Jérôme Pasquier

Multimorbidity and patterns of chronic conditions in a primary care population in Switzerland: a cross-sectional study.

Objective To characterise in details a random sample of multimorbid patients in Switzerland and to evaluate the clustering of chronic conditions in that sample. Methods 100 general practitioners (GPs) each enrolled 10 randomly selected multimorbid patients aged ≥18 years old and suffering from at least three chronic conditions. The prevalence of 75 separate chronic conditions from the International Classification of Primary Care-2 (ICPC-2) was evaluated in these patients. Clusters of chronic conditions were studied in parallel. Results The final database included 888 patients. Mean (SD) patient age was 73.0 (12.0) years old. They suffered from 5.5 (2.2) chronic conditions and were prescribed 7.7 (3.5) drugs; 25.7% suffered from depression. Psychological conditions were more prevalent among younger individuals (≤66 years old). Cluster analysis of chronic conditions with a prevalence ≥5% in the sample revealed four main groups of conditions: (1) cardiovascular risk factors and conditions, (2) general age-related and metabolic conditions, (3) tobacco and alcohol dependencies, and (4) pain, musculoskeletal and psychological conditions. Conclusion Given the emerging epidemic of multimorbidity in industrialised countries, accurately depicting the multiple expressions of multimorbidity in family practices’ patients is a high priority. Indeed, even in a setting where patients have direct access to medical specialists, GPs nevertheless retain a key role as coordinators and often as the sole medical reference for multimorbid patients.

Multicentre observational screening survey for the detection of CTEPH following pulmonary embolism

Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe complication of pulmonary embolism. Its incidence following pulmonary embolism is debated. Active screening for CTEPH in patients with acute pulmonary embolism is yet to be recommended. This prospective, multicentre, observational study (Multicentre Observational Screening Survey for the Detection of Chronic Thromboembolic Pulmonary Hypertension (CTEPH) Following Pulmonary Embolism (INPUT on PE); ISRCTN61417303) included patients with acute pulmonary embolism from 11 centres in Switzerland from March 2009 to November 2016. Screening for possible CTEPH was performed at 6, 12 and 24 months using a stepwise algorithm that included a dyspnoea phone-based survey, transthoracic echocardiography, right heart catheterisation and radiological confirmation of CTEPH. Out of 1699 patients with pulmonary embolism, 508 patients were assessed for CTEPH screening over 2 years. CTEPH incidence following pulmonary embolism was 3.7 per 1000 patient-years, with a 2-year cumulative incidence of 0.79%. The Swiss pulmonary hypertension registry consulted in December 2016 did not report additional CTEPH cases in these patients. The survey yielded 100% sensitivity and 81.6% specificity. The second step echocardiography in newly dyspnoeic patients showed a negative predictive value of 100%. CTEPH is a rare but treatable disease. A simple and sensitive way for CTEPH screening in patients with acute pulmonary embolism is recommended. Chronic thromboembolic pulmonary hypertension is an uncommon disease; active screening of CTEPH in patients after acute pulmonary embolism should be considered http://ow.ly/mmFI30j3Lca

Clinical significance of post-prophylaxis cytomegalovirus infection in lung transplant recipients

Cytomegalovirus (CMV) disease has been associated with the development of chronic lung allograft dysfunction (CLAD) after transplantation. However, the relevance of CMV replication occurring after the discontinuation of antiviral prophylaxis on the development of CLAD has not been fully established. Patients who underwent lung transplantation during 2004‐2014 were included. All patients received antiviral prophylaxis for 3‐6 months, followed by monitoring of CMV replication during the first year post‐transplantation (preemptive therapy). Risk factors for the development of CLAD were assessed by Cox models. A linear regression model with an interaction coefficient between time and CMV infection was used to evaluate the influence of CMV infection on the evolution of FEV1. Overall, 69 patients were included, 30/69 (43%) patients developed at least 1 episode of significant CMV infection, and 8/69 (11.5%) patients developed CMV disease. After a median follow‐up of 3.67 years, 25/69 (36%) patients developed CLAD and 14/69 (20%) patients died. In the univariate Cox analysis, significant CMV infection (HR 1.177, P = .698), CMV disease (HR 1.001, P = .998), and duration of CMV replication (HR 1.004, P = .758) were not associated with CLAD. Only bacterial pneumonia tended to be associated with CLAD in the multivariate model (HR 2.579, P = .062). We did not observe a significant interaction between CMV replication and evolution FEV1 (interaction coefficient 0.006, CI 95% [−0.084 to 0.096], P = .890). In this cohort of lung transplant recipients receiving antiviral prophylaxis and monitored by preemptive therapy post‐prophylaxis, CMV infection did not have impact on long‐term allograft lung function.

Primary care physicians’ attitude and reported prescribing behavior for chronic low back pain: An exploratory cross-sectional study

Objective Recent guidelines for chronic or recurrent low back pain recommend non-pharmacologic treatments as first-line options. The objective of this study was thus to explore the perceived usefulness of several conventional and complementary medicine treatments for chronic or recurrent low back pain by primary care physicians and their reported prescribing behavior. Design An exploratory cross-sectional study. Setting and participants Primary care physicians of the French-speaking part of Switzerland. Main outcome measures Primary care physicians’ perceived usefulness of each conventional and complementary medicine treatment and their reported recommendation behavior were considered dependent variables in multivariate logistic regression models. All correlations were computed between binary variables, and phi coefficients were calculated to estimate correlation strengths. Results 533 primary care physicians answered the questionnaire (response rate: 25.6%). The top 3 conventional treatments most often considered useful by primary care physicians for chronic or recurrent low back pain were physiotherapy (94.8%), nonsteroidal anti-inflammatory drugs (87.9%), and manual therapy (82.5%), whereas the most prescribed conventional treatments were physiotherapy (99.2%), nonsteroidal anti-inflammatory drugs (97.4%), and acetaminophen (94.4%). Osteopathic treatment (78.4%), yoga (69.3%), and therapeutic massage (63.9%) were the complementary medicine treatments most often considered useful by primary care physicians in managing chronic or recurrent low back pain. Being a female physician, younger than 56 years, trained in complementary medicine, or using complementary medicine were all associated with higher perceived usefulness of complementary medicine treatments in general. The most recommended complementary medicine treatments by primary care physicians were osteopathic treatment (87.3%), acupuncture (69.3%), and therapeutic massage (58.7%). Being a female physician, younger than 56, and using complementary medicine were all associated with more complementary medicine recommendation in general. Conclusion Our results highlight the importance of better understanding the prescribing patterns of primary care physicians for chronic or recurrent low back pain. Considering the frequency and burden of chronic or recurrent low back pain, programs focusing on the most (cost-) effective treatments should be implemented.

OATPB1/B3 and MRP3 expression in hepatocellular adenoma predicts Gd-EOB-DTPA uptake and correlates with risk of malignancy

Hepatobiliary phase (HBP) Gd‐EOB‐DTPA‐enhanced magnetic resonance imaging (MRI) has increased the accuracy in differentiating focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA). However, the ability of this technique to distinguish HCA subtypes remains controversial. The aim of this study was to investigate the expression of hepatocyte transporters (OATPB1/B3, MRP2, MRP3) in HCA subtypes, hence to understand their MRI signal intensity on HBP Gd‐EOB‐DTPA‐enhanced MRI.

Factors associated with health literacy in multimorbid patients in primary care: a cross-sectional study in Switzerland

Objective To identify factors associated with health literacy in multimorbid patients. Design A nationwide cross-sectional study in Switzerland. Univariate and multivariate linear regressions were calculated to identify variables associated with health literacy. A multiple imputation approach was used to deal with missing values. Participants Multimorbid patients recruited in primary care settings (n=888), above 18 years old and suffering from at least 3 of 75 chronic conditions on a predefined list based on the International Classification of Primary Care 2. Main measures Health literacy was assessed using the European Health Literacy Survey project questionnaire (HLS-EU 6). This comprises six items scored from 1 to 4 (very difficult=1, fairly difficult=2, fairly easy=3, very easy=4), and the total health literacy score is computed as their mean. As we wished to understand the determinants associated with lower health literacy, the HLS-EU 6 score was the only dependent variable; all other covariates were considered independent. Results The mean health literacy score (SD) was 2.9 (0.5). Multivariate analyses found significant associations between low health literacy scores and treatment burden scores (β=−0.004, 95% CI −0.006 to 0.002); marital status, predominantly the divorced group (β=0.136, 95% CI 0.012 to 0.260); dimensions of the EuroQuol 5 Dimension 3 Level (EQ5D3L) quality of life assessment, that is, for moderate problems with mobility (β=−0.086, 95% CI −0.157 to 0.016); and with moderate problems (β=−0.129, 95% CI −0.198 to 0.060) and severe problems with anxiety/depression (β=−0.343, 95% CI −0.500 to 0.186). Conclusions Multimorbid patients with a high treatment burden, altered quality of life by problems with mobility, anxiety or depression, often also have low levels of health literacy. Primary care practitioners should therefore pay particular attention to these patients in their daily practice.

Multimorbidity: can general practitioners identify the health conditions most important to their patients? Results from a national cross-sectional study in Switzerland.

BackgroundFaced with patients suffering from more than one chronic condition, or multimorbidity, general practitioners (GPs) must establish diagnostic and treatment priorities. Patients also set their own priorities to handle the everyday burdens associated with their multimorbidity and these may be different from the priorities established by their GP. A shared patient–GP agenda, driven by knowledge of each other’s priorities, would seem central to managing patients with multimorbidity. We evaluated GPs’ ability to identify the health condition most important to their patients.MethodsData on 888 patients were collected as part of a cross-sectional Swiss study on multimorbidity in family medicine. For the main analyses on patients-GP agreement, data from 572 of these patients could be included. GPs were asked to identify the two conditions which their patient considered most important, and we tested whether either of them agreed with the condition mentioned as most important by the patient. In the main analysis, we studied the agreement rate between GPs and patients by grouping items medically-related into 46 groups of conditions. Socio-demographic and clinical variables were fitted into univariate and multivariate models.ResultsIn 54.9% of cases, GPs were able to identify the health condition most important to the patient. In the multivariate model, the only variable significantly associated with patient–GP agreement was the number of chronic conditions: the higher the number of conditions, the less likely the agreement.ConclusionGPs were able to correctly identify the health condition most important to their patients in half of the cases. It therefore seems important that GPs learn how to better adapt treatment targets and priorities by taking patients’ perspectives into account.

Determinants associated with deprivation in multimorbid patients in primary care-A cross-sectional study in Switzerland.

Background Deprivation usually encompasses material, social, and health components. It has been shown to be associated with greater risks of developing chronic health conditions and of worse outcome in multimorbidity. The DipCare questionnaire, an instrument developed and validated in Switzerland for use in primary care, identifies patients subject to potentially higher levels of deprivation. Objectives To identifying determinants of the material, social, and health profiles associated with deprivation in a sample of multimorbid, primary care patients, and thus set priorities in screening for deprivation in this population. Design Secondary analysis from a nationwide cross-sectional study in Switzerland. Participants A random sample of 886 adult patients suffering from at least three chronic health conditions. Main measures The outcomes of interest were the patients’ levels of deprivation as measured using the DipCare questionnaire. Classification And Regression Tree analysis identified the independent variables that separated the examined population into groups with increasing deprivation scores. Finally, a sensitivity analysis (multivariate regression) confirmed the robustness of our results. Key results Being aged under 64 years old was associated with higher overall, material, and health deprivation; being aged over 77 years old was associated with higher social deprivation. Other variables associated with deprivation were the level of education, marital status, and the presence of depression or chronic pain. Conclusion Specific profiles, such as being younger, were associated with higher levels of overall, material, and health deprivation in multimorbid patients. In contrast, patients over 77 years old reported higher levels of social deprivation. Furthermore, chronic pain and depression added to the score for health deprivation. It is important that GPs consider the possibility of deprivation in these multimorbid patients and are able to identify it, both in order to encourage treatment adherence and limit any forgoing of care for financial reasons.

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 (r s=−.211, p=0.049). Multivariate linear regression indicated that depressive symptoms (β=−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.