Coordination of care for multimorbid patients from the perspective of general practitioners - a qualitative study

A Case Management Approach in Stroke Care: A Mixed-Methods Acceptance Analysis From the Perspective of the Medical Profession

PURPOSE OF STUDY

In terms of continuous and coordinated health care, cross-sectoral care structures are crucial. However, the German health care system is characterized by fragmentation of medical services and responsibilities. This fragmentation leads to multiple interfaces frequently causing loss of information, effectiveness, and quality. The concept of case management has the potential to improve cooperation between sectors and health care providers. Hence, a case management intervention for patients with stroke was evaluated with an acceptance analysis on the physicians' willingness to cooperate with stroke managers and their assessment of the potential of case management for the health care of patients with stroke.

PRIMARY PRACTICE SETTINGS

Primary practice settings included physicians working in the hospital, rehabilitation, and outpatient sectors who had actual or potential contact with a stroke case manager within the project region of East Westphalia-Lippe.

METHODOLOGY AND SAMPLE

The analysis was conducted using a mixed-methods approach. Expert interviews were conducted in 2020. Afterward a questionnaire was developed, which was then distributed to physicians in 2021. Both the interviews and the questionnaire included questions on conceptual knowledge and concrete expectations prior of the project, on experiences during the project and on recommendations and physicians' assessment of future organization in health care to classify and describe the acceptance.

RESULTS

Nine interviews were conducted and 23 questionnaires were completed. Only slightly more than 50% of the physicians had prior knowledge of the case management approach. Overall, ambiguous results concerning the acceptance of case managers were revealed. Additional personal assistance for patients with stroke was seen as beneficial at the same time critical perspectives regarding further fragmentation of health care and overlapping of competences with existing professional groups or forms of health care were collected. General practitioners in particular were critical of the case management approach.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

From the physicians' point of view, at least two changes are necessary for the project approach to be integrated into standard care. First, the target group should be adapted according to the case management approach. Second, the delegation of tasks and responsibilities to case managers should be revised. The sectoral difference in the acceptance of case managers by physicians indicates that active cooperation and communication in everyday work has direct impact on the acceptance of a new occupational profession. Physician acceptance has a significant impact on the implementation of new treatment modalities and thus influences the overall quality of health care.

Comparing the quality of care in physician networks to usual care for elderly patients in three German regions: a quasi-experimental cohort study

OBJECTIVES

Patients in Germany have free choice of physicians in the ambulatory care sector and can consult them as often as they wish without a referral. This can lead to inefficiencies in treatment pathways. In response, some physicians have formed networks to improve the coordination and quality of care. This study aims to investigate whether the care provided by these networks results in better health and process outcomes than usual care.

STUDY DESIGN

This was a quasi-experimental cohort study.

METHODS

We analysed claims data from 2017 to 2018 in Bavaria, Brandenburg, and Westphalia-Lippe. Our study population includes patients aged 65 years or older with heart failure (n = 267,256), back pain (n = 931,672), or depression (n = 483,068). We compared condition-specific and generic quality indicators between patients treated in physician networks and usual care. Ambulatory care-sensitive emergency department cases were used as a primary outcome measure. Imbalances between the groups were minimized using propensity score matching.

RESULTS

Rates of ambulatory care-sensitive emergency department cases yielded insignificant differences between networks and usual care in the depression and heart failure subgroups. For back pain patients, rates were 0.17 percentage points higher (P < 0.01) in network patients compared with usual care. Among network patients, generic indicators for prevention and coordination showed significantly better performance. For instance, the rate of completed vaccination against influenza is 3.03 percentage points higher (P < 0.01), and the rate of specialist visits after referral is 1.6 percentage points higher (P < 0.01) in heart failure patients, who are treated in physician networks. This is accompanied by higher rates of polypharmacy. Furthermore, the results for condition-specific indicators suggest that for most indicators, a greater proportion of the care provided by physician networks adhered to national treatment guidelines.

CONCLUSIONS

Our findings suggest that physician networks in Germany do not reduce rates of ambulatory care-sensitive emergency department cases but perform better than usual care in terms of care coordination and prevention. Further research is needed to confirm our findings and explore the implications of the potentially higher rates of polypharmacy seen in physician networks.

Insights from end-of-career general practitioners on changing working conditions and generational differences: considerations for future strategies

The landscape of general practice has experienced notable transformations in recent decades, profoundly influencing the working conditions of general practitioners (GPs). This study aimed to examine the most salient changes affecting GPs' daily practices. Through semi-structured qualitative interviews with 15 end-of-career GPs, the study explored how these changes affected work organization, equipment, working hours, work-life balance, job satisfaction, training, patient relationships, and reputation. The interviews revealed that these changes were perceived as barriers, opportunities, or a complex interplay of both for general practice. While the interviewed GPs valued technological advancements and reported positive developments in working conditions, challenges included a gradual reduction in the range of tasks, growing administrative burdens, and less practical training for young physicians. Other changes, such as new doctor-patient dynamics, the transition from single to group practice, and differing professional expectations of the younger generation, were seen as both challenging and strengthening for general practice. By combining these factors and trade-offs observed by end-of-career GPs in our study over the past few decades with general societal changes, we provide ideas for the design of future framework conditions in general practice that might enhance the attractiveness of the profession. These insights offer key considerations that can guide future strategies for general practice and medical education.

Effectiveness of an adaptive, multifaceted intervention to enhance care for patients with complex multimorbidity in general practice: protocol for a pragmatic cluster randomised controlled trial (the MM600 trial)

INTRODUCTION

Patients with complex multimorbidity face a high treatment burden and frequently have low quality of life. General practice is the key organisational setting in terms of offering people with complex multimorbidity integrated, longitudinal, patient-centred care. This protocol describes a pragmatic cluster randomised controlled trial to evaluate the effectiveness of an adaptive, multifaceted intervention in general practice for patients with complex multimorbidity.

METHODS AND ANALYSIS

In this study, 250 recruited general practices will be randomly assigned 1:1 to either the intervention or control group. The eligible population are adult patients with two or more chronic conditions, at least one contact with secondary care within the last year, taking at least five repeat prescription drugs, living independently, who experience significant problems with their life and health due to their multimorbidity. During 2023 and 2024, intervention practices are financially incentivised to provide an extended consultation based on a patient-centred framework to eligible patients. Control practices continue care as usual. The primary outcome is need-based quality of life. Outcomes will be evaluated using linear and logistic regression models, with clustering considered. The analysis will be performed as intention to treat. In addition, a process evaluation will be carried out and reported elsewhere.

ETHICS AND DISSEMINATION

The trial will be conducted in compliance with the protocol, the Helsinki Declaration in its most recent form and good clinical practice recommendations, as well as the regulation for informed consent. The study was submitted to the Danish Capital Region Ethical Committee (ref: H-22041229). As defined by Section 2 of the Danish Act on Research Ethics in Research Projects, this project does not constitute a health research project but is considered a quality improvement project that does not require formal ethical approval. All results from the study (whether positive, negative or inconclusive) will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05676541.

Experiences of hospital care for people with multiple long-term conditions: a scoping review of qualitative research

BACKGROUND

Multiple long-term conditions-the co-existence of two or more chronic health conditions in an individual-present an increasing challenge to populations and healthcare systems worldwide. This challenge is keenly felt in hospital settings where care is oriented around specialist provision for single conditions. The aim of this scoping review was to identify and summarise published qualitative research on the experiences of hospital care for people living with multiple long-term conditions, their informal caregivers and healthcare professionals.

METHODS

We undertook a scoping review, following established guidelines, of primary qualitative research on experiences of hospital care for people living with multiple long-term conditions published in peer-reviewed journals between Jan 2010 and June 2022. We conducted systematic electronic searches of MEDLINE, CINAHL, PsycInfo, Proquest Social Science Premium, Web of Science, Scopus and Embase, supplemented by citation tracking. Studies were selected for inclusion by two reviewers using an independent screening process. Data extraction included study populations, study design, findings and author conclusions. We took a narrative approach to reporting the findings.

RESULTS

Of 8002 titles and abstracts screened, 54 papers reporting findings from 41 studies conducted in 14 countries were identified as eligible for inclusion. The perspectives of people living with multiple long-term conditions (21 studies), informal caregivers (n = 13) and healthcare professionals (n = 27) were represented, with 15 studies reporting experiences of more than one group. Findings included poor service integration and lack of person-centred care, limited confidence of healthcare professionals to treat conditions outside of their specialty, and time pressures leading to hurried care transitions. Few studies explored inequities in experiences of hospital care.

CONCLUSIONS

Qualitative research evidence on the experiences of hospital care for multiple long-term conditions illuminates a tension between the desire to provide and receive person-centred care and time pressures inherent within a target-driven system focussed on increasing specialisation, reduced inpatient provision and accelerated journeys through the care system. A move towards more integrated models of care may enable the needs of people living with multiple long-term conditions to be better met. Future research should address how social circumstances shape experiences of care.

[General practices and community care points work hand in hand in the care of multimorbid patients: What are the advantages? - A qualitative study with general practitioners and medical practice assistants]

BACKGROUND

Caring for an increasing number of multimorbid people is a challenge for general practices in Germany. A possible approach to ensure future care could be the cooperation between general practices and community care points, which have so far been a little-known option among general practitioners. The aim of this study was to investigate the benefits or additional burdens that, from the perspective of general practices, a cooperation between general practices and community care points would bring for both the general practitioners themselves and their patients.

METHODS

In the mixed-methods study COMPASS II, general practices were able to refer multimorbid patients with social counselling needs to a community care point. Semi-structured guideline-based telephone interviews were conducted with nine general practitioners and nine medical practice assistants regarding the feasibility of cooperation with the community care points. The interviews were analysed using framework analysis.

RESULTS

In the qualitative interviews, the general practitioners and medical practice assistants reported that the community care points helped them save time by relieving them of social counselling tasks. The interviewees felt relieved by knowing that the community care points expertly take care of their patients' social concerns. From the perspective of the interviewees, multimorbid patients experienced changes in their care through the counselling in community care points, such as adjusting the level of care they require. Social counsellors provided patients and their relatives with an overview of the support options available. The majority of the interviewees did not feel that cooperating with the community care point put an additional burden on their patients or on themselves.

DISCUSSION AND CONCLUSION

Cooperation between general practices and community care points has the potential to improve care for multimorbid patients and reduce the workload burden on general practices. Community care points are legally anchored counselling services which general practitioners could increasingly involve in the care of patients with multimorbidity.

Clinical leaders crossing boundaries: A study on the role of clinical leadership in crossing boundaries between specialties

BACKGROUND

Due to the growing number of complex (multimorbid) patients, integrating and coordinating care across medical specialties around patient needs is an urgent theme in current health care. Clinical leadership plays an important role in stimulating coordination both within and between specialty groups, which results in better outcomes in terms of job satisfaction and quality of care.

PURPOSE

In this light, this study aims to understand the relation between physicians' clinical leadership and outcomes, focusing on the sequential mediation of relationships and coordination with physicians within their own medical specialty group and from other specialties.

METHODOLOGY

A cross-sectional self-administered survey among physicians in a Dutch hospital (n = 107) was conducted to measure clinical leadership, relational coordination at two levels (medical specialty group and between different specialties), quality of care, and job satisfaction.

RESULTS

Clinical leadership was related to better quality of care through more relational coordination within the medical specialty group. Clinical leadership was related to more job satisfaction through more relational coordination within the medical specialty group, through more relational coordination between specialties, and sequentially through both kinds of relational coordination.

CONCLUSION

Physicians who act as clinical leaders are important for crossing specialist boundaries and increasing care outcomes.

PRACTICAL IMPLICATIONS

To improve multidisciplinary collaboration, managers should encourage clinical leadership and pay attention to the strong relationships between physicians from the same specialty.

[Do General Practitioners have Experience with Social Care Points? A Berlin-Wide Survey]

Primary care for multimorbid patients involves social counseling in addition to medical care. Community care points are established institutions for social counseling at district level in Berlin. A Berlin-wide questionnaire survey examined primary care physicians' knowledge of and experience with community care points. 700 questionnaires were analysed exploratively and descriptively. General practitioners were only partially familiar with the services of community care points (60% barely or not at all). 57% of the general practitioners stated that they already had contact with community care points. General practitioners who had not yet had contact with a community care point recommended other advice centers for social (76%) and care-related advice (79%) to their patients. A majority of general practitioners expressed a wish to get more information about community care points.

[Coordinated primary care of older patients with complex needs. The perspective of family doctors in the light of a case management project within practice networks of independent physicians in Germany]

BACKGROUND

Cross-sectoral and interdisciplinary care and case management can contribute to an improved integration of the primary care for patients with geriatric characteristics. Following this approach, the pilot study RubiN (Regional ununterbrochen betreut im Netz / Continuous Care in Regional Networks) implemented a specific geriatric Care and Case Management (CCM) in five certified practice networks of independent physicians in different regions in Germany. As part of the accompanying process-based evaluation of the project, a survey was conducted among general practitioners and other specialists from these networks in order to find out how, in their view, collaboration with case managers can improve medical care of geriatric patients and contribute to closing possible gaps in primary care structures.

METHODS

The overall project RubiN, which was designed as a pragmatic controlled trial, compared patients from five practice networks where CCM has been implemented (intervention networks), with patients from three networks where the intervention was not taking place (control networks). Physicians of all eight participating practice networks were included in the present survey. The survey was conducted via a self-developed questionnaire.

RESULTS

A total of 111 physicians participated in the survey, 76 of whom were part of an intervention network and 35 part of a control network. The calculated response rate was 15.4% (networks reported a total of approx. 720 members). 91,1% of the participants from intervention networks, who had joined RubiN with their patients, reported satisfaction with their collaboration with case managers (n=41 of 45). 87.0% of the physicians from intervention networks stated that care for geriatric patients had improved as a result of their participation in the pilot study (n=40 of 46). When asked about the overall quality of care provided for their geriatric patients, the assessments of participants from intervention networks were more positive than those of the participants from control networks (MV 3.48 vs. 3.27 on a scale of 1=poor to 5=very good). Agreement with whether external case managers could provide certain services was higher among participants from intervention networks compared to participants from control networks. This was the case, in particular, of services related to medical data collection and test procedures. Overall, both comparison groups showed a high level of willingness to delegate tasks to a CCM.

DISCUSSION

Delegation of tasks to geriatric case managers seems to be more readily accepted by physicians in intervention networks than by their colleagues from the control networks, especially as regards medical assessment methods and advanced advisory tasks. The results suggest that interventions in this domain were able to convince physicians of the value that case managers can bring to medical practice and help resolve reservations and skepticism. Especially, the implemented CCM seemed to be an effective way of generating geriatric anamnestic data and fostering the flow of general patient-centered information.

CONCLUSION

From the point of view of general practitioners and other specialists participating in the intervention, CCM has been successfully implemented in their practice networks and seems to be a worthwhile approach that will help provide better coordinated and more team-oriented care to their geriatric patients.

[Referrals from general practice to community care points. What are the patients' experiences? An interview study]

INTRODUCTION

Primary care for multimorbid patients does not only include medical but also social counseling. In Germany, community care points represent an institutionalised support offer for counseling for social and care-related issues at district level.

METHODS

Within the framework of an intervention study on the cooperation between general practices and community care points in Berlin, 14 telephone interviews were conducted with multimorbid patients with social counseling needs who received advice by a community care point. The aim was to investigate satisfaction with the cooperation process as a whole and with the counseling provided by the community care points. The transcribed interviews were analysed using the framework analysis.

RESULTS

Overall, the patients were satisfied with the counseling they received from the community care points. In many cases, even after counseling, patients were not aware of the range of services offered by the community care points, and there was confusion about community care points and locally known mobile care services. Patients felt that it was particularly important to have a friendly, reliable contact person, to be close to their own place of residence and to have a long-term connection to the service. From the point of view of those affected, the general practitioner remains an important contact person who initiates the counseling, if necessary, and coordinates the interventions to be derived from the counseling result.

DISCUSSION

The confusion about community care points and mobile care services due to a lack of knowledge about the range of services offered by community care points are central topics in the interviews. This could be due to the heterogeneous supply of the community care points as well as the lack of networking with GP practices. A standardisation of the offer and increased information and networking activities of the community care points at district level could contribute to an increased level of awareness and improve transparency of their services.

CONCLUSION

In the long term, cooperation between community care points and general practitioners could help relieve the burden on general practitioners and improve social care for multimorbid patients at district level.

Analysis of the key themes in the healthcare of older people with multimorbidity in Germany: a framework analysis as part of the LoChro trial

OBJECTIVES

Multimorbidity challenges healthcare systems. In Germany, coordination of healthcare for older multimorbid patients remains unstructured.This study aims to identify key themes in the healthcare of these patients and the inter-relationships between them.

DESIGN

Framework analysis of six cases based on 1-year data of primary and secondary care, patient-answered questionnaires and video material.

SETTING

Southern Germany.

PARTICIPANTS

Six multimorbid older patients participating in a randomised controlled trial that compared usual care with a local, collaborative, stepped and personalised care management approach for older people with chronic diseases (LoChro-trial). The LoChro care intervention involved a care manager who assisted participants in self-management. The primary outcome was a composite of functional health and depressive symptoms at 12 and 18 months. The LoChro-intervention had no effect on the primary outcome.

PRIMARY OUTCOME MEASURE

Key themes in the healthcare of older patients with multimorbidity and the inter-relationships between them.

METHODS

One-year data included diagnoses, treatment plans, examinations, assessments and discharge reports. Patient perspectives were assessed using the Patient Assessment of Chronic Illness Care. In three cases, videos of the LoChro intervention showed patients describing their health needs. These data were evaluated by three doctors and public health researchers. Using framework analysis, recurring themes influencing the healthcare situation of multimorbid older patients and their inter-relationships were identified.

RESULTS

Participants had an average age of 77, with 13 diagnoses, taking eight medications regularly. The five key themes describing the healthcare situation of these multimorbid patients were as follows: insufficient coordination, overuse and underuse of medical care, doctor and patient roles. Each theme covered three to four subcategories. The most significant inter-relationships between these themes were a lack of coordination leading to overuse and underuse of medical care. These were characterised by redundant inpatient stays, potential prescribing omissions and missed examinations. Deficiencies in vaccinations and secondary prevention were also demonstrated.

CONCLUSION

Coordination of care for multimorbid older patients in Germany is still deficient. Future healthcare arrangements should be explored with the participation of physicians and patients.

TRIAL REGISTRATION NUMBER

LoChro trial: DRKS00013904.

Continuity and care coordination of primary health care: a scoping review

BACKGROUND

Healthcare coordination and continuity of care conceptualize all care providers and organizations involved in health care to ensure the right care at the right time. However, systematic evidence synthesis is lacking in the care coordination of health services. This scoping review synthesizes evidence on different levels of care coordination of primary health care (PHC) and primary care.

METHODS

We conducted a scoping review of published evidence on healthcare coordination. PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science and Google Scholar were searched until 30 November 2022 for studies that describe care coordination/continuity of care in PHC and primary care. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines to select studies. We analysed data using a thematic analysis approach and explained themes adopting a multilevel (individual, organizational, and system) analytical framework.

RESULTS

A total of 56 studies were included in the review. Most studies were from upper-middle-income or high-income countries, primarily focusing on continuity/care coordination in primary care. Ten themes were identified in care coordination in PHC/primary care. Four themes under care coordination at the individual level were the continuity of services, linkage at different stages of health conditions (from health promotion to rehabilitation), health care from a life-course (conception to elderly), and care coordination of health services at places (family to hospitals). Five themes under organizational level care coordination included interprofessional, multidisciplinary services, community collaboration, integrated care, and information in care coordination. Finally, a theme under system-level care coordination was related to service management involving multisectoral coordination within and beyond health systems.

CONCLUSIONS

Continuity and coordination of care involve healthcare provisions from family to health facility throughout the life-course to provide a range of services. Several issues could influence multilevel care coordination, including at the individual (services or users), organizational (providers), and system (departments and sectors) levels. Health systems should focus on care coordination, ensuring types of care per the healthcare needs at different stages of health conditions by a multidisciplinary team. Coordinating multiple technical and supporting stakeholders and sectors within and beyond health sector is also vital for the continuity of care especially in resource-limited health systems and settings.

Practice and Enlightenment of Chronic Disease Management at the County Level in China from the Perspective of Professional Integration: A Qualitative Case Study of Youxi County, Fujian Province

Background

It is currently the most cost-effective management model to have multiple professionals from relevant institutions collaborate so as to provide integrated chronic disease management services. The "classified, color-coded, hierarchical and regionalized" chronic disease management model in Youxi County, Fujian Province is a typical case in China. However, related research is limited. This paper aims to analyze the practice measures and lessons learned in Youxi County, focusing on the professional integration of service providers.

Methods

From January to March 2021, interviews with 15 key informants in Youxi County were conducted to collect qualitative data, which was analyzed by the thematic framework method as well as the policy data, using the professional integration dimension in the evaluation framework of the integrated healthcare system.

Results

A series of measures were taken, such as improving the professional division and collaboration mechanism, establishing the incentive and restraint mechanism geared toward chronic disease management, formulating norms and standards of chronic disease management for patients with different color labels, and promoting the compatibility of inter-professional value and culture under the governmental institutional supply and the organizational support of the tight county healthcare alliance in Youxi County, to prompt professionals of different levels and types to collaborate in order to provide integrated chronic disease management services. However, some problems remained, such as limited capacity of primary health care, the relatively narrow range and weak effect of the incentive and restraint mechanism, inadequate implementation of the norms and standards, and so forth.

Conclusions

Our findings provide reference for other regions in China and other low- and middle-income countries in exploring the integrated chronic disease management model. Long-term follow-up surveys and mixed research designs are required in the future to enrich relevant evidence.

Evaluation of a community-based integrated care model (CIE) for frail older people in rural Foshan, China: study protocol for a stepped-wedge cluster randomized controlled trial {1}

BACKGROUND

While community-based eldercare has proven to be effective in qualitative studies, there is limited evidence on the effectiveness of this geriatric care model in rural communities where caring for older people is traditionally the responsibility of family members, but a formal long-term care was recently introduced in China. CIE is a rural community-embedded intervention using multidisciplinary team, to provide evidenced-based integrated care services for frail older people including social care services and allied primary healthcare and community-based rehabilitation services.

METHODS

CIE is a prospective stepped-wedge cluster randomized trial conducted at 5 community eldercare centers in rural China. The multifaceted CIE intervention, guided by chronic care model and integrated care model, consists of five components: comprehensive geriatric assessment, individualized care planning, community-based rehabilitation, interdisciplinary case management, and care coordination. The intervention is rolled out in a staggered manner in these clusters of centers at an interval of 1 month. The primary outcomes include functional status, quality of life, and social support. Process evaluation will also be conducted. Generalized linear mixed model is employed for binary outcomes.

DISCUSSION

This study is expected to provide important new evidence on clinical effectiveness and implementation process of an integrated care model for frail older people. The CIE model is also unique as the first registered trial implementing a community-based eldercare model using multidisciplinary team to promote individualized social care services integrated with primary healthcare and community-based rehabilitation services for frail older people in rural China, where formal long-term care was recently introduced. TRIAL REGISTRATION {2A}: China Clinical Trials Register ( http://www.chictr.org.cn/historyversionpub.aspx?regno=ChiCTR2200060326 ). May 28th, 2022.

Validation of patient- and GP-reported core sets of quality indicators for older adults with multimorbidity in primary care: results of the cross-sectional observational MULTIqual validation study

BACKGROUND

Older adults with multimorbidity represent a growing segment of the population. Metrics to assess quality, safety and effectiveness of care can support policy makers and healthcare providers in addressing patient needs. However, there is a lack of valid measures of quality of care for this population. In the MULTIqual project, 24 general practitioner (GP)-reported and 14 patient-reported quality indicators for the healthcare of older adults with multimorbidity were developed in Germany in a systematic approach. This study aimed to select, validate and pilot core sets of these indicators.

METHODS

In a cross-sectional observational study, we collected data in general practices (n = 35) and patients aged 65 years and older with three or more chronic conditions (n = 346). One-dimensional core sets for both perspectives were selected by stepwise backward selection based on corrected item-total correlations. We established structural validity, discriminative capacity, feasibility and patient-professional agreement for the selected indicators. Multilevel multivariable linear regression models adjusted for random effects at practice level were calculated to examine construct validity.

RESULTS

Twelve GP-reported and seven patient-reported indicators were selected, with item-total correlations ranging from 0.332 to 0.576. Fulfilment rates ranged from 24.6 to 89.0%. Between 0 and 12.7% of the values were missing. Seventeen indicators had agreement rates between patients and professionals of 24.1% to 75.9% and one had 90.7% positive and 5.1% negative agreement. Patients who were born abroad (- 1.04, 95% CI =  - 2.00/ - 0.08, p = 0.033) and had higher health-related quality of life (- 1.37, 95% CI =  - 2.39/ - 0.36, p = 0.008), fewer contacts with their GP (0.14, 95% CI = 0.04/0.23, p = 0.007) and lower willingness to use their GPs as coordinators of their care (0.13, 95% CI = 0.06/0.20, p < 0.001) were more likely to have lower GP-reported healthcare quality scores. Patients who had fewer GP contacts (0.12, 95% CI = 0.04/0.20, p = 0.002) and were less willing to use their GP to coordinate their care (0.16, 95% CI = 0.10/0.21, p < 0.001) were more likely to have lower patient-reported healthcare quality scores.

CONCLUSIONS

The quality indicator core sets are the first brief measurement tools specifically designed to assess quality of care for patients with multimorbidity. The indicators can facilitate implementation of treatment standards and offer viable alternatives to the current practice of combining disease-related metrics with poor applicability to patients with multimorbidity.

The Contribution of Intersectoral Healthcare Centres with an Extended Outpatient Care Model to Improve Regional Care-Structures-A Qualitative Study

Many smaller hospitals in Germany are currently threatened with closure due to economic reasons and politically derived centralization. In some-especially rural areas-this may result in a lack of accessible local care structures. At the same time, patients are unnecessarily admitted to hospitals due to insufficient primary care structures and healthcare coordination. Intersectoral health centers (IHC), as new intermediary structures, may offer round-the-clock monitoring (Extended Outpatient Care, EOC), with fewer infrastructure needs than hospitals and, thus, could offer a sustainable solution. In an iterative process, 30 expert interviews (with physicians, nurses and other healthcare experts) formed the basis for the derivation of diagnostic groups, relevant related patient characteristics and scenarios, as well as structural preconditions necessary for safe care in the setting of the new model of IHC/EOC. Additionally, three workshops within the multidisciplinary research team (including healthcare services researchers, GPs, and health economists) were performed. Inductive categories on disease-, case-, sociodemographic- and infrastructure-related criteria were derived following thematic analysis. Due to the expert interviews, general practice equipment plus continuous monitoring beds should form the basic infrastructure for EOCs, which should be adjusted to local needs and infrastructure demands. GPs could be aided through (electronic) support by other specialists. IHC, as a physician-led facility, should rely on experienced nurses to allow for 24-h services and to support integrated team-based primary care with GPs. Alongside nurses, case managers, therapists and social workers can be included in the structure, allowing for improved integration of (primary) care services. In order to sustain low-threshold, local access to care, especially in rural areas, IHC with extended monitoring and integration of coordinative support, emerged as a promising solution that could solve many common patient needs without the need for hospital-based inpatient care.

Changes to utilization and provision of health care in German GP practices during the COVID 19-pandemic: Protocol for a mixed methods study on the viewpoint of GPs, medical practice assistants, and patients

INTRODUCTION

During the COVID-19 pandemic, general practitioners (GPs) continued to be a main point of contact for patients. For GP practices, it was and still is a challenge to meet constantly changing requirements due to the various phases of the pandemic. The aim of the study is to explore retrospectively the subjective experience with supply and utilization of health care services from the perspective of general practitioners, medical practice assistants and patients, in particular regarding instances of underutilization of services for non-Covid related conditions, adjustments due to the pandemic, and the appropriateness of care.

METHODS

The study is carried out within the RESPoNsE research practice network in three of Germany's federal states: Berlin, Brandenburg, and Thuringia (RESPoNsE-Research practice network east). The study follows a convergent mixed method design, and consists of the following sections: a) two anonymous paper-based questionnaires filled out by GPs and medical practice assistants (MPAs), at an interval of 12 to 18 months; b) in-depth qualitative interviews conducted among a subgroup of GPs and MPAs; c) anonymous paper-based questionnaires among patients of participating practices. The idea for the study was derived from discussions with the practice advisory board of the RESPoNsE network. The themes and issues to be explored in the surveys and interviews are developed and discussed in the practice advisory board, the patient advisory board, and with interested MPAs. The questionnaires will be analyzed descriptively, exploring the effect of demographic variables. Qualitative content analysis is used to analyze the data from the interviews and focus groups.

DISCUSSION

The study focuses on the conditions of GP care during the COVID-19 pandemic. A broad insight is provided as GPs and MPAs, as well as patients, are involved. It provides the opportunity to express needs and concerns. The results can support future discussions on lessons learned from the pandemic and necessary changes in health care delivery.

TRIAL REGISTRATION

Trial registration at the German Clinical Trials Register: DRKS00028095.

Non-acute chest pain in primary care; referral rates, communication and guideline adherence: a cohort study using routinely collected health data

BACKGROUND

The prevalence of coronary artery disease is increasing due to the aging population and increasing prevalence of cardiovascular risk factors. Non-acute chest pain often is the first symptom of stable coronary artery disease. To optimise care for patients with non-acute chest pain and make efficient use of available resources, we need to know more about the current incidence, referral rate and management of these patients.

METHODS

We used routinely collected health data from the STIZON data warehouse in the Netherlands between 2010 and 2016. Patients > 18 years, with no history of cardiovascular disease, seen by the general practitioner (GP) for non-acute chest pain with a suspected cardiac origin were included. Outcomes were (i) incidence of new non-acute chest pain in primary care, (ii) referral rates to the cardiologist, (iii) correspondence from the cardiologist to the GP, (iv) registration by GPs of received correspondence and; (v) pharmacological guideline adherence after newly diagnosed stable angina pectoris.

RESULTS

In total 9029 patients were included during the study period, resulting in an incidence of new non-acute chest pain of 1.01/1000 patient-years. 2166 (24%) patients were referred to the cardiologist. In 857/2114 (41%) referred patients, correspondence from the cardiologist was not available in the GP's electronic medical record. In 753/1257 (60%) patients with available correspondence, the GP did not code the conclusion in the electronic medical record. Despite guideline recommendations, 37/255 (15%) patients with angina pectoris were not prescribed antiplatelet therapy nor anticoagulation, 69/255 (27%) no statin and 67/255 (26%) no beta-blocker.

CONCLUSION

After referral, both communication from cardiologists and registration of the final diagnosis by GPs were suboptimal. Both cardiologists and GPs should make adequate communication and registration a priority, as it improves health outcomes. Secondary pharmacological prevention in patients with angina pectoris was below guideline standards. So, proactive attention needs to be given to optimise secondary prevention in this high-risk group in primary care.

A systematic literature review of patient self-assessment instruments concerning quality of primary care in multiprofessional clinics

BACKGROUND

Quality of care remains a priority issue and is correlated with patient experience. Measuring multidimensional patient primary care experiences in multiprofessional clinics requires a robust instrument. Although many exist, little is known about their quality.

OBJECTIVE

To identify patient perception instruments in multiprofessional primary care and evaluate their quality.

METHODS

Systematic review using Medline, Pascal, PsycINFO, Google Scholar, Cochrane, Scopus, and CAIRN. Eligible articles developed, evaluated, or validated 1 or more self-assessment instruments. The instruments had to measure primary care delivery, patient primary care experiences and assess at least 3 quality-of-care dimensions. The COnsensus-based Standards for the selection of health status Measurement Instruments (COSMIN) checklist was used to assess methodological quality of included studies. Instrument measurement properties were appraised using 3 possible quality scores. Data were combined to provide best-evidence synthesis based on the number of studies, their methodological quality, measurement property appraisal, and result consistency. Subscales used to capture patient primary care experiences were extracted and grouped into the 9 Institute of Medicine dimensions.

RESULTS

Twenty-nine articles were found. The included instruments captured many subscales illustrating the diverse conceptualization of patient primary care experiences. No included instrument demonstrated adequate validity and the lack of scientific methodology for assessing reliability made interpreting validity questionable. No study evaluated instrument responsiveness.

CONCLUSION

Numerous patient self-assessment instruments were identified capturing a wide range of patient experiences, but their measurement properties were weak. Research is required to develop and validate a generic instrument for assessing quality of multiprofessional primary care.

TRIAL REGISTRATION

Not applicable.

COMPASS II—Coordination of Medical Professions Aiming at Sustainable Support Protocol for a feasibility study of cooperation between general practitioner practices and community care points

Introduction

General practitioners (GP) increasingly face the challenge of meeting the complex care needs of multi-morbid patients. Previous studies show that GP practices would like support from other institutions in advising on social aspects of care for multi-morbid patients. Already existing counselling services, like community care points, are not sufficiently known by both GPs and patients. The aim of COMPASS II is to investigate the feasibility of cooperation between GP practices and community care points.

Methods and analysis

During the intervention, GPs send eligible multi-morbid patients with social care needs to a community care point. The community care points report the consultation results back to the GPs. In preparation for the intervention, in a moderated process, GP practices meet with the community care points to agree on information exchange. The primary outcome is the feasibility of the cooperation: Questionnaires will be sent to GPs, medical practice assistances and community care point personnel (focus: practicality, acceptability). Data will be collected on frequency and reasons for GP-initiated consultations at community care points (focus: demand). Qualitative interviews will be conducted with all participating groups (focus: acceptability, satisfaction). The secondary outcome is the assessment of changes in health-related quality of life, social support and satisfaction with care: participating patients complete a questionnaire before and three to six months after their counselling. The results of the study will be incorporated into a manual in which the experiences of the cooperation will be made available to other GP practices and community care points.

Discussion

In COMPASS II, GP practices establish cooperation with community care points. The latter are already existing institutions that provide independent and free advice on social matters. By using an existing institution, the established cooperation and experiences from the study can be used beyond the end of the study.

Trial registration

The trial is registered with DRKS-ID: DRKS00023798, Coordination of Medical Professions Aiming at Sustainable Support II.

Development of a patient-oriented navigation model for patients with lung cancer and stroke in Germany

Background

The concept of patient navigation was first established in the USA to support vulnerable patient groups in receiving timely and comprehensive access to cancer care. It has recently gained increasing interest in Germany to support patients with chronic diseases in a fragmented healthcare system. The aim of this paper is to present the development of such a model adapted to the German context based on the results of mixed-methods studies investigating the need for and barriers to patient-oriented care.

Methods

In a process adapted from Delphi rounds, we conducted regular structured workshops with investigators of the project to discuss results of their studies and identify content and structure of the model based on the data. Workshop discussions were structured along seven core components of a navigation model including target patient groups, navigator tasks, occupational background and education of navigators, and patient-navigator interaction mode.

Results

Using an approach based on empirical data of current care practices with special focus on patients’ perspectives, we developed a patient-oriented navigation model for patients who have experienced stroke and lung cancer in the German healthcare context. Patients without personal social support were viewed as struggling most with the healthcare system, as well as multimorbid and elderly patients. Navigators should serve as a longer-term contact person with a flexible contact mode and timing based on the individual situation and preferences of patients. Navigator tasks include the provision of administrative and organizational support as well as referral and guidance to available resources and beneficial health programs with special forms of knowledge. Implementation of the navigator should be flexibly located to ensure a reliable outreach to vulnerable patients for first contact in settings like specialized in-patient and out-patient settings, while navigation itself focuses on care coordination in the out-patient setting.

Conclusion

Flexibility of navigator tasks needed to be a core characteristic of a navigation model to be perceived as supportive from patients’ perspectives. In a subsequent feasibility study, an intervention based on the model will be evaluated according to its acceptance, demand, and practicality.

Multimorbidity and healthcare utilization among Black Americans: A cross-sectional study

Aim

Racial disparities between multimorbidity presence and healthcare utilization are present within the United States, but less is known about the relationship between multimorbidity presence and healthcare utilization among Black Americans. This study was conducted to examine the relationship between multimorbidity and healthcare utilization among Black Americans.

Design

Cross‐sectional study.

Methods

This study (n = 425, 57% female) used adult level data from the 2012–2013 Connecticut Health Care Survey.

Results

Multivariate logistic regressions indicated that multimorbidity presence predicted a doctor and a specialist visit, but not a dentist visit.

Conclusion

This study identified multimorbidity presence as a predictor for healthcare utilization, but further research is necessary to understand healthcare utilization experiences among Black Americans with multimorbidity to assess the quality of care. Appropriate measures should also be considered to increase access to dental care for Black Americans with multimorbidity.

Scaling-up an Integrated Care for Patients with Non-communicable Diseases: An Analysis of Healthcare Barriers and Facilitators in Slovenia and Belgium

Introduction

Although the concept of integrated care for non-communicable diseases was introduced at the primary level to move from disease-centered to patient-centered care, it has only been partially implemented in European countries. The aim of this study was to identify and compare identified facilitators and barriers to scale-up this concept between Slovenia and Belgium.

Methods

This was a qualitative study. Fifteen focus groups and fifty-one semi-structured interviews were conducted with stakeholders at the micro, meso and macro levels. In addition, data from two previously published studies were used for the analysis. Data collection and analysis was initially conducted at country level. Finally, the data was evaluated by a cross-country team to assess similarities and differences between countries.

Results

Four topics were identified in the study: patient-centered care, teamwork, coordination of care and task delegation. Despite the different contexts, true teamwork and patient-centered care are limited in both countries by hierarchies and a very heavily skewed medical approach. The organization of primary healthcare in Slovenia probably facilitates the coordination of care, which is not the case in Belgium. The financing and organization of primary practices in Belgium was identified as a barrier to the implementation of task delegation between health professionals.

Conclusions

This study allowed formulating some important concepts for future healthcare for non-communicable diseases at the level of primary healthcare. The results could provide useful insights for other countries with similar health systems.

Perceived facilitators and barriers to chronic disease management in primary care networks of Singapore: a qualitative study

OBJECTIVE

The increasing chronic disease burden has placed tremendous strain on tertiary healthcare resources in most countries, necessitating a shift in chronic disease management from tertiary to primary care providers. The Primary Care Network (PCN) policy was promulgated as a model of care to organise private general practitioners (GPs) into groups to provide GPs with resources to anchor patients with chronic conditions with them in the community. As PCN is still in its embryonic stages, there is a void in research regarding its ability to empower GPs to manage patients with chronic conditions effectively. This qualitative study aims to explore the facilitators and barriers for the management of patients with chronic conditions by GPs enrolled in PCN.

DESIGN

We conducted 30 semistructured interviews with GPs enrolled in a PCN followed by a thematic analysis of audio transcripts until data saturation was achieved.

SETTING

Singapore.

RESULTS

Our results suggest that PCNs facilitated GPs to more effectively manage patients through (1) provision of ancillary services such as diabetic foot screening, diabetic retinal photography and nurse counselling to permit a 'one-stop-shop', (2) systematic monitoring of process and clinical outcome indicators through a chronic disease registry (CDR) to promote accountability for patients' health outcomes and (3) funding streams for PCNs to hire additional manpower to oversee operations and to reimburse GPs for extended consultations. Barriers include high administrative load in maintaining the CDR due to the lack of a smart electronic clinic management system and financial gradient faced by patients seeking services from private GPs which incur higher out-of-pocket expenses than public primary healthcare institutions.

CONCLUSION

PCNs demonstrate great promise in empowering enrolled GPs to manage patients with chronic conditions. However, barriers will need to be addressed to ensure the viability of PCNs in managing more patients in the face of an ageing population.

The Acceptability of Task-Shifting from Doctors to Allied Health Professionals

BACKGROUND

The shifting of medical tasks (MT) to Qualified Medical Practice Assistants (MPA) is an option that can be pursued to ensure adequate health care in Germany despite the increasing scarcity of physicians. The goal of this study was to determine the acceptability of medical task-shifting to MPA among the general population.

METHODS

In a nationwide, representative telephone survey, 6105 persons aged 18 or older were asked whether they would be willing to receive care from a specially trained MPA at a physician's office. Their responses were tested for correlations with sociodemographic characteristics by means of bivariate (chi-squared test, Mann-Whitney U test) and multivariable statistics (logistic regression).

RESULTS

Of the respondents, 67.2% expressed willingness to accept the shifting of MT to an MPA for the treatment of a minor illness, and 51.8% for a chronic illness. Rejection of task-shifting was associated with old age, residence in western Germany, and citizenship of a country other than Germany. For example, non-Germans rejected task-shifting more commonly than Germans, for both minor illnesses (odds ratio [OR] 2.96; 95% confidence interval [2.28; 3.85]) and chronic illnesses (OR 1.61; [1.24; 2.10]).

CONCLUSION

Further studies are needed to investigate the motives for rejection of medical task-shifting to MPA in order to assess the likelihood of successful nationwide introduction of a uniform delegation model.

Fragmentation of care: a major challenge for older people living with multimorbidity

As the world’s aging population is rising, so too is the prevalence of multimorbidity increasing among older adults. Multimorbidity is therefore a growing public health challenge among the older population. Researchers have reported fragmentation of care to be one of the major problems facing this population. The leading factors responsible for this issue are use of disease-centered approaches and specialism to manage people living with multimorbidity; poor communication between professionals and people with multimorbidity; and poor communication among the professionals caring for these people. Failure to address this problem leads to increased treatment burden, including polypharmacy. There is therefore a need for all healthcare professionals caring for older people living with multimorbidity to address this problem by providing continuous, coordinated person-centered care. For the person-centered care approach to be well-coordinated and continuous, there is a need for effective means of sharing information among healthcare providers, to facilitate inter-professional collaboration; extension of consultation time to better enable healthcare providers to understand the patient's needs; review of organizational frameworks and policies where necessary; and development of new guidelines for the management of multimorbidity.

[Non-medical aspects in the care for multimorbid patients in general practice. What kind of support and cooperation is desired? Focus groups with general practitioners in Berlin]

BACKGROUND

General practitioners (GPs) are the first point of contact and they coordinate the care for multimorbid patients. This article discusses possible solutions for GPs' needs and wishes regarding the support for non-medical issues, in particular social and legal tasks as well as the cooperation with already existing institutions.

METHODS

In the third study phase of a mixed-methods approach, two focus groups with eleven GPs from Berlin were carried out. The project is part of the NAVICARE project, funded by the federal Ministry of Education and Research. The focus groups were analyzed using the framework analysis.

RESULTS

GPs caring for multimorbid patients are often faced with non-medical patient needs and social consultation issues. They would like to receive support in these areas and want more cooperative care structures. They are largely unaware of existing offers by social institutions in their city districts. The designation of a fixed contact person in social institutions could improve communication and thus enable low-threshold access.

DISCUSSION AND CONCLUSION

The GPs agree that there is a need for support with social and legal matters in general practice. The focus groups discussed already existing offers that GPs could use more frequently and how a cooperation with providers of social care could succeed. GPs in Berlin think that support and relief measures, in particular in the form of cooperation with institutions in the district that provide social and legal support, are both desirable and conceivable.