Attractiveness of medical disciplines amongst Swiss first-year medical students allocated to different medical education tracks: cross-sectional study.

BACKGROUND: As most countries, Switzerland is experiencing a shortage of physicians especially in general practice and new medical education tracks with respective focusses have been started in response. This study investigated Swiss medical students' career openness and attractiveness of different medical disciplines as well as the concordance of students' career intentions with assigned medical education tracks. METHODS: Cross-sectional study surveying first year medical students assigned to four different Swiss medical education tracks with distinctive additional education focuses (ETH Zurich: medical technology and engineering, University of St. Gallen and University of Lucerne: primary healthcare and University of Zurich: no distinctive focus). RESULTS: We surveyed 354 medical students (response rate across all included medical education tracks 71.1%), 64.8% female, mean age 20 years. Regarding career openness, we found that 52.8% of medical students had neither a strong commitment nor a strong reservation for any of the proposed career options and 17.0% had a strong commitment. Among medical disciplines, medical subspecialties were attractive to the largest part of students (inpatient subspecialties attractive for 71%, outpatient for 58%), attractiveness of general practice was moderate (30%), academic (22%) and industrial sector (17%) careers were least attractive. Proportions of medical students attracted to general practice were similar at medical education tracks with focus on primary healthcare compared to other medical education tracks (32.2% vs. 25.8%, p = 0.391). Conversely, proportions of medical students attracted to academic or industry careers were significantly higher at the ETH Zurich compared to other medical education tracks (37.2%, vs. 13.1%, p < 0.001 and 31.9%, vs. 8.8%, p < 0.001 respectively). CONCLUSION: While most first-year medical students were open to careers in many medical disciplines, attractiveness of disciplines varied strongly. Students attracted to academic or industrial careers accumulated at the medical education track with concordant teaching focus but students attracted to general practice did not accumulate at medical education tracks focused on primary healthcare. For medical education tracks with primary care teaching focus this is both a challenge and an opportunity to specifically counteract the shortage of general practitioners in Switzerland.

Can the CalproQuest predict a positive Calprotectin test? A prospective diagnostic study.

BACKGROUND: Diagnosis of inflammatory bowel disease (IBD) in primary care (PC) is challenging and associated with a considerable diagnostic delay. Using a calprotectin test for any PC patient with abdominal complaints would cause significant costs. The 8-item-questionnaire CalproQuest was developed to increase the pre-test probability for a positive Calprotectin. It is a feasible instrument to assess IBD in PC, but has not yet been evaluated in clinical routine. This study, therefore, aimed to validate whether the CalproQuest increases pretest-probability for a positive fecal Calprotectin. METHODS: Prospective diagnostic trial. The CalproQuest consists of 4 major and 4 minor questions suggestive for IBD. It is considered positive if ≥ 2 major or 1 major and 2 minor criteria are positive. Primary outcome: Sensitivity and specificity of the CalproQuest for Calprotectin levels ≥ 50 µg/g and for positive IBD diagnosis among patients referred to endoscopic evaluation at secondary care level. Secondary finding: Patient-reported diagnostic delay. RESULTS: 156 patients from 7 study centers had a complete CalproQuest and fecal Calprotectin test. The sensitivity and specificity of CalproQuest for Calprotectin ≥ 50 µg/g was 36% and 57%. The sensitivity and specificity of the CalproQuest for positive IBD diagnosis was 37% and 67%. The diagnostic delay was 61 months (SD 125.2). CONCLUSION: In this prospective diagnostic study, the sensitivity and specificity of CalproQuest for Calprotectin levels ≥ 50 µg/g and positive IBD diagnosis were poor. Additional prospective studies concerning the ideal cut-off values, validity and cost-effectiveness of a combined use with the Calprotectin test in the PC setting are necessary.

One in seven Swiss physicians has left patient care - results from a national cohort study from 1980-2009.

AIMS OF THE STUDY: Physician shortage is problematic, but the percentage of physicians who left patient care in Switzerland is unclear. We set out to describe this percentage and determine whether gender or language region was associated with leaving patient care. METHODS: We analysed the National Registry (Medreg) of all physicians who graduated between 1980 and 2009 in Switzerland. Based on the last known working status noted in Medreg, physicians were classified as “probably involved in patient care” or “potentially left patient care”. We drew an unrestricted random sample of 250 from each category. We searched professional directories / social media to classify each sample. Those with undetermined status received a questionnaire that asked their working status. We quantified the percentage of physicians who left patient care and used Poisson and Cox regression to determine rates and the association of leaving patient care with gender, language region, and year of graduation. RESULTS: We identified 23,112 living physicians in Medreg in 2015. Of these, 18,406 (79.6%) were probably involved in patient care and 4706 (20.4%) had potentially left patient care. In the random sample of 250 physicians probably involved in patient care, 237 were involved in patient care, 11 had left and the status of 2 was undetermined (0.8%). In the random sample of 250 physicians who had potentially left patient care, 109 were involved in patient care, 109 had left, and the status of 32 was undetermined (12.8%). We estimated that 13.6% of physicians had left patient care (95% confidence interval [CI] 11.1–16.1%). According to the most realistic scenario, the rate of physicians who had left patient care was 1.2 per 100 physicians/year (95% CI 0.9–1.6) for those who had graduated between 1980 and 1994, and 1.8 per 100 physicians/year (95% CI 1.4–2.3) for those who graduated between 1995 and 2009 (adjusted hazard ratio 1.74, 95% CI 1.12–2.71). There was no evidence that the risk of leaving patient care was associated with gender or language region. CONCLUSIONS: Approximately one in seven physicians in Switzerland who graduated between 1980 and 2009 left patient care. Leaving patient care was not associated with gender, but the probability of leaving patient care was increased considerably in physicians who graduated more recently. Interventions that aim at keeping physicians in the work force and encourage their return to practice are sorely needed.

Feasibility of an 8-item questionnaire for early diagnosis of inflammatory bowel disease in primary care.

AIMS: Diagnosis of inflammatory bowel disease (IBD) is often associated with a diagnostic delay. Although faecal calprotectin is a helpful screening tool, the widespread use in primary care (PC) may not be appropriate due to the low prevalence of IBD in this setting. To increase pretest probability for a positive calprotectin test, an 8-item questionnaire (CalproQuest) was tested for its feasibility and acceptability in PC. METHODS: Population: PC patients with unspecific gastrointestinal complaints for at least 2 weeks. The CalproQuest consists of four major and four minor questions specific for IBD. It is considered positive if greater than or equal to two major or one major and two minor criteria are positive. PRIMARY OUTCOME: feasibility of CalproQuest, secondary outcome: patient's acceptance of stool sampling. RESULTS: Of 95 patients with a complete CalproQuest 52 (54.7%) were positive, 39 (41.1%) fulfilled two major and 13 (13.7%) one major and greater than or equal to two minor criteria. Twenty-seven general practitioners completed 83 (87.4%) questionnaires on feasibility which was assessed positive. Eighty-two patients (86.3%) completed questionnaires on acceptance which was high. CONCLUSION: The CalproQuest is a feasible instrument for assessing IBD in PC. Further prospective studies concerning validity and cost effectiveness of a combined use with the calprotectin test in this setting are necessary.

Referral determinants in Swiss primary care with a special focus on managed care.

Studies have shown large variation of referral probabilities in different countries, and many influencing factors have been described. This variation is most likely explained by different healthcare systems, particularly to which extent primary care physicians (PCPs) act as gatekeepers. In Switzerland no mandatory gatekeeping system exists, however insurance companies offer voluntary managed care plans with reduced insurance premiums. We aimed at investigating the role of managed care plans as a potential referral determinant in a non-gatekeeping healthcare system. We conducted a cross-sectional study with 90 PCPs collecting data on consultations and referrals in 2012/2013. During each consultation up to six reasons for encounters (RFE) were documented. For each RFE PCPs indicated whether a referral was initiated. Determinants for referrals were analyzed by hierarchical logistic regression, taking the potential cluster effect of the PCP into account. To further investigate the independent association of the managed care plan with the referral probability, a hierarchical multivariate logistic regression model was applied, taking into account all available data potentially affecting the referring decision. PCPs collected data on 24'774 patients with 42'890 RFE, of which 2427 led to a referral. 37.5% of patients were insured in managed health care plans. Univariate analysis showed significant higher referral rates of patients with managed care plans (10.7% vs. 8.5%). The difference in referral probability remained significant after controlling for other confounders in the hierarchical multivariate regression model (OR 1.355). Patients in managed care plans were more likely to be referred than patients without such a model. These data contradict the argument that patients in managed care plans have limited healthcare access, but underline the central role of PCPs as coordinator of care.

Improvements in primary care skills and knowledge with a vocational training program - a pre-post survey.

BACKGROUND: Facing the upcoming shortage of primary care physicians (PCPs), medical and governmental organizations have recently made major investments to foster vocational training programs in Switzerland, designed to provide context-specific training for trainees in primary care practices. Less is known about the impact of these programs on the skills and specific knowledge of trainees. We aimed to evaluate the Cantonal program for vocational primary care training in the Canton of Zurich, Switzerland's largest Canton. METHODS: We undertook a pretest-posttest study and surveyed physicians before and after participating in the Cantonal program for vocational primary care training in the Swiss Canton of Zurich. All trainees who participated in the program from 2013 until the end of 2015 were eligible. Primary outcome was the proportion of trainees being confident about their professional, organizational, examination and management skills before and after completing vocational training. Secondary outcomes were the proportion of trainees stating knowledge gain in entrepreneurship and the proportion of trainees being motivated to pursue a career as PCP. RESULTS: Data of 47 trainees participating in the vocational training between 2013 and 2015 were eligible. In total, 35 (74.5%) participated in the T1 survey and 34 (72.3%) in the T2 survey. At T2, significantly more trainees (T1: 11%-89%, T2: 79%-100%) stated to be at least "slightly confident" about their skills (p<0.05 for each individual skill). Knowledge gain in entrepreneurship was highly expected and experienced by the trainees (55%-77% of respondents) in case of medicine-specific contents, but hardly expected in case of general business contents (≤47% of respondents). Concerning trainees' motivation to pursue a career as PCP, we observed only a minimal, statistically insignificant change, suggesting that the vocational training did not alter trainees' preconceived career plans as PCP. CONCLUSION: Given the measured increase in confidence, evaluation of training programs should focus on operationalizing key skills of PCPs. Given the lack of change in trainees' motivation; however, statements about the effect of program implementation on national shortage of PCPs cannot be made.

Multimorbidity and patterns of chronic conditions in a primary care population in Switzerland: a cross-sectional study.

OBJECTIVE: To characterise in details a random sample of multimorbid patients in Switzerland and to evaluate the clustering of chronic conditions in that sample. METHODS: 100 general practitioners (GPs) each enrolled 10 randomly selected multimorbid patients aged ≥18 years old and suffering from at least three chronic conditions. The prevalence of 75 separate chronic conditions from the International Classification of Primary Care-2 (ICPC-2) was evaluated in these patients. Clusters of chronic conditions were studied in parallel. RESULTS: The final database included 888 patients. Mean (SD) patient age was 73.0 (12.0) years old. They suffered from 5.5 (2.2) chronic conditions and were prescribed 7.7 (3.5) drugs; 25.7% suffered from depression. Psychological conditions were more prevalent among younger individuals (≤66 years old). Cluster analysis of chronic conditions with a prevalence ≥5% in the sample revealed four main groups of conditions: (1) cardiovascular risk factors and conditions, (2) general age-related and metabolic conditions, (3) tobacco and alcohol dependencies, and (4) pain, musculoskeletal and psychological conditions. CONCLUSION: Given the emerging epidemic of multimorbidity in industrialised countries, accurately depicting the multiple expressions of multimorbidity in family practices' patients is a high priority. Indeed, even in a setting where patients have direct access to medical specialists, GPs nevertheless retain a key role as coordinators and often as the sole medical reference for multimorbid patients.

Internists' career choice towards primary care: a cross-sectional survey.

BACKGROUND: Swiss primary care (PC) is facing workforce shortage. Up to 2011 this workforce was supplied by two board certifications: general medicine and internal medicine. To strengthen them against subspecialties, they were unified into one: general internal medicine. However, since unification general practitioners' career options are no longer restrained by early commitment to PC. This may lead to a decrease of future primary care physicians (PCPs). METHODS: To gain insights in timing and factors influencing career choice of internists, we addressed a cross sectional survey to all board certified internists in the years 2000-2010 (n = 1462). Main measures were: final career choice (PCPs, hospital internists or subspecialists), timing and factors influencing career choice, and attractiveness of PCP career during medical school and residency. RESULTS: Response rate was 53.2%, 44.8% were female and median age was 45 years old. Final career choice was PCP for 39.1% of participants, 15.0% chose to become hospital internists, 41.8% became subspecialists and 4.0% other. Timing of career choice significantly differed between groups. Most of the subspecialists have chosen their career during residency (65.3%), while only 21.9% of the PCPs chose during residency. Work experience in an academic hospital was negatively associated with becoming PCP (P < 0.001). Family influence on career choice was more frequently reported among PCPs and chiefs' influence more reported among non-PCPs (P < 0.001). Fifty-nine percent of the participants considered a career as PCP to be attractive during medical school, this proportion decreased over time. CONCLUSIONS: Timing of career choice of PCPs and subspecialists strongly differed. PCPs opted late for their career and potentially modifiable external factors seem to contribute to their decision. This stresses the importance of fostering attractiveness of PC during medical school as well as during and after residency and of tailored residency positions for future PCPs in the hospital-dominated new general internal medicine training.

Mobile teledermatology for skin cancer screening: A diagnostic accuracy study.

Skin cancer screening has undoubted potential to reduce cancer-specific morbidity and mortality. Total-body exams remain the prevailing concept of skin cancer screening even if effectiveness and value of this method are controversial. Meanwhile, store and forward teledermatology was shown to be a reliable instrument for several diagnostic purposes mostly in specialized dermatology settings. The objective of this study was to evaluate most convenient mobile teledermatology interventions as instruments for skin cancer screening in a representative population.Prospective diagnostic study with visitors of a skin cancer screening campaign in Switzerland. Histopathology was used as reference standard. Mobile teledermatology with or without dermoscopic images was assessed for performance as a screening test (i.e., rule-in or rule-out the need for further testing). Outcomes were sensitivity, specificity, and predictive values.Seven cases of skin cancer were present among 195 skin lesions. All skin cancers were ruled-in by teledermatology with or without dermoscopic images (sensitivity and negative predictive value 100%). The addition of dermoscopic images to conventional images resulted in higher specificity (85% vs. 77%), allowing reduction of unnecessary further testing in a larger proportion of skin lesions.Store and forward mobile teledermatology could serve as an instrument for population-based skin cancer screening because of favorable test performance.

[Reasons for General Practitioner Shortage ­ a Comparison Between France and Switzerland]. / Ursachen des Hausärztemangels - ein Vergleich zwischen Frankreich und der Schweiz.

BACKGROUND AND OBJECTIVES: Both France and Switzerland face a general practitioner (GP) shortage. What differences or parallels exist between the two countries with regard to the causes for this shortage? What conclusions might be drawn from a systematic comparison? METHODS: Literature review with qualitative and semi-quantitative content analysis. RESULTS: Parallels exist in the comparing categories work contents, working structure, income and social status, medical school formation, private life, psychological motives. Differences are found in the categories biography and social selection, medical socialisation, residency. In Switzerland, residency is not uniformly structured, rarely institutionally organised and contains only few elements specific to general medicine. In France, medical socialisation not only exalts the specialists, but also strongly devaluates the GPs. CONCLUSIONS: By systematic analysis and comparison of both countries' pertinent literature, France and Switzerland can deepen their understanding of GP shortage. This paper identifies possible fields of action from medical school through residency up to workplace conditions that are pivotal in addressing the shortage of GPs.

From chronic conditions to relevance in multimorbidity: a four-step study in family medicine.

BACKGROUND: Chronic conditions and multimorbidity (MM) are major concerns in family medicine (FM). OBJECTIVES: Based on the International Classification of Primary Care, Second Edition (ICPC-2), this study aimed to list (i)the chronic conditions and (ii)those most relevant to MM in FM. METHODS: A panel of FM experts used a four-step process to identify chronic conditions among ICPC-2 items and list chronic conditions most relevant in MM. They also evaluated the importance of eight criteria, previously identified in the literature, for characterizing chronic conditions. Step one involved a focus group of five experts. Steps two, three and four involved 10, 25 and 25 experts, respectively. They rated ICPC-2 items via an online questionnaire using a Likert scale from 1 (never chronic/irrelevant in MM) to 9 (always chronic/always relevant in MM). A median value cut-off was used to evaluate appropriateness of each item and the inter-percentile range adjusted for symmetry to determine the agreement/disagreement between experts. In parallel, in steps two and three, experts rated the importance of eight criteria to characterize chronic conditions, using a Likert scale from 1 (strongly disagree) to 9 (strongly agree). RESULTS: Of the ICPC-2's 686 items, experts identified 139 chronic conditions, of which 75 were deemed most relevant in the context of MM. Four of the eight criteria were retained as important to define chronic conditions: duration, sequelae, recurrence/pattern and the diagnosis itself. CONCLUSION: Using this list of 75 chronic conditions most relevant in the context of MM should enhance the validity of studies of MM in FM.

Referral rates in Swiss primary care with a special emphasis on reasons for encounter.

QUESTIONS UNDER STUDY: Referrals from primary to secondary care reflect a crucial role of primary care physicians (PCPs). Most referral rates are based on the number of consultations, rather than on the number of problems addressed during consultations (reasons for encounter = RFE). The aim of the study was to update data on consultations, RFE and referrals in Swiss primary care and calculate a referral rate based on RFE rather than on the number of consultations. METHOD: Cross-sectional study in Swiss primary care. PCPs collected data on consultations on 15 different days in three nonconsecutive months in 2012/2013. Demographic data of patients and up to six RFE per consultation were collected. For each RFE the PCP had to indicate whether a referral was initiated. Data were analysed using descriptive statistics. RESULTS: Ninety PCPs (18.9% females) participated and 24 774 consultations with 42 890 RFE (corresponding to 1.73 [standard deviation 1.07] RFE per consultation) were recorded. A total of 2 427 RFE (of 2 341 consultations) led to a referral, corresponding to a referral rate of 9.44% (95% confidence interval [CI] 9.08-9.81%) based on consultations and 5.65% (95% CI 5.43-5.87%) based on the number of RFE. CONCLUSIONS: An average of 1.7 RFE per consultation and a broad clinical spectrum of problems were presented in primary care; nevertheless, 94.3% of all problems were solved in primary care, reflecting the crucial role of PCPs as a coordinator of healthcare.

Acceptance of interventions to promote primary care: What do physicians prioritize?

BACKGROUND: Switzerland is facing a shortage of primary care physicians (PCPs); government organizations therefore suggested a broad variety of interventions to promote primary care. The aim of the study was to prioritize these interventions according to the acceptance and perceived barriers of most relevant groups of physicians in this context (hospital physicians and PCPs). METHODS: The study was conducted during summer 2014. An online-based questionnaire assessed demographic data, working conditions and future plans. Participants were asked to rank the usefulness of 22 interventions to promote primary care. Interventions to promote primary care that received ratings of 4 or 5 on the Likert scale (corresponding to "useful" or "very useful") by at least 80 % of the participants were categorized as interventions with very high acceptance. We analyzed whether the groups (PCPs, hospital physicians) ranked the interventions differently using the Mann-Whitney U test. We assumed a two tailed p < 0.05 after Bonferroni correction for multiple testing as statistically significant. RESULTS: Two hundred thirty physicians (response rate 58.4 %) completed the survey. Among those 69 PCPs and 66 hospital physicians were included in the analysis. Among those 14 PCPs were planning to leave clinical practice due to retirement, whereas only 8 hospital physicians planned a career as PCPs. Among PCPs the intervention with the highest acceptance was the increase of reimbursement, whereas family friendly measures achieved highest acceptance among hospital physicians. Financial support for primary care traineeships was considered to be very useful by both groups. CONCLUSIONS: Interventions on PCPs close to retirement or on PCPs considering an early retirement will not adequately prevent shortage of primary care providers. Governmental interventions should therefore also aim at encouraging hospital physicians to start a career in primary care by governmental support for traineeships in primary care and investments in family friendly measures.

Multimorbidity in primary care: protocol of a national cross-sectional study in Switzerland.

INTRODUCTION: With the ageing of the population and the general improvement of care, an increasing number of people are living with multiple chronic health conditions or 'multimorbidity'. Multimorbidity often implies multiple medical treatments. As a consequence, the risk of adverse events and the time spent by patients for their treatments increase exponentially. In many cases, treatment guidelines traditionally defined for single conditions are not easily applicable. Primary care for individuals with multimorbidity requires complex patient-centred care and good communication between the patient and the general practitioner (GP). This often includes prioritising among the different chronic conditions. METHODS AND ANALYSIS: The main objectives of this study are to describe the burden related to multimorbidity (disease-related burden and burden of treatment) in primary care and to identify the factors influencing it. Other objectives include evaluating patients' perception of treatment burden and quality of life, assessing factors influencing that perception, and investigating prioritisation in the management of multimorbidity from the perspectives of GPs and patients. For this cross-sectional study, patient enrolment will take place in GP's private practices across Switzerland. A convenient sample of 100 GPs will participate; overall, 1000 patients with at least three chronic health conditions will be enrolled. Data will be collected as paper-based questionnaires for GPs and delayed telephone interview questionnaires for patients. GPs will provide demographic and practice-related data. In addition, each GP will complete a paper-based questionnaire for each patient that they enrol. Each patient will complete a telephone interview questionnaire. ETHICS AND DISSEMINATION: This study has been approved by the research ethics committee of Canton Vaud, Switzerland (Protocol 315/14). The results of the study will be reported in international peer-reviewed journals.

Undirected health IT implementation in ambulatory care favors paper-based workarounds and limits health data exchange.

BACKGROUND: The adoption and use of health information technology (IT) continues to grow around the globe. In Switzerland, the government nor professional associations have to this day provided incentives for health IT adoption. OBJECTIVE: We aim to assess the proportion of physicians who are routinely working with electronic health data and describe to what extent physicians exchange electronic health data with peers and other health care providers. Additionally, we aim to estimate the effect of physicians' attitude towards health IT on the adoption of electronic workflows. METHODS: Between May and July 2013, we conducted a cross-sectional survey of 1200 practice based physicians in Switzerland. Respondents were asked to report on their technical means and where applicable their paper-based workarounds to process laboratory data, examination results, referral letters and physician's letters. Physicians' view of barriers and facilitators towards health IT use was determined by a composite score. RESULTS: A response rate of 57.1% (n=685) was reached. The sample was considered to be representative for physicians in Swiss ambulatory care. 35.2% of the respondents documented patients' health status with the help of a longitudinal semi-structured electronic text record generated by one or more encounters in the practice. Depending on the task within a workflow, around 11-46% of the respondents stated to rely on electronic workflow practices to process laboratory and examination data and dispatch referral notes and physician's letters. The permanent use of electronic workflow processes was infrequent. Instead, respondents reported paper-based workarounds affecting specific tasks within a workflow. Physicians' attitude towards health IT was significantly associated with the adoption of electronic workflows (OR 1.04-1.31, p<0.05), but the effect sizes of factors related to the working environment (e.g., regional factors, medical specialty, type of practice) were larger. CONCLUSION: At present, only a few physicians in Swiss ambulatory care routinely work with electronic health data. Until more of their peers participate in electronic exchange of structured clinical information, most physicians will continue to stay in paper-based systems and workarounds. The survey found that physicians with a positive attitude towards health IT were more likely to adopt electronic workflows, but the impact is minor. It will likely be necessary to introduce financial incentives and develop national standards in order to promote the adoption by a critical mass of practicing clinicians.

The impact of physician-nurse task shifting in primary care on the course of disease: a systematic review.

BACKGROUND: Physician-nurse task shifting in primary care appeals greatly to health policymakers. It promises to address workforce shortages and demands of high-quality, affordable care in the healthcare systems of many countries. This systematic review was conducted to assess the evidence about physician-nurse task shifting in primary care in relation to the course of disease and nurses' roles. METHODS: We searched MEDLINE, Embase, The Cochrane Library and CINAHL, up to August 2012, and the reference list of included studies and relevant reviews. All searches were updated in February 2014. We selected and critically appraised published randomized controlled trials (RCTs). RESULTS: Twelve RCTs comprising 22,617 randomized patients conducted mainly in Europe met the inclusion criteria. Nurse-led care was delivered mainly by nurse practitioners following structured protocols and validated instruments in most studies. Twenty-five unique disease-specific measures of the course of disease were reported in the 12 RCTs. While most (84 %) study estimates showed no significant differences between nurse-led care and physician-led care, nurses achieved better outcomes in the secondary prevention of heart disease and a greater positive effect in managing dyspepsia and at lowering cardiovascular risk in diabetic patients. The studies were generally small, of varying follow-up episodes and were at risk of biases. Descriptive details about roles, qualifications or interventions were also incomplete or not reported. CONCLUSION: Trained nurses may have the ability to achieve outcome results that are at least similar to physicians' for managing the course of disease, when following structured protocols and validated instruments. The evidence, however, is limited by a small number of studies reporting a broad range of disease-specific outcomes; low reporting standards of interventions, roles and clinicians' characteristics, skills and qualifications; and the quality of studies. More rigorous studies using validated tools could clarify these findings.

Task-Shifting From Physicians to Nurses in Primary Care and its Impact on Resource Utilization: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Task-shifting from physicians to nurses has gained increasing interest in health policy but little is known about its efficiency. This systematic review was conducted to compare resource utilization with task-shifting from physicians to nurses in primary care. Literature searches yielded 4,589 citations. Twenty studies comprising 13,171 participants met the inclusion criteria. Meta-analyses showed nurses had more return consultations and longer consultations than physicians but were similar in their use of referrals, prescriptions, or investigations. The evidence has limitations, but suggests that the effects may be influenced by the utilization of resources, context of care, available guidance, and supervision. Cost data suggest physician-nurse salary and physician's time spent on supervision and delegation are important components of nurse-led care costs. More rigorous research involving a wider range of nurses from many countries is needed reporting detailed accounts of nurses' roles and competencies, qualifications, training, resources, time available for consultations, and all-cause costs.

VAlidation of an 8-item-questionnaire predictive for a positive caLprotectin tEst and Real-life implemenTation in primary care to reduce diagnostic delay in inflammatory bowel disease (ALERT): protocol for a prospective diagnostic study.

INTRODUCTION: Diagnosis of inflammatory bowel disease (IBD) in primary healthcare is challenging and often associated with a considerable diagnostic delay. This delay is associated with worse disease progression and outcomes. Although testing for faecal calprotectin is a useful screening tool to identify patients who need endoscopy for IBD, the widespread use may not be appropriate due to the low prevalence of patients with IBD among all patients attending a general practitioner (GP) with gastrointestinal symptoms. To increase the appropriate application of the faecal calprotectin test, an 8-item questionnaire, the CalproQuest, has been developed to increase pretest probability for a positive test result. METHODS AND ANALYSIS: This is a prospective diagnostic trial. The study consists of two independent and consecutive parts A and B, conducted by gastroenterologists (A) and GPs (B), respectively. Patients included in part A are referred to the gastroenterologist for any endoscopic evaluation. Patients included in part B present at their GP because of ongoing unspecific gastrointestinal symptoms (abdominal pain, bloating, stool irregularities, diarrhoea) for at least 2 weeks. CalproQuest consists of four main and four secondary questions specific for IBD; it is considered positive if ≥2 main criteria are answered positively or one main criterion and two secondary criteria are answered positively. In part A, the sensitivity and specificity of CalproQuest for stool calprotectin levels ≥50 µg/g faeces and for positive IBD diagnosis will be investigated. In part B, the feasibility of CalproQuest in daily primary healthcare practice will be assessed. ETHICS AND DISSEMINATION: The study protocol was approved by the Ethics Committee of the Kanton Zurich (reference KEK-ZH-number 2013-0516). The results will be published in a peer-reviewed journal and shared with the worldwide medical community. TRIAL REGISTRATION NUMBER: ISRCTN66310845.

Feasibility and diagnostic accuracy of teledermatology in Swiss primary care: process analysis of a randomized controlled trial.

RATIONALE, AIM AND OBJECTIVE: To test feasibility and diagnostic accuracy of dermatologist's feedback based on digital images of skin lesions collected in Swiss primary care. METHODS: This was a process analysis of a randomized controlled trial, conducted in 2011/2012. 30 of 78 general practitioners (GPs) were randomized to an intervention, which included dermatologist's feedback on digital images of skin lesions. Feedback was categorized into four categories: (1) no further investigation; (2) clinical observation; (3) biopsy; and (4) other. Histologic findings were allocated to the same categories. Feasibility was measured in the perspective of GPs concerning technical handling and of dermatologists as proportion of images usable for feedback. Diagnostic accuracy was measured as proportion of malignant histology of the first three feedback groups. No long-term data was collected. RESULTS: 981 images of skin lesions were collected, two were not eligible due to low quality of images. The majority of GPs (77.8%) reported no problem with the procedure. 207 images were in feedback category 1, 353 in 2, 360 in 3 and 59 in 4. A total of 236 histologic tests were collected. Three cases in category 1 indicated malignancy (1 melanoma). 201 of category 3 received a biopsy, where in 91 (45.3%) malignancy was confirmed. CONCLUSION: Teledermatology with digital images taken in primary care was feasible from a GP and from a specialist perspective. However, diagnostic appropriateness regarding avoidance of specialist care and possible missed skin cancer raises concerns. These results therefore question a promotion of teledermatology in clinical routine.

The effect of physician-nurse substitution in primary care in chronic diseases: a systematic review.

BACKGROUND: Chronically ill and ageing populations demand increasing human resources who can provide on-going and frequent follow-up care. We performed a systematic review to assess the effect of physician-nurse substitution on process care outcomes. METHODS: We searched OVID Medline, Embase, CINAHL and The Cochrane Library for all available dates up to August 2012 and updated in February 2014. We selected and critically appraised published randomised controlled trials (RCT) and followed the PRISMA guidelines for the reporting of systematic reviews. RESULTS: A total of 14 RCTs comprising 10,743 participants met the inclusion criteria. Studies were generally small and suffered from attrition of ≥20% and selection biases. There were 53 process measurements investigated in the 14 RCTs, many of which were unique to specific conditions. Accounts of nurses' roles, responsibilities, tasks, qualifications and training content/components were not described in sufficient detail. Most study estimates showed no significant differences between nurse-led care and physician-led care while less than a half (~40%) favoured nurse-led care. CONCLUSIONS: Despite the methodological limitations and the varying nurses' roles and competencies across studies, specially trained nurses can provide care that is at least as equivalent to care provided by physicians for the management of chronic diseases, in terms of process of care. Future, larger studies with better quality methods are needed and should report and assess whether the differences in effects vary due to diversity in roles, qualifications, training competencies and characteristics of clinicians delivering substitution of care.