Cost Estimates for Human Immunodeficiency Virus (HIV) Care and Patient Characteristics for Health Resource Use From Linkage of Claims Data With the Swiss HIV Cohort Study.

BACKGROUND: Comprehensive and representative data on resource use are critical for health policy decision making but often lacking for human immunodeficiency virus (HIV) infection. Privacy-preserving probabilistic record linkage of claim and cohort study data may overcome these limitations. METHODS: Encrypted dates of birth, sex, study center, and antiretroviral therapy (ART) from the Swiss HIV Cohort Study (SHCS) records for 2012 and 2013 were linked by privacy-preserving probabilistic record linkage with claim data from the largest health insurer covering 15% of the Swiss residential population. We modeled predictors for mean annual costs adjusting for censoring and grouped patients by cluster analysis into 3 risk groups for resource use. RESULTS: The matched subsample of 1196 patients from 9326 SHCS and 2355 claim records was representative for all SHCS patients receiving ART. The corrected mean (standard error) total costs in 2012 and 2013 were $30462 ($582) and $30965 ($629) and mainly accrued in ambulatory care for ART (70% of mean costs). The low-risk group for resource use had mean (standard error) annual costs of $26772 ($536) and $26132 ($589) in 2012 and 2013. In the moderate- and high-risk groups, annual costs for 2012 and 2013 were higher by $3526 (95% confidence interval, $1907-$5144) (13%) and $4327 ($2662-$5992) (17%) and $14026 ($8763-$19289) (52%) and $13567 ($8844-$18288) (52%), respectively. CONCLUSIONS: In a representative subsample of patients from linkage of SHCS and claim data, ART was the major cost factor, but patient profiling enabled identification of factors related to higher resource use.

Neighbourhood socio-economic position, late presentation and outcomes in people living with HIV in Switzerland.

OBJECTIVES: Inequalities and inequities in health are an important public health concern. In Switzerland, mortality in the general population varies according to the socio-economic position (SEP) of neighbourhoods. We examined the influence of neighbourhood SEP on presentation and outcomes in HIV-positive individuals in the era of combination antiretroviral therapy (cART). METHODS: The neighbourhood SEP of patients followed in the Swiss HIV Cohort Study (SHCS) 2000-2013 was obtained on the basis of 2000 census data on the 50 nearest households (education and occupation of household head, rent, mean number of persons per room). We used Cox and logistic regression models to examine the probability of late presentation, virologic response to cART, loss to follow-up and death across quintiles of neighbourhood SEP. RESULTS: A total of 4489 SHCS participants were included. Presentation with advanced disease [CD4⁺ cell count <200 cells/µl or AIDS] and with AIDS was less common in neighbourhoods of higher SEP: the age and sex-adjusted odds ratio (OR) comparing the highest with the lowest quintile of SEP was 0.71 [95% confidence interval (95% CI) 0.58-0.87] and 0.59 (95% CI 0.45-0.77), respectively. An undetectable viral load at 6 months of cART was more common in the highest than in the lowest quintile (OR 1.52; 95% CI 1.14-2.04). Loss to follow-up, mortality and causes of death were not associated with neighbourhood SEP. CONCLUSION: Late presentation was more common and virologic response to cART less common in HIV-positive individuals living in neighbourhoods of lower SEP, but in contrast to the general population, there was no clear trend for mortality.

Genetic diversity of EBV-encoded LMP1 in the Swiss HIV Cohort Study and implication for NF-Κb activation.

Epstein-Barr virus (EBV) is associated with several types of cancers including Hodgkin's lymphoma (HL) and nasopharyngeal carcinoma (NPC). EBV-encoded latent membrane protein 1 (LMP1), a multifunctional oncoprotein, is a powerful activator of the transcription factor NF-κB, a property that is essential for EBV-transformed lymphoblastoid cell survival. Previous studies reported LMP1 sequence variations and induction of higher NF-κB activation levels compared to the prototype B95-8 LMP1 by some variants. Here we used biopsies of EBV-associated cancers and blood of individuals included in the Swiss HIV Cohort Study (SHCS) to analyze LMP1 genetic diversity and impact of sequence variations on LMP1-mediated NF-κB activation potential. We found that a number of variants mediate higher NF-κB activation levels when compared to B95-8 LMP1 and mapped three single polymorphisms responsible for this phenotype: F106Y, I124V and F144I. F106Y was present in all LMP1 isolated in this study and its effect was variant dependent, suggesting that it was modulated by other polymorphisms. The two polymorphisms I124V and F144I were present in distinct phylogenetic groups and were linked with other specific polymorphisms nearby, I152L and D150A/L151I, respectively. The two sets of polymorphisms, I124V/I152L and F144I/D150A/L151I, which were markers of increased NF-κB activation in vitro, were not associated with EBV-associated HL in the SHCS. Taken together these results highlighted the importance of single polymorphisms for the modulation of LMP1 signaling activity and demonstrated that several groups of LMP1 variants, through distinct mutational paths, mediated enhanced NF-κB activation levels compared to B95-8 LMP1.

Regional variation in orthopedic surgery in Switzerland.

The study systematically describes the frequency and geographic variability of major surgical interventions for musculoskeletal disorders in Switzerland. Age- and sex-standardized rates for joint replacements, arthroscopies, spine surgery and hip fracture repair were calculated for hospital service regions. Various statistical analyses were used to measure the extent of variation. The authors argue that the surgery of hip fractures can be used as index surgery in the context of analyzing variations in orthopedic surgery. Temporal trends imply that patient demand and supply factors related to clinical ambiguity and non-medical incentives of providers are far more important components leading to increased use than the sole effect of an aging population.

Hospital use of young children in Switzerland: a nation-wide study based on a complete survey over 4 years.

BACKGROUND: Young children are known to be the most frequent hospital users compared to older children and young adults. Therefore, they are an important population from economic and policy perspectives of health care delivery. In Switzerland complete hospitalization discharge records for children [<5 years] of four consecutive years [2002-2005] were evaluated in order to analyze variation in patterns of hospital use. METHODS: Stationary and outpatient hospitalization rates on aggregated ZIP code level were calculated based on census data provided by the Swiss federal statistical office (BfS). Thirty-seven hospital service areas for children [HSAP] were created with the method of "small area analysis", reflecting user-based health markets. Descriptive statistics and general linear models were applied to analyze the data. RESULTS: The mean stationary hospitalization rate over four years was 66.1 discharges per 1000 children. Hospitalizations for respiratory problem are most dominant in young children (25.9%) and highest hospitalization rates are associated with geographical factors of urban areas and specific language regions. Statistical models yielded significant effect estimates for these factors and a significant association between ambulatory/outpatient and stationary hospitalization rates. CONCLUSION: The utilization-based approach, using HSAP as spatial representation of user-based health markets, is a valid instrument and allows assessing the supply and demand of children's health care services. The study provides for the first time estimates for several factors associated with the large variation in the utilization and provision of paediatric health care resources in Switzerland.

Patient-based evaluations of primary care for cardiovascular diseases: a comparison between conventional and complementary medicine.

BACKGROUND: Patients with chronic diseases, including cardiovascular conditions, increasingly rely on complementary and alternative medical (CAM) therapies. OBJECTIVES: The Swiss Program for Complementary Medicine Evaluation offers a unique opportunity to analyse cardiovascular patients' satisfaction with CAM and conventional medical (COM) therapies. The treatment choices of doctors certified in conventional as well as complementary therapies also could be studied. METHODS: A national observational evaluation on treatment satisfaction of patients consulting COM or CAM doctors. Out of this evaluation project, data related to patients with cardiovascular diseases were specifically analysed for patient satisfaction with treatment and outcome when treated by COM or CAM doctors. RESULTS: Of 199 included doctors (78 COM, 121 CAM) treating cardiovascular patients, COM doctors treated twice as many cardiovascular patients per doctor than CAM doctors. CAM doctors treated less than 1/3 of their cardiovascular patients solely by CAM, while they treated 42% exclusively by COM therapies. Patients seeing a CAM doctor had a significantly longer consultation and were more likely to be highly satisfied with overall treatment outcome and patient-practitioner communication. Moreover, patients seeing a CAM doctor and being treated solely by a CAM therapy more often report 'complete fulfilment of outcome expectation' and 'high overall satisfaction with treatment', although their symptoms less often disappear totally than those of COM therapy-treated patients. CONCLUSION: CAM therapies are not the first treatment choice for cardiovascular diseases. However, even though CAM doctors preferentially apply COM therapies, cardiovascular patients treated by CAM doctors are more likely to be satisfied with the overall treatment outcome, possibly because of the longer and better patient-practitioner interaction.

Satisfaction with primary health care in patients with upper respiratory tract infection: a three-level approach.

BACKGROUND: Upper respiratory tract infections (URTI) are common conditions for which individuals seek health care. The present study analyzes the satisfaction of URTI patients with general practitioners offering conventional treatment, alternative treatment, or a combination of both. PATIENTS AND METHODS: Patients' satisfaction with care was evaluated based on concepts of structure, process and outcome. Data were drawn from a nationwide cross-sectional survey, conducted in Switzerland, which evaluated conventional (COM) and complementary and/or alternative medicine (CAM). Participating physicians provided information about care structure. A questionnaire filled in by doctors and patients in parallel during the first visit provided information about the process of care (e.g. patients' general health, duration and severity of symptoms, co-morbid conditions, diagnostic/therapeutic procedures and consultation time). One month later, patients completed a second questionnaire on their subjective disease- and treatment-related health status, beliefs and fulfillment of expectations, and treatment effects (outcome). RESULTS: Structural and procedural differences were found. The most striking was the significantly longer consultation time with CAM physicians. Patients' satisfaction as an outcome variable, however, did not differ between the different treatment approaches. CONCLUSIONS: General practitioners, offering a variety of treatments, accommodate an important demand in primary health care. Regardless of differences in structure and procedure of the practice types, patients perceive equal benefits of treatment after one month. Nonetheless, possible long-term effects of longer consultations in CAM practices, such as a possibly more stable long-term amelioration of health, have to be carefully evaluated in future studies with the same study design.

Risk factors for allergic bronchopulmonary aspergillosis and sensitisation to Aspergillus fumigatus in patients with cystic fibrosis.

UNLABELLED: An increasing incidence of allergic bronchopulmonary aspergillosis (ABPA) as a complication in patients with cystic fibrosis (CF) is reported. The objective of this retrospective case-control study was to assess potential risk factors for ABPA and for Aspergillus fumigatus sensitisation (AFS). In a group of 160 CF patients, 11 (7%) fulfilled the diagnostic criteria for ABPA and 20 (13%) had evidence of AFS. They were compared to 62 control CF patients (25 for ABPA and 37 for AFS group) without evidence of ABPA or AFS using extended matching for sex, age and weight. AFS patients had received significantly higher cumulative doses of inhaled corticosteroids than their respective controls (OR 8.0; 95% CI 1.74-63). Bronchial colonisation with Stenotrophomonas maltophilia was strongly and independently associated with ABPA (OR 20; 95% CI 2.8- infinity). A longer duration of Pseudomonas aeruginosa colonisation was independently associated with AFS (OR per year 1.50; 95% CI 1.12- infinity). CONCLUSION: Cystic fibrosis patients with allergic bronchopulmonary aspergillosis have a more frequent isolation of S. maltophilia in their sputum than their controls. Longer duration of colonisation with P. aeruginosa is a risk factor for Aspergillus fumigatus sensitisation. Higher cumulative doses of inhaled corticosteroids are associated with Aspergillus fumigatus sensitisation and their role as a risk factor needs to be clarified.