Patients requiring anticoagulation suffer from comorbidities such as hypertension. On the occasion of INR monitoring, general practitioners (GPs) have the opportunity to control for blood pressure (BP). We aimed to evaluate the impact of Vitamin-K Antagonist (VKA) monitoring by GPs on BP control in patients with hypertension.

BACKGROUND:Can the application of local anesthetics (Neural Therapy, NT) alone durably improve pain symptoms in referred patients with chronic and refractory pain? If the application of local anesthetics does lead to an improvement that far exceeds the duration of action of local anesthetics, we will postulate that a vicious circle of pain in the reflex arcs has been disrupted (hypothesis).METHODS:Case series design. We exclusively used procaine or lidocaine. The inclusion criteria were severe pain and chronic duration of more than three months, pain unresponsive to conventional medical measures, written referral from physicians or doctors of chiropractic explicitly to NT. Patients with improvement of pain who started on additional therapy during the study period for a reason other than pain were excluded in order to avoid a potential bias. Treatment success was measured after one year follow-up using the outcome measures of pain and analgesics intake.RESULTS:280 chronic pain patients were included; the most common reason for referral was back pain. The average number of consultations per patient was 9.2 in the first year (median 8.0). After one year, in 60 patients pain was unchanged, 52 patients reported a slight improvement, 126 were considerably better, and 41 pain-free. At the same time, 74.1% of the patients who took analgesics before starting NT needed less or no more analgesics at all. No adverse effects or complications were observed.CONCLUSIONS:The good long-term results of the targeted therapeutic local anesthesia (NT) in the most problematic group of chronic pain patients (unresponsive to all evidence based conventional treatment options) indicate that a vicious circle has been broken. The specific contribution of the intervention to these results cannot be determined. The low costs of local anesthetics, the small number of consultations needed, the reduced intake of analgesics, and the lack of adverse effects also suggest the practicality and cost-effectiveness of this kind of treatment. Controlled trials to evaluate the true effect of NT are needed.

Background Avoidable hospitalizations (AH) are hospital admissions for diseases and conditions that could have been prevented by appropriate ambulatory care. We examine regional variation of AH in Switzerland and the factors that determine AH. Methods We used hospital service areas, and data from 2008–2010 hospital discharges in Switzerland to examine regional variation in AH. Age and sex standardized AH were the outcome variable, and year of admission, primary care physician density, medical specialist density, rurality, hospital bed density and type of hospital reimbursement system were explanatory variables in our multilevel poisson regression. Results Regional differences in AH were as high as 12-fold. Poisson regression showed significant increase of all AH over time. There was a significantly lower rate of all AH in areas with more primary care physicians. Rates increased in areas with more specialists. Rates of all AH also increased where the proportion of residences in rural communities increased. Regional hospital capacity and type of hospital reimbursement did not have significant associations. Inconsistent patterns of significant determinants were found for disease specific analyses. Conclusion The identification of regions with high and low AH rates is a starting point for future studies on unwarranted medical procedures, and may help to reduce their incidence. AH have complex multifactorial origins and this study demonstrates that rurality and physician density are relevant determinants. The results are helpful to improve the performance of the outpatient sector with emphasis on local context. Rural and urban differences in health care delivery remain a cause of concern in Switzerland.

PURPOSE:To provide normal values of the cervical spinal canal and spinal cord dimensions in several planes with respect to spinal level, age, sex, and body height.MATERIALS AND METHODS:This study was approved by the institutional review board; all individuals provided signed informed consent. In a prospective multicenter study, two blinded raters independently examined cervical spine magnetic resonance (MR) images of 140 healthy volunteers who were white. The midsagittal diameters and areas of spinal canal and spinal cord, respectively, were measured at the midvertebral levels of C1, C3, and C6. A multivariate general linear model described the influence of sex, body height, age, and spinal level on the measured values.RESULTS:There were differences for sex, spinal level, interaction between sex and level, and body height, while age had significant yet limited influence. Normative ranges for the sagittal diameters and areas of spinal canal and spinal cord were defined at C1, C3, and C6 levels for men and women. In addition to a calculation of normative ranges for a specific sex, spinal level, age, and body height data, data for three different height subgroups at 45 years of age were extracted. These results show a range of the spinal canal dimensions at C1 (from 10.7 to 19.7 mm), C3 (from 9.4 to 17.2 mm), and C6 (from 9.2 to 16.8 mm) levels.CONCLUSION:The dimensions of the cervical spinal canal and cord in healthy individuals are associated with spinal level, sex, age, and height. Online supplemental material is available for this article.

To review systematic reviews and meta-analyses of integrated care programmes in chronically ill patients, with a focus on methodological quality, elements of integration assessed and effects reported.Meta-review of systematic reviews and meta-analyses identified in Medline (1946-March 2012), Embase (1980-March 2012), CINHAL (1981-March 2012) and the Cochrane Library of Systematic Reviews (issue 1, 2012).Methodological quality assessed by the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) checklist; elements of integration assessed using a published list of 10 key principles of integration; effects on patient-centred outcomes, process quality, use of healthcare and costs.Twenty-seven systematic reviews were identified; conditions included chronic heart failure (CHF; 12 reviews), diabetes mellitus (DM; seven reviews), chronic obstructive pulmonary disease (COPD; seven reviews) and asthma (five reviews). The median number of AMSTAR checklist items met was five: few reviewers searched for unpublished literature or described the primary studies and interventions in detail. Most reviews covered comprehensive services across the care continuum or standardization of care through inter-professional teams, but organizational culture, governance structure or financial management were rarely assessed. A majority of reviews found beneficial effects of integration, including reduced hospital admissions and re-admissions (in CHF and DM), improved adherence to treatment guidelines (DM, COPD and asthma) or quality of life (DM). Few reviews showed reductions in costs.Systematic reviews of integrated care programmes were of mixed quality, assessed only some components of integration of care, and showed consistent benefits for some outcomes but not others.

BACKGROUND:There is a growing interest in examining the current state of care and identifying opportunities for improving care and reducing costs at the end of life. The aim of this study is to examine patterns of health care use at the end of life and place of death and to describe the basic characteristics of the decedents in the last six months of their life.METHODS:The empirical analysis is based on data from 58,732 Swiss residents who died between 2007 and 2011. All decedents had mandatory health insurance with Helsana Group, the largest health insurer in Switzerland. Descriptive statistical techniques were used to provide a general profile of the study population and determinants of the outcome for place of death were analyzed with an econometric approach.RESULTS:There were substantial and significant differences in health care utilization in the last six months of life between places of death. The mean numbers of consultations with a general practitioner or a specialist physician as well as the number of different medications and the number of hospital days was consistently highest for the decedents who died in a hospital. We found death occurred in Switzerland most frequently in hospitals (38.4% of all cases) followed by nursing homes (35.1%) and dying at home (26.6%). The econometric analysis indicated that the place of death is significantly associated with age, sex, region and multiple chronic conditions.CONCLUSIONS:The importance of nursing homes and patients' own homes as place of death will continue to grow in the future. Knowing the determinants of place of death and patterns of health care utilization of decedents can help decision makers on the allocation of these needed health care services in Switzerland.

Purpose: To compare the magnetic resonance (MR) imaging findings in patients with acute whiplash injury with those in matched control subjects. Materials and Methods: In a prospective multicenter controlled study, from 2005 to 2008, 100 consecutive patients underwent 1.5-T MR imaging examinations of the cervical spine within 48 hours after a motor vehicle accident. Findings in these patients were compared in a blinded fashion with those in 100 age-and sex-matched healthy control subjects. Four blinded independent readers assessed the presence of occult vertebral body and facet fractures, vertebral body and facet contusions, intervertebral disk herniations, ligamentum nuchae strains, ligamentum nuchae tears, muscle strains or tears, and perimuscular fluid. Accuracy (as compared with clinical findings) and interobserver reliability were calculated. Results: Accuracy of MR imaging and interreader reliability were generally poor (sensitivity, 0.328; specificity, 0.728; positive and negative likelihood ratios, 1.283 and 1.084, respectively). MR imaging findings significantly associated with whiplash injuries were occult fracture (P < .01), bone marrow contusion of the vertebral body (P = .01), muscle strain (P < .01) or tear (P < .01), and the presence of perimuscular fluid (P < .01). While 10 findings thought to be specific for whiplash trauma were significantly (P < .01) more frequent in patients (507 observations), they were also regularly found in healthy control subjects (237 observations). There were no serious occult injuries that required immediate therapy. Conclusion: MR imaging at 1.5 T reveals only limited evidence of specific changes to the cervical spine and the surrounding tissues in patients with acute symptomatic whiplash injury compared with healthy control subjects.

OBJECTIVES:Swiss health care is relatively costly. In order better to understand the drivers of spending, this study analyses geographic variation in per capita consultation costs for ambulatory care.METHODS:Small area and longitudinal analysis of costs of ambulatory services covered by compulsory health insurance, 2003-07.RESULTS:The results show considerable geographic variation in per capita consultation costs, with higher costs in urban compared to rural areas. Areas with higher availability of care had higher costs, and residents of urban and high income areas used more specialist care and generated higher costs than residents of rural areas.CONCLUSIONS:There are persistent regional differences in the per capita cost of ambulatory care that are not explained by demographic factors, access to care, or needs. It is likely that higher access to care leads to greater inappropriate use, particularly of specialists. Implementing gatekeeping systems and financial incentives that encourage better coordination of primary care may slow growth in costs and improve care.

Purpose: To investigate the role of the cervical spine muscles in whiplash injury. We hypothesized that (i) cervical muscle hypotrophy would be evident after a 6-month follow-up and, (ii) cervical muscle hypotrophy would correlate with symptom persistence probably related to pain or inactivity. Materials and Methods: Ninety symptomatic patients (48 females) were recruited from our emergency department and examined within 48 h, and at 3, and 6 months after a motor vehicle accident. MRI cross-sectional muscle area (CSA) measurements were performed bilaterally of the cervical extensor and sternocleidomastoid muscles using transverse STIR (Short Tau inversion Recovery) sequences at the C2 (deep and total dorsal cervical extensor muscles), C4 (sternocleidomastoid muscles) and C5 (deep and total dorsal cervical extensor muscles) levels. Two blinded raters independently performed the measurements at each time point. First, CSA changes over time were analyzed and, second, CSAs were correlated with clinical outcomes (EuroQuol, Whiplash Disability Score, neck pain intensity [VAS], cervical spine mobility). Results: There was a high agreement of CSA measurements between the two raters. Women consistently had smaller CSAs than men. There were no significant changes of CSAs over time at any of the three levels. There were no consistent significant correlations of CSA values with the clinical scores at all time points except with the body mass index. Conclusion: Our results do not support a major role of cervical muscle volume in the genesis of symptoms after whiplash injury. J. Magn. Reson. Imaging 2012; 36:14131420. (C) 2012 Wiley Periodicals, Inc.

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.

BACKGROUND Various studies have been performed on differences in quality measures between different models of primary care with inconclusive results. In Switzerland, up to a third of the population chooses network health plans including gatekeeping to profit from lower premiums and almost half of GPs work in primary care networks. OBJECTIVE To determine differences in the quality of interpersonal care and practice management between patients consulting a physician organized in a GP network or in independent practice. METHODS We analysed data of the European Project on Patient Evaluation of General Practice Care (EUROPEP) questionnaire measuring the quality of the patient-physician interaction and practice management of 473 primary care physicians. From the 25178 patients who completed the questionnaire, 72.2% (18174) consulted a physician participating in a network and 27.8% (7004) a physician working in independent practice. RESULTS The overall answer pattern of EUROPEP questions shows that patients were generally more satisfied with physicians in independent practice. Particularly, questions within the domains 'relation and communication' and 'information and support' and to a lesser degree within 'Medical care' were significantly answered more favourable by patients of independent physicians. Stratification for chronic diseases showed that significant differences favouring independent physicians were less evident in patients with chronic diseases than in the non-chronic group. CONCLUSIONS The results show differences in the quality of interpersonal care and practice management experienced by patients consulting network-or independent physicians. Therefore, we suggest that efforts to reduce health care spending by promoting more integrated care must also focus on monitoring and improving patient perceived qualities.

Purpose. To evaluate the influence of patient characteristics on stem loosening after cemented or uncemented total hip arthroplasty (THA) using a matched case-control study. Methods. Consecutive records of 4372 cemented (716 cases and 3656 controls) and 809 uncemented (115 cases and 694 controls) primary THAs between 1981 and 2003 in 30 hospitals in 8 European countries were reviewed. Cases and controls were defined as patients with and without stem loosening, respectively. In cases of bilateral THA, patients were their own controls. Cases and controls were matched for hospital, date of surgery, date of follow-up, stem type, and head size. Patient characteristics such as gender, age, weight, height, body mass index (BMI), diagnosis, presence of previous surgery on the affected hip, and walking restrictions according to the Charnley classification were recorded. Results. Male patients were at higher risk of cemented stem loosening (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.4–2.2). Older patients were at lower risk of cemented stem loosening; the odds decreased by 3% per year older (OR, 0.97; 95% CI, 0.96–0.98). Regarding BMI, the odds of cemented stem loosening increased by 3% for each additional unit of BMI over 25 kg/m 2 (OR, 1.03; 95% CI, 1.004–1.05). Patients in Charnley class B had a lower risk of cemented stem loosening (OR, 0.75; 95% CI, 0.61–0.93). Conclusion. Advanced age, female gender, and Charnley class B (as a proxy measure of reduced walking activity) have a protective effect on survival of cemented stems, whereas a higher BMI was a risk factor.

QUESTIONS UNDER STUDY The aim of the study was to analyse the effects of supplementary health insurance on the incidence of hospitalisations for musculoskeletal conditions in Switzerland. METHODS Cross sectional and small area analyses of surgical interventions for major musculoskeletal disorders in Switzerland were conducted. The regional distributions of populations with basic and basic plus supplementary insurance were estimated using census data for the period of 2002-2005. Effects of insurance class on the incidence of orthopaedic interventions were calculated with logistic regression using the complete discharge dataset of hospitalisations for orthopaedic conditions performed in the years 2002 to 2005. RESULTS The data show significant differences in the age- and gender-adjusted incidence of surgery between populations with compulsory basic health insurance and those with basic plus supplementary cover. CONCLUSIONS The study provides evidence that health insurance status accounts for variation in surgery for musculoskeletal problems in Switzerland. There are indications that supplementary health insurance - as a proxy for higher socioeconomic status - is related to lower need for surgery. There are signs that resources for spinal surgery and arthroscopy are diverted to the private sector at the expense of social health insurance. The results are only partially consistent with the hypothesis that volume of services increases with comprehensiveness of coverage.