[An exploratory cross-sectional study on technical affinity and smartphone use among practice staff and patients: development of an app for multimorbid patients in general practice]

INTRODUCTION

Due to individual care needs, the provision of care to patients with two or more chronic diseases (multimorbidity) is described as complex. In addition, the number of chronically ill people is increasing, due in part to demographic changes which pose a challenge, especially for outpatient primary care. In order to fulfil patients' needs and to promote self-management as a central care element of chronically ill patients, the use of eHealth applications increases. TelePraCMan will be developed as one of these applications and includes a symptom-based electronic diary, which will be implemented in the established German disease management programme 'PraCMan'. This study is conducted as a part of the TelePraCMan project and aims to detect the needs of potential end users (physicians, medical assistants, patients).

METHODS

In the TelePraCMan development phase, an explorative cross-sectional study was conducted with potential end users of the TelePraCMan app (patients, physicians and medical assistants). For this purpose, a written survey was conducted in Baden-Wurttemberg between April 2019 and March 2020. The survey covered smartphone usage behaviour, technology affinity using the standardised questionnaire TA-EG, support network for technical questions and sociodemographic data.

RESULTS

A total of n=202 patients (n=98), physicians (n=58) and medical assistants (n=43) participated in the survey. Concerning smartphone use, 78.2 % of the participants stated that the function used most frequently was writing short messages. Health apps were the least used function (9.6 %). Furthermore, patients (12.6 %) use health apps more often than medical assistants (10.3%) and doctors (4.4 %). Participants aged 50 and younger were found to have a higher affinity for technology (mean=3.20, SD=0.51) than participants over 50 years of age (mean=2.98, SD=0.67). Older, multimorbid respondents had a particularly low affinity for technology (mean=2.52, SD=0.69). 10.9 % of the over-fifties and 12.5 % of the multimorbid persons felt able to fix any technical problems on their own without help. Multimorbid participants over the age of 50 were observed to prefer personal support over internet-based support.

DISCUSSION

On average, multimorbid respondents in the age group over 50 have a lower affinity for technology than respondents aged under 50 without multimorbidity. The most frequent negative attitude towards electronic devices is also found among patients over 50 years of age, who are expected to be the main target group of the TelePraCMan app. These findings can be used to derive requirements for the design and development of functions of the app, as well as accompanying measures, such as intuitive and simple user interface, a telephone hotline to support users, close consultation with users on the planned functions, and more.

CONCLUSION

Based on this survey, we were able to determine the needs of the future target group of the TelePraCMan app. This is seen as a starting point for the development of an implementation strategy and the pilot testing of the app in primary care.

[Clinical Nutrition for the Medical Patient: From Screening to Diagnosis and Start of Nutritional Therapy]

Clinical Nutrition for the Medical Patient: From Screening to Diagnosis and Start of Nutritional Therapy Abstract. With the demographic increase of elderly, multimorbid patients, the number of those with disease-related malnutrition is also steadily increasing. We now know that malnutrition is a strong and independent risk factor for morbidity, mortality, and poor quality of life. Fortunately, however, several studies have shown that malnutrition screening followed by physiological nutritional therapy to meet individual nutritional goals has a positive impact on the clinical course of medical patients. In this context, Nutritional Risk Screening is suitable as a tool for assessing nutritive risk in hospitalized and ambulatory patients in family practice. Patients at risk for malnutrition should undergo an in-depth clinical assessment in an interdisciplinary team of nutritionists, nurses, and physicians to clarify the etiology of malnutrition and risk factors, and to examine the indication for nutritional therapy. Such nutrition therapy should be individually tailored to the patient's nutritional needs (calorie, protein, and micronutrient requirements), the underlying disease and the patient's preferences. Patients should be closely monitored, and the therapy should be adapted during the disease.

Gut leben zuhause mit Multimorbidität

Living well at home with multimorbidity - A project on the contribution of advanced practice nursing in home health care Abstract. Background: Multimorbidity has increased among the elderly, leading to loss of autonomy, lower quality of life, complex treatment plans and higher rates of complications and hospitalisations. Functional impairment and challenging therapy management make the use of home health nursing services essential. Experience in primary care and in hospitals has shown that Advanced Practice Nurses (APN) lead to a better quality of care for patients with multimorbidity. However, there is no data yet regarding the potential contribution of APNs to the care of these patients in home healthcare settings. Aim: To develop the role of the APN in a home health nursing organisation for patients with multimorbidity, applying internationally established APN core competencies. Methods: Characteristics of referred clients were collected and presented in case studies in an APN practice development project based on the PDCA-cycle. Benefits for clients, family caregivers, the nursing team, and for interprofessional collaboration were elaborated. Results: During the project period, a total of 40 clients were assigned to APN-care. An increase in stability in complex situations and higher confidence of clients and family caregivers in their individual health management were achieved. Discussion: The key factors were the APN's leadership role in best practice development and interprofessional collaboration. The APN played an important role in coordinating the numerous parties involved. Limits and transfer: This role must be further established. Empirical research is required to show the effect on quality of care.

[Reasons for non-acceptance and non-use of a home telemonitoring application by multimorbid patients aged 65 years and over]

BACKGROUND

User acceptance is a key indicator and driver for the use and implementation of telemonitoring applications (TMA) in healthcare. Despite various positive effects that previous studies have revealed for users of TMA, there are always patients who discontinue their participation in a telemedicine study or even decline participation. There is little evidence for the reasons for non-acceptance and non-use of TMA, especially in multimorbid patients at the age of 65 and over in their home environment. To close this research gap, this sub-study focuses on patient-reported reasons for non-acceptance and non-use of TMA in the home environment.

METHODS

This study follows a mixed-method approach and focuses on patients' perspective. Quantitative data collection took place via computer-assisted telephone interviews among all drop-outs and non-participants. Qualitative data were collected via semi-structured interviews with drop-out patients and non-users. Eligible patients were recruited consecutively by general practitioners, informed and included in the study according to the inclusion criteria. Amongst others, patients measured their vital signs (blood pressure, heart frequency, oxygen saturation, weight) via telemedical measures and sent them via tablet to a Care Coordination Center to ascertain the need for intervention. Collected data on non-acceptance and non-use of TMA were analyzed quantitatively and qualitatively.

RESULTS

Nine general practices in two German cities included a total of 177 patients according to the inclusion criteria. During the study, 61 study participants (34.5 %) dropped out, 80 patients (31.1 %) declined participation in the study. Drop-outs and non-participants were significantly older than active participants (p=.004 and p=.001, respectively). Predominant reasons for drop-out were the lack of the perceived added value and the content-related variety of the program on the patient's tablet, the missing interest/need for telemedical monitoring as well as the time spent participating in the study. Patients living alone, single and widowed patients reported significantly more difficulties in handling the hardware (tablet) (p=.040) and the program (Motiva) (p=.013) than married and cohabiting patients. These reasons were also reported mainly by female patients, patients aged 75 years and over, and those with a low level of education.

CONCLUSION

In order to increase the acceptance and the added value of TMA for patients, the individual needs of the future target group should be analyzed at the beginning of the development. To ensure maximum user centricity, individual development steps should be continuously evaluated by the target group. TMA should be adapted to the functional abilities of elderly, multimorbid patients through, e. g., an appropriate design of the content, which is tailored to patients' individual needs. TMA should be used to an appropriate degree to avoid overburdening and should fit unobtrusively into patients' usual daily routine. For patient-specific acceptance of TMA, easy handling of the telemedical measuring and input devices is as important as the variety of offers on the platform and personal contact for technical queries. Special attention should be paid to patients who live alone, women, elderly patients over 75 years of age, and poorly educated patients in order to ensure full and easy access to technology-based telemonitoring for their own healthcare.

[Prevalence and influencing factors of chronic wounds among clients of home care services in Germany]

INTRODUCTION

Chronic or non-healing wounds are a serious problem for both the parties involved and the healthcare system. Currently, there are hardly any reliable data on the prevalence of chronic wounds in outpatient care, although this setting is becoming increasingly important. Therefore, the aim of this study was to determine the prevalence of and the factors associated with chronic wounds in clients cared for by home care services.

METHOD

As part of a cross-sectional study throughout Germany in 2012, a survey was conducted among care recipients provided by home care services. The sample was drawn in a two-step procedure. First, a random sample of home care services was drawn for each federal state, followed by random selection of clients to be interviewed for each service. The aim of the study was to describe the prevalence of chronic wounds and influencing factors such as BMI, age, housing situation, activity and diabetes mellitus. Data collection through questionnaire was carried out by trained nurses.

RESULTS

A total of 144 home care services with 1,296 clients had agreed to participate. With 880 care recipients from 100 home care services finally taking part in the survey, the response rate was 68 %. Of all care recipients examined, 101 had at least one chronic wound; the highest prevalence rates were observed for pressure ulcers (4.6 %) and leg ulcers (4.0 %). Care recipients with diabetes mellitus were more frequently affected by chronic wounds (16.4 %) than non-diabetic recipients (9.5 %). Community-living care recipients (14.1 % chronic wounds; 6.0 % pressure ulcers) and care recipients under the age of 65 (20 % chronic wounds; 9.5 % pressure ulcers) were affected more frequently than care recipients living alone (9.1 % chronic wounds; 3.0 % pressure ulcers) or care recipients older than 65 years (10.5 % chronic wounds; 4.0 % pressure ulcers). In the multivariate calculation, the BMI proved to be the strongest predictor. The prevalence of chronic wounds in the group of obese (BMI>35.3kg/m²) care recipients and those with activity restriction is 44.8 %.

CONCLUSION

In view of the fact that one out of nine care recipients receiving assistance from home care services is affected by at least one non-healing wound, special attention should be paid to the prevention, detection and treatment of chronic wounds. Furthermore, it seems particularly necessary to identify the relevant risk groups in order to be able to initiate adequate and preventive measures at an early stage.

[Increasing Complexity in Performance Delivery - Management Approach for Tertiary Care Centers]

Increasing Complexity in Performance Delivery - Management Approach for Tertiary Care Centers Abstract. General social trends such as individualization and female shift increase the complexity for management in both technical and system management in addition to the inherent development in the hospital industry such as subspecialization, ageing societies and multimorbidity. Reduction of complexity is therefore absolutely necessary in order to be able to manage in a patient-friendly way as a maximum care provider. Reducing complexity means resolving therapeutic conflicts. Essential tools for this are digitization, a comprehensive quality paradigm that includes patient experience, patient assessment of treatment outcomes, indication and service quality, and good management. The latter integrates the fragmentation of skills and knowledge of a subspecialized medicine through appropriate system design. This requires the appropriate functional strategies and a comprehensive process management competence that can transform the numerous interfaces into seams.

[Diseases as a 'Stumbling Block' - a Case of Multimorbidity in Clinical Practice]

Diseases as a `Stumbling Block` - a Case of Multimorbidity in Clinical Practice Abstract. Here we report on a 83 year-old patient with cardiac syncope and consecutive traumatic brain injury with intracranial haemorrhage receiving anticoagulation for recurrent pulmonary embolism: a 'medical dilemma' due to the syncope with consecutive traumatic event and the underlying condition. A pre-existing underlying cardiac disease was identified as the cause of the syncope and the intracranial haemorrhage was most likely due to oral anticoagulation for recurrent pulmonary embolisms. The intracranial bleeding inhibited an optimal management of the underlying cardiac condition and the patient deceased shortly thereafter.

[Not Available]

Zusammenfassung. Aufgrund der demografischen Entwicklung gewinnt die Rehabilitation Betagter an Bedeutung. Im Vergleich zum jüngeren Patienten sind beim betagten Patienten die Autonomie und die Handlungsfähigkeit in Alltagssituationen meist rascher bedroht, die soziale Partizipation fragiler, und somit die Gefahr der Vereinsamung prinzipiell grösser. Die Kommunikation mit dem Umfeld spielt eine grössere Rolle. Das Risiko für Komplikationen ist hoch; andererseits äussern betagte Patienten in der Regel weniger Angst vor dem Tod als vor einem völligen Verlust der Selbständigkeit und davor, ihren Angehörigen «zur Last zu fallen». Auch betagte Patienten profitieren von organspezifischen Rehabilitationsmassnahmen auf dem Niveau der Alltagsfunktionalität und sozialen Partizipation, wie dies exemplarisch für die Neurorehabilitation nach Schlagfanfall gezeigt wurde. Die geriatrische Rehabilitation fokussiert spezifisch auf die Bedürfnisse Betagter, die durch Multimorbidität, Vulnerabilität oder Gebrechlichkeit (Frailty) charakterisiert sind. Sie ist als interprofessioneller Prozess aufgebaut, der polymodal körperliche, psychische und soziale Aspekte systematisch erfasst und mit dem Patienten und seinem Umfeld ein individuell adaptiertes Ziel erarbeitet. Zentral sind die Aspekte Mobilität, Selbsthilfefähigkeit, Ernährung, Kognition, Stimmung, Kontinenz und soziale Situation. Ein Tragpfeiler ist dabei eine altersadaptierte, proteinreiche Ernährung. Ärztlicherseits wird es – gerade bei der Rehabilitation Betagter – hilfreich sein, die Kompetenzen aus verschiedenen Fachrichtungen synergistisch zu nutzen. Unter der Vorstellung einer optimalen Betreuung und Beratung gerade in den Kompetenzfeldern Mobilität, Kognition und Ernährung kann eine Co-Betreuung ein zukunftsfähiges Modell sein. Im Hinblick auf die rehabilitative Prognose dürfte «Alter» im Sinne der Anzahl bisheriger Lebensjahre eine überschätzte Prognosevariable sein. «Höheres Alter» kann hingegen als Surrogatmarker für Komorbiditäten gelten, die mit zunehmendem Lebensalter an Häufigkeit zunehmen. Unter diesen Gesichtspunkten ist es unbedingt zu vermeiden, dass betagte Patienten rein auf Grund ihrer bereits verbrachten Lebensjahre weniger häufig als Jüngere die Chance einer rehabilitativen Behandlung erhalten.

Choosing Wisely - An international and multimorbid perspective

Some medical diagnostic and therapeutic interventions are non-beneficial or even harmful. The Choosing Wisely campaign has encouraged the generation of "top five" lists of unnecessary low-value services in different specialist areas. In the USA alone, where the campaign was launched, these lists include a total of 450 evidence-based recommendations. Medical scientific societies in further countries such as Canada, Australia, New Zealand, England, Switzerland and Germany have since initiated Choosing Wisely campaigns. Besides implementing top five lists, these aim to change attitudes, expectations and practices in the culture of medicine. The field of internal medicine has initiated change in Switzerland (Swiss Society of General Internal Medicine: Smarter Medicine) and Germany (German Society of Internal Medicine: Klug entscheiden). Formulating Choosing Wisely principles in managing complex patients with multiple concurrent acute or chronic diseases, i. e., multimorbidity (MM), will present a particular challenge. Research is needed to determine the primary sources of overuse in specific combinations of diseases (i. e., MM clusters) and spearhead corresponding recommendations. National Choosing Widely campaigns may serve as a forerunner to a more global initiative.

[Cardiovascular drugs in aged and multimorbid patients]

Cardiovascular diseases, such as arterial hypertension, heart failure, coronary artery disease, peripheral circulatory problems and atrial fibrillation are increasingly present in aged patients. Comorbidities, mainly diabetes, renal dysfunction, chronic bronchitis and degenerative joint diseases, are also frequent and need additional drug treatment. The usual polypharmacy often causes side effects due to overdosage and/or drug interactions. The main difficulty in choosing the proper therapeutic regimen consists in the lack of suitable dosing guidelines with adapted therapeutic targets for the older multimorbid population, usually not represented in the large controlled trials forming the basis of general recommendations. European guidelines for hypertension and heart failure are discussed as examples.

[Comorbidity in medical guidelines: comparison of the current state, epidemiologic models and expert opinion]

INTRODUCTION

Medical guidelines focusing on monomorbidities can be associated with adverse events in multimorbid patients. This study investigates how comorbidities are actually particularised in a set of German guidelines. In addition, it evaluates whether two epidemiologic approaches (disease combinations or clusters of comorbidities) can be used to systematically integrate multimorbidity in guideline development.

METHODS

Based on a matrix of 30 comorbidities, mentioning of comorbidities in 8 current German guidelines (diabetes mellitus, hypertension, heart failure, coronary heart disease, chronic obstructive lung disease/asthma, coxarthrosis, low back pain, osteoporosis) was investigated. These so called index diseases were selected on the basis of the hypothetical case of a multimorbid patient published by Cynthia Boyd and colleagues in 2005. Mentioning of comorbidities in the guidelines was compared to the epidemiologic approaches of disease combinations and clusters of comorbidities. In addition, using the comorbidity matrix, 36 physicians involved in everyday care of multimorbid patients assessed whether an explicit recommendation for the listed comorbidities would be helpful.

RESULTS

Mentioning of comorbidities was very heterogeneous across the guidelines investigated, ranging from 0 to more than 10. The proportion of the comorbidities that were considered relevant by the survey participants ranged from 0 % to 62 % with a focus on cardiovascular and metabolic diseases. When using disease combinations, only 0 to 3 of the "relevant" comorbidities were identified. Using the cluster model may be helpful in identifying whether a particular comorbidity is thematically close to the index disease or whether it is associated with an interacting thematic area.

CONCLUSIONS

Methodological support is needed for addressing comorbidities in guidelines in a more consistent way. The currently existing epidemiologic approaches should not be used in their current form without being further developed and re-evaluated. Expert opinion of physicians involved in the care of multimorbid patients should be systematically included in methodological refinement studies.

[Size and type of frequent use of ambulatory medical care among the elderly population in Germany: a study based on statutory health insurance data]

BACKGROUND

The authors report the results of a study on frequent attenders in ambulatory medical care among elderly people in Germany and on the factors related to frequent attendance such as age, sex, multi-morbidity and long-term care dependency.

METHODS

The study was based on claims data of all policy holders aged 65 and over of a statutory health insurance company operating nationwide in Germany in 2004 (n=123,224). Utilisation was analysed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different practices contacted. The criteria for frequent attendance included greater than or equal to 50 contacts and/or greater than or equal to 10 different practices contacted and/or greater than or equal to 3 practices of the same discipline contacted within one year. Descriptive statistical analysis and logistic regression were used.

RESULTS

19% of the elderly were identified as frequent attenders, which corresponds to some 3.5 million people in Germany. Two main types of frequent attendance were identified: one is characterised by very many contacts, old age, frequent presence of multi-morbidity, and/or long-term care dependency. The other type is the younger, less frequently multi-morbid attender who is considerably less often dependent on long-term care, and characterised by large numbers of contacted practices and/or practices of the same discipline.

CONCLUSION

Frequent attendance is due to several factors. The problem of frequent attendance needs further research that is not exclusively based on claims data. We found a high rate of frequent attendance. Further research should clarify if this is to the benefit of elderly people.