The quality of primary care in a country with universal health care coverage.

BACKGROUND: Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage. OBJECTIVE: To assess the quality of preventive care and care for cardiovascular risk factors in a country with universal health care coverage. DESIGN AND PARTICIPANTS: Retrospective cohort of a random sample of 1,002 patients aged 50-80 years followed for 2 years from all Swiss university primary care settings. MAIN MEASURES: We used indicators derived from RAND's Quality Assessment Tools. Each indicator was scored by dividing the number of episodes when recommended care was delivered by the number of times patients were eligible for indicators. Aggregate scores were calculated by taking into account the number of eligible patients for each indicator. KEY RESULTS: Overall, patients (44% women) received 69% of recommended preventive care, but rates differed by indicators. Indicators assessing annual blood pressure and weight measurements (both 95%) were more likely to be met than indicators assessing smoking cessation counseling (72%), breast (40%) and colon cancer screening (35%; all p < 0.001 for comparisons with blood pressure and weight measurements). Eighty-three percent of patients received the recommended care for cardiovascular risk factors, including >75% for hypertension, dyslipidemia and diabetes. However, foot examination was performed only in 50% of patients with diabetes. Prevention indicators were more likely to be met in men (72.2% vs 65.3% in women, p < 0.001) and patients <65 years (70.1% vs 68.0% in those ≥ 65 years, p = 0.047). CONCLUSIONS: Using standardized tools, these adults received 69% of recommended preventive care and 83% of care for cardiovascular risk factors in Switzerland, a country with universal coverage. Prevention indicator rates were lower for women and the elderly, and for cancer screening. Our study helps pave the way for targeted quality improvement initiatives and broader assessment of health care in Continental Europe.

[Integration of nutritional care into cancer treatment: need for improvement]. / Soin nutritionnel intégré au soin oncologique: un besoin d'optimisation.

Progresses in cancer treatment transformed cancer into a chronic disease associated with growing nutritional problems. Poor nutritional status of cancer patients worsens morbidity, mortality, overall cost of care and decreases patients' quality of life, oncologic treatments tolerance and efficacy. These adverse effects lead to treatment modifications or interruptions, reducing the chances to control or cure cancer. Implementation of an interdisciplinary and longitudinal integration of nutritional care and nutritional information into cancer treatment (The OncoNut Program) could prevent or treat poor nutritional status and its adversely side effects.

Accuracy of cardiac auscultation in the era of Doppler-echocardiography: a comparison between cardiologists and internists.

To investigate the present accuracy of cardiac auscultation, we asked a group of senior cardiologists and internists to auscultate respectively 72 and 70 selected patients and to give a diagnosis of the type of lesions heard and their degree of severity, using transthoracic Doppler-echocardiography as the standard reference. The percentage of correctly identified auscultations by cardiologists and by internists, particularly for common valvular lesions, such as aortic stenosis and mitral regurgitation, was respectively 76.1 vs 64.9% (P=0.0787) for all types of lesions taken together, 57.1 vs 48%.0 (P=0.5057) for mild, 82.4 vs 76.0% (P= 0.3335) for moderate-severe and 81.8 vs 27.3% (P=0.0300) for lesions without degree of severity, which included cases of atrial septal defect (ASD) and of hypertrophic cardiomyopathiy (HCM). Our findings show that in the Doppler-echocardiographic era overall cardiac auscultatory proficiency for common valvular lesions is similar in cardiologists and internists. Cardiologists perform better than internists only when auscultating more rare cadiac lesions, such as cases of ASD or HCM.

Obstructive sleep apnoea/hypopnea influences high-density lipoprotein cholesterol in the elderly.

BACKGROUND AND PURPOSE: An association between obstructive sleep apnoea/hypopnea (OSAH) and cardiovascular risk factors such as dyslipidemia has been described in adults and high-risk populations. PATIENTS AND METHODS: We examined this association in a prospective cohort (SYNAPSE study) of 846 elderly (68.5+/-1.1 years) volunteers (41.6% of men). No subject presented with recognized OSAH syndrome, heart disease, or any neurological disorder. Unattended at-home polygraphy was done by all subjects. OSAH severity was defined as moderate (apnoea/hypopnea index: AHI>15/h) or severe (AHI>30/h). High-density lipoprotein cholesterol (HDL-c) was measured by immuno-separation-based homogenous assay. RESULTS: The prevalence of severe cases reached 21.5% (AHI mean+/-SD: 43.5+/-11.9). Using univariate linear regression analysis, AHI (R=-0.172; p<0.0001), oxyhemoglobin desaturation index (ODI) (R=-0.108; p<0.002), mean SaO(2) (R=0.125; p<0.0003) and Nadir SaO(2) (R=0.094; p<0.007) were significantly associated with HDL-c. Multiple regression analysis demonstrated that male gender, BMI, waist to hip ratio, ODI, and AHI represent independent predictors of HDL-c. Logistic regression analysis showed a significant association between severe OSAH and low HDL-c serum levels (p<0.03) after adjustment for gender, BMI, hypertension, glycaemia, waist to hip ratio, alcohol intake and treated dyslipidemia. The association appears more evident in subjects free of lipid-lowering medications and beta-blockers (p<0.007). There was no independent association of OSAH syndrome with low-density lipoprotein (LDL) cholesterol. CONCLUSION: Unrecognized moderate to severe apnoea/hypopnea syndrome was independently associated with low HDL-c serum levels in the present cross-sectional based elderly population. This could explain the deleterious effect of OSAH syndrome on cardiovascular risk.

Eight-year longitudinal changes in body composition in healthy Swiss adults.

OBJECTIVE: Significant changes in body composition occur during lifetime. This longitudinal study (8.0 +/- 0.8 yrs) in a cohort of healthy sedentary and physically active men (n = 78) and women (n = 53), aged 20 to 74 yr describes: 1) the longitudinal changes in weight and body composition and 2) their associations with age and physical activity. METHOD: Fat-free mass (FFM) and body fat (BF) were assessed by bioelectrical impedance analysis (BIA). Subjects who regularly performed >3 hours per week of endurance type physical activity were classified as "Active". Others were classified as "Sedentary". Subjects were also separated by age (<45 yr vs > or =45 yr). RESULTS: FFM increased by 1.7 +/- 2.8 kg in men <45 yr who gained 4.0 +/- 5.0 kg of body weight and was maintained (0.5 +/- 1.6 kg) in women <45 y who gained 1.6 +/- 3.0 kg of weight. A weight gain of 1.2 +/- 3.3 kg in men > or =45 yr was accompanied by stable FFM (-0.1 +/- 2.3 kg), and of 1.0 +/- 3.2 kg was accompanied by a loss of FFM in women > or =45 yr. In active men > or =45 yr, maintenance of FFM was associated with smaller weight gains than in sedentary; sedentary men > or =45 yr decreased FFM with larger weight gains than active subjects. Sedentary women <45 yr were able to gain FFM; the active women maintained, but did not gain FFM with smaller weight gains than in sedentary women. FFM decreased in >/=45 yr women despite of small weight gains. CONCLUSION: Weight change is clearly associated with a change in FFM. Weight gain is necessary to offset age-related FFM loss between 20 and 74 yrs. In active men, a FFM increase was associated with less weight gain than sedentary men. Future studies should evaluate the threshold of weight change and the level of physical activity necessary to prevent age-related losses of FFM.