Corinne Chmiel

Ganciclovir/Valganciclovir Prophylaxis Decreases Cytomegalovirus-Related Events and Bronchiolitis Obliterans Syndrome after Lung Transplantation

BACKGROUND Until recently, cytomegalovirus (CMV) infection represented a major threat to lung transplant recipients. Preliminary studies have shown that antiviral prophylaxis might improve the outcome for these patients. METHODS We extended our initial pilot trial of prolonged prophylaxis with either oral ganciclovir (1 g 3 times per day) or valganciclovir (450 mg twice per day). The trial included 96 patients who were at risk for CMV-related events. RESULTS CMV prophylaxis resulted in a significant decrease in CMV-related events (i.e., active infection and disease), from 75% in a control group and for 274 cases from the literature who did not receive prophylaxis to a cumulative incidence of 27% (P < .001). Only 11% of the prophylaxis recipients experienced CMV disease (P = .002). Moreover, at 5 years, there was a significant decrease in the rate of bronchiolitis obliterans syndrome, from 60% to 43% (P = .002), and an improved rate of survival, from 47% to 73% (P= .036), irrespective of the immunosuppressive regimen received. CMV strains with UL97 mutations were recovered from 7 of 12 analyzed cases, but the presence of this mutation had no impact on the severity of CMV disease. CONCLUSIONS A regimen of prolonged ganciclovir or valganciclovir prophylaxis decreased the rate of active CMV infection and disease, reduced the incidence of bronchiolitis obliterans syndrome, and improved the survival rate. Drug-resistant CMV strains may occur, but such strains appeared to have no impact on the outcome of CMV-related events.

Arthroscopic Repair of Traumatic Isolated Subscapularis Tendon Lesions (Lafosse Type III or IV): A Prospective Magnetic Resonance Imaging–Controlled Case Series With 1 Year of Follow-Up

PURPOSE The purpose of this study was to prospectively assess the efficacy of arthroscopic repair of isolated high-grade subscapularis (SSC) tendon lesions by means of clinical follow-up combined with magnetic resonance imaging investigations. METHODS Between January 2008 and September 2010, 11 patients (9 men and 2 women; mean age, 45 ± 10 years) with Lafosse type III or IV traumatic isolated SSC tendon lesions underwent arthroscopic repair including tenodesis of the long head of the biceps tendon. All patients were preoperatively assessed by clinical examination (Constant-Murley score [CMS]) and contrast-enhanced magnetic resonance arthrography. At 1 year of follow-up, specific clinical SSC tests, the CMS, and the loss of external rotation were evaluated. A native magnetic resonance investigation was performed to assess the structural integrity of the repair. The SSC muscle was compared with its preoperative condition regarding fatty infiltration and size (cross-sectional area). Patient satisfaction was graded from 1 (poor) to 4 (excellent). RESULTS The mean time interval from trauma to surgery was 3.7 months. A concomitant lesion of the biceps tendon was observed in 10 patients (91%). The mean CMS improved from 44 to 89 points (P < .001). The functional tests showed a significant increase in strength (P < .05) (belly-press test, 4.8 v 2.9; lift-off test, 4.8 v 2.9). The mean loss of external rotation at 0° of abduction was 10° compared with the contralateral side (P < .05). Patient satisfaction was high. Magnetic resonance imaging evaluation showed complete structural integrity of the tendon repair in all studies. The SSC showed a significant decrease in fatty infiltration and increase in the cross-sectional area. CONCLUSIONS Arthroscopic repair of higher-grade isolated SSC lesions provides reliable tendon healing accompanied by excellent functional results 1 year after surgery. LEVEL OF EVIDENCE Level IV, prospective therapeutic case series.

The FIRE project: a milestone for research in primary care in Switzerland.

QUESTIONS UNDER STUDY/PRINCIPLES Research is scarce where most patients are found. One of the main reasons is the difficulty in extracting data from traditionally conducted paper-based medical records. Thus, until now most existing patient records have originated from invoicing-tools. Endeavours to truly reflect a doctors consultation have been rare. FIRE (Family Medicine ICPC-Research using Electronic Medical Records) is an ambitious project to establish a proper knowledge base in primary care by using the ongoing implementation of EPR (electronic patient records). FIRE will enable many questions on epidemiology and performance within the PC (primary care) setting to be answered. METHODS GPs (general practitioners) throughout Switzerland working with EPR were eligible for participation. Workshops were held to train and standardise ICPC-coding (International Classification of Primary Care), a classification system especially designed for the PC-setting. The recorded data included administrative information on the GP and patient, vital signs, ICPC codes, laboratory analysis and medication. Data exporter software was developed for extracting anonymised data automatically from the EPR onto a database for further statistical analysis. RESULTS From 1.1.2009 until the beginning of April 2010 24 GPs were successfully recruited providing standardised information on 127,922 consultations in 29,398 patients and 159,956 medical problems according to the ICPC-2 classification. CONCLUSION The project proves the feasibility of standardised ongoing collection of research data embedded in routine clinical practice. FIRE provides a unique database for research in PC and highlights the potential of broad implementation of EPR in a PC-setting. Studies resulting from the ongoing project have the potential to assess the quality of care provided by GPs.

Implementation of the Chronic Care Model in Small Medical Practices Improves Cardiovascular Risk but Not Glycemic Control

OBJECTIVE To test whether the implementation of elements of the Chronic Care Model (CCM) via a specially trained practice nurse leads to an improved cardiovascular risk profile among type 2 diabetes patients. RESEARCH DESIGN AND METHODS This cluster randomized controlled trial with primary care physicians as the unit of randomization was conducted in the German part of Switzerland. Three hundred twenty-six type 2 diabetes patients (age >18 years; at least one glycosylated hemoglobin [HbA1c] level of ≥7.0% [53 mmol/mol] in the preceding year) from 30 primary care practices participated. The intervention included implementation of CCM elements and involvement of practice nurses in the care of type 2 diabetes patients. Primary outcome was HbA1c levels. The secondary outcomes were blood pressure (BP), LDL cholesterol, accordance with CCM (assessed by Patient Assessment of Chronic Illness Care [PACIC] questionnaire), and quality of life (assessed by the 36-item short-form health survey [SF-36]). RESULTS After 1 year, HbA1c levels decreased significantly in both groups with no significant difference between groups (−0.05% [−0.60 mmol/mol]; P = 0.708). Among intervention group patients, systolic BP (−3.63; P = 0.050), diastolic BP (−4.01; P < 0.001), LDL cholesterol (−0.21; P = 0.033), and PACIC subscores (P < 0.001 to 0.048) significantly improved compared with control group patients. No differences between groups were shown in the SF-36 subscales. CONCLUSIONS A chronic care approach according to the CCM and involving practice nurses in diabetes care improved the cardiovascular risk profile and is experienced by patients as a better structured care. Our study showed that care according to the CCM can be implemented even in small primary care practices, which still represent the usual structure in most European health care systems.

Characteristics of poorly controlled Type 2 diabetes patients in Swiss primary care

BackgroundAlthough a variety of treatment guidelines for Type 2 diabetes patients are available, a majority of patients does not achieve recommended targets. We aimed to characterise Type 2 diabetes patients from Swiss primary care who miss HbA1c treatment goals and to reveal factors associated with the poorly controlled HbA1c level.MethodsCross-sectional study nested within the cluster randomised controlled Chronic Care for Diabetes study. Type 2 diabetes patients with at least one HbA1c measurement ≥7.0 % during the last year were recruited from Swiss primary care. Data assessment included diabetes specific and general clinical measures, treatment factors and patient reported outcomes.Results326 Type 2 diabetes patients from 30 primary care practices with a mean age 67.1 ± 10.6 years participated in the study. The patients’ findings for HbA1c were 7.7 ± 1.3 %, for systolic blood pressure 139.1 ± 17.6 mmHg, for diastolic blood pressure 80.9 ± 10.5 mmHg and for low density lipoprotein 2.7 ± 1.1. 93.3 % of the patients suffered from at least one comorbidity and were treated with 4.8 ± 2.1 different drugs. No determining factor was significantly related to HbA1c in the multiple analysis, but a significant clustering effect of GPs on HbA1c could be found.ConclusionsWithin our sample of patients with poorly controlled Type 2 diabetes, no “bullet points” could be pointed out which can be addressed easily by some kind of intervention. Especially within this subgroup of diabetes patients who would benefit the most from appropriate interventions to improve diabetes control, a complex interaction between diabetes control, comorbidities, GPs’ treatment and patients’ health behaviour seems to exist. So far this interaction is only poorly described and understood.Trial registrationCurrent Controlled Trials ISRCTN05947538.

Sustained health-economic effects after reorganisation of a Swiss hospital emergency centre: a cost comparison study

Background Emergency departments (EDs) are increasingly overcrowded by walk-in patients. However, little is known about health-economic consequences resulting from long waiting times and inefficient use of specialised resources. We have evaluated a quality improvement project of a Swiss urban hospital: In 2009, a triage system and a hospital-associated primary care unit with General Practitioners (H-GP-unit) were implemented beside the conventional hospital ED. This resulted in improved medical service provision with reduced process times and more efficient diagnostic testing. We now report on health-economic effects. Methods From the hospital perspective, we performed a cost comparison study analysing treatment costs in the old emergency model (ED, only) versus treatment costs in the new emergency model (triage plus ED plus H-GP-unit) from 2007 to 2011. Hospital cost accounting data were applied. All consecutive outpatient emergency contacts were included for 1 month in each follow-up year. Results The annual number of outpatient emergency contacts increased from n=10 440 (2007; baseline) to n=16 326 (2011; after intervention), reflecting a general trend. In 2007, mean treatment costs per outpatient were €358 (95% CI 342 to 375). Until 2011, costs increased in the ED (€423 (396 to 454)), but considerably decreased in the H-GP-unit (€235 (221 to 250)). Compared with 2007, the annual local budget spent for treatment of 16 326 patients in 2011 showed cost reductions of €417 600 (27 200 to 493 600) after adjustment for increasing patient numbers. Conclusions From the health-economic point of view, our new service model shows ‘dominance’ over the old model: While quality of service provision improved (reduced waiting times; more efficient resource use in the H-GP-unit), treatment costs sustainably decreased against the secular trend of increase.

Improving the quality of morbidity indicators in electronic health records in Swiss primary care.

QUESTIONS UNDER STUDY The FIRE Project established a standardised data collection to facilitate research and quality improvement projects in Swiss primary care. The project is based on the concept of merging clinical and administrative data. Since chronic conditions and multimorbidity are major challenges in primary care, in this study we investigated the agreement between different approaches to identify patients with chronic and multimorbid conditions in electronic medical records (EMRs). METHODS A total of 60 primary care physicians were included and data were collected between October 2008 and June 2011. In total, data from 509594 consultations derived from 98152 patients were analysed. Chronic and multimorbid conditions were identified either by ICPC-2 codes or by the type of prescribed medication. We compared these different approaches regarding the completeness of the data to describe chronic conditions and multimorbidity of patients in primary care practices. RESULTS The data showed a high correlation between the two morbidity schemes and both indicators apparently provide reliable measures of morbidity within practices. There was considerable variability of patients with chronic conditions across practices, irrespective of whether ICPC-2-diagnoses or prescribed drugs were used to code clinical encounters. Obvious discrepancies between diagnoses and therapies across major disease categories existed. CONCLUSIONS This study describes the current situation of EMRs in terms of the ability to measure the burden of chronic conditions in primary care practices. The results illustrate a need of action for this specific topic and the results of this study will be incorporated into the functional specification of EMRs of a planned eHealth project in Swiss primary care.

The provision of out-of-hours care and associated costs in an urban area of Switzerland: a cost description study

BackgroundIn Switzerland, General Practitioners (GPs) play an important role for out-of-hours emergency care as one service option beside freely accessible and costly emergency departments of hospitals. The aim of this study was to evaluate the services provided and the economic consequences of a Swiss GP out-of-hours service.MethodsGPs participating in the out-of-hours service in the city of Zurich collected data on medical problems (ICPC coding), mode of contact, mode of resource use and services provided (time units; diagnostics; treatments). From a health care insurance perspective, we assessed the association between total costs and its two components (basic costs: charges for time units and emergency surcharge; individual costs: charges for clinical examination, diagnostics and treatment in the discretion of the GP).Results125 GPs collected data on 685 patient contacts. The most prevalent health problems were of respiratory (24%), musculoskeletal (13%) and digestive origin (12%). Home visits (61%) were the most common contact mode, followed by practice (25%) and telephone contacts (14%). 82% of patients could be treated by ambulatory care. In 20% of patients additional technical diagnostics, most often laboratory tests, were used. The mean total costs for one emergency patient contact were €144 (95%-CI: 137-151). The mode of contact was an important determinant of total costs (mean total costs for home visits: €176 [95%-CI: 168-184]; practice contact: €90 [95%-CI: 84-98]; telephone contact: €48 [95%-CI: 40-55]). Basic costs contributed 83% of total costs for home visits and 70% of total costs for practice contacts. Individual mean costs were similarly low for home visits (€30) and practice contacts (€27). Medical problems had no relevant influence on this cost pattern.ConclusionsGPs managed most emergency demand in their out-of-hours service by ambulatory care. They applied little diagnostic testing and basic care. Our findings are of relevance for policy makers even from other countries with different pricing policies. Policy makers should be interested in a reimbursement system promoting out-of-hours care run by GPs as one valuable service option.

Appropriateness of Diagnostic Coronary Angiography as a Measure of Cardiac Ischemia Testing in Non-Emergency Patients - A Retrospective Cross-Sectional Analysis

Background Adequate application of guidelines concerning non-invasive ischemia testing (NIIT) could avoid inappropriate invasive testing in non-emergency situations. Hardly any data exists regarding frequency and appropriateness of diagnostic coronary angiography (CA). The aim of this study was to evaluate the proportion and predictors of patients without NIIT prior to elective purely diagnostic CA without therapeutic intervention. Methods Retrospective cross-sectional analysis of insurance claims data from 2012 and 2013. Patients <18 years, acute cardiac ischemia and emergency procedures and patients insured in a managed care model were excluded from analysis. The proportion of patients with NIIT procedures (stress-ECG, transthoracic echocardiography, stress echocardiography, scintigraphy, computer tomography, heart MRI) undertaken within two months before diagnostic CA was assessed. Multiple logistic regression analysis was applied to investigate independent determinants for receiving NIIT. Findings 2714 patients were included for analysis. 37.5% (1018) did not receive any NIIT before CA. When high risk patients (patients having received therapeutic cardiac intervention within one month after or 18 months prior to diagnostic CA, n = 766) were excluded 34.3% (669) did not receive NIIT before CA. High risk status as well as >6 chronic comorbidities were independently associated with a lower proportion of NIIT (p<0.0001, OR 0.607 and p = 0.0041, OR 0.648), when additionally controlled for age, sex, language area, insurance coverage, inpatient treatment, cardiovascular medication and lower number of chronic comorbidities. Age (p<0.05, OR 1.009) and intake of oral antiplatelet therapy (p<0.0001, OR 1.914) were independently associated with a higher proportion of NIIT when controlled for the mentioned cofactors. Conclusions Our data show that despite the existence of guidelines a substantial overuse of a potentially harmful and inappropriate diagnostic intervention is performed suggesting the need for improvement of diagnostic pathways prior to invasive testing.

Transfusion practice in anemic, non-bleeding patients: Cross-sectional survey of physicians working in general internal medicine teaching hospitals in Switzerland

Background Transfusion practice might significantly influence patient morbidity and mortality. Between European countries, transfusion practice of red blood cells (RBC) greatly differs. Only sparse data are available on transfusion practice of general internal medicine physicians in Switzerland. Methods In this cross-sectional survey, physicians working in general medicine teaching hospitals in Switzerland were investigated regarding their self-reported transfusion practice in anemic patients without acute bleeding. The definition of anemia, transfusion triggers, knowledge on RBC transfusion, and implementation of guidelines were assessed. Results 560 physicians of 71 hospitals (64%) responded to the survey. Anemia was defined at very diverging hemoglobin values (by 38% at a hemoglobin <130 g/L for men and by 57% at <120 g/L in non-pregnant women). 62% and 43% respectively, did not define anemia in men and in women according to the World Health Organization. Fifty percent reported not to transfuse RBC according to international guidelines. Following factors were indicated to influence the decision to transfuse: educational background of the physicians, geographical region of employment, severity of anemia, and presence of known coronary artery disease. 60% indicated that their knowledge on Transfusion-related Acute Lung Injury (TRALI) did not influence transfusion practice. 50% of physicians stated that no local transfusion guidelines exist and 84% supported the development of national recommendations on transfusion in non-acutely bleeding, anemic patients. Conclusion This study highlights the lack of adherence to current transfusion guidelines in Switzerland. Identifying and subsequently correcting this deficit in knowledge translation may have a significant impact on patient care.