Continuity in general practice and hospitalization patterns: an observational study

[Ensuring primary care in Germany-findings from a quantitative survey of general practitioners]

BACKGROUND

Given the risk of a shortage of general practitioners in private practice, the question arises as to which concepts can make an effective contribution. To date, there is a lack of studies that comprehensively shed light on how general practitioners, based on their professional experience, view different approaches to ensuring primary care in the long term.

OBJECTIVES

The aim of the study was to determine the positions, attitudes, and experiences of general practitioners with regard to ensuring primary care.

METHODS

Using an online survey, a total of 4176 general practitioners were surveyed between February and June 2023. In addition to the descriptive analysis, a t-test on independent samples was used to determine significant differences between two groups.

RESULTS

Of those surveyed, 42% reported a noticeable decline of general medical practices in their area. In addition, 53% saw a declining attractiveness of primary care for young doctors, which is attributed to three problem areas: 1) the position of primary care in the healthcare system, 2) requirements for training and further education, and 3) working conditions. In order to secure primary care, those surveyed were primarily in favor of the following approaches: establishing a primary care physician system (85%), increasing the promotion of interest and points of contact in training and further education (80%), strengthening multi-professional outpatient care centers (64%), restructuring curricula (56%) and admission criteria for medical studies (50%), and reforming general medical training (53%).

CONCLUSIONS

As the results show, general practitioners have their own suggestions and preferences that complement existing expert assessments. General practitioners should be more consistently involved in the planning, implementation, and evaluation of measures to stabilize primary care.

[Changes in the provision and utilization of health care in German primary care practices during the COVID-19 pandemic - A survey of patients in three federal states]

INTRODUCTION

During the COVID-19 pandemic general practitioners (GP) practice teams were temporally confronted with major challenges which were accompanied by changes in practice organization and service provision. So far, little has been known about the views of patients who visited the GP practice for other than COVID-related reasons with regard to provision and use of GP services, the adjustments in the practice and the work of the practice team members.

METHODS

The patient survey is a sub-study of the mixed-methods study VeCo-Praxis (GP healthcare for patients not suffering from COVID during the Corona pandemic) of the research practice network RESPoNsE (Research Practice Network East), which was conducted in the federal states of Berlin, Brandenburg and Thuringia. The questionnaire-based survey was carried out among patients who visited their GP practice in November 2022. The topics covered in the survey were developed by two focus groups consisting of 13 members of the RESPoNsE patient advisory board. The questionnaire was developed and piloted in a participatory approach with the RESPoNsE Patient Advisory Board. The results were analyzed descriptively using SPSS and discussed with the advisory board.

RESULTS

1,405 questionnaires from 37 practices were analyzed. 97% of respondents felt that the treatment they received at their GP practice during the COVID-19 pandemic was good. For the vast majority, appointments and acute consultations, prescriptions, laboratory tests, discussions of diagnostic results, routine follow-up check-ups and health checks were available to a sufficient extent. From the patients' perspective, the practices have successfully adapted to the challenges caused by COVID-19. Overall, the patients' trust in and their appreciation of the work of the practice staff have increased since the pandemic. Patients stated that GP practices should continue hygiene procedures, such as wearing a mask or keeping physical distance, in the future.

DISCUSSION

Despite multiple reports of a significant decline in both provision and utilization of standard care in GP practices during the pandemic, our survey showed that the majority of patients felt that they received adequate GP care and were highly satisfied. The results should be interpreted against the background of possible selection bias.

CONCLUSION

In this survey, GP patients were predominantly appreciative of GP care during the COVID-19 pandemic. The patients' assessment of the provision and use of GP services during the pandemic complements the corresponding perspective of GPs and medical practice assistants.

Would you zoom with your doctor? A discrete choice experiment to identify patient preferences for video and in-clinic consultations in German primary care

INTRODUCTION

The popularity of video consultations in healthcare has accelerated during the COVID-19 pandemic. Despite increased availability and obvious benefits, many patients remain hesitant to use video consultations. This study investigates the relative importance of the consultation mode compared to other attributes in patients' appointment choices in Germany.

METHODS

A discrete choice experiment was conducted to examine the influence of appointment attributes on preferences for video over in-clinic consultations. A total of 350 participants were included in the analysis.

RESULTS

The level of continuity of care (46%) and the waiting time until the next available appointment (22%) were shown to have higher relative importance than consultation mode (18%) and other attributes. Participants with fewer data privacy concerns, higher technology proficiency, and more fear of COVID-19 tended to prefer video over in-clinic consultations. The predicted choice probability of a video over a typical in-clinic consultation and opting out increased from <1% to 40% when the video consultation was improved from the worst-case to the best-case scenario.

CONCLUSION

This study provides insight into the effect of the consultation mode on appointment choice at a time when telemedicine gains momentum. The results suggest that participants preferred in-clinic over video consultations. Policymakers and service providers should focus on increasing the level of continuity of care and decreasing the time until the next available appointment to prompt the adoption of video consultations. Although participants preferred to talk to their physician in person over consulting via video per se, the demand for video consultations can be increased significantly by improving the other appointment attributes of video consultations such as the level of continuity of care.

Optimising personal continuity for older patients in general practice: a cluster randomised stepped wedge pragmatic trial

AIM

To evaluate the effectiveness, feasibility and acceptability of a multicomponent intervention for improving personal continuity for older patients in general practice.

DESIGN

A cluster randomised three-wedged, pragmatic trial during 18 months.

SETTING

32 general practices in the Netherlands.

PARTICIPANTS

221 general practitioners (GPs), practice assistants and other practice staff were included. Practices were instructed to include a random sample of 1050 patients aged 65 or older at baseline and 12-month follow-up.

INTERVENTION

The intervention took place at practice level and included opTimise persOnal cOntinuity for oLder (TOOL)-kit: a toolbox containing 34 strategies to improve personal continuity.

OUTCOMES

Data were collected at baseline and at six 3-monthly follow-up measurements. Primary outcome measure was experienced continuity of care at the patient level measured by the Nijmegen Continuity Questionnaire (NCQ) with subscales for personal continuity (GP knows me and GP shows commitment) and team/cross-boundary continuity at 12-month follow-up. Secondary outcomes were measured in GPs, practice assistants and other practice staff and included work stress and satisfaction and perceived level of personal continuity. In addition, a process evaluation was undertaken among GPs, practice assistants and other practice staff to assess the acceptability and feasibility of the intervention.

RESULTS

No significant effect of the intervention was observed on NCQ subscales GP knows me (adjusted mean difference: 0.05 (95% CI -0.05 to 0.15), p=0.383), GP shows commitment (0.03 (95% CI -0.08 to 0.14), p=0.668) and team/cross-boundary (0.01 (95% CI -0.06 to 0.08), p=0.911). All secondary outcomes did not change significantly during follow-up. Process evaluation among GPs, practice assistants and other practice staff showed adequate acceptability of the intervention and partial implementation due to the COVID-19 pandemic and a high perceived workload.

CONCLUSION

Although participants viewed TOOL-kit as a practical and accessible toolbox, it did not improve personal continuity as measured with the NCQ. The absence of an effect may be explained by the incomplete implementation of TOOL-kit into practice and the choice of general outcome measures instead of outcomes more specific for the intervention.

TRIAL REGISTRATION NUMBER

International Clinical Trials registry Platform (ICTRP), trial NL8132 (URL: ICTRP Search Portal (who.int).

"I do not know the advantages of having a general practitioner" - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care

BACKGROUND

Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP.

METHOD

Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis.

RESULTS

Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity.

CONCLUSION

Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00023480; date: 2020/11/27.

Two-year follow-up of a clustered randomised controlled trial of a multicomponent general practice intervention for people at risk of poor health outcomes

BACKGROUND

This study was a two-year follow-up evaluation of health service use and the cost-effectiveness of a multicomponent general practice intervention targeted at people at high risk of poor health outcomes.

METHODS

A two-year follow-up study of a clustered randomised controlled trial was conducted in South Australia during 2018-19, recruiting 1044 patients from three cohorts: children; adults (aged 18-64 years with two or more chronic diseases); and older adults (aged ≥ 65 years). Intervention group practices (n = 10) provided a multicomponent general practice intervention for 12 months. The intervention comprised patient enrolment to a preferred general practitioner (GP), access to longer GP appointments and timely general practice follow-up after episodes of hospital care. Health service outcomes included hospital use, specialist services and pharmaceuticals. The economic evaluation was based on quality-adjusted life years (QALYs) calculated from EuroQoL 5 dimensions, 5 level utility scores and used an A$50,000 per QALY gained threshold for determining cost-effectiveness.

RESULTS

Over the two years, there were no statistically significant intervention effects for health service use. In the total sample, the mean total cost per patient was greater for the intervention than control group, but the number of QALYs gained in the intervention group was higher. The estimated incremental cost-effectiveness ratio (ICER) was A$18,211 per QALY gained, which is lower than the A$50,000 per QALY gained threshold used in Australia. However, the intervention's cost-effectiveness was shown to differ by cohort. For the adult cohort, the intervention was associated with higher costs and lower QALYs gained (vs the total cohort) and was not cost-effective. For the older adults cohort, the intervention was associated with lower costs (A$540 per patient), due primarily to lower hospital costs, and was more effective than usual care.

CONCLUSIONS

The positive cost-effectiveness results from the 24-month follow-up warrant replication in a study appropriately powered for outcomes such as hospital use, with an intervention period of at least two years, and targeted to older people at high risk of poor health outcomes.

Greater temporal regularity of primary care visits was associated with reduced hospitalizations and mortality, even after controlling for continuity of care

BACKGROUND

Previous studies have shown that more temporally regular primary care visits are associated with improved patient outcomes.

OBJECTIVE

To examine the association of temporal regularity (TR) of primary care with hospitalizations and mortality in patients with chronic illnesses. Also, to identify threshold values for TR for predicting outcomes.

DESIGN

Retrospective cohort study.

PARTICIPANTS

We used data from the electronic health record of a health maintenance organization in Israel to study primary care visits of 70,095 patients age 40 + with one of three chronic conditions (diabetes mellitus, heart failure, chronic obstructive pulmonary disease).

MAIN MEASURES

We calculated TR for each patient during a two-year period (2016-2017), and divided patients into quintiles based on TR. Outcomes (hospitalization, death) were observed in 2018-2019. Covariates included the Bice-Boxerman continuity of care score, demographics, and comorbidities. We used multivariable logistic regression to examine TR's association with hospitalization and death, controlling for covariates.

KEY RESULTS

Compared to patients receiving the most regular care, patients receiving less regular care had increased odds of hospitalization and mortality, with a dose-response curve observed across quintiles (p for linear trend < 0.001). For example, patients with the least regular care had an adjusted odds ratio of 1.40 for all-cause mortality, compared to patients with the most regular care. Analyses stratified by age, sex, ethnic group, area-level SES, and certain comorbid conditions did not show strong differential associations of TR across groups.

CONCLUSIONS

We found an association between more temporally regular care in antecedent years and reduced hospitalization and mortality of patients with chronic illness in subsequent years, after controlling for covariates. There was no clear threshold value for temporal regularity; rather, more regular primary care appeared to be better across the entire range of the variable.

Fall-risk-increasing drugs in older patients: the role of guidelines and GP-centred health care in Germany

BACKGROUND

fall-risk-increasing drugs (FRIDs) are a ubiquitous issue, especially for older patients. As part of a German guideline for pharmacotherapy, from 2019, a new quality indicator for this patient group was developed to measure the percentage of patients receiving FRIDs.

METHODS

patients, aged at least 65 years in 2020, insured by the Allgemeine OrtsKrankenkasse statutory health insurance (Allgemeine Ortskrankenkasse, Baden-Wuerttemberg, Germany) with a particular general practitioner (GP) were observed from 1 January to 31 December 2020 cross-sectionally. The intervention group received GP-centred health care. Within GP-centred health care, GPs have the role of gatekeepers for patients within the health system and are-in contrast to regular care GPs in addition to other commitments-obliged to regularly attend training sessions on appropriate pharmacotherapy. The control group received regular GP care. For both groups, we measured the percentage of patients receiving FRIDs as well as the occurrence of (fall-related) fractures as the main outcomes. To test our hypotheses, we performed multivariable regression modelling.

RESULTS

a total of 634,317 patients were eligible for analysis. Within the intervention group (n = 422,364), we could observe a significantly reduced odds ratio (OR) for obtaining a FRID (OR = 0.842, confidence interval [CI]: [0.826, 0.859], P < 0.0001) in comparison to the control group (n = 211,953). Moreover, we could observe a significantly reduced chance for (fall-related) fractures in the intervention group (OR: 0.932, CI: [0.889, 0.975], P = 0.0071).

CONCLUSIONS

the findings point in the direction that the health care providers' awareness of the potential danger of FRIDs for older patients is higher in the GP-centred care group.

Exploring the views of low-acuity emergency department consulters on an educational intervention and general practitioner appointment service: a qualitative study in Berlin, Germany

OBJECTIVES

Low-acuity patients presenting to emergency departments (EDs) frequently have unmet ambulatory care needs. This qualitative study explores the patients' views of an intervention aimed at education about care options and promoting primary care (PC) attachment.

DESIGN

Qualitative telephone interviews were conducted with a subsample of participants of an interventional pilot study, based on a semi-structured interview guide. The data were analysed through qualitative content analysis.

SETTING

The study was carried out in three EDs in the city centre of Berlin, Germany.

PARTICIPANTS

Thirty-two low-acuity ED consulters with no connection to a general practitioner (GP) who had participated in the pilot study were interviewed; (f/m: 15/17; mean age: 32.9 years).

INTERVENTION

In the pilot intervention, ED patients with low-acuity complaints were provided with an information leaflet on appropriate ED usage and alternative care paths and they were offered an optional GP appointment scheduling service. Qualitative interviews explored the views of a subsample of the participants on the intervention.

RESULTS

Interviewees perceived both parts of the intervention as valuable. Receiving a leaflet about appropriate ED use and alternatives to the ED was viewed as helpful, with participants expressing the desire for additional online information and a wider distribution of the content. The GP appointment service was positively assessed by the participants who had made use of this offer and seen as potentially helpful in establishing a long-term connection to GP care. The majority of patients declining a scheduled GP appointment expected no personal need for further medical care in the near future or preferred to choose a GP independently.

CONCLUSIONS

Low-acuity ED patients seem receptive to information on alternative acute care options and prevailingly appreciate measures to encourage and facilitate attachment to a GP. Promoting PC integration could contribute to a change in future usage behaviour.

TRIAL REGISTRATION NUMBER

DRKS00023480.

Barriers to home exercise for patients with Parkinson's disease: a qualitative study

OBJECTIVE

This study aimed to explore the barriers to home exercise for patients with Parkinson's disease (PwPDs) and to provide guidelines for healthcare providers to build and implement home exercise strategies for PwPDs.

DESIGN

A qualitative descriptive method was used. Semistructured interviews were conducted and thematic analysis was employed.

SETTING

The study was conducted at the Department of Neurology at a grade 3 Class A general hospital in China.

PARTICIPANTS

A total of 24 participants were interviewed, including 10 PwPDs, 7 caregivers, 4 nurses, 1head nurse, and 2 Parkinson's clinicians.

RESULTS

Five themes were identified in this analysis. (1) Psychosomatic stress and low activity; (2) Lack of early rehabilitation authorisation; (3) Poor 'flow' state of home exercise; (4) iInaccessibility of continued service; (5) Sociocultural impact on family coping.

CONCLUSION

PwPDs, caregivers and specialised medical staff raised the challenges faced by patients' home exercises from different perspectives. We can improve services and integrate resources through the management of multi-disciplinary, early rehabilitation authorisation, exercise experience, continuous service mode, and family coping strategies under different cultures to gradually adjust the home exercise behaviour of PwPDs.

The Influence of Provider Connectedness on Continuity of Care and Hospital Readmissions in Patients With COPD: A Claims Data Based Social Network Study

Background

Hospital readmission rates are very high in patients with chronic obstructive pulmonary disease (COPD). Continuity of care (CoC) with general practitioners (GPs) and ambulatory specialists can impact readmission rates. This study aimed to identify shared patient networks of ambulatory care physicians and to examine the effect of provider connectedness on CoC and hospital readmissions.

Methods

A retrospective observational study was conducted in claims data from the years 2016 to 2018 in patients with COPD (aged 40 years or older; hospital stay in 2017). Linkages between GPs, pneumologists, and cardiologists were determined on the basis of shared patients. Multilevel regression models were used to analyze the impact of provider connectedness, operationalized by several social network characteristics, on continuity of care (sequential continuity [SECON] index) and hospital readmission rates.

Results

A total of 7294 patients linked to 3673 GPs were available for analysis. Closeness centrality (β=- 0.029) and the external-internal (EI)-index (β =0.037) impacted on the SECON index. The EI-index (odds ratio [OR]=1.25) and degree centrality (OR=1.257) impacted 30-day readmission. Network density (OR=0.811) and the SECON index (OR=1.121) affected the likelihood of a 90-day readmission. None of the predictors had a significant impact on 180-day and 365-day readmissions.

Conclusions

Ambulatory care providers' connectedness showed some effects on hospital readmissions and CoC in patients with COPD up to 90 days after hospital discharge, but the additional predictive power is limited.

Hospital Admission and Discharge: Lessons Learned from a Large Programme in Southwest Germany

Introduction

In the context of a GP-based care programme, we implemented an admission, discharge and follow-up programme.

Description

The VESPEERA programme consists of three sets of components: pre-admission interventions, in-hospital interventions and post-discharge interventions. It was aimed at all patients with a hospital stay participating in the GP-based care programme and was implemented in 7 hospitals and 72 general practices in southwest Germany using a range of strategies. Its' effectiveness was evaluated using readmissions within 90 days after discharge as primary outcome. Questionnaires with staff were used to explore the implementation process.

Discussion

A statistically significant effect was not found, but the effect size was similar to other interventions. Intervention fidelity was low and contextual factors affecting the implementation, amongst others, were available resources, external requirements such as legal regulations and networking between care providers. Lessons learned were derived that can aid to inform future political or scientific initiatives.

Conclusion

Structured information transfer at hospital admission and discharge makes sense but the added value in the context of a GP-based programme seems modest. Primary care teams should be involved in pre- and post-hospital care.

General practitioner-centred paediatric primary care reduces risk of hospitalisation for mental disorders in children and adolescents with ADHD: findings from a retrospective cohort study

Background

General practitioners (GPs) play an essential role in the sustainable management of attention-deficit/hyperactivity disorder (ADHD). To our knowledge, the healthcare programme described here is the first integrated care programme for paediatric ambulatory care embedded in GP-centred-healthcare in Germany.

Objectives

To compare the health-service-utilisation of patients with ADHD enrolled in a GP-centred-paediatric-primary-care-programme with usual care in terms of disease-related hospitalisation, pharmacotherapy and psychotherapy.

Methods

In 2018, we conducted a retrospective cohort study of 3- to 18-year-old patients with ADHD in Baden-Wuerttemberg, southern Germany. The intervention group (IG) comprised patients enrolled in a GP-centred-paediatric-primary-healthcare-programme and consulted a participating GP for ADHD at least once. GP-centred-paediatric-primary-care provides high continuity of care, facilitated access to specialist care, extended routine examinations and enhanced transition to adult healthcare. Patients in the control group (CG) received usual care, meaning they consulted a non-participating GP for ADHD at least once. Main outcomes were disease-related hospitalisation, pharmacotherapy and psychotherapy. Multivariable logistic regression was performed to compare groups.

Results

A total of 2317 patients were included in IG and 4177 patients in CG. Mean age was 8.9 ± 4.4. The risk of mental-disorder-related hospitalisations was lower in IG than CG (odds ratio (OR): 0.666, 95% confidence interval (CI): 0.509–0.871). The prescription rate for stimulants was lower in IG (OR: 0.817; 95% CI: 0.732–0.912). There was no statistically significant difference in the participation rate of patients in cognitive behavioural therapy between groups (OR: 0.752; 95% CI: 0.523–1.080).

Conclusion

Children and adolescents with ADHD enrolled in GP-centred-paediatric-primary-care are at lower risk of mental-disorder-related hospitalisation and less likely to receive stimulants.

Patient-reported continuity of care and the association with patient experience of cardiovascular prevention: an observational study in Germany

Background

Cardiovascular diseases are often accompanied by comorbidities, which require good coordination of care. Especially in fragmented healthcare systems, it is important to apply strategies such as case management to achieve high continuity of care. The aim of this study was to document continuity of care from the patients’ perspective in ambulatory cardiovascular care in Germany and to explore the associations with patient-reported experience of cardiovascular prevention.

Methods

This cross-sectional observational study was performed in primary care practices in Germany. The study included patients with three recorded chronic diseases, including coronary heart disease. Continuity of care was measured with the Nijmegen Continuity Questionnaire, which addresses personal/relational and team/cross-boundary continuity. From aspects of medical care and health-related lifestyle counselling a patient-reported experience of cardiovascular prevention index was formed with a range of 0–7. The association between continuity of care within the family practice and patient-reported experience of cardiovascular prevention was examined, using a linear multilevel regression model that adjusted for sociodemographics, structured care programme and numbers of contacts with the family practice.

Results

Four hundred thirty-five patients from 26 family practices participated. In a comparison between general practitioners (GPs) and cardiologists, higher values for relational continuity of care were given for GPs. Team/cross-boundary continuity for ‘within the family practice’ had a mean of 4.0 (standard deviation 0.7) and continuity between GPs and cardiologists a mean of 3.8 (standard deviation 0.7). Higher personal continuity of care for GPs was positively associated with patient-reported experience (b = 0.75, 95% CI 0.45–1.05, P < 0.001).

Conclusions

Overall, there was high patient-reported continuity, which positively influenced the experience of cardiovascular prevention. Nevertheless, there is potential for improvement of personal continuity of the cardiologists and team/cross-boundary continuity between GPs and cardiologists. Structured care programs may be able to support this.

Trial registration

We registered the study prospectively on 7 November 2019 at the German Clinical Trials Register (DRKS) under ID no. DRKS00019219.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01788-7.

Measuring continuity of ambulatory cardiovascular care: a cross-sectional study on the applicability of the Nijmegen Continuity Questionnaire in Germany

Background

Chronic cardiovascular diseases demand continuous care from general practitioners and medical specialists. Especially in fragmented healthcare systems, such as in Germany, a large body of research is devoted to the improvement of care continuity. Meanwhile, measuring continuity of care itself has been a challenge due to the absence of validated instruments. In 2011, the Dutch Nijmegen Continuity Questionnaire (NCQ) was developed and validated to measure continuity of care across care settings from the patients’ perspectives in the Netherlands. Its applicability in other countries and health systems, however, has rarely been tested. We therefore aimed at assessing the applicability of the Nijmegen Continuity Questionnaire to the German health care context. 

Methods

We translated and applied the original NCQ to an ambulatory cardiovascular care setting in Germany. Qualitative interview data and quantitative survey data on our adaptation were collected from patients in 27 general practices within the German states of Baden-Wuerttemberg and Rhineland-Palatinate. Qualitative data on understandability and clearness of the questionnaire was obtained using semi-structured telephone interviews and think aloud-protocols. Quantitative data was obtained through an anonymous written questionnaire containing the translated NCQ items to assess applicability of our translation. We performed confirmatory and exploratory factor analyses based on the original NCQ-structure mapped to general practitioners and an aggregated analysis of general practitioners and cardiologists combined.

Results

A total of 6 patients participated in the interviews and a total of 435 patients participated in the written survey. The interviews showed that, overall, patients had little difficulties comprehending and answering to our translation of the NCQ. The confirmatory factor analyses then showed that the structure of the original NCQ with 12 items and 3 latent factors can also be found in the German context. However, a simpler 2-factor-structure would also fit well with the data.

Conclusion

A German translation of the NCQ yielded a factor structure comparable to the original version and proved to be understandable for patients.

Trial registration

The project underlying the study was registered on November 7, 2019 in the German Clinical Trials Register (www.drks.de) under ID: DRKS00019219.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08612-z.

Differences in opioid prescription rates between patients with musculoskeletal disorders enrolled in coordinated ambulatory healthcare and patients receiving usual care: a retrospective observational cohort study

OBJECTIVES

To compare opioid prescription rates between patients enrolled in coordinated ambulatory care and patients receiving usual care.

DESIGN

In this retrospective cohort study, we analysed claims data for insured patients with non-specific/specific back pain or osteoarthritis of hip or knee from 2014 to 2017.

SETTING

The study was based on administrative data provided by the statutory health insurance fund 'Allgemeine Ortskrankenkasse', in the state of Baden-Wurttemberg, Germany.

PARTICIPANTS

The intervention group consisted of patients enrolled in a coordinated ambulatory healthcare model; the control group included patients receiving usual care. Outcomes were overall strong and weak opioid prescriptions. Generalised linear regression models were used to analyse the effect of the intervention.

RESULTS

Overall, 46 001 (non-specific 18 787/specific 27 214) patients with back pain and 19 366 patients with osteoarthritis belonged to the intervention group, and 7038 (2803/4235) and 963 patients to the control group, respectively. No significant difference in opioid prescriptions existed between the groups. However, the chance of being prescribed strong opioids was significantly lower in the intervention group (non-specific back pain: Odds Ratio (OR) 0.735, 95% Confidential Interval (CI) 0.563 to 0.960; specific back pain: OR 0.702, 95% CI 0.577 to 0.852; osteoarthritis: OR 0.644, 95% CI 0.464 to 0.892). The chance of being prescribed weak opioids was significantly higher in patients with specific back pain (OR 1.243, 95% CI 1.032 to 1.497) and osteoarthritis (OR 1.493, 95% CI 1.037 to 2.149) in the intervention group.

CONCLUSION

Coordinated ambulatory healthcare appears to be associated with a lower prescription rate for strong opioids in patients with chronic musculoskeletal disorders.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register (DRKS00017548).

Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway

BACKGROUND

Continuity, usually considered a quality aspect of primary care, is under pressure in Norway, and elsewhere.

AIM

To analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospital admission, and mortality.

DESIGN AND SETTING

Registry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs.

METHOD

Duration of RGP-patient relationship was used as explanatory variable for the use of OOH services, acute hospital admission, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP-patient relationship was categorised as 1, 2-3, 4-5, 6-10, 11-15, or >15 years. Results are given as adjusted odds ratio (OR) with 95% confidence intervals (CI) resulting from multilevel logistic regression analyses.

RESULTS

Compared with a 1-year RGP-patient relationship, the OR for use of OOH services decreased gradually from 0.87 (95% CI = 0.86 to 0.88) after 2-3 years' duration to 0.70 (95% CI = 0.69 to 0.71) after >15 years. OR for acute hospital admission decreased gradually from 0.88 (95% CI = 0.86 to 0.90) after 2-3 years' duration to 0.72 (95% CI = 0.70 to 0.73) after >15 years. OR for dying decreased gradually from 0.92 (95% CI = 0.86 to 0.98) after 2-3 years' duration, to 0.75 (95% CI = 0.70 to 0.80) after an RGP-patient relationship of >15 years.

CONCLUSION

Length of RGP-patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose-response relationship between continuity and these outcomes indicates that the associations are causal.