Maria Monika Wertli

Introduction Diagnostic stewardship is an emerging concept, so far primarily associated with microbiology, specifically antibiotic stewardship. However, its core idea, ensuring ‘the right test at the right time for the right patient’, holds relevance across all areas of clinical medicine. By optimising the diagnostic process, diagnostic stewardship aims to enhance clinical decision-making and promote more effective, efficient and patient-centred care. Key objectives are the reduction of diagnostic errors, namely overdiagnosis, underdiagnosis and misdiagnosis, as well as optimal resource management. The aim of our review was to establish whether and how diagnostic stewardship has been implemented outside the area of antibiotic stewardship. Methods and analysis This scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI) guidelines and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist. Medline, Embase, Web of Science, Scopus, Google Scholar and Proquest Thesis and Dissertation will be searched using a search strategy based on the population, concept, context (PCC) framework, adding an outcome variable. Studies will be screened by two independent reviewers and reported using the PRISMA flowchart. Included will be studies starting from 2015, which will describe stewardship interventions in different diagnostic modalities. Excluded will be results regarding antimicrobial stewardship. No language restriction will be applied. Information on the definition and application of the concept of diagnostic stewardship, as well as general study characteristics, will be extracted using a previously developed and piloted data extraction form. Extracted data will be analysed and reported using narrative and descriptive analysis. Ethics and dissemination Ethics approval is not required for this scoping review. Dissemination activities include peer-reviewed journal publication and conference presentations.

Objective To assess the clinical patient exposure of residents over 20 years following the statutory introduction of a maximum working week of 50 hours in 2005. Design Retrospective analysis of longitudinal cohorts of residents who worked on the medical wards between 2001 and 2023 or the emergency department (ED) between 2007 and 2023. Setting Cantonal Hospital of Baden, a representative, large Swiss teaching hospital affiliated with the University Hospital of Zurich. Participants Residents in training working on the internal medical wards and the ED. Primary outcome measures Annual Patient Exposure (APEX) of residents, which is the ratio of annual patients to residents and describes the annual number of patients treated per resident. Methods and analysis We assessed time trends of the APEX in annual cohorts of residents in training on the internal medicine wards (2001–2023) and the ED (2007–2023). We analysed the annual case severity (Case Mix Index and Emergency Severity Index (ESI)), patient age and the length of hospital stay (LOS) as a proxy for changes in the patient population over time and the readmission rate as a quality indicator. Results The medical ward APEX even increased by 5.2% from 325 patients to 342, despite the workhour restrictions and the increased number of residents (+90%). Inpatients increased by 100% (from 3250 to 6507). Their LOS decreased from 12.4 to 7.5 days and the readmission rate decreased from 4.2% to 3.3%. In the ED, the APEX decreased by 21% (from 3261 to 2576), but the case complexity (ESI) and the LOS increased substantially. Conclusions In contrast to the general belief, work hour restrictions and the increased number of residents did not reduce the inpatient APEX over 20 years. The reduced APEX in the ED may be compensated by the increase in case complexity and the LOS.

Hospital-initiated opioid analgesics that extend beyond discharge can lead to long-term use and adverse outcomes. Despite a growing understanding of opioid-related harms, there is a lack of published protocols for structured deprescribing in Europe. We aimed to develop an actionable opioid deprescribing framework that builds on trialed reduction protocols with patient-centered determinants for systematic implementation in tertiary care. We conducted a multi-level consensus study to bridge evidence, clinician expertise, and patient perspectives. Initial framework development included focus group discussions with multidisciplinary clinicians (n=5). The framework was validated for our institution via a two-round Delphi survey across six medical specialties (n=11). An opioid reduction calculator was developed in Python (version 3.12.3), incorporating clinical parameters to determine reduction trajectories for prespecified starting and end doses. Final refinement included interviews with patients receiving opioid therapy (n=11) to optimize understandability of the reduction plan as a patient handout and for developing a patient pamphlet on opioids with patients (n=13). The framework identified four critical domains for successful opioid deprescribing: interventional reduction strategies, patient-specific physiological variables, environmental enablers, and procedural elements. Reduction strategies categorized patients into chronic and new users, incorporating grace periods for dose stabilization, with particular attention given to patients exhibiting pain catastrophizing behavior and frailty. Environmental and procedural factors included shared responsibility and interdisciplinarity, ensuring that follow-up is facilitated by a coordinated care team. These findings were operationalized into the reduction calculator, proposing initial individualized reduction plans (10-25%) based on key patient-specific variables with built-in stabilization periods. Delphi validation achieved full consensus (87.8% first-round agreement; 100% final consensus) on all framework components. Patient involvement refined the handout to improve understandability and actionability, and yielded comprehensive information on opioids. We developed an actionable opioid deprescribing framework that bridges published evidence with patient-centered care for our institution, providing other healthcare institutions with a practical blueprint for their own implementation. Our multi-level consensus identified critical patient-specific and environmental determinants, and established individualized reduction protocols, addressing a critical gap in transitional care while facilitating safe opioid deprescribing practices.

Background: High‐dose long‐term opioid treatment for chronic non‐cancer pain (CNCP) has become an increasing burden in industrialised countries. Opioid tapering and withdrawal in patients with CNCP remain challenging. This study evaluated a two‐phase inpatient opioid withdrawal (OW) programme aimed at safely discontinuing opioid use in CNCP patients.Methods: This prospective observational study was conducted from 2018 to 2023 at a Swiss tertiary care centre, involving CNCP patients on long‐term opioid therapy (≥ 6 months, ≥ 100 mg morphine equivalent daily dose) who had failed outpatient withdrawal attempts. The programme consisted of a withdrawal phase (Phase 1) followed by multimodal pain rehabilitation (Phase 2). Outcomes included the proportion of patients opioid‐free after Phase 2 (primary) and at 3 months, pain intensity changes, and adverse events (secondary).Results: Among the 38 enrolled patients (58% female, median age 54 years [IQR 49, 62]), 34 (89%) completed both phases, and 32 (84%) were opioid‐free at the end of Phase 2. At 3 months, 23 patients (61%) remained opioid‐free, while 4 (11%) resumed opioids, and 11 (29%) were lost to follow‐up. Median pain intensity remained stable after discharge. One patient died by suicide 10 days post‐withdrawal.Conclusions: This two‐phase inpatient withdrawal and rehabilitation programme enabled most CNCP patients to discontinue opioids without increased pain intensity, with a majority remaining opioid‐free at 3 months. These findings highlight the importance of ongoing psychological support and careful patient selection in OW management.Significance Statement: This study introduces a structured inpatient opioid withdrawal model tailored for chronic non‐cancer pain patients on high‐dose opioid therapy, demonstrating that high cessation rates can be achieved without worsening pain intensity. By addressing the gap in care for patients who fail outpatient tapering, this research provides clinical insights into optimising withdrawal protocols and highlights the need for targeted resource allocation for intensive, multidisciplinary pain management. These findings support evidence‐based decision‐making in designing more effective opioid tapering strategies.

BACKGROUND: Clinical guidelines for acute non-specific low back pain recommend avoiding imaging studies, refraining from strong opioids and invasive treatments, and providing information to patients to stay active. Despite these recommendations, many patients undergo diagnostic and therapeutic assessments that are not in line with the current evidence. AIM: To assess the management of acute non-specific low back pain by Swiss general practitioners (GPs) and their adherence to guideline recommendations. METHODS: We performed a survey using two clinical case vignettes of patients with acute non-specific low back pain without red flags or neurological deficits. The main differences between the vignettes were sex, age, profession, pain duration and medical history. GPs were asked about their management of those patients. RESULTS: Of 1253 GPs, 61% reported knowing current clinical guidelines and 76% being aware of “Choosing Wisely” recommendations. Diagnostic evaluations included X-ray (18% for vignette 1, 32% for vignette 2) and magnetic resonance imaging (MRI) (31% and 62%). For pain management, GPs recommended mostly non-steroidal anti-inflammatory drugs, paracetamol and metamizole. Treatments with potential harm included muscle relaxants (78% and 77%), oral steroids (26% and 33%), long-acting opioids (8% and 11%) and spinal injections (28% and 42%). A very high proportion recommended activity restrictions (82% and 71%) and some recommended bed rest (3% and 2%). CONCLUSION: Although GPs reported being aware of current guideline recommendations, management of acute non-specific low back pain was not in line with these recommendations. A substantial proportion of GPs considered imaging, treatments (e.g. muscle relaxants, long-acting strong opioids), and activity and work restrictions with potentially harmful consequences.

Objective To assess the effect of goal-directed mobilisation (GDM) on physical functioning in medical inpatients. Design Randomised, controlled, single-centre, parallel, superiority trial with a 3-month follow-up and blinded outcome assessment. Setting General internal medicine wards of a Swiss tertiary acute hospital, September 2021 to April 2023. Participants Adults with expected hospitalisation of ≥5 days, physiotherapy prescription and ability to follow study procedures. Intervention GDM during hospitalisation, which includes personal goal setting and a short session of patient education through a physiotherapist (experimental group), versus standard care (control group). Outcome measures The primary outcome was the change in physical activity between baseline and day 5 (De Morton Mobility Index (DEMMI)). Secondary outcomes included in-hospital accelerometer-measured mobilisation time; in-hospital falls; delirium; length of stay; change in independence in activities of daily living, concerns of falling and quality of life; falls, readmission and mortality within 3 months. Results The study was completed by 123 of 162 (76%) patients enrolled, with the primary outcome collected at day 5 in 126 (78%) participants. DEMMI Score improved by 8.2 (SD 15.1) points in the control group and 9.4 (SD 14.2) in the intervention group, with a mean difference of 0.3 (adjusted for the stratification factors age and initial DEMMI Score, 95% CI −4.1 to 4.8, p=0.88). We did not observe a statistically significant difference in effects of the interventions on any secondary outcome. Conclusions The patient’s physical functioning improved during hospitalisation, but the improvement was similar for GDM and standard of care. Improving physical activity during an acute medical hospitalisation remains challenging. Future interventions should target additional barriers that can be implemented without augmenting resources. Trial registration number NCT04760392.

Objectives In our study, we aimed to characterise adult childhood cancer survivors (ACCS), assess their health issues, gauge health-related quality of life (HRQOL) and evaluate visit satisfaction. Design Prospective cohort study using data from clinical visits and questionnaires. Setting Interdisciplinary follow-up programme for ACCS based on the long-term follow-up (LTFU) guidelines of the Children’s Oncology Group and overseen by internists in two Swiss hospitals. Participants ACCS attending our LTFU clinics between April 2017 and January 2022 were eligible. Interventions We documented medical history, current health status and assessed HRQOL using Short Form-36 V.2, comparing it with Swiss general population (SGP) norms (T mean=50, SD=10; age stratified). 3 months post visit, a feedback questionnaire was distributed. Main results Among 102 ACCS (mean age: 32 years (range: 18–62 years), 68% women), 43 had no prior follow-up (36 ACCS>28 years, 7 ACCS≤28 years). A notable 94% had health issues, affecting an average of 6.1 (SD=3.3) organ systems. HRQOL was lower in ACCS>28 years than the SGP>28 years (physical: 44.8 (SD=11.65) vs 49.3 (SD=10.29), p=0.016; mental: 44.4 (SD=13.78) vs 50.53 (SD=9.92), p=0.004). Older ACCS (>28 years) reported inferior physical (44.8 vs 50.1 (SD=9.30), p=0.017) and mental HRQOL (44.4 vs 50.3 (SD=7.20), p=0.009) than younger ACCS. The majority of respondents reported high levels of satisfaction with the consultation, exceeding 90%. Conclusion ACCS attending LTFU clinics face diverse health issues impacting multiple organ systems and exhibit lower HRQOL compared with the SGP. Thus, internist-led LTFU clinics are crucial for optimising follow-up care.

AIM OF THIS STUDY: General internal medicine is a crucial element in healthcare systems. Understanding how many people are and will be working in this field is important to maintain and improve quality for patients in healthcare systems. This can provide a basis for political decisions. METHODS: We conducted a cross-sectional study to analyse the current and future workforce of generalists (general practitioners and internists in hospitals) in Switzerland. The Swiss Society of General Internal Medicine (SSGIM) distributed a survey to all members. Respondents were asked about their current average workload in 2023 and planned workload in 2033. The responses were used to calculate full-time equivalent (FTE) for the current and future workforce of generalists and to extrapolate FTE for all active SSGIM members. To model the demand by 2033, we derived different scenarios. RESULTS: Of all 6,232 active SSGIM members, 2,030 (33%) participated: 46% female, 25% (largest age group) 56-65 years old, 19% still in postgraduate training. The average workload in 2023 was 78% for female and 87% for male generalists; the FTE extrapolated to all active SSGIM members in 2023 was 5,246. By 2033, 1,935 FTEs (36%) will retire, 502 FTEs (10%) will reduce their workload, 116 FTEs (2%) will increase their workload and 2,800 FTEs (53%) will remain in the workforce with the same workload as in 2023. To maintain the same workforce as in 2023, 2,321 new FTEs (44%) will be needed by 2033. To fill this gap of 232 FTE new generalists per year, we modelled different scenarios with assumptions of interest, workload, migration and dropouts. CONCLUSIONS: Within only one decade, 44% of the current workforce of generalists will disappear, mainly due to retirement and decreased workload. To fill this gap, various scenarios need to be incorporated. Politicians are called upon to create the political framework to create attractive training and working conditions for generalists to address the future demand for healthcare services.

Background: The present study sought to determine the prevalence of chronic non‐cancer pain (CNCP) among older adult inpatients with polypharmacy. It also aimed to analyse prescription patterns and assess the therapy adequacy and patient complexity for those with and without CNCP.Methods: This 4‐year longitudinal study examined data from an exhaustive acute care hospital register on home‐dwelling older adult patients (≥65) with polypharmacy. Commonly known combinations of potentially inappropriate medications were used to estimate therapy adequacy. Patient complexity was evaluated by comparing number of comorbidities and investigating physical and cognitive deficits.Results: We determined a prevalence of CNCP of 9.7% among all older adult inpatients with polypharmacy, rising to 11.3% for those aged ≥85. Overall, CNCP patients were prescribed more drugs and had more comorbidities and physical and cognitive deficits than patients without CNCP. Older adult patients with CNCP received more analgesics, greater quantities of opioids, paracetamol and co‐analgesics and elevated opioid dosages. Older adult patients with CNCP aged ≥85 received fewer analgesics, opioids, non‐steroidal anti‐inflammatory drugs and co‐analgesics but more paracetamol. Older adult patients with CNCP were prescribed more potentially inappropriate medications involving opioids. In particular, 24.5% received an opioid and a hypnotic (benzodiazepine or Z‐drug), and 8.6% received an opioid and a gabapentinoid.Conclusion: Observed differences in medication use between older adult inpatients with or without CNCP may be relevant for clinical practice. Potentially inadequate co‐prescribing (such as hypnotics and opioids) affects a higher proportion of patients with CNCP and may have serious unintended consequences.Significance Statement: This study describes differences in prescription patterns between people with and without chronic non‐cancer pain in a large dataset of 20,422 discharges. The differences found may be relevant to clinical practice. In particular, high co‐prescribing of opioids and hypnotics may have serious unintended consequences. Greater physical and cognitive deficits may indicate greater patient complexity, and appropriate interventions need to be developed to improve the management of this vulnerable patient group.