Trajectories of post-traumatic stress in sepsis survivors two years after ICU discharge: a secondary analysis of a randomized controlled trial

BACKGROUND

Post-traumatic stress has been identified as a frequent long-term complication in survivors of critical illnesses after sepsis. Little is known about long-term trajectories of post-traumatic stress and potentially modifiable risk factors following the ICU stay. Study objective was to explore and compare different clinical trajectories of post-traumatic stress symptoms in sepsis survivors up to two years after discharge from ICU.

METHODS

Data on post-traumatic stress symptoms by means of the Post-traumatic Symptom Scale (PTSS-10) were collected in sepsis survivors at one, six, 12 and 24 months after discharge from ICU. Data on chronic psychiatric diagnoses prior ICU were derived from the primary care provider's health records, and data on intensive care treatment from ICU documentation. Trajectories of post-traumatic symptoms were identified ex post, discriminating patterns of change and k-means clustering. Assignment to the trajectories was predicted in multinomial log-linear models.

RESULTS

At 24 months, all follow-up measurements of the PTSS-10 were completed in N = 175 patients. Three clusters could be identified regarding clinical trajectories of PTSS levels: stable low symptoms (N = 104 patients [59%]), increasing symptoms (N = 45 patients [26%]), and recovering from symptoms (N = 26 patients [15%]). Patients with initially high post-traumatic symptoms were more likely to show a decrease (OR with 95% CI: 1.1 [1.05, 1.16]). Females (OR = 2.45 [1.11, 5.41]) and patients reporting early traumatic memories of the ICU (OR = 4.04 [1.63, 10]) were at higher risk for increasing PTSS levels.

CONCLUSION

Post-traumatic stress is a relevant long-term burden for sepsis patients after ICU stay. Identification of three different trajectories within two years after ICU discharge highlights the importance of long-term observation, as a quarter of patients reports few symptoms at discharge yet an increase in symptoms in the two years following. Regular screening of ICU survivors on post-traumatic stress should be considered even in patients with few symptoms and in particular in females and patients reporting traumatic memories of the ICU.

[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.

Women's sexually transmitted infections in primary care: General practitioners' challenges and strategies - A qualitative study in Germany

BACKGROUND

The incidence of sexually transmitted infections (STI) is rising. Amongst women, STIs are often asymptomatic and thus likely underreported. STI care in Germany is fragmented. General Practitioners (GPs) could offer accessible care; however, to which extent GPs provide STI care and which challenges they face remains unclear.

OBJECTIVES

To increase understanding of how GPs provide STI care for women in German high-incidence settings and to identify challenges and opportunities for improved care.

METHODS

Between 10/20 and 09/21, we contacted 75 practices using snowball and theoretical sampling. We conducted qualitative guide-assisted interviews with 19 GPs in their practices in Berlin, Germany. Data were analysed using thematic analysis with grounded theory components.

RESULTS

Responsibilities and financing of STI care services were unclear. Most GPs perceived specialised doctors to be responsible for STI care in women; however, many non-STI specialised doctors were the first point of contact for patients and felt responsible to help. (LBTQI) Women were perceived to have less access to care. Stigmatising perceptions of women with STI-related needs were common. Doctors immediately referred patients to other providers, offered STI care for selected cases, or routinely offered primary STI care. GPs' referral strategies were often unsystematic. Those who offered primary STI care perceived patients' need for STI care, showed open attitudes to sexual health, and had undergone further training on STI care.

CONCLUSION

Training regarding STI care, remuneration, and referral pathways should be provided for GPs. Comprehensive STI care could be offered through the cooperation of GPs and specialists.

[Attitudes of general practitioners and medical practice assistants towards the delegation of medical services: Results of a survey in Berlin, Brandenburg and Thuringia]

INTRODUCTION

The delegation of tasks and responsibilities from general practitioners (GPs) to medical practice assistants (MPAs) can contribute to ensuring primary care in Germany. The aim of the study was to collect and analyze attitudes and procedures of GPs and MPAs regarding the delegation of physician-related tasks and activities.

METHODOLOGY

A self-designed, piloted questionnaire was sent to all GPs listed within the regional Associations of Statutory Health Insurance Physicians (KV) in Thuringia, Berlin, and Brandenburg (n=5,516) and their MPAs. Participants were asked to indicate which physician-related activities were already delegated and on which occasions further delegations could be considered.

RESULTS

890 GPs (response rate: 16.1%) and 566 MPAs participated in the written survey. The participants were predominantly female and most of them worked in urban areas. Numerous activities, such as medical history taking, triage, Disease Management Program (DMP) controls, vaccinations and home visits, have already been delegated. The willingness to delegate further tasks (e. g., follow-up prescriptions and referrals, independent takeover of simple consultations, assessing the necessity of physician consultation) was high.

CONCLUSION

The survey showed a high level of willingness of both occupational groups to delegate physician-related activities to MFAs. An expansion seems possible under certain conditions. Many activities have already been delegated to MPAs in primary care practices. Our survey provides suggestions regarding further tasks suitable for delegation, some of which go beyond the delegation agreement valid in Germany.

Patient perspective on task shifting from general practitioners to medical practice assistants - a quantitative survey in Germany

INTRODUCTION

Various developments result in increasing workloads in general practices. New models of care and a restructuring of the division of tasks could provide relief. One approach is to extend the delegation of medical tasks from general practitioners (GPs) to medical practice assistants (MPAs). So far, there has been a lack of information about specific situations in which patients are willing to be treated exclusively by MPAs.

METHODS

In three German federal states, patients who visited a general practice were surveyed exploratively and cross-sectionally with a self-designed, paper-based questionnaire. The data were analysed descriptively and multivariate. A mixed binary logistic regression model was calculated to account for cluster effects at practice level (random intercept model). The dependent variable was patients' acceptance of task delegation.

RESULTS

A total of 1861 questionnaires from 61 general practices were included in the analysis. Regarding the current problem/request, a total of 30% of respondents could imagine being treated only by MPAs. Regarding theoretical reasons for consultation, more than half of the patients agreed to be treated by MPAs. According to the regression model, MPAs were preferred when patients were younger (10-year OR = 0.84, 95%-CI [0.75, 0.93]) or had a less complicated issue (OR = 0.44, 95%-CI [0.26, 0.8]). For four current problems/requests ("acute complaints" OR = 0.27, 95%-CI [0.17, 0.45], "routine health check" OR = 0.48, 95%-CI [0.3, 0.79], "new problem" OR = 0.13, 95%-CI [0.06, 0.28], "known problem" OR = 0.16, 95%-CI [0.1, 0.27]) patients prefer to be treated by GPs instead of MPAs.

DISCUSSION

For the first time, statements could be made on patients' acceptance of task delegation in relation to current and theoretical reasons for treatment in general practices in Germany. The discrepancy in response behaviour on a theoretical and individual level could be explained by different contexts of questions and differences at practice level. Overall, patients seem to be open to increased delegation of medical tasks, depending on the reason for treatment. Selection and response biases should be considered in the interpretation.

CONCLUSION

The results are not completely opposed to an extension of task delegation. Further interventional studies could provide information on the possible effects of expansion of delegable tasks.

GPs' Perspective on a Multimodal Intervention to Enhance Guideline-Adherence in Uncomplicated Urinary Tract Infections: A Qualitative Process Evaluation of the Multicentric RedAres Cluster-Randomised Controlled Trial

Urinary tract infections (UTIs) are among the most common reasons patients seeking health care and antibiotics to be prescribed in primary care. However, general practitioners' (GPs) guideline adherence is low. The RedAres randomised controlled trial aims to increase guideline adherence by implementing a multimodal intervention consisting of four elements: information on current UTI guidelines (1) and regional resistance data (2); feedback regarding prescribing behaviour (3); and benchmarking compared to peers (4). The RedAres process evaluation assesses GPs' perception of the multimodal intervention and the potential for implementation into routine care. We carried out 19 semi-structured interviews with GPs (intervention arm). All interviews were carried out online and audio recorded. For transcription and analysis, Mayring's qualitative content analysis was used. Overall, GPs considered the interventions helpful for knowledge gain and confirmation when prescribing. Information material and resistance were used for patient communication and teaching purposes. Feedback was considered to enhance reflection by breaking routines of clinical workup. Implementation into routine practice could be enhanced by integrating feedback loops into patient management systems and conveying targeted information via trusted channels or institutions. The process evaluation of RedAres intervention was considered beneficial by GPs. It confirms the convenience of multimodal interventions to enhance guideline adherence.

Effects of a multimodal intervention in primary care to reduce second line antibiotic prescriptions for urinary tract infections in women: parallel, cluster randomised, controlled trial

OBJECTIVES

To evaluate whether a multimodal intervention in general practice reduces the proportion of second line antibiotic prescriptions and the overall proportion of antibiotic prescriptions for uncomplicated urinary tract infections in women.

DESIGN

Parallel, cluster randomised, controlled trial.

SETTING

General practices in five regions in Germany. Data were collected between 1 April 2021 and 31 March 2022.

PARTICIPANTS

General practitioners from 128 randomly assigned practices.

INTERVENTIONS

Multimodal intervention consisting of guideline recommendations for general practitioners and patients, provision of regional data for antibiotic resistance, and quarterly feedback, which included individual first line and second line proportions of antibiotic prescribing, benchmarking with regional or supra-regional practices, and telephone counselling. Participants in the control group received no information on the intervention.

MAIN OUTCOME MEASURES

Primary outcome was the proportion of second line antibiotics prescribed by general practices, in relation to all antibiotics prescribed, for uncomplicated urinary tract infections after one year between the intervention and control group. General practices were randomly assigned in blocks (1:1), with a block size of four, into the intervention or control group using SAS version 9.4; randomisation was stratified by region. The secondary outcome was the prescription proportion of all antibiotics, relative within all cases (instances of UTI diagnosis), for the treatment of urinary tract infections after one year between the groups. Adverse events were assessed as exploratory outcomes.

RESULTS

110 practices with full datasets identified 10 323 cases during five quarters (ie, 15 months). The mean proportion of second line antibiotics prescribed was 0.19 (standard deviation 0.20) in the intervention group and 0.35 (0.25) in the control group after 12 months. After adjustment for preintervention proportions, the mean difference was -0.13 (95% confidence interval -0.21 to -0.06, P<0.001). The overall proportion of all antibiotic prescriptions for urinary tract infections over 12 months was 0.74 (standard deviation 0.22) in the intervention and 0.80 (0.15) in the control group with a mean difference of -0.08 (95% confidence interval -0.15 to -0.02, P<0.029). No differences were noted in the number of complications (ie, pyelonephritis, admission to hospital, or fever) between the groups.

CONCLUSIONS

The multimodal intervention in general practice significantly reduced the proportion of second line antibiotics and all antibiotic prescriptions for uncomplicated urinary tract infections in women.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), DRKS00020389.

[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.

[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.

Superfluid Fraction in an Interacting Spatially Modulated Bose-Einstein Condensate

At zero temperature, a Galilean-invariant Bose fluid is expected to be fully superfluid. Here we investigate theoretically and experimentally the quenching of the superfluid density of a dilute Bose-Einstein condensate due to the breaking of translational (and thus Galilean) invariance by an external 1D periodic potential. Both Leggett's bound fixed by the knowledge of the total density and the anisotropy of the sound velocity provide a consistent determination of the superfluid fraction. The use of a large-period lattice emphasizes the important role of two-body interactions on superfluidity.

Transparency of clinical practice guideline funding: a cross-sectional analysis of the German AWMF registry

BACKGROUND

While reporting of individual conflicts of interest is formalised, it is unclear to what extent the funding of clinical practice guidelines (CPGs) is formally reported. The aim of this study is to explore the accuracy and comprehensiveness of reporting on funding in German CPGs.

METHODS

We searched for CPGs in the registry of the Association of the Scientific Medical Societies in Germany in July 2020. Information on guideline funding was categorised by two reviewers independently and discrepancies were clarified by discussion with a third reviewer. Accuracy and comprehensiveness of reporting on funding was assessed using the German Instrument for Methodological Guideline Appraisal (DELBI).

RESULTS

We included 507 CPGs published between 2015 and 2020 in the main analysis. 23/507 (4.5%) of the CPGs achieved the highest DELBI score by including information on funding sources, expenses and the amount of funding provided, as well as a statement on the independence of the guideline authors from the funding institution(s). CPGs with more rigorous methodological requirements (systematic review of the literature and/or structured consensus-building) received higher DELBI scores.

CONCLUSION

German CPGs do not communicate their funding transparently. Transparency of CPG funding could be achieved by making it mandatory to publish information for all guidelines. For that purpose, a standardised form and guidance should be developed.

[Medical care in GP practices during the Covid-19 pandemic: A questionnaire-based survey among general practitioners and medical practice assistants asking for their opinion about changes, needs and burdens]

INTRODUCTION

The coronavirus pandemic did not only result in changes in the provision and utilization of health care services in general practice but also in an increased workload for physicians and medical practice assistants. The VeCo practice study retrospectively explores the experiences of both professional groups two years after the start of the pandemic.

METHODS

In March and April 2022, general practitioners and medical practice assistants in the three German federal states of Berlin, Brandenburg and Thuringia were asked to complete a paper-based questionnaire.

RESULTS

657 general practitioners and 762 medical practice assistants completed the questionnaire. Both professional groups agreed to statements indicating a reduction in regular health care provisions. Nevertheless, 74% of the physicians and 82.9% of the medical practice assistants considered the health care provided to their patients during the pandemic as good. This was only possible through considerable additional effort and stress. While more than half of both groups reported that work was still enjoyable, three quarters of both groups stated that the challenges arising from the pandemic outstripped their capacity. Both groups would like to receive more recognition from society (medical practice assistants 93.2%, general practitioners 85.3%) and from their patients (87.7% and 69.9%, respectively).

DISCUSSION

General practitioners and medical practice assistants reduced regular health care provision but were still able to maintain a good quality of care for their patients during the pandemic. It became clear that more appreciation and adequate financial compensation are necessary to ensure long-term sustainability of GP care.

CONCLUSION

The subjective view of general practitioners and medical practice assistants on their health care provision shows that appreciation and adequate financial renumeration, particularly when working under most difficult conditions, are necessary to increase the attractiveness of a career in general practice, for both physicians and medical practice assistants.

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.

Patients' and GPs' duties and responsibilities in long-term care after myocardial infarction: a qualitative study of patients' perspectives

BACKGROUND

Cardiovascular disease is one of the main causes of death in Europe and around the world. Effective and individualized long-term treatment of patients with chronic diseases such as cardiovascular disease and myocardial infarction reduces mortality and the risk of recurrence and prevents secondary disease. However, there is little data on patients' views.

OBJECTIVE

To examine patients' perspectives on long-term care after myocardial infarction.

METHODS

A qualitative interview study with patients after myocardial infarction in Berlin and Brandenburg, Germany. Fifteen episodic interviews were conducted, transcribed, coded, and analyzed using framework analysis.

RESULTS

Participants consistently emphasized major functions fulfilled by general practitioners: monitoring, advice, diagnosis, referral, coordination. Furthermore, other functions such as empathy and feeling emotionally valued. Major patient roles emerged such as information sharing, lifestyle change, and coping. Responsibility toward doctors was expressed in terms of active participation in describing their symptoms, following the doctor's directions, and sharing in decision-making. Self-responsibility in participants showed 2 contrasting approaches. On the one hand, a passive attitude (acceptance, helplessness), and on the other, active resistance and taking action.

CONCLUSION

The study underlines the importance of communication and awareness of the patient's perspective. General practitioners must address patients' aims and fears, encourage their initiative, and focus on empathy and education.

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.

Examining the impact of a symptom assessment application on patient-physician interaction among self-referred walk-in patients in the emergency department (AKUSYM): study protocol for a multi-center, randomized controlled, parallel-group superiority trial

Background

Due to the increasing use of online health information, symptom checkers have been developed to provide an individualized assessment of health complaints and provide potential diagnoses and an urgency estimation. It is assumed that they support patient empowerment and have a positive impact on patient-physician interaction and satisfaction with care. Particularly in the emergency department (ED), symptom checkers could be integrated to bridge waiting times in the ED, and patients as well as physicians could take advantage of potential positive effects. Our study therefore aims to assess the impact of symptom assessment application (SAA) usage compared to no SAA usage on the patient-physician interaction in self-referred walk-in patients in the ED population.

Methods

In this multi-center, 1:1 randomized, controlled, parallel-group superiority trial, 440 self-referred adult walk-in patients with a non-urgent triage category will be recruited in three EDs in Berlin. Eligible participants in the intervention group will use a SAA directly after initial triage. The control group receives standard care without using a SAA. The primary endpoint is patients’ satisfaction with the patient-physician interaction assessed by the Patient Satisfaction Questionnaire.

Discussion

The results of this trial could influence the implementation of SAA into acute care to improve the satisfaction with the patient-physician interaction.

Trial registration

German Clinical Trials Registry DRKS00028598. Registered on 25.03.2022

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.

Redirecting emergency medical services patients with unmet primary care needs: the perspective of paramedics on feasibility and acceptance of an alternative care path in a qualitative investigation from Berlin, Germany

Background

Against the backdrop of emergency department (ED) overcrowding, patients’ potential redirection to outpatient care structures is a subject of current political debate in Germany. It was suggested in this context that suitable lower-urgency cases could be transported directly to primary care practices by emergency medical services (EMS), thus bypassing the ED. However, practicality is discussed controversially. This qualitative study aimed to capture the perspective of EMS personnel on potential patient redirection concepts.

Methods

We conducted qualitative, semi-structured phone interviews with 24 paramedics. Interviews were concluded after attainment of thematic saturation. Interviews were transcribed verbatim, and qualitative content analysis was performed.

Results

Technical and organizational feasibility of patients’ redirection was predominantly seen as limited (theme: “feasible, but only under certain conditions”) or even impossible (theme: “actually not feasible”), based on a wide spectrum of potential barriers. Prominently voiced reasons were restrictions in personnel resources in both EMS and ambulatory care, as well as concerns for patient safety ascribed to a restricted diagnostic scope. Concerning logistics, alternative transport options were assessed as preferable. Regarding acceptance by stakeholders, the potential for releasing ED caseload was described as a factor potentially promoting adoption, while doubt was raised regarding acceptance by EMS personnel, as their workload was expected to conversely increase. Paramedics predominantly did not consider transporting lower-urgency cases as their responsibility, or even as necessary. Participants were markedly concerned of EMS being misused for taxi services in this context and worried about negative impact for critically ill patients, as to vehicles and personnel being potentially tied up in unnecessary transports. As to acceptance on the patients’ side, interview participants surmised a potential openness to redirection if this would be associated with benefits like shorter wait times and accompanied by proper explanation.

Conclusions

Interviews with EMS staff highlighted considerable doubts about the general possibility of a direct redirection to primary care as to considerable logistic challenges in a situation of strained EMS resources, as well as patient safety concerns. Plans for redirection schemes should consider paramedics’ perspective and ensure a provision of EMS with the resources required to function in a changing care environment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00660-2.

Shedding light on silica biomineralization by comparative analysis of the silica-associated proteomes from three diatom species

Morphogenesis of the intricate patterns of diatom silica cell walls is a protein-guided process, yet to date only very few such silica biomineralization proteins have been identified. Therefore, it is currently unknown whether all diatoms share conserved proteins of a basal silica forming machinery, and whether unique proteins are responsible for the morphogenesis of species-specific silica patterns. To answer these questions, we extracted proteins from the silica of three diatom species (Thalassiosira pseudonana, Thalassiosira oceanica, and Cyclotella cryptica) by complete demineralization of the cell walls. Liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) analysis of the extracts identified 92 proteins that we name 'soluble silicome proteins' (SSPs). Surprisingly, no SSPs are common to all three species, and most SSPs showed very low similarity to one another in sequence alignments. In-depth bioinformatics analyses revealed that SSPs could be grouped into distinct classes based on short unconventional sequence motifs whose functions are yet unknown. The results from the in vivo localization of selected SSPs indicates that proteins, which lack sequence homology but share unconventional sequence motifs may exert similar functions in the morphogenesis of the diatom silica cell wall.

[Acute Cough in Adult Patients]

Background

Acute cough (< 8 weeks) is a frequent complaint in family practice consultations. The most common cause are respiratory infections. The Guideline "Acute and chronic cough" of the German College of General Practitioners and Family Physicians (DEGAM) was updated in 2021 and contains recommendations for an evidence-based approach for the management of acute cough in primary care.

Methods

The guideline has been updated in accordance with the findings of a systematic search of the literature for international guidelines and systematic reviews. All recommendations were developed by an interdisciplinary guideline committee and agreed by formal consensus.

Results

History-taking, exclusion of red flags and a physical examination are the basis of diagnostic evaluation. If an acute, uncomplicated bronchitis is likely, no laboratory tests, sputum diagnostics, or chest x-rays should be performed, and antibiotics should not be administered. Evidence based strategies to avoid antibiotic therapy (delayed prescribing, shared decision making, point-of-care-tests) can be used. There is inadequate evidence for the efficacy of antitussive or expectorant drugs against acute cough. The state of the evidence for phytotherapeutic agents is heterogeneous; clinical importance is minimal. COVID-19 should currently be considered in cases of acute respiratory symptoms. If specific symptoms or red flags occur, further diagnoses in the context of acute cough such as community-acquired pneumonia, influenza disease and exacerbations of chronic respiratory diseases (bronchial asthma, COPD) should be taken into consideration.

Conclusions

These evidence-based recommendations are intended to reduce the use of antibiotics to treat colds and acute bronchitis, for which they are not indicated. Further clinical trials of symptomatic treatments for cough should be performed in order to extend the evidence base.

Healthcare Utilization and Costs in Sepsis Survivors in Germany-Secondary Analysis of a Prospective Cohort Study

Background: Survivors of sepsis often face long-term sequelae after intensive care treatment. Compared to the period of hospitalization, little is known about the ambulatory healthcare utilization in sepsis patients. The study evaluated healthcare utilization and associated costs of sepsis care including allied health professions after initial hospitalization. Methods: Secondary analysis was performed on data in 210 sepsis patients prospectively enrolled from nine intensive care study centers across Germany. Data was collected via structured surveys among their Primary care (Family-) physicians (PCPs) within the first month after discharge from ICU (baseline) and again at 6, 12 and 24 months after discharge, each relating to the period following the last survey. Costs were assessed by standardized cost unit rates from a health care system’s perspective. Changes in healthcare utilization and costs over time were calculated using the Wilcoxon rank-sum test. Results: Of the 210 patients enrolled, 146 (69.5%) patients completed the 24 months follow-up. In total, 109 patients were hospitalized within the first 6 months post-intensive care. Mean total direct costs per patient at 0–6 months were €17,531 (median: €6047), at 7–12 months €9029 (median: €3312), and at 13–24 months €18,703 (median: €12,828). The largest contributor to the total direct costs within the first 6 months was re-hospitalizations (€13,787 (median: €2965). After this first half year, we observed a significant decline in inpatient care costs for re-hospitalizations (p ≤ 0.001). PCPs were visited by more than 95% of patients over 24 months. Conclusions: Sepsis survivors have high health care utilization. Hospital readmissions are frequent and costly. Highest costs and hospitalizations were observed in more than half of patients within the first six months post-intensive care. Among all outpatient care providers, PCPs were consulted most frequently. Clinical impact: Sepsis survivors have a high healthcare utilization and related costs which persist after discharge from hospital. Within outpatient care, possible needs of sepsis survivors as physiotherapy or psychotherapy seem not to be met appropriately. Development of sepsis aftercare programs for early detection and treatment of complications should be prioritized.

Emergency department consultations for respiratory symptoms revisited: exploratory investigation of longitudinal trends in patients' perspective on care, health care utilization, and general and mental health, from a multicenter study in Berlin, Germany

BACKGROUND

Only few studies of emergency department (ED) consulters include a longitudinal investigation. The EMACROSS study had surveyed 472 respiratory patients in eight inner-city EDs in Berlin in 2017/2018 for demographic, medical and consultation-related characteristics. This paper presents the results of a follow-up survey at a median of 95 days post-discharge. We aimed to explore the post hoc assessment of ED care and identify potential longitudinal trends.

METHODS

The follow-up survey included items on satisfaction with care received, benefit from the ED visit, potential alternative care, health care utilization, mental and general health, and general life satisfaction. Univariable between-subject and within-subject statistical comparisons were conducted. Logistic regression was performed for multivariable investigations of determinants of dropout and of retrospectively rating the ED visit as beneficial.

RESULTS

Follow-up data was available for 329 patients. Participants of lower education status, migrants, and tourists were more likely to drop out. Having a general practitioner (GP), multimorbidity, and higher general life satisfaction were determinants of response. Retrospective satisfaction ratings were high with no marked longitudinal changes and waiting times as the most frequent reason for dissatisfaction. Retrospective assessment of the visit as beneficial was positively associated with male sex, diagnoses of pneumonia and respiratory failure, and self-referral. Concerning primary care as a viable alternative, judgment at the time of the ED visit and at follow-up did not differ significantly. Health care utilization post-discharge increased for GPs and pulmonologists. Self-reported general health and PHQ-4 anxiety scores were significantly improved at follow-up, while general life satisfaction for the overall sample was unchanged.

CONCLUSIONS

Most patients retrospectively assess the ED visit as satisfactory and beneficial. Possible sex differences in perception of care and its outcomes should be further investigated. Conceivable efforts at diversion of ED utilizers to primary care should consider patients' views regarding acceptable alternatives, which appear relatively independent of situational factors. Representativeness of results is restricted by the study focus on respiratory symptoms, the limited sample size, and the attrition rate.

TRIAL REGISTRATION

German Clinical Trials Register ( DRKS00011930 ); date: 2017/04/25.

Clinical Practice Guideline: Chronic Cough

BACKGROUND

Chronic cough, i.e., cough lasting longer than eight weeks, affects approximately 10% of the population and is a common reason for outpatient medical consultation. Its differential diagnosis is extensive, and it is generally evaluated in poorly structured fashion with a variety of diagnostic techniques. The German Clinical Practice Guideline on Acute and Chronic Cough was updated in 2021 and contains a description of the recommended stepwise, patient-centered, and evidence-based procedure for the management of chronic cough.

METHODS

The guideline has been updated in accordance with the findings of a systematic search of the literature for international guidelines and systematic reviews. All recommendations were developed in an interdisciplinary manner and agreed upon by formal consensus. The target group consists of adult patients with cough.

RESULTS

History-taking, after the exclusion of red flags, should include questioning about smoking status, medications, and relevant present and past illnesses (COPD, asthma). Subsequent diagnostic testing should include a chest x-ray and pulmonary function tests. If the patient is taking an ACE inhibitor, a test of drug discontinuation can be carried out first. Radiologically detected pulmonary masses or evidence of rare diseases (interstitial lung diseases, bronchiectasis) are an indication for chest CT or for direct referral to an appropriate specialist. If the imaging studies and pulmonary function tests are normal, the patient is most likely suffering from a disease entity that can be treated empirically, such as upper airway cough syndrome or cough variant asthma. Any patient with an unexplained or refractory cough must receive proper patient education; individual therapeutic trials of physiotherapeutic or speechtherapeutic methods are possible, as is the off-label use of gabapentin or morphine.

CONCLUSION

Chronic cough should be evaluated according to an established diagnostic algorithm in collaboration with specialists. Treatments such as inhaled corticosteroids should be tested exhaustively in accordance with the guidelines, and the possibility of multiple causes as well as the role of patient compliance should be kept in mind before a diagnosis of unexplained or intractable cough is assigned.

REDuction of Antibiotic RESistance (REDARES) in urinary tract infections using treatments according to national clinical guidelines: study protocol for a pragmatic randomized controlled trial with a multimodal intervention in primary care

Background

Urinary tract infections (UTIs) are a common cause of prescribing antibiotics in family medicine. In Germany, about 40% of UTI-related prescriptions are second-line antibiotics, which contributes to emerging resistance rates. To achieve a change in the prescribing behaviour among family physicians (FPs), this trial aims to implement the guideline recommendations in German family medicine.

Methods/design

In a randomized controlled trial, a multimodal intervention will be developed and tested in family practices in four regions across Germany. The intervention will consist of three elements: information on guideline recommendations, information on regional resistance and feedback of prescribing behaviour for FPs on a quarterly basis. The effect of the intervention will be compared to usual practice. The primary endpoint is the absolute difference in the mean of prescribing rates of second-line antibiotics among the intervention and the control group after 12 months. To detect a 10% absolute difference in the prescribing rate after one year, with a significance level of 5% and a power of 86%, a sample size of 57 practices per group will be needed. Assuming a dropout rate of 10%, an overall number of 128 practices will be required. The accompanying process evaluation will provide information on feasibility and acceptance of the intervention.

Discussion

If proven effective and feasible, the components of the intervention can improve adherence to antibiotic prescribing guidelines and contribute to antimicrobial stewardship in ambulatory care. 

Trial registration DRKS, DRKS00020389, Registered 30 January 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020389.

Collaboration amongst general practitioners and gynaecologists working in primary health care in Germany: a cross-sectional study

AIM

This cross-sectional study is the first one to explore the collaboration of the influencing factors thereof amongst general practitioners (GPs) and gynaecologists (Gyns) working in primary care in urban and rural settings in Germany.

BACKGROUND

The number of women aged ≥ 50 years is predicted to increase in the next years in Germany. This coincides with the ageing of primary care specialists providing outpatient care. Whereas delegation of tasks to nurses as a form of interprofessional collaboration has been the target of recent studies, there is no data regarding collaboration amongst physicians in different specialisations working in primary care. We explored collaboration amongst GPs and Gyn regarding the healthcare provision to women aged ≥ 50 years.

METHODS

A quantitative postal survey was administered to GPs and Gyns in three federal states in Germany, focusing on care provision to women aged ≥ 50 years. A total of 4545 physicians, comprising 3514 GPs (67% of the total GP population) randomly selected, and all 1031 Gyns practicing in these states received the postal survey in March 2018. A single reminder was sent in April 2018 with data collection ending in June 2018. Multiple logistic regressions were performed for collaboration, adjusted by age and sex, alongside descriptive methods.

FINDINGS

The overall response rate was 31% (1389 respondents): 861 GPs (25%) and 528 Gyns (51%), with the mean respondent age being 54.4 years. Seventy-two per cent were female. Key competencies of collaboration are associated with working in rural federal states and with network participation. Physicians from rural states [odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.2, 1.9] and physicians in networks (OR = 3.0, CI = 2.3, 3.9) were more satisfied with collaboration. Collaboration to deliver services for women aged ≥ 50 years is more systematic amongst GPs and Gyns who are members of a network; increased networking could improve collaboration, and ultimately, outcomes too.

[Am I an emergency patient? Emergency perception and decision-making competence in acute situations: a qualitative study of ED patients]

BACKGROUND

The number of patients visiting emergency departments (ED) due to acute but less than urgent treatment needs is increasing. A deeper understanding of emergency perception and decision-making competencies of patients is fundamentally important for developing strategies to reduce ED utilization. The aim of this study was to assess ED patients' subjective understanding of an emergency in general as well as relating to their own specific consultation. Additionally, the patients' perspective on the ability to make appropriate decisions in acute situations should be explored.

METHODS

Seventeen qualitative semi-structured patient interviews were conducted and analyzed using qualitative content analysis.

RESULTS

The majority of participants attributed their ED consultation to a subjectively perceived emergency situation. Interviewees mostly understood an emergency as a serious or life-threatening constellation associated with impending long-term health damage. They believed that uncertainty concerning the interpretation of their symptoms and associated anxiety may particularly promote situations in which referring to an ED appears to be the only alternative. Patients' health competencies were assessed negatively by a majority of interviewees with regard to assessment of complaints and decision-making in acute situations ("insecure patients"). In contrast, few patients, including those with chronic disease and experience in dealing with health problems, were considered to have a high level of competence ("confident patients").

CONCLUSION

Improving patients' health literacy skills to strengthen their assessment of acute situations and their decision-making is important in order to promote appropriate ED utilization.

Management of COVID-19 ICU-survivors in primary care: - a narrative review

Many survivors of critical illness suffer from long-lasting physical, cognitive, and mental health sequelae. The number of affected patients is expected to markedly increase due to the COVID-19 pandemic. Many ICU survivors receive long-term care from a primary care physician. Hence, awareness and appropriate management of these sequelae is crucial. An interdisciplinary authorship team participated in a narrative literature review to identify key issues in managing COVID-19 ICU-survivors in primary care. The aim of this perspective paper is to synthesize important literature to understand and manage sequelae of critical illness due to COVID-19 in the primary care setting.

Diverting less urgent utilizers of emergency medical services to primary care: is it feasible? Patient and morbidity characteristics from a cross-sectional multicenter study of self-referring respiratory emergency department consulters

Objective

Diversion of less urgent emergency medical services (EMS) callers to alternative primary care (PC) is much debated. Using data from the EMACROSS survey of respiratory ED patients, we aimed to characterize self-referred EMS patients, compare these with non-EMS patients, and assess scope and acceptability of a potential redirection to alternative PC.

Results

Of n = 292 self-referred patients, n = 99 were transported by EMS. Compared to non-EMS patients, these were older, triaged more urgently and arrived out-of-hours more frequently. The share of chronically and severely ill patients was greater. Out-of-hours ED visit, presence of a chronic pulmonary condition as well as a hospital diagnosis of respiratory failure were identified as determinants of EMS utilization in a logistic model, while consultation for access and quality motives as well as migrant status decreased the probability. EMS-transported lower urgency outpatients visiting during regular physicians’ hours were defined as potential PC cases and evaluated descriptively (n = 9). As a third was medically complex and potentially less suitable for PC, redirection potential could be estimated at only 6% of EMS cases. This would be reduced to 2% if considering patients’ judgment concerning the appropriate setting. Overall, the scope for PC diversion of respiratory EMS patients seems limited.

General practitioners' views and experiences in caring for patients after sepsis: a qualitative interview study

BACKGROUND

Patients surviving critical illnesses, such as sepsis, often suffer from long-term complications. After discharge from hospital, most patients are treated in primary care. Little is known how general practitioners (GPs) perform critical illness aftercare and how it can be improved. Within a randomised controlled trial, an outreach training programme has been developed and applied.

OBJECTIVES

The aim of this study is to describe GPs' views and experiences of caring for postsepsis patients and of participating a specific outreach training.

DESIGN

Semistructured qualitative interviews.

SETTING

14 primary care practices in the metropolitan area of Berlin, Germany.

PARTICIPANTS

14 GPs who had participated in a structured sepsis aftercare programme in primary care.

RESULTS

Themes identified in sepsis aftercare were: continuity of care and good relationship with patients, GP's experiences during their patient's critical illness and impact of persisting symptoms. An outreach education as part of the intervention was considered by the GPs to be acceptable, helpful to improve knowledge of the management of postintensive care complications and useful for sepsis aftercare in daily practice.

CONCLUSIONS

GPs provide continuity of care to patients surviving sepsis. Better communication at the intensive care unit-GP interface and training in management of long-term complications of sepsis may be helpful to improve sepsis aftercare.

TRIAL REGISTRATION NUMBER

ISRCTN61744782.

Is time running out? The urgent need for appropriate global health curricula in Germany

Recently, representatives of politics, health officials and academia in Germany have advocated a greater role for Germany in matters concerning global health. However, health professionals in Germany are rarely taught about global health topics and accordingly real expertise in this field is lacking. To advance knowledge and competencies at German universities and adequately equip health professionals to achieve Germany’s political goals, global health curricula must be developed at medical schools and other institutions. Such ambitions raise questions about the required content and dimensions of global health curricula as the field is currently highly heterogeneous and ill defined. To systematically identify strengths and shortcomings of current curricula, we scrutinised the global health curriculum at our institution, Charité—Universitätsmedizin Berlin, using an analytical framework that integrates the various approaches of global health. Our analysis identified that four (technical, social justice, security and humanitarian) of five approaches are present in our core global health curriculum. Local and global aspects of the field are equally represented. We propose that the use of such a structured analytical framework can support the development of GH curricula for all health professionals—in Germany and elsewhere. But it can also help to evaluate existing curricula like ours at Charité. This framework has the potential to support the design of comprehensive GH trainings, serving German aspirations in politics and academia to promote health worldwide.

[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.

Implications for post critical illness trial design: sub-phenotyping trajectories of functional recovery among sepsis survivors

BACKGROUND

Patients who survive critical illness suffer from a significant physical disability. The impact of rehabilitation strategies on health-related quality of life is inconsistent, with population heterogeneity cited as one potential confounder. This secondary analysis aimed to (1) examine trajectories of functional recovery in critically ill patients to delineate sub-phenotypes and (2) to assess differences between these cohorts in both clinical characteristics and clinimetric properties of physical function assessment tools.

METHODS

Two hundred ninety-one adult sepsis survivors were followed-up for 24 months by telephone interviews. Physical function was assessed using the Physical Component Score (PCS) of the Short Form-36 Questionnaire (SF-36) and Activities of Daily Living and the Extra Short Musculoskeletal Function Assessment (XSFMA-F/B). Longitudinal trajectories were clustered by factor analysis. Logistical regression analyses were applied to patient characteristics potentially determining cluster allocation. Responsiveness, floor and ceiling effects and concurrent validity were assessed within clusters.

RESULTS

One hundred fifty-nine patients completed 24 months of follow-up, presenting overall low PCS scores. Two distinct sub-cohorts were identified, exhibiting complete recovery or persistent impairment. A third sub-cohort could not be classified into either trajectory. Age, education level and number of co-morbidities were independent determinants of poor recovery (AUROC 0.743 ((95%CI 0.659-0.826), p < 0.001). Those with complete recovery trajectories demonstrated high levels of ceiling effects in physical function (PF) (15%), role physical (RP) (45%) and body pain (BP) (57%) domains of the SF-36. Those with persistent impairment demonstrated high levels of floor effects in the same domains: PF (21%), RP (71%) and BP (12%). The PF domain demonstrated high responsiveness between ICU discharge and at 6 months and was predictive of a persistent impairment trajectory (AUROC 0.859 (95%CI 0.804-0.914), p < 0.001).

CONCLUSIONS

Within sepsis survivors, two distinct recovery trajectories of physical recovery were demonstrated. Older patients with more co-morbidities and lower educational achievements were more likely to have a persistent physical impairment trajectory. In regard to trajectory prediction, the PF score of the SF-36 was more responsive than the PCS and could be considered for primary outcomes. Future trials should consider adaptive trial designs that can deal with non-responders or sub-cohort specific outcome measures more effectively.

[Delegation modalities for general practitioners in North Rhine-Westphalia: Results of a survey among general practitioners on the assignment of defined tasks to EVA, VERAH and VERAH Plus]

BACKGROUND

The delegation of traditional GP tasks to qualified medical assistants (MFA) includes several modalities based on extended qualification curricula known as "Nicht-ärztliche Praxisassistentin" (NäPa) [non-physician practice assistant], also known as the "Entlastende Versorgungsassistentin" (EVA) and the "Versorgungsassistentin in der Hausarztpraxis" (VERAH and VERAH Plus) [professional healthcare assistants in the family practice]. Delegation to MFA has gained importance in recent years due to an increasing workload of general practitioners in Germany.

OBJECTIVES

This article examines the characteristics of general practitioners (GPs) currently delegating activities to MFAs with and without extended qualification based on the three mentioned modalities (EVA, VERAH and VERAH Plus). In addition, we explore whether the delegated activities are delivered in the office, at the patient's home or in the nursing home and how GPs perceived the potential of future delegation.

MATERIALS AND METHODS

Between April and August 2016, we conducted an anonymous postal survey of a representative randomized sample of general practitioners in North Rhine-Westphalia (n = 2,404). The questionnaire contained questions about practice staff, setting for delivery of the delegated activity as well as the perceived added values of and barriers to delegation. We compare characteristics of GPs delegating to MFA with extended qualification to those delegating to standard qualified MFA.

RESULTS

The response rate was 32 % (n = 762). Almost one third of the respondents (n = 239) delegated tasks to MFAs with extended qualification. These GPs are more likely to be younger and male and less likely to be working alone in individual practice. They delegate more activities to be delivered in all settings than GPs employing MFAs without extended qualification.

DISCUSSION AND CONCLUSIONS

GPs benefit from delegating to MFA with extended qualification as shown by the associated added values and setting of deployment for delivery of tasks. Delegation to non-medical staff should be considered by more GPs as a means of supporting healthcare delivery. In addition to legal changes, further procedures are needed to encourage GPs to get more actively involved with the issue of delegation and consider to further develop the competence of their staff and deploy them accordingly.

Self-referred walk-in patients in the emergency department - who and why? Consultation determinants in a multicenter study of respiratory patients in Berlin, Germany

BACKGROUND

Emergency department (ED) consultations are on the rise, and frequently consultations by non-urgent patients have been held accountable. Self-referred walk-in (SRW) consulters supposedly represent a predominantly less urgent patient population. The EMACROSS study aimed to explore consultation determinants and motives in SRW patients with respiratory symptoms.

METHODS

Multicenter survey of adult ED patients with respiratory complaints in eight emergency departments in central Berlin, Germany. Secondary hospital records data including diagnoses was additionally assessed. Characteristics of SRW and non-SRW patients were compared. Determinants of SRW consultation were evaluated by binary logistic regression. Consultation motives were analyzed descriptively. As a supplemental approach, network analysis (lasso-regularized mixed graphical model) was performed to explore connections between consultation determinants, consultation features and motives.

RESULTS

Between June 2017 and November 2018, n = 472 participants were included, the median age was 55 years (range 18-96), 53.2% of patients were male and n = 185 cases (39.2%) were SRW consulters. The SRW group showed lower proportions of potentially severe (pneumonia and respiratory failure, p < 0.001, χ2 test) and chronic pulmonary conditions. Determinants of SRW consultation identified by logistic regression were younger age (p < 0.001), tertiary education (p = 0.032), being a first-generation migrant (p = 0.002) or tourist (p = 0.008), having no regular primary care provider (p = 0.036) and no chronic pulmonary illness (p = 0.017). The area under the curve (AUC) for the model was 0.79. Personal distress and access problems in ambulatory care were stated most frequently as consultation motives in the SRW group; network analysis showed the scarcity of associations between demographic and medical SRW determinants and motives triggering the actual decision to consult.

CONCLUSIONS

As to "who" consults, this study identified demographic and medical predictors of SRW utilization. The said markers seem only remotely connected to "why" people decide for SRW visits. To alleviate ED crowding by addressing frequent SRW consultation motives, interventions focused on the ability for symptom self-assessment and at better-accessible alternative care seem sensible.

TRIAL REGISTRATION

German Clinical Trials Register ( DRKS00011930 ); date: 2017/04/25.

[The Delegation Agreement and its Implementation Inside and Outside the GP Office from the Perspective of Practice Owners]

BACKGROUND

In many regions in Germany, demographic changes are affecting general practitioners (GPs). The 2017 "Delegation Agreement" (D-A) rolled out the 2015 reform and was introduced initially only for regions with GP shortages, allowing delegation to non-medical practice personnel for all regions in Germany.

OBJECTIVES

This article explores GPs' knowledge regarding current regulations and the task-based delegation inside and outside their office.

MATERIALS AND METHODS

We conducted a quantitative anonymous postal questionnaire survey of a randomized sample of 30% of GPs working in Nord Rhine-Westphalia. The response rate was 32%. Outcomes included attitude towards delegation, self-perceived level of information about the D-A and task-based attitude towards delegation (is being delegated/is not delegable) for 34 medical tasks.

RESULTS

Over two-thirds of GPs had a positive attitude towards delegation, but only 24% reported having a good/very good level of Information regarding the D-A. "Diagnostic tasks" were most frequently delegated. Agreement on what can be delegated in the areas of "general tasks" and "counselling/education" showed significant differences based on level of information. Both well-informed and poorly informed GPs delegated in equal measure "therapeutic tasks". Two distinct groups of "diagnostic tasks" were distinguished based on GPs' information level.

CONCLUSIONS

The list of tasks being currently delegated to PAs in the fields of "diagnostics", "organization/administration" and "general tasks" shows further potential for expansion. This could be supported by improved information communicated to GPs about the health policy reform introduced by the D-A.

An intimate view into the silica deposition vesicles of diatoms

Diatoms are single-celled microalgae that produce silica-based cell walls with intricate nano- and micropatterns. Biogenesis of diatom biosilica is a bottom-up process that occurs in large intracellular compartments termed silica deposition vesicles (SDVs). Investigating the mechanisms of silica morphogenesis has so far been severely limited by the lack of methods for imaging the entire volume of an SDV with high spatial resolution during all stages of development. Here we have developed a method that allows for rapid identification and electron microscopy imaging of many different, full sized SDVs that are in the process of producing biosilica valves. This enabled visualizing the development of characteristic morphological biosilica features with unprecedented spatio-temporal resolution. During early to mid-term development, valve SDVs contained ~ 20 nm sized particles that were primarily associated with the radially expanding rib-like biosilica structures. The results from electron dispersive X-ray analysis suggests that the immature biosilica patterns are silica-organic composites. This supports the hypothesis that silica morphogenesis is dependent on organic biomolecules inside the SDV lumen.

What role does the GP play for emergency department utilizers? A qualitative exploration of respiratory patients' perspectives in Berlin, Germany

BACKGROUND

While motives for emergency department (ED) self-referrals have been investigated in a number of studies, the relevance of general practitioner (GP) care for these patients has not been comprehensively evaluated. Respiratory symptoms constitute an important utilization trigger in both EDs and in primary care. In this qualitative study, we aimed to explore the role of GP care for patients visiting EDs as outpatients for respiratory complaints and the relevance of the relationship between patient and GP in the decision making process leading up to an ED visit.

METHODS

Qualitative descriptive study. Semi-structured, face-to-face interviews with a sample of 17 respiratory ED patients in Berlin, Germany. Interviews were recorded and transcribed verbatim. Qualitative content analysis was performed. The study was embedded into the EMACROSS (Emergency and Acute Care for Respiratory Diseases beyond Sectoral Separation) cohort of ED patients with respiratory symptoms, which is part of EMANet (Emergency and Acute Medicine Network for Health Care Research).

RESULTS

Three patterns of GP utilization could be differentiated: long-term regular consulters, sporadic consulters and patients without GP. In sporadic consulters and patients without GP, an ambivalent or even aversive view of GP care was prevalent, with lack of confidence in GPs' competence and a deficit in trust as seemingly relevant influencing factors. Regardless of utilization or relationship type, patients frequently made contact with a GP before visiting an ED.

CONCLUSIONS

With regard to respiratory symptoms, our qualitative data suggest a hypothesis of limited relevance of patients' primary care utilization pattern and GP-patient relationship for ED consultation decisions.

[Support for General Practitioners in the Care of Patients with Complex Needs: A Questionnaire Survey of General Practitioners in Berlin]

OBJECTIVES

Because of demographic changes, new models of care are important for supporting general practitioners in the care of patients with complex needs. This study addresses the question of the type of support that is requested by general practitioners working in Berlin.

METHODS

All general practitioners working in Berlin (n=2354) were asked between August and September 2018 to return a questionnaire by post which has been developed for this study. Questions addressed support needs as well as support models within the practice (delegation, substitution) and outside the practice (social worker, navigator, community care points). Data were analysed descriptively and by exploratory multivariate analysis to show the influence of practice and doctor characteristics on the preference of support models (age, gender, location of the practice, type of practice, working hours).

RESULTS

A total of 557 questionnaires (response rate 23.7%) were included in the analysis. Need for support was seen particularly for administrative, coordinative and organisational tasks and for advice on social issues. The majority of the study participants approved delegation and substitution. In their view, it was conceivable to get support from professionals or institutions outside their practice, such as mobile care services, community care points, social workers or navigators. Particularly younger and female doctors working in group practices were open for cooperative care models integrating other health professions.

CONCLUSIONS

There is unused potential for delegation and cooperation within existing structures. Further research should investigate the acceptance and feasibility of different support models.

Prescribing and medical non-adherence after myocardial infarction: qualitative interviews with general practitioners in Germany

BACKGROUND

An increasing prevalence of having survived a myocardial infarction increases the importance of medical secondary prevention. Although preventive medication reduces mortality, prescribing and adherence are known to be frequently insufficient. General practitioners are the most important prescriber. However, their perspective on prescribing and medical non-adherence following myocardial infarction has not yet been explored. Thus, the aim of this study was to explore the general practitioners' perspective on long-term care after myocardial infarction focussing on medical prevention.

METHODS

In this qualitative interview study we conducted episodic interviews with sixteen general practitioners from rural and urban surgeries in Germany. Framework analysis with focus on general practitioners' prescribing and patients' non-adherence was performed.

RESULTS

Almost all general practitioners reported following guidelines for myocardial infarction aftercare and prescribing the medication that was initiated in the hospital; however, they described deviating from guidelines because of drugs' side effects or patients' intolerances. Some questioned the benefits of medical secondary prevention for the oldest of patients. General practitioners perceived good adherence among their patients who had had an MI while they regarded their methods for assessing medical non-adherence as limited. They perceived diverse reasons for non-adherence, particularly side effects, patients' freedom from symptoms and patients' indifference to health. They attributed mainly negative characteristics, like lack of knowledge and understanding, to non-adherent patients. These characteristics contribute to the difficulty of convincing these patients to take medications as prescribed. General practitioners improved adherence by preventing side effects, explaining the medication's necessity, facilitating intake and involving patients in decision-making. However, about half of the general practitioners reported threatening their patients with negative consequences of non-adherence.

CONCLUSIONS

General practitioners should be aware that discharge medication can be insufficient and thus, should always check hospital recommendations for accordance with guideline recommendations. Improving physicians' communication skills and informing and motivating patients in an adequate manner, for example in simple language, should be an important goal in the hospital and the general practitioner setting. General practitioners should assess patients' motivations through motivational interviewing, which no general practitioner mentioned during the interviews, and talk with them about adherence and long-term treatment goals regularly.

Train the trainer course for general practice trainers in ambulatory care: the Berlin model

Objective: Demands for a stronger competence orientation of specialty postgraduate medical training require the expansion of the didactic qualifications of those responsible for postgraduate medical training. In the context of the foundation of the Berlin competence center for postgraduate general practice training, a train the trainer basic seminar was designed together with the Berlin chamber of physicians. The seminar aims to convey formal-legal aspects in close connection with the development of didactic competences of the general practice trainers. This article presents the didactic concept, focal points and the schedule of the one-and-a-half-day seminar to be able to adapt it to one's own context. Methodology: After the seminars, participants filled out an evaluation form. The questionnaire included the subjective experiences of increased competence, the relevance of the contents, and the satisfaction with the structure and methods of the seminar. The data were analyzed descriptively. Results: Since June 2018, 46 general practice trainers have participated in one of three train the trainer seminars. 97.6% of the participants were very satisfied or satisfied with the overall seminar and felt that the timeframe was right, 92.7% would recommend the seminar to colleagues. 68.3% fully agreed that by attending the seminar they were able to improve their didactic skills, 90% were confident that they could integrate what they had learned into their work as general practice trainers. 85.4% stated that they had reflected on their role as trainers. In particular, the atmosphere, the high degree of interactivity and the protected framework for collegial exchange were positively emphasized. Conclusion: Together with the Berlin chamber of physicians, we succeeded in designing a train the trainer seminar which, on the one hand, met the needs of the general practice trainers for clarification of formal-legal questions of their further training activities and, on the other hand, allowed the further development of didactic skills. At the moment, a modular program is being planned in order to give general practice trainers the opportunity to expand their didactic competence and regularly exchange ideas with colleagues.

Long-Term Courses of Sepsis Survivors: Effects of a Primary Care Management Intervention

BACKGROUND

Sepsis survivors face mental and physical sequelae even years after discharge from the intensive care unit. The aim of this study was to evaluate the long-term courses of sepsis survivors and the effects of a primary care management intervention in sepsis aftercare.

METHODS

This study presents a 24-month follow-up of a randomized controlled trial that recruited 291 patients who survived sepsis (including septic shock) from nine German intensive care units. Participants were randomized to usual care (n=143) or to a 12-month-intervention (n=148). The intervention included training of patients and their primary care physicians (PCP) in evidence-based post-sepsis care, case management provided by trained nurses, and clinical decision support for PCPs by consulting physicians. Usual care was provided by PCPs in the control group. At the 24-month follow-up, 12 months after the 1-year-intervention, survival and measures of mental and physical health were collected by telephone interviews.

RESULTS

One hundred eighty-six (63.9%, 98 intervention, 88 control) of 291 patients completed the 24-month follow-up, showing both increased mortality and recovery from functional impairment. Unlike the intervention group, the control group showed a significant increase of posttraumatic stress symptoms according to the Posttraumatic Symptom Scale (difference between baseline and 24-months follow-up values, mean [standard deviation] 3.7 [11.8] control vs -0.7 [12.1] intervention; P = .016). There were no significant differences in all other outcomes between the intervention and control groups.

CONCLUSIONS

Twelve months after completion, a primary care management intervention among survivors of sepsis did not improve mental health-related quality of life. Patients in the intervention group showed less posttraumatic stress symptoms.

Health care utilisation and medication one year after myocardial infarction in Germany - a claims data analysis

BACKGROUND

After myocardial infarction, guidelines recommend pharmaceutical treatment with a combination of five different types of drugs for prevention in patients. However, studies from different countries have shown that this goal is not achieved in many patients. The aim of this study was to assess both healthcare and prescribed pharmaceutical treatment in the fourth quarter after index myocardial infarction.

METHODS

We conducted a claims data analysis with the data of patients who had had a myocardial infarction in the years 2013 or 2014, using information from the largest German health insurance fund ('AOK'). We analysed contact with physicians, hospital care and actual prescriptions for medication recommended in international guidelines, referring to beta-blockers, ACE inhibitors or angiotensin II receptor blockers, P2Y12-antiplatelet agents, acetylsalicylic acid and statins, one year after myocardial infarction. Analysis was stratified by age and sex, compared between patient groups and over time.

RESULTS

We identified 2352 patients who had survived myocardial infarction. Some 96.9% of these participants had at least one contact with their general practitioner (GP) one year after myocardial infarction, 22.8% contacted a cardiologist and 19.7% were hospitalised. Prescription rates range from 37.8% for acetylsalicylic acid to 70.4% for ACE inhibitors. However, only 24.1% received statins, beta-blockers, ACE inhibitors and an antiplatelet drug simultaneously. Prescription of recommended drugs after myocardial infarction decreased steadily over time.

DISCUSSION

Long-term medical prevention after myocardial infarction is improvable. GPs should take care of the pharmaceutical prevention after myocardial infarction as they are the physicians seen most intensively in this period.

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

BACKGROUND

In Germany, a decreasing number of general practitioners (GPs) face a growing number of patients with multimorbidity. Whilst care for patients with multimorbidity involves various healthcare providers, the coordination of this care is one of the many responsibilities of GPs. The aims of this study are to identify the barriers to the successful coordination of multimorbid patient care and these patients' complex needs, and to explore the support needed by GPs in the care of multimorbid patients. Interviewees were asked for their opinion on concepts which involve the support by additional employees within the practice or, alternatively, external health care professionals, providing patient navigation.

METHODS

Thirty-two semi-structured, qualitative interviews were conducted with 16 GPs and 16 medical practice assistants (MPAs) from 16 different practices in Berlin. A MPA is a qualified non-physician practice employee. He or she undergoes a three years vocational training which qualifies him or her to provide administrative and clinical support. The interviews were digitally recorded, transcribed and analysed using the framework analysis methodology.

RESULTS

The results of this paper predominantly focus on GPs' perspectives of coordination within and external to general practice. Coordination in the context of care for multimorbid patients consists of a wide range of different tasks. Organisational and administrative obstacles under the regulatory framework of the German healthcare system, and insufficient communication with other healthcare providers constitute barriers described by the interviewed GPs and MPAs. In order to ensure optimal care for patients with multimorbidity, GPs may have to delegate responsibilities associated with coordinating tasks. GPs consider the deployment of an additional specifically qualified employee inside the general practice to take on coordinative and social and legal duties to be a viable option.

CONCLUSIONS

The cross-sectoral cooperation between all involved key players working within the healthcare system, as well as the coordination of the whole care process, is seemingly challenging for GPs within the complex care system of multimorbid patients. GPs are generally open to the assignment of a person to support them in coordination tasks, preferably situated within the practice team.

Experiencing and designing community-based medicine - development and evaluation of an elective based on explorative learning

Objective: To develop and evaluate an elective for the 6^th semester in the medical curriculum at Charité - Universitätsmedizin Berlin. In this elective, medical students could experience and test Community Oriented Primary Care, hence the integration of public health into primary care, by using explorative learning methods. Method: In three consecutive semester, all participants of the elective filled in a questionnaire before and after the elective. The self-developed questionnaire covered socio-demographic features, an evaluation of the elective as well as a self-assessment regarding learning objectives and attitudes. The results were analyzed descriptively; the learning success was measured by mixed model regression. Results: Thirty-one students (100% of the elective participants) took part in the evaluation, 30 of them (96.8%) at both survey dates. The students evaluated the elective and particularly the commitment of the teachers as very positive. The five-level Likert scale showed a significant growth of knowledge by an average of 1.3 points. The attitudes of the students hardly changed. Conclusion: Students can experience Public Health practically by means of Community Oriented Primary Care. In doing so, explorative learning is an appropriate method providing a significant increase in competences.

How to decide adequately? Qualitative study of GPs' view on decision-making in self-referred and physician-referred emergency department consultations in Berlin, Germany

OBJECTIVES

Patients with acute symptoms present not only to general practitioners (GPs), but also frequently to emergency departments (EDs). Patients' decision processes leading up to an ED self-referral are complex and supposed to result from a multitude of determinants. While they are key providers in primary care, little is known about GPs' perception of such patients. This qualitative study explores the GPs' view regarding motives and competences of patients self-referring to EDs, and also GPs' rationale for or against physician-initiated ED referrals.

DESIGN

Qualitative study with semi-structured, face-to-face interviews; qualitative content analysis.

SETTING

GP practices in Berlin, Germany.

PARTICIPANTS

15 GPs (female/male: 9/6; mean age 53.6 years).

RESULTS

The interviewed GPs related a wide spectrum of factors potentially influencing their patients' decision to visit an ED, and also their own decision-making in potential referrals. Considerations go beyond medical urgency. Statements concerning patients' surmised rationale corresponded to GPs' reasoning in a variety of important areas. For one thing, the timely availability of an extended spectrum of diagnostic and therapeutic options may make ED services attractive to both. Access difficulties in the ambulatory setting were mentioned as additional triggers for an ED visit initiated by a patient or a GP. Key patient factors like severity of symptoms and anxiety also play a major role; a desire for reassurance may lead to both self-referred and physician-initiated ED visits. Patients' health competence was prevailingly depicted as limited, with the internet as an important influencing factor. Counselling efforts by GP were described as crucial for improving health literacy.

CONCLUSIONS

Health education could hold promise when aiming to reduce non-urgent ED consultations. Primary care providers are in a key position here. Amelioration of organisational shortages in ambulatory care, for example, limited consultation hours, might also make an important impact, as these trigger both self-referrals and GP-initiated ED referrals.

TRIAL REGISTRATION NUMBER

DRKS00011930.

'Managing scarcity'- a qualitative study on volunteer-based healthcare for chronically ill, uninsured migrants in Berlin, Germany

OBJECTIVES

In Germany, healthcare for people lacking legal residency status and European Union citizens without health insurance is often provided by non-governmental organisations. Scientific studies assessing the situation of the patients with chronic diseases in this context are scarce. We aimed to characterise medical care for chronically ill migrants without health insurance and outline its possibilities and limitations from the treating physicians' perspective.

DESIGN

Qualitative semi-structured interviews; qualitative content analysis.

SETTING

Organisations and facilities providing healthcare for uninsured migrants: free clinics, medical practices and public health services.

PARTICIPANTS

14 physicians working regularly in healthcare for uninsured migrants.

RESULTS

Delayed contact to the healthcare system was frequently addressed in the interviews. Care was described as constrained by a scarcity of resources that often impedes adequate treatment for many conditions, most pronounced in the case of oncological diseases or chronic viral infections (HIV, hepatitis). For other chronic conditions such as cardiovascular diseases or diabetes, some diagnostics and basic medications were described as partially available, while management of complications or rehabilitative measures are frequently unfeasible. For the patients with mental health problems, attainability of psychotherapeutic treatment is reported as severely limited. Care is predominantly described as fragmented with limitations to information flow and continuity. Which level of care a patient receives appears to depend markedly on the respective non-governmental organisation and the individual commitment, subjective decisions and personal connections of the treating physician.

CONCLUSIONS

Restrictions in medical care for uninsured migrants have even more impact on chronically ill patients. Volunteer-based care often constitutes an inadequate compensation for regular access to the healthcare system, as it is strongly influenced by the limitation of its resources and its arbitrariness.

[Empirical health services research in emergency and acute medicine : Preliminary results of concomitant monitoring of patient recruitment and sample quality]

BACKGROUND

Up until now, research data on the implementation of empirical health services research in emergency departments in Germany are scarce.

STUDY AIM

A monitoring instrument applied in a multicenter prospective cohort study in emergency departments (EDs) is described and discussed regarding requirements for the control and supervision of data collection.

MATERIALS AND METHODS

Patients with cardiac diseases, respiratory tract infections, and hip fractures were recruited in eight EDs located in a central district of Berlin. Enrolment figures and nonresponder reasons were analyzed through descriptive statistics. Potential sample bias was examined in terms of response rates as well as the distribution of age and sex in the group of participants and nonresponders. Qualitative content analysis was applied to data from routine supervisory and feedback meetings with study nurses.

RESULTS

Within the first 8 months of data collection, 61.1% of the aimed 1104 patients were recruited. Most frequently stated nonresponder reasons were the dense work and care processes in EDs (41.9%) and patients' disease burden (24.7%). Moreover, qualitative results revealed problems with identifying potentially eligible participants and difficulties because of missing research infrastructure in study centers. The response rate of 50.7% and approximately equal distribution of age and sex in participants and nonresponders do not indicate sample biases.

DISCUSSION

The monitoring instrument has proven to be suited for empirical research in EDs and revealed optimization potential. We recommend using qualitative and quantitative data systematically.