Epidemiology of Renal Replacement Therapy for Critically Ill Patients across Seven Health Jurisdictions.

INTRODUCTION: Acute kidney injury (AKI) requiring treatment with renal replacement therapy (RRT) is a common complication after admission to an intensive care unit (ICU) and is associated with significant morbidity and mortality. However, the prevalence of RRT use and the associated outcomes in critically patients across the globe are not well described. Therefore, we describe the epidemiology and outcomes of patients receiving RRT for AKI in ICUs across several large health system jurisdictions. METHODS: Retrospective cohort analysis using nationally representative and comparable databases from seven health jurisdictions in Australia, Brazil, Canada, Denmark, New Zealand, Scotland, and the USA between 2006 and 2023, depending on data availability of each dataset. Patients with a history of end-stage kidney disease receiving chronic RRT and patients with a history of renal transplant were excluded. RESULTS: A total of 4,104,480 patients in the ICU cohort and 3,520,516 patients in the mechanical ventilation cohort were included. Overall, 156,403 (3.8%) patients in the ICU cohort and 240,824 (6.8%) patients in the mechanical ventilation cohort were treated with RRT for AKI. In the ICU cohort, the proportion of patients treated with RRT was lowest in Australia and Brazil (3.3%) and highest in Scotland (9.2%). The in-hospital mortality for critically ill patients treated with RRT was almost fourfold higher (57.1%) than those not receiving RRT (16.8%). The mortality of patients treated with RRT varied across the health jurisdictions from 37 to 65%. CONCLUSION: The outcomes of patients who receive RRT in ICUs throughout the world vary widely. Our research suggests that differences in access to and provision of this therapy are contributing factors.

Solidarity and reciprocity during the COVID-19 pandemic: a longitudinal qualitative interview study from Germany.

BACKGROUND: While solidarity practices were important in mitigating the Coronavirus Disease 2019 (COVID-19) pandemic, their limits became evident as the pandemic progressed. Taking a longitudinal approach, this study analyses German residents' changing perceptions of solidarity practices during the COVID-19 pandemic and examines potential reasons for these changes. METHODS: Adults living in Germany were interviewed in April 2020 (n = 46), October 2020 (n = 43) and October 2021 (n = 40) as part of the SolPan Research Commons, a large-scale, international, qualitative, longitudinal study uniquely situated in a major global public health crisis. Interviews were analysed using qualitative content analysis. RESULTS: While solidarity practices were prominently discussed and positively evaluated in April 2020, this initial enthusiasm waned in October 2020 and October 2021. Yet, participants still perceived solidarity as important for managing the pandemic and called for institutionalized forms of solidarity in October 2020 and October 2021. Reasons for these changing perceptions of solidarity included (i) increasing personal and societal costs to act in solidarity, (ii) COVID-19 policies hindering solidarity practices, and (iii) a perceived lack of reciprocity as participants felt that solidarity practices from the state were not matching their individual efforts. CONCLUSIONS: Maintaining solidarity contributes to maximizing public health during a pandemic. Institutionalized forms of solidarity to support those most in need contribute to perceived reciprocity among individuals, which might increase their motivation to act in solidarity. Thus, rather than calling for individual solidarity during times of crisis, authorities should consider implementing sustaining solidarity-based social support systems that go beyond immediate crisis management.

Scoping review and characteristics of publicly available checklists for assessing clinical trial feasibility.

BACKGROUND: Whether there is sufficient capacity and capability for the successful conduct and delivery of a clinical trial should be assessed by several stakeholders according to transparent and evidence-based criteria during trial planning. For this openly shared, user-tested, and validated tools are necessary. Therefore, we systematically examined the public availability and content of checklists which assess the study-level feasibility in the planning phase of clinical trials. METHODS: In our scoping review we systematically searched Medline, EMBASE, and Google (last search, June 2021). We included all publicly available checklists or tools that assessed study level feasibility of clinical trials, examined their content, and checked whether they were user-tested or validated in any form. Data was analysed and synthesised using conventional content analysis. RESULTS: A total of 10 publicly available checklists from five countries were identified. The checklists included 48 distinct items that were classified according to the following seven different domains of clinical trial feasibility: regulation, review and oversight; participant recruitment; space, material and equipment; financial resources; trial team resources; trial management; and pilot or feasibility studies. None of the available checklists appeared to be user-tested or validated. CONCLUSIONS: Although a number of publicly available checklists to assess the feasibility of clinical trials exist, their reliability and usefulness remain unclear. Openly shared, user-tested, and validated feasibility assessment tools for a better planning of clinical trials are lacking.

Embedded ethics: a proposal for integrating ethics into the development of medical AI.

The emergence of ethical concerns surrounding artificial intelligence (AI) has led to an explosion of high-level ethical principles being published by a wide range of public and private organizations. However, there is a need to consider how AI developers can be practically assisted to anticipate, identify and address ethical issues regarding AI technologies. This is particularly important in the development of AI intended for healthcare settings, where applications will often interact directly with patients in various states of vulnerability. In this paper, we propose that an 'embedded ethics' approach, in which ethicists and developers together address ethical issues via an iterative and continuous process from the outset of development, could be an effective means of integrating robust ethical considerations into the practical development of medical AI.

Practices and Attitudes of Bavarian Stakeholders Regarding the Secondary Use of Health Data for Research Purposes During the COVID-19 Pandemic: Qualitative Interview Study.

BACKGROUND: The COVID-19 pandemic is a threat to global health and requires collaborative health research efforts across organizations and countries to address it. Although routinely collected digital health data are a valuable source of information for researchers, benefiting from these data requires accessing and sharing the data. Health care organizations focusing on individual risk minimization threaten to undermine COVID-19 research efforts, and it has been argued that there is an ethical obligation to use the European Union's General Data Protection Regulation (GDPR) scientific research exemption during the COVID-19 pandemic to support collaborative health research. OBJECTIVE: This study aims to explore the practices and attitudes of stakeholders in the German federal state of Bavaria regarding the secondary use of health data for research purposes during the COVID-19 pandemic, with a specific focus on the GDPR scientific research exemption. METHODS: Individual semistructured qualitative interviews were conducted between December 2020 and January 2021 with a purposive sample of 17 stakeholders from 3 different groups in Bavaria: researchers involved in COVID-19 research (n=5, 29%), data protection officers (n=6, 35%), and research ethics committee representatives (n=6, 35%). The transcripts were analyzed using conventional content analysis. RESULTS: Participants identified systemic challenges in conducting collaborative secondary-use health data research in Bavaria; secondary health data research generally only happens when patient consent has been obtained, or the data have been fully anonymized. The GDPR research exemption has not played a significant role during the pandemic and is currently seldom and restrictively used. Participants identified 3 key groups of barriers that led to difficulties: the wider ecosystem at many Bavarian health care organizations, legal uncertainty that leads to risk-adverse approaches, and ethical positions that patient consent ought to be obtained whenever possible to respect patient autonomy. To improve health data research in Bavaria and across Germany, participants wanted greater legal certainty regarding the use of pseudonymized data for research purposes without the patient's consent. CONCLUSIONS: The current balance between enabling the positive goals of health data research and avoiding associated data protection risks is heavily skewed toward avoiding risks; so much so that it makes reaching the goals of health data research extremely difficult. This is important, as it is widely recognized that there is an ethical imperative to use health data to improve care. The current approach also creates a problematic conflict with the ambitions of Germany, and the federal state of Bavaria, to be a leader in artificial intelligence. A recent development in the field of German public administration known as norm screening (Normenscreening) could potentially provide a systematic approach to minimize legal barriers. This approach would likely be beneficial to other countries.

Interfaces of occupational health management and corporate social responsibility: a multi-centre qualitative study from Germany.

BACKGROUND: The workplace has been identified as a priority setting for health promotion. There are potential advantages of systematically integrating Occupational Health Management (OHM) and Corporate Social Responsibility (CSR). However, OHM and CSR are usually overseen by different management branches with different sets of values, and there is a lack of empirical research regarding interfaces between OHM and CSR. Germany offers a particularly useful setting due to legislation requiring health to be promoted in the workplace. This study aims to examine key stakeholders' views and experiences regarding interfaces between OHM and CSR in German companies. METHODS: Individual semi-structured qualitative interviews were conducted with a sample of 77 German stakeholders from three different groups: experts in occupational health and corporate social responsibility from various companies (n = 35), business partners (n = 19), and various non-business partners (n = 23). Transcripts were analysed using qualitative content analysis. RESULTS: Participants identified several areas in which OHM and CSR are already interacting at strategic, structural and cultural levels, but also highlighted several barriers that undermine a more meaningful interaction. Participants reported difficulties in articulating the underlying ethical values relevant to both OHM and CSR at the strategic level. Several structural barriers were also highlighted, including a lack of resources (both financial and knowledge), and OHM and CSR departments not being fully developed or undertaken at entirely different operational levels. Finally, the missing practical implementation of corporate philosophy was identified as a critical cultural barrier to interfaces between OHM and CSR, with existing guidelines and companies' philosophies that already connect OHM and CSR not being embraced by employees and managers. CONCLUSIONS: There is already significant overlap in the focus of OHM and CSR, at the structural, strategic and cultural levels in many German companies. The potential is there, both in theory and practice, for the systematic combination of OHM and CSR. The insights from this study will be useful to ensure that closer integration between both management branches is set up in a socially sustainable and ethical manner.

The full spectrum of ethical issues in pediatric genome-wide sequencing: a systematic qualitative review.

BACKGROUND: The use of genome-wide sequencing in pediatric medicine and research is growing exponentially. While this has many potential benefits, the normative and empirical literature has highlighted various ethical issues. There have not been, however, any systematic reviews of these issues. The aim of this systematic review is to determine systematically the spectrum of ethical issues that is raised for stakeholders in in pediatric genome-wide sequencing. METHODS: A systematic review in PubMed and Google Books (publications in English or German between 2004 and 2021) was conducted. Further references were identified via reference screening. Data were analyzed and synthesized using qualitative content analysis. Ethical issues were defined as arising when a relevant normative principle is not adequately considered or when two principles come into conflict. RESULTS: Our literature search retrieved 3175 publications of which 143 were included in the analysis. Together these mentioned 106 ethical issues in pediatric genome-wide sequencing, categorized into five themes along the pediatric genome-wide sequencing lifecycle. Most ethical issues identified in relation to genome-wide sequencing typically reflect ethical issues that arise in general genetic testing, but they are often amplified by the increased quantity of data obtained, and associated uncertainties. The most frequently discussed ethical aspects concern the issue of unsolicited findings. CONCLUSION: Concentration of the debate on unsolicited findings risks overlooking other ethical challenges. An overarching difficulty presents the terminological confusion: both with regard to both the test procedure/ the scope of analysis, as well as with the topic of unsolicited findings. It is important that the genetics and ethics communities together with other medical professions involved work jointly on specific case related guidelines to grant the maximum benefit for the care of the children, while preventing patient harm and disproportionate overload of clinicians and the healthcare system by the wealth of available options and economic incentives to increase testing.

One Decade of Online Patient Feedback: Longitudinal Analysis of Data From a German Physician Rating Website.

BACKGROUND: Feedback from patients is an essential element of a patient-oriented health care system. Physician rating websites (PRWs) are a key way patients can provide feedback online. This study analyzes an entire decade of online ratings for all medical specialties on a German PRW. OBJECTIVE: The aim of this study was to examine how ratings posted on a German PRW have developed over the past decade. In particular, it aimed to explore (1) the distribution of ratings according to time-related aspects (year, month, day of the week, and hour of the day) between 2010 and 2019, (2) the number of physicians with ratings, (3) the average number of ratings per physician, (4) the average rating, (5) whether differences exist between medical specialties, and (6) the characteristics of the patients rating physicians. METHODS: All scaled-survey online ratings that were posted on the German PRW jameda between 2010 and 2019 were obtained. RESULTS: In total, 1,906,146 ratings were posted on jameda between 2010 and 2019 for 127,921 physicians. The number of rated physicians increased constantly from 19,305 in 2010 to 82,511 in 2018. The average number of ratings per rated physicians increased from 1.65 (SD 1.56) in 2010 to 3.19 (SD 4.69) in 2019. Overall, 75.2% (1,432,624/1,906,146) of all ratings were in the best rating category of "very good," and 5.7% (107,912/1,906,146) of the ratings were in the lowest category of "insufficient." However, the mean of all ratings was 1.76 (SD 1.53) on the German school grade 6-point rating scale (1 being the best) with a relatively constant distribution over time. General practitioners, internists, and gynecologists received the highest number of ratings (343,242, 266,899, and 232,914, respectively). Male patients, those of higher age, and those covered by private health insurance gave significantly (P<.001) more favorable evaluations compared to their counterparts. Physicians with a lower number of ratings tended to receive ratings across the rating scale, while physicians with a higher number of ratings tended to have better ratings. Physicians with between 21 and 50 online ratings received the lowest ratings (mean 1.95, SD 0.84), while physicians with >100 ratings received the best ratings (mean 1.34, SD 0.47). CONCLUSIONS: This study is one of the most comprehensive analyses of PRW ratings to date. More than half of all German physicians have been rated on jameda each year since 2016, and the overall average number of ratings per rated physicians nearly doubled over the decade. Nevertheless, we could also observe a decline in the number of ratings over the last 2 years. Future studies should investigate the most recent development in the number of ratings on both other German and international PRWs as well as reasons for the heterogeneity in online ratings by medical specialty.

Early Perceptions of COVID-19 Contact Tracing Apps in German-Speaking Countries: Comparative Mixed Methods Study.

BACKGROUND: The main German-speaking countries (Germany, Austria, and Switzerland) have implemented digital contact tracing apps to assist the authorities with COVID-19 containment strategies. Low user rates for these apps can affect contact tracing and, thus, its usefulness in controlling the spread of the novel coronavirus. OBJECTIVE: This study aimed to assess the early perceptions of people living in the German-speaking countries and compare them with the frames portrayed in the newspapers during the first wave of the COVID-19 pandemic. METHODS: We conducted qualitative interviews with 159 participants of the SolPan project. Of those, 110 participants discussed contact tracing apps and were included in this study. We analyzed articles regarding contact tracing apps from 12 newspapers in the German-speaking countries. RESULTS: Study participants perceived and newspaper coverage in all German-speaking countries framed contact tracing apps as governmental surveillance tools and embedded them in a broader context of technological surveillance. Participants identified trust in authorities, respect of individual privacy, voluntariness, and temporary use of contact tracing apps as prerequisites for democratic compatibility. Newspapers commonly referenced the use of such apps in Asian countries, emphasizing the differences in privacy regulation among these countries. CONCLUSIONS: The uptake of digital contact tracing apps in German-speaking countries may be undermined due to privacy risks that are not compensated by potential benefits and are rooted in a deeper skepticism towards digital tools. When authorities plan to implement new digital tools and practices in the future, they should be very transparent and proactive in communicating their objectives and the role of the technology-and how it differs from other, possibly similar, tools. It is also important to publicly address ethical, legal, and social issues related to such technologies prior to their launch.

Rejected Online Feedback From a Swiss Physician Rating Website Between 2008 and 2017: Analysis of 2352 Ratings.

BACKGROUND: Previous research internationally has only analyzed publicly available feedback on physician rating websites (PRWs). However, it appears that many PRWs are not publishing all the feedback they receive. Analysis of this rejected feedback could provide a better understanding of the types of feedback that are currently not published and whether this is appropriate. OBJECTIVE: The aim of this study was to examine (1) the number of patient feedback rejected from the Swiss PRW Medicosearch, (2) the evaluation tendencies of the rejected patient feedback, and (3) the types of issues raised in the rejected narrative comments. METHODS: The Swiss PRW Medicosearch provided all the feedback that had been rejected between September 16, 2008, and September 22, 2017. The feedback were analyzed and classified according to a theoretical categorization framework of physician-, staff-, and practice-related issues. RESULTS: Between September 16, 2008, and September 22, 2017, Medicosearch rejected a total of 2352 patient feedback. The majority of feedback rejected (1754/2352, 74.6%) had narrative comments in the German language. However, 11.9% (279/2352) of the rejected feedback only provided a quantitative rating with no narrative comment. Overall, 25% (588/2352) of the rejected feedback were positive, 18.7% (440/2352) were neutral, and 56% (1316/2352) were negative. The average rating of the rejected feedback was 2.8 (SD 1.4). In total, 44 subcategories addressing the physician (n=20), staff (n=9), and practice (n=15) were identified. In total, 3804 distinct issues were identified within the 44 subcategories of the categorization framework; 75% (2854/3804) of the issues were related to the physician, 6.4% (242/3804) were related to the staff, and 18.6% (708/3804) were related to the practice. Frequently mentioned issues identified from the rejected feedback included (1) satisfaction with treatment (533/1903, 28%); (2) the overall assessment of the physician (392/1903, 20.6%); (3) recommending the physician (345/1903, 18.1%); (4) the physician's communication (261/1903, 13.7%); (5) the physician's caring attitude (220/1903, 11.6%); and (6) the physician's friendliness (203/1903, 10.6%). CONCLUSIONS: It is unclear why the majority of the feedback were rejected. This is problematic and raises concerns that online patient feedback are being inappropriately manipulated. If online patient feedback is going to be collected, there needs to be clear policies and practices about how this is handled. It cannot be left to the whims of PRWs, who may have financial incentives to suppress negative feedback, to decide which feedback is or is not published online. Further research is needed to examine how many PRWs are using criteria for determining which feedback is published or not, what those criteria are, and what measures PRWs are using to address the manipulation of online patient feedback.

The ethical oversight of learning health care activities in Switzerland: a qualitative study.

OBJECTIVE: This study aims to identify the key issues regarding the ethical oversight of health care improvement activities in Switzerland. DESIGN: Individual semi-structured qualitative interviews, analysed using conventional content analysis. SETTING: Interviews were conducted in Switzerland between July 2017 and February 2018. PARTICIPANTS: A purposive sample of 38 key stakeholders from four different groups: health care improvement researchers and practitioners (n = 19), representatives of clinical trial units (n = 3), clinical ethicists (n = 5), quality heads of university hospitals (n = 5), and cantonal ethics committee members (n = 6). RESULTS: There appears to be widespread uncertainty regarding when certain learning health care activities require ethical review by a research ethics committee in Switzerland. This situation is exacerbated by legislative ambiguity and limited guidance. It was reported that the lack of other oversight mechanisms for activities outside of the Human Research Act is also leading many investigators to submit projects to research ethics committees to avoid barriers to publication. CONCLUSIONS: The continuous, integrated, and dynamic nature of learning health care poses significant challenges to the current regulatory framework. It will be important that more clarification and guidance is provided regarding which activities require ethical review, and that it is considered how the ethical oversight of activities falling outside human research legislation can be strengthened. However, the traditional model of ethical oversight is poorly suited to learning health care and may need to be replaced with new systemic oversight approaches.

Quantitative Ratings and Narrative Comments on Swiss Physician Rating Websites: Frequency Analysis.

BACKGROUND: Physician rating websites (PRWs) have been developed as part of a wider move toward transparency around health care quality, and these allow patients to anonymously rate, comment, and discuss physicians' quality on the Web. The first Swiss PRWs were established in 2008, at the same time as many international PRWs. However, there has been limited research conducted on PRWs in Switzerland to date. International research has indicated that a key shortcoming of PRWs is that they have an insufficient number of ratings. OBJECTIVE: The aim of this study was to examine the frequency of quantitative ratings and narrative comments on the Swiss PRWs. METHODS: In November 2017, a random stratified sample of 966 physicians was generated from the regions of Zürich and Geneva. Every selected physician was searched for on 4 rating websites (OkDoc, DocApp, Medicosearch, and Google) between November 2017 and July 2018. It was recorded whether the physician could be identified, what the physician's quantitative rating was, and whether the physician had received narrative comments. In addition, Alexa Internet was used to examine the number of visitors to the PRWs, compared with other websites. RESULTS: Overall, the portion of physicians able to be identified on the PRWs ranged from 42.4% (410/966) on OkDoc to 87.3% (843/966) on DocApp. Of the identifiable physicians, only a few of the selected physicians had been rated quantitatively (4.5% [38/843] on DocApp to 49.8% [273/548] on Google) or received narrative comments (4.5% [38/843] on DocApp to 31.2% [171/548] on Google) at least once. Rated physicians also had, on average, a low number of quantitative ratings (1.47 ratings on OkDoc to 3.74 rating on Google) and narrative comments (1.23 comment on OkDoc to 3.03 comments on Google). All 3 websites allowing ratings used the same rating scale (1-5 stars) and had a very positive average rating: DocApp (4.71), Medicosearch (4.69), and Google (4.41). There were significant differences among the PRWs (with the majority of ratings being posted on Google in past 2 years) and regions (with physicians in Zurich more likely to have been rated and have more ratings on average). Only Google (position 1) and Medicosearch (position 8358) are placed among the top 10,000 visited websites in Switzerland. CONCLUSIONS: It appears that this is the first time Google has been included in a study examining physician ratings internationally and it is noticeable how Google has had substantially more ratings than the 3 dedicated PRWs in Switzerland over the past 2 and a half years. Overall, this study indicates that Swiss PRWs are not yet a reliable source of unbiased information regarding patient experiences and satisfaction with Swiss physicians; many selected physicians were unable to be identified, only a few physicians had been rated, and the ratings posted were overwhelmingly positive.

The Content and Nature of Narrative Comments on Swiss Physician Rating Websites: Analysis of 849 Comments.

BACKGROUND: The majority of physician rating websites (PRWs) provide users the option to leave narrative comments about their physicians. Narrative comments potentially provide richer insights into patients' experiences and feelings that cannot be fully captured in predefined quantitative rating scales and are increasingly being examined. However, the content and nature of narrative comments on Swiss PRWs has not been examined to date. OBJECTIVE: This study aimed to examine (1) the types of issues raised in narrative comments on Swiss PRWs and (2) the evaluation tendencies of the narrative comments. METHODS: A random stratified sample of 966 physicians was generated from the regions of Zürich and Geneva. Every selected physician was searched for on 3 PRWs (OkDoc, DocApp, and Medicosearch) and Google, and narrative comments were collected. Narrative comments were analyzed and classified according to a theoretical categorization framework of physician-, staff-, and practice-related issues. RESULTS: The selected physicians had a total of 849 comments. In total, 43 subcategories addressing the physician (n=21), staff (n=8), and practice (n=14) were identified. None of the PRWs' comments covered all 43 subcategories of the categorization framework; comments on Google covered 86% (37/43) of the subcategories, Medicosearch covered 72% (31/43), DocApp covered 60% (26/43), and OkDoc covered 56% (24/43). In total, 2441 distinct issues were identified within the 43 subcategories of the categorization framework; 83.65% (2042/2441) of the issues related to the physician, 6.63% (162/2441) related to the staff, and 9.70% (237/2441) related to the practice. Overall, 95% (41/43) of the subcategories of the categorization framework and 81.60% (1992/2441) of the distinct issues identified were concerning aspects of performance (interpersonal skills of the physician and staff, infrastructure, and organization and management of the practice) that are considered assessable by patients. Overall, 83.0% (705/849) of comments were classified as positive, 2.5% (21/849) as neutral, and 14.5% (123/849) as negative. However, there were significant differences between PRWs, regions, and specialty regarding negative comments: 90.2% (111/123) of negative comments were on Google, 74.7% (92/123) were regarding physicians in Zurich, and 73.2% (90/123) were from specialists. CONCLUSIONS: From the narrative comments analyzed, it can be reported that interpersonal issues make up nearly half of all negative issues identified, and it is recommended that physicians should focus on improving these issues. The current suppression of negative comments by Swiss PRWs is concerning, and there is a need for a consensus-based criterion to be developed to determine which comments should be published publicly. Finally, it would be helpful if Swiss patients are made aware of the current large differences between Swiss PRWs regarding the frequency and nature of ratings to help them determine which PRW will provide them with the most useful information.

Racial and Geographic Disparities in Interhospital ICU Transfers.

OBJECTIVES: Interhospital transfer, a common intervention, may be subject to healthcare disparities. In mechanically ventilated patients with sepsis, we hypothesize that disparities not disease related would be found between patients who were and were not transferred. DESIGN: Retrospective cohort study. SETTING: Nationwide Inpatient Sample, 2006-2012. PATIENTS: Patients over 18 years old with a primary diagnosis of sepsis who underwent mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We obtained age, gender, length of stay, race, insurance coverage, do not resuscitate status, and Elixhauser comorbidities. The outcome used was interhospital transfer from a small- or medium-sized hospital to a larger acute care hospital. Of 55,208,382 hospitalizations, 46,406 patients met inclusion criteria. In the multivariate model, patients were less likely to be transferred if the following were present: older age (odds ratio, 0.98; 95% CI, 0.978-0.982), black race (odds ratio, 0.79; 95% CI, 0.70-0.89), Hispanic race (odds ratio, 0.79; 95% CI, 0.69-0.90), South region hospital (odds ratio, 0.79; 95% CI, 0.72-0.88), teaching hospital (odds ratio, 0.31; 95% CI, 0.28-0.33), and do not resuscitate status (odds ratio, 0.19; 95% CI, 0.15-0.25). CONCLUSIONS: In mechanically ventilated patients with sepsis, we found significant disparities in race and geographic location not explained by medical diagnoses or illness severity.

Why are so few patients rating their physicians on German physician rating websites? A qualitative study.

BACKGROUND: Physician rating websites (PRWs) allow patients to rate, comment and discuss physicians' quality online as a source of information for others searching for a physician. It is generally assumed that PRWs will only be helpful for users, and fair for the rated, if there are a high number of ratings. However, the number of ratings on PRWs remains low internationally and there is currently a lack of research examining the reasons why patients are not rating their physicians. The aim of this study is to therefore identify the spectrum of factors influencing people's willingness to rate their physician on PRWs. METHODS: A mailed cross-sectional survey sent to a random sample from 4 North German cities between April and July 2016. Fifty participants who had previously used PRWs but not rated a physician provided reasons for why that had not rated a physician in a free text response. Semi-structured qualitative telephone interviews were then conducted with 22 interested participants to explore factors influencing their willingness to rate their physician on PRWs in more detail. RESULTS: Participants identified a total of 21 distinct incentives and disincentives for rating physicians on PRWs, which could be further categorised under the headings: user-specific, PRW-specific and physician-specific. Two key overarching groups of factors emerged: (1) factors concerning the physician-patient relationship, and (2) factors issues regarding technical aspects of PRWs. CONCLUSION: These findings will be helpful in guiding future research and health policy initiatives to increase the usefulness and fairness of PRWs.

The spectrum of ethical issues in a Learning Health Care System: a systematic qualitative review.

PURPOSE: To determine systematically the spectrum of ethical issues that is raised for stakeholders in a 'Learning Health Care System' (LHCS). DATA SOURCES: The systematic review was conducted in PubMed and Google Books between the years 2007 and 2015. STUDY SELECTION: The literature search retrieved 1258 publications. Each publication was independently screened by two reviewers for eligibility for inclusion. Ethical issues were defined as arising when a relevant normative principle is not adequately considered or two principles come into conflict. DATA EXTRACTION: A total of 65 publications were included in the final analysis and were analysed using an adapted version of qualitative content analysis. A coding frame was developed inductively from the data, only the highest-level categories were generated deductively for a life-cycle perspective. RESULTS OF DATA SYNTHESIS: A total of 67 distinct ethical issues could be categorized under different phases of the LHCS life-cycle. An overarching theme that was repeatedly raised was the conflict between the current regulatory system and learning health care. CONCLUSION: The implementation of a LHCS can help realize the ethical imperative to continuously improve the quality of health care. However, the implementation of a LHCS can also raise a number of important ethical issues itself. This review highlights the importance for health care leaders and policy makers to balance the need to protect and respect individual participants involved in learning health care activities with the social value of improving health care.

Developments in the Frequency of Ratings and Evaluation Tendencies: A Review of German Physician Rating Websites.

BACKGROUND: Physician rating websites (PRWs) have been developed to allow all patients to rate, comment, and discuss physicians' quality online as a source of information for others searching for a physician. At the beginning of 2010, a sample of 298 randomly selected physicians from the physician associations in Hamburg and Thuringia were searched for on 6 German PRWs to examine the frequency of ratings and evaluation tendencies. OBJECTIVE: The objective of this study was to examine (1) the number of identifiable physicians on German PRWs; (2) the number of rated physicians on German PRWs; (3) the average and maximum number of ratings per physician on German PRWs; (4) the average rating on German PRWs; (5) the website visitor ranking positions of German PRWs; and (6) how these data compare with 2010 results. METHODS: A random stratified sample of 298 selected physicians from the physician associations in Hamburg and Thuringia was generated. Every selected physician was searched for on the 6 PRWs (Jameda, Imedo, Docinsider, Esando, Topmedic, and Medführer) used in the 2010 study and a PRW, Arztnavigator, launched by Allgemeine Ortskrankenkasse (AOK). RESULTS: The results were as follows: (1) Between 65.1% (194/298) on Imedo to 94.6% (282/298) on AOK-Arztnavigator of the physicians were identified on the selected PRWs. (2) Between 16.4% (49/298) on Esando to 83.2% (248/298) on Jameda of the sample had been rated at least once. (3) The average number of ratings per physician ranged from 1.2 (Esando) to 7.5 (AOK-Arztnavigator). The maximum number of ratings per physician ranged from 3 (Esando) to 115 (Docinsider), indicating an increase compared with the ratings of 2 to 27 in the 2010 study sample. (4) The average converted standardized rating (1=positive, 2=neutral, and 3=negative) ranged from 1.0 (Medführer) to 1.2 (Jameda and Topmedic). (5) Only Jameda (position 317) and Medführer (position 9796) were placed among the top 10,000 visited websites in Germany. CONCLUSIONS: Whereas there has been an overall increase in the number of ratings when summing up ratings from all 7 analyzed German PRWs, this represents an average addition of only 4 new ratings per physician in a year. The increase has also not been even across the PRWs, and it would be advisable for the users of PRWs to utilize a number of PRWs to ascertain the rating of any given physician. Further research is needed to identify barriers for patients to rate their physicians and to assist efforts to increase the number of ratings on PRWs to consequently improve the fairness and practical importance of PRWs.

Public Awareness and Use of German Physician Ratings Websites: Cross-Sectional Survey of Four North German Cities.

BACKGROUND: Physician rating websites (PRWs) allow patients to rate, comment, and discuss physicians' quality. The ability of PRWs to influence patient decision making and health care quality is dependent, in part, on sufficient awareness and usage of PRWs. However, previous studies have found relatively low levels of awareness and usage of PRWs, which has raised concerns about the representativeness and validity of information on PRWs. OBJECTIVE: The objectives of this study were to examine (1) participants' awareness, use, and contribution of ratings on PRWs and how this compares with other rating websites; (2) factors that predict awareness, use, and contribution of ratings on PRWs; and (3) participants' attitudes toward PRWs in relation to selecting a physician. METHODS: A mailed cross-sectional survey was sent to a random sample (N=1542) from four North German cities (Nordhorn, Hildesheim, Bremen, and Hamburg) between April and July 2016. Survey questions explored respondents' awareness, use, and contribution of ratings on rating websites for service (physicians, hospitals, and hotels and restaurants) and products (media and technical) in general and the role of PRWs when searching for a new physician. RESULTS: A total of 280 completed surveys were returned (280/1542, 18.16% response rate), with the following findings: (1) Overall, 72.5% (200/276) of respondents were aware of PRWs. Of the respondents who were aware of PRWs, 43.6% (86/197) had used PRWs. Of the respondents who had used PRWs, 23% (19/83) had rated physicians at least once. Awareness, use, and contribution of ratings on PRWs were significantly lower in comparison with all other rating websites, except for hospital rating websites. (2) Except for the impact of responders' gender and marital status on the awareness of PRWs and responders' age on the use of PRWs, no other predictors had a relevant impact. (3) Whereas 31.8% (85/267) of the respondents reported that PRWs were a very important or somewhat important information source when searching for a new physician, respondents significantly more often reported that family, friends and colleagues (259/277, 93.5%), other physicians (219/274, 79.9%), and practice websites (108/266, 40.6%) were important information sources. CONCLUSIONS: Whereas awareness of German PRWs appears to have substantially increased, the use of PRWs and contribution of ratings remains relatively low. Further research is needed to examine the reasons why only a few patients are rating physicians. However, given the information inequality between provider and consumer will always be higher for consumers using the services of physicians, it is possible that people will always rely more on interpersonal recommendations than impersonal public information before selecting a physician.

Reasons why nurses decline influenza vaccination: a qualitative study.

BACKGROUND: To explore reasons of non-vaccinated nursing staff for declining seasonal influenza vaccination. The annual influenza vaccination of healthcare workers reduces morbidity and mortality among vulnerable patients. Still, vaccination rates remain very low, particularly in nursing staff. While several studies have explored barriers for healthcare workers to get vaccinated, most have used a quantitative approach. METHODS: Data were collected by in-depth individual semi-structured interviews with 18 nurses from a range of fields, positions in organizational hierarchy, work experience and hospitals in two German-speaking cantons in Switzerland. Interviews were transcribed and analysed using conventional content analysis. RESULTS: Three interconnected themes explaining why nurses decline influenza vaccination were identified: Firstly, the idea of maintaining a strong and healthy body, which was a central motif for rejecting the vaccine. Secondly, the wish to maintain decisional autonomy - especially over one's body and health. Thirdly, nurses' perception of being surrounded by an untrustworthy environment, which restricts their autonomy and seemingly is in opposition to their goal of maintaining a strong and healthy body. CONCLUSION: Nurses tend to rely on conventional health beliefs rather than evidence based medicine when making their decision to decline influenza vaccination. Interventions to increase influenza vaccination should be tailored specifically for nurses. Empowering nurses by promoting decision-making skills and by strengthening their appraisal may be important factors to consider when planning future interventions to improve vaccination rates. The teaching of evidence-based decision-making should be integrated on different levels, including nurses' training curricula, their workspace and further education.