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Biomedical subjects

J F Etter

Publications and source records attributed to J F Etter.

At least 37 records · Page 2Linked to original sources
PubMed1998

Health care expenditures after introduction of a gatekeeper and a global budget in a Swiss health insurance plan.

STUDY OBJECTIVES: To assess whether the introduction of "managed care" (capitated budget and utilisation control by general practitioners) in a Swiss health insurance plan caused a selective disenrolment of plan members, and whether it achieved its goal of reducing health care expenditures. DESIGN: Controlled before-after analysis of health insurance claims. SETTING: Health insurance plan of the University of Geneva, Switzerland, which introduced managed care at the end of 1992, and comparison plan, which reimbursed health care expenditures without setting a budget or controlling access. PARTICIPANTS: Analysis of self selection: university plan members who accepted (3993) or refused (659) transfer to managed care. Analysis of change in expenditures: cohorts of persons continuously enrolled in the university (1575) and comparison (3384) plans in 1992 and 1993. MAIN RESULTS: During 1992, the year before the transformation of the university plan, persons who refused managed care had generated 35% higher expenditures than those who accepted managed care (p < 0.001). Between 1992 and 1993, expenditures per member decreased by 9% in the university cohort and increased by 11% in the comparison cohort (p = 0.004). Technical procedures (laboratory tests, physical therapy, drugs) decreased most in the university plan. No impact on hospital admissions was detected. CONCLUSIONS: Introduction of gatekeeping and budget management by physicians caused a favourable self selection process for the university plan. In addition, the managed care plan achieved a substantial decrease in overall health care expenditures in its first year of operation, chiefly by reducing outlays for technical procedures.

Adult↗
PubMed1997

[Educational strategies and tools in a public health program at the University of Geneva].

In the Swiss context, the newly developed MPH programme at the University of Geneva is experimental in educational matters. Indeed the programme is fully learner-centered and community-oriented. Throughout the curriculum students plan, implement and evaluate intervention programmes or/and research projects related to health problems of the communities they are in charge of. In this article, we describe the educational strategies and tools used in this MPH curriculum (professional profile, mind-mapping procedures, field-work either on research projects or on intervention programmes, group work and evaluation procedures). These strategies and tools might assist some educational experimentation in MPH programmes in search of public health relevance and pedagogic efficacy.

Certification↗
PubMed1997

[Health status, health behavior and attitudes of young Geneva adults].

This study was aimed at assessing the health status, health-related life-styles and health concerns among young urban adults, 41% of them university students. Two mailed surveys were conducted in Geneva (Switzerland), in 1992 among 1007 persons and in 1993 among 1424 persons. Participation rates were over 80%. Study participants were aged 18-45 (mean age 31 years in 1993). For most health status dimensions, men declared to be healthier than women. Mental health-related concerns were frequent, especially among university students. Prevalence of health-related life-styles were: smoking 39%, drinking-and-driving at least once in past year 18%, always wear a seat belt 35%, had several sexual partners in past year but did not always use condoms 11%, exercise each week 46%. The more educated persons had healthier life styles, for all aspects except for unprotected sex with several sexual partners. These results are worrying and call for more active prevention strategies, directed at mental health problems, use of seat belts, drinking-and-driving, smoking and sexually transmitted diseases.

Adolescent↗
PubMed1997

Validating a satisfaction questionnaire using multiple approaches: a case study.

We examined the validity of a questionnaire designed to measure the satisfaction of users of health services, using multiple tests of construct validity. Members of 2 health insurance plans in Geneva (Switzerland) answered a mailed questionnaire in 1992 (n = 1007) and 1993 (n = 1424). Response rates were 82% participants were 18-44 years old in 1992. The questionnaire included 22 questions on satisfaction with medical care received during the past 12 months. Most items were adapted from the Patient Satisfaction Questionnaire. Four dimensions of satisfaction were measured: satisfaction with physician services (8 items), communication (8 items), access (4 items) and insurance services (2 items). Reliability (Cronbach's alpha) was satisfactory for the 2 former dimensions (alpha = 0.81 and 0.82 respectively), but lower than desired for the 2 latter (alpha = 0.63 and 0.49 respectively). Participants who gave positive open-ended comments had satisfaction scores 0.7-1.2 standard deviation units higher than participants who gave negative comments. Satisfaction scores were weakly correlated with satisfaction with private life, which indicates that the instrument did not simply measure a general tendency to be satisfied. Participants who said that care received in 1993 was worse than care received in 1992 (retrospective assessment) experienced a decrease in satisfaction scores between 1992 and 1993 (prospective assessment). Most validation procedures provided independent but partial evidence for the validity of the instrument. Triangulation of several validation methods, as illustrated in this paper, may greatly improve the understanding of an instrument's properties.

Consumer Behavior↗
PubMed1997

Analysis of non-response bias in a mailed health survey.

The objective of this study was to identify characteristics of non-respondents and late respondents to a mailed health survey. Persons who returned and those who did not return the questionnaire were compared using health insurance data, which indicated their age, sex, and health care expenditures in the previous year. Insurance and questionnaire data were used to compare early and late survey respondents and to compare categories of non-respondents. Questions covered use of health services, health status, and sociodemographic characteristics. Participants were members of health insurance plans in Geneva, Switzerland, 19-45 years old (n = 1822). Respondents (n = 1424) and non-respondents (n = 398) were of similar age and sex. The proportion of persons who had health care expenditures greater than zero Swiss francs (SFr) was higher among respondents (75%) than among non-respondents (69%, p = 0.03). Among non-respondents, expenditures of persons who explicitly refused to participate (2378 SFr) were higher than expenditures of persons who moved out of Geneva (1085 SFr) or who failed to return the questionnaire (1592 SFr, p = .02). Among respondents, being born in a Switzerland, having completed elementary school, having generated health care expenditures, and reporting good physical health were independent predictors of early response. In conclusion, low response rates to mailed health surveys may result in overestimating the utilization of health services. However, non-respondents did not constitute a homogeneous group, and the strength and even direction of non-response bias depended on the mechanisms of non-response.

Adult↗
PubMed1997

Prospective versus retrospective measurement of change in health status: a community based study in Geneva, Switzerland.

STUDY OBJECTIVES: To compare prospective and retrospective measurements of change in health status. DESIGN: Health status was measured using a French language version of the short form 36 (SF-36) health survey on two occasions one year apart--in 1992 and 1993. Differences in SF-36 scores measured prospectively were compared with the patients' single item retrospective evaluation of change in health (transition item). SETTING: This was a community based study among members of two health insurance plans in Geneva, Switzerland. PARTICIPANTS: Altogether 831 young adults (mean age 30 years at baseline). MAIN RESULTS: Health status remained stable on average during the study period. The retrospective rating correlated well with changes in health measured prospectively: those who said in 1993 that their current health was "much worse" than in 1992 experienced an average decrease of 1.06 SD on the eight SF-36 scales, while those who said that their health was "much better" recorded an average improvement of 0.43 SD. The associations between prospective and retrospective assessments of change were approximately linear for all scales but physical functioning. The transition item also discriminated between time periods: transition reported for 1991-92 did not correlate with changes recorded for 1992-93. Relative validity analyses indicated that the transition item was better suited to capture changes in general health than changes in purely physical or mental aspects of health. CONCLUSIONS: The concordance between retrospective and prospective measures of change in health suggests that both are sensitive, to some extent, to true changes in health status. Using both types of assessment may improve the reliability of measurements of change.

Adult↗
PubMed1997

Introducing managed care in Switzerland: impact on use of health services.

The objectives of this study were to assess changes in the self-reported use of health care services after gatekeeping by general practitioners and a global budget were introduced in the health insurance plan for students at the University of Geneva, Switzerland, in October 1992. A random sample of 336 members of the University plan answered questions about their use of health care services during the year before (1992) and the year after (1993) the introduction of managed care. Similar data were collected among a random sample of 300 members of a comparison plan. All participants were 18-44 y old in 1992, spoke French and lived in Geneva. The proportion of insurees who visited specialists decreased by 10% in the University plan between 1992 and 1993 and remained unchanged in the comparison group. The proportion of insurees who visited general practitioners increased by 12% in the University plan and remained unchanged in the comparison group. No effects on the total number of health care visits, on hospitalisations or on use of medications were detected. The introduction of gatekeeping and of a global budget managed by physicians was associated with a transfer of patient visits from specialists to general practitioners.

Adolescent↗
PubMed1996

[Patient satisfaction in the ambulatory setting: validation of a scale and identification of associated factors].

BACKGROUND: Patient satisfaction is increasingly used to evaluate the performance of health services. Validated French-language instruments to measure satisfaction are currently lacking. This study was designed to validate a questionnaire of this kind and to identify factors associated with patient satisfaction. METHODS: Mail survey of 1027 patients who consulted at 4 different ambulatory health care settings in Geneva, Switzerland. The participation rate was 81%. The questionnaire measured 7 dimensions of satisfaction using 16 items adapted from other sources. RESULTS: The questionnaire was easy to respond to (scores were available for 95 to 99% of respondents, depending on the scale). The internal consistency of the scales was satisfactory (Cronbach alpha between 0.65 and 0.82) for 5 of 6 multi-item scales; it was lower for the scale which measures satisfaction with access to care. Factor analysis identified two principal components corresponding roughly to the "process" and to the "organization" of care. Open comments also confirmed the validity of the multi-item scales. Several patient or visit characteristics were independently associated with the level of satisfaction: older patients, those who were born in Switzerland, who had a visit appointment, who consulted a specialist, and those who saw the same physician as at their previous visit were more satisfied than other patients. CONCLUSIONS: The brief satisfaction questionnaire described in this paper is easy to use, and its reliability and validity are good. Its use can be recommended in ambulatory health care settings. Several variables associated with the level of satisfaction were identified; they should be measured in satisfaction surveys to allow correct appraisal of the results.

Adolescent↗
PubMed1996

[Current models in health insurance and health care delivery].

Health care organizations similar to American HMOs have recently appeared in Switzerland. They elicit many reactions, both in the general public and among the medical profession. In contrast to traditional health insurance, HMOs organize and actively manage health care delivered to their members. This paper reviews the historical background of similar organizations in Europe and in the United States, and focuses in particular on the recent evolution and fragmentation of the concept of "managed care". Follows a discussion of the mechanisms and the side-effects of various tools used to manage care, both in managed care settings and by traditional health insurance plans. It appears that all of health care is managed, that all management tools have potential side effects, and that use of some management tools implies a redistribution of the respective roles of plan members, administrators, and physicians. The authors suggest that the complexity of health care management requires a more active implication of the health professions in that process.

Delivery of Health Care↗
PubMed1996

Does sponsorship matter in patient satisfaction surveys? A randomized trial.

The purpose of this study was to assess the impact of sponsorship of a mailed satisfaction survey on response patterns and patient satisfaction ratings, and to establish whether satisfaction ratings depend on the timing of response. The study was part of a patient satisfaction survey conducted in a medical group practice in Geneva, Switzerland. All persons who had received an outpatient visit at the medical practice in the last week of September 1993 were assigned randomly to receiving the survey package either on university letterhead or on the medical practice letterhead. Participation rates were 80.5% and 80.4% in the two groups, respectively. The sponsorship of the survey had no detectable impact on response speed or response completeness. Six out of seven satisfaction scores were higher in the "medical practice" group, but the differences were not statistically significant. As data collection progressed, the cumulative satisfaction rating decreased gradually. This association was statistically significant but moderate. Whether a satisfaction survey is sponsored by a university or a health care provider does not seem to affect survey results. However, low survey response rates may moderately bias satisfaction estimates toward higher values.

Data Collection↗
PubMed1996

Comparison of patient satisfaction with ambulatory visits in competing health care delivery settings in Geneva, Switzerland.

OBJECTIVES: To measure satisfaction with medical visits in various health care settings and to assess the extent to which differences in satisfaction scores between health care settings can be attributed to patients' characteristics. DESIGN: This was a cross sectional survey to measure seven dimensions of patient satisfaction. SETTINGS: Ambulatory visits to 'gatekeepers' or specialists in a newly established managed care organisation, a private group practice, or a university hospital outpatient clinic in Geneva, Switzerland. PATIENTS: There were altogether 1027 adult patients (81% participation rate). RESULTS: Patients who consulted physicians in the private group practice reported higher levels of satisfaction (overall mean 83.2 on a scale between 0 and 100) than university clinic patients (79.7), patients of independent specialists within the managed plan (78.5), and patients of managed plan gatekeepers (69.8, intergroup differences p < 0.001). Differences between settings were reduced after adjustment for sex, age, country of origin, general practitioner versus specialist visit, and scheduled versus urgent visit (adjusted scores: 80.8, 78.8, 77.6, and 72.7 in the four settings, p < 0.001). Intergroup differences were largest for general satisfaction, but small and non-significant for satisfaction with explanations given by the physician and for time spent with the patient. CONCLUSIONS: Patient satisfaction varied widely between health care settings. Differences in satisfaction ratings could be ascribed only partly to disparities in patient populations. Patients of managed plan gatekeepers were least satisfied, presumably because they could not choose their physician freely. Comparison of patient satisfaction across health care settings can provide a basis for targeted quality improvement initiatives.

Adolescent↗
PubMed1996

Switching Swiss enrollees from indemnity health insurance to managed care: the effect on health status and stisfaction with care.

OBJECTIVES: In 1992, most members of a Swiss indemnity health insurance plan were automatically transferred into a newly created managed care organization. This study examined whether this semivoluntary change affected enrollees' health status and satisfaction with care. METHODS: Three groups of enrollees were compared: 332 plan members who accepted the switch (managed care joiners); 186 plan members who opted to maintain indemnity coverage (non-joiners); and 296 persons continuosly enrolled in another indemnity plan (indemnity plan members). Health status, health related behaviors, and satisfaction with care received in the previous year were surveyed at baseline and 1 year later. RESULTS: Health status remained unchanged in all three groups. Smoking prevalence decreased among managed care joiners but remained constant in the other groups. Satisfaction with insurance coverage increased between baseline and follow-up in managed care joiners, but decreased in nonjoiners and indemnity plan members. The latter groups had higher satisfaction with health care, particularly with continuity of care. CONCLUSIONS: A semivoluntary switch from indemnity health insurance to managed care reduced satisfaction with health care but increased satisfaction with insurance coverage. There were no changes in self-perceived health status.

Adult↗
PubMed1995

Validation of a French-language version of the MOS 36-Item Short Form Health Survey (SF-36) in young healthy adults.

The MOS 36-Item Short Form Health Survey (SF-36) is designed to measure 8 dimensions of health in clinical and general population settings. The main aim of this paper was to examine the reliability and validity of this instrument in young adults. A secondary aim was to document the results of a rapid translation procedure of the instrument, to be compared later to the more thorough official French adaptation. The translated survey was answered in 1992 by 1007 residents of Geneva, Switzerland, 18-44 years old, identified from health insurance rolls (82% response rate). Completion rate for all 8 dimensions of health was 95.5%. The instrument demonstrated excellent covergent (100%) and discriminant (98%) validity against pre-set criteria. Interval scaling of responses could be verified in some, but not all, items. Cronbach alpha (reliability) coefficients ranged from 0.76 to 0.92. Factorial analysis yielded 2 principal components, corresponding to mental and physical health. Thirteen of 16 correlations between health dimensions and principal components were within a pre-established range. Validation by independent clinical variables was also, with few exceptions, consistent with theory. Thus the SF-36 retained excellent psychometric properties even when used in a generally very healthy group. The careful but rapid translation procedure used in this study may be an effective alternative to full-scale cultural adaptations when resources are limited.

Adult↗
PubMed1995

Mental health and choice between managed care and indemnity health insurance.

OBJECTIVE: Populations enrolled in various health insurance plans may differ in their health care needs. Whether mental health affects choice among competing health plans is not clear. This study examined self-selection by participants in a Swiss indemnity insurance plan that was transformed into a managed care organization that controlled access to specialists through gatekeeping and restricted coverage for psychiatric treatments. METHOD: Information regarding past use of health services and health status was provided by 421 persons who joined the new managed care organization and 222 nonjoiners. The mental health and somatic health characteristics of these two groups were compared. RESULTS: In the year preceding the creation of the managed care organization, the nonjoiners had made on average 2.3 more visits to psychiatrists than the joiners but 0.0 to 0.6 more visits to other physicians. The nonjoiners were more likely to have used psychoactive medications but not other medications. The rates of treatment for depression were similar in the two groups. The joiners reported significantly lower mental health status, but not somatic health status, than the nonjoiners. CONCLUSIONS: Both mental health status and past use of mental health services strongly affected choice of health insurance plan. The effects of somatic health and use of somatic health services on selection were consistently weaker. People who join managed care organizations may have substantial uncovered needs for psychiatric care. Minimum mandatory benefits for mental health care may be an effective countermeasure to unequitable self-selection.

Adolescent↗
PubMed1993

Randomized trial of use of a monetary incentive and a reminder card to increase the response rate to a mailed health survey.

Insufficient response rates are a frequent problem in mailed epidemiologic health surveys. As part of a health survey of 1,235 young adults conducted from November 1992 through January 1993 in Geneva, Switzerland, a randomized factorial trial was carried out to assess the contributions of two tactics to increase response rates. The first incentive was the promise of sending 10 Swiss francs (7 US dollars) to respondents; the second was a red postcard, mailed 2 days after the questionnaire, which reminded potential participants to complete the questionnaire. The most effective strategy according to interim analysis was to be selected for follow-up mailings. Two weeks after the first mailing, response rates were 65% for those who had received both incentives, 57% for those who had been offered the money reward only, 54% for recipients of the reminder card, and 48% for those who had received neither incentive (p based on chi 2 (3 df) test < 0.001). The relative hazards of responding were 1.34 (95% confidence interval 1.15-1.55) for the money reward and 1.22 (95% confidence interval 1.05-1.41) for the reminder card. Follow-up mailings to all nonrespondents included both incentives. At the end of data collection, 1,007 persons (82%) had returned the questionnaire. The final response rates were 83, 84, 82, and 78% in the four groups, respectively (p = 0.29). Both the promise of a monetary reward and a reminder postcard considerably improved early response rates. The use of both incentives in follow-up mailings brought final response rates above 80%, except for those who had received no initial incentive. Testing various combinations of incentives in the early stages of a mailed health survey may be a generally useful strategy.

Adult↗