Impact of osteosynthesis in fracture care: a cost comparison study.

Aim: To estimate the health economic impact of osteosynthesis (OS) in fracture care over six decades in 17 high-income countries. Patients & methods: Applying a decision tree model, we assumed a hypothetical absence of OS and compared OS (intervention) with conservative treatment (CONS; comparator). We included patients with femur, tibia and radius fractures (age <65 years) and for proximal femur fractures also elderly patients (≥70 years). Results: We estimated savings in direct and indirect costs of 855 billion Swiss francs in the working age population in addition to 4.6 million years of life gained. In the elderly population, 69 billion Swiss francs were saved in direct costs of proximal femur fractures in addition to 73 million years of life gained. Conclusion: OS contributed to maximize health gains of society.

The impact of the AO Foundation on fracture care: An evaluation of 60 years AO Foundation.

OBJECTIVES: Sixty years ago, the Association of Osteosynthesis (AO) was founded with the aim to improve fracture treatment and has since grown into one of the largest medical associations worldwide. Aim of this study was to evaluate AO's impact on science, education, patient care and the MedTech business. DESIGN/METHODS: Impact evaluations were conducted as appropriate for the individual domains: Impact on science was measured by analyzing citation frequencies of publications promoted by AO. Impact on education was evaluated by analyzing the evolution of number and location of AO courses. Impact on patient care was evaluated with a health economic model analyzing cost changes and years of life gained through the introduction of osteosynthesis in 17 high-income countries (HICs). Impact on MedTech business was evaluated by analyzing sales data of AO-associated products. RESULTS: Thirty-five AO papers and 2 major AO textbooks are cited at remarkable frequencies in high ranking journals with up to 2000 citations/year. The number of AO courses steadily increased with a total of 645'000 participants, 20'000 teaching days and 2'500 volunteer faculty members so far. The introduction of osteosynthesis saved at least 925 billion Swiss Francs [CHF] in the 17 HICs analyzed and had an impact on avoiding premature deaths comparable to the use of antihypertensive drugs. AO-associated products generated sales of 55 billion CHF. CONCLUSION: AO's impact on science, education, patient care, and the MedTech business was significant because AO addressed hitherto unmet needs by combining activities that mutually enriched and reinforced each other.

The contribution of lifestyle and work factors to social inequalities in self-rated health among the employed population in Switzerland.

We sought to examine the joint and independent contributions of working conditions and health-related behaviours in explaining social gradients in self-rated health (SRH). Nationally representative cross-sectional data from the Swiss Health Survey of 2007 were used for this study. Bi- and multivariate statistical analyses were carried out on a sample of 6950 adult employees of working age. We examined a comprehensive set of five health behaviours and lifestyle factors as well as twelve physical and psychosocial work factors as potential mediators of the relationship between social status and SRH. Analyses were stratified by sex and performed using two measures of social status, educational level and occupational position. Strong social gradients were found for SRH, but mainly in men whereas in women the associations were either not linear (educational level) or not statistically significant (occupational position). Social gradients were also found for most lifestyle and all physical and psychosocial work factors studied. These three groups of factors equally contributed to and largely accounted for the social gradients in SRH although not all of the individual factors turned out to be independent and significant risk factors for poor SRH. Such risk factors included physical inactivity and obesity, poor posture and no or low social support at work (both sexes), heavy smoking (men) and underweight, overweight, uniform arm or hand movements at work, monotonous work and job insecurity (women). In conclusion, social inequalities (or more precisely educational and occupational status differences) in SRH were more pronounced in men and can be attributed for the most part to a sedentary lifestyle and to a physically demanding and socially unsupportive and insecure work environment. Apart from this main finding and overall pattern, sex-specific risk profiles were observed with regard to SRH and need to be taken into consideration.

Current challenges in handling genetic data.

In no other field of biomedicine has such revolutionary change taken place in recent decades as it has in molecular genetics. The accumulated knowledge in this field will not only enable clinicians to make new treatment decisions in future, but will also help to save on healthcare costs. A positive test result will be the prerequisite for carrying out targeted drug treatment (companion diagnostics). Specific molecular diagnostics provide doctors with additional information that was not previously available, enabling them to optimise treatment accordingly. At the same time, prognostic tests mean that targeted preventive measures can be taken. Highly informative non-invasive tests will enable early detection and prevention to play a greater role. Technological breakthroughs, such as high-throughput sequencing, will lead to a flood of data in the future. The challenge lies in the quality of interpretation, which means extracting useful information for doctor and patient. Unlike data collection, interpretation is complex and expensive: it requires a high degree of expertise and a lot of resources. At the same time, experts stress that - as well as improvements in the accuracy and speed of data analysis - defined quality criteria must be generated for reliable interpretation of results. These challenges need to be tackled so that the population can benefit to the utmost from the opportunities offered by these developments: rapidly available and informative tests for targeted therapies based on high-quality data.

Cancer comortality patterns in schizophrenia and psychotic disorders: a new methodological approach for unique databases.

The aim of this study was to determine the pattern of cancer comortality in deaths registered with schizophrenia and psychotic disorders. It focused on the question of whether the proportions of different types of cancer diverge when they are co-registered with schizophrenia/psychotic disorders or with other causes of death in mortality statistics. We developed an analysis approach applicable to common mortality statistics data when no linkage with morbidity databases or other registers is possible. The analysis covered Swiss mortality data from a 39-year period (1969 - 2007) and was confined to the most frequent cancers. We applied a two-step case-control analysis with bootstrapping (1000 repetitions). The cases were defined by the cancer-schizophrenia registrations for each specific cancer, whereas the controls were matched from the remaining cases (matching criteria: sex, age, region, subperiod). Cancers with deviant standardized mortality ratios (SMRs) included stomach cancer (1.6; 2.2 after reweighting), lung cancer (0.8; 0.5 after reweighting) and breast cancer (1.6; 1.5 after reweighting). The comortality pattern of cancers in schizophrenia and psychotic disorders diverges from the pattern found in other co-registered causes of death. The relatively low frequency of lung cancers is particularly paradoxical in view of the smoking habits of schizophrenia patients.

Religion and suicide in patients with mental illness or cancer.

In Switzerland, the highest rates of suicide are observed in persons without religious affiliation and the lowest in Catholics, with Protestants in an intermediate position. We examined whether this association was modified by concomitant psychiatric diagnoses or malignancies, based on 6,909 suicides (ICD-10 codes X60-X84) recorded in 3.69 million adult residents 2001-2008. Suicides were related to mental illness or cancer if codes F or C, respectively, were mentioned on the death certificate. The protective effect of religion was substantially stronger if a diagnosis of cancer was mentioned on the death certificate and weaker if a mental illness was mentioned.

Death has a preference for birthdays-an analysis of death time series.

PURPOSE: To examine the relation between the day of death and the day of birth. To determine whether the "death postponement" hypothesis or the "anniversary reaction" hypothesis is more appropriate. METHODS: We analyzed data from the Swiss mortality statistics 1969-2008. Deaths below the age of 1 were excluded from the analysis. Time series of frequencies of deaths were based on differences between the day of death and the day of birth. We applied autoregressive integrated moving average modeling with intervention effects both in straight and reverse time series. RESULTS: The overall death excess on the day of birth was 13.8%, mainly because of cardiovascular and cerebrovascular diseases (more in women than in men) as well as suicides and accidents (in particular, falls in men). Unexpectedly, we also found an excess of deaths in cancers. An (negative) aftereffect was found in cancers, and (positive) anticipatory effects were found in falls in men. CONCLUSIONS: In general, birthdays do not evoke a postponement mechanism but appear to end up in a lethal way more frequently than expected ("anniversary reaction").

Characteristics and Outcome in Acute Coronary Syndrome Patients with and without Established Modifiable Cardiovascular Risk Factors: Insights from the Nationwide AMIS Plus Registry 1997-2010.

OBJECTIVES: Little is known about patients without known modifiable risk factors presenting initially with acute coronary syndrome (ACS). This study assessed baseline characteristics and outcomes of ACS patients with and without the known modifiable risk factors arterial hypertension, dyslipidemia, obesity, smoking or diabetes. METHODS: All ACS patients enrolled in the AMIS Plus Registry between 1997 and 2010 were analyzed until hospital discharge; a subgroup was re-assessed at the 1-year follow-up. Outcome measures were in-hospital mortality and major adverse cardiac or cerebrovascular events (MACCE) defined as a composite outcome of mortality, re-infarction and cerebrovascular events. RESULTS: Of 33,306 patients, 2,125 (6.4%) had none of these modifiable risk factors. They were older (males), had less moderate or severe comorbidities and were more frequently in Killip class I on admission. Treatment of ACS patients with or without modifiable risk factors was similar with regard to interventional therapies and use of antiplatelet agents. In-hospital mortality was lower in patients without modifiable risk factors but in-hospital MACCE and 1-year survival was similar. CONCLUSION: Lack of modifiable risk factors was an independent predictor of lower in-hospital mortality but not of MACCE in patients who presented with ACS.

Health risk or resource? Gradual and independent association between self-rated health and mortality persists over 30 years.

BACKGROUND: Poor self-rated health (SRH) is associated with increased mortality. However, most studies only adjust for few health risk factors and/or do not analyse whether this association is consistent also for intermediate categories of SRH and for follow-up periods exceeding 5-10 years. This study examined whether the SRH-mortality association remained significant 30 years after assessment when adjusting for a wide range of known clinical, behavioural and socio-demographic risk factors. METHODS: We followed-up 8,251 men and women aged ≥ 16 years who participated 1977-79 in a community based health study and were anonymously linked with the Swiss National Cohort (SNC) until the end of 2008. Covariates were measured at baseline and included education, marital status, smoking, medical history, medication, blood glucose and pressure. RESULTS: 92.8% of the original study participants could be linked to a census, mortality or emigration record of the SNC. Loss to follow-up 1980-2000 was 5.8%. Even after 30 years of follow-up and after adjustment for all covariates, the association between SRH and all-cause mortality remained strong and estimates almost linearly increased from "excellent" (reference: hazard ratio, HR 1) to "good" (men: HR 1.07 95% confidence interval 0.92-1.24, women: 1.22, 1.01-1.46) to "fair" (1.41, 1.18-1.68; 1.39, 1.14-1.70) to "poor"(1.61, 1.15-2.25; 1.49, 1.07-2.06) to "very poor" (2.85, 1.25-6.51; 1.30, 0.18-9.35). Persons answering the SRH question with "don't know" (1.87, 1.21-2.88; 1.26, 0.87-1.83) had also an increased mortality risk; this was pronounced in men and in the first years of follow-up. CONCLUSIONS: SRH is a strong and "dose-dependent" predictor of mortality. The association was largely independent from covariates and remained significant after decades. This suggests that SRH provides relevant and sustained health information beyond classical risk factors or medical history and reflects salutogenetic rather than pathogenetic pathways.

Birth cohort effects in neurological diseases: amyotrophic lateral sclerosis, Parkinson's disease and multiple sclerosis.

BACKGROUND: Generational differences in disease rates are the main subject of age-period-cohort (APC) analysis, which is mostly applied in cancer and suicide research. This study applied APC analysis to selected neurological diseases: amyotrophic lateral sclerosis (ALS), Parkinson's disease (PD) and multiple sclerosis (MS). METHODS: The analyses were based on Swiss mortality data. Age-stratified data has been available for MS, PD and ALS since 1901, 1921, and 1942, respectively. APC analysis was performed within the framework of logit models. Main effect models were extended by implementing nested effects, i.e. age effects nested in subperiods, in order to account for the fact that age profiles may change for reasons other than generational influences. RESULTS: In preliminary analyses, APC analysis yielded noteworthy birth cohort effects in all three diseases. After implementing nested effects, the birth cohort effects disappeared in ALS, and smoothed out in PD, where they were greater for the generations born before the 1920s. In MS, the birth cohort effects remained stable, and exhibited a peak in cohorts born in the 1910s and 1920s. CONCLUSIONS: APC analysis yielded some evidence for birth cohort effects, i.e. predisposing risk factors that may change in historical terms, in MS and PD, but probably not in ALS.

Lower age at first myocardial infarction in female compared to male smokers.

BACKGROUND: Smoking is one of the most important risk factors for myocardial infarction. Smokers usually suffer their first myocardial infarction earlier in life compared to non-smokers. This age difference seems to be greater in women than in men. The aim of this study was to examine the age and sex differences in terms of smoking in patients with first myocardial infarction who were enrolled in the Swiss National Registry of myocardial infarction, AMIS Plus. METHODS: Data of 15,711 patients admitted to an AMIS Plus hospital between 1999 and 2008 with a first myocardial infarction were analysed. Several multivariate regression, interaction and sensitivity analyses were conducted. RESULTS: The mean age at first myocardial infarction was 68.5 ± 12.2 years for non-smokers and 56.6 ± 11.7 years for smokers (P < 0.001). After stratification by sex the difference between non-smokers and smokers was 10.2 years in men and 13.1 years in women. Even after adjustment for risk factors (overweight, hypertension, dyslipidaemia, diabetes), comorbidities (peripheral vascular disease, cerebrovascular disease, chronic lung disease), regular cardiovascular medication intake before admission, Killip classification and ECG on admission, male smokers were 8.7 years younger than male non-smokers at first myocardial infarction. In women, the age difference between smokers and non-smokers was 10.8 years, giving a sex-specific difference of 2.1 years (P < 0.001). CONCLUSIONS: In the AMIS Plus cohort, smoking was associated with younger age at first myocardial infarction and this was much more pronounced in women. Public health campaigns should take into account the impact of smoking on premature first myocardial infarction, especially in women.

Persistent work-life conflict and health satisfaction - a representative longitudinal study in Switzerland.

BACKGROUND: The objectives of the present study were (1) to track work-life conflict in Switzerland during the years 2002 to 2008 and (2) to analyse the relationship between work-life conflict and health satisfaction, examining whether long-term work-life conflict leads to poor health satisfaction. METHODS: The study is based on a representative longitudinal database (Swiss Household Panel), covering a six-year period containing seven waves of data collection. The sample includes 1261 persons, with 636 men and 625 women. Data was analysed by multi-level mixed models and analysis of variance with repeated measures. RESULTS: In the overall sample, there was no linear increase or decrease of work-life conflict detected, in either its time-based or strain-based form. People with higher education were more often found to have a strong work-life conflict (time- and strain-based), and more men demonstrated a strong time-based work-life conflict than women (12.2% vs. 5%). A negative relationship between work-life conflict and health satisfaction over time was found. People reporting strong work-life conflict at every wave reported lower health satisfaction than people with consistently weak work-life conflict. However, the health satisfaction of those with a continuously strong work-life conflict did not decrease during the study period. CONCLUSIONS: Both time-based and strain-based work-life conflict are strongly correlated to health satisfaction. However, no evidence was found for a persistent work-life conflict leading to poor health satisfaction.

Diagnostic accuracy of point-of-care testing for acute coronary syndromes, heart failure and thromboembolic events in primary care: a cluster-randomised controlled trial.

BACKGROUND: Evidence of the clinical benefit of 3-in-1 point-of-care testing (POCT) for cardiac troponin T (cTnT), N-terminal pro-brain natriuretic peptide (NT-proBNP) and D-dimer in cardiovascular risk stratification at primary care level for diagnosing acute coronary syndromes (ACS), heart failure (HF) and thromboembolic events (TE) is very limited. The aim of this study is to analyse the diagnostic accuracy of POCT in primary care. METHODS: Prospective multicentre controlled trial cluster-randomised to POCT-assisted diagnosis and conventional diagnosis (controls). Men and women presenting in 68 primary care practices in Zurich County (Switzerland) with chest pain or symptoms of dyspnoea or TE were consecutively included after baseline consultation and working diagnosis. A follow-up visit including confirmed diagnosis was performed to determine the accuracy of the working diagnosis, and comparison of working diagnosis accuracy between the two groups. RESULTS: The 218 POCT patients and 151 conventional diagnosis controls were mostly similar in characteristics, symptoms and pre-existing diagnoses, but differed in working diagnosis frequencies. However, the follow-up visit showed no statistical intergroup difference in confirmed diagnosis frequencies. Working diagnoses overall were significantly more correct in the POCT group (75.7% vs 59.6%, p = 0.002), as were the working diagnoses of ACS/HF/TE (69.8% vs 45.2%, p = 0.002). All three biomarker tests showed good sensitivity and specificity. CONCLUSION: POCT confers substantial benefit in primary care by correctly diagnosing significantly more patients. TRIAL REGISTRATION: DRKS: DRKS00000709.

Acute coronary syndromes in young patients: presentation, treatment and outcome.

BACKGROUND: Acute coronary syndromes (ACS) in very young patients have been poorly described. We therefore evaluate ACS in patients aged 35 years and younger. METHODS: In this prospective cohort study, 76 hospitals treating ACS in Switzerland enrolled 28,778 patients with ACS between January 1, 1997, and October 1, 2008. ACS definition included ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). RESULTS: 195 patients (0.7%) were 35 years old or younger. Compared to patients>35 years, these patients were more likely to present with chest pain (91.6% vs. 83.7%; P=0.003) and less likely to have heart failure (Killip class II to IV in 5.2% vs. 23.0%; P<0.001). STEMI was more prevalent in younger than in older patients (73.1% vs. 58.3%; P<0.001). Smoking, family history of CAD, and/or dyslipidemia were important cardiovascular risk factors in young patients (prevalence 77.2%, 55.0%, and 44.0%). The prevalence of overweight among young patients with ACS was high (57.8%). Cocaine abuse was associated with ACS in some young patients. Compared to older patients, young patients were more likely to receive early percutaneous coronary interventions and had better outcome with fewer major adverse cardiac events. CONCLUSIONS: Young patients with ACS differed from older patients in that the younger often presented with STEMI, received early aggressive treatment, and had favourable outcomes. Primary prevention of smoking, dyslipidemia and overweight should be more aggressively promoted in adolescence.

Religion and assisted and non-assisted suicide in Switzerland: National Cohort Study.

BACKGROUND: In the 19th century, eminent French sociologist Emile Durkheim found suicide rates to be higher in the Protestant compared with the Catholic cantons of Switzerland. We examined religious affiliation and suicide in modern Switzerland, where assisted suicide is legal. METHODS: The 2000 census records of 1,722,456 (46.0%) Catholics, 1,565,452 (41.8%) Protestants and 454,397 (12.2%) individuals with no affiliation were linked to mortality records up to December 2005. The association between religious affiliation and suicide, with the Protestant faith serving as the reference category, was examined in Cox regression models. Hazard ratios (HRs) with 95% confidence intervals (CIs) were adjusted for age, marital status, education, type of household, language and degree of urbanization. RESULTS: Suicide rates per 100,000 inhabitants were 19.7 in Catholics (1664 suicides), 28.5 in Protestants (2158 suicides) and 39.0 in those with no affiliation (882 suicides). Associations with religion were modified by age and gender (P < 0.0001). Compared with Protestant men aged 35-64 years, HRs (95% CI) for all suicides were 0.80 (0.73-0.88) in Catholic men and 1.09 (0.98-1.22) in men with no affiliation; and 0.60 (0.53-0.67) and 1.96 (1.69-2.27), respectively, in men aged 65-94 years. Corresponding HRs in women aged 35-64 years were 0.90 (0.80-1.03) and 1.46 (1.25-1.72); and 0.67 (0.59-0.77) and 2.63 (2.22-3.12) in women aged 65-94 years. The association was strongest for suicides by poisoning in the 65-94-year-old age group, the majority of which was assisted: HRs were 0.45 (0.35-0.59) for Catholic men and 3.01 (2.37-3.82) for men with no affiliation; 0.44 (0.36-0.55) for Catholic women and 3.14 (2.51-3.94) for women with no affiliation. CONCLUSIONS: In Switzerland, the protective effect of a religious affiliation appears to be stronger in Catholics than in Protestants, stronger in older than in younger people, stronger in women than in men, and particularly strong for assisted suicides.

Establishing a follow-up of the Swiss MONICA participants (1984-1993): record linkage with census and mortality data.

BACKGROUND: To assess the feasibility and quality of an anonymous linkage of 1) MONICA (MONItoring of trends and determinants in CArdiovscular disease, three waves between 1984 and 1993) data with 2) census and mortality records of the Swiss National Cohort in order to establish a mortality follow-up until 2008. Many countries feature the defect of lacking general population cohorts because they have missed to provide for follow-up information of health surveys. METHODS: Record linkage procedures were used in a multi-step approach. Kaplan-Meier curves from our data were contrasted with the survival probabilities expected from life tables for the general population, age-standardized mortality rates from our data with those derived from official cross-sectional mortality data. Cox regression models were fit to investigate the influence of covariates on survival. RESULTS: 97.8% of the eligible 10,160 participants (25-74y at baseline) could be linked to a census (1990: 9,737; 2000: 8,749), mortality (1,526, 1984-2008) and/or emigration record (320, 1990-2008). Linkage success did not differ by any key study characteristic. Results of survival analyses were robust to linkage step or certainty of a correct link. Loss to follow-up between 1990 and 2000 amounted to 4.7%. MONICA participants had lower mortality than the general population, but similar mortality patterns, (e.g. variation by educational level, marital status or region). CONCLUSIONS: Using anonymized census and death records allowed an almost complete mortality follow-up of MONICA study participants of up to 25 years. Lower mortality compared to the general population was in line with a presumable 'healthy participant' selection in the original MONICA study. Apart from that, the derived data set reproduced known mortality patterns and showed only negligible potential for selection bias introduced by the linkage process. Anonymous record linkage was feasible and provided robust results. It can thus provide valuable information, when no cohort study is available.

Impact of a normal or non-specific admission ECG on the treatment and early outcome of patients with myocardial infarction in Swiss hospitals between 2003 and 2008.

BACKGROUND: Diagnosis of acute myocardial infarction (AMI) rests upon clinical, electrocardiographic and biochemical parameters. Previous studies reported AMI patients who present with non-specific ECGs. OBJECTIVES: To examine clinical or demographic features of AMI patients presenting with or without ECG changes and assess the impact of these ECGs on treatment and outcome. METHODS: Using the AMIS Plus data, patients admitted between 2003 and 2008 with a definite diagnosis of AMI (clinical symptoms, elevated troponin levels) were stratified according to the admission ECG into group 1 with normal/non-specific ECGs and group 2 with ECG changes. RESULTS: Of 14 957 patients, 1085 (7.3%) belonged to group 1 and 13 872 (92.7%) to group 2. There were no differences between the two groups in age (65.9 yr vs. 65.4 yr), gender (28% female), diabetes (19% vs. 18%), hypertension (61% vs. 59%), family history (35% vs. 33%) or smoking (37% vs. 38%). Dyslipidaemia (62% vs. 56%; p <0.001), history of CAD (39% vs. 35%; p = 0.023) and obesity (BMI >30 kg/m2 [23% vs. 19%; p = 0.003]) were more frequent in group 1 who were admitted longer after symptom onset (280 min vs. 230 min). Patients in group 1 were exposed to less intensive pharmacological and interventional treatments (aspirin [93.6% vs. 95.3%; p = 0.012], clopidogrel [70% vs. 73%; p = 0.046], unfractionated heparin [59% vs. 65%; p <0.001], ACE inhibitors or angiotensin II antagonists [46% vs. 53%; p <0.001]). However, therapy with beta-blockers (72% vs. 70%), statins (75% vs. 76%) and nitrates (59% vs. 57%) did not differ between groups. Patients in group 1 underwent PCI significantly less frequently (69% vs. 77%) with a longer hospital delay (589 min vs. 96 min). No differences were found for reinfarction (both 1.4%) and a cerebrovascular event (0.4% vs. 0.8%). Cardiogenic shock (5% vs. 2%; p <0.001) and mortality during hospitalisation were higher in group 2 (6% vs. 3%; p <0.001). A normal/non-specific ECG on admission was not an independent predictor of in-hospital mortality (OR 0.61; 95% CI 0.34-1.11; p = 0.104). CONCLUSIONS: Despite less intensive treatment, AMI patients who presented with a normal/non-specific ECG developed cardiogenic shock less frequently during their hospitalisation and had a lower crude mortality rate compared to those with ECG changes on admission. Nevertheless, reinfarctions and cerebrovascular events occurred evenly in all AMI patients, regardless of their admission ECG.

Seasonality in suicide--a review and search of new concepts for explaining the heterogeneous phenomena.

Seasonality is one of the oldest and most resistant-to-elucidation issues in suicide research. However, in recent years epidemiological research has yielded new results, which provide new perspectives on the matter. This qualitative review summarizes research published since the 1990 s. In particular, the focus is on studies dealing with the historical change of seasonality, cross-sectional comparisons including method-specific diversity, and the association with weather variables and other putative covariates. Recent research has shown that in Western countries the seasonality of suicide is tending to diminish and may, eventually, disappear. It can no longer be considered a universal and homogeneous phenomenon. In addition, different major seasonal cycles have now been determined which mainly depend on different suicide methods. Just as in the epidemiology of suicide methods, the (seasonal) availability and perceived adequacy of methods emerge as the major driving force beyond the seasonal phenomena in suicide.

Outcome of patients with acute coronary syndrome in hospitals of different sizes. A report from the AMIS Plus Registry.

OBJECTIVE: To assess the impact of admission to different hospital types on early and 1-year outcomes in patients with acute coronary syndrome (ACS). METHODS: Between 1997 and 2009, 31 010 ACS patients from 76 Swiss hospitals were enrolled in the AMIS Plus registry. Large tertiary institutions with continuous (24 hour/7 day) cardiac catheterisation facilities were classified as type A hospitals, and all others as type B. For 1-year outcomes, a subgroup of patients admitted after 2005 were studied. RESULTS: Eleven type A hospitals admitted 15987 (52%) patients and 65 type B hospitals 15023 (48%) patients. Patients admitted into B hospitals were older, more frequently female, diabetic, hypertensive, had more severe comorbidities and more frequent non-ST segment elevation (NSTE)-ACS/unstable angina (UA). STE-ACS patients admitted into B hospitals received more thrombolysis, but less percutaneous coronary intervention (PCI). Crude in-hospital mortality and major adverse cardiac events (MACE) were higher in patients from B hospitals. Crude 1-year mortality of 3747 ACS patients followed up was higher in patients admitted into B hospitals, but no differences were found for MACE. After adjustment for age, risk factors, type of ACS and comorbidities, hospital type was not an independent predictor of in-hospital mortality, in-hospital MACE, 1-year MACE or mortality. Admission indicated a crude outcome in favour of hospitalisation during duty-hours while 1-year outcome could not document a significant effect. CONCLUSION: ACS patients admitted to smaller regional Swiss hospitals were older, had more severe comorbidities, more NSTE-ACS and received less intensive treatment compared with the patients initially admitted to large tertiary institutions. However, hospital type was not an independent predictor of early and mid-term outcomes in these patients. Furthermore, our data suggest that Swiss hospitals have been functioning as an efficient network for the past 12 years.