[Cost analysis for ambulatory patients in internal medicine]. / Kostenanalyse ambulanter Patienten einer medizinischen Poliklinik.

We analyzed the diagnostical and therapeutical costs of 300 ambulatory patients over a two year period in a Swiss university policlinic of internal medicine. The calculations were based on the catalogue of hospital services (Spitalleistungskatalog) and the drugstore prices for pharmaceuticals (Apothekenpreise). The overall costs for the 300 patients were about 238,400 CHF. The refund by the health insurances represented 56% (excluding specific services such as radiological examinations). The main costs concerned analytical laboratory services (32%), physicians services (27%), technical services (26%), and pharmaceuticals (15%). Some analytical and technical services were prescribed unexpectedly frequently. Prevalent among the emitted pharmaceuticals were protone pump inhibitors, modern cardiovascular drugs and statins. Presumed reasons may be a minor cost awareness of the physicians and a trend towards modern but expensive therapies. An adequate cost awareness can only emerge from precise data of effective costs.

[Curriculum and structure of modern medical education]. / Inhalte und Struktur des neuen Medizinstudiums.

The Medical Faculty of the University of Zurich compiles a fundamental restructuring of the Medical curriculum. Basic conditions represent the new Swiss Federal law for the education in medical professions (MedBG), heterogeneous implementation stages of curriculum reforms of other Swiss Medical Faculties of the medicine as well as efforts to improve mobility of students. The strategy of the curriculum reform is represented based on the principles decided by the Faculty. The authors demonstrate the corresponding organizational structures and give a future view focusing on aspects of the implementation and the dynamic adaptation of curriculum items.

[Comparative assessment of ambulatory blood pressure monitoring and blood pressure measurement by the patient at home]. / Vergleichende Untersuchungen zwischen ambulantem 24h-Blutdruckmonitoring (ABPM) und Heimblutdruckmessungen.

Ambulatory blood pressure monitoring (ABPM) over 24 hours was compared to two blood pressure measurements taken in the morning by the 22 test persons themselves. ABPM was carried out at the beginning and the end of the study using a spacelabs SL 90207 apparatus. A semiautomatic sphygmomanometer was used for self-measurements (Visomat OZ 2). Monitored systolic and diastolic 24 hour values and the mean 24 hour value were on the average slightly higher than the self-measured pressures. Both methods yielded almost constant values over the test period. The mean of self-measured systolic and diastolic values from the second measurement over the entire two week period was significantly lower than the initially registered values (p < 0.001). Therefore a high correlation (r = 0.88, p < 0.001) was found between the mean systolic value of the second self-measurement with the mean ABPM 24 hour value; the corresponding correlation for the first measurement with ABPM was lower (r = 0.84, p < 0.01). The correlation of the diastolic values with ABPM was also lower (r = 0.70, p < 0.01). These results show that ABPM and self-measurements in the morning differ only slightly. The use and reliability of semiautomatic blood pressure measuring devices provide a practicable and economic alternative to ABPM.

[Evaluation of disability pensions by a medical polyclinic: 1990-1995]. / Beurteilung von Invalidenrenten-Anträgen durch eine Medizinische Poliklinik: 1990-1995.

The question if and in what manner changes of the labour market, in first line increasing unemployment, may influence the composition of the collective demanding a disability pension on one hand and the diagnoses relevant for assessment of requests on the other hand have been investigated as well as possible influences on the criteria for assessments. To this end all expert reports elaborated by the Medical Outpatient Clinic of the University Hospital of Zürich and submitted to the disability insurance between 1990 and 1995 have been evaluated retrospectively. The results show that the fraction of men remained stable around 70% over the whole observation period. The number of persons employed in auxiliary functions remained also constantly high. Over the whole period of observation there was a high, growing percentage of foreign applicants. The most marked change during the observation period was a significant increase of unemployment in the collective. This increase particularly affected applicants with higher ranking jobs or persons over 50. Foreigners became an important part of the unemployed applicants. Rheumatoid disorders and "back pain" in particular were of increasing importance among the relevant diagnoses for assessment of disability. There was a significant decline in the extent of invalidity acknowledged in marked contrast to our initial expectation that the strictness of the applied criteria would weaken when confronted with an increasing number of applications.

[Diagnostic costs for ambulatory care patients]. / Diagnosekosten bei ambulanten Patienten.

Few analyses of the costs of diagnostic plans have been published. We have determined and analyzed the diagnostic costs of 1000 consecutively evaluated patients at the medical outpatient clinic. A data base was developed for this purpose. Based on the itemized tarif the total costs amounted to 622,553.25 SFR. Medical services (consultations) required 20 per cent of this sum, laboratory services and technical investigations 40 per cent each. The average number of consultations per patient was 2.83 +/- 1.85. As expected the first consultation was the most expensive. It amounted on the average to 350.-SFR, 54% of which were used for laboratory and 27% for technical procedures. Chest X-ray, ECG, abdominal ultrasound and upper gastrointestinal endoscopy caused about 20% of the total diagnostic costs. Cost reduction could probably be achieved by using more stringent indications for laboratory and technical services.

[Importance of sleep apnea syndromes in the assessment of hypertension]. / Stellenwert des Schlaf-Apnoe-Syndroms in der Hypertonieabklrung.

Alterations in circadian blood pressure rhythm have been described in patients with sleep apnea syndrome or arterial hypertension. Epidemiologic data indicate an association of circadian blood pressure rhythm and obstructive snoring; however, only little is known about effects of apneic phases during sleep on arterial hypertension and their relevance for management of hypertension. Effects of arterial desaturation phases caused by apnea or hypopnea during sleep on arterial blood pressure have been investigated in altogether 16 probands. Thereby, a significant reduction of circadian blood pressure rhythm (p < 0.003) and of the difference between daily and nocturnal diastolic blood pressure values (p < 0.002) was found with increasing apnea index. Our results show that the sleep apnea syndrome or obstructive snoring, respectively, should be integrated more often in diagnostic and therapeutic management of arterial hypertension, especially when the circadian blood pressure rhythm appears to be levelled by ambulatory 24-hour monitoring of blood pressure values.

[Patient compliance--concept formation, assessment methods]. / Patientencompliance--Begriffsbestimmung, Messmethoden.

The topic of patient compliance is presented synoptically in a three-part review. In this first part the definition as well as the methods for the measurement of compliance are treated. Patient compliance is a problem that concerns every physician and patient. The phenomenon is not new and is the term for an old central problem of cooperation between physician and patient. Compliance is the intention to follow a medical advice. Noncompliance is common, occurs in all kinds of diseases and is expensive. There are several methods of different accuracy that allow to assess the extent of compliance or noncompliance, respectively. Direct and indirect procedures are distinguished. Questionnaires offered to patients, 'pill-counting', 'appointment-keeping' as well as registration of drug effects represent indirect methods. The direct approach includes measurement of drugs or metabolites in urine or serum. The next issues feature on factors determining compliance, interactions between physician and patient as well as methods for the determination of compliance.

[Angina pectoris--drug therapy and costs in a medical outpatient clinic in Switzerland]. / Angina pectoris--medikamentöse Therapie und Kosten an einer medizinischen Poliklinik der Schweiz.

Prescriptions and costs of pharmacotherapy for exertional angina pectoris were studied in males treated in 1975, 1980 or 1985 at the outpatient clinic of the university of Zürich. Monotherapy was increasingly replaced by two drug regimens (1975 43%, 1980 59%, 1985 35%) or by triple therapy (1975 2%, 1980 10%, 1985 28%) respectively. In 1985 beta-blocking agents and calcium antagonists were more frequently used instead of nitrates in monotherapy. In combined treatment modalities, nitrates associated with calcium antagonists or calcium antagonists combined with beta blockers were used increasingly in 1985. The most used substances in 1985 were isosorbide dinitrate, atenolol and nifedipine. In 1985 nonselective beta blockers (propranolol, pindolol) were administered almost exclusively. The number of tablets administered per day decreased slightly over the years, while the doses of most commonly prescribed drugs increased. The cost per patient doubled during the observation period. Pharmacotherapy of stable angina calculated on the basis of 1985 pharmacy prices rose from 577 SFr. in 1975 to 1180 SFr. in 1985.

Prescription patterns and costs of antihypertensive drugs in two outpatient clinics: Zürich (Switzerland) and Münster (FRG), 1975-1985.

In the present study the prescription patterns and cost of antihypertensive drugs in two outpatient clinics located in two different countries (Zürich, Switzerland, and Münster, FRG), were analyzed from 1975 till 1985 by using representative random samples of hypertensive outpatients. Throughout the observed period the leading positions were held by diuretics and beta-blockers, whereas central sympatholytics and ganglion blockers nearly disappeared. A rapid increase in the use of calcium antagonists occurred within the last 2 analyzed years. Drugs in fixed combination containing reserpin showed a constant decrease during the observed period, whereas beta-blocker-containing combination drugs increased in both clinics. The comparison between the two clinics revealed only minor differences in the prescription pattern of the various known classes of antihypertensive drugs. However, marked differences were observed within given classes between the preferred products. Both in Zürich and Münster the mean annual drug cost per patient doubled from 1975 to 1985. Especially during the last few years these changes took place with a remarkable rapidity, obviously the result of a more intense promotion of new antihypertensive drugs.

Altered calcium and sodium metabolism in red blood cells of hypertensive man: assessment by ion-selective electrodes.

Free intracellular calcium [Ca2+]i, sodium [Na+]i and potassium [K+]i were assessed in freeze-thawed human red blood cells (RBC) by ion-selective electrodes. After metabolic depletion by 30 mM 2-desoxy-glucose, [Ca2+]i increased faster and to significantly higher values in RBC from 16 patients with mild to moderate essential hypertension (mean diastolic blood pressure 111 +/- 10 mmHg) than in the RBC of 24 normotensives. The rate of [Ca2+]i increase was 7.0 +/- 3.6 versus 3.7 +/- 4.0 mumol/h/l cells (P less than 0.01) for the first 24 h and 8.1 +/- 4.8 versus 6.4 +/- 3.5 mumol/h/l cells for the following 24 h. [Na+]i before and after 24 h incubation was significantly higher in hypertensives, whereas basal [Ca2+]i and [K+]i before and after incubation were the same in both groups. After Ca loading by ionophore A 23187, the maximum rate of [Ca2+]i extrusion was not significantly lower in intact RBC from hypertensives than in those from normotensives (59.5 +/- 7.8 versus 87.9 +/- 18.1 mumol/min/l cells). These results indicate disturbances in RBC Ca metabolism similar to those observed earlier for Na and K. If generalized, the defect could lead to raised [Ca2+]i in smooth muscle and sympathetic nerve tissue, thus causing increased vascular tone and probably catecholamine release with subsequent arterial hypertension.