RESUMO
In June 2021, the Swiss parliament accepted a legislative proposal calling for the introduction of a fee to fight emergency department (ED) overcrowding. Although this issue remains a major challenge for health policies, the introduction of such a fee raises many questions, notably regarding health equity. However, other more equitable solutions exist: improving the case management of ED frequent users and improving coordination between ED and primary care.
En juin 2021, le Parlement fédéral a accepté une proposition législative demandant l'instauration d'une taxe aux urgences pour lutter contre leur surfréquentation. Bien que cette problématique demeure un enjeu majeur des politiques de santé, l'instauration d'une telle taxe pose de nombreuses questions, notamment d'équité en santé. Pourtant, d'autres solutions existent, en améliorant la prise en charge des usager-ère-s fréquent-e-s des urgences, ainsi que la coordination entre soins primaires et services d'urgences.
Assuntos
Equidade em Saúde , Administração de Caso , Serviço Hospitalar de Emergência , HumanosRESUMO
In complex health systems with growing healthcare spending, combining reimbursement systems that incentivize cost-efficient healthcare provision within and across care sectors is key. This study investigates whether dual reimbursement systems lead hospitals to offset financial pressures in one care sector by inducing demand in another. We find that hospital imaging units induced demand for costly and unnecessary ambulatory imaging examinations reimbursed under fee-for-service, following a reform that introduced prospective payment and increased competition in the inpatient sector in Switzerland in 2012. Market structure, competitive pressures, and price regulations also influence demand inducement by varying the response to the reform. Reimbursement systems can influence supplier-induced demand in other care sectors within hospitals where revenue is tied to the intensity of care provision. In particular, the possibility to self-refer patients to high-margin diagnostic examinations bears negative consequences on healthcare expenditures and potentially patient health.
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Reforma dos Serviços de Saúde , Demanda Induzida , Diagnóstico por Imagem , Planos de Pagamento por Serviço Prestado , Gastos em Saúde , HumanosRESUMO
PURPOSE: Frequent Emergency Department users are likely to experience poor quality of life (QOL). Case management interventions are efficient in responding to the complex needs of this population, but their effects on QOL have not been tested yet. Therefore, the aim of our study was to examine to what extent a case management intervention improved frequent Emergency Department users' QOL in a universal health coverage system. METHODS: Data were part of a randomized controlled trial designed to improve frequent Emergency Department users' QOL at the Lausanne University Hospital, Switzerland. A total of 250 frequent Emergency Department users (≥ 5 attendances during the previous 12 months) were randomly assigned to the control (n = 125) or the intervention group (n = 125). The latter benefited from case management intervention. QOL was evaluated using the WHOQOL-BREF at baseline, two, five and a half, nine, and twelve months later. It included four dimensions: physical health, psychological health, social relationship, and environment. Linear mixed-effects models were used to analyze the change in the patients' QOL over time. RESULTS: Patients' QOL improved significantly (p < 0.001) in both groups for all dimensions after two months. However, environment QOL dimension improved significantly more in the intervention group after 12 months. CONCLUSIONS: Environment QOL dimension was the most responsive dimension for short-term interventions. This may have been due to case management's assistance in obtaining income entitlements, health insurance coverage, stable housing, or finding general health care practitioners. Case management in general should be developed to enhance frequent users' QOL. TRIAL REGISTRATION: http://www.clinicaltrials.gov , Unique identifier: NCT01934322.
Assuntos
Administração de Caso/normas , Serviço Hospitalar de Emergência/normas , Seguro Saúde/normas , Qualidade de Vida/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Prison health systems are subject to increasing pressures given the specific health needs of a growing and aging prison population. Identifying the drivers of medical spending among incarcerated individuals is therefore key for health care governance in prisons. This study assesses the determinants of individual health care expenditures within the prisons of the canton of Vaud, a large region of Switzerland. METHODS: We use a unique dataset linking demographic and prison stay characteristics as well as objective measures of morbidity to detailed medical invoice data. We adopt a multivariate regression approach to model total, somatic and psychiatric outpatient health care expenditures. RESULTS: We find that chronic infectious, musculoskeletal and skin diseases are strong predictors of total and somatic costs. Schizophrenia, neurotic and personality disorders as well as the abuse of illicit drugs and pharmaceuticals drive total and psychiatric costs. Furthermore, cumulating psychiatric and somatic comorbidities has an incremental effect on costs. CONCLUSION: By identifying the characteristics associated with health care expenditures in prison, this study constitutes a key step towards a more efficient use of medical resources in prison.
Assuntos
Gastos em Saúde/estatística & dados numéricos , Prisioneiros/estatística & dados numéricos , Prisões/economia , Adolescente , Adulto , Doença Crônica/economia , Comorbidade , Feminino , Humanos , Masculino , Transtornos Mentais/economia , Pessoa de Meia-Idade , Prisioneiros/psicologia , Suíça/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Frequent emergency department (ED) users account for a disproportionately high number of ED visits. Studies on case management (CM) interventions to reduce frequent ED use have shown mixed results, and few studies have been conducted within a universal health coverage system. OBJECTIVE: To determine whether a CM intervention-compared to standard emergency care-reduces ED attendance. DESIGN: Randomized controlled trial. PARTICIPANTS: Two hundred fifty frequent ED users (5 or more visits in the prior 12 months) who visited a public urban ED at the Lausanne University Hospital between May 2012 and July 2013 were allocated to either an intervention (n = 125) or control (n = 125) group, and monitored for 12 months. INTERVENTIONS: An individualized CM intervention consisting of concrete assistance in obtaining income entitlements, referral to primary or specialty medical care, access to mental health care or substance abuse treatment, and counseling on at-risk behaviors and health care utilization (in addition to standard care) at baseline and 1, 3, and 5 months. MAIN MEASURES: We used a generalized linear model for count data (negative binomial distribution) to compare the number of ED visits during the 12-month follow-up between CM and usual care, from an intention-to-treat perspective. KEY RESULTS: At 12 months, there were 2.71 (±0.23) ED visits in the intervention group versus 3.35 (±0.32) visits among controls (ratio = 0.81, 95 % CI = 0.63; 1.02). In the multivariate model, the effect of the CM intervention on the number of ED visits approached statistical significance (b = -0.219, p = 0.075). The presence of poor social determinants of health was a significant predictor of ED use in the multivariate model (b = 0.280, p = 0.048). CONCLUSIONS: CM may reduce ED use by frequent users through an improved orientation to the health care system. Poor social determinants of health significantly increase use of the ED by frequent users.
Assuntos
Administração de Caso/tendências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/tendências , Programas Nacionais de Saúde/tendências , Aceitação pelo Paciente de Cuidados de Saúde , Adulto , Idoso , Feminino , Seguimentos , Hospitais Universitários/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Método Simples-Cego , Suíça/epidemiologiaRESUMO
BACKGROUND: Coronary artery disease (CAD) continues to be one of the top public health burden. Perfusion cardiovascular magnetic resonance (CMR) is generally accepted to detect CAD, while data on its cost effectiveness are scarce. Therefore, the goal of the study was to compare the costs of a CMR-guided strategy vs two invasive strategies in a large CMR registry. METHODS: In 3'647 patients with suspected CAD of the EuroCMR-registry (59 centers/18 countries) costs were calculated for diagnostic examinations (CMR, X-ray coronary angiography (CXA) with/without FFR), revascularizations, and complications during a 1-year follow-up. Patients with ischemia-positive CMR underwent an invasive CXA and revascularization at the discretion of the treating physician (=CMR + CXA-strategy). In the hypothetical invasive arm, costs were calculated for an initial CXA and a FFR in vessels with ≥50% stenoses (=CXA + FFR-strategy) and the same proportion of revascularizations and complications were applied as in the CMR + CXA-strategy. In the CXA-only strategy, costs included those for CXA and for revascularizations of all ≥50% stenoses. To calculate the proportion of patients with ≥50% stenoses, the stenosis-FFR relationship from the literature was used. Costs of the three strategies were determined based on a third payer perspective in 4 healthcare systems. RESULTS: Revascularizations were performed in 6.2%, 4.5%, and 12.9% of all patients, patients with atypical chest pain (n = 1'786), and typical angina (n = 582), respectively; whereas complications (=all-cause death and non-fatal infarction) occurred in 1.3%, 1.1%, and 1.5%, respectively. The CMR + CXA-strategy reduced costs by 14%, 34%, 27%, and 24% in the German, UK, Swiss, and US context, respectively, when compared to the CXA + FFR-strategy; and by 59%, 52%, 61% and 71%, respectively, versus the CXA-only strategy. In patients with typical angina, cost savings by CMR + CXA vs CXA + FFR were minimal in the German (2.3%), intermediate in the US and Swiss (11.6% and 12.8%, respectively), and remained substantial in the UK (18.9%) systems. Sensitivity analyses proved the robustness of results. CONCLUSIONS: A CMR + CXA-strategy for patients with suspected CAD provides substantial cost reduction compared to a hypothetical CXA + FFR-strategy in patients with low to intermediate disease prevalence. However, in the subgroup of patients with typical angina, cost savings were only minimal to moderate.
Assuntos
Cateterismo Cardíaco/economia , Angiografia Coronária/economia , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/terapia , Técnicas de Apoio para a Decisão , Custos de Cuidados de Saúde , Imageamento por Ressonância Magnética/economia , Imagem de Perfusão do Miocárdio/economia , Revascularização Miocárdica/economia , Tomografia Computadorizada por Raios X/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Angina Pectoris/diagnóstico , Angina Pectoris/economia , Angina Pectoris/terapia , Angiografia Coronária/métodos , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/fisiopatologia , Redução de Custos , Análise Custo-Benefício , Europa (Continente)/epidemiologia , Feminino , Reserva Fracionada de Fluxo Miocárdico , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Imagem de Perfusão do Miocárdio/métodos , Revascularização Miocárdica/efeitos adversos , Seleção de Pacientes , Valor Preditivo dos Testes , Prevalência , Estudos Prospectivos , Sistema de Registros , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Literature on the disease profile of prisoners that differentiates by age and gender remains sparse. This study aimed to describe the health of correctional inmates in terms of substance abuse problems and mental and somatic health conditions, and compare it by gender and age. METHODS: This study examined cross-sectional data from the Canton of Vaud in Switzerland on the health conditions of detainees who were in prison on January 1, 2011 or entered prison in 2011. Health conditions validated by physician examination were reported using the International Classification of Diseases (ICD) version 10. The analyses were descriptive by groups of prisoners: the entire sample (All), Men, Older adults and Women. RESULTS: A total of 1,664 individuals were included in the analysis. Men comprised 91.5 % of the sample and had a mean age of 33 years. The other 8.5 % were women and had an average age of 39. Older adults (i.e., age 50 and older) represented 7 % of the total sample. Overall, 80 % of inmates were non-Swiss citizens, but the proportion of Swiss prisoners was higher among the older adults (51 %) and women (29 %). Overall, 41 % of inmates self-reported substance abuse problems. Of those, 27 % were being treated by psychiatrists for behavioral disorders related to substance abuse. Chronic infectious diseases were found in 9 % of the prison population. In addition, 27 % of detainees suffered from serious mental health conditions. Gender and age had an influence on the disease profile of this sample: compared to the entire prison population, the older inmates were less likely to misuse illegal drugs and to suffer from communicable infections but exhibited more problems with alcohol and a higher burden of chronic health conditions. Female prisoners were more disposed to mental health problems (including drug abuse) and infectious diseases. In terms of chronic diseases, women suffered from the same conditions as men, but the diseases were more prevalent in women. CONCLUSION: It is important to understand the different disease profiles of prisoners by gender and age, as it helps identify the needs of different groups and tailor age-and gender-specific interventions.
Assuntos
Doença Crônica/epidemiologia , Disparidades nos Níveis de Saúde , Saúde Mental/estatística & dados numéricos , Prisioneiros/psicologia , Prisões , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Doenças Transmissíveis/epidemiologia , Estudos Transversais , Feminino , Humanos , Masculino , Prontuários Médicos/estatística & dados numéricos , Pessoa de Meia-Idade , Prevalência , Prisioneiros/estatística & dados numéricos , Suíça/epidemiologiaRESUMO
BACKGROUND: According to recent guidelines, patients with coronary artery disease (CAD) should undergo revascularization if significant myocardial ischemia is present. Both, cardiovascular magnetic resonance (CMR) and fractional flow reserve (FFR) allow for a reliable ischemia assessment and in combination with anatomical information provided by invasive coronary angiography (CXA), such a work-up sets the basis for a decision to revascularize or not. The cost-effectiveness ratio of these two strategies is compared. METHODS: Strategy 1) CMR to assess ischemia followed by CXA in ischemia-positive patients (CMR + CXA), Strategy 2) CXA followed by FFR in angiographically positive stenoses (CXA + FFR). The costs, evaluated from the third party payer perspective in Switzerland, Germany, the United Kingdom (UK), and the United States (US), included public prices of the different outpatient procedures and costs induced by procedural complications and by diagnostic errors. The effectiveness criterion was the correct identification of hemodynamically significant coronary lesion(s) (= significant CAD) complemented by full anatomical information. Test performances were derived from the published literature. Cost-effectiveness ratios for both strategies were compared for hypothetical cohorts with different pretest likelihood of significant CAD. RESULTS: CMR + CXA and CXA + FFR were equally cost-effective at a pretest likelihood of CAD of 62% in Switzerland, 65% in Germany, 83% in the UK, and 82% in the US with costs of CHF 5'794, 1'517, £ 2'680, and $ 2'179 per patient correctly diagnosed. Below these thresholds, CMR + CXA showed lower costs per patient correctly diagnosed than CXA + FFR. CONCLUSIONS: The CMR + CXA strategy is more cost-effective than CXA + FFR below a CAD prevalence of 62%, 65%, 83%, and 82% for the Swiss, the German, the UK, and the US health care systems, respectively. These findings may help to optimize resource utilization in the diagnosis of CAD.
Assuntos
Angiografia Coronária/economia , Estenose Coronária/diagnóstico , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Reserva Fracionada de Fluxo Miocárdico , Custos de Cuidados de Saúde , Imageamento por Ressonância Magnética/economia , Pesquisa Comparativa da Efetividade , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/economia , Estenose Coronária/fisiopatologia , Estenose Coronária/terapia , Redução de Custos , Análise Custo-Benefício , Europa (Continente) , Hemodinâmica , Humanos , Funções Verossimilhança , Modelos Econômicos , Revascularização Miocárdica , Seleção de Pacientes , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Estados UnidosRESUMO
BACKGROUND: We devised a randomised controlled trial to evaluate the effectiveness and efficiency of an intervention based on case management care for frequent emergency department users. The aim of the intervention is to reduce such patients' emergency department use, to improve their quality of life, and to reduce costs consequent on frequent use. The intervention consists of a combination of comprehensive case management care and standard emergency care. It uses a clinical case management model that is patient-identified, patient-directed, and developed to provide high intensity services. It provides a continuum of hospital- and community-based patient services, which include clinical assessment, outreach referral, and coordination and communication with other service providers. METHODS/DESIGN: We aim to recruit, during the first year of the study, 250 patients who visit the emergency department of the University Hospital of Lausanne, Switzerland. Eligible patients will have visited the emergency department 5 or more times during the previous 12 months. Randomisation of the participants to the intervention or control groups will be computer generated and concealed. The statistician and each patient will be blinded to the patient's allocation. Participants in the intervention group (N = 125), additionally to standard emergency care, will receive case management from a team, 1 (ambulatory care) to 3 (hospitalization) times during their stay and after 1, 3, and 5 months, at their residence, in the hospital or in the ambulatory care setting. In between the consultations provided, the patients will have the opportunity to contact, at any moment, the case management team. Participants in the control group (N = 125) will receive standard emergency care only. Data will be collected at baseline and 2, 5.5, 9, and 12 months later, including: number of emergency department visits, quality of life (EuroQOL and WHOQOL), health services use, and relevant costs. Data on feelings of discrimination and patient's satisfaction will also be collected at the baseline and 12 months later. DISCUSSION: Our study will help to clarify knowledge gaps regarding the positive outcomes (emergency department visits, quality of life, efficiency, and cost-utility) of an intervention based on case management care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01934322.
Assuntos
Administração de Caso/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Mau Uso de Serviços de Saúde/prevenção & controle , Humanos , Qualidade de Vida , Projetos de Pesquisa , Inquéritos e Questionários , SuíçaRESUMO
According to the Swiss legislation on maternity protection in the workplace (OProMa), if pregnant workers are exposed to occupational hazards and no protective measures are taken, a gynecologist will prescribe a certificate of preventive leave and the women must stop working. Returning to work is only possible if job adjustments are made. This study aims to evaluate the burden of absences on companies and to examine the predictors of the return to work for pregnant workers on preventive leave, by examining both the probability of return to work and the time required to return to work. The study sample includes data on 258 workplaces of pregnant workers on preventive leave, collected during an occupational medicine consultation aimed at supporting the implementation of the OProMa. Information is available on the worker (age, date of consultation), the hazards to which she is exposed, the company's knowledge of the OProMa and whether a risk analysis exists. Descriptive statistics and multivariate regression analysis are carried out. In 58% of the workplaces, it was not possible to return to work before the end of the pregnancy. This corresponds to an average absence of 4.5 months. In 42% of the workplaces, a return to work was possible thanks to workplace adaptations. A conforming risk analysis and a full knowledge of the OProMa for companies, and an early visit to the occupational medicine consultation for workers are good predictors of the likelihood of returning to work. Younger age and exposure to certain types of risks are factors that influence the duration of preventive leave. The implementation of OProMa in Switzerland poses serious challenges, but early identification of occupational hazards and practices that anticipate compliance with the law in the company increase the return to work in safety for pregnant workers.
Assuntos
Medicina do Trabalho , Humanos , Feminino , Gravidez , Suíça , Retorno ao Trabalho , Emprego , Local de Trabalho , Encaminhamento e ConsultaRESUMO
BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is characterized by difficulty paying attention, poor impulse control, and hyperactive behavior. It is associated with several adverse health and social outcomes and leads to an increased risk of criminality and recidivism. Worldwide, ADHD is thus highly prevalent in prisons. However, ADHD treatment has been neglected in such environments. Stimulant medications such as osmotic-release oral system methylphenidate (OROS-MPH) are first-line treatments in the general population, but they are under-prescribed in prisons due to concerns about abuse, even though such claims are not empirically supported. This project aims to compare the efficacy of a 3-month in-prison OROS-MPH vs. placebo treatment on the severity of core ADHD symptoms and relevant in- and post-prison outcomes. METHODS: This study is a phase III, double-blinded, randomized, superiority, controlled trial of OROS-MPH vs. placebo. After randomization, the participants will receive 3 months of treatment with OROS-MPH or placebo (1:1 ratio) while incarcerated. Upon release, all participants will be offered the treatment (OROS-MPH) for 1 year but will remain blinded to their initial study group. The study will be conducted at the Division of Prison Health, Geneva, Switzerland, among incarcerated men (n = 150). Measures will include (1) investigator-rated ADHD symptoms, (2) acute events collected by the medical and prison teams, (3) assessment of the risk of recidivism, (4) medication side effects, (5) medication adherence, (6) study retention, (7) health care/prison costs, and (8) 1-year recidivism. Analyses will include bivariable and multivariable modeling (e.g., regression models, mixed-effects models, survival analyses) and an economic evaluation (cost-benefit analysis). DISCUSSION: We expect that early identification and treatment of ADHD in prison will be an important public health opportunity and a cost-effective approach that is likely to reduce the vulnerability of incarcerated individuals and promote pathways out of criminal involvement. The study will also promote standards of care for people with ADHD in prison and provide recommendations for continuity of care after release. TRIAL REGISTRATION: ClinicalTrials.gov NCT05842330 . Registered on June 5, 2023. Kofam.ch SNCTP000005388. Registered on July 17, 2023.
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Transtorno do Deficit de Atenção com Hiperatividade , Estimulantes do Sistema Nervoso Central , Metilfenidato , Masculino , Humanos , Metilfenidato/efeitos adversos , Transtorno do Deficit de Atenção com Hiperatividade/tratamento farmacológico , Transtorno do Deficit de Atenção com Hiperatividade/diagnóstico , Prisões , Estimulantes do Sistema Nervoso Central/efeitos adversos , Preparações de Ação Retardada/uso terapêutico , Resultado do Tratamento , Método Duplo-Cego , Ensaios Clínicos Controlados Aleatórios como Assunto , Ensaios Clínicos Fase III como AssuntoRESUMO
The Swiss healthcare system is well known for the quality of its healthcare and population health but also for its high cost, particularly regarding out-of-pocket expenses. We conduct the first national study on the association between socioeconomic status and access to community-based ambulatory care (CBAC). We analyze administrative and hospital discharge data at the small area level over a four-year time period (2014 - 2017). We develop a socioeconomic deprivation indicator and rely on a well-accepted indicator of potentially avoidable hospitalizations as a measure of access to CBAC. We estimate socioeconomic gradients at the national and cantonal levels with mixed effects models pooled over four years. We compare gradient estimates among specifications without control variables and those that include control variables for area geography and physician availability. We find that the most deprived area is associated with an excess of 2.80 potentially avoidable hospitalizations per 1,000 population (3.01 with control variables) compared to the least deprived area. We also find significant gradient variation across cantons with a difference of 5.40 (5.54 with control variables) between the smallest and largest canton gradients. Addressing broader social determinants of health, financial barriers to access, and strengthening CBAC services in targeted areas would likely reduce the observed gap.
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Hospitalização , Classe Social , Humanos , Suíça , Fatores Socioeconômicos , Atenção à SaúdeRESUMO
Most women continue to work during pregnancy. However, some of them have to stop working before giving birth. Absence from work poses several challenges for employers and employees, as well as for society. The literature on absence from work during pregnancy and its determinants remains inconsistent and rather scarce. To conduct a narrative literature review on the factors associated with work interruption and on existing interventions aimed at reducing the absence prevalence during pregnancy. The review refers to published peer-reviewed articles dealing with all types of work interruption among pregnant women. Keyword searches were performed in the electronic databases PubMed, EMBASE, and Google Scholar, covering the period 2000-2022. The review, which includes 42 papers, presents a broad and comprehensive picture of factors and interventions associated with absence from work among pregnant workers. The factors appear at different levels and include factors related to the pregnant women, such as individual health and socio-demographic factors; employer and workplace-related factors, such as risk exposures and working conditions; factors related to the role of the healthcare provider; and factors related to the national context (social benefits/insurance). The determinants of absence from work during pregnancy are complex and multifactorial and involve multiple stakeholders. The discussion addresses gaps and needs in the literature on pregnancy at work and in the field of occupational health. Int J Occup Med Environ Health. 2023;36(3):303-23.
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Pessoal de Saúde , Saúde Ocupacional , Gravidez , Humanos , Feminino , Condições de TrabalhoRESUMO
BACKGROUND: Cardiovascular magnetic resonance (CMR) has favorable characteristics for diagnostic evaluation and risk stratification of patients with known or suspected CAD. CMR utilization in CAD detection is growing fast. However, data on its cost-effectiveness are scarce. The goal of this study is to compare the costs of two strategies for detection of significant coronary artery stenoses in patients with suspected coronary artery disease (CAD): 1) Performing CMR first to assess myocardial ischemia and/or infarct scar before referring positive patients (defined as presence of ischemia and/or infarct scar to coronary angiography (CXA) versus 2) a hypothetical CXA performed in all patients as a single test to detect CAD. METHODS: A subgroup of the European CMR pilot registry was used including 2,717 consecutive patients who underwent stress-CMR. From these patients, 21% were positive for CAD (ischemia and/or infarct scar), 73% negative, and 6% uncertain and underwent additional testing. The diagnostic costs were evaluated using invoicing costs of each test performed. Costs analysis was performed from a health care payer perspective in German, United Kingdom, Swiss, and United States health care settings. RESULTS: In the public sectors of the German, United Kingdom, and Swiss health care systems, cost savings from the CMR-driven strategy were 50%, 25% and 23%, respectively, versus outpatient CXA. If CXA was carried out as an inpatient procedure, cost savings were 46%, 50% and 48%, respectively. In the United States context, cost savings were 51% when compared with inpatient CXA, but higher for CMR by 8% versus outpatient CXA. CONCLUSION: This analysis suggests that from an economic perspective, the use of CMR should be encouraged as a management option for patients with suspected CAD.
Assuntos
Angiografia Coronária/economia , Estenose Coronária/diagnóstico , Estenose Coronária/economia , Atenção à Saúde/economia , Custos de Cuidados de Saúde , Imageamento por Ressonância Magnética/economia , Idoso , Assistência Ambulatorial/economia , Estenose Coronária/diagnóstico por imagem , Análise Custo-Benefício , Europa (Continente) , Feminino , Custos Hospitalares , Humanos , Seguro Saúde/economia , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Projetos Piloto , Valor Preditivo dos Testes , Prognóstico , Setor Público/economia , Encaminhamento e Consulta/economia , Sistema de Registros , Medicina Estatal/economia , Estados UnidosRESUMO
OBJECTIVES: The aim of this study was to compare the costs of a noninvasive cardiac magnetic resonance (CMR)-guided strategy versus 2 invasive strategies with and without fractional flow reserve (FFR). BACKGROUND: Coronary artery disease (CAD) is a major contributor to the public health burden. Stress perfusion CMR has excellent accuracy to detect CAD. International guidelines recommend as a first step noninvasive testing of patients in stable condition with known or suspected CAD. However, nonadherence in routine clinical practice is high. METHODS: In the EuroCMR (European Cardiovascular Magnetic Resonance) registry (n = 3,647, 59 centers, 18 countries) and the U.S.-based SPINS (Stress-CMR Perfusion Imaging in the United States) registry (n = 2,349, 13 centers, 11 states), costs were calculated for 12 health care systems (8 in Europe, the United States, 2 in Latin America, and 1 in Asia). Costs included diagnostic examinations (CMR and x-ray coronary angiography [CXA] with and without FFR), revascularizations, and complications during 1-year follow-up. Seven subgroup analyses covered low- to high-risk cohorts. Patients with ischemia-positive CMR underwent CXA and revascularization at the treating physician's discretion (CMR+CXA strategy). In the hypothetical invasive CXA+FFR strategy, costs were calculated for initial CXA and FFR in vessels with ≥50% stenoses, assuming the same proportion of revascularizations and complications as with the CMR+CXA strategy and FFR-positive rates as given in the published research. In the CXA-only strategy, costs included CXA and revascularizations of ≥50% stenoses. RESULTS: Consistent cost savings were observed for the CMR+CXA strategy compared with the CXA+FFR strategy in all 12 health care systems, ranging from 42% ± 20% and 52% ± 15% in low-risk EuroCMR and SPINS patients with atypical chest pain, respectively, to 31% ± 16% in high-risk SPINS patients with known CAD (P < 0.0001 vs 0 in all groups). Cost savings were even higher compared with CXA only, at 63% ± 11%, 73% ± 6%, and 52% ± 9%, respectively (P < 0.0001 vs 0 in all groups). CONCLUSIONS: In 12 health care systems, a CMR+CXA strategy yielded consistent moderate to high cost savings compared with a hypothetical CXA+FFR strategy over the entire spectrum of risk. Cost savings were consistently high compared with CXA only for all risk groups.
Assuntos
Doença da Artéria Coronariana , Reserva Fracionada de Fluxo Miocárdico , Constrição Patológica , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Custos e Análise de Custo , Atenção à Saúde , Humanos , Valor Preditivo dos Testes , Sistema de RegistrosRESUMO
BACKGROUND: This study investigates the prisoner and prison-level factors associated with healthcare utilization (HCU) and the dynamic effects of previous HCU and health events. We analyze administrative data collected on annual adult prisoner-stay HCU (n = 10,136) including physical and mental chronic disease diagnoses, acute health events, penal circumstances and prison-level factors between 2013 and 2017 in 4 prisons of Canton of Vaud, Switzerland. Utilization of four types of health services: primary, nursing, mental and emergency care; are assessed using multivariate and multi-level negative binomial regressions with fixed/random effects and dynamic models conditional on prior HCU and lagged health events. RESULTS: In a prison setting with health screening on detention, removal of financial barriers to care and a nurse-led gatekeeping system, we find that health status, socio-demographic characteristics, penal history, and the prison environment are associated with HCU overtime. After controlling for chronic and past acute illnesses, female prisoners have higher HCU, younger adults more emergencies, and prisoners from Africa, Eastern Europe, and the Americas lower HCU. New prisoners, pretrial detainees or repeat offenders utilize more all types of care. Overcrowding increases primary care but reduces utilization of mental and emergency services. Higher expenditure on medical staff resources is associated with more primary care visits and less emergency visits. The dynamics of HCU across types of care shows persistence over time related to emergency use, previous somatic acute illnesses, and acting out events. There is also evidence of substitution between psychiatric and primary care. CONCLUSIONS: The prison healthcare system provides an opportunity to diagnose and treat unmet health needs for a marginalized population. Access to psychiatric and chronic disease management during incarceration and prevention of emergency or acute events can reduce future demand for care. Prioritization of high-risk patients and continuity of care inside and outside of prisons may reduce public health pressures in the criminal system. The prison environment and prisoners' penal circumstances impacts healthcare utilization, suggesting better coordination between the criminal justice and prison health systems is required.
RESUMO
BACKGROUND: The role of income in cardiovascular disease prevention after an acute coronary syndrome (ACS) remains unclear. We aimed to assess the association between income and control of cardiovascular risk factors one year after an ACS in a country with universal health insurance. METHODS: Between 2013 and 2014, we studied 255 consecutive patients with ACS in an observational study in a university hospital in Switzerland in which self-reported household income was assessed. We classified patients into two categories based on the median income in Switzerland: higher than CHF 6000 (€ 5300) or less than or equal to CHF 6000 (€ 5300) per month. One year after discharge, patients were evaluated for the achievement of lipid and blood pressure targets, smoking cessation and drug adherence. Multivariate odds ratios (OR) were adjusted for age, sex, education, living status and working status. RESULTS: Overall, 52.2% (n = 133) of patients with ACS were in the low-income category and 47.8% (n = 122) were in the high-income category. One year after discharge, high-income patients had higher rates of smoking cessation (64.2 vs 30.1%, multivariate-adjusted odds ratio (OR) 3.82, 95% confidence interval (CI) 1.58–9.24) and blood pressure target achievement (78.6 vs 60.2%, multivariate-adjusted OR 2.19, 95% CI 1.09–4.41) compared to those in the low-income category. There were no differences regarding adherence to drugs or lipid control between the two income groups. CONCLUSION: A high household income was associated with a higher rate of smoking cessation and better control of blood pressure one year after ACS, independently of education, living status and working status.
Assuntos
Síndrome Coronariana Aguda/complicações , Doenças Cardiovasculares/prevenção & controle , Renda/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Classe Social , Idoso , Pressão Sanguínea , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Alta do Paciente/estatística & dados numéricos , Fatores de Risco , Abandono do Hábito de Fumar/estatística & dados numéricos , SuíçaRESUMO
BACKGROUND: In most emergency departments (EDs), few patients account for a relatively high number of ED visits. To improve the management of these patients, the university hospital of Lausanne, Switzerland, implemented an interdisciplinary case management (CM) intervention. This study examined whether the CM intervention-compared with standard care (SC) in the ED-reduced costs generated by frequent ED users, not only from the hospital perspective, but also from the third-party payer perspective, that is, from a broader perspective that takes into account the costs of health care services used outside the hospital offering the intervention. METHODS: In this randomized controlled trial, 250 frequent ED users (>5 visits during the previous 12 months) were allocated to either the CM or the SC group and followed up for 12 months. Cost data were obtained from the hospital's analytical accounting system for the entire sample and from health insurance companies for a subgroup (n = 140). Descriptive statistics and multivariate regressions were used to make comparisons between groups and assess the contribution of patient characteristics to the main cost components. RESULTS: At the end of the 12-month follow-up, 115 patients were in the CM group and 115 in the SC group (20 had died). Despite differences in economic costs between patients in the CM intervention and the SC groups, our results do not show any statistically significant reduction in costs associated with the intervention, either for the hospital that housed the intervention or for the third-party payer. Frequent ED users were big users of health services provided by both the hospital and community-based services, with 40% of costs generated outside the hospital that housed the intervention. Higher age, Swiss citizenship, and having social difficulty increased costs significantly. CONCLUSIONS: As the role of the CM team is to guide patients through the entire care process, the intervention location is not limited to the hospital but often extends into the community.
Assuntos
Serviço Hospitalar de Emergência/economia , Seguro Saúde/economia , Adulto , Custos e Análise de Custo , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: Frequent Emergency Department (ED) users have an elevated mortality, yet little is known about risk factors. Our aim was to characterize deceased frequent ED users and determine predictors of mortality. METHODS: This is a post-hoc analysis of all-cause mortality among frequent ED users participating in a randomized clinical trial on case management at the Lausanne University Hospital (Switzerland). We enrolled 250 frequent ED users (5+ visits/past year) in a 12-month randomized clinical trial; those with an estimated survival of fewer than 18 months were excluded. The primary outcome was 12-month all-cause mortality. We performed descriptive statistics to compare the baseline characteristics of living and deceased participants, and examined predictors of all-cause mortality using logistic regressions, including age adjustment. RESULTS: Twenty of the 250 (8%) frequent users died during the 12-month follow-up. Seven (35%) deaths were because of cardiac causes and six (30%) were because of cancer. The median age at death was 71 years. Deceased participants were older and more likely to report any somatic determinant, chronic illness, and medical comorbidity. Age (odds ratio 1.07, 95% confidence interval 1.04-1.11) and medical comorbidity (odds ratio 4.76, 95% confidence interval 1.86-12.15) were statistically significant predictors of mortality. CONCLUSION: Despite excluding those with an estimated survival of fewer than 18 months, 8% of frequent ED users died during the study. Age and medical comorbidity were significant predictors of mortality. Interventions, such as case management, should target older frequent ED users and those with multiple medical conditions, and future research should explore their potential impact on mortality.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Uso Excessivo dos Serviços de Saúde/estatística & dados numéricos , Mortalidade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Índice de Gravidade de Doença , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Suíça , Populações Vulneráveis/estatística & dados numéricosRESUMO
Prison healthcare is an important public health concern given the increasing healthcare needs of a growing and aging prison population, which accumulates vulnerability factors and suffers from higher disease prevalence than the general population. This study identifies the key factors associated with outpatient general practitioner (GP), nursing or psychiatric healthcare utilization (HCU) within prisons. Cross-sectional data systematically collected by the prison medical staff were obtained for a sample of 1664 adult prisoners of the Canton of Vaud, Switzerland, for the year 2011. They contain detailed information on demographics (predisposing factors), diagnosed chronic somatic and psychiatric disorders (needs factors), as well as prison stay characteristics (contextual factors). For GP, nurse and psychiatric care, two-part regressions are used to model separately the probability and the volume of HCU. Predisposing factors are generally not associated with the probability to use healthcare services after controlling for needs factors. However, female inmates use higher volumes of care, and the volume of GP consultations increases with age. Chronic somatic and psychiatric conditions are the most important predictors of the probability of HCU, but associations with volumes differ in their magnitude and significance across disease groups. Infectious, musculoskeletal, nervous and circulatory diseases actively mobilize GP and nursing staff. Schizophrenia, illicit drug and pharmaceuticals abuse are strongly positively associated with psychiatric and nurse HCU. The occupancy rate displays positive associations among contextual factors. Prison healthcare systems face increasingly complex organizational, budgetary and ethical challenges. This study provides relevant insights into the HCU patterns of a marginalized and understudied population.