Management of residents in difficulty in a Swiss general internal medicine outpatient clinic: Change is necessary!

AIMS OF THE STUDY: Residents in difficulty are a major cause for concern in medical education, with a prevalence of 7-15%. They are often detected late in their training and cannot make use of remediation plans. Nowadays, most training hospitals in Switzerland do not have a specific program to identify and manage residents in difficulty. The aim of the study was to explore the challenges perceived by physicians regarding the process of identifying, diagnosing, and supporting residents in difficulty in a structured and programmatic way. We explored perceptions of physicians at different hierarchical levels (residents (R), Chief residents (CR), attending physicians (A), Chief Physician (CP)) in order to better understand these challenges. METHODS: We conducted an exploratory qualitative study between December 2015 and July 2016. We asked volunteers from the Primary Care Division of the Geneva University Hospitals to partake to three focus groups (with CR, A, R) and one interview with the division's CP. We transcribed, coded, and qualitatively analyzed the three focus groups and the interview, using a content thematic approach and Fishbein's conceptual framework. RESULTS: We identified similarities and differences in the challenges of the management of residents in difficulty on a programmatic way amongst physicians of different hierarchical levels. Our main findings: Supervisors (CR, A, CP) have good identification skills of residents in difficulty, but they did not put in place systematic remediation strategies.Supervisors (CR, A) were concerned about managing residents in difficulty. They were aware of the possible adverse effects on patient care, but "feared to harm" resident's career by documenting a poor institutional assessment.Residents "feared to share" their own difficulties with their supervisors. They thought that it would impact their career negatively.The four physician's hierarchical level reported environmental constraints (lack of funding, time constraint, lack of time and resources…). CONCLUSION: Our results add two perspectives to specialized recommendations regarding the implementation of remediation programs for residents in difficulty. The first revolves around the need to identify and fully understand not only the beliefs but also the implicit norms and the feeling of self-efficacy that are shared by teachers and that are likely to motivate them to engage in the management of residents in difficulty. The second emphasizes the importance of analyzing these elements that constitute the context for a change and of identifying, in close contact with the heads of the institutions, which factors may favor or hinder it. This research action process has fostered awareness and discussions at different levels. Since then, various actions and processes have been put in place at the Faculty of Medicine in Geneva.

Roadmap for the treatment of heart failure patients after hospital discharge: an interdisciplinary consensus paper.

The transition period from the hospital to the outpatient setting is a critical phase when managing heart failure. A well-structured transition is paramount and helps to ensure a tight follow-up schedule for the heart failure patient, thereby improving treatment outcomes. This article aims to provide guidance for the first three follow-up visits after hospital discharge, with a focus on monitoring heart failure patients and up-titrating their medication in primary care.

Overlapping spatial clusters of sugar-sweetened beverage intake and body mass index in Geneva state, Switzerland.

BACKGROUND: Obesity and obesity-related diseases represent a major public health concern. Recently, studies have substantiated the role of sugar-sweetened beverages (SSBs) consumption in the development of these diseases. The fine identification of populations and areas in need for public health intervention remains challenging. This study investigates the existence of spatial clustering of SSB intake frequency (SSB-IF) and body mass index (BMI), and their potential spatial overlap in a population of adults of the state of Geneva using a fine-scale geospatial approach. METHODS: We used data on self-reported SSB-IF and measured BMI from residents aged between 20 and 74 years of the state of Geneva (Switzerland) that participated in the Bus Santé cross-sectional population-based study (n = 15,423). Getis-Ord Gi spatial indices were used to identify spatial clusters of SSB-IF and BMI in unadjusted models and models adjusted for individual covariates (education level, gender, age, nationality, and neighborhood-level median income). RESULTS: We identified a significant spatial clustering of BMI and SSB-IF. 13.2% (n = 2034) of the participants were within clusters of higher SSB-IF and 10.7% (n = 1651) were within clusters of lower SSB-IF. We identified overlapping clusters of SSB-IF and BMI in specific areas where 11.1% (n = 1719) of the participants resided. After adjustment, the identified clusters persisted and were only slightly attenuated indicating that additional neighborhood-level determinants influence the spatial distribution of SSB-IF and BMI. CONCLUSIONS: Our fine-scale spatial approach allowed to identify specific populations and areas presenting higher SSB-IF and highlighted the existence of an overlap between populations and areas of higher SSB-IF associated with higher BMI. These findings could guide policymakers to develop locally tailored interventions such as targeted prevention campaigns and pave the way for precision public health delivery.

Patients' time perception in the waiting room of an ambulatory emergency unit: a cross-sectional study.

BACKGROUND: Patient satisfaction has become an increasingly important element in a service-oriented healthcare market. Although satisfaction is influenced by many factors, the waiting time to be seen by medical staff has been shown to be one of the key criteria. However, waiting is not an objective experience and several factors can influence its perception. METHODS: We conducted a questionnaire-based, cross-sectional study among patients attending the emergency unit of a Swiss university hospital in order to explore the key factors influencing wait perception. RESULTS: A total of 509 patients participated in the study. Appropriate assessment of emergency level by caregivers, the feeling of being forgotten, respect of privacy, and lack of information on the exact waiting time were identified as significant variables for wait perception. CONCLUSIONS: Our study confirmed the existence of a 'golden hour' when the patient is willing to wait until the medical encounter. In case the wait cannot be limited, an appropriate assessment of the emergency level by caregivers and avoiding the patients of feeling being forgotten are very important factors to avoid a negative perception of the waiting time before seeing a doctor. TRIAL REGISTRATION: (ID REQ-2016-00555).

Using a Triple Aim Approach to Implement "Less-is-More Together" and Smarter Medicine Strategies in an Interprofessional Outpatient Setting: Protocol for an Observational Study.

BACKGROUND: Increased awareness of the world's problematic growing health care expenditure and health care shortages requires sustainable use of available resources. To promote cultural changes in medical mindsets, societies representing medical specialties have developed new Choosing Wisely strategies. The Valais Medical Society and the Valais Pharmacy Association have developed an interprofessional collaboration project entitled "Less-is-more Together-PPI" to analyze and optimize change management practices focusing on the prescription and deprescription of proton pump inhibitors (PPIs). OBJECTIVE: This study aims to enhance interprofessional collaboration between physicians, pharmacists, and patients to optimize PPI use, avoid unnecessary treatments and improve therapeutic adherence to indicated therapies, and to analyze hindrances and facilitators to implementing interprofessional Less-is-more strategies in the field. METHODS: Home-dwelling adults domiciled in Valais and prescribed PPIs in the last 6 months will be invited to participate in this observational study. The studied subpopulation will be constituted of consenting patients whose physicians and pharmacists also voluntarily agree to participate. The process of collecting, pooling, transmitting, evaluating, and protecting data has been validated by the Human Research Ethics Committee of the Canton Vaud. RESULTS: The Primary Triple Aim outcome measures will be (1) population health: patient's assessment of their own health, functional status, and disease burden using a monthly questionnaire for 6 months; Behavioral/physiological factors will be investigated using a final questionnaire at 6 months, (2) experience of care: assessment using a final questionnaire for participating patients, pharmacists and physicians, and an analysis of negative/positive experiences via 6 follow-up questionnaires, and (3) Per capita cost: participants' fluctuating or decreasing PPI intake (number of pills/dosage) and an analysis of participants' different categories following their medical prescription, in relation to possible bias effects on the overall drug intake of the population studied. Secondary outcomes will be participation rates; patient, physician, and pharmacist follow-up; and evaluations of participants' experiences and their perceived benefits, as well as whether the interprofessional process can be improved. CONCLUSIONS: This project seeks a deeper understanding of how Less-is-more and smarter-medicine strategies are perceived by patients and health care providers in their daily lives in a very specific context. It will reveal some of the hindrances to and facilitators for efficient cultural change toward a more sustainable health care system. The results will be useful to optimize and scale up further Choosing Wisely approaches. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13896.

Four versus six weeks of antibiotic therapy for osteoarticular infections after implant removal: a randomized trial.

BACKGROUND: The optimal duration of antibiotic therapy for treating orthopaedic implant infections after surgical drainage and complete implant removal is unknown. METHODS: This was a single-centre, unblinded, prospective trial randomizing (1:1) eligible patients to either 4 or 6 weeks of systemic, pathogen-targeted antibiotic therapy. Clinical trial registration number: ClinicalTrials.gov (NCT0362209). RESULTS: We analysed 123 eligible patients (62 in the 4 week antibiotic arm and 61 in the 6 week arm) in the ITT analysis. The patients' median age was 64 years, 75 (61%) were men and 38 (31%) were immunocompromised. The most common types of infection treated included: two-stage exchange procedure for prosthetic joint infection (n = 38); orthopaedic plate infection (44) and infected nail implants (11). The median duration of post-explant intravenous antibiotic therapy was 4 days. Overall, 120 episodes (98%) were cured microbiologically and 116 (94%) clinically after a median follow-up period of 2.2 years. During follow-up, four patients had a clinical recurrence with a pathogen other than the initial causative agent. We noted recurrence of clinical infection in four patients in the 4 week arm and three patients in the 6 week arm (4/62 versus 3/61; χ2 test; P = 0.74); in all cases, this occurred at around 2 months following the end of antibiotic treatment. CONCLUSIONS: We found no statistically significant difference in the rates of clinical or microbiological remission between patients randomized to only 4 compared with 6 weeks of systemic antibiotic therapy after removal of an infected osteoarticular implant.

Alcohol control policies and socioeconomic inequalities in hazardous alcohol consumption: a 22-year cross-sectional study in a Swiss urban population.

OBJECTIVE: Harmful use of alcohol represents a large socioeconomic and disease burden and displays a socioeconomic status (SES) gradient. Several alcohol control laws were devised and implemented, but their equity impact remains undetermined.We ascertained if an SES gradient in hazardous alcohol consumption exists in Geneva (Switzerland) and assessed the equity impact of the alcohol control laws implemented during the last two decades. DESIGN: Repeated cross-sectional survey study. SETTING: We used data from non-abstinent participants, aged 35-74 years, from the population-based cross-sectional Bus Santé study (n=16 725), between 1993 and 2014. METHODS: SES indicators included educational attainment (primary, secondary and tertiary) and occupational level (high, medium and low). We defined four survey periods according to the implemented alcohol control laws and hazardous alcohol consumption (outcome variable) as >30 g/day for men and >20 g/day for women.The Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were used to quantify absolute and relative inequalities, respectively, and were compared between legislative periods. RESULTS: Lower educated men had a higher frequency of hazardous alcohol consumption (RII=1.87 (1.57; 2.22) and SII=0.14 (0.11; 0.17)). Lower educated women had less hazardous consumption ((RII=0.76 (0.60; 0.97)and SII=-0.04 (-0.07;-0.01]). Over time, hazardous alcohol consumption decreased, except in lower educated men.Education-related inequalities were observed in men in all legislative periods and did not vary between them. Similar results were observed using the occupational level as SES indicator. In women, significant inverse SES gradients were observed using educational attainment but not for occupational level. CONCLUSIONS: Population-wide alcohol control laws did not have a positive equity impact on hazardous alcohol consumption. Targeted interventions to disadvantaged groups may be needed to address the hazardous alcohol consumption inequality gap.

Twenty-four-year trends and determinants of change in compliance with Swiss dietary guidelines.

BACKGROUND AND AIMS: A healthy diet is the cornerstone of disease prevention, and dietary guidelines have been issued in most countries. We aimed to assess trends in compliance with dietary guidelines in the population of Geneva, Switzerland. METHODS: Multiple cross-sectional, population-based surveys conducted between 1993 and 2016 in the canton of Geneva, Switzerland [20,310 participants (52.3% women, mean age 51.9 ± 10.7 years)]. Trends in compliance with the Swiss dietary guidelines regarding food intake were assessed using logistic regression (a) for each guideline and (b) for at least three guidelines. Compliance before and after the first and second issuing of the guidelines was assessed. RESULTS: After multivariable adjustment, compliance with fruits increased overall [odds ratio and (95% confidence interval) for 1-year increase: 1.007 (1.003-1.012), p < 0.001], in men, participants aged over 45 and with low educational level. Compliance with vegetables increased overall [1.015 (1.008-1.022), p < 0.001], in both genders, age groups [45-54 and 55-64] and participants with low educational level. Compliance with meat increased in women [1.007 (1.001-1.013), p = 0.021] and participants with a university degree. Compliance with fresh fish increased in age group [55-64] [1.009 (1.000-1.018), p = 0.041]. Compliance with dairy products decreased overall [0.979 (0.972-0.986), p < 0.001] and in all groups studied, except for age group [65-74]. Compliance with at least three guidelines increased in age group [55-64] only [1.013 (1.002-1.024), p = 0.019]. No effect of the issuing of the guidelines was found. CONCLUSION: In the Geneva adult population, compliance with the Swiss dietary guidelines improved little. Issuing of dietary guidelines did not impact trends.

Spatial distribution of mammography adherence in a Swiss urban population and its association with socioeconomic status.

PURPOSE: Local physical and social environment has a defining influence on individual behavior and health-related outcomes. However, it remains undetermined if its impact is independent of individual socioeconomic status. In this study, we evaluated the spatial distribution of mammography adherence in the state of Geneva (Switzerland) using individual-level data and assessed its independence from socioeconomic status (SES). METHODS: Georeferenced individual-level data from the population-based cross-sectional Bus Santé study (n = 5002) were used to calculate local indicators of spatial association (LISA) and investigate the spatial dependence of mammography adherence. Spatial clusters are reported without adjustment; adjusted for neighborhood income and individual educational attainment; and demographic factors (age and Swiss nationality). The association between adjusted clusters and the proximity to the nearest screening center was also evaluated. RESULTS: Mammography adherence was not randomly distributed throughout Geneva with clusters geographically coinciding with known SES distributions. After adjustment for SES indicators, clusters were reduced to 56.2% of their original size (n = 1033). Adjustment for age and nationality further reduced the number of individuals exhibiting spatially dependent behavior (36.5% of the initial size). The identified SES-independent hot spots and cold spots of mammography adherence were not explained by proximity to the nearest screening center. CONCLUSIONS: SES and demographic factors play an important role in shaping the spatial distribution of mammography adherence. However, the spatial clusters persisted after confounder adjustment indicating that additional neighborhood-level determinants could influence mammography adherence and be the object of targeted public health interventions.

Hepatitis B prevalence, risk factors, infection awareness and disease knowledge among inmates: a cross-sectional study in Switzerland's largest pre-trial prison.

BACKGROUND: Hepatitis B virus (HBV) is a major health concern in prison, but data are scarce in European prisons. This study aims to measure the prevalence of HBV infection, risk factors, awareness about infection, and HBV knowledge among inmates in Switzerland's largest pre-trial prison. METHODS: Serological blood tests (HBsAg, anti-HBs, and anti-HBc) and a standardized socio-demographic and sexual health survey were offered to consenting prisoners in 2009 and 2011. HBV knowledge was assessed using a standardized questionnaire among participants recruited in 2009. FINDINGS: A total of 273 male participants were included in the study (116 participants answered the HBV knowledge survey), with 38.1% originating from Eastern Europe, 28.2% from sub-Saharan Africa, 14.3% from North Africa, and 9.5% from Latin America. The prevalence of anti-HBc (resolved/chronic infection) was 38.2% and the prevalence of HBsAg (chronic infection) was 5.9%; 14% of participants had vaccine-acquired immunity (anti-HBs positive/anti-HBc negative). We estimated that 15.5% of people living in Geneva having chronic infection go through the Geneva's prison. Region of origin was significantly associated with chronic/resolved HBV infection (P < 0.001): 72.2% of participants from sub-Saharan African, 34.6% from Eastern Europe and 13.2% from other regions. In terms of chronic infection, 15.6% of participants from sub-Saharan Africa were positive for HBsAg, vs 2% of those from other regions (P < 0.001). In stratified analyses, region of origin remained significantly associated with HBV infection. Among those with chronic infection, only 12.5% were aware of their status. A minority of inmates knew how HBV could be transmitted. CONCLUSIONS: The primary factor associated with HBV infection in this study was the geographical region of origin of participants. Given the high HBV prevalence found in this prison population, a targeted testing and vaccination approach based on prisoners' region of origin would be a cost-effective strategy when resources are limited. Additionally, identification of at-risk people should not rely on sensitive questions nor self-reported history of HBV. An inclusive approach to global health needs to incorporate prison population, as incarcerated people have a disproportionate burden of HBV infection and because an important proportion of hard-to-reach chronic HBV infected people go through the incarceration system.

Public smoking ban and socioeconomic inequalities in smoking prevalence and cessation: a cross-sectional population-based study in Geneva, Switzerland (1995-2014).

INTRODUCTION: Smoking bans were suggested to reduce smoking prevalence and increase quit ratio but their equity impact remains unclear. We aimed to characterise the socioeconomic status (SES)-related inequalities in smoking prevalence and quit ratio before and after the implementation of a public smoking ban. METHODS: We included data from 17 544 participants in the population-based cross-sectional Bus Santé study in Geneva, Switzerland, between 1995 and 2014. We considered educational attainment (primary, secondary and tertiary) as a SES indicator. Outcomes were smoking prevalence (proportion of current smokers) and quit ratio (ex-smokers to ever-smokers ratio). We used segmented linear regression to assess the overall impact of smoking ban on outcome trends. We calculated the relative (RII) and slope (SII, absolute difference) indexes of inequality, quantifying disparities between educational groups in outcomes overall (1995-2014), before and after ban implementation (November 2009). RESULTS: Least educated participants displayed higher smoking prevalence (RII=2.04, P<0.001; SII=0.15, P<0.001) and lower quit ratio (RII=0.73, P<0.001; SII=-0.18, P<0.001). As in other studies, smoking ban implementation coincided with a temporary reduction of smoking prevalence (P=0.003) and increase in quit ratio (P=0.02), with a progressive return to preban levels. Inequalities increased (P<0.05) in relative terms for smoking prevalence (RIIbefore=1.84, P<0.001 and RIIafter=3.01, P<0.001) and absolute terms for both outcomes (smoking prevalence: SIIbefore=0.14, P<0.001 and SIIafter=0.19, P<0.001; quit ratio: SIIbefore=-0.15, P<0.001 and SIIafter=-0.27, P<0.001). CONCLUSIONS: Implementation of a public smoking ban coincided with a short-lived decrease in smoking prevalence and increase in quit ratio but also with a widening in SES inequalities in smoking-related outcomes.

How do Swiss general practitioners agree with and report adhering to a top-five list of unnecessary tests and treatments? Results of a cross-sectional survey.

BACKGROUND: In 2014, the 'Smarter Medicine' campaign released a top five list of unnecessary tests and treatments in Swiss primary care, such as imaging for acute low-back pain and long-term prescribing of proton pump inhibitors. OBJECTIVES: Measure general practitioners' (GPs) agreement with the recommendations and self-reported adherence. METHODS: Cross-sectional, online survey of GPs in the 'Swiss primary care active monitoring' (SPAM) network, which assessed awareness of 'Smarter Medicine' and views on each recommendation. Questions included whether the clinical situation is common, whether the recommendation is followed, whether GPs agree with the recommendation and reasons why the recommendation would not be followed. RESULTS: One-hundred-and-sixty-seven of 277 GPs from the SPAM network participated (60%), of which 104 (62%) knew of 'Smarter Medicine', including 79% in German areas, 49% in French areas and 38% in Italian areas (P < 0.001). Agreement with the five recommendations was high, with scores around nine out of 10. The proportion saying they typically follow each recommendation was 68 to 74%, except not continuing long-term PPI prescriptions without attempting dose reduction, with only 34%. Common reasons for not following the recommendations were patient or other provider requests and situations that might suggest the need for more aggressive care. CONCLUSION: Two years after the launch of the campaign, awareness and acceptance of 'Smarter Medicine' appear to be high among Swiss GPs. By self-report, the recommendations are adhered to by most of the respondents but there may be room for improvement, especially for long-term PPI prescriptions.

Introduction of an organised programme and social inequalities in mammography screening: A 22-year population-based study in Geneva, Switzerland.

In developed countries, breast cancer mortality has decreased during the last decades due to, at least partially, the advent of mammography screening. Organised programmes aim, among other objectives, to increase participation and decrease social inequalities in screening access. We aimed to characterise the evolution of socioeconomic disparities in mammography screening before and after the implementation of an organised programme in Geneva, Switzerland. We included 5345 women, aged 50-74years, without past history of breast cancer who participated in the cross-sectional Bus Santé study, between 1992 and 2014. Outcome measures were: 1) never had a mammography (1992-2014) and 2) never had a mammography or not screened in the two years before being surveyed (subgroup analysis, 2007-2014). Educational attainment was divided in three groups (primary, secondary and tertiary) and period in two (before/after introduction of a screening programme in 1999). We calculated measures of relative and absolute change, including the relative (RII) and slope (SII) indices of social inequality adjusted for age and nationality. We compared the prevalence of screening before and after screening programme implementation using Poisson models. The proportion of unscreened women decreased during the study period from 30.5% to 3.6%. Lower educated women were more frequently unscreened (RII=2.39, p<0.001; SII=0.10, p<0.001). Organised screening decreased the proportion of unscreened women independently of education (prevalence ratiobefore vs. after=4.41, p<0.001), but absolute and relative inequalities persisted (RII=2.11, p=0.01; SII=0.04, p=0.01). Introduction of an organised programme increased women's adherence to mammography screening but did not eliminate social disparities in screening participation.

[Precision medicine : a required approach for the general internist]. / Médecine de précision : un rendez-vous à ne pas manquer pour l'interniste généraliste.

The general internist cannot be a passive bystander of the anticipated medical revolution induced by precision medicine. This latter aims to improve the predictive and/or clinical course of an individual by integrating all biological, genetic, environmental, phenotypic and psychosocial knowledge of a person. In this article, national and international initiatives in the field of precision medicine are discussed as well as the potential financial, ethical and limitations of personalized medicine. The question is not to know if precision medicine will be part of everyday life but rather to integrate early the general internist in multidisciplinary teams to ensure optimal information and shared-decision process with patients and individuals.

L'interniste généraliste ne peut pas être un spectateur passif du bouleversement induit par la médecine de précision. Cette dernière vise à améliorer les aspects prédictifs ou l'évolution clinique d'une personne en intégrant toutes les connaissances biologiques et génétiques, environnementales, phénotypiques et psychosociales qui lui sont propres. Dans cet article, les initiatives nationales et internationales dans ce domaine sont abordées, ainsi que les potentiels enjeux financiers, éthiques et d'équité sociale. Cette médecine de précision fera partie de notre quotidien et il s'agit d'intégrer très tôt l'interniste généraliste dans des plateformes multidisciplinaires pour assurer les restitutions d'informations, les partages de décision, les incertitudes et ultimement contribuer au maintien de la santé de la population et améliorer la qualité des soins pour nos patients.