Costs of treatment of Swiss patients with HIV on antiretroviral therapy in hospital-based and general practice-based care: a prospective cohort study.

Some ambulant people with HIV are cared for primarily by their general practitioner and some in an outpatient clinic. Costs and patterns of care in these settings were studied in 65 such patients based in Zürich, from a limited societal perspective (excluding patient costs) based on medical resource use. Antiretroviral therapy (ART), other medications and patient variables were collected prospectively, and non-medication resources (professional time and investigations) and treatment history data were collected from medical records and by record linkage to the Swiss HIV Cohort Study database. Cost differences between the settings were estimated using multiple regression, controlling for differences in case-mix. ART comprised 80% of the total cost, non-medication costs 15% and non-ART medications 5%. Total costs were higher in the outpatient clinic (estimated additional cost after controlling for case-mix = 3489 Swiss Francs per year at 1999 prices, 95% confidence interval 742 to 6236, p=0.017). The difference was accounted for by higher ART costs in the outpatient clinic, not through a tendency to use more expensive drugs or higher doses but rather through the use of more drugs concurrently. Differences in ART prescribing patterns between the doctors in the outpatient clinic and the general practitioners were considerable and appear worthy of further investigation.

Quality of generalist vs. specialty care for people with HIV on antiretroviral treatment: a prospective cohort study.

OBJECTIVES: To describe health-care use by persons with HIV in an urban area of Switzerland (Zurich). Further, to compare the different health-care settings. DESIGN: A 1-year prospective cohort study recruiting 60 patients at general practices and 60 patients at a specialized university outpatient clinic. METHODS: Patients and their treating physicians were interviewed or answered questionnaires, respectively, at baseline, month 6 and 12. RESULTS: During the study period, five patient groups were identified among the 106 enrolled patients, of whom (i) 42% saw a general practitioner exclusively, (ii) 31% were treated at the specialized outpatient clinic, (iii) 8% were in shared care, (iv) 10% changed health-care model, and (v) 9% were lost to follow-up. Baseline demographic, psychosocial and clinical data were similar among patient groups. At study end, the proportion of patients with HIV-1 RNA < 400 copies/mL was 72%, 74%, 88%, 55% among groups (i) to (iv), respectively (ns), and 22% at month 6 among those lost to follow-up. Indicators for quality of care were similarly good among all patient groups. CONCLUSIONS: A well-working system offers high-quality healthcare to persons living with HIV, where existing teams of specialty and primary health-care professionals efficiently and effectively co-operate.

[Structures of co-operation between an HIV-outpatient clinic and private care physicians]. / Kooperationsstrukturen in der HIV-Betreuung zwischen einem spezialisierten HIV-Zentrum und niedergelassenen Arztinnen und Arzten.

OBJECTIVES OF THE STUDY: This qualitative study looks at structures of co-operation between the two major HIV-care settings in the region of Zurich (Switzerland), i.e. a HIV-specialised outpatient clinic at the University hospital and private practitioners. Hypothesizing that good co-operation between the institutions increases the quality and effectiveness of care for patients living with HIV and treated with highly active antiretroviral therapy (HAART), the structures of co-operation are investigated. METHODS: Qualitative data were collected by means of three focus-group discussions with physicians from both settings. By means of a structured interview guide, different aspects of co-operation were assessed (e. g. current status, deficits, degree of satisfaction). Contents analysis of the data revealed consensus versus dissonance pertaining to different areas of co-operation. RESULTS: Results show that co-operation has been implemented effectively on three different planes (case-related, knowledge-related, training-related) and generally has been perceived by the participants to function well. Institutions have different emphasis on care (specialists vs. generalists). They formulate different concepts of co-operation, which result in diverse degrees of satisfaction. CONCLUSIONS: On the basis of the results obtained, suggestions for improved co-operation as recommended by the participants are discussed, which could further increase the quality of HIV-related care.

"Getting Switzerland to move": evaluation of a new "Sport for All" programme.

OBJECTIVES: Even though sports participation in Switzerland appears to be quite elevated, recent research suggests that only about a third of the population are doing enough sports from a health perspective. METHODS: Against this background several Swiss health insurance companies together with the Swiss Olympic Association have recently developed a novel approach to get people to start physical exercise: Under the label of "Allez Hopl" sport clubs offer training and information courses aimed at motivating and helping previously inactive people to take on regular exercise. RESULTS: The paper presents results from an interdisciplinary evaluation of the first three years of the "Allez Hopl" campaign. Starting from an overview of the basic idea and features of the campaign it asks whether "Allez Hopl" has reached its self-declared goal of "getting Switzerland moving". Available evidence on the social background of participants and their further activities shows that by systematically avoiding any reference to conventional notions of sport and by stressing the health and fun aspect instead. "Allez Hopl" has indeed managed to mobilise an important group with under-average levels of activity (particularly middle-aged women). In addition, on average the level of physical exercise of participants appears to have increased. Yet, the number of participants is below the original target values and, contrary to the campaign's initial goal, participants are reluctant to leave the programme after one course to take up an independent activity or to join a club. CONCLUSIONS: The paper explores the achievements and problems of the campaign so far and offers an explanation of recent problems which can also serve as a basis for the implementation of similar programmes in other countries.

How complete is AIDS surveillance in Europe? An eagle eye comparison with mortality data.

OBJECTIVES: Preliminary assessment of the adequacy of AIDS surveillance efforts in Europe by comparing data from two official sources-AIDS surveillance and mortality statistics. METHODS: The study used ENAADS (European Non-Aggregate AIDS Data Set) data compiled by the European Centre for the Epidemiological Monitoring of AIDS in St Maurice, France, and mortality statistics from WHO. As ENAADS provides information about AIDS incidence as well as AIDS mortality, both series were compared with WHO mortality data. Western European countries with more than 1000 adult AIDS cases as of July 1997 were included in the cross country comparative analyses. RESULTS: AIDS surveillance and mortality statistics in Europe depict four different patterns: (1) high overall concordance (Austria, Italy, Switzerland); (2) concordance between incidence by ENAADS and mortality by WHO, but a delay in mortality reporting in ENAADS (France, Spain); (3) more cases in WHO mortality data than in ENAADS data (Germany, Portugal); (4) more cases in ENAADS data than in WHO mortality data (Sweden, United Kingdom, Greece, Belgium). CONCLUSIONS: National AIDS surveillance systems in Europe exhibit important differences in terms of completeness and functionality. New challenges such as the introduction of effective but expensive and complex treatments will exert demands on surveillance efforts. Countries with discrepant AIDS and mortality data should try to improve and update their surveillance systems.

Stages of change for perceived stress in a Swiss population sample: an explorative study.

OBJECTIVES: Data from a cross-sectional survey of the Swiss general population were used in an explorative attempt to apply the transtheoretical model of behavioural change to perceived stress. METHODS: The sample comprised 575 respondents who reported having experienced stressful situations in the previous month. Other variables assessed included gender, age, education, reported symptoms, and three constructs representing stages and processes of change as well as self-efficacy. RESULTS: Findings indicated that (1) about one third of respondents appeared to cope successfully with the stressful situations they experienced, one third intended to do so, while one quarter appeared to have no intention of managing their stress more effectively. (2) There was no difference in stage of change distribution by gender or age, while those with higher education were more frequently represented in the latter stages than those with lower education. (3) Those in the maintenance stage reported significantly less symptoms than others. CONCLUSIONS: We conclude that the assessment of readiness to change could be of valuable support in designing stage-specific interventions in the area of stress management.

A continuing concern: HIV and hepatitis testing and prevalence among drug users in substitution programmes in Zurich, Switzerland.

Phase I of the Zurich Prometheus Study is a cross-sectional study focusing on an up-to-date serology for HIV and hepatitis B/C and associated risk factors for all clients in four participating clinics offering opiate substitution in Zurich, Switzerland. The mean age of the 603 respondents is 30.7 years (SD = 6.2) and 38% of them are women. Seventy-five per cent of the respondents have a history of injecting drug use (IDU), and over half have injected within the past six months. Laboratory-confirmed seroprevalence for HBV (50%) and HCV (57%) is twice that of HIV (24%). There is an 80% risk reduction for all three viral infections among those starting IDU after 1991--when harm reduction efforts were in full swing--compared to those who began before 1988--before clean needles were widely available. These findings suggest a strongly protective effect of harm reduction measures. But while a stabilization in HIV prevalence at 15% can be seen among drug users who started injecting after 1991, prevalence rates for HBV and HCV still remain several times higher. The prevalence data in this study support data showing continued high incidence rates for HBV and HCV, even among new injectors in the harm reduction era.

[A quality culture for health promotion!]. / Eine Qualitätskultur für die Gesundheitsförderung!

Quality and quality management are omnipresent as notions in the daily life of projects but there exists neither a clear conception nor a homogeneous quality understanding. This expresses the fact that a critical and self-reflecting project culture is not rooted strongly enough. A good project and quality management is indispensable to optimize the goal attainment. Up to now, however, concrete implementations as far as quality improvement in the daily lift of projects is concerned, were lacking. This article shows the necessity of health promotion being confronted with quality and what can be gained by that. It presents a project of the Institute of Social and Preventive Medicine of the University of Zurich in which quality promotion is specifically put into practice. In co-operation with project leaders, instruments for a quality management are being developed and tested which support and steer the constant process of quality promotion.

[Health promotion and prevention in the Lucerne canton--1995 analysis and prospects]. / Gesundheitsförderung und Prävention im Kanton Luzern--Analyse 1995 und Ausblick.

Considering the legal situation the canton of Lucerne is addressed to make his contribution to health promotion and prevention. His target groups are authorities on cantonal and community levels, specialised organisations and other health professionals, as for example physicians and pharmacists. The objectives of this study are to survey the health promotional and preventive activities, to evaluate the needs of the target groups as well as to focus on the opportunities of improved cooperation. Based on these results recommendations to the cantonal health authorities will be formulated. As far as the allocation of financial and personal resources are concerned health promotion and prevention do not figure as top priorities. Besides, the study results suggest to improve the cooperation between political representatives and health professionals. The cantonal health promotion authorities are well known among the target groups. However, cooperation could be intensified on all levels of action and is regarded as most desirable. A mutual forum focused on information and experience transfer would support these results and could stimulate joint projects. In addition, the needs of the communities have to be given special attention.

[Computer-assisted smoking cessation]. / Computergestützte Raucherentwöhnung.

Though the prevalence of cigarette smoking has declined it still remains the leading cause of premature death from chronic disease. In the prevention of tobacco associated disease the promotion of smoking cessation is a key strategy. This article presents a smoking cessation program based on the transtheoretical model, an empirical model distinguishing five stages of behavioral change. Specific interventions are matched to the current stage of change. Smokers in the intervention program repeatedly fill in questionnaires about their smoking habits, attitudes and strategies in the smoking cessation process. The individual questionnaires are analyzed by a computerized expert system which creates letters with comments on the smoking cessation process and suggestions for further steps from a pool of feedback paragraphs. A further component of the program are five stage-matched brochures. The efficacy of the expert system and its potential impact on Public Health are discussed.

Trends in age at AIDS diagnosis in Europe and the United States: evidence of pronounced "ageing' among injecting drug users.

OBJECTIVES: To analyse trends in age at diagnosis for adult AIDS cases reported in Europe and the United States. DESIGN: We used AIDS surveillance data for the seven European countries with the highest cumulative number of AIDS cases reported through June 1994 and for the United States through June 1993. Mean age at AIDS diagnosis over time was calculated by sex, transmission category and country. Linear regression yielded annual increase in age and permitted statistical evaluation of the trends observed. Annual AIDS incidence was calculated for homo-/bisexual men and injecting drug users (IDU) by 5-year age groups over time. RESULTS: We found an overall increase in age at AIDS diagnosis among the main transmission categories in Europe and the United States. The epidemiologic profiles of the two regions were highly similar, despite the lower average age among IDU in Europe compared with the United States (30.6 versus 36.7 years) and lower annual increases in age in the United States. In contrast to homo-/bisexual men, the increase in age at diagnosis is strikingly uniform and pronounced among IDU. Between 1986 and 1993, IDU in all countries exhibited at least a 6-month increase in age at diagnosis per annum. Although annual AIDS incidence remains consistent between various age groups of homo-/bisexual men, IDU aged 30-49 years show continuing increase, whereas their younger counterparts show signs of stabilization or decrease. CONCLUSIONS: Despite different epidemic profiles and prevention policies, the age trends for the European countries examined and the United States were strikingly similar. The meaning of this general increase in age among the main transmission categories and the especially high increase among IDU may provide important insight into epidemic dynamics and intervention assessment.

[The extent of transfusion-associated HIV infections in Switzerland until 1994: an updated estimate]. / Das Ausmass der transfusionsassoziierten HIV-Infektionen in der Schweiz bis 1994: eine aktualisierte Schätzung.

OBJECTIVE: The first report on transfusion-associated HIV infections was published in the USA in 1982. The first case reports in Switzerland were published in 1986. So far there has never been a methodologically sound answer to the question of how many persons were infected with HIV by receiving transfusions in Switzerland before the introduction of universal HIV blood donor screening. METHODS: The following available data sources were analyzed simultaneously: firstly, the results of the look-back study conducted in 1993, secondly, the reports of HIV infections and AIDS cases in the national surveillance system, and, thirdly, the claims for compensation for HIV-infected transfusion recipients and hemophiliacs. Two methodologically different and independent estimates were obtained. Firstly, the coverage of the look-back study was estimated, which made it possible to calculate the total number of documentable transfusion-associated HIV infections in Switzerland. Secondly, matching was performed on the cases in the look-back study and the reports in the national surveillance system. Applying formulas of capture-recapture designs provided a second estimate of the total number of documentable transfusion-associated HIV infections. The claims for compensation were used to corroborate the estimates obtained. RESULTS: The two methods produced almost identical figures which were corroborated by the number of claims for compensation. It is therefore estimated that 80 to 100 persons in Switzerland may have been diagnosed as having HIV infection because of transfusions in Switzerland in the years after 1980. The last five known infections occurred in 1986 (four) and, after termination of the look-back study, in 1994 (one). However, the estimate of 80 to 100 does not include individuals who were infected before 1986 and died soon--within weeks or a few months--after the transfusion without diagnosis of HIV infection being possible. CONCLUSION: This estimate of the total number of transfusion-associated HIV infections in Switzerland is approximately half earlier published ones. In addition, the present study will probably reduce the remaining uncertainties about the size of these iatrogenic HIV infections in the 1980s.

[How well do condoms protect against HIV infection?]. / Wie sicher schützen Kondome vor einer HIV-Infektion?

A review of the literature shows that condoms offer good protection against HIV infection and other sexually transmitted diseases. A series of in vitro experiments demonstrate that quality condoms made of latex are impermeable to HIV. In addition, more than 30 in vivo studies confirm that condoms are highly effective in preventing the transmission of HIV. Condom breakage or slippage is relatively uncommon (1-5%). Most condom failure probably results from incorrect or inconsistent usage. Failures may be minimized by increasing experience, choice of quality condoms and by strictly following instructions for use.

Completeness of AIDS reporting in Switzerland: a study based on deaths between December 1987 and June 1990.

OBJECTIVES: To assess completeness and determinants of reporting to the AIDS registry of the Swiss Federal Office of Public Health. DESIGN AND METHODS: Death certificates indicative of AIDS or HIV for deaths occurring between December 1987 and June 1990 were reviewed and compared with reports to the AIDS registry. RESULTS: The completeness of the AIDS registry was 68%. However, almost all cases have now been ascertained, because more than 90% of unreported AIDS cases are detected when death certificates are reviewed. Thus, the ongoing review of death certificates adds to the total case ascertainment. The most important determinant of reporting was the reporting source: specialized AIDS clinics reported 85% of their cases, while all other sources reported only 48%. CONCLUSION: The investigation of the heterogeneity of reporting is important. It can wrongly suggest regional and national differences in the epidemic and lead to a decrease in completeness of reporting over time without actual changes in reporting behavior.

[Epidemiology and prevention of AIDS]. / Epidemiologie und Prävention von Aids.

For ten years now the Aids epidemic has worried mankind. In the same time the virus has spread all over the world. Ever more people fall ill. 56,000 cases of Aids have been notified only in Europe until June 1991. Prognoses for the future are difficult to make, some areas will be strongly affected. The surveillance and epidemiology for HIV and Aids are to be expanded with reasonable means. Such knowledge will serve as basis for prevention, which in some areas and with certain groups has already shown a certain effectiveness in the last years. In Switzerland e.g., use of condoms in the age group of 17-30 with casual sexual contacts has increased from 7% (1986) to about 50% (1991). The number of sexually transmitted diseases has decreased. Solidarity is the basis for effective prevention programmes concerning Aids. Maturity of people concerning health has to be stimulated by means of information and education.

[Medical examination of asylum seekers at entry]. / Die grenzsanitarische Untersuchung von Asylbewerbern.

It was the purpose of this analysis to summarize the salient findings made with the initial medical examination of asylum seekers in Switzerland. The evaluation covered the period from 1984 to 1987. The epidemiologic impact of diseases discovered by this screening and the logistic problems encountered with the decentralization of the program have required a modification and a reassessment of the necessary measures. As a consequence, indiscriminate stool examinations for bacteria and parasites have been abandoned. These examinations had required a considerable investment which is not considered to be justified by the limited epidemiologic significance of these intestinal pathogens. More emphasis is being placed on improved tuberculosis control measures, by providing concise guidelines for screening, prevention, and treatment. A simplified procedure for hepatitis B screening is to be maintained for the time being, conditional upon special emphasis on children, adolescents and adults of reproductive age groups. Hepatitis B vaccination of seronegative persons is a part of the standard basic immunization program. The core of the screening program and the delivery of initial preventive measures is to be carried out in the federal registration and transit centers for asylum seekers.

[AIDS: epidemiology and prevention for clinical practice]. / Aids: Epidemiologie und Prävention für die Praxis.

From the institution of an European statistic for the incidence of Aids onwards Switzerland has had the highest per capita rate. The marked increase of Aids victims in drug-addicts over the past years is also well established. An improved surveillance of HIV spread is mandatory for actual assessment of the epidemiologic situation. The long lag between HIV-infection and the manifestation of Aids impede counter measures. Prevention has thus to relay on three levels simultaneously: The 'Stop-Aids' crusade for the entire population, target group oriented activities and individual counseling. For the latter individual level physicians play the decisive role. The minimal goal for the physician should aim at the immediate prevention of HIV-infection in any of his patients. Good approaches to this directive are available.

Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network.

STUDY OBJECTIVE: The relation between a history of disorders suggestive of acute otitis media, symptoms, and findings of an examination of the tympanic membrane and doctors' certainty of diagnosis. Also, to examine differences in prescribing habits for acute otitis media among doctors from different countries. DESIGN: Questionnaires were completed by participating doctors for a maximum of 15 consecutive patients presenting with presumed acute otitis media. SETTING: General practices in Australia, Belgium, Great Britain, Israel, The Netherlands, New Zealand, Canada, Switzerland, and the United States. PATIENTS: 3660 Children divided into the three age groups 0-12 months, 13-30 months, and greater than or equal to 31 months. MAIN OUTCOME MEASURES: General practitioners' responses to questions on their diagnostic certainty and resolution of patients' symptoms after two months. RESULTS: The diagnostic certainty in patients aged 0-12 months was 58.0%. This increased to 66.0% in those aged 13-30 months and 73.3% in those aged greater than or equal to 31 months. In all age groups diagnostic certainty was positively associated with the finding of a tympanic membrane that was discharging pus or bulging. Redness of the membrane and pain were also associated with certainty in patients aged 13-30 months, and a history of decreased hearing or recent upper respiratory infection was positively associated in patients aged greater than or equal to 31 months. The proportion of patients prescribed antibiotics varied greatly among the countries, from 31.2% in The Netherlands to 98.2% in both Australia and New Zealand, as did the duration of treatment. Patients who did not take antibiotics had a higher rate of recovery than those who did; the rate of recovery did not differ between different types of antibiotic. CONCLUSIONS: Doctors' certainty of diagnosis of acute otitis media was linked to patient's age. Improved criteria or techniques for diagnosing acute otitis media, especially in very young children, need to be developed. Antibiotic treatment did not improve the rate of recovery of patients in this study.

Malaria chemoprophylaxis among European tourists in tropical Africa: use, adverse reactions, and efficacy.

In order to determine knowledge, attitudes and practices towards malaria prophylaxis, as well as its side-effects and efficacy, a self-administered questionnaire was distributed to European travellers on return flights from tropical Africa to Europe. Between 1985 and 1988 the questionnaire was completed by 44,472 passengers (80.1% of those on board) on 242 flights. A follow-up questionnaire was completed by 42,202 (94.9%) of the same travellers 3 months later. Almost all knew about the risk of malaria, but 10% relied solely on advice from nonmedical sources. While 55.6% had taken at least one measure against mosquito bites, only 4.5% adopted three such measures (used repellents and insecticides and wore long clothing after dusk). Compliance with chemoprophylaxis use was reported by 57.0% of travellers who spent less than 3 months in Africa, compared with 29.2% who stayed 3-12 months. Depending on the antimalaria regimen taken, 11-44% of the travellers experienced adverse effects, while four deaths were attributed to the chemoprophylaxis. The incidence of malaria per month of exposure for travellers who took no chemoprophylaxis was 15.2 per 1000 in East Africa and 24.2 per 1000 in West Africa. In East Africa, the prophylactic efficacy of the currently recommended antimalaria regimens (relative to that of no chemoprophylaxis) was zero for a chloroquine dosage of 300 mg base per week (4 malaria fatalities), 64.1% for a chloroquine dosage of 600 mg base per week (P = 0.03), and 94.0% for mefloquine (P = 0.003).