Outpatient parenteral antimicrobial therapy (OPAT) in Germany: insights and clinical outcomes from the K-APAT cohort study.

PURPOSE: Outpatient parenteral antimicrobial therapy (OPAT) offers several key advantages, including enhanced patient quality of life, reduced healthcare costs, and a potential reduction of nosocomial infections. It is acknowledged for its safety and effectiveness. This study provides the first systematic clinical data for Germany, where OPAT has not yet been widely adopted. The aim is to establish a foundational reference point for further research and integration of OPAT into the German healthcare system. METHODS: This prospective observational study descriptively analyses data obtained from a cohort of patients receiving OPAT. Both in- and outpatients from all medical specialties could be recruited. Patients administered the anti-infective medications themselves at home using elastomeric pumps. RESULTS: 77 patients received OPAT, with a median duration of 15 days and saving 1782 inpatient days. The most frequently treated entities were orthopaedic infections (n = 20, 26%), S. aureus bloodstream infection (n = 16, 21%) and infectious endocarditis (n = 11, 14%). The most frequently applied drugs were flucloxacillin (n = 18, 23%), penicillin G (n = 13, 17%) and ceftriaxone (n = 10; 13%). Only 5% of patients (n = 4) reported to have missed more than one outpatient dose (max. 3 per patient). Only one catheter-related adverse event required medical intervention, and there were no catheter-related infections. CONCLUSION: The study demonstrates that OPAT can be safely conducted in Germany. In preparation for its broader implementation, crucial next steps include creating medical guidelines, fostering interdisciplinary and inter-sectoral communication, as well as creating financial and structural regulations that facilitate and encourage the adoption of OPAT. TRIAL REGISTRATION NUMBER: NCT04002453.

Exploring patients' perspectives: a mixed methods study on Outpatient Parenteral Antimicrobial Therapy (OPAT) experiences.

BACKGROUND: Outpatient Parenteral Antimicrobial Therapy (OPAT), an alternative to inpatient intravenous antibiotic therapy, has shown benefits in international studies such as increased patient satisfaction. Because OPAT has been used only sporadically in Germany so far, no structured results on patients' experiences and concerns regarding OPAT have yet been available. This study therefore aims to explore the experiences of OPAT patients in a pilot region in Germany. METHODS: This is an observational study in a German pilot region, including a survey of 58 patients on their experiences with OPAT, and in-depth interviews with 12 patients (explanatory-sequential mixed-methods design). RESULTS: Patients reported that they were satisfied with OPAT. That a hospital discharge was possible and anti-infective therapy could be continued in the home environment was rated as being particularly positive. In the beginning, many patients in the interviews were unsure about being able to administer the antibiotic therapy at home on their own. However, healthcare providers (doctors and pharmacy service provider staff) were able to allay these concerns. Patients appreciated regular contact with care providers. There were suggestions for improvement, particularly concerning the organization of the weekly check-up appointments and the provision of information about OPAT. CONCLUSIONS: Patients were generally satisfied with OPAT. However, the treatment structures in Germany still need to be expanded to ensure comprehensive and high-quality OPAT care. TRIAL REGISTRATION: NCT04002453, https://www. CLINICALTRIALS: gov/ , (registration date: 2019-06-21).

[Five Key Questions for Health Services Research: are SHI Claims Data Suitable for Your Research Project?] / 5 Leitfragen für die Versorgungsforschung ­ Eignen sich GKV-Routinedaten für Ihr Forschungsvorhaben?

Health services research examines the structures and processes of health care under everyday conditions. Routine data of the statutory health insurance (SHI) - the so-called routine practice data - represent real health care and are therefore an important data source for health services research. This paper presents 5 key questions that researchers and data-holding institutions can use to assess the suitability of this data source for answering their health services research question. The aim of these guiding questions is to generate a common understanding between researchers and data-holding institutions of the research project, the research objective, and the feasibility of implementation in health services research. The five guiding questions cover the formulation of the research question, the planned method, the target population, the relevant study periods, and the required information from SHI data. These methodologically oriented guiding questions are supplemented by the question of how the results of the research project could improve care. Thus, for researchers, the five guiding questions provide an initial structuring for data requests; for data-holding institutions, they provide a framework for considering possible involvement in or support of a research idea in health services research.

[Algorithm for the Classification of Type 1 and Type 2 Diabetes Mellitus for the Analysis of Routine Data]. / Algorithmus zur Unterscheidung von Diabetes mellitus Typ 1 und Typ 2 bei der Analyse von Routinedaten.

BACKGROUND: Diabetes mellitus is a disease of high public health relevance. To estimate the temporal development of prevalence, routine data of statutory health insurances (SHI) are being increasingly used. However, these data are primarily collected for billing purposes and the case definition of specific diseases remains challenging. In this study, we present an algorithm for differentiation of diabetes types analyzing SHI routine data. METHODS: The basis for the analysis was an age and sex-stratified random sample of persons of the Barmer SHI with a continuous insurance duration from 2010 to 2018 in the magnitude of 1% of the German population. Diabetes was defined in the reporting year 2018, as documentation of (1) a "confirmed" ICD diagnosis E10.- to E14.- in at least two quarters, (2) a "confirmed" ICD diagnosis E10.- to E14.- in one quarter with an additional prescription of an antidiabetic drug (ATC codes A10), or (3) an ICD diagnosis E10.- to E14.- in the inpatient sector, outpatient surgery, or work disability. Individuals were assigned to a diabetes type based on the specific ICD diagnosis E10.- to E14.- and prescribed medications, differentiated by insulin and other antidiabetics. Still unclear or conflicting constellations were assigned on the basis of the persons' age or the frequency and observation of the diagnosis documentation over more than one year. The participation in a disease management program was considered in a sensitivity analysis. RESULTS: The prevalence of documented diabetes in the Barmer sample was 8.8% in 2018. Applying the algorithm, 98.5% of individuals with diabetes could be classified as having type 1 diabetes (5.5%), type 2 diabetes (92.6%), or another specific form of diabetes (0.43%). Thus, the prevalence was 0.48% for type 1 diabetes and 8.1% for type 2 diabetes in 2018. CONCLUSION: The vast majority of people with diabetes can be classified by their diabetes type on the basis of just a few characteristics, such as diagnoses, drug prescription, and age. Further studies should assess the external validity by comparing the results with primary data. The algorithm enables the analysis of important epidemiological indicators and the frequency of comorbidities based on routine data differentiated by type 1 and type 2 diabetes, which should be considered in the surveillance of diabetes in the future.

[Recommendations for the Utilization of Claims Data During a Pandemic: Lessons Learned from the Project EgePan-Unimed of the Netzwerk Universitätsmedizin (NUM)]. / Potentiale von und Empfehlungen zur Nutzung von GKV Routinedaten in einer pandemischen Versorgungslage ­ Erfahrungen aus dem Projekt egePan-Unimed des Netzwerk Universitätsmedizin (NUM).

For appropriate response to the COVID-19 pandemic, and for obtaining answers to various relevant research questions, empirical data are required. Claims data of health insurances are a valid data source in such a situation. Within the project egePan-Unimed of the Netzwerk Universitätsmedizin (NUM) we investigated five COVID-19-related research questions using German claims data of statutory health insurances. We studied the prevalence and relevance of risk factors for a severe course of COVID-19, the background incidence of cerebral venous sinus thrombosis and myocarditis, the frequency and symptoms of post-COVID as well as the care of people with a psychiatric condition during the COVID-19 pandemic. Based on these cases, context-specific recommendations regarding the use of German claims data for future pandemics or other public health emergencies were derived, namely that the utilization of established and interdisciplinary project teams enables a timely project start and furthermore, meta-analytic methods are a valuable way to pool aggregated results of claims data analyses when data protection regulations do not allow a consolidation of data sets from different statutory health insurances. Under these circumstances, claims data are a readily available and valid data source of empirical evidence base necessary for public health measures during a pandemic.

[Research Data Center on Health - Vision for Further Development from the Research Perspective]. / Forschungsdatenzentrum Gesundheit ­ Vision für eine Weiterentwicklung aus Sicht der Forschung.

The German research data center for health will provide claims data of statutory health insurances. The data center was set up at the medical regulatory body BfArM pursuant to the German data transparency regulation (DaTraV). The data provided by the center will cover about 90% of the German population, supporting research on healthcare issues, including questions of care supply, demand and the (mis-)match of both. These data support the development of recommendations for evidence-based healthcare. The legal framework for the center (including §§ 303a-f of Book V of the Social Security Code and two subsequent ordinances) leaves a considerable degree of freedom when it comes to organisational and procedural aspects of the center's operation. The present paper addresses these degrees of freedom. From the point of view of researchers, ten statements show the potential of the data center and provide ideas for its further and sustainable development.

Assessing the effect of a regional integrated care model over ten years using quality indicators based on claims data - the basic statistical methodology of the INTEGRAL project.

BACKGROUND: The regional integrated health care model "Healthy Kinzigtal" started in 2006 with the goal of optimizing health care and economic efficiency. The INTEGRAL project aimed at evaluating the effect of this model on the quality of care over the first 10 years. METHODS: This methodological protocol supplements the study protocol and the main publication of the project. Comparing quality indicators based on claims data between the intervention region and 13 structurally similar control regions constitutes the basic scientific approach. Methodological key issues in performing such a comparison are identified and solutions are presented. RESULTS: A key step in the analysis is the assessment of a potential trend in prevalence for a single quality indicator over time in the intervention region compared to the corresponding trends in the control regions. This step has to take into account that there may be a common - not necessarily linear - trend in the indicator over time and that trends can also appear by chance. Conceptual and statistical approaches were developed to handle this key step and to assess in addition the overall evidence for an intervention effect across all indicators. The methodology can be extended in several directions of interest. CONCLUSIONS: We believe that our approach can handle the major statistical challenges: population differences are addressed by standardization; we offer transparency with respect to the derivation of the key figures; global time trends and structural changes do not invalidate the analyses; the regional variation in time trends is taken into account. Overall, the project demanded substantial efforts to ensure adequateness, validity and transparency.

Appetitive and aversive sensory preconditioning in rats is impaired by disruption of the postrhinal cortex.

Episodic memory involves binding stimuli and/or events together in time and place. Furthermore, memories become more complex when new experiences influence the meaning of stimuli within the original memory. Thus collectively, complex episodic memory formation and maintenance involves processes such as encoding, storage, retrieval, updating and reconsolidation, which can be studied using animal models of higher-order conditioning. In the present study aversive and appetitive sensory preconditioning paradigms were used to test the hypothesis that the postrhinal cortex (POR), which is a component of the hippocampal memory system, is involved in higher-order conditioning. Drawing on the known role of the POR in contextual learning, Experiment 1 employed a four-phase sensory preconditioning task that involved fear learning and context discrimination in rats with or without permanent lesions of the POR. In parallel, to examine POR function during higher-order conditioning in the absence of a particular spatial arrangement, Experiments 2 and 3 used a three-phase sensory preconditioning paradigm involving phasic stimuli. In Experiment 2, bilateral lesions of the POR were made and in Experiment 3, a chemogenetic approach was used to temporarily inactivate POR neurons during each phase of the paradigm. Evidence of successful sensory preconditioning was observed in sham rats which, during the critical context discrimination test, demonstrated higher levels of freezing behavior when re-exposed to the paired versus the unpaired context, whereas POR-lesioned rats did not. Data from the appetitive sensory preconditioning paradigm also confirmed the hypothesis in that during the critical auditory discrimination test, sham rats showed greater food cup responding following presentations of the paired compared to the unpaired auditory stimulus, whereas POR-lesioned rats did not. Lastly, in Experiment 3, when the POR was inactivated only during preconditioning or only during conditioning, discrimination during the critical auditory test was impaired. Thus, regardless of whether stimulus-stimulus associations were formed between static or phasic stimuli or whether revaluation of the paired stimulus occurred through association with an aversive or an appetitive unconditioned stimulus, the effects were the same; POR lesions disrupted the ability to use higher-order conditioned stimuli to guide prospective behavior.

Mental disorders and utilization of mental health services in newly diagnosed cancer patients: An analysis of German health insurance claims data.

OBJECTIVE: People with cancer are often confronted not only with the burdens of medical treatment but also with psychological strain, which can lead to mental disorders (MD). To date, the prevalence of MD in newly diagnosed cancer patients and their utilization of mental health services (MHS) are mainly estimated through data of primary studies than considering healthcare-related claims data. METHODS: Statutory health insurance claims data of the AOK/KV Hesse from 2011 to 2014 was analyzed. The number of incident cancer patients with MD and the utilization of MHS within the period of the quarter of incident cancer diagnosis and three subsequent quarters were determined. For incident cancer patients with an incident MD, the predictive values of sex, age group, and tumor entity on the documentation of MD diagnosis and utilization were investigated. RESULTS: The 12-month prevalence of MD in incident cancer patients was 31.1% for depression, 11.2% for anxiety disorders, and 9.2% for post-traumatic stress/adjustment disorder (PTSD/AD). Of these, 65.9% received outpatient psychotherapy and 43.0% at least one psychopharmacological drug prescription. Men had a significantly lower chance of receiving an MD diagnosis following cancer. CONCLUSIONS: The prevalence of MD observed was higher for depression and lower for PTSD/AD compared to meta-analyses of clinical trials. Male cancer patients had a lower chance of receiving an MD diagnosis than females, which coincides with existing results.

Health Care Analysis on Myocardial Revascularization in Patients with Chronic Coronary Artery Disease: The Multicenter REVASK Study: Design and Protocol.

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are available for revascularization of coronary artery disease (CAD) with the aims to reduce cardiovascular morbidity and mortality and to improve disease-related quality of life in particular. The German National Care Guideline (NVL-cKHK) on chronic CAD recommends the establishment of so-called heart teams for decision making in myocardial revascularization to improve the quality of care. Preferred recommendations for PCI or CABG are given for different patient subgroups depending on patient characteristics, concomitant diseases, and coronary morphology. The myocardial revascularization study (REVASK) is a noninterventional cohort study on care of patients undergoing PCI or CABG based on retrospective statutory health insurance (SHI) routine data, registry data from the German Cardiac Society (DGK) resp., the German Society for Thoracic and Cardiovascular Surgery (DGTHG), combined with prospective primary data collection from health care providers and patients. The primary goal is to investigate whether and to which extent heart teams, consisting of cardiologists and cardiac surgeons, increase guideline adherence in decision making for myocardial revascularization. Ultimately the study project aims to improve patient care in terms of decision making for appropriate myocardial revascularization. Through the consistent implementation of the German National Care Guideline on chronic Coronary Artery Disease (NVL-cKHK) and the European Guidelines on myocardial revascularization, the reduction of morbidity, mortality and the reduced need for subsequent revascularization procedures are also desirable from a health economics perspective.

[What do We Mean by Secondary Data? - A Keynote Contribution to the Terminological Classification and Definition]. / Was verstehen wir unter Sekundärdaten? ­ Ein Grundsatzbeitrag zur terminologischen Einordnung und Definition.

Data are both material and product for health services research. As a "substrate" or starting point for health-related analyses, they have gained immense importance in recent decades. Data are an essential raw material for the assessment of services in the health care system, for its control and development. In everyday scientific life and in research work that uses this raw material, the meaning of the term "data" - especially "secondary data" - is often neglected. This article aims to shed more light on the context of meaning of the two terms and to attempt to classify the term "secondary data" terminologically.

[Sustainable Infrastructure for Health Services Research: Development of a Regional SHI Routine Database]. / Nachhaltige Infrastruktur für die Versorgungsforschung: Der Aufbau einer regionalen, krankenkassenübergreifenden GKV-Routinedatenbank.

AIM: The scientific use of SHI routine data is increasing, especially in the field of health services research. This also raises new questions with regard to the development of databases, which make it possible to store these data for longitudinal analyses over a longer period of time and by combining data from different SHI companies. On the basis of the experience gained in setting up the CoRe-Net database, we want to show that it is possible to install such a research infrastructure and make it usable in the long term. METHODOLOGY/RESULTS: On the basis of the current regulatory framework (e. g. the added specification of § 75 SGB X) and taking into account strict data protection criteria, it is possible to set up a database covering several health insurance funds: In CoRe-Net, a pseudonymisation centre and a trust centre were implemented for this purpose. At the same time, multiple pseudonymisation was carried out using a one-way hash procedure. Data analysis are only possible after approval by the participating health insurance funds and if valid approval has been obtained from relevant ethics committees. CONCLUSION: The amendment of § 75 SGB X in 2018 creates a legal framework for the collection and storage of SHI routine data within the framework of a research project for future questions within a defined research area.

[Now is the Time to Establish an Efficient Health Research Data Centre]. / Jetzt die Weichen stellen für ein leistungsfähiges Forschungsdatenzentrum Gesundheit.

Based on sections 303a to 303f social code book V, the course is currently being set for an innovative and high-performance national information and data platform. This requires short-term provision of current and relevant data on the health care system, especially process data on statutory health insurance and other social insurance carriers, using established methodological standards as well as taking into account data protection regulations. From the point of view of future users, expectations regarding an "ideal" research health data centre are formulated in ten recommendations. The present article is an offer from health services researchers intended to support decision-makers in the field of politics and self-administration in the German health system in their task of establishing and further development of a research health data centre.

[Epidemiology and treatment of adult patients with atopic dermatitis : Analysis of longitudinal data of the statutory health insurance scheme]. / Epidemiologie und Therapie von erwachsenen Patienten mit atopischer Dermatitis : Analyse von Längsschnittdaten der gesetzlichen Krankenversicherung.

BACKGROUND: The goal was to report incidence, prevalence, and treatment patterns in adult atopic dermatitis (AD) patients in the German statutory health insurance system. PATIENT AND METHODS: Anonymized claims data were evaluated at patient level for 3.3 million persons insured by six different statutory health insurance companies (SHI). Patients for whom the ICD-10 diagnosis code L20 (AD) was applied at least twice were analyzed and data on prescription patterns for AD were reported for the years 2011-2015. RESULTS: AD prevalence in adults was 1.6-1.9% in 2012-2015. Annual incidence was 0.28%. In Q3/Q4 2015, 44.2% of the adult population with AD diagnosis by a dermatologist received prescriptions for AD medications: 1.6% low-potency topical glucocorticoids (without previous prescription of systemic drugs), 46.9% moderate or high-potency topical glucocorticoids or topical calcineurin inhibitors, 23.9% current systemic therapy (systemic glucocorticoids, ciclosporin, methotrexate, azathioprine, mycophenolate mofetil) and 27.6% systemic therapy in the past. CONCLUSIONS: The AD prevalence estimate was in the range of previous reports (1.35-4%) that used different methodologies. Based on treatment proxy, it appeared that almost more than half of AD patients treated with prescription ready-to-use drugs had a severe form of AD which required treatment with systemic drugs.

New use of psychotropic medication after hospitalization among people with dementia.

OBJECTIVES: Psychotropic medication is commonly used among people with dementia (PWD), but it shows modest efficacy and it has been associated with severe adverse events. Hospitalizations are an opportunity for medication management as well as treatment recommendations for outpatient physicians. The aim of this study was to asses factors associated with new use of psychotropic medication after hospitalization among PWD. METHODS: We conducted a retrospective dynamic cohort study from 2004 to 2015 using claims data from a German health insurance company. PWD were identified by an algorithm that included ICD-10 diagnosis and diagnostic measures. The medication classes included were antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication. The assessment period was up to 30 days after discharge from the hospital across four hospitalizations. RESULTS: The main predictors for new use of psychotropic medication were similar across medication classes. Neuropsychiatric symptoms (NPS) and the need of care were associated with higher odds of new use of antidepressants, antipsychotics, and anxiolytics or hypnotics/sedatives. A hospital stay due to dementia was an independent predictor for new use across medication classes as well. Delirium increased the odds for new use of antipsychotics and anxiolytics or hypnotics/sedatives. CONCLUSIONS: Factors associated with new use of psychotropic medication included delirium, NPS, and the need of care in PWD. The findings highlight the need for preventive interventions and non-medical treatment options in regards to delirium and NPS as well as for a more intensive use of screening tools for inappropriate medication use among PWD. Key points The percentage of new users was 1.8%, 7.1%, 2.1%, and 2.5% across hospitalizations for antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication, respectively. 83.0%, 61.9%, 56.9%, and 88.1% of new users received antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication for more than 6 weeks. Delirium and neuropsychiatric symptoms were associated with significantly increased odds of new psychotropic medication use. Hospital stays due to dementia and the need of care were predictors for new use of psychotropic medication.

Can Routine Data be used to Determine the Target Population of Patients with Type 2 Diabetes in Early Benefit Assessments in Germany?

OBJECTIVES: Since 2011, early benefit assessment of all new drugs launched in Germany is mandatory. The exact determination of the appropriate target population (i. e. patients eligible for a drug) plays an important role for subsequent price negotiations. In type 2 diabetes, the size of the target population varies considerably between company dossiers submitted for assessment. Our aim was to explore whether routine data from all persons insured in German statutory health insurance (SHI) funds can be used to derive information on the size of the target population with type 2 diabetes. METHODS: We explored how the data available at the German Institute of Medical Documentation and Information (DIMDI) can be used to obtain the information required. A data-based concept was chosen and the selection criteria were developed in a multidisciplinary project group. Before finalizing the database query, the criteria were evaluated in a test database and the database query was then repeatedly modified. RESULTS: At the time of the design of our analysis in 2017, the most recent data available at DIMDI were for 2013. The algorithm we developed for identifying patients with type 2 diabetes and classifying them according to their medication, based primarily on the combination of ICD and ATC codes, enabled us to determine the size of target populations for different indications in diabetes mellitus type 2. CONCLUSION: Our methodological approach seems to be suitable to determine target populations in type 2 diabetes.

[Cancer Patients and the Last Year of Life: Palliative Care, Hospitalization and Place of Death]. / Krebserkrankung und das letzte Lebensjahr: Palliative Leistungen, Krankenhausaufenthalte und Sterbeort.

INTRODUCTION: Palliative care patients frequently suffer from cancer diagnoses. Specialised palliative home care (German acronym 'SAPV') enables patients with complex symptoms and intensive care needs to receive home care until death. In the German Federal State of Hesse, the first SAPV teams were set up in 2009. Against this background, the aim of this study was (i) to investigate the utilization of SAPV and specialised inpatient palliative care in the last year of life of cancer patients, (ii) to detect the medical professions prescribing SAPV and (iii) to analyse the place of death and the hospitalization rate in the last 91 days of life. METHODS: A retrospective secondary data analysis was conducted. Routine data from the statutory health insurance company AOK Hesse in Germany for 2009-2014 were analysed using descriptive statistical methods. The study population comprised breast, prostate, and colorectal cancer patients who died in the year of observation (2010-2014) and who were fully insured 360 days before death. RESULTS: Depending on the year of observation, 492-545 breast, 546-625 prostate, and 709-752 colorectal cancer patients were included in the study. The analysis showed an increase of cancer patients receiving palliative care from 2010 to 2014. A higher proportion of breast, prostate, and colorectal cancer patients received SAPV as compared to services from palliative care units or inpatient hospices. All in all, over 90% of the SAPV prescriptions were issued by family doctors. The hospitalization rate of cancer patients in the last 91 days of life as well as the share of those dying in hospital decreased between 2010 and 2014. CONCLUSION: The results must be assessed in the context of the implementation of SAPV in the state of Hesse. The increase of SAPV services and the reduction of hospitalizations at the end of life indicate a successful introduction of SAPV in the state of Hesse.

[Good Practice Data Linkage]. / Gute Praxis Datenlinkage (GPD).

Individual data linkage of different data sources for research purposes is being increasingly used in Germany in recent years. However, generally accepted methodological guidance is missing. The aim of this article is to define such methodological standards for research projects. Another aim is to provide readers with a checklist for critical appraisal of research proposals and articles. Since 2016, an expert panel of members of different German scientific societies have worked together and developed 7 guidelines with a total of 27 practical recommendations. These recommendations include (1) research aims, questions, data sources and resources, (2) infrastructure and data flow, (3) data privacy, (4) ethics, (5) key variables and type of linkage, (6) data validation/quality assurance and (7) long-term use for future research questions. The authors provide a rationale for each recommendation. Future revisions will include any new developments in science and data privacy.

Putting fear in context: Elucidating the role of the retrosplenial cortex in context discrimination in rats.

The retrosplenial cortex (RSC), which receives visuo-spatial sensory input and interacts with numerous hippocampal memory system structures, has a well-established role in contextual learning and memory. While it has been demonstrated that RSC function is necessary to learn to recognize a single environment that is directly paired with an aversive event, the role of the RSC in discriminating between two different contexts remains largely unknown. To address this, first order (Experiment 1) and higher order (Experiment 2) fear conditioning paradigms were conducted with sham and RSC-lesioned rats. In Experiment 1 rats were exposed to one context in which shock was delivered and to a second, distinct context without shock. Their ability to discriminate between the contexts was assessed during a re-exposure test. In a second experiment, a new cohort of RSC-lesioned rats was exposed to two contexts made distinct through visual, olfactory and auditory stimuli. In a subsequent conditioning phase, the salience of one of the auditory stimuli was paired to an aversive footshock while the other was not. Similar to Experiment 1, freezing behavior was analyzed upon re-exposure to the contexts in the absence of both the auditory cue and the footshock. The results revealed that RSC is not necessary for rats to use contextual information to successfully discriminate between two contexts under the relatively simple demands involved in this first order conditioning paradigm but that context discrimination is impaired when the processing of complex and/or ambiguous contextual stimuli is required to select appropriate behavioral responses.