Saxon Epidemiological Study in General Practice-6 (SESAM-6): protocol of a cross-sectional study.

INTRODUCTION: General practitioners (GPs) are mostly the first point of contact for patients with health problems in Germany. There is only a limited epidemiological overview data that describe the GP consultation hours based on other than billing data. Therefore, the aim of Saxon Epidemiological Study in General Practice-6 (SESAM-6) is to examine the frequency of reasons for encounter, prevalence of long-term diagnosed diseases and diagnostic and therapeutic decisions in general practice. This knowledge is fundamental to identify the healthcare needs and to develop strategies to improve the GP care. The results of the study will be incorporated into the undergraduate, postgraduate and continuing medical education for GP. METHODS AND ANALYSIS: This cross-sectional study SESAM-6 is conducted in general practices in the state of Saxony, Germany. The study design is based on previous SESAM studies. Participating physicians are assigned to 1 week per quarter (over a survey period of 12 months) in which every fifth doctor-patient contact is recorded for one-half of the day (morning or afternoon). To facilitate valid statements, a minimum of 50 GP is required to document a total of at least 2500 doctor-patient contacts. Univariable, multivariable and subgroup analyses as well as comparisons to the previous SESAM data sets will be conducted. ETHICS AND DISSEMINATION: The study was approved by the Ethics Committee of the Technical University of Dresden in March 2023 (SR-EK-7502023). Participation in the study is voluntary and will not be remunerated. The study results will be published in peer-reviewed scientific journals, preferably with open access. They will also be disseminated at scientific and public symposia, congresses and conferences. A final report will be published to summarise the central results and provided to all study participants and the public.

Planetary health in medical guidelines - A workshop report from the conference of the evidence-based medicine network 2023.

INTRODUCTION: Guidelines may play an important role in the process of adopting a planetary health perspective in clinical medicine. Current issues relating to the integration of planetary health aspects in guidelines were discussed during a workshop at the German Network for Evidence-Based Medicine conference in 2023. METHODS: In a multidisciplinary workshop, 25 persons with an interest in guideline development selected important planetary health dimensions that could be promptly included in guidelines. Group discussions addressed the challenges of integrating planetary health aspects in guidelines and feasible solutions. RESULTS: Participants recommended to first integrate the dimensions Environmental impacts, Prevention & co-benefits and Choosing wisely and provided corresponding rationales. Updating evidence to decision frameworks and including relevant climate outcomes (e.g., CO2 equivalents) in clinical trials were regarded as crucial. Pragmatic steps to integrate planetary health aspects such as an adapted guideline layout and prioritization of recommendations were proposed. DISCUSSION: Changes in the guideline development processes are necessary to incorporate the planetary health perspective into guidelines. Capacity building for guideline developers and modifications to frameworks are important next steps. Public discussion and cooperation between guideline developing bodies are therefore essential to move beyond the results of this workshop. CONCLUSION: The aforementioned workshop underpins the strong interest to integrate planetary health aspects into guideline frameworks to eventually promote planetary health in clinical medicine.

A drug recommender system for the treatment of hypertension.

BACKGROUND: One third (20% to 30%) of patients suffering from hypertension show increased blood pressure resistant to treatment. This resistance often has multifactorial causes, like therapeutic inertia and inappropriate medication but also poor patient adherence. Evidence-based guidelines aim to support appropriate health care decisions. However, (i) research and appraisal of clinical guidelines is often not practicable in daily routine care and (ii) guidelines alone are often insufficient to make suitable and personalized treatment decisions. Shared decision-making (SDM) can significantly improve patient adherence, but is also difficult to implement in routine care due to time constraints. METHODS: Clinical Decision Support Systems (CDSSs), designed to support clinical decision-making by providing explainable and personalized treatment recommendations, are expected to remedy the aforementioned issues. In this work we describe a digital recommendation system for the pharmaceutical treatment of hypertension and compare its recommendations with clinical experts. The proposed therapy recommender algorithm combines external evidence (knowledge-based) - derived from clinical guidelines and drugs' professional information - with information stored in routine care data (data-based) - derived from 298 medical records and 900 doctor-patient contacts from 7 general practitioners practices. The developed Graphical User Interface (GUI) visualizes recommendations along with personalized treatment information and intents to support SDM. The CDSS was evaluated on 23 artificial test patients (case vignettes), by comparing its output with recommendations from five specialized physicians. RESULTS: The results show that the proposed algorithm provides personalized treatment recommendations with large agreement with clinical experts. This is true for agreement with all experts (agree_all), with any expert (agree_any), and with the majority vote of all experts (agree_majority). The performance of a solely data-based approach can be additionally improved by applying evidence-based rules (external evidence). When comparing the achieved results (agree_all) with the inter-rater agreement among experts, the CDSS's recommendations partly agree more often with the experts than the experts among each other. CONCLUSION: Overall, the feasibility and performance of medication recommendation systems for the treatment of hypertension could be shown. The major challenges when developing such a CDSS arise from (i) the availability of sufficient and appropriate training and evaluation data and (ii) the absence of standardized medical knowledge such as computerized guidelines. If these challenges are solved, such treatment recommender systems can support physicians with exploiting knowledge stored in routine care data, help to comply with the best available clinical evidence and increase the adherence of the patient by reducing site-effects and individualizing therapies.

[Regional Influences on Home Visits - Is Care in Rural Areas Secured in the Long Term?] / Regionale Einflüsse auf die Hausbesuchstätigkeit ­ Ist die ländliche Versorgung auf Dauer gesichert?

BACKGROUND: Demographic change and urbanisation are proceeding at a rapid pace in Germany. Although the need for care is increasing due to a growing older and multimorbid generation, the number of home visits by general practitioners has been declining since years. Previous studies have shown that the workload for general practitioners is increasing, especially in rural areas. Research question What kind of structural practice characteristics are associated with the frequency of GP home visits? What influence do regional characteristics of GP practices have? METHODS: In a study of family doctors̓ practices in Saxony, 4286 home visits were documented by questionnaires from 303 participating practices over a period of one year. Each practice surveyed the home visits within a randomly assigned week. In addition to the characteristics of the home visits, information about the practice, such as regional location, home visit organization and patient numbers was also collected. The frequency of home visits was based on information provided by the doctors surveyed. Subsequently, the data based on the postal code were supplemented with structural information from the State Statistical Office and data from the Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung-KV). The data were first analysed regarding bivariate associations. Significantly associated variables were finally tested in a multivariate regression model. RESULTS: According to their own statements, the interviewed general practitioners carried out an average of 14.5 (SD 9.5) home visits per week, which included the care of 32.0 (SD 30.0) nursing home patients. The number of home visits correlated significantly negatively with the number of inhabitants and significantly positively with the average age of the region. In the multivariate analysis, the age of the doctor was found to be the largest predictor of the number of home visits per week, with younger doctors making significantly fewer home visits. CONCLUSION: The number of home visits per week continues to decline compared to preliminary studies. In the regression model, the great influence of the doctor̓s age on the number of home visits is striking. While regional-structural characteristics fade into the background, a changed attitude towards home visits must be assumed, with telemedicine and delegation coming to the fore.

A mixed-methods evaluation of interprofessional education in palliative care: changes in student attitudes towards health professions.

Background: Future health care increasingly requires interprofessional thinking and decision-making which should be taught during medical study and vocational training. Against this backdrop, the Medical Faculty at TU Dresden developed an elective course on "Interprofessional Palliative Medicine" in which medical students and trainees in different health professions have been taught together since the 2017 summer semester. An extensive and simultaneous course evaluation conducted in the 2019 summer semester and 2019/20 winter semester investigated if and how strongly attendees' perceptions of interprofessional collaboration had changed as a result of the elective course. Method: The course evaluations included quantitative pre- and post-questions on a questionnaire (n=50) covering, among other things, the perception of roles, according to the Role Perception Questionnaire, and qualitative interviews (n=20). The pre- and post-questions were compared using the Wilcoxon test for related samples and the effect sizes were calculated according to Cohen. The qualitative interviews were analyzed for content using a combined deductive-inductive approach. Results: It was seen that the perceptions and attitudes of each professional group were mutually influenced as a result of the elective course. The quantitative analysis showed the largest effects regarding gains in understanding the roles and competencies of one's own and the other professions (d=0.975) and a reciprocal feeling of "being dependent on each other" (d=0.845). In the interviews, it was seen that medical students developed a greater appreciation for the subject matter and tasks associated with nursing. A strengthening of self-perception was primarily found in the trainees. Conclusion: The elective course on "Interprofessional Palliative Medicine" contributed to the changes in attitude not only with an increased self-awareness of one's own professional group, but also a greater understanding of the roles and expertise of the other health professions. The results speak for the benefit of expanding the interprofessional courses offered.

[Assessment of care in patients with dementia in house calls by general practitioners]. / Beurteilung der Betreuung dementer Patienten im allgemeinärztlichen Hausbesuch.

BACKGROUND: Patients with dementia (PD) are a special challenge for the healthcare system. They are responsible for 5% of the expenditure in the German healthcare service. The disease-related deficits and the associated need for care leads to the fact that patients are not able to live in their own residence and rely on the care of nursing homes (NH). OBJECTIVE: How is the overall care in PD assessed in house calls (HC)? Does the regional situation influence the living conditions of PD? MATERIAL AND METHODS: As part of the SESAM­5 study 303 participating general practices in Saxony were asked to document their HC within a period of 1 year whereby 4286 HC were documented through questionnaires and analyzed for content and structural data. RESULTS: The prevalence of dementia in HC patients was 27.5% and 72.6% of PD lived in a NH or assisted living home. The medical staff assessed the overall care of PD in the NH to be significantly better than in their own residence. This discrepancy was greater in rural compared to urban regions although in urban regions significantly more patients live in NHs (27% vs. 51%). CONCLUSIONS: The overall care of PD in HC was assessed predominantly as good by medical personnel, whereby PD in NH were assessed comparatively better than those in their own residence. This could be explained by the high need of care in PD. The difference between rural and urban regions is explainable through differences in the infrastructure and also in the organization in rural areas, where relatives participate in care significantly more frequently. In the future more focus could be placed on alternative types of housing because in PD cognitive deficits are in the foreground.

[Delegation of Home Visits and Qualification of Health Care Assistants in Family Practices in Saxony, Germany - Results of the Cross-Sectional Study SESAM-5]. / Delegation von Hausbesuchen und Qualifikation nicht-ärztlicher Mitarbeiter in sächsischen Hausarztpraxen ­ Ergebnisse der Querschnittstudie SESAM-5.

BACKGROUND: In the context of demographic changes and the shortage of family physicians in the primary care sector in Germany, the delegability of home visits to health care assistants is discussed. There is little information on the extent of home visits delegated. The aim of this article is to examine differences in the socio-demographic and organizational profile of delegating vs. non-delegating family doctors in Saxony and to describe the level of qualification of health care assistants. METHODOLOGY: This cross-sectional study is part of a series of epidemiological studies in the federal state of Saxony, Germany. All family doctors in Saxony were contacted in 2014 (n=2677), of whom 11,2% participated. In a period of 12 months, family practices documented home visits within a randomly assigned week. Socio-demographic characteristics of the family practice and the level of qualification of health care assistants were surveyed. RESULTS: A total of 274 family practices participated; 52,9% of all participating family doctors declared their willingness to delegate home visits, but only 8,5% of home visits were made by health care assistants. There were non-significant trends between the willingness to delegate and self-employment vs. being employed (92,4 vs. 84,6%, p=0,06), establishment in a single vs. shared practice (35,2 vs. 31,4%, p=0,09) and higher patient numbers per 3 months (x̄+= 1183,08 vs. 1092,16, p=0,07). The 224 health care assistants that participated in the study were mostly trained in nursing (39,7%) or as medical assistants (50,8%). The vast majority of the health care assistants (82,5%) had no further training or additional qualification; 19,6% completed further training that qualified them to have home visits formally delegated to them. CONCLUSION: Among family doctors in Saxony there is a reported high willingness to delegate, which is not implemented sufficiently in practice. Delegation is based on personal confidence in health care assistants without formal qualification. Qualified delegation ensures high standards in patient care and this potential is not used in Saxony, particularly in rural areas with imminent shortages of medical care. More education about the opportunities of qualified delegation seems necessary.

Pertussis vaccination status and vaccine acceptance among medical students: multicenter study in Germany and Hungary.

BACKGROUND: Medical students are at risk of contracting and transmitting infectious diseases such as pertussis. Complete vaccination status is important to protect own, patient and public health. Knowing own vaccination status is elementary for following current vaccination recommendations, including boosters. We aimed to assess pertussis vaccination status and vaccination acceptance among medical students of different nationalities. METHODS: A cross-sectional multicenter health survey at German and Hungarian universities enclosed international medical students in the 1st, 3rd and 5th year of study. Self-reported data from 2655 students regarding pertussis vaccination status were analyzed. Subgroup analysis enclosed data of German (n = 1217), Hungarian (n = 960) and other nationality (n = 478) students ("other"). RESULTS: More Hungarians reported basic immunization (39.0% vs 15.8% Germans vs 24.3% others, p ≤ 0.05). Booster vaccination was reported more by Germans (60.5% vs 43.6% Hungarians vs 36.0% others, p ≤ 0.05). Germans were more likely to report being unvaccinated (3.7% vs 0.9% Hungarians, p ≤ 0.05). More medical students of other nationalities were unaware of their pertussis vaccination status (37.4% vs 20.0% Germans/ 16.5% Hungarians, p ≤ 0.05). 75.2% (n = 1931) rated pertussis vaccinations as absolutely necessary (86.2% Hungarians vs 69.8% Germans/ 66.1% others, p ≤ 0.05). CONCLUSIONS: Positive attitudes towards vaccinations were reported but a large group reported insufficient vaccination status and being not aware of their status, especially among international students. Hungarians possibly have a better vaccination status than reported, based on mandatory vaccinations in childhood. The low awareness of vaccination status has implications for future booster vaccinations. All students should be informed about current recommendations and receive vaccination offers in frames of low-threshold medical services.

The workload for home visits by German family practitioners: an analysis of regional variation in a cross-sectional study.

BACKGROUND: In Germany, home visits account for a considerable workload for many family practitioners, substantial rural-urban disparities are assumable with regards to home visit frequency and duration. Considering the ongoing demographic change and a rural-urban migration a significant regional difference in the provision of care is assumable. There is a lack of reliable data on the current provision of home visits and how their organisational procedures can be ensured in the future. The aim of this study was to describe and assess the average workload of family practitioners during home visits and compare their rural-urban variations. METHODS: A cross-sectional study over a period of 12 months was conducted in Saxony as part of the fifth project of the Saxon Epidemiologic Studies in General Practice (SESAM-5). Over a 1-week period, family practitioners documented every home visit and answered questionnaires about sociodemographic, organisational and clinical characteristics. According to common categorizations in empirical studies four regional groups (rural, semi-rural, semi-urban, urban) were analysed and compared by non-parametric tests: Kruskal-Wallis followed by Dunn's, Jonckheere-Terpstra and Mann-Whitney-U. Multinomial logistic regression analyses were carried out using a collection of plausible predictors to assess influences for a high frequency and a long duration of home visits. RESULTS: The sample included 3673 home visits conducted by 253 family practitioners. On average, 14.5 home visits were carried out per week with an average duration of almost 28 min. After comparing regional areas, the number and total duration per home visit showed significant differences between the regions: 8.2 h (rural), 7 h (semi-rural), 6.6 h (semi-urban) and 5 h (urban). The regression analyses found that a high frequency of home visits was most likely accomplished in rural regions and a long duration was most likely performed in private homes. CONCLUSIONS: Workload of home visits is strongly associated with the regional location of the practice, leading to rural-urban disparities. Strategies to reduce regional disparities to ensure the future provision of care in the German and comparable health care systems should be discussed, e.g. by financial incentives (short-term), exploiting the potential of delegation (medium-term) and discussing the implementation of substitution (long-term).

Latent Hypothyroidism in Adults.

BACKGROUND: The prevalence of latent/subclinical hypothyroidism is between 3% and 10%, according to epidemiologic studies that have been carried out in the USA, the United Kingdom, and Denmark. As persons with latent hypo - thyroidism are often asymptomatic, the diagnosis is often made incidentally in routine laboratory testing. METHODS: This review is based on a selective search in PubMed for publications on the diagnosis and treatment of latent hypothyroidism. All pertinent articles and guidelines published from 1 January 2000 to 31 July 2016 were included. RESULTS: The diagnosis of latent hypothyroidism is generally assigned after repeated measurement of a TSH concentration above 4.0 mU/L in a person whose fT4 concentration is in the normal range. The most common cause is autoimmune thyroiditis, which can be detected by a test for autoantibodies. L-thyroxin supplementation is a controversial matter: its purpose is to prevent the development of overt hypothyroidism, but there is a danger of overtreatment, which increases the risk of fracture. To date, no benefit of L-thyroxin supplementation has been demonstrated with respect to morbidity and mortality, health-related quality of life, mental health, cognitive function, or reduction of overweight. There is, however, evidence of a beneficial effect on cardiac function in women, and on the vascular system. At present, treatment is generally considered indicated only if the TSH level exceeds 10.0 mU/L. CONCLUSION: Limited data are available on the relevant clinical endpoints and undesired side effects of supplementation therapy. Physicians should advise patients about the indications for such treatment on an individual basis after due consideration of the risks and benefits.

[Quality of documented diagnosis in primary care - An analysis using the example of thyroid disorders]. / Qualität der hausärztlichen Diagnosedokumentation in Patientenakten ­ Eine Analyse am Beispiel von Schilddrüsenerkrankungen.

BACKGROUND: Routine data of statutory health insurance (SHI) provide a great potential for evaluating the healthcare situation in Germany by providing, e. g., morbidity estimates. In the context of secondary data, analyses based on insurance data were conducted using the outpatient medical billing diagnosis. If, however, medical billing data, which are collected for this primary purpose, are the only source of these morbidity estimates, a limited validity of outpatient medical diagnostic data will have to be assumed or validity will have to be assured. This investigation aimed to analyse the quality of family practitioners' documentation regarding diagnostic data in patients with thyroid disease based on medical records for billing purposes. METHODS: As part of the pilot study General practitioners' Views on Polypharmacy and its Consequences for Patient Health Care, the medical records of 548 multi-morbid patients with thyroid disease from six general practices in Dresden, Saxony, were analysed with respect to the congruence of prescriptions of thyroid medication and associated thyroid diagnosis. Logistic regression was used to investigate predictors of limited diagnostic data of thyroid disease. RESULTS: There was insufficient documentation of thyroid diagnoses in 26.8% (n=147) of the included patients diagnosed with or treated for thyroid disease. The proportion of undocumented (1.1 to 35.8%), imprecise (4.6 to 22.3%) and non-specific documented (14.9 to 73.8%) thyroid diagnoses varied in all general practices. Due to undocumented thyroid disease, the corrected prevalence of thyroid diseases summarised for all practices was 5.5 percentage points higher than the originally documented prevalence (29.7 instead of 24.2%). An increasing number of prescribed drugs was a significant predictor for inadequate documentation of thyroid disease (for 5 to 8 routinely taken medications: OR=2.4/p<0.001; for 9 to 12: OR=4.0/p<0.001; for 13 to 20: OR=7.4/p<0.001). CONCLUSIONS: Due to the limited data quality of outpatient medical billing diagnoses as a basis for morbidity estimates, GPs' diagnostic data should be subjected to regular internal and external diagnostic validation in SHI routine data. Additional case-related interviews with documenting GPs would significantly increase data validity. Also, intelligent e-tools supporting electronic patient documentation could be helpful to improve the quality of primary care documentation.

Why do family doctors prescribe potentially inappropriate medication to elderly patients?

BACKGROUND: Based on changes in pharmacokinetics and -dynamics in elderly patients, there are potentially inappropriate medications (PIM) that should be avoided in patients aged ≥ 65 years. Current studies showed prescription rates of PIM between 22.5 and 28.4 % in the primary care setting. The evidence concerning reasons for PIM prescription by FPs is limited. METHODS: This mixed method study consisted of three research parts: 1) semi-standardized content analysis of patients' records, 2) qualitative interviews with FPs using a) open questions and b) selected patient-specific case vignettes and 3) qualitative interviews with FPs' medical assistants. The integration of qualitative interviews was used to explain the quantitative results (triangulation design). PIM were identified according to the German PRISCUS list. Descriptive and multivariate statistical analysis was done using SPSS 22.0. Qualitative content analysis of interviews was used to classify the content of the interviews for indicating pertinent categories. All data were pseudonymously recorded and analyzed. RESULTS: Content analysis of 1846 patients' records and interviews with 7 related FPs were conducted. Elderly patients [n = 1241, mean age: 76, females: 56.6 %] were characterized in average by 8.3 documented chronic diagnosis. 23.9 % of elderly patients received at least one PIM prescription. Sedatives/hypnotics were the most frequent prescribed PIM-drugs (13.7 %). Mental disorders, gender and number of long-term medication were detected as predictors for the probability of a PIM prescription. Common reported reasons for PIM prescription by FPs concerned limited knowledge regarding PIM, limited applicability of PIM lists in daily practice, lack of time, having no alternatives in medication, stronger patient-related factors than age that influence prescription, own bad experiences regarding changes of medication or refusal of following prescriptions of sedative/hypnotics. CONCLUSIONS: It is essential to see FPs in a complex decision making situation with several influencing factors on their prescribing, including: patient-oriented prioritization, FPs' experiences in daily practice, FPs' knowledge regarding existing recommendations and their trust in it and organizational characteristics of FPs' daily medical practice. These pros and cons of PIM prescription in elderly patients should be considered in FPs' advanced training.

Vaccination status among nurses in hospitals. Results of a cross sectional study at Harzklinikum Dorothea Christiane Erxleben Quedlinburg / Impfstatus bei Pflegepersonal. Ergebnisse einer Querschnittstudie am Harzklinikum Dorothea Christiane Erxleben Quedlinburg

Background: Health care workers can be multiplicators for infectious diseases due to their patient contacts. Vaccinations are not mandatory in Germany but there are recommendations for people at higher risk such as health care workers. There is no representative data regarding vaccination status of health care workers in Germany. Aim: We examined vaccination status among nurses regarding diphtheria, tetanus, pertussis, poliomyelitis, hepatitis A (HA) and hepatitis B (HB) as well as correlations between age, professional years, vaccination status and acceptance. Methods: An anonymous cross sectional survey concerning health burden and health behavior including vaccination was conducted among health care workers. Statistical analysis using SPSS included descriptive analysis, subgroup specific differences of distribution were tested by chi2-tests. Results: Regardless of age or professional years, 99 % of the nurses evaluated that vaccinations are at least "partly necessary". Sufficient vaccination status was reported more often concerning tetanus (82 %) and HB (70 %) but less often regarding diphtheria (52 %), poliomyelitis (49 %), HA (43 %) and pertussis (42 %). With respect to some vaccinations, proportion of nurses not knowing their vaccination status was higher than 20 %. Conclusions: Despite the high vaccination acceptance, vaccination status among participating nurses was not sufficient. Implementation of vaccination measures targeting health care workers should be strengthened to reach higher vaccination coverages to prevent vaccination preventable infectious diseases among health care workers and patients in hospitals.

Current vaccination status regarding measles among university students in Dresden, Germany.

Germany aimed to eliminate measles by 2015, but vaccination coverage is still insufficient, especially in respect to adolescents and young adults. A cross-sectional survey with 711 students studying a range of subjects showed a high acceptance regarding vaccination. Actual self-reported vaccination rates were lower; only 65.5% of medical students and 25.3%-39.4% of other student groups reported complete vaccination against measles. Of the students, 12.6%-45% did not know their vaccination status. Vaccination acceptance did not correlate with vaccination behavior: accessible vaccination opportunities at universities should be offered.

Comparison of collegial individual and group reviews of general practice multiple choice questions.

AIMS: In most German medical faculties, credits in general practice can be earned via exams using multiple-choice questions (MCQ). Measures such as peer-reviews may help assure the quality of these exams. In order to use time and personnel intensive peer reviews effectively and efficiently, the procedures used are key. Therefore, we wanted to find out whether there are differences between group and individual reviews regarding defined parameters. METHODS: We conducted a controlled cross-over study with three GP reviewers from four different German universities. Each reviewed 80 MCQs, 40 individually and 40 within a group, including external assessments by a panel of experts. Furthermore all reviewers were asked to evaluate the review process and the time spent carrying out these reviews. OUTCOMES: We found no significant differences between the reliability and the validity of individual reviews versus group reviews. On average slightly more time was spent on group reviews compared with the individual reviews. The subjective assessments of the study participants regarding their satisfaction with the process and the efficiency and effectiveness of the reviews suggest a preference for group reviews. CONCLUSIONS: Based on this study, there are no definite recommendations for or against either approach. When choosing between the two, the specific work structures and organisation at the local faculty should be taken into account.