7.45 and 5.77 for the 2 WTD assessment instruments) and demoralization (OR 2.62 and 3.66). CONCLUSIONS AND IMPLICATIONS: The WTD is a relevant concern affecting approximately 1 in 6 LTCF residents. Further research is needed to investigate which interventions could best address the potentially modifiable factors that were associated with the WTD in this specific setting and population.

Système de santé suisse†: aux origines de la machine.

Le système de santé suisse s'est construit au fil des 2 derniers siècles au gré de choix politiques et de l'évolution de la médecine. Mais, à l'heure où les questions de santé et de coûts sont de plus en plus souvent mises à l'agenda politique et que des défis majeurs de santé publique se présentent, il apparaît important pour la population et, en particulier, pour les professionnels de santé de se réapproprier son fonctionnement, sa construction et ses valeurs afin d'être en capacité d'en débattre avec le plus d'acuité possible. Cet article reprend, à partir d'un regard historique, les fondements du système de santé suisse et tente de préciser ce qu'il recouvre en termes de «â€…santé ¼ et de «â€…système ¼.

[Health data: the new digital gold, but for whom?] / Données de santé : le nouvel or numérique, mais pour qui ?

Rapidly growing health-related data have the potential to improve health and healthcare, as well as to make health systems more efficient and focused on patients' needs. Their efficient and secure management represents major technological, organizational and societal challenges. Currently too compartmentalized and insufficiently accessible, these data are often in the hands of private providers and their collection does not necessarily guarantee data security and privacy protection. Professionals as well as some private for-profit companies are on the lookout for this new digital "gold". It is therefore urgent to define a democratic and legal framework for the governance, collection and use of health data in the highly decentralized and fragmented Swiss context.

Les données de santé, dont le volume croît rapidement, ont le potentiel d'améliorer la santé et les soins, de rendre les systèmes de santé plus efficients et centrés sur les besoins des patients. Leur gestion efficace et sécurisée représente des défis technologiques, organisationnels et sociétaux majeurs. Actuellement, trop cloisonnées et insuffisamment accessibles, ces données sont souvent en main de prestataires privés et leur collecte ne garantit pas forcément l'ensemble des éléments de sécurité des données et de protection de la vie privée. Les professionnels, comme certaines entreprises privées à but lucratif, sont à l'affût de ce nouvel « or ¼ numérique. Il apparaît donc urgent de définir un cadre démocratique et légal autour de la gouvernance, de la collecte et de l'utilisation des données de santé dans le contexte suisse fortement décentralisé et fragmenté.

Use of standardized brief geriatric evaluation compared with routine care in general practice for preventing functional decline: a pragmatic cluster-randomized trial.

BACKGROUND: Although assessment of geriatric syndromes is increasingly encouraged in older adults, little evidence exists to support its systematic use by general practitioners (GPs). The aim of this study was to determine whether a systematic geriatric evaluation performed by GPs can prevent functional decline. METHODS: We conducted a controlled, open-label, pragmatic cluster-randomized trial in 42 general practices in Switzerland. Participating GPs were expected to enrol an average of 10 community-dwelling adults (aged ≥ 75 yr) who understood French, and had visited their GP at least twice in the previous year. The intervention consisted of yearly assessment by the GP of 8 geriatric syndromes with an associated tailored management plan according to assessment results, compared with routine care. Our primary outcomes were the proportion of patients who lost at least 1 instrumental activity of daily living (ADL) and the proportion who lost at least 1 basic ADL, over 2 years. Our secondary outcomes were quality-of-life scores, measured using the older adult module of the World Health Organization Quality of Life Instrument, and health care use. RESULTS: Forty-two GPs recruited 429 participants (63% women) with a mean age of 82.5 years (standard deviation 4.8 yr) at time of recruitment. Of these, we randomly assigned 217 participants to the intervention and 212 to the control arm. The proportion of patients who lost at least 1 instrumental ADL in the intervention and control arms during the course of the study was 43.6% and 47.6%, respectively (risk difference -4.0%, 95% confidence interval [CI] -14.9% to 6.7%, p = 0.5). The proportion of patients who lost at least 1 basic ADL was 12.4% in the intervention arm and 16.9% in the control arm (risk difference -5.1%, 95% CI -14.3% to 4.1%, p = 0.3). INTERPRETATION: A yearly geriatric evaluation with an associated management plan, conducted systematically in GP practices, does not significantly lessen functional decline among community-dwelling, older adult patients, compared with routine care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02618291.

[Interests and need for strengthening home care in the context of psychological crisis situations - The result of a strong public health policy]. / Intérêts et nécessité du renfort des soins à domicile dans le cadre des situations de crise psychique - Le résultat d'une politique de santé publique forte.

With the constant increase in life expectancy and the development of chronic diseases in the elderly population, the General Direction of Health of the Canton of Vaud has developed a community plan to strengthen the care of residents in psychological crisis. This strong position of Public Health has made it possible to carry out an ambitious project, with a view to « care management ¼ in elderly psychiatry, involving partners from the care network and promoting care at the place of residence of the individual. This project made it possible to develop recommendations for the strengthening of local and outpatient care, in order to reduce the systematic recourse to hospitalization, and the increase in functional dependence of the elderly on leaving the hospital.

Avec l'augmentation constante de l'espérance de vie et le développement des maladies chroniques, la Direction générale de la santé du canton de Vaud a développé un dispositif communautaire de renforcement des soins pour les résidents en situation de crise psychique. Cette prise de position forte a permis la réalisation d'un projet ambitieux, dans une optique de care management en psychiatrie de l'âge avancé, impliquant les partenaires du réseau de soins et favorisant la prise en soins sur le lieu de vie de l'individu. Ce projet a permis d'élaborer des recommandations quant au renforcement des soins communautaires et ambulatoires, afin de lutter contre le recours systématique à l'hospitalisation, et l'augmentation de la dépendance fonctionnelle des âgés au sortir de l'hôpital.

Wish to Die in Older Patients: Development and Validation of Two Assessment Instruments.

OBJECTIVES: The wish to die may be different in geriatric patients than in younger terminally ill patients. This study aimed to develop and validate instruments for assessing the wish to die in geriatric patients. DESIGN: Cross-sectional study. SETTING: Geriatric rehabilitation unit of a university hospital. PARTICIPANTS: Patients (N = 101) aged 65 years or older with a Mini-Mental State Examination score of 20 or higher, admitted consecutively over a 5-month period. MEASUREMENTS: The Schedule of Attitudes Toward Hastened Death (SAHD) was adapted to the older population (SAHD-Senior). A second tool was developed based on qualitative literature, the Categories of Attitudes Toward Death Occurrence (CADO). After cognitive pretesting, these instruments were validated in a sample of patients admitted to a geriatric rehabilitation unit. RESULTS: The SAHD-Senior showed good psychometric properties and a unifactorial structure. In the studied sample, 12.9% had a SAHD-Senior score of 10 or higher, suggesting a significant wish to die. Associations were observed between high levels of the SAHD-Senior and advanced age, high levels of depressive symptoms, lower quality of life, and lower cognitive function. The CADO allowed for passive death wishes to be distinguished from wishes to actively hasten death. According to the CADO, 14.9% of the sample had a wish to die. The two instruments showed a concordance rate of 90.1%. CONCLUSION: The wish to die in older patients admitted to rehabilitation can be validly assessed with two novel instruments. The considerable proportion with a wish to die warrants investigation into concept, determinants, and management of the wish to die. J Am Geriatr Soc 68:1202-1209, 2020.

Unknown osteoporosis in older patients admitted to post-acute rehabilitation.

BACKGROUND: Osteoporotic fractures are associated with increased morbidity, mortality, and increased health care use. As the number of older adults increases, identifying those at increased risk for osteoporotic fractures has become of utmost importance to providing them with preventive and therapeutic interventions. AIMS: To determine the prevalence of unknown clinical and densitometric osteoporosis and to investigate the performance of different diagnostic strategies for osteoporosis in elderly patients admitted to rehabilitation. METHOD: This is an observational study. Eligible participants were older adults admitted to rehabilitation in an academic hospital in Switzerland over an 11-month period. Patients with previously unknown osteoporosis underwent dual-energy X-ray absorptiometry (DXA), vertebral fracture assessment (VFA), and history review for past fractures. RESULTS: Complete assessment was available for 252 patients. Previously undiagnosed osteoporosis was identified in 62.3% of these patients, a proportion that was higher among women (71.5%) than men (44.8%). DXA proved most sensitive, followed by VFA and history review. Results differed across gender: DXA remained the most sensitive single test among women, but VFA proved most sensitive in men. The best test to combine with history review was DXA in women (detection increasing from 47.5 to 93.2%) and VFA in men (detection increasing from 35.9 to 84.6%). CONCLUSIONS: Prevalence of previously unknown osteoporosis appears very high in elderly patients admitted to post-acute rehabilitation. The combination of history review of previous fractures with DXA in women and with VFA in men appears the best two-step strategy to improving detection of osteoporosis in this population.

Differences in triage category, priority level and hospitalization rate between young-old and old-old patients visiting the emergency department.

BACKGROUND: Emergency Department (ED) are challenged by the increasing number of visits made by the heterogeneous population of elderly persons. This study aims to 1) compare chief complaints (triage categories) and level of priority; 2) to investigate their association with hospitalization after an ED visit; 3) to explore factors explaining the difference in hospitalization rates among community-dwelling older adults aged 65-84 vs 85+ years. METHODS: All ED visits of patients age 65 and over that occurred between 2005 and 2010 to the University of Lausanne Medical Center were analyzed. Associations of hospitalization with triage categories and level of priority using regressions were compared between the two age groups. Blinder-Oaxaca decomposition was performed to explore how much age-related differences in prevalence of priority level and triage categories contributed to predicted difference in hospitalization rates across the two age groups. RESULTS: Among 39'178 ED visits, 8'812 (22.5%) occurred in 85+ patients. This group had fewer high priority and more low priority conditions than the younger group. Older patients were more frequently triaged in "Trauma" (20.9 vs 15.0%) and "Home care impossible" (10.1% vs 4.2%) categories, and were more frequently hospitalized after their ED visit (69.1% vs 58.5%). Differences in prevalence of triage categories between the two age groups explained a quarter (26%) of the total age-related difference in hospitalization rates, whereas priority level did not play a role. CONCLUSIONS: Prevalence of priority level and in triage categories differed across the two age groups but only triage categories contributed moderately to explaining the age-related difference in hospitalization rates after the ED visit. Indeed, most of this difference remained unexplained, suggesting that age itself, besides other unmeasured factors, may play a role in explaining the higher hospitalization rate in patients aged 85+ years.

Performance of a brief geriatric evaluation compared to a comprehensive geriatric assessment for detection of geriatric syndromes in family medicine: a prospective diagnostic study.

BACKGROUND: Geriatric syndromes are rarely detected in family medicine. Within the AGE program (active geriatric evaluation), a brief assessment tool (BAT) designed for family physicians (FP) was developed and its diagnostic performance estimated by comparison to a comprehensive geriatric assessment. METHODS: This prospective diagnostic study was conducted in four primary care sites in Switzerland. Participants were aged at least 70 years and attending a routine appointment with their physician, without previous documented geriatric assessment. Participants were assessed by their family physicians using the BAT, and by a geriatriciant who performed a comprehensive geriatric assessment within the following two-month period (reference standard). Both the BAT and the full assessment targeted eight geriatric syndromes: cognitive impairment, mood impairment, urinary incontinence, visual impairment, hearing loss, undernutrition, osteoporosis and gait and balance impairment. Diagnostic accuracy of the BAT was estimated in terms of sensitivity, specificity, and predictive values; secondary outcomes were measures of feasibility, in terms of added consultation time and comprehensiveness in applying the BAT items. RESULTS: Prevalence of the geriatric syndromes in participants (N=85, 46 (54.1%) women, mean age 78 years (SD 6))ranged from 30.0% (malnutrition and cognitive impairment) to 71.0% (visual impairment), with a median number of 3 syndromes (IQR 2 to 4) per participant. Sensitivity of the BAT ranged from 25.0% for undernutrition (95%CI 9.8% - 46.7%) to 82.1% for hearing impairment (95%CI 66.5% - 92.5%), while specificity ranged from 45.8% for visual impairment (95%CI 25.6-67.2) to 87.7% for undernutrition (76.3% to 94.9%). Finally, most negative predictive values (NPV) were between 73.5% and 84.1%, excluding visual impairment with a NPV of 50.0%. Family physicians reported BAT use as per instructions for 76.7% of the syndromes assessed. CONCLUSIONS: Although the BAT does not replace a comprehensive geriatric assessment, it is a useful and appropriate tool for the FP to screen elderly patients for most geriatric syndromes. TRIAL REGISTRATION: The study was registered on ClinicalTrials.gov on February 20, 2013 ( NCT01816087 ).

Factors associated with quality of life in elderly hospitalised patients undergoing post-acute rehabilitation: a cross-sectional analytical study in Switzerland.

OBJECTIVES: We investigated whether biopsychosocial and spiritual factors and satisfaction with care were associated with patients' perceived quality of life. DESIGN: This was a cross-sectional analytical study. SETTING: Data were collected from inpatients at a postacute geriatric rehabilitation centre in a university hospital in Switzerland. PARTICIPANTS: Participants aged 65 years and over were consecutively recruited from October 2014 to January 2016. Exclusion criteria included significant cognitive disorder and terminal illness. Of 227 eligible participants, complete data were collected from 167. MAIN OUTCOME MEASURES: Perceived quality of life was measured using WHO Quality of Life Questionnaire-version for older people. Predictive factors were age, sex, functional status at admission, comorbidities, cognitive status, depressive symptoms, living conditions and satisfaction with care. A secondary focus was the association between spiritual needs and quality of life. RESULTS: Patients undergoing geriatric rehabilitation experienced a good quality of life. Greater quality of life was significantly associated with higher functional status (rs=0.204, p=0.011), better cognitive status (rs=0.175, p=0.029) and greater satisfaction with care (rs=0.264, p=0.003). Poorer quality of life was significantly associated with comorbidities (rs=-.226, p=0.033), greater depressive symptoms (rs=-.379, p<0.001) and unmet spiritual needs (rs=-.211, p=0.049). Multivariate linear regression indicated that depressive symptoms (ß=-0.961; 95% CIs -1.449 to 0.472; p<0.001) significantly predicted quality of life. CONCLUSIONS: Patient perceptions of quality of life were significantly associated with depression. More research is needed to assess whether considering quality of life could improve care plan creation.

A prospective study assessing agreement and reliability of a geriatric evaluation.

BACKGROUND: The present study takes place within a geriatric program, aiming at improving the diagnosis and management of geriatric syndromes in primary care. Within this program it was of prime importance to be able to rely on a robust and reproducible geriatric consultation to use as a gold standard for evaluating a primary care brief assessment tool. The specific objective of the present study was thus assessing the agreement and reliability of a comprehensive geriatric consultation. METHOD: The study was conducted at the outpatient clinic of the Service of Geriatric Medicine, University of Lausanne, Switzerland. All community-dwelling older persons aged 70 years and above were eligible. Patients were excluded if they hadn't a primary care physician, they were unable to speak French, or they were already assessed by a geriatrician within the last 12 months. A set of 9 geriatricians evaluated 20 patients. Each patient was assessed twice within a 2-month delay. Geriatric consultations were based on a structured evaluation process, leading to rating the following geriatric conditions: functional, cognitive, visual, and hearing impairment, mood disorders, risk of fall, osteoporosis, malnutrition, and urinary incontinence. Reliability and agreement estimates on each of these items were obtained using a three-way Intraclass Correlation and a three-way Observed Disagreement index. The latter allowed a decomposition of overall disagreement into disagreements due to each source of error variability (visit, rater and random). RESULTS: Agreement ranged between 0.62 and 0.85. For most domains, geriatrician-related error variability explained an important proportion of disagreement. Reliability ranged between 0 and 0.8. It was poor/moderate for visual impairment, malnutrition and risk of fall, and good/excellent for functional/cognitive/hearing impairment, osteoporosis, incontinence and mood disorders. CONCLUSIONS: Six out of nine items of the geriatric consultation described in this study (functional/cognitive/hearing impairment, osteoporosis, incontinence and mood disorders) present a good to excellent reliability and can safely be used as a reference (gold standard) to evaluate the diagnostic performance of a primary care brief assessment tool. More objective/significant measures are needed to improve reliability of malnutrition, visual impairment, and risk of fall assessment before they can serve as a safe gold standard of a primary care tool.