Management of injuries in Swiss primary care practices: a cross-sectional study within the Sentinella surveillance system.

INTRODUCTION: Injuries are amongst the most frequent causes of morbidity and mortality worldwide. Our aim was to describe the frequency, type of injury and care provided in primary care in Switzerland. METHODS: We used anonymous data from 14,307 injury-related consultations of all ages, with a representative sample of 160 primary care physicians from the Sentinella network throughout the year 2017. Descriptive information about patients presenting with one or multiple injuries and the type of care provided were collected in a weekly questionnaire. Data about the primary care physicians including their experience, postgraduate training, equipment and skills were obtained using a single anonymous questionnaire. Negative binomial regression models with mixed effects were used to examine the association between primary care physicians' characteristics, the proportion represented by injured patients in their total activity and independent management in primary care (without referral). With these models, the associations are expressed as a ratio of prevalence (PR). RESULTS: The median proportion (prevalence) of injury-related consultations was 2.0% (range 0.0-19.8%), with a significant difference between paediatricians and general practitioners (median 1.2% vs 2.1%). Nearly 60% of consultations for injuries involved men, 21.0% were for patients <18 years and 15.3% for those above 65. Sprains and dislocations (31.2%) were the most frequent diagnoses followed by cutaneous injuries (23.0%), contusions (20.1%) and fractures (18.8%). Of the injuries presenting directly to primary care, 87.0% were managed by the primary care physician without referral to external services. Fractures were the main diagnosis motivating referral, yet 67.9% of them were entirely managed within primary care. Multivariable analyses showed that training as a paediatrician and a longer experience in primary care were associated with having a lower prevalence of injury-related consultations (adjusted PR [adjPR] 0.49, 95% confidence interval [CI] 0.31-0.78 and adjPR 0.41, 95% CI 0.23-0.75, respectively), whereas the ability to offer wound care including sutures and both splints and casts were associated with a much higher prevalence of injury-related consultations (adjPR 9.36, 95% CI 3.42-25.61 and adjPR 2.38, 95% CI 1.43-3.97, respectively). CONCLUSION: The proportion represented by injured patients in a primary care physician's total activity is heterogeneous. Most patients with mild to moderate injuries could be managed in primary care without referral to secondary care. Further studies could explore factors associated with patients' decision to consult their primary care physician or emergency services for injuries. Exploring outcomes of primary care and patients' satisfaction is another future research priority.

A cross-sectional study of Swiss ambulatory care services use by multimorbid patients in primary care in the light of the Andersen model.

BACKGROUND: Multimorbidity is frequently encountered in primary care and is associated with increasing use of healthcare services. The Andersen Behavioral Model of Health Services Use is a multilevel framework classifying societal, contextual, and individual characteristics about the use of healthcare services into three categories: 1. predisposing factors, 2. enabling factors, and 3. need factors. The present study aimed to explore multimorbid patients' use of ambulatory healthcare in terms of homecare and other allied health services, visits to GPs, and number of specialists involved. A secondary aim was to apply Andersen's model to explore factors associated with this use. METHOD: In a cross-sectional study, 100 Swiss GPs enrolled up to 10 multimorbid patients each. After descriptive analyses, we tested the associations of each determinant and outcome variable of healthcare use, according to the Andersen model: predisposing factors (patient's demographics), enabling factors (health literacy (HLS-EU-Q6), deprivation (DipCare)), and need factors (patient's quality of life (EQ-5D-3L), treatment burden (TBQ), severity index (CIRS), number of chronic conditions, and of medications). Logistic regressions (dichotomous variables) and negative binomial regressions (count variables) were calculated to identify predictors of multimorbid patients' healthcare use. RESULTS: Analyses included 843 multimorbid patients; mean age 73.0 (SD 12.0), 28-98 years old; 48.3% men; 15.1% (127/843) used homecare. Social deprivation (OR 0.75, 95%CI 0.62-0.89) and absence of an informal caregiver (OR 0.50, 95%CI 0.28-0.88) were related to less homecare services use. The use of other allied health services (34.9% (294/843)) was associated with experiencing pain (OR 2.49, 95%CI 1.59-3.90). The number of contacts with a GP (median 11 (IQR 7-16)) was, among other factors, related to the absence of an informal caregiver (IRR 0.90, 95%CI 0.83-0.98). The number of specialists involved (mean 1.9 (SD 1.4)) was linked to the treatment burden (IRR 1.06, 95%CI 1.02-1.10). CONCLUSION: Multimorbid patients in primary care reported high use of ambulatory healthcare services variably associated with the Andersen model's factors: healthcare use was associated with objective medical needs but also with contextual or individual predisposing or enabling factors. These findings emphasize the importance of adapting care coordination to individual patient profiles.

Primary care patients' use of conventional and complementary medicine for chronic low back pain.

PURPOSE: To investigate among primary care patients and their physicians in western Switzerland the prevalence of use, perceived usefulness, and communication about common treatments for chronic or recurrent low back pain (crLBP) including complementary medicine (CM). PATIENTS AND METHODS: A cross-sectional cluster observational study involving 499 crLBP patients visiting 45 primary care physicians (PCPs) was conducted from November 1, 2015, to May 31, 2016. Patients and primary care physicians completed questionnaires about lifetime use and usefulness of 30 crLBP therapies. We conducted multivariate analyses of factors associated with therapy use, including sociodemographic variables, pain duration, insurance coverage, and primary care physicians' characteristics. RESULTS: The five most frequent modalities used at least once by patients were physiotherapy (81.8%), osteopathic treatment (63.4%), exercise therapy (53.4%), opioids (52.5%), and therapeutic massage (50.8%). For their PCPs, the five most useful therapies were physiotherapy, osteopathic treatment, yoga, meditation, and manual therapy. In multivariate analysis, the use of physiotherapy was significantly associated with longer pain duration; osteopathic treatment was associated with age under 75 years, female gender, higher education, and CM insurance coverage. Exercise therapy was associated with non-smoking and longer pain duration. Smokers were more likely and patients of PCPs with CM training were less likely to have used opioids. During their lifetime, 86.6% of the participants had used at least one CM therapy to manage their crLBP, with a mean of 3.3 (SD=2.9) therapies used per participant; 46.1% of participants reported that their PCP did not enquire about CM use. Among CM users, 64.7% informed their PCP about it. CONCLUSION: Patients with crLBP use a variety of treatments, including self-prescribed and unreimbursed therapies, most frequently physiotherapy and osteopathy. The results suggest that PCPs should systematically discuss with their patients the treatments they tried to manage crLBP, including CM.

Factors associated with patients' and GPs' assessment of the burden of treatment in multimorbid patients: a cross-sectional study in primary care.

BACKGROUND: Multimorbid patients may experience a high burden of treatment. This has a negative impact on treatment adherence, health outcomes and health care costs. The objective of our study was to identify factors associated with the self-perceived burden of treatment of multimorbid patients in primary care and to compare them with factors associated with GPs assessment of this burden. METHOD: A cross sectional study in general practices, 100 GPs in Switzerland and up to 10 multimorbid patients per GP. Patients reported their self-perceived burden of treatment using the Treatment Burden Questionnaire (TBQ, possible score 0-150), whereas GPs evaluated the burden of treatment on a Visual Analog Scale (VAS) from 1 to 9. The study explored medical, social and psychological factors associated with burden of treatment, such as number and type of chronic conditions and drugs, severity of chronic conditions (CIRS score), age, quality of life, deprivation, health literacy. RESULTS: The GPs included 888 multimorbid patients. The overall median TBQ was 20 and the median VAS was 4. Both patients' and GPs' assessment of the burden of treatment were inversely associated with patients' age and quality of life. In addition, patients' assessment of their burden of treatment was associated with a higher deprivation score and lower health literacy, and with having diabetes or atrial fibrillation, whereas GPs' assessment of this burden was associated with the patient having a greater number of chronic conditions and drugs, and a higher CIRS score. CONCLUSION: Both from patients' and GPs' perspectives TB appears to be higher in younger patients. Whereas for patients the burden of treatment is associated with socio-economic and psychological factors, GPs' assessments of this burden are associated with medical factors. Including socio-economic and psychological factors on patients' self-perception is likely to improve GPs' assessments of their patients' burden of treatment thus favoring patient-centered care.

Family practitioners' top medical priorities when managing patients with multimorbidity: a cross-sectional study.

BACKGROUND: Managing multiple chronic and acute conditions in patients with multimorbidity requires setting medical priorities. How family practitioners (FPs) rank medical priorities between highly, moderately, or rarely prevalent chronic conditions (CCs) has never been described. The authors hypothesised that there was no relationship between the prevalence of CCs and their medical priority ranking in individual patients with multimorbidity. AIM: To describe FPs' medical priority ranking of conditions relative to their prevalence in patients with multimorbidity. DESIGN & SETTING: This cross-sectional study of 100 FPs in Switzerland included patients with ≥3 CCs on a predefined list of 75 items from the International Classification of Primary Care 2 (ICPC-2); other conditions could be added. FPs ranked all conditions by their medical priority. METHOD: Priority ranking and distribution were calculated for each condition separately and for the top three priorities together. RESULTS: The sample contained 888 patients aged 28-98 years (mean 73), of which 48.2% were male. Included patients had 3-19 conditions (median 7; interquantile range [IQR] 6-9). FPs used 74/75 CCs from the predefined list, of which 27 were highly prevalent (>5%). In total, 336 different conditions were recorded. Highly prevalent CCs were only the top medical priority in 66%, and the first three priorities in 33%, of cases. No correlation was found between prevalence and the ranking of medical priorities. CONCLUSION: FPs faced a great diversity of different conditions in their patients with multimorbidity, with nearly every condition being found at nearly every rank of medical priority, depending on the patient. Medical priority ranking was independent of the prevalence of CCs.

Sex/gender bias in the management of chest pain in ambulatory care.

OBJECTIVE: Cardiovascular diseases (CVD) are the main cause of death worldwide and despite a higher prevalence in men, mortality from CVD is higher among women. Few studies have assessed sex differences in chest pain management in ambulatory care. The objective of this post hoc analysis of data from a prospective cohort study was to assess sex differences in the management of chest pain in ambulatory care. SETTING: We used data from the Thoracic Pain in Community cohort study that was realized in 58 primary care practices and one university ambulatory clinic in Switzerland. PARTICIPANTS: In total, 672 consecutive patients aged over 16 years attending a primary care practice or ambulatory care clinic with a complaint of chest pain were included between February and June 2001. Their mean age was 55.2 years and 52.5% were women. MAIN OUTCOME MEASURES: The main outcome was the proportion of patients referred to a cardiologist at 12 months follow-up. A panel of primary care physicians assessed the final diagnosis retained for chest pain at 12 months. RESULTS: The prevalence of chest pain of cardiovascular origin (n = 108, 16.1%) was similar for men and women (17.5% vs 14.8%, respectively, p = 0.4). Men with chest pain were 2.5 times more likely to be referred to a cardiologist than women (16.6% vs 7.4%, odds ratio: 2.49, 95% confidence interval: 1.52-4.09). After adjustment for the patients' age and cardiovascular disease risk factors, the estimates did not significantly change (odds ratio: 2.30, 95% confidence interval: 1.30-3.78). CONCLUSION: Although the same proportion of women and men present with a chest pain of cardiovascular origin in ambulatory care, there is a strong sex bias in their management. These data suggest that effort must be made to assure equity between men and women in medical care.

Primary care physicians' attitude and reported prescribing behavior for chronic low back pain: An exploratory cross-sectional study.

OBJECTIVE: Recent guidelines for chronic or recurrent low back pain recommend non-pharmacologic treatments as first-line options. The objective of this study was thus to explore the perceived usefulness of several conventional and complementary medicine treatments for chronic or recurrent low back pain by primary care physicians and their reported prescribing behavior. DESIGN: An exploratory cross-sectional study. SETTING AND PARTICIPANTS: Primary care physicians of the French-speaking part of Switzerland. MAIN OUTCOME MEASURES: Primary care physicians' perceived usefulness of each conventional and complementary medicine treatment and their reported recommendation behavior were considered dependent variables in multivariate logistic regression models. All correlations were computed between binary variables, and phi coefficients were calculated to estimate correlation strengths. RESULTS: 533 primary care physicians answered the questionnaire (response rate: 25.6%). The top 3 conventional treatments most often considered useful by primary care physicians for chronic or recurrent low back pain were physiotherapy (94.8%), nonsteroidal anti-inflammatory drugs (87.9%), and manual therapy (82.5%), whereas the most prescribed conventional treatments were physiotherapy (99.2%), nonsteroidal anti-inflammatory drugs (97.4%), and acetaminophen (94.4%). Osteopathic treatment (78.4%), yoga (69.3%), and therapeutic massage (63.9%) were the complementary medicine treatments most often considered useful by primary care physicians in managing chronic or recurrent low back pain. Being a female physician, younger than 56 years, trained in complementary medicine, or using complementary medicine were all associated with higher perceived usefulness of complementary medicine treatments in general. The most recommended complementary medicine treatments by primary care physicians were osteopathic treatment (87.3%), acupuncture (69.3%), and therapeutic massage (58.7%). Being a female physician, younger than 56, and using complementary medicine were all associated with more complementary medicine recommendation in general. CONCLUSION: Our results highlight the importance of better understanding the prescribing patterns of primary care physicians for chronic or recurrent low back pain. Considering the frequency and burden of chronic or recurrent low back pain, programs focusing on the most (cost-) effective treatments should be implemented.

Multimorbidity: can general practitioners identify the health conditions most important to their patients? Results from a national cross-sectional study in Switzerland.

BACKGROUND: Faced with patients suffering from more than one chronic condition, or multimorbidity, general practitioners (GPs) must establish diagnostic and treatment priorities. Patients also set their own priorities to handle the everyday burdens associated with their multimorbidity and these may be different from the priorities established by their GP. A shared patient-GP agenda, driven by knowledge of each other's priorities, would seem central to managing patients with multimorbidity. We evaluated GPs' ability to identify the health condition most important to their patients. METHODS: Data on 888 patients were collected as part of a cross-sectional Swiss study on multimorbidity in family medicine. For the main analyses on patients-GP agreement, data from 572 of these patients could be included. GPs were asked to identify the two conditions which their patient considered most important, and we tested whether either of them agreed with the condition mentioned as most important by the patient. In the main analysis, we studied the agreement rate between GPs and patients by grouping items medically-related into 46 groups of conditions. Socio-demographic and clinical variables were fitted into univariate and multivariate models. RESULTS: In 54.9% of cases, GPs were able to identify the health condition most important to the patient. In the multivariate model, the only variable significantly associated with patient-GP agreement was the number of chronic conditions: the higher the number of conditions, the less likely the agreement. CONCLUSION: GPs were able to correctly identify the health condition most important to their patients in half of the cases. It therefore seems important that GPs learn how to better adapt treatment targets and priorities by taking patients' perspectives into account.

Chronic conditions and multimorbidity in a primary care population: a study in the Swiss Sentinel Surveillance Network (Sentinella).

OBJECTIVES: To provide estimates of the prevalence of chronic conditions in Swiss primary care. METHODS: In total, 175 general practitioners (GP) or pediatricians (PED) reporting to the Swiss Sentinel Surveillance Network collected morbidity data. RESULTS: In 26,853 patient contacts, mean (± SD) age was 55.8 ± 21.6 or 6.1 ± 5.7 years (in GPs vs. PEDs, respectively) and 47% were males. In GP patients, median Thurgau Morbidity Index was 2 (IQR 1-3). The median numbers of chronic conditions and permanently used prescribed drugs were 2 (0-5) and 2 (1-4), respectively; in PEDs medians were 0. Out of all patients, 16.7 and 7.0% of the PED patients were hospitalized during the previous year; patients cared by family/proxies or community nurses were hospitalized significantly more often than patients living in homes (50.1 vs. 35.4%, OR 1.41, p < 0.001). Out of patients over 80 years of age, 51.5% were care dependent and 45.5% of the patients over 90 years were living in homes for the elderly. CONCLUSIONS: In a representative sample of Swiss primary care patients, a substantial part shows multimorbidity with a high prevalence of chronic diseases, multiple drug treatment, and care dependency. These data may serve to be compared with other patient groups or other primary care systems. Trial registration www.clinicaltrials.gov NCT0229537, national study registry www.kofam.ch SNCTP000001207.

Prevalence of multimorbidity in general practice: a cross-sectional study within the Swiss Sentinel Surveillance System (Sentinella).

OBJECTIVES: To estimate the prevalence of multimorbidity using a list of 75 chronic conditions derived from the International Classification for Primary Care, Second edition and developed specifically to assess multimorbidity in primary care. Our aim was also to provide prevalence data for multimorbidity in primary care in a country in which general practitioners (GPs) do not play a gatekeeping role in the health system. SETTING: A representative sample of GPs within the Swiss Sentinel Surveillance Network. PARTICIPANTS: 118 GPs completed a paper-based questionnaire about 25 consecutive patients of all ages between September and November 2015. There were no patient exclusion criteria. Recorded data included date of birth, gender and the patients' chronic conditions. PRIMARY AND SECONDARY OUTCOME MEASURES: We estimated the prevalence of multimorbidity, defined as ≥2, and ≥3 chronic conditions stratified by gender and age group, and adjusted for clustering by GPs. We also computed the prevalence of each chronic condition individually and grouped by system. RESULTS: Data from 2904 patients were included (mean age (SD)=56.5 (20.5) years; male=43.7%). Prevalence was 52.1% (95% CI 48.6% to 55.5%) for ≥2 and 35.0% (95% CI 31.6% to 38.5%) for ≥3 chronic conditions, with no significant gender differences. Prevalence of two or more chronic conditions was low (6.2%, 95% CI 2.8% to 13.0%) in those below 20 but affected more than 85% (85.8%, 95% CI 79.6% to 90.3%) of those above the age of 80. The most prevalent conditions were cardiovascular (42.7%, 95% CI 39.7% to 45.7%), psychological (28.5%, 95% CI 26.1% to 31.1%) and metabolic or endocrine disorders (24.1%, 95% CI 21.6% to 26.7%). Elevated blood pressure was the most prevalent cardiovascular condition and depression the most common psychological disorder. CONCLUSION: In a country in which GPs do not play a gatekeeping role within the health system, the prevalence of multimorbidity, as assessed using a list of chronic conditions specifically relevant to primary care, is high and increases with age.

Factors associated with health literacy in multimorbid patients in primary care: a cross-sectional study in Switzerland.

OBJECTIVE: To identify factors associated with health literacy in multimorbid patients. DESIGN: A nationwide cross-sectional study in Switzerland. Univariate and multivariate linear regressions were calculated to identify variables associated with health literacy. A multiple imputation approach was used to deal with missing values. PARTICIPANTS: Multimorbid patients recruited in primary care settings (n=888), above 18 years old and suffering from at least 3 of 75 chronic conditions on a predefined list based on the International Classification of Primary Care 2. MAIN MEASURES: Health literacy was assessed using the European Health Literacy Survey project questionnaire (HLS-EU 6). This comprises six items scored from 1 to 4 (very difficult=1, fairly difficult=2, fairly easy=3, very easy=4), and the total health literacy score is computed as their mean. As we wished to understand the determinants associated with lower health literacy, the HLS-EU 6 score was the only dependent variable; all other covariates were considered independent. RESULTS: The mean health literacy score (SD) was 2.9 (0.5). Multivariate analyses found significant associations between low health literacy scores and treatment burden scores (ß=-0.004, 95% CI -0.006 to 0.002); marital status, predominantly the divorced group (ß=0.136, 95% CI 0.012 to 0.260); dimensions of the EuroQuol 5 Dimension 3 Level (EQ5D3L) quality of life assessment, that is, for moderate problems with mobility (ß=-0.086, 95% CI -0.157 to 0.016); and with moderate problems (ß=-0.129, 95% CI -0.198 to 0.060) and severe problems with anxiety/depression (ß=-0.343, 95% CI -0.500 to 0.186). CONCLUSIONS: Multimorbid patients with a high treatment burden, altered quality of life by problems with mobility, anxiety or depression, often also have low levels of health literacy. Primary care practitioners should therefore pay particular attention to these patients in their daily practice.

Comparing the self-perceived quality of life of multimorbid patients and the general population using the EQ-5D-3L.

OBJECTIVES: To assess and compare the self-perceived Health Related Quality of Life (HRQoL) of multimorbid patients and the general population using health utilities (HU) and visual analogue scale (VAS) methods. METHODS: We analyzed data (n = 888) from a national, cross-sectional Swiss study of multimorbid patients recruited in primary care settings. Self-perceived HRQoL was assessed using the EQ-5D-3L instrument, composed of 1) a questionnaire on the five dimensions of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression (EQ-5D dimensions), and 2) a 0-100 (0 = worst- and 100 = best-imaginable health status) VAS. We described the EQ-5D dimensions and VAS and computed HU using a standard pan-European value set. HU and VAS are the two components of the overall HRQoL assessment. We examined the proportions of multimorbid patients reporting problems (moderate/severe) in each EQ-5D dimension, corresponding proportions without problems, and mean HU and VAS values across patient characteristics. To test differences between subgroups, we used chi-square tests for dichotomous outcomes and T-tests (ANOVA if more than two groups) for continuous outcomes. Finally, we compared observed and predicted HU and VAS values. RESULTS: All 888 participants answered every EQ-5D item. Mean (SD) HU and VAS values were 0.70 (0.18) and 63.2 (19.2), respectively. HU and VAS were considerably and significantly lower in multimorbid patients than in the general population and were also lower in multimorbid patients below 60 years old and in women. Differences between observed and predicted means (SD) were -0.07 (0.18) for HU and -11.8 (20.3) for VAS. CONCLUSIONS: Self-perceived HRQoL is considerably and significantly affected by multimorbidity. More attention should be given to developing interventions that improve the HRQoL of multimorbid patients, particularly women and those aged below 60 years old.

Determinants associated with deprivation in multimorbid patients in primary care-A cross-sectional study in Switzerland.

BACKGROUND: Deprivation usually encompasses material, social, and health components. It has been shown to be associated with greater risks of developing chronic health conditions and of worse outcome in multimorbidity. The DipCare questionnaire, an instrument developed and validated in Switzerland for use in primary care, identifies patients subject to potentially higher levels of deprivation. OBJECTIVES: To identifying determinants of the material, social, and health profiles associated with deprivation in a sample of multimorbid, primary care patients, and thus set priorities in screening for deprivation in this population. DESIGN: Secondary analysis from a nationwide cross-sectional study in Switzerland. PARTICIPANTS: A random sample of 886 adult patients suffering from at least three chronic health conditions. MAIN MEASURES: The outcomes of interest were the patients' levels of deprivation as measured using the DipCare questionnaire. Classification And Regression Tree analysis identified the independent variables that separated the examined population into groups with increasing deprivation scores. Finally, a sensitivity analysis (multivariate regression) confirmed the robustness of our results. KEY RESULTS: Being aged under 64 years old was associated with higher overall, material, and health deprivation; being aged over 77 years old was associated with higher social deprivation. Other variables associated with deprivation were the level of education, marital status, and the presence of depression or chronic pain. CONCLUSION: Specific profiles, such as being younger, were associated with higher levels of overall, material, and health deprivation in multimorbid patients. In contrast, patients over 77 years old reported higher levels of social deprivation. Furthermore, chronic pain and depression added to the score for health deprivation. It is important that GPs consider the possibility of deprivation in these multimorbid patients and are able to identify it, both in order to encourage treatment adherence and limit any forgoing of care for financial reasons.

Medication incidents in primary care medicine: a prospective study in the Swiss Sentinel Surveillance Network (Sentinella).

OBJECTIVES: To describe the type, frequency, seasonal and regional distribution of medication incidents in primary care in Switzerland and to elucidate possible risk factors for medication incidents. DESIGN: Prospective surveillance study. SETTING: Swiss primary healthcare, Swiss Sentinel Surveillance Network. PARTICIPANTS: Patients with drug treatment who experienced any erroneous event related to the medication process and interfering with normal treatment course, as judged by their physician. The 180 physicians in the study were general practitioners or paediatricians participating in the Swiss Federal Sentinel reporting system in 2015. OUTCOMES: Primary: medication incidents; secondary: potential risk factors like age, gender, polymedication, morbidity, care-dependency, previous hospitalisation. RESULTS: The mean rates of detected medication incidents were 2.07 per general practitioner per year (46.5 per 1 00 000 contacts) and 0.15 per paediatrician per year (2.8 per 1 00 000 contacts), respectively. The following factors were associated with medication incidents (OR, 95% CI): higher age 1.004 per year (1.001; 1.006), care by community nurse 1.458 (1.025; 2.073) and care by an institution 1.802 (1.399; 2.323), chronic conditions 1.052 (1.029; 1.075) per condition, medications 1.052 (1.030; 1.074) per medication, as well as Thurgau Morbidity Index for stage 4: 1.292 (1.004; 1.662), stage 5: 1.420 (1.078; 1.868) and stage 6: 1.680 (1.178; 2.396), respectively. Most cases were linked to an incorrect dosage for a given patient, while prescription of an erroneous medication was the second most common error. CONCLUSIONS: Medication incidents are common in adult primary care, whereas they rarely occur in paediatrics. Older and multimorbid patients are at a particularly high risk for medication incidents. Reasons for medication incidents are diverse but often seem to be linked to communication problems.

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.

Alcohol screening among young people: a prospective study from the Swiss Sentinel Surveillance System (Sentinella) of physicians' a priori opinions.

Background: Systematic screening for excessive alcohol use among young people is recommended but rarely implemented. Family practitioners tend to select patients for screening, based on their preliminary subjective opinions, which may be biased. Objective: To evaluate the ability of family practitioners to identify excessive alcohol use among young people prior to screening them. Methods: This prospective study was conducted through Sentinella, an epidemiological network involving 150 family practitioners across Switzerland. All patients aged 10-24 years old, consulting participating physicians between January 1 and December 31, 2014 were eligible. First, physicians were asked to give their a priori opinion about patients' potential alcohol use. Subsequently, they asked two screening questions: (i) 'Do you drink alcohol?' and (ii) 'How many times have you had 5 (4 for girls) or more standard drinks in one day over the past year?'. Excessive alcohol use was defined as ≥1 episode of binge drinking a month. Physicians' a priori opinions were regarded as a screening test and were compared with patients' answers. Results: 7723 patients were eligible for analysis. Their mean age (SD) was 17.3(4.0) years. The two screening questions identified 3559 (46.1%) and 509 (6.6%) patients who consumed alcohol occasionally and regularly, respectively. 406 patients (5.3%) reported excessive alcohol use. Physicians' a priori opinions had a sensitivity of 26.4% and a positive predictive value of 35.5% for the identification of excessive alcohol use. Conclusion: The systematic use of a screening tool should be preferred over family practitioners' subjective opinions to identify excessive alcohol use in young people.

Pooled individual patient data from five countries were used to derive a clinical prediction rule for coronary artery disease in primary care.

OBJECTIVE: To construct a clinical prediction rule for coronary artery disease (CAD) presenting with chest pain in primary care. STUDY DESIGN AND SETTING: Meta-Analysis using 3,099 patients from five studies. To identify candidate predictors, we used random forest trees, multiple imputation of missing values, and logistic regression within individual studies. To generate a prediction rule on the pooled data, we applied a regression model that took account of the differing standard data sets collected by the five studies. RESULTS: The most parsimonious rule included six equally weighted predictors: age ≥55 (males) or ≥65 (females) (+1); attending physician suspected a serious diagnosis (+1); history of CAD (+1); pain brought on by exertion (+1); pain feels like "pressure" (+1); pain reproducible by palpation (-1). CAD was considered absent if the prediction score is <2. The area under the ROC curve was 0.84. We applied this rule to a study setting with a CAD prevalence of 13.2% using a prediction score cutoff of <2 (i.e., -1, 0, or +1). When the score was <2, the probability of CAD was 2.1% (95% CI: 1.1-3.9%); when the score was ≥ 2, it was 43.0% (95% CI: 35.8-50.4%). CONCLUSIONS: Clinical prediction rules are a key strategy for individualizing care. Large data sets based on electronic health records from diverse sites create opportunities for improving their internal and external validity. Our patient-level meta-analysis from five primary care sites should improve external validity. Our strategy for addressing site-to-site systematic variation in missing data should improve internal validity. Using principles derived from decision theory, we also discuss the problem of setting the cutoff prediction score for taking action.

Impact of the primary care curriculum and its teaching formats on medical students' perception of primary care: a cross-sectional study.

BACKGROUND: Switzerland is facing an impending primary care workforce crisis since almost half of all primary care physicians are expected to retire in the next decade. Only a minority of medical students choose a primary care specialty, further deepening the workforce shortage. It is therefore essential to identify ways to promote the choice of a primary care career. The aim of the present study was to explore students' views about the undergraduate primary care teaching curriculum and different teaching formats, and to evaluate the possible impact of these views on students' perceptions of primary care. METHODS: We surveyed fifth year medical students from the Medical Faculties in Geneva and Lausanne, Switzerland (n = 285) with a four sections electronic questionnaire. We carried out descriptive analyses presented as frequencies for categorical data, and means and/or medians for continuous data. RESULTS: The response rate was 43 %. Overall, primary care teaching had a positive impact on students' image of primary care. In Lausanne, primary care curricular components were rated more positively than in Geneva. Curricular components that were not part of the primary care teaching, but were nevertheless cited by some students, were frequently perceived as having a negative impact. CONCLUSIONS: The primary care curriculum at Lausanne and Geneva Universities positively influences students' perceptions of this discipline. However, there are shortcomings in both the structure and the content of both the primary care and hidden curriculum that may contribute to perpetuating a negative image of this specialization.

[Multimorbidity in family medicine]. / Multimorbidité en médecine de famille.

Multimorbidity, or co-occurrence of several chronic diseases, is of increasing importance for health professionals and the organization of the health care system. It is important for patients, particularly in relation to quality of life and functional status, for family practitioners in relation to support and coordination skills and for the health system in relation to costs and organization. In this article we introduce the concepts of chronic conditions, multimorbidity and its impact (burden) on the patient and the family practitioner, the importance of a prioritization of care and of the patient's health skills (health literacy), the consequences of polypharmacy and the importance of a network of health professionals. These themes will be developed throughout this issue.