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.

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.

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.

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.

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.

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.

[Home visits by GPs - Considerations in Europe and in Switzerland]. / Visite à domicile par le médecin de famille : état des lieux en Europe et en Suisse.

Home visits are essential for promoting the ability to remain at home and prevent nursing home admissions ; general practitioners play a key role in the development of this specific ambulatory care. Although the frequency of home visits seems to be overall decreasing in recent years, they remain essential, given the expected demographic changes. This is why education on home visits should be introduced in the training of our students during early years. However, there is a gap in literature regarding the optimal number and length of home visits, as well as the kind of groups most likely to benefit from them and thus more research is needed to enlighten these aspects of home visits.

Les visites à domicile (VAD) jouent un rôle primordial dans la promotion du maintien à domicile pour une population de plus en plus âgée ; le médecin de famille est le chef d'orchestre parmi les intervenants dans cette prise en charge. Bien que la fréquence des VAD semble diminuer globalement ces dernières années, celles-ci vont rester essentielles aux soins ambulatoires étant donné les changements démographiques attendus. C'est pourquoi l'enseignement sur les VAD devrait être introduit dans la formation de nos étudiants dès les premières années d'études. D'autre part, notre connaissance sur le nombre optimal et la durée des VAD, ainsi que les groupes de patients les plus susceptibles d'en bénéficier vont demander le développement d'études ciblées à l'avenir.

[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.

[Multimorbidity in primary care from GPs' and patients' perspectives: a national database]. / La multimorbidité en médecine de famille du point de vue du médecin et du patient: une banque de données nationale.

Multimorbidity is often synonym with complexity and generally implies multiple medical treatments. In many cases, treatment guidelines traditionally defined for single conditions are not easily applicable. Primary care for individuals with multimorbidity requires complex patient-centered care and good communication between the patient and the general practitioner (GP). This often includes prioritizing among the different chronic conditions. The burden related to multimorbidity from the GP and the patients' perspective, as well as the prioritization of care between in patients with multimorbidity, has not been studied extensively yet. We report here the preliminary results of a national research aiming at characterizing these aspects in a sample of patients identified through their GP and suffering from at least 3 chronic conditions.

[Prioritization strategies in the care of multimorbid patients in family medicine]. / Stratégies de priorisation dans la prise en charge des patients multimorbides en médecine de famille.

The aging of the population together with the increasing life expectancy lead to a drastic increase in the number of patients with multi-morbidity (MM). Caring for these patients is time-consuming and the treatment of multiple conditions might be burdensome. Therefore both general practitioner (GP) and patients need to establish priorities and, among others, to decide which pathology to treat primarily or to which treatment to renounce. How they do this is currently unknown. This qualitative study based on individual interviews reports prioritization's strategies used by five GPs and five of their patients in Switzerland. Our study underlined the importance of the discussion between GPs and their patients and the use of the shared decision-making in the prioritization process.

[Interprofessionnal care and multimorbidity in family medicine]. / Multimorbidité et interprofessionnalité en médecine de famille.

The future of interprofessionnal care for multimorbid patients can be considered at 3 levels: organisation of the system, coordination of care and promotion of relationship between patients and careers and between careers (doctor, pharmacist, nurse, health and social workers). The development of innovating systems must consider and prioritize the relationship over control and management.

[Quaternary prevention: is acting always justified in family medicine?]. / Prévention quaternaire: agir est-il toujours justifié en médecine de famille?

Quaternary prevention aims to protect the patient or population against overmedicalisation. Quaternary prevention influences all the activities of family medicine by questioning the utility of primary prevention and early diagnosis, identifying the risks of creating new pathological entities and practicing a maximalist medicine. Family doctors can support quaternary prevention by focusing on their patients' priorities and the local resources of an efficient health system.

[Prevention of binge drinking in adolescents: do family doctors have a role to play?]. / Prévention des alcoolisations aiguës a l'adolescence: quel rôle pour le médecin de famille?

Binge drinking has nearly become the norm for young people and is thus worrying. Although alcohol use in males attracts more media attention, females are also frequently affected. A variety of preventive measures can be proposed: at the individual level by parents, peers and family doctors; at the school and community level, particularly to postpone age of first use and first episode of drunkenness; at the structural level through a policy restricting access to alcohol for young people and increasing its price. Family doctors can play an important role in identifying at risk users and individualising preventive messages to which these young people are exposed in other contexts.

[Interprofessional pill box management in an ambulatory care setting]. / Gérer un semainier a plusieurs chez un patient bénéficiaire de soins a domicile.

Complex multimorbid patients are now more common in ambulatory care and the management of their medication more frequently needs interprofessional collaboration. This qualitative study explored health professional's main challenges when introducing, preparing and sharing the use of a pill box for a patient. Another objective of this study was to explore options for improving care in these situations.

[Teaching practice recommendations: prevention and screening]. / Enseignement de recommandations pour la pratique: la prévention et le dépistage.

The aim of this article is to provide guidance to family doctors on how to tutor students about effective screening and primary prevention. Family doctors know their patients and adapt national and international guidelines to their specific context, risk profile, sex and age as well as to the prevalence of the disorders under consideration. Three cases are presented to illustrate guideline use according to the level of evidence (for a 19-year-old man, a 60-year-old woman, and an 80-year-old man). A particular strength of family medicine is that doctors see their patients over the years. Thus they can progressively go through the various prevention strategies, screening, counselling and immunisation, accompanying their patients with precious advice for their health throughout their lifetime.

[Patients forgoing health care for economic reasons: how to identify this in a primary care setting?]. / Renoncement aux soins: comment appréhender cette réalité en médecine de premier recours?

Although the performance of the Swiss health system is high, one out of ten patients in general practitioner's (GP) office declares having foregone care in the previous twelve months for economic reasons. Reasons for foregoing care are several and include a lack of knowledge of existing social aids in getting health insurance, unavailability of GPs and long waiting lists for various types of care. Although long term knowledge of patients or a psychosocial history of deprivation or poverty may help identify individuals at risk of foregoing care, many may remain undetected. We propose then a few instruments to help GPs to identify, in a simple and structured approach, patients at risk of forgoing care for economic reasons; these patients are frequently deprived and sometimes poor.

Ordinary defensive medicine: in the shadows of general practitioners' postures toward (over-)medicalisation.

This paper draws on qualitative research using focus groups involving 38 general practitioners (GPs). It explores their attitudes and feelings about (over-)medicalisation. Our main findings were that GPs had a complex representation of (over-)medicalisation, composed of many professional, social, technological, economic and relational issues. This representation led GPs to feel uncomfortable. They felt pressure from all sides, which led them to question their social roles and responsibilities. We identified four main GP-driven proposals to deal with (over-)medicalisation: (1) focusing on the communication in doctor-patient relationships; (2) grounding practices in evidence-based medicine; (3) relying on clinical skills, experience and intuition; and (4) promoting training, leadership bodies and social movements. Drawing on these proposals, we identify and discuss five paradigms that underpin GPs' attitudes toward (over-)medicalisation: underlying social factors, preventing medicalisation, managing uncertainties, sharing medical decision-making and thinking about care as a rationale. We suggest that these paradigms constitute a defensive posture against GPs' uncomfortable feelings. All five defensive paradigms were identified in our focus groups, echoing contemporary political debates on public health. This non-exhaustive framework forms the outline of what we call ordinary defensive medicine. GPs' uncomfortable feelings are the origin of their defensive solutions and the manifestation of their vulnerability. This professional vulnerability can be shared with the patient's vulnerability. In our view, this creates an opportunity to rediscover patient-doctor relationships and examine patients' and doctors' vulnerabilities together."There are many cases in which-though the signs of a confusion of tongues between the patient and his doctor are painfully present-there is apparently no open controversy. Some of these cases demonstrate the working of two other, often interlinked, factors. One is the patient's increasing anxiety and despair, resulting in more and more fervently clamouring demands for help. Often the doctor's response is guilt feelings and despair that his most conscientious, most carefully devised examinations do not seem to throw real light on the patient's "illness", that his most erudite, most modern, most circumspect therapy does not bring real relief." (Balint M. The Doctor, His Patient and the Illness. New York: International Universities; 2005. [1957].)"Theories about care put an unprecedented emphasis on vulnerability-taking up that challenge to transform what really counts in today's hospitals implies letting colleagues inside previously closely guarded professional boundaries" (2, our translation).

[Prescribing monitoring in clinical practice: from enlightened empiricism to rational strategies]. / Prescription du monitoring pratique médicate: de l'empirisme eclairé aux stratégies rationnelles.

Monitoring of a medical condition is the periodic measurement of one or several physiological or biological variables to detect a signal regarding its clinical progression or its response to treatment. We distinguish different medical situations between diagnostic, clinical and therapeutic process to apply monitoring. Many clinical, variables can be used for monitoring, once their intrinsic properties (normal range, critical difference, kinetics, reactivity) and external validity (pathophysiological importance, predictive power for clinical outcomes) are established. A formal conceptualization of monitoring is being developed and should support the rational development of monitoring strategies and their validation through appropriate clinical trials.

[Medication adherence in chronic patients: from its concepts to its management in primary care]. / Adhésion thérapeutique du patient chronique: des concepts a la prise en charge ambulatoire.

Medication nonadherence is common and its determinants are diverse. Adherence is influenced by many parameters, such as patient's self-efficacy, knowledge of health risk, outcome expectations, benefits of change, and barriers and facilitators. The sociocognitive theory helps professionals to structure their approach and to support patients in managing their treatment. Professionals need skills and time, and benefit from coordination in care, in particular between physicians and pharmacists. This article presents the key elements of a medication adherence program as well as tools and some useful questions.

Development of mental disorders one year after exposure to psychosocial stressors; a cohort study in primary care patients with a physical complaint.

BACKGROUND: Mental disorders, common in primary care, are often associated with physical complaints. While exposure to psychosocial stressors and development or presence of principal mental disorders (i.e. depression, anxiety and somatoform disorders defined as multisomatoforme disorders) is commonly correlated, temporal association remains unproven. The study explores the onset of such disorders after exposure to psychosocial stressors in a cohort of primary care patients with at least one physical symptom. METHOD: The cohort study SODA (SOmatization, Depression and Anxiety) was conducted by 21 private-practice GPs and three fellow physicians in a Swiss academic primary care centre. GPs included patients via randomized daily identifiers. Depression, anxiety or somatoform disorders were identified by the full Patient Health Questionnaire (PHQ), a validated procedure to identify mental disorders based on DSM-IV criteria. The PHQ was also used to investigate exposure to psychosocial stressors (before the index consultation and during follow up) and the onset of principal mental disorders after one year of follow up. RESULTS: From November 2004 to July 2005, 1020 patients were screened for inclusion. 627 were eligible and 482 completed the PHQ one year later and were included in the analysis (77%). At one year, prevalence of principal mental disorders was 30/153 (19.6% CI95% 13.6; 26.8) for those initially exposed to a major psychosocial stressor and 26/329 (7.9% CI95% 5.2; 11.4) for those not. Stronger association exists between psychosocial stressors and depression (RR = 2.4) or anxiety (RR = 3.5) than multisomatoforme disorders (RR = 1.8). Patients who are "bothered a lot" (subjective distress) by a stressor are therefore 2.5 times (CI95% 1.5; 4.0) more likely to experience a mental disorder at one year. A history of psychiatric comorbidities or psychological treatment was not a confounding factor for developing a principal mental disorder after exposure to psychosocial stressors. CONCLUSION: This primary care study shows that patients with physical complaints exposed to psychosocial stressors had a higher risk for developing mental disorders one year later. This temporal association opens the field for further research in preventive care for mental diseases in primary care patients.