Patrick Bodenmann

Effectiveness of Interventions Targeting Frequent Users of Emergency Departments: A Systematic Review

STUDY OBJECTIVE Frequent users of emergency departments (EDs) are a relatively small group of vulnerable patients accounting for a disproportionally high number of ED visits. Our objective is to perform a systematic review of the type and effectiveness of interventions to reduce the number of ED visits by frequent users. METHODS We searched MEDLINE, EMBASE, CINAHL, PsychINFO, the Cochrane Library, and ISI Web of Science for randomized controlled trials, nonrandomized controlled trials, interrupted time series, and controlled and noncontrolled before-and-after studies describing interventions targeting adult frequent users of EDs. Primary outcome of interest was the reduction in ED use. We also explored costs analyses and various clinical (alcohol and drug use, psychiatric symptoms, mortality) and social (homelessness, insurance status, social security support) outcomes. RESULTS We included 11 studies (3 randomized controlled trials, 2 controlled and 6 noncontrolled before-and-after studies). Heterogeneity in both study designs and definitions of frequent users precluded meta-analyses of the results. The most studied intervention was case management (n=7). Only 1 of 3 randomized controlled trials showed a significant reduction in ED use compared with usual care. Six of the 8 before-and-after studies reported a significant reduction in ED use, and 1 study showed a significant increase. ED cost reductions were demonstrated in 3 studies. Social outcomes such as reduction of homelessness were favorable in 3 of 3 studies, and clinical outcomes trended toward positive results in 2 of 3 studies. CONCLUSION Interventions targeting frequent users may reduce ED use. Case management, the most frequently described intervention, reduced ED costs and seemed to improve social and clinical outcomes. It appears to be beneficial to patients and justifiable for hospitals to implement case management for frequent users in the framework of a clear and consensual definition of frequent users and standardized outcome measures.

Chikungunya: an epidemic in real time

On Feb 15, 2006, a 28-year-old woman attended our clinic because of fever, headache, and photophobia that had lasted for 3 days and rash of 1 day’s duration. 2 days earlier she had returned from a 2-week trip to Mauritius. She reported many mosquito bites during her trip. On examination, there was painful inguinal lymphadenopathy and a maculopapular rash on her trunk (fi gure), and her thighs; knees, wrists, and hands were painful. The diff erential diagnosis included Chikungunya fever because of the continuing and large epidemic in Mauritius, the compatible chronology, and the typical clinical presentation. Less likely diagnoses were primary HIV infection, rickettsiosis, malaria, and dengue, typhoid, or relapsing fever (see www.fevertravel.ch for details on diff erential diagnosis). Rapid diagnostic test and microscopy were negative for malaria. Full blood count showed a low whitecell count (2·8×109/L; normal range 4–10×109/L) and monocytosis (15%; 2–8%). No other laboratory tests were done other than serology for Chikungunya. Because of the high probability of Chikungunya, she was given symptomatic treatment, discharged the same day, and followed up as an outpatient. Chikungunya fever was later confi rmed by serology results (IgM positive 0·42 [positive if >0·15] and IgG negative [positive if >0·10] on Feb 15; IgM 3·51 and IgG 0·72 on Feb 28). When the patient was last seen on Feb 22, 2006, fever had subsided but diff use arthralgia on both hands persisted. Chikungunya is transmitted by Aedes aegypti or A albopictus. In his original report of this arbovirosis, Robinson mentioned fever (100% of the cases diagnosed on La Reunion), arthralgia (100%), myalgia (97%), headache (84%), and diff use maculopapular rash (33%). Symptoms appear 4–7 days after the infecting bite and can be associated with lymphadenopathy, gastrointestinal symptoms, and mild haemorrhagic signs. In Swahili, Chikungunya means the illness of the bended walker; indeed, arthralgia is often severe and can persist for a long time—12% of patients have chronic arthralgia 3 years after onset of illness. During the recent epidemic in the Indian Ocean islands, 12 cases of meningoencephalitis have been confi rmed, which could suggest that the present strain is more virulent than those causing previous epidemics; six cases were diagnosed in neonates whose mothers had contracted the virus 48 h before giving birth and six in elderly people. 77 death certifi cates issued in the region between Jan 1, 2006, and March 2, 2006, state Chikungunya as the cause of death, but, for most of them, there was underlying comorbidity (median age 78 years). Thanks to the rapid development of internet surveillance networks, more developed countries can be informed in real time about the dynamic of an epidemic that potentially threatens travellers’ health. Chikungunya on La Reunion is a good example: once the epidemic worsened in January, 2006, reports rapidly accumulated with detailed description of clinical cases, rate, and type of complications. However, the local population had to wait for the fi rst cases in tourists to see the deployment of eff ective control measures. As travel-medicine physicians, we were pressurised by the media and our patients to give informed advice on whether to go or to cancel a planned journey. After thorough assessment of the documents available on the internet, we developed recommendations based on the evidence from several disease-surveillance systems. We strongly discouraged pregnant women, families with young children, people older than 70 years, and those with signifi cant comorbidity from travelling to the Indian Ocean islands. We informed other patients about the magnitude of the risk of contracting the disease and let them decide according to their own judgment. We reinforced the message on protective measures against mosquito bites. This case emphasises the importance of disease-surveillance communication networks, which allow the constant modifi cation of preventive and therapeutic measures.

Social and Medical Vulnerability Factors of Emergency Department Frequent Users in a Universal Health Insurance System

OBJECTIVES The objectives were to identify the social and medical factors associated with emergency department (ED) frequent use and to determine if frequent users were more likely to have a combination of these factors in a universal health insurance system. METHODS This was a retrospective chart review case-control study comparing randomized samples of frequent users and nonfrequent users at the Lausanne University Hospital, Switzerland. The authors defined frequent users as patients with four or more ED visits within the previous 12 months. Adult patients who visited the ED between April 2008 and March 2009 (study period) were included, and patients leaving the ED without medical discharge were excluded. For each patient, the first ED electronic record within the study period was considered for data extraction. Along with basic demographics, variables of interest included social (employment or housing status) and medical (ED primary diagnosis) characteristics. Significant social and medical factors were used to construct a logistic regression model, to determine factors associated with frequent ED use. In addition, comparison of the combination of social and medical factors was examined. RESULTS A total of 359 of 1,591 frequent and 360 of 34,263 nonfrequent users were selected. Frequent users accounted for less than a 20th of all ED patients (4.4%), but for 12.1% of all visits (5,813 of 48,117), with a maximum of 73 ED visits. No difference in terms of age or sex occurred, but more frequent users had a nationality other than Swiss or European (n = 117 [32.6%] vs. n = 83 [23.1%], p = 0.003). Adjusted multivariate analysis showed that social and specific medical vulnerability factors most increased the risk of frequent ED use: being under guardianship (adjusted odds ratio [OR] = 15.8; 95% confidence interval [CI] = 1.7 to 147.3), living closer to the ED (adjusted OR = 4.6; 95% CI = 2.8 to 7.6), being uninsured (adjusted OR = 2.5; 95% CI = 1.1 to 5.8), being unemployed or dependent on government welfare (adjusted OR = 2.1; 95% CI = 1.3 to 3.4), the number of psychiatric hospitalizations (adjusted OR = 4.6; 95% CI = 1.5 to 14.1), and the use of five or more clinical departments over 12 months (adjusted OR = 4.5; 95% CI = 2.5 to 8.1). Having two of four social factors increased the odds of frequent ED use (adjusted = OR 5.4; 95% CI = 2.9 to 9.9), and similar results were found for medical factors (adjusted OR = 7.9; 95% CI = 4.6 to 13.4). A combination of social and medical factors was markedly associated with ED frequent use, as frequent users were 10 times more likely to have three of them (on a total of eight factors; 95% CI = 5.1 to 19.6). CONCLUSIONS Frequent users accounted for a moderate proportion of visits at the Lausanne ED. Social and medical vulnerability factors were associated with frequent ED use. In addition, frequent users were more likely to have both social and medical vulnerabilities than were other patients. Case management strategies might address the vulnerability factors of frequent users to prevent inequities in health care and related costs.

Independent contribution of parental migrant status and educational level to adiposity and eating habits in preschool children

Background/Objective:Little is known about the precise role of parental migrant status (MS) and educational level (EL) on adiposity and various eating habits in young children. Therefore, we assessed their independent contribution in preschoolers.Subjects/Methods:Of 655 randomly selected preschoolers, 542 (5.1±0.6 years; 71% of parental MS and 37% of low parental EL) were analysed. Body composition was measured by bioelectrical impedance. Eating habits were assessed using a semiqualitative food frequency questionnaire and analysed according to five messages developed by the Swiss Society for Nutrition, based on factors implicated in childhood obesity: (1) ‘Drinking water and decreasing sweetened drinks’, (2) ‘Eating fruit and vegetables’, (3) ‘Decreasing breakfast skipping’, (4) ‘Reducing fatty and sweet foods’ and (5) ‘Reducing the intake of meals and snacks in front of television’.Results:Children of migrant and low EL parents had higher body fat, ate more meals and snacks while watching television and had more fruit and fatty foods compared with their respective counterparts (all P⩽0.04). Children of low EL parents also consumed less water and vegetables compared with their counterparts (all P⩽0.04). In most instances, we found an independent contribution of parental MS and EL to adiposity and eating habits. A more pronounced effect was found if both parents were migrants or of low EL. Differences in adiposity and eating habits were relatively similar to the joint parental data when assessed individually for maternal and paternal MS and EL.Conclusions:Parental MS and EL are independently related to adiposity and various eating habits in preschoolers.

Screening for latent tuberculosis infection among undocumented immigrants in Swiss healthcare centres; a descriptive exploratory study

BackgroundMigration is one of the major causes of tuberculosis in developed countries. Undocumented patients are usually not screened at the border and are not covered by a health insurance increasing their risk of developing the disease unnoticed. Urban health centres could help identify this population at risk. The objective of this study is to assess the prevalence of latent tuberculosis infection (LTBI) and adherence to preventive treatment in a population of undocumented immigrant patients.MethodsAll consecutive undocumented patients that visited two urban healthcare centres for vulnerable populations in Lausanne, Switzerland for the first time were offered tuberculosis screening with an interferon-γ assay. Preventive treatment was offered if indicated. Adherence to treatment was evaluated monthly over a nine month period.ResultsOf the 161 participants, 131 (81.4%) agreed to screening and 125 had complete examinations. Twenty-four of the 125 patients (19.2%; CI95% 12.7;27.2) had positive interferon-γ assay results, two of which had active tuberculosis. Only five patients with LTBI completed full preventive treatments. Five others initiated the treatment but did not follow through.ConclusionScreening for tuberculosis infection in this hard-to-reach population is feasible in dedicated urban clinics, and the prevalence of LTBI is high in this vulnerable population. However, the low adherence to treatment is an important public health concern, and new strategies are needed to address this problem.

Detecting and measuring deprivation in primary care: development, reliability and validity of a self-reported questionnaire: the DiPCare-Q

Objectives Advances in biopsychosocial science have underlined the importance of taking social history and life course perspective into consideration in primary care. For both clinical and research purposes, this study aims to develop and validate a standardised instrument measuring both material and social deprivation at an individual level. Methods We identified relevant potential questions regarding deprivation using a systematic review, structured interviews, focus group interviews and a think-aloud approach. Item response theory analysis was then used to reduce the length of the 38-item questionnaire and derive the deprivation in primary care questionnaire (DiPCare-Q) index using data obtained from a random sample of 200 patients during their planned visits to an ambulatory general internal medicine clinic. Patients completed the questionnaire a second time over the phone 3 days later to enable us to assess reliability. Content validity of the DiPCare-Q was then assessed by 17 general practitioners. Psychometric properties and validity of the final instrument were investigated in a second set of patients. The DiPCare-Q was administered to a random sample of 1898 patients attending one of 47 different private primary care practices in western Switzerland along with questions on subjective social status, education, source of income, welfare status and subjective poverty. Results Deprivation was defined in three distinct dimensions: material (eight items), social (five items) and health deprivation (three items). Item consistency was high in both the derivation (Kuder-Richardson Formula 20 (KR20) =0.827) and the validation set (KR20 =0.778). The DiPCare-Q index was reliable (interclass correlation coefficients=0.847) and was correlated to subjective social status (rs=−0.539). Conclusion The DiPCare-Q is a rapid, reliable and validated instrument that may prove useful for measuring both material and social deprivation in primary care.

Effect of a lifestyle intervention on adiposity and fitness in socially disadvantaged subgroups of preschoolers : a cluster-randomized trial (Ballabeina)

OBJECTIVE A multidimensional lifestyle intervention performed in 652 preschoolers (72% of migrant, 38% of low educational level (EL) parents) reduced body fat, but not BMI and improved fitness. The objective of this study is to examine whether the intervention was equally effective in children of migrant and/or low EL parents. METHODS Cluster-randomized controlled single blinded trial, conducted in 2008/09 in 40 randomly selected preschools in Switzerland. The culturally tailored intervention consisted of a physical activity program and lessons on nutrition, media use and sleep. Primary outcomes included BMI and aerobic fitness. Secondary outcomes included %body fat, waist circumference and motor agility. RESULTS Children of migrant parents benefitted similarly from the intervention compared to their counterparts (p for interaction≥ 0.09). However, children of low EL parents benefitted less, although these differences did not reach statistical significance (p for interaction≥ 0.06). Average intervention effect sizes for BMI were -0.10, -0.05, -0.11 and 0.04 kg/m(2) and for aerobic fitness were 0.55, 0.20, 0.37 and -0.05 stages for children of non-migrant, migrant, middle/high EL and low EL parents, respectively. CONCLUSIONS This intervention was similarly effective among preschoolers of migrant parents compared to their counterparts, while children of low EL parents benefitted less.

Characteristics of highly frequent users of a Swiss academic emergency department: a retrospective consecutive case series

Objectives The aim of this study was to describe the demographic, social and medical characteristics, and healthcare use of highly frequent users of a university hospital emergency department (ED) in Switzerland. Methods A retrospective consecutive case series was performed. We included all highly frequent users, defined as patients attending the ED 12 times or more within a calendar year (1 January 2009 to 31 December 2009). We collected their characteristics and calculated a score of accumulation of risk factors of vulnerability. Results Highly frequent users comprised 0.1% of ED patients, and they accounted for 0.8% of all ED attendances (23 patients, 425 attendances). Of all highly frequent users, 87% had a primary care practitioner, 82.6% were unemployed, 73.9% were socially isolated, and 60.9% had a mental health or substance use primary diagnosis. One-third had attempted suicide during study period, all of them being women. They were often admitted (24.0% of attendances), and only 8.7% were uninsured. On average, they cumulated 3.3 different risk factors of vulnerability (SD 1.4). Conclusion Highly frequent users of a Swiss academic ED are a highly vulnerable population. They are in poor health and accumulate several risk factors of being even in poorer health. The small number of patients and their high level of insurance coverage make it particularly feasible to design a specific intervention to approach their needs, in close collaboration with their primary care practitioner. Elaboration of the intervention should focus on social reinsertion and risk-reduction strategies with regard to substance use, hospital admissions and suicide.

Factors associated with latent tuberculosis among asylum seekers in Switzerland: a cross-sectional study in Vaud County

BackgroundScreening and treatment of latent tuberculosis infection (LTBI) in asylum seekers (AS) may prevent future cases of tuberculosis. As the screening with Interferon Gamma Release Assay (IGRA) is costly, the objective of this study was to assess which factors were associated with LTBI and to define a score allowing the selection of AS with the highest risk of LTBI.MethodsIn across-sectional study, AS seekers recently arrived in Vaud County, after screening for tuberculosis at the border were offered screening for LTBI with T-SPOT.TB and questionnaire on potentially risk factors. The factors associated with LTBI were analyzed by univariate and multivariate regression.ResultsAmong 393 adult AS, 98 (24.93%) had a positive IGRA response, five of them with active tuberculosis previously undetected. Six factors associated with LTBI were identified in multivariate analysis: origin, travel conditions, marital status, cough, age and prior TB exposure. Their combination leads to a robust LTBI predictive score.ConclusionsThe prevalence of LTBI and active tuberculosis in AS is high. A predictive score integrating six factors could identify the asylum seekers with the highest risk for LTBI.

Undocumented Migrants in Switzerland: Geographical Origin Versus Legal Status as Risk Factor for Tuberculosis

Undocumented migrants, meaning migrants without a legal residency permit, come to Geneva from countries with high tuberculosis (TB) incidence. We estimate here whether being undocumented is a determinant of TB, independently of origin. Cross-sectional study including undocumented migrants in a TB screening program in 2002; results were compared to 12,904 age and frequency matched participants in a general TB screening program conducted at various workplaces in Geneva, Switzerland from 1992 to 2002. A total of 206 undocumented migrants (36% male, 64% female, mean age 37.8 years (SD 11.8), 82.5% from Latin America) participated in the TB screening program. Compared to legal residents, undocumented migrants had an adjusted OR for TB-related fibrotic signs of 1.7 (95% CI 0.8;3.7). The OR of TB-related fibrotic signs for Latin American (vs. other) origin was 2.7 (95% CI 1.6;4.7) among legal residents and 5.5 (95% CI 2.8;10.8) among undocumented migrants. Chest X-ray screening identified a higher proportion of TB-related fibrotic signs among Latin Americans, independently of their residency status.