The potential for health
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Journal Article↗
Biomedical subjects
F Paccaud
Publications and source records attributed to F Paccaud.
[Evolution of health systems].
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Delivery of Health Care↗
Impact of infertility treatments on the health of newborns.
OBJECTIVE: To measure the use of infertility treatments in the general population and their association with neonatal health. DESIGN: Cross-sectional, population-based study. SETTING: Canton of Vaud, Switzerland; Etude du Developpement des Nouveau-nés (EDEN), a prospective study of chronic childhood conditions. PATIENT(S): Six thousand four hundred seventy-seven live newborns (6,379 pregnancies) delivered of residents of Vaud in the 19 maternity hospitals between 1993 and 1994. MAIN OUTCOME MEASURE(S): Neonatal morbidity, multiplicity, low birth weight, prematurity, intrauterine growth retardation, transfer to intensive care, and length of hospital stay. RESULT(S): Infertility treatments were reported for 2.1% of pregnancies (129 women, 148 newborns) and were associated significantly with adverse outcomes. Population-attributable risks varied from 3%-20%. The outcomes of twins did not differ regardless of whether their mother was treated for infertility. Among singletons, only low birth weight was significantly more frequent when infertility treatments were used. Unadjusted odds ratios for neonatal morbidity were significant only for multiple births (2.56; 95% confidence interval 1.21-5.42). This association was not influenced by maternal characteristics and it disappeared after controlling for sex, gestational age, and birth weight. CONCLUSIONS(S): An independent effect of infertility treatments on neonatal morbidity cannot be ruled out, but most of their impact appeared to be mediated by multiplicity and prematurity. Reducing the number of medically induced multiple pregnancies is the most effective prevention of neonatal morbidity related to infertility treatments. Follow-up studies are needed.
Confidence Intervals↗
Time trends in the treatment of acute myocardial infarction in Switzerland from 1986 to 1993: do they reflect the advances in scientific evidence from clinical trials?
Three acute coronary care surveys (1986, 1990, and 1993) were conducted in the Swiss region of Vaud-Fribourg on all men aged 25 to 64 years hospitalized for a definite myocardial infarction (218, 224, and 167 cases). Nearly all patients received anticoagulants and nitrates. The proportion of patients treated increased significantly, between 1986 and 1990, for antiplatelet drugs (from 51% to 96%) and thrombolytics (from 9% to 44%) and, between 1990 and 1993, for beta-blockers (from 57% to 78%) and angiotensin-converting enzyme inhibitors (from 26% to 43%). The use of calcium antagonists and antiarrhythmics dropped over time. Coronary arteriography and angioplasty were increasingly performed (53% and 18% in 1993), although progressively postponed in-hospital stay. The observed trends reflect a rapid translation of clinical trials into medical practice. However the use of thrombolytics could be raised further by shortening the hospitalization delay (median: 3 hours in 1993) and door-to-needle time (median: 47 minutes) which remained stable over time.
Adrenergic beta-Antagonists↗
Fitting the distributions of length of stay by parametric models.
OBJECTIVES: The purpose of this study was to assess the adequacy of three widely used models--Lognormal, Weibull, and Gamma--for describing the distribution of length of stay. This is a fundamental step in the development of outliers resistant (robust) methods for the statistical analysis of this kind of data, where the main objective is to determine measures of average and total resource consumption of groups of patients. Current practice uses several types of trimming rules, many of which are based on the Lognormal model, although theoretical and experimental bases are still insufficient. METHODS: The three models were adjusted using robust procedures based on M-estimators to approximately 5 million stays grouped by Diagnosis-Related Groups (DRGs). The resulting 3,279 samples were collected in five European countries during 3 years. RESULTS: Most of the distributions observed could be fitted with one of these models. The descriptions provided by the Gamma and the Weibull models were similar, and the Gamma model could be omitted. The casemix description provided by the Log-normal-Weibull family was, for certain countries, significantly better than the one provided by the single Lognormal model. Often, for a given DRG and a given country, length of stay distributions could be described with the same model during several years. A given DRG, however, usually had to be described by means of different models for different countries. CONCLUSIONS: Practical and conceptual consequences of the results are discussed. They can be extended to the analyses of other consumption variables used in health services. Statistical procedures for casemix description, including current rules of trimming, should be improved by means of more flexible families of models.
Belgium↗
Blood thiamin status and determinants in the population of Seychelles (Indian Ocean).
STUDY OBJECTIVE: Micronutrient deficiencies have become rare in industrialised countries as availability of fresh food, supplementation, and fortification have improved but a less favourable situation may still prevail in many developing countries. Blood thiamin status and determinants were therefore investigated in the Seychelles in view of the high incidence of dilated cardiomyopathy and as the staple diet is polished rice that is deficient in thiamin. DESIGN: This was a cross sectional population study using an age and sex stratified random sample. SETTING: Seychelles Islands (Indian Ocean). PARTICIPANTS: A subsample of 206 subjects aged 25-64 years from the population of Seychelles. MAIN OUTCOME MEASURES: Measurement of total thiamin concentration in whole blood using high performance liquid chromatography. Dietary variables measured using a face to face semi-quantitative food questionnaire. RESULTS: Mean (SD) whole blood thiamin concentration was 77.9 (22.4) nmol/l and low concentration (< 70 nmol/l) was found in 37% of the subjects (95% CI: 31%, 44%). Blood thiamin was significantly related to education and diet but not to age, sex, smoking, and body mass index. Blood thiamin was associated positively with meat, vegetable, salad, and tea intake and negatively with alcohol and fish intake. However, no combination of the examined variables could explain more than 15% of the observed variance in blood thiamin values. CONCLUSIONS: These data suggest that the distribution of blood thiamin in the sampled population is shifted to lower values compared with that generally accepted as normal in European populations. Further research should establish the significance of such lower values in this specific population to facilitate clinical and public health action as necessary.
Adult↗
Age at death and rectangularisation of the survival curve: trends in Switzerland, 1969-1994.
OBJECTIVE: To check if signs of rectangularisation of the survival curve appeared during recent decades in Switzerland--that is, if life expectancy is approaching a maximum with a clustering of age at death around an average value (the so called "compression of mortality"). METHODS: Descriptive analysis of age of death and its trends over 26 years, as characterised by the modal value, median, and various percentiles beyond the median. POPULATION: All deaths occurring after the 50th birthday in Switzerland between 1969 and 1994 (n = 1,390,362). MAIN RESULTS: Age at death is increasing at a sustained rate at all percentiles equal or greater than 50, without any slow down in the trend during this period. The increase is more marked among women. Rates of increase are diminishing as the percentiles of age at death are higher, suggesting some clustering of deaths beyond the median value. However, the maximum age at death, if any, seems to be far from the current median values, even for women who enjoy a relatively high median age at death.
Age Factors↗
Knowledge, attitudes, and practices on hypertension in a country in epidemiological transition.
Assessment of knowledge, attitudes, and practices (KAP) is a crucial element of hypertension control, but little information is available from developing countries where hypertension has lately been recognized as a major health problem. Therefore, we examined KAP on hypertension in a random sample of 1067 adults aged 25 to 64 years from the Seychelles Islands (Indian Ocean). KAP were assessed from an administered structured questionnaire. The age-standardized prevalence of hypertension (screening blood pressure [BP] > or = 160/95 mm Hg or taking antihypertensive medication) was 36% in men and 25% in women aged 25 to 64 years. Among hypertensive persons, 50% were aware of the condition, 34% were treated, and 10% had controlled BP (ie, BP <160/95 mm Hg). Most persons, whether nonhypertensive, unaware hypertensive, or aware hypertensive, had good basic knowledge related to hypertension determinants and consequences, possibly an effect of a nationwide cardiovascular disease prevention program over the last years. However, favorable outcome expectation, positive attitudes, and appropriate practices for hypertension and relevant healthy lifestyles were found in smaller proportions of participants, with little difference between aware hypertensives, unaware hypertensives, and nonhypertensives. Furthermore, hypertensive persons with other concurrent cardiovascular risk factors affecting the overall heart risk knew well the detrimental effects of these other factors but reported making little actual change to control them (particularly regarding overweight and sedentary habits). These data point to the need to maximize the efficiency of hypertension prevention and control programs so that delay in achieving effective hypertension control is minimized in countries experiencing recent emergence of hypertension as a major public health problem.
Adult↗
Appropriateness of indications for surgery of lumbar disc hernia and spinal stenosis.
STUDY DESIGN: This prospective study examines the appropriateness of indications for surgery of herniated intervertebral disc and spinal stenosis in patients undergoing surgery in a university hospital setting. OBJECTIVE: To evaluate the appropriateness of surgery using explicit criteria developed by an expert panel in the United States. SUMMARY OF BACKGROUND DATA: The use of surgery for herniated intervertebral disc and spinal stenosis varies widely within and among countries. It has been postulated that the main reason for treatment failure is poor selection of candidates for the procedure. METHODS: The authors prospectively evaluated appropriateness of surgical indications for herniated lumbar intervertebral disc or spinal stenosis in 328 consecutive patients undergoing the operation in two university neurosurgery departments. Outcome was measured 1 year after surgery by a standardized interview. RESULTS: Indications for surgery were considered to be appropriate or equivocal in 202 (62%) patients and inappropriate in 126 (38%). Among the 126 inappropriate procedures, 66 were so rated because of insufficient activity restriction before the procedure. One year after surgery, 74% of the patients perceived the results of the operation as good or very good. CONCLUSIONS: Appropriateness as measured by the criteria established by the American panel identified a large percentage of day-to-day practice in the two surgical units as inappropriate. However, use of criteria that include new findings about lack of efficacy of bed rest probably would lower this percentage. Criteria of appropriateness of medical and surgical procedures, developed through the panel process, need to be updated regularly.
Adolescent↗
Enrollment of a population-based cohort of newborns at higher risk of developing a chronic condition: the EDEN study. Etude du Developpement des Nouveau-nés Study.
OBJECTIVE: To describe the methods used at birth to recruit a population-based cohort of newborns of all birthweights at higher risk of having a chronic condition, and to present baseline results. METHODS: Screening of all newborns at hospital discharge for five non-exclusive criteria: (1) low birthweight (LBW), (2) congenital anomalies or genetic disease, (3) specified conditions associated with a high probability of chronicity, (4) referral to a neonatal intensive care unit (NICU), (5) or defined social problems. Calculation of Hobel risk scores for children satisfying > or = 1 criterion. SUBJECTS: All 6477 live births delivered in the 19 maternity hospitals of a geographically defined region (Vaud, Switzerland) to resident mothers in 1993-1994. RESULTS: Twelve per cent (n = 760) of newborns met > or = 1 criterion: 6.3% of all newborns had an LBW (criterion 1), 2.4% had a birth defect, 0.9% met criterion (3), 4.4% stayed in an NICU and 1.6% had serious social problems. Hobel prenatal score was high (> or = 10 points) for 41% of children with > or = 1 criterion, the intrapartum score for 87% and the neonatal score for 68%. CONCLUSIONS: Most newborns identified by the above simple criteria also had elevated perinatal risks. The validity of the criteria will later be tested against the results of the examinations of children with > or = 1 criterion at 18 months and 4 years of age, but the assessment at birth already shows that normal birthweight (NBW) children, in agreement with previous studies, contribute half the children at high risk perinatally.
Birth Weight↗
Frequency and impact of autosomal dominant polycystic kidney disease in the Seychelles (Indian Ocean).
BACKGROUND: As little such data is available in African populations, we investigated the prevalence of ADPKD and the impact of the disease in the Seychelles islands, where approximately 65% of the population is of African descent and 30% of Caucasian or mixed descent. METHODS: Prevalent cases were identified over a 3-year period by requesting all the doctors in the country (most of them are employed within a national health system) to refer all presumed or confirmed cases and by systematically examining the family members of all confirmed cases. The diagnosis was based on standard criteria including ultrasonographic findings and family history. RESULTS: Forty-two cases were identified in this population of 74,331 inhabitants, a total prevalence (per 100,000 total population) of 57 (95% CI, 41-76). All but one of the cases were of Caucasian descent so that the prevalence rates of the disease in the populations of Black and Caucasian descents were respectively 2 (0-11) and 184 (132-249). The prevalence rates of the gene(s) carriers were estimated to be 75 (45-117) in the total population respectively 6 (0-33) and 236 (140-372) in the Black and Caucasian populations. Haplotype analysis in 58 cases from three families showed a common DNA fragment in all affected individuals. Cases had significantly higher blood pressure compared to the general population and 21% had serum creatinine higher than 120 mumol/l. Among the established pedigrees, mean age of death between 1960 and 1995 (haemodialysis was introduced in 1992) was younger in subjects with than those without ADPKD (50.5 vs 67.7 years; P < 0.001). CONCLUSIONS: In the Seychelles, ADPKD clusters in the Caucasian population (possibly a founder effect), is rare in individuals of black descent, and is associated with substantial clinical and survival impact.
Adolescent↗
Variation in guidelines.
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Evidence-Based Medicine↗
Increased condom use without other major changes in sexual behavior among the general population in Switzerland.
OBJECTIVES: This study is part of a continuous evaluation of the Swiss AIDS prevention strategy from 1987 through 1994. METHODS: Annual telephone surveys of samples representative of the general population aged 17 through 45 years have been conducted since 1987 to monitor behavioral change. RESULTS: No major changes in level of sexual activity (lifetime number of partners, frequency of sexual encounters in the past week) or potential exposure to risk of HIV transmission (acquisition of a new steady partner during the year or of casual partners in the last 6 months) were observed. Systematic condom use with a new steady partner increased between 1988 and 1994, from 40% to 64% among 17- to 30-year-olds and from 57% to 72% among those aged 31 to 45. Systematic condom use with casual partners increased from 8% to 56% between 1987 and 1994 among 17- to 30-year-olds and from 22% to 42% between 1989 and 1994 among those aged 31 to 45. Condom use was higher among those with multiple partners. CONCLUSIONS: A general-population approach to AIDS prevention was able to achieve large-scale improvements in condom-based protection against HIV infection without inducing other major changes in sexual behavior.
Acquired Immunodeficiency Syndrome↗
[Prenatal care of women delivering in the Vaud canton: retrospective study of 854 cases].
The association between prenatal care and infant health has been shown in many studies. Therefore, accurate information on prenatal care is required to assess the organization of preventive measures aiming at a reducing in neonatal mortality any morbidity. We retrospectively collected data on 854 pregnancies. According to a classification scheme developed by Kessner, 61.6% of women had access to adequate prenatal care. Overall, the proportion of adequate prenatal care was lower among multiparas, and in this subgroup we found a lower rate for women with base line insurance. In the primiparas subgroup we found a lower rate of adequate prenatal care for foreigners, women under 20 years or unmarried mothers, and for women without professional activity during pregnancy, besides preterm birth was more frequent amongst women in the group of prenatal care qualified as intermediate or inadequate. The frequency of pregnancy visits and the Kessner index are discussed in a literature review. The association between socio-economic indicators and prenatal care was unexpected considering the overall wealth of Switzerland. With a 6.8% infant mortality registered in 1989, this country can be considered to have one of the lowest rates in the world. These findings nevertheless suggest the way to possible additional gains by interventions targeted to specific socio-economic groups.
Adult↗
[Regional variations in health services: various methodological problems].
Many studies show strong variation of health consumption between regions, suggesting that theses variations are related to the uncertainty of medical practice or to other factors related to health services or patients attitude. However the statistical interpretation of these variations is far from easy: apart from usual and specific information bias, there are statistical problems when observing incidence of events like health care consumption: it is in fact a rare event, which is observed within small population, and among regions with unequal number of person. Therefore, most of the variation reported might be well explained by a purely statistical phenomenon. This paper presents some aspects of this variability for three common indicators of variation, and suggest the use of ad hoc simulation to get statistical criteria.
Bias↗
Introducing a first AIDS vaccine in Switzerland: a Policy Delphi analysis.
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AIDS Vaccines↗
Quality assurance in Swiss University Hospitals: a survey among clinical department heads.
OBJECTIVE: To obtain information to help design and implement quality improvement programmes. DESIGN: Questionnaire survey. SETTING: Swiss University Hospitals. STUDY PARTICIPANTS: Clinical Department heads. MAIN OUTCOME MEASURES: Attitudes towards quality assurance and percentage of departments with procedures for measurement and improvement of structure, process and outcome of medical care. RESULTS: Among 138 departments responding, 69 indicated a designated person or group in charge of quality and 57 were involved in collaborative quality improvement programmes. Mortality data at the level of the department was unavailable to 33% of respondents, and data on adverse treatment effects to 67% of them. Most respondents (69%) favoured the use of outcome indicators for quality control; only 13% favoured indicators pertaining to process or structure of care. Among indicators of outcome, patient satisfaction was the preferred indicator (25% of respondents), followed by morbidity (16%) and mortality (12%) data. CONCLUSION: Although the quality of medical care in Switzerland enjoys an excellent reputation, this study highlights important gaps in the information system and the processes necessary to evaluate quality.
Adult↗