Potentially Inappropriate Medication Dispensing in Outpatients: Comparison of Different Measurement Approaches.

Purpose of the Research: This paper aims at comparing different approaches to measure potentially inappropriate medication (PIM) with routinely collected data on prescriptions, patient age institutionalization status (ie in nursing home or in the community). A secondary objective is to measure the rate and prevalence of PIM dispensing and to identify problematic practices in Switzerland. Material and Methods: The studied population includes about 90,000 insured over 17 years old from a Swiss health maintenance organization in 2019 and 2020. We computed and compared the number of PIM per patient for Beers criteria, Priscus list, Laroche, NORGEP and Prescrire approaches. We also created a composite indicator that accounts for the specificities of the Swiss context (adaptation to the Swiss drugs' market, recommendations in force related to sleeping pills, anxiolytics and NSAIDs). We also stratified the analysis per physician, including initiation and cessation of PIM prescription. Results: Our comparison revealed similarities between the approaches, but also that each of them had specific gaps that provides further motivation for the development of a composite approach. PIM rate was particularly high for sleeping pills, anxiolytics, NSAIDs, even when analyses were limited to chronic use. Drugs with anticholinergic effect were also frequently prescribed. Based on our composite indicator, 27% of insured over 64 years old received at least one PIM in 2020, and 8% received more than one. Our analyses also reveal that for sleeping pills and anxiolytics, half of the volume (or prevalence?) occurs in the <65 population. We observed strong variations between physicians and a significant proportion of new users among patients with PIM. Conclusion: Our results show that PIMs prescribing is very frequent in Switzerland and is driven mostly by a few drug categories. There is important physician variation in PIM prescribing that warrants the development of intervention targeted at high PIM-prescribers.

Team-Based Care for Improving Hypertension Management: A Pragmatic Randomized Controlled Trial.

Objective: We evaluated the effect on long term blood pressure (BP) of an interprofessional team-based care (TBC) intervention, involving nurses, pharmacists, and physicians, compared to usual care. Methods: We conducted a pragmatic randomized controlled study in ambulatory clinics and community pharmacies in Switzerland (ClinicalTrials.gov: NCT02511093). Uncontrolled treated hypertensive patients were randomized to TBC or usual care (UC). In the TBC group, nurses and pharmacists met patients every 6 weeks to measure BP, assess lifestyle, support medication adherence, and provide health education for 6 months. After each visit, they wrote a report to the physician who could adjust antihypertensive therapy. The outcome was the intention-to-treat difference in mean daytime ambulatory blood pressure measurement (ABPM) and control (<135/85 mmHg) at 6 and 12 months. Results: Eighty-nine patients (60 men/29 women; mean (SD) age: 61(12) year) were randomized to TBC (n = 43) or UC (n = 46). At baseline, mean (SD) BP was 144(10)/90(8) mmHg and 147(12)/87(11) mmHg in the TBC and UC groups. At 6 months, the between-groups difference in daytime systolic ABPM was-3 mmHg [95% confidence interval (CI):-10 to +4; p = 0.45]; at 12 months, this difference was-7 mmHg [95% CI:-13 to-2; p = 0.01]. At 6 months, the between-groups difference in daytime diastolic ABPM was +2 mmHg [95% CI:-1 to +6; p = 0.20]; at 12 months, this difference was-2 mmHg [95% CI:-5 to +2; 0.42]. Upon adjustment for baseline covariates including baseline BP, the between-groups differences at 6 and 12 months were maintained. At 6 months, there was no difference in BP control. At 12 months, the TBC group tended to have a better control in systolic BP (p = 0.07) but not in diastolic BP (p = 0.33). Conclusion: While there was not significant effect on BP at 6 months of follow-up, the TBC intervention can help decrease long-term systolic BP among uncontrolled hypertensive patients.

[Leveraging data from electronic medical record to improve quality of outpatient care]. / Exploiter les données du dossier médical informatisé pour améliorer la qualité des soins en ambulatoire.

Healthcare providers need indicators to monitor the quality of ambulatory care by making the best use of routinely collected data ; the goal is to provide high-value, patient-centered, evidence-based, and data-informed health care. While it may seem simple to produce indicators via the electronic medical record (EMR), these data do not speak by themselves. Indeed, it is necessary to : a) make the data usable ; b) define relevant indicators ; and c) ensure the dissemination of these indicators to patients and healthcare providers. In this article, we explain how the EMR can be used to produce indicators of quality of ambulatory care, using the example of hypertension and diabetes.

Les professionnels de santé souhaitent des indicateurs pour monitorer la qualité des soins ambulatoires en exploitant au mieux les données récoltées de routine ; la finalité est de fournir des soins de haute valeur, centrés sur le patient, fondés sur l'évidence et orientés par les données. Alors que cela semble simple de produire des indicateurs via le dossier médical informatisé (DMI), ces données ne parlent pas toutes seules. En effet, il faut : a) rendre les données exploitables ; b) définir des indicateurs pertinents et c) assurer la diffusion de ces indicateurs auprès des patients et professionnels de santé. Dans cet article, nous explicitons comment le DMI peut être utilisé pour produire des indicateurs de qualité des soins ambulatoires en prenant l'exemple de l'hypertension et du diabète.

Centre de santé de soins primaires : à quoi ressemblera-t-il dans le futur ?

Poussé par les besoins croissants des patient·e·s et l'augmentation des différents professionnel·le·s de la santé, le lieu de travail du monde ambulatoire doit évoluer. La pandémie a montré que la digitalisation des pratiques, avec toutes les questions que cette transformation soulève, est l'un des aspects du futur qui s'ouvre. Mais elle n'est de loin pas le seul enjeu du centre de santé de demain. Prévention et promotion de la santé, santé intégrative, social, économie, architecture, durabilité : les défis sont multiples. Pour les matérialiser, la Revue Médicale Suisse, en partenariat avec Unisanté, organise un concours avec une vingtaine de jeunes médecins et professionnel·le·s de la santé entourés de douze tuteur·trice·s pour imaginer le centre de santé de demain. Le résultat sera présenté dans un show-room de 200 m2 aux Assises de la médecine romande le 4 novembre 2021.

Physician Assessment and Feedback During Quality Circle to Reduce Low-Value Services in Outpatients: a Pre-Post Quality Improvement Study.

BACKGROUND: The impact of the Choosing Wisely (CW) campaign is debated as recommendations alone may not modify physician behavior. OBJECTIVE: The aim of this study was to assess whether behavioral interventions with physician assessment and feedback during quality circles (QCs) could reduce low-value services. DESIGN AND PARTICIPANTS: Pre-post quality improvement intervention with a parallel comparison group involving outpatients followed in a Swiss-managed care network, including 700 general physicians (GPs) and 150,000 adult patients. INTERVENTIONS: Interventions included performance feedback about low-value activities and comparison with peers during QCs. We assessed individual physician behavior and healthcare use from laboratory and insurance claims files between August 1, 2016, and October 31, 2018. MAIN MEASURES: Main outcomes were the change in prescription of three low-value services 6 months before and 6 months after each intervention: measurement of prostate-specific antigen (PSA) and prescription rates of proton pump inhibitors (PPIs) and statins. KEY RESULTS: Among primary care practices, a QC intervention with physician feedback and peer comparison resulted in lower rates of PPI prescription (pre-post mean prescriptions per GP 25.5 ± 23.7 vs 22.9 ± 21.4, p value<0.01; coefficient of variation (Cov) 93.0% vs 91.0%, p=0.49), PSA measurement (6.5 ± 8.7 vs 5.3 ± 6.9 tests per GP, p<0.01; Cov 133.5% vs 130.7%, p=0.84), as well as statins (6.1 ± 6.8 vs 5.6 ± 5.4 prescriptions per GP, p<0.01; Cov 111.5% vs 96.4%, p=0.21). Changes in prescription of low-value services among GPs who did not attend QCs were not statistically significant over this time period. CONCLUSION: Our results demonstrate a modest but statistically significant effect of QCs with educative feedback in reducing low-value services in outpatients with low impact on coefficient of variation. Limiting overuse in medicine is very challenging and dedicated discussion and real-time review of actionable data may help.

[Network for disabled adults in Geneva]. / Réseau handicap pour adultes à Genève.

It is estimated that about 1 712 000 people are suffering from disability in Switzerland, and that 1 to 3% of them present a severe form of disability associated with intellectual deficiency. Management of such patients is complex and faces various challenges. Communication and collaboration with the patients and among all stakeholders are key. In this review, we highlight the value of creating a network supporting people with disabilities. We also present the network available for in- and outpatients in Geneva, which offers consultations and training courses for healthcare workers, and encourages coordination between institutions and network collaboration.

Le nombre de personnes en situation de handicap en Suisse est estimé à 1 712 000, et 1 à 3 % d'entre elles présentent un handicap sévère avec retard mental. Ce dernier complexifie significativement les prises en charge en raison des difficultés de communication, d'interprétation des plaintes et des symptômes. De plus, le retard mental requiert un soutien psychosocial non négligeable. Cet article propose une réponse possible à cette problématique grâce à la création d'un réseau de soins intra- et extrahospitalier à Genève, qui inclut consultations, formations spécialisées, coordinations interinstitutionnelles et collaboration en réseau.

Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial.

BACKGROUND: Care of frail and dependent older adults with multiple chronic conditions is a major challenge for health care systems. The study objective was to test the efficacy of providing integrated care at home to reduce unnecessary hospitalizations, emergency room visits, institutionalization, and mortality in community dwelling frail and dependent older adults. METHODS: A prospective controlled trial was conducted, in real-life clinical practice settings, in a suburban region in Geneva, Switzerland, served by two home visiting nursing service centers. Three hundred and one community-dwelling frail and dependent people over 60 years old were allocated to previously randomized nursing teams into Control (N = 179) and Intervention (N = 122) groups: Controls received usual care by their primary care physician and home visiting nursing services, the Intervention group received an additional home evaluation by a community geriatrics unit with access to a call service and coordinated follow-up. Recruitment began in July 2009, goals were obtained in July 2012, and outcomes assessed until December 2012. Length of follow-up ranged from 5 to 41 months (mean 16.3). Primary outcome measure was the number of hospitalizations. Secondary outcomes were reasons for hospitalizations, the number and reason of emergency room visits, institutionalization, death, and place of death. RESULTS: The number of hospitalizations did not differ between groups however, the intervention led to lower cumulative incidence for the first hospitalization after the first year of follow-up (69.8%, CI 59.9 to 79.6 versus 87 · 6%, CI 78 · 2 to 97 · 0; p = .01). Secondary outcomes showed that the intervention compared to the control group had less frequent unnecessary hospitalizations (4.1% versus 11.7%, p = .03), lower cumulative incidence for the first emergency room visit, 8.3%, CI 2.6 to 13.9 versus 23.2%, CI 13.1 to 33.3; p = .01), and death occurred more frequently at home (44.4 versus 14.7%; p = .04). No significant differences were found for institutionalization and mortality. CONCLUSIONS: Integrated care that included a home visiting multidisciplinary geriatric team significantly reduced unnecessary hospitalizations, emergency room visits and allowed more patients to die at home. It is an effective tool to improve coordination and access to care for frail and dependent older adults. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT02084108 . Retrospectively registered on March 10th 2014.

Team-based care for improving hypertension management among outpatients (TBC-HTA): study protocol for a pragmatic randomized controlled trial.

BACKGROUND: Blood pressure (BP) is poorly controlled among a large proportion of hypertensive outpatients. Innovative models of care are therefore needed to improve BP control. The Team-Based Care for improving Hypertension management (TBC-HTA) study aims to evaluate the effect of a team-based care (TBC) interprofessional intervention, involving nurses, community pharmacists and physicians, on BP control of hypertensive outpatients compared to usual care in routine clinical practice. METHODS/DESIGN: The TBC-HTA study is a pragmatic randomized controlled study with a 6-month follow-up which tests a TBC interprofessionnal intervention conducted among uncontrolled treated hypertensive outpatients in two ambulatory clinics and among seven nearby community pharmacies in Lausanne and Geneva, Switzerland. A total of 110 patients are being recruited and randomized to TBC (TBC: N = 55) or usual care group (UC: N = 55). Patients allocated to the TBC group receive the TBC intervention conducted by an interprofessional team, involving an ambulatory clinic nurse, a community pharmacist and a physician. A nurse and a community pharmacist meet patients every 6 weeks to measure BP, to assess lifestyle, to estimate medication adherence, and to provide education to the patient about disease, treatment and lifestyle. After each visit, the nurse and pharmacist write a summary report with recommendations related to medication adherence, lifestyle, and changes in therapy. The physician then adjusts antihypertensive therapy accordingly. Patients in the UC group receive usual routine care without sessions with a nurse and a pharmacist. The primary outcome is the difference in daytime ambulatory BP between TBC and UC patients at 6-month of follow-up. Secondary outcomes include patients' and healthcare professionals' satisfaction with the TBC intervention and BP control at 12 months (6 months after the end of the intervention). DISCUSSION: This ongoing study aims to evaluate the effect of a newly developed team-based care intervention engaging different healthcare professionals on BP control in a primary care setting in Switzerland. The results will inform policymakers on implementable strategies for routine clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov registration: NCT02511093 . Retrospectively registered on 28 July 2015.

[Materializing interdisciplinary outpatient management of complex situations]. / Concrétiser la prise en charge interdisciplinaire ambulatoire de la complexité.

Patient management is becoming increasingly complex, particularly because of the growing prevalence ofchronic diseases and ageing populations. The Swiss health care system is fragmented and struggles to coordinate care provided by professionals from multiple disciplines or working for different institutions. Models to improve health care of complex situations are available that particularly advocate a coordinated team approach. This article presents an action-research designed to empower health professionals to manage complex situations in outpatient settings by means of this type of approach. Health professionals - good practice leaders in the medical and nursing fields in the Geneva Canton (Switzerland) - explored complex management situations, as well as facilitating components and obstacles. A team approach is essential to manage all of the patient's issues, to take the patient's priorities into account, and to work on a joint care plan. The legitimate role of each member of this team is highlighted, together with new roles for existing practices: informing and motivating the patient, highlighting and supporting care givers, coordination by nurses. The creation of such teams, and implementation of these roles involve new processes, which require financing of coordination as well as development of new methods of interdisciplinary management, particularly novel information technology tools.

[Geriatric institutions, between ambulatory and hospital care: patients' description and performance assessment]. / Évaluation d'une structure gériatrique entre l'ambulatoire et l'hospitalier.

INTRODUCTION: To describe patients admitted to a geriatric institution, providing short-term hospitalizations in the context of ambulatory care in the canton of Geneva. To measure the performances of thisstructure in terms of quality ofcare and costs. METHOD: Data related to the clinical,functioning and participation profiles of the first 100 patients were collected. Data related to effects (readmission, deaths, satisfaction, complications), services and resources were also documented over an 8-month period to measure various quality and costindicators. Observed values were systematically compared to expected values, adjustedfor case mix. RESULTS: Explicit criteria were proposed to focus on the suitable patients, excluding situations in which other structures were considered to be more appropriate. The specificity of this intermediate structure was to immediately organize, upon discharge, outpatient services at home. The low rate of potentially avoidable readmissions, the high patient satisfaction scores, the absence of premature death and the low number of iatrogenic complications suggest that medical and nursing care delivered reflect a good quality of services. The cost was significantly lower than expected, after adjusting for case mix. CONCLUSION: The pilot experience showed that a short-stay hospitalization unit was feasible with acceptable security conditions. The attending physician's knowledge of the patients allowed this system tofocus on essential issues without proposing inappropriate services.

[Determinants of strategic management of a health center]. / Éléments pour une gestion stratégique d'une maison de santé

AIM: The article highlights the value of a strategic approach for the development of a primary care health centre. METHODS: The method is adapted from corporate strategy: (i) analysis of the situation of the health centre and the obstacles to its development. (ii) selection of relations on which the strategy can be developed. (iii) elaboration of a system of interventions to create a cumulative development process. (iv) Illustration of the method by application to a case. RESULTS: The example illustrates the principles and method and highlights the importance of interpretations and choices in elaboration of a strategy, which is therefore always a unique construction. CONCLUSION: The strategic approach provides a framework that (i) provides a subject of discussion and negotiation between members of the health centre, (ii) strengthens the consistency of structural decisions, (iii) helps the health centre to overcome obstacles and initiate a development process.

[Continuity, coordination and integration of care: from theory to practice]. / Continuité, coordination, intégration des soins: entre théorie et pratique.

If the Swiss health care system has reached several important objectives, fragmentation of its organization alter its efficacy, its effectiveness and its quality. Numerous experts put forward the necessity of coordinating care and services, particularly for complex and, most often, chronic diseases. Physicians have a key role to play in that coordination, but the exponential growth of medical knowledge, together with a more and more sophisticated technology, requires this role to be based on interdisciplinarity and network organization. This article proposes a model to implement, around the primary care physician, a first level organization of care to ensure this organization. Such a model may better meet future challenges of the Swiss health care system.

[Chronic diseases and integrated health care delivery system: the example of Kaiser Permanente]. / Maladies chroniques et réseaux de soins: l'exemple de Kaiser Permanente.

Kaiser Permanente (California, Etats-Unis) is an integrated health care delivery system, particularly in what is related to the management of chronic conditions. This article describes the strategies developed by this organization in order to improve the quality of care of patients suffering from chronic diseases, through coordination of care, enhancement of a team based approach, self-management education programs, and patient involvement and empowerment.