Evaluation of utilization and consequences of CRP point-of-care-testing in primary care practices: qualitative interviews with general practitioners from Germany.

BACKGROUND: The use and advantages of point-of-care tests (POCTs) for C-reactive protein (CRP) in general practice, especially for upper respiratory tract infections (uRTIs), have been studied extensively. However, there is limited knowledge about test indications, prerequisites, and integration of these tests into everyday practice. AIM: This study aims to investigate the attitudes and experiences of general practitioners (GPs) in Germany regarding the use of semi-quantitative CRP-POCTs. The study places special emphasis on implementation in routine care, including testing procedures, feasibility, opportunities and barriers for specific consultation scenarios, as well as test indications and their impact on GP-patient communication. DESIGN & SETTING: Qualitative interview study with 10 GPs (May/2023 to Aug/2023) METHOD: Ten German GPs who participated in an observational study on CRP-POCT use in general practices were interviewed using semi-structured interviews. Audio recordings were transcribed and content analysis was performed. RESULTS: Interviewed GPs stated that CRP-POCTs offer several advantages for various treatment cases. They improve diagnostic confidence and certainty of GPs' therapeutic decisions, and offer a broad spectrum of indications and application scenarios. Additionally, they have a positive impact on GP-patient communication, and their ease of use enables rapid implementation into existing workflows. On the other hand, CRP-POCT increase the time required for test performance and patient consultation. CONCLUSION: Due to the numerous benefits of semi-quantitative CRP-POCTs, interviewed GPs have a favourable attitude towards their regular integration into everyday practice. Implementation barriers include increased time and personnel expenses for testing and inadequate reimbursement by German statutory health insurance.

Utilization and consequences of CRP point-of-care-testing in primary care practices: a real-world multicentre observational study with 1,740 patient cases in Germany.

BACKGROUND: Point-of-care tests (POCTs) for C-reactive protein can support clinical decision-making of general practitioners (GPs) but are not widely used in German general practices. AIM: To investigate the utilization of semi-quantitative CRP-POCTs in routine primary care. DESIGN & SETTING: Prospective observational study in 49 general practices in Germany (Nov/2022 to Apr/2023). METHOD: GPs were provided with CRP-POCTs and collected data for each CRP-POCT use using standardized data collection sheets. RESULTS: Data from 1,740 CRP-POCT uses were recorded. GPs employed CRP-POCTs mainly for patients with respiratory tract infections (RTIs, 70.9% of all cases) and to a lesser extent for gastrointestinal infections (GIs, 10.3%). In RTIs, CRP-POCTs were frequently used to distinguish between bacterial and viral aetiology (60.8%) and to guide decisions on antibiotic prescribing (62.8%). In GIs, CRP-POCTs were mainly used to rule out severe disease progressions (53.2%) and for decisions on further diagnostic procedures (45.6%). In RTIs, CRP-POCTs influenced antibiotic prescribing in 77.5 % of the cases (32.3% in favour vs. 45.2% waiver). In GIs, CRP levels mainly affected decisions on further diagnostic procedures. GPs reported that CRP-POCTs were helpful in 88.6% of all cases. CONCLUSIONS: When available, German GPs predominantly use semi-quantitative CRP-POCTs to guide decisions on antibiotic prescribing in patients with RTI. CRP-POCT use improves clinical decision-making and increases the GPs' clinical confidence.

[Changes in the provision and utilization of health care in German primary care practices during the COVID-19 pandemic - A survey of patients in three federal states]. / Veränderungen in der Bereitstellung und Inanspruchnahme der Gesundheitsversorgung in deutschen Hausarztpraxen während der COVID-19-Pandemie ­ eine Befragung von Patient*innen in drei Bundesländern.

INTRODUCTION: During the COVID-19 pandemic general practitioners (GP) practice teams were temporally confronted with major challenges which were accompanied by changes in practice organization and service provision. So far, little has been known about the views of patients who visited the GP practice for other than COVID-related reasons with regard to provision and use of GP services, the adjustments in the practice and the work of the practice team members. METHODS: The patient survey is a sub-study of the mixed-methods study VeCo-Praxis (GP healthcare for patients not suffering from COVID during the Corona pandemic) of the research practice network RESPoNsE (Research Practice Network East), which was conducted in the federal states of Berlin, Brandenburg and Thuringia. The questionnaire-based survey was carried out among patients who visited their GP practice in November 2022. The topics covered in the survey were developed by two focus groups consisting of 13 members of the RESPoNsE patient advisory board. The questionnaire was developed and piloted in a participatory approach with the RESPoNsE Patient Advisory Board. The results were analyzed descriptively using SPSS and discussed with the advisory board. RESULTS: 1,405 questionnaires from 37 practices were analyzed. 97% of respondents felt that the treatment they received at their GP practice during the COVID-19 pandemic was good. For the vast majority, appointments and acute consultations, prescriptions, laboratory tests, discussions of diagnostic results, routine follow-up check-ups and health checks were available to a sufficient extent. From the patients' perspective, the practices have successfully adapted to the challenges caused by COVID-19. Overall, the patients' trust in and their appreciation of the work of the practice staff have increased since the pandemic. Patients stated that GP practices should continue hygiene procedures, such as wearing a mask or keeping physical distance, in the future. DISCUSSION: Despite multiple reports of a significant decline in both provision and utilization of standard care in GP practices during the pandemic, our survey showed that the majority of patients felt that they received adequate GP care and were highly satisfied. The results should be interpreted against the background of possible selection bias. CONCLUSION: In this survey, GP patients were predominantly appreciative of GP care during the COVID-19 pandemic. The patients' assessment of the provision and use of GP services during the pandemic complements the corresponding perspective of GPs and medical practice assistants.

[Attitudes of general practitioners and medical practice assistants towards the delegation of medical services: Results of a survey in Berlin, Brandenburg and Thuringia]. / Einstellungen von Hausärzt:innen und Medizinischen Fachangestellten zur Delegation ärztlicher Leistungen ­ Ergebnisse einer Befragung in Berlin, Brandenburg und Thüringen.

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.

[A regional comparison of outcomes quality and costs of general and specialized palliative care in Germany: a claims data analysis]. / Ergebnisqualität und Kosten der allgemeinen und spezialisierten Palliativversorgung in Deutschland im regionalen Vergleich: eine GKV-Routinedatenstudie.

BACKGROUND: The main framework conditions for palliative care are set at the regional level. The scope of the forms of care used (outpatient, inpatient, general, specialized) varies widely. What is the quality of outcomes achieved by the palliative care provided on a federal states level? What are the associated costs of care? METHOD: Retrospective observational study using BARMER claims data from 145,372 individuals who died between 2016 and 2019 and had palliative care in the last year of life. Regional comparison with regard to the following outcomes: proportion of palliative care patients who died in the hospital, potentially burdensome care in the last 30 days of life (ambulance calls, [intensive care] hospitalizations, chemotherapy, feeding tubes, parenteral nutrition), total cost of care (last three months), cost of palliative care (last year), and cost-effectiveness ratios. Calculation of patient/resident characteristic adjusted rates, costs, and ratios. RESULTS: Federal states vary significantly with respect to the outcomes (also adjusted) of palliative care. Palliative care costs vary widely, most strongly for specialized outpatient palliative care (SAPV). Across all indicators and the cost-effectiveness ratio of total cost of care to at-home deaths, Westphalia-Lippe shows favorable results. CONCLUSION: Regions with better quality and more favorable cost (ratios) can provide guidance for other regions. The extent to which the new federal SAPV agreement can incorporate the empirical findings should be reviewed. Patient-relevant outcome parameters should be given greater weight than parameters aiming at structures of care.

[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]. / Die hausärztliche Versorgung während der COVID-19-Pandemie: eine Fragebogenerhebung unter Hausärzt*innen und Medizinischen Fachangestellten zu ihrer Perspektive auf Veränderungen, Bedarfe und Belastungen.

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.

[Is it feasible to conduct drug studies in general practice? - Results of a survey among investigating physicians and medical staff]. / Sind Arzneimittelstudien in der Hausarztpraxis durchführbar? ­ Ergebnisse einer Befragung von Prüfärzt*innen und Medizinischen Fachangestellten.

BACKGROUND: Pragmatic randomized controlled trials are able to make an essential contribution to the further development of evidence-based treatment recommendations for primary care patients. However, drug trials are regulated by specific guidelines and have not yet become a routine task in GP practices. Within the scope of a multi-center, double-blind, randomized controlled trial on treating urinary tract infections in women with and without antibiotics (REGATTA), the feasibility of pharmaceutical studies in GP practices was evaluated by means of a questionnaire sent out to participating physicians and practice nurses. METHODS: Using a self-designed, non-validated questionnaire, the perspectives, attitudes and experiences of participating physicians and practice nurses were assessed anonymously. In this way, we identified both hindering and beneficial factors affecting the conduct of drug trials in German GP practices. RESULTS: 39 physicians and 48 practice nurses participated in the survey. 95 % of the physicians and 88 % of the practice nurses indicated that the implementation of drug trials with all their regulatory requirements is, in principle, possible in GP practices. In particular, the high amount of time and documentation necessary were identified as barriers. The implementation can be facilitated by formulating a research question that is relevant to practice and patients and by support from the study center. CONCLUSION: Although participation in a drug trial is an additional burden in everyday practice, it is considered feasible and worthwhile by the GPs and practice nurses involved. Due to an assumed selection bias, the predominantly positive experiences of the respondents may be overestimated and transferable only to a limited extent.

Effectiveness of two types of palliative home care in cancer and non-cancer patients: A retrospective population-based study using claims data.

BACKGROUND: Comparative effectiveness of different types of palliative homecare is sparsely researched internationally-despite its potential to inform necessary decisions in palliative care infrastructure development. In Germany, specialized palliative homecare delivered by multi-professional teams has increased in recent years and factors beyond medical need seem to drive its involvement and affect the application of primary palliative care, delivered by general practitioners who are supported by nursing services. AIM: To compare effectiveness of primary palliative care and specialized palliative homecare in reducing potentially aggressive interventions at the end-of-life in cancer and non-cancer. DESIGN: Retrospective population-based study with claims data from 95,962 deceased adults in Germany in 2016 using multivariable regression analyses. SETTINGS/PARTICIPANTS: Patients having received primary palliative care or specialized palliative homecare (alone or in addition to primary palliative care), for at least 14 days before death, differentiating between cancer and non-cancer patients. RESULTS: Rates of potentially aggressive interventions in most indicators were higher in primary palliative care than in specialized palliative homecare (p < 0.01), in both cancer and non-cancer patients: death in hospital (odds ratio (OR) 4.541), hospital care (OR 2.720), intensive care treatment (OR 6.749), chemotherapy (OR 2.173), and application of a percutaneous endoscopic gastrostomy (OR 4.476), but not for parenteral nutrition (OR 0.477). CONCLUSION: Specialized palliative homecare is more strongly associated with reduction of potentially aggressive interventions than primary palliative care in the last days of life. Future research should identify elements of specialized palliative homecare applicable for more effective primary palliative care, too. German Clinical Trials Register (DRKS00014730).

[Palliative care at the end of life in Germany : Utilization and regional distribution]. / Palliativversorgung am Lebensende in Deutschland : Inanspruchnahme und regionale Verteilung.

BACKGROUND: Palliative care supply increased in Germany in recent years. But how many people use which forms of palliative care and how does this differ between regions? METHOD: Retrospective cohort study with claims data from insured persons who died in 2016: Based on services billed at least once in the last six months of life, we determined the use of primary palliative care (PPC), specialized palliative homecare (SPHC), as well as inpatient palliative and hospice care, using regional billing codes for PPC and SPHC services for the first time. RESULTS: Of the 95,962 deceased in the study population, 32.7% received palliative care nationwide, with variations from 26.4% in Bremen to 40.8% in Bavaria. PPC services were billed at 24.4% (16.9% in Brandenburg to 34.1% in Bavaria). SPHC services received 13.1% (6.3% in Rhineland-Palatinate to 18.9% in Brandenburg and 22.9% in Westphalia-Lippe with different SPHC practices). Inpatient palliative care was received by 8.1% (6.7% in Schleswig-Holstein/Hesse to 13.0% in Thuringia); 3.3% (1.6% in Bremen to 5.6% in Berlin) with hospice services. CONCLUSION: SPHC is used more frequently than previously reported, while PPC is declining. Utilization seems to be based less on objective needs than on region-specific framework conditions. Besides needs criteria, further development of palliative care should be oriented more towards outcomes and relevant framework conditions.