Impact of the COVID-19 Pandemic on Elective and Emergency Inpatient Procedure Volumes in Switzerland – A Retrospective Study Based on Insurance Claims Data

Background: The severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) pandemic forced hospitals to redistribute resources for the treatment of patients with coronavirus disease 2019 (COVID-19), yet the impact on elective and emergency inpatient procedure volumes is unclear. Methods: We analyzed anonymized data on 234 921 hospitalizations in 2017-2020 (55.9% elective) from a big Swiss health insurer. We used linear regression models to predict, based on pre-pandemic data, the expected weekly numbers of procedures in 2020 in the absence of a pandemic and compared these to the observed numbers in 2020. Compensation effects were investigated by discretely integrating the difference between the two numbers over time. Results: During the first COVID-19 wave in spring 2020, elective procedure numbers decreased by 52.9% (95% confidence interval -64.5% to -42.5%), with cardiovascular and orthopedic elective procedure numbers specifically decreasing by 45.5% and 72.4%. Elective procedure numbers normalized during summer with some compensation of postponed procedures, leaving a deficit of -9.9% (-15.8% to -4.5%) for the whole year 2020. Emergency procedure numbers also decreased by 17.1% (-23.7% to -9.8%) during the first wave, but over the whole year 2020, net emergency procedure volumes were similar to control years. Conclusion: Inpatient procedure volumes in Switzerland decreased considerably in the beginning of the pandemic but recovered quickly after the first wave. Still, there was a net deficit in procedures at the end of the year. Health system leaders must work to ensure that adequate access to non-COVID-19 related care is maintained during future pandemic phases in order to prevent negative health consequences. Keywords: COVID-19; Hospitals; Inpatient; Surgery; Switzerland; Undertreatment

Inferior control of low-density lipoprotein cholesterol in women is the primary sex difference in modifiable cardiovascular risk: A large-scale, cross-sectional study in primary care

BACKGROUND AND AIMS Sex differences in cardiovascular prevention have been reported, yet the role of sex with regard to different modifiable risk factors such as low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (BP), and glycated hemoglobin (HbA1c) in primary care settings is unclear. Therefore, we studied sex differences in assessment and measured values of LDL-C, BP, and HbA1c in primary and secondary cardiovascular prevention delivered by general practitioners. METHODS This cross-sectional study was based on electronic medical records of 59,092 primary care patients (51.9% women) aged 40-79 years in Switzerland. Multilevel regression was used to model associations of sex with assessment and measured values of LDL-C, BP, and HbA1c in 2018. RESULTS In both primary and secondary prevention, women had lower LDL-C assessment rates (age-adjusted odds ratio (aOR) 0.71 [95% confidence interval (CI) 0.67 to 0.75] and 0.70 [CI 0.51 to 0.95]), and higher measured LDL-C values than men (age-adjusted difference 0.30 mmol/L [CI 0.25 to 0.35] and 0.28 mmol/L [CI 0.07 to 0.48]). Compared with men, women in primary prevention displayed lower BP and HbA1c assessment frequencies (aOR 0.77 [CI 0.73 to 0.81] and 0.76 [CI 0.71 to 0.80]) and measured values (age-adjusted difference -2.49 mmHg [CI -2.99 to -1.79] and -0.19% [CI -0.24 to -0.14]), while there was no sex difference in secondary prevention. Age-dependent increases in measured values of LDL-C, BP, and HbA1c were greater in women than men. CONCLUSIONS Control of LDL-C in women in primary care should be improved to reduce sex-based inequalities in prevention of cardiovascular disease

Impact of a deprescribing tool on the use of sedative hypnotics among older patients: study protocol for a cluster randomised controlled trial in Swiss primary care (the HYPE trial)

INTRODUCTION Benzodiazepines and other sedative hypnotics (BSH) are potentially inappropriate and harmful medications in older people due to their higher susceptibility for adverse drug events. BSH prescription rates are constantly high among elderly patients and even increase with higher age and comorbidity. Deprescribing BSH can be challenging both for healthcare providers and for patients for various reasons. Thus, physicians and patients may benefit from a supportive tool to facilitate BSH deprescribing in primary care consultations. This study intends to explore effectiveness, safety, acceptance and feasibility of such a tool. METHODS AND ANALYSIS In this prospective, cluster randomised, controlled, two-arm, double-blinded trial in the ambulatory primary care setting, we will include general practitioners (GPs) from German-speaking Switzerland and their BSH consuming patients aged 65 years or older, living at home or in nursing homes. GPs will be randomly assigned to either intervention or control group. In the intervention group, GPs will participate in a 1-hour online training on how to use a patient support tool (decision-making guidance plus tapering schedule and non-pharmaceutical alternative treatment suggestions for insomnia). The control group GPs will participate in a 1-hour online instruction about BSH epidemiology and sleep hygiene counselling. This minimal intervention aims to prevent unblinding of control group GPs without jeopardising their 'usual care'.The primary outcome will be the percentage of patients who change their BSH use (ie, stop, reduce or switch to a non-BSH insomnia treatment) within 6 months from the initial consultation. EXPECTED BENEFIT Based on the results of the study, we will learn how GPs and their patients benefit from a supportive tool that facilitates BSH deprescribing in primary care consultations. The study will emphasise on exploring barriers and facilitators to BSH deprescribing among patients and providers. Positive results given, the study will improve medication safety and the quality of care for patients with sleeping disorders. ETHICS AND DISSEMINATION The study has been approved by the Ethics Committee of the Canton of Zurich (KEK-ZH Ref no. 2023-00054, 4 April 2023). Informed consent will be sought from all participating GPs and patients. The results of the study will be publicly disseminated

Procedure Prioritization During a Nationwide Ban on Non-Urgent Healthcare: A Quasi-Experimental Retrospective Study of Hospital Data in Switzerland

Background: During the COVID-19 lockdown in spring 2020, Switzerland restricted non-urgent healthcare services to safeguard capacity. While prioritization of care was supposed to be driven by medical urgency, demographic factors or economic incentives might have influenced the hospitals’ resource allocation decisions. Objectives: This study investigates potential determinants of procedure prioritization in hospitalized patients during the lockdown period. Design: Quasi-experimental retrospective study of hospital data in Switzerland. Methods: We analyzed 496 456 adult patients with known insurance status and a recorded procedure, admitted for cardiovascular, orthopedic/musculoskeletal or oncological reasons from January 2017 (3 years before the COVID-19 outbreak) to mid-April 2020 (in the first year of the COVID-19 pandemic), to obtain admission rate ratios (ARRs, “lockdown” admission rates divided by “normal” rates) from negative binomial regression analysis of fortnightly admissions for frequent procedure-diagnosis combinations. Quade and Wilcoxon signed-rank tests compared ARRs between sex×age, insurance and comorbidity strata. Results: Admission rates showed significant reductions for 29 of 53 procedure-diagnosis combinations. Reductions varied strongly by emergency, with largest decreases in orthopedic procedures for arthrosis (osteoarthritis) and non-arthritic joint disorders, and the smallest in cerebral imaging for stroke patients and surgical procedures for malignant neoplasms. The only difference in ARRs between strata was a stronger decrease in admission rates for cardiovascular combinations for patients with private versus basic health insurance. Conclusion: While medical procedures were affected to varying degrees by the ban on non-urgent healthcare during the COVID-19 lockdown, we found no robust evidence that factors other than medical urgency influenced healthcare prioritization

Hepatitis C antibody test frequencies and positive rates in Switzerland from 2007 to 2017: a retrospective longitudinal study

ACKGROUND AND AIMS: The prevalence of chronic hepatitis C in Switzerland is currently estimated at approximately 32,000 affected individuals (0.37% of the permanent resident population). An estimated 40% of affected individuals in Switzerland is undiagnosed. The Swiss Federal Office of Public Health requires laboratories to report all positive hepatitis C virus (HCV) test results. Approximately 900 newly diagnosed cases are reported annually. The number of HCV tests performed, however, is not collected by the Federal Office of Public Health and positive rates are therefore unknown. The aim of this study was to describe the longitudinal course of the numbers of hepatitis C antibody tests and of positive rates in Switzerland for the years 2007 to 2017. METHODS: Twenty laboratories were asked to provide the number of HCV antibody tests performed and the number of positive antibody tests per year. Using data from the Federal Office of Public Health reporting system for the years 2012 to 2017, we calculated a factor to correct our values for multiple tests of the same person. RESULTS: The annual number of HCV antibody tests performed tripled linearly from 2007 to 2017 (from 42,105 to 121,266) while the number of positive HCV antibody test results increased by only 75% over the same period (from 1360 to 2379). The HCV antibody test positive rate steadily decreased from 3.2% in 2007 to 2.0% in 2017. After correction for multiple tests per person, the person-level HCV antibody tested positive rate decreased from 2.2% to 1.7% from 2012 to 2017. CONCLUSION: In the Swiss laboratories considered, more HCV antibody tests were performed each year in the period (2007–2017) before and during the approval of the new hepatitis C drugs. At the same time, the HCV antibody positive rates decreased, both on a per-test as well as a per-person level. This study is the first to describe the evolution of tests performed and of positive rates for HCV antibody in Switzerland at the national level over several years. In order to more accurately guide future measures to achieve the goal of eliminating hepatitis C by 2030, we recommend annual collection and publication of positive rates by health authorities, along with mandatory reporting of numbers of tests and people treated

The Effectiveness of a Multi-Domain Electronic Feedback Report on the Performance of Quality Indicators for Chronic Conditions : Protocol for a Randomized Controlled Trial in General Practice

BACKGROUND Chronic conditions are a significant public health concern due to their rising prevalence, association with high mortality, and substantial healthcare costs. General practitioners play a crucial role in managing these conditions, and quality indicators are essential tools for assessing the quality of care. Electronic feedback reports incorporating quality indicator performance have shown promise in improving care quality. However, most studies have focused on single conditions or link feedback to financial incentives, which may not sustain long-term practice changes. This study aims to evaluate the effectiveness of a multi-condition electronic feedback reports on quality indicator performance in Swiss general practice without financial incentives. METHODS This randomized controlled trial involves general practitioners enrolled in the FIRE project, a database of electronic medical records from Swiss primary care. Participants are randomized to receive either a plain feedback report or a comprehensive quality indicator -specific feedback report bi-monthly for 12 months. The plain feedback report contains descriptive summaries of practice activities, while the quality indicator-specific feedback report includes performance data on 14 quality indicators across cardiovascular, endocrine, pulmonary, and renal domains. The quality indicators were selected in multi-step process involving review of the literature and clinical guidelines, domain expert consultations, and a panel discussion with general practitioners. The primary study objective is to compare the effectiveness of the quality indicator-specific feedback report and of the plain feedback report with respect to the performance of the selected quality indicators. CONCLUSION The study addresses a critical gap by evaluating a multi-condition feedback report without financial incentives. Its findings can inform future health policies and strategies, in line with national and international initiatives that promote or even require the implementation of quality measurement activities in general practice. TRIAL REGISTRATION Trial registry: ISRCTN. Registration number: ISRCTN10637092, https://www.isrctn.com/ISRCTN10637092. Registered January 9, 2024

Potentially Inappropriate Medication Use in Primary Care in Switzerland

IMPORTANCE: Potentially inappropriate medication (PIM) exposes patients to an increased risk of adverse outcomes. Many lists of explicit criteria provide guidance on identifying PIM and recommend alternative prescribing, but the complexity of available lists limits their applicability and the amount of data available on PIM prescribing. OBJECTIVE: To determine PIM prevalence and the most frequently prescribed PIMs according to 6 well-known PIM lists and to develop a best practice synthesis for clinicians. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used anonymized electronic health record data of Swiss primary care patients aged 65 years or older with drug prescriptions from January 1, 2020, to December 31, 2021, extracted from a large primary care database in Switzerland, the FIRE project. Data analyses took place from October 2022 to September 2023. EXPOSURE: PIM prescription according to PIM criteria operationalized for use with FIRE data. MAIN OUTCOMES AND MEASURES: The primary outcomes were PIM prevalence (percentage of patients with 1 or more PIMs) and PIM frequency (percentage of prescriptions identified as PIMs) according to the individual PIM lists and a combination of all 6 lists. The PIM lists used were the American 2019 Updated Beers criteria, the French list by Laroche et al, the Norwegian General Practice Norwegian (NORGEP) criteria, the German PRISCUS list, the Austrian list by Mann et al, and the EU(7) consensus list of 7 European countries. RESULTS: This study included 115 867 patients 65 years or older (mean [SD] age, 76.0 [7.9] years; 55.8% female) with 1 211 227 prescriptions. Among all patients, 86 715 (74.8%) were aged 70 years or older, and 60 670 (52.4%) were aged 75 years or older. PIM prevalence among patients 65 years or older was 31.5% (according to Beers 2019), 15.4% (Laroche), 16.1% (NORGEP), 12.7% (PRISCUS), 31.2% (Mann), 37.1% (EU[7]), and 52.3% (combined list). PIM prevalence increased with age according to every PIM list (eg, according to Beers 2019, from 31.5% at age 65 years or older to 37.4% for those 75 years or older, and when the lists were combined, PIM prevalence increased from 52.3% to 56.7% in those 2 age groups, respectively). PIM frequency was 10.3% (Beers 2019), 3.9% (Laroche), 4.3% (NORGEP), 2.4% (PRISCUS), 6.7% (Mann), 9.7% (EU[7]), and 19.3% (combined list). According to the combined list, the 5 most frequently prescribed PIMs were pantoprazole (9.3% of all PIMs prescribed), ibuprofen (6.9%), diclofenac (6.3%), zolpidem (4.5%), and lorazepam (3.7%). Almost two-thirds (63.5%) of all PIM prescriptions belonged to 5 drug classes: analgesics (26.9% of all PIMs prescribed), proton pump inhibitors (12.1%), benzodiazepines and benzodiazepine-like drugs (11.2%), antidepressants (7.0%), and neuroleptics (6.3%). CONCLUSIONS AND RELEVANCE: In this cross-sectional study of adults aged 65 or older, PIM prevalence was high, varied considerably depending on the criteria applied, and increased consistently with age. However, only few drug classes accounted for the majority of all prescriptions that were PIM according to any of the 6 PIM lists, and by considering this manageable number of drug classes, clinicians could essentially comply with all 6 PIM lists. These results raise awareness of the most common PIMs and emphasize the need for careful consideration of their risks and benefits and targeted deprescribing

Late presentation for hepatitis C treatment: prevalence and risk factors in the Swiss Hepatitis C Cohort

OBJECTIVE Patients with 'late presentation' (LP) of chronic hepatitis C infection (HCV) have already developed advanced liver disease before receiving direct-acting antiviral (DAA) treatment. Even after successful treatment, the risk of morbidity and premature death remains elevated, leading to an unnecessary disease burden. This study aimed to assess the prevalence of LP within the prospective observational Swiss Hepatitis C Cohort (SCCS) and evaluate risk factors as determinants of LP. METHODS Treatment-naïve participants of SCCS who received DAA treatment between 2014 and 2019 were included. Demographic, clinical and behavioural data were compared between the LP and non-LP strata. LP prevalence was calculated over time and by year. LASSO regression was used to identify potential risk factors for LP, and odds ratios were calculated by refitting logistic regression models. RESULTS In this explorative, retrospective case-control study using data of n = 5829 SCCS members, a total of 21.3% received their first HCV treatment. The cumulative LP prevalence decreased from mid-2015 and stabilised at 46.5% (n = 579) by the end of 2019. Male gender, higher age and a history of alcohol overuse were associated with a higher risk of LP. CONCLUSION Despite the study's limitations, LP prevalence was higher than anticipated, considering Switzerland's availability period and universal access to DAAs. Therefore, any HCV LP should be viewed as a healthcare system failure, primarily in high-income economies. As LP is directly linked to the disease burden, it must be included as a mandatory parameter in surveillance response systems of HCV elimination programs

What interventions do general practitioners recommend avoiding? A nationwide survey from Switzerland

Background: To address low-value interventions in healthcare, “Choosing Wisely” campaigns provide recommendations of interventions to avoid (RIAs). These are usually developed by expert panels rather than general practitioners (GPs). The aim of our study was to develop RIAs for ambulatory general medicine based on the suggestions of GPs, with their involvement from the very beginning. Methods: This was a nationwide online Delphi survey among Swiss Society of General Internal Medicine members. In round one, each participant suggested two interventions perceived as particularly inappropriate. In round two, the 16 most frequent RIAs were rated by importance on a 0–100 scale and compared with “Choosing Wisely” lists. We calculated descriptive statistics for suggestions and importance ratings, and used regression models to search for associations with GP characteristics. Results: Response rates were 7.4% (538/7318) for round one and 18.2% (1357/7468) for round two. GPs provided 1074 suggestions. Out of the 16 most frequent RIAs, 13 corresponded to existing “Choosing Wisely” lists. The RIAs rated most important were: antibiotics in viral infections, unnecessarily duplicated tests and imaging in unspecific low back pain (means 88.5–91.7, standard deviations 18.6–19.9). None of the GPs’ characteristics were associated with any of the five highest rated RIAs except for working in a hospital setting. Conclusion: Most RIA suggestions from GPs were concordant with previously published recommendations of interventions to avoid, independently of GPs knowledge of these and reflecting their high clinical relevance. In addition, our study revealed some more relevant topics and may help to develop future “Choosing Wisely” recommendations, with the final goal to reduce low-value care

Medication Review and Enhanced Information Transfer at Discharge of Older Patients with Polypharmacy: a Cluster-Randomized Controlled Trial in Swiss Hospitals

Background: Medication safety in patients with polypharmacy at transitions of care is a focus of the current Third WHO Global Patient Safety Challenge. Medication review and communication between health care professionals are key targets to reduce medication-related harm. Objective: To study whether a hospital discharge intervention combining medication review with enhanced information transfer between hospital and primary care physicians can delay hospital readmission and impact health care utilization or other health-related outcomes of older inpatients with polypharmacy. Design: Cluster-randomized controlled trial in 21 Swiss hospitals between January 2019 and September 2020, with 6 months follow-up. Participants: Sixty-eight senior physicians and their blinded junior physicians included 609 patients ≥ 60 years taking ≥ 5 drugs. Interventions: Participating hospitals were randomized to either integrate a checklist-guided medication review and communication stimulus into their discharge processes, or follow usual discharge routines. Main measures: Primary outcome was time-to-first-readmission to any hospital within 6 months, analyzed using a shared frailty model. Secondary outcomes covered readmission rates, emergency department visits, other medical consultations, mortality, drug numbers, proportions of patients with potentially inappropriate medication, and the patients' quality of life. Key results: At admission, 609 patients (mean age 77.5 (SD 8.6) years, 49.4% female) took a mean of 9.6 (4.2) drugs per patient. Time-to-first-readmission did not differ significantly between study arms (adjusted hazard ratio 1.14 (intervention vs. control arm), 95% CI [0.75-1.71], p = 0.54), nor did the 30-day hospital readmission rates (6.7% [3.3-10.1%] vs. 7.0% [3.6-10.3%]). Overall, there were no clinically relevant differences between study arms at 1, 3, and 6 months after discharge. Conclusions: The combination of a structured medication review with enhanced information transfer neither delayed hospital readmission nor improved other health-related outcomes of older inpatients with polypharmacy. Our results may help researchers in balancing practicality versus stringency of similar hospital discharge interventions. Study registration: ISRCTN18427377, https://doi.org/10.1186/ISRCTN18427377. Keywords: communication; health care quality improvement; hospital medicine; medication safety; primary care