Optimizing blood pressure control by an Information Communication Technology-supported case management (PIA study): study protocol for a cluster-randomized controlled trial of a delegation model for general practices

Small Changes in Patient Arrival and Consultation Times Have Large Effects on Patients' Waiting Times: Simulation Analyses for Primary Care

(1) Background: Workflows are a daily challenge in general practices. The desired smooth work processes and patient flows are not easy to achieve. This study uses an operational research approach to illustrate the general effects of patient arrival and consultation times on waiting times. (2) Methods: Stochastic simulations were used to model complex daily workflows of general practice. Following classical queuing models, patient arrivals, queuing discipline, and physician consultation times are three key factors influencing work processes. (3) Results: In the first scenario, with patients arriving every 7.6 min and random consultation times, the individual patients' maximum waiting time increased to more than 200 min. The second scenario with random patient arrivals and random consultation times increased the average waiting time by up to 30 min compared to patients arriving on schedule. A busy morning session based on the second scenario was investigated to compare two alternative intervention strategies to reduce subsequent waiting times. Both could reduce waiting times by a multiple for each minute of reduced consultation time. (4) Conclusions: Aiming to improve family physicians' awareness of strategies for improving workflows, this simulation study illustrates the effects of strategies that address consultation times and patient arrivals.

Digital redesign of hypertension management with practice and patient apps for blood pressure control (PIA study): A cluster-randomised controlled trial in general practices

BACKGROUND

Long-term hypertension control prevents heart attacks and other cardiovascular diseases, yet implementation is insufficient worldwide. The redesign of hypertension management by information and communication technology (ICT) improved hypertension control, e.g., by transmission of blood pressure (BP) measurements to a central webspace. However, an easy-to-use secure patient app connected with a practice management centre is lacking. This study evaluates the effectiveness of the newly developed PIA (PC-supported case management of hypertensive patients to implement guideline-based hypertension therapy using a physician-defined and -supervised, patient-specific therapeutic algorithm) intervention with PIA-ICT and eLearning for general practices.

METHODS

The effectiveness of the PIA intervention was evaluated in a cluster-randomised study. Practices were randomly allocated (1:1) to the intervention or the control group (usual care). Group allocation was unmasked for participants and researchers. The primary outcome was the BP control rate (BP < 140/90 mmHg) after 6-12 months. Secondary outcomes included BP changes and satisfaction with PIA-ICT. The trial is registered in the German Clinical Trials Register (DRKS00012680).

FINDINGS

Starting from December 1, 2019, 64 general practices were recruited over 1 year during the COVID-19 pandemic. Overall, 848 patients were enrolled between April 15, 2020 and March 31, 2021. The study was completed Sept 30, 2021. At baseline, 636 patients (intervention: 331; control: 305) of 50 general practices met the inclusion criteria. The final dataset for analyses comprised 47 practices and 525 patients (intervention 265; control 260). In the adjusted hierarchical model, the PIA intervention increased the BP control rate significantly by 23.1% points (95% CI: 5.4-40.8%): intervention 59.8% (95% CI: 47.4-71.0%) compared to 36.7% (95% CI: 24.9-50.3%) in the control group. Systolic BP decreased by 21.1 mmHg in the intervention and 15.5 mmHg in the control group.

INTERPRETATION

The PIA redesign of care processes improved BP in an outcome-relevant way. Prospectively, it may constitute an important model for hypertension care in Germany.

FUNDING

This study is funded by the German Innovation Fund (Grant number: 01NVF17002).

Higher Work-Privacy Conflict and Lower Job Satisfaction in GP Leaders and Practice Assistants Working Full-Time Compared to Part-Time: Results of the IMPROVEjob Study

Background: Work-privacy conflict (WPC) has become an important issue for medical professionals. The cluster-randomized controlled IMPROVEjob study aimed at improving job satisfaction (primary outcome), with additional outcomes such as examining the work-privacy conflict in German general practice personnel. Using baseline data of this study, the relationship between work-privacy conflict and job satisfaction (JS) was analyzed. In addition, factors associated with higher WPC were identified. Methods: At baseline, 366 participants (general practitioners (GPs) in leadership positions, employed general practitioners, and practice assistants) from 60 German practices completed a questionnaire addressing socio-demographic data and job characteristics. Standardized scales from the German version of the COPSOQ III requested data concerning job satisfaction and work-privacy conflict. Both scores range from 0 (lowest) to 100 (highest). Multilevel analysis accounted for the clustered data. Statistical analyses were performed using IBM SPSS and RStudio software, with a significance level set at p < 0.05. Results: Job satisfaction was 77.16 (mean value; SD = 14.30) among GPs in leadership positions (n = 84), 79.61 (SD = 12.85) in employed GPs (n = 28), and 72.58 (SD = 14.42) in practice assistants (n = 254). Mean values for the WPC-scale were higher for professionals with more responsibilities: GPs in leadership positions scored highest with 64.03 (SD = 29.96), followed by employed physicians (M = 45.54, SD =30.28), and practice assistants (M = 32.67, SD = 27.41). General practitioners and practice assistants working full-time reported significantly higher work-privacy conflict than those working part-time (p < 0.05). In a multilevel analysis, work-privacy conflict was significantly associated with job satisfaction (p < 0.001). A multiple regression analysis identified working hours, as well as and being a practice owner or an employed physician as factors significantly influencing WPC. Discussion: WPC was high among general practice leaders and practice personnel working full-time. Future interventions to support practice personnel should focus on reducing WPC, as there is good evidence of its effects on job satisfaction.