Measuring continuity of ambulatory cardiovascular care: a cross-sectional study on the applicability of the Nijmegen Continuity Questionnaire in Germany.

BACKGROUND: Chronic cardiovascular diseases demand continuous care from general practitioners and medical specialists. Especially in fragmented healthcare systems, such as in Germany, a large body of research is devoted to the improvement of care continuity. Meanwhile, measuring continuity of care itself has been a challenge due to the absence of validated instruments. In 2011, the Dutch Nijmegen Continuity Questionnaire (NCQ) was developed and validated to measure continuity of care across care settings from the patients' perspectives in the Netherlands. Its applicability in other countries and health systems, however, has rarely been tested. We therefore aimed at assessing the applicability of the Nijmegen Continuity Questionnaire to the German health care context.  METHODS: We translated and applied the original NCQ to an ambulatory cardiovascular care setting in Germany. Qualitative interview data and quantitative survey data on our adaptation were collected from patients in 27 general practices within the German states of Baden-Wuerttemberg and Rhineland-Palatinate. Qualitative data on understandability and clearness of the questionnaire was obtained using semi-structured telephone interviews and think aloud-protocols. Quantitative data was obtained through an anonymous written questionnaire containing the translated NCQ items to assess applicability of our translation. We performed confirmatory and exploratory factor analyses based on the original NCQ-structure mapped to general practitioners and an aggregated analysis of general practitioners and cardiologists combined. RESULTS: A total of 6 patients participated in the interviews and a total of 435 patients participated in the written survey. The interviews showed that, overall, patients had little difficulties comprehending and answering to our translation of the NCQ. The confirmatory factor analyses then showed that the structure of the original NCQ with 12 items and 3 latent factors can also be found in the German context. However, a simpler 2-factor-structure would also fit well with the data. CONCLUSION: A German translation of the NCQ yielded a factor structure comparable to the original version and proved to be understandable for patients. TRIAL REGISTRATION: The project underlying the study was registered on November 7, 2019 in the German Clinical Trials Register ( www.drks.de ) under ID: DRKS00019219.

[Potentially Inappropriate Medication of Nursing Home Residents: An Analysis of Risk Factors Based on National Claims Data (AOK) for 2017]. / Potentiell inadäquate Medikation bei Heimbewohnern: Eine Analyse von Risikofaktoren anhand bundesweiter GKV-Routinedaten der AOK für das Jahr 2017.

AIM OF THE STUDY: The aim of this study was to assess risk factors for prescription of potentially inappropriate medication (PIM) to nursing home residents using the PRISCUS list in 2017. METHODS: Using claims data (AOK) we analysed insured nursing home residents aged 65 or older in 2017. The PRISCUS list was used to identify PIMs. A multivariate logistic regression analysis was performed to analyse risk factors. RESULTS: The study population in 2017 included 259 328 nursing home residents, out of them 25.5% received at least one potentially inappropriate medication (women: 25.6%/men: 24.9%). Female and younger aged nursing home residents had a higher risk for at least one PRISCUS prescription. Polypharmacy, an increasing number of attending physicians, and hospital stays were additional risk factors for a PRISCUS prescription. Furthermore, regional (Bundesland) variations contributed to differences in PRISCUS prescriptions. CONCLUSION: The frequent PIM prescriptions in nursing home residents are a relevant topic regarding drug therapy safety. Regional differences, which cannot be explained by nursing home resident characteristics, show options for modifications and the need for further research.

Cost-Effectiveness and Cost-Utility of a Home-Based Exercise Program in Geriatric Patients with Cognitive Impairment.

INTRODUCTION: There is a substantial lack of home-based exercise programs in the highly vulnerable group of geriatric patients with cognitive impairment (CI) after discharge from ward rehabilitation. Beyond clinical effectiveness, the cost-effectiveness of intervention programs to enhance physical performance is not well investigated in this target group. OBJECTIVE: The aim of the study was to determine the cost-effectiveness of a 12-week home-based exercise intervention following discharge from ward rehabilitation compared to unspecified flexibility training for geriatric patients with CI from a societal perspective. METHODS: This cost-effectiveness study was conducted alongside a randomized placebo-controlled trial. A total of 118 geriatric patients with CI (Mini-Mental State Examination score: 17-26) were randomized either to the intervention group (IG, n = 63) or control group (CG, n = 55). Participants in the IG received a home-based individually tailored exercise program to increase physical performance, while participants in the CG received unspecific flexibility training (placebo control). Healthcare service use, physical performance (Short Physical Performance Battery, SPPB), and quality of life (EQ-5D-3L) were measured over 24 weeks. The net monetary benefit (NMB) approach was applied to calculate incremental cost-effectiveness of the exercise intervention compared to the CG with respect to improvement of (a) physical performance on the SPPB and (b) quality-adjusted life years (QALYs). RESULTS: Physical performance was significantly improved in the IG compared to the CG (mean difference at 24 weeks: 1.3 points; 95% confidence interval [95% CI] = 0.5-2.2; p = 0.003), while health-related quality of life did not significantly differ between the groups at 24 weeks (mean difference: 0.08; 95% CI = -0.05 to 0.21; p = 0.218). Mean costs to implement the home-based exercise intervention were EUR 284 per patient. The probability of a positive incremental NMB of the intervention reached a maximum of 92% at a willingness to pay (WTP) of EUR 500 per point on the SPPB. The probability of cost-utility referring to QALYs was 85% at a WTP of EUR 5,000 per QALY. CONCLUSION: The home-based exercise intervention demonstrated high probability of cost-effectiveness in terms of improved physical performance in older adults with CI following discharge from ward rehabilitation, but not in terms of quality of life.

Healthcare planning across healthcare sectors in Baden-Wuerttemberg, Germany: a stakeholder online survey to identify indicators.

BACKGROUND: Stakeholders in the German state of Baden-Wuerttemberg agreed upon the central aims for healthcare planning. These include a focus on geographical districts; a comprehensive, cross-sectoral perspective on healthcare needs and services; and use of regional data for healthcare planning. Therefore, healthcare data at district level is needed. Nevertheless, decision makers face the challenge to make a selection from numerous indicators and frameworks, which all have limitations or do not well apply to the targeted setting. The aim of this study was to identify district level indicators to be used in Baden-Wuerttemberg for the purpose of cross-sectoral and needs-based healthcare planning involving stakeholders of the health system. METHODS: A conceptual framework for indicators was developed. A structured search for indicators identified 374 potential indicators in indicator sets of German and international institutions and agencies (n = 211), clinical practice guidelines (n = 50), data bases (n = 35), indicator databases (n = 25), published literature (n = 35), and other sources (n = 18). These indicators were categorised according to the developed framework dimensions. In an online survey, institutions of various stakeholders were invited to assess the relevance of these indicators from December 2016 until January 2017. Indicators were selected in terms of a median value of the assessed relevance. RESULTS: 22 institutions selected 212 indicators for the five dimensions non-medical determinants of health (20 indicators), health status (25), utilisation of the health system (34), health system performance (87), and healthcare provision (46). CONCLUSIONS: Stakeholders assessed a large number of indicators as relevant for use in healthcare planning on district level. TRIAL REGISTRATION: Not applicable.

Use of a quantitative data report in a hypothetical decision scenario for health policymaking: a computer-assisted laboratory study.

BACKGROUND: Quantitative data reports are widely produced to inform health policy decisions. Policymakers are expected to critically assess provided information in order to incorporate the best available evidence into the decision-making process. Many other factors are known to influence this process, but little is known about how quantitative data reports are actually read. We explored the reading behavior of (future) health policy decision-makers, using innovative methods. METHODS: We conducted a computer-assisted laboratory study, involving starting and advanced students in medicine and health sciences, and professionals as participants. They read a quantitative data report to inform a decision on the use of resources for long-term care in dementia in a hypothetical decision scenario. Data were collected through eye-tracking, questionnaires, and a brief interview. Eye-tracking data were used to generate 'heatmaps' and five measures of reading behavior. The questionnaires provided participants' perceptions of understandability and helpfulness as well as individual characteristics. Interviews documented reasons for attention to specific report sections. The quantitative analysis was largely descriptive, complemented by Pearson correlations. Interviews were analyzed by qualitative content analysis. RESULTS: In total, 46 individuals participated [students (85%), professionals (15%)]. Eye-tracking observations showed that the participants spent equal time and attention for most parts of the presented report, but were less focused when reading the methods section. The qualitative content analysis identified 29 reasons for attention to a report section related to four topics. Eye-tracking measures were largely unrelated to participants' perceptions of understandability and helpfulness of the report. CONCLUSIONS: Eye-tracking data added information on reading behaviors that were not captured by questionnaires or interviews with health decision-makers.

Cooperation networks of ambulatory health care providers: exploration of mechanisms that influence coordination and uptake of recommended cardiovascular care (ExKoCare): a mixed-methods study protocol.

BACKGROUND: As the number of elderly and multimorbid patients increases, healthcare has become more complex. This requires good coordination of treatment and care given the various  health care professionals involved (e.g. general practitioners, medical specialists, physicians' assistants). Lack of coordination jeopardizes seamless, evidence-based treatment and care, and eventually reduces clinical effectiveness. The aim of the study is a) to describe and explore information transfer and interprofessional collaboration in ambulatory cardiac care, b) to describe and explore the role of provider networks from the perspective of patients and providers, focusing on healthcare coordination and the uptake of recommended practices. METHODS: Two related studies are planned: a) an observational study of healthcare provider networks, involving 600 patients with chronic (atherosclerosis-related) cardiovascular disease from 40 general practices and up to 320 healthcare providers (general practitioners, medical specialist, physicians' assistants), and b) a qualitative interview study with up to 80 healthcare professionals and patients. Furthermore, we will analyse claims data of a large German health insurer to explore provider networks in ambulatory cardiac care. DISCUSSION: The project aims to provide insight into factors, processes and mechanisms of information transfer and interprofessional collaboration, which affect seamless, evidence-based healthcare practice. This will contribute to the design of strategies for improving health care practice and to the development of measures of coordination for future research. TRIAL REGISTRATION: We registered the study prospectively on 7 November 2019 at the German Clinical Trials Register (DRKS, www.drks.de) under ID no. DRKS00019219 .

Patient cardiovascular risk self-management: results from a randomized trial of motivational interviewing delivered by practice nurses.

BACKGROUND: To enhance cardiovascular risk management and patients' self-management, a tailored programme to improve cardiovascular risk management was tested in a randomized trial. The presented study concerned secondary analysis. OBJECTIVES: To explore the correlations of practice nurses' counselling skills at baseline on chronic illness care (measured with Patient Assessment of Chronic Illness Care questionnaire) and patients' self-management (assessed with Patient Activation Measure) at follow-up and to examine the effect of the tailored implementation programme on chronic illness care and patients' self-management. METHODS: A two-arm cluster randomized trial was conducted in 34 general practices in the Netherlands. Counselling skills of practice nurses at baseline were abstracted from audio-taped consultations, which were assessed by Motivational Interviewing Treatment Integrity. Data of 2184 patients with established cardiovascular disease or at high cardiovascular risk were gathered at inclusion and at 6 months follow-up by a composite questionnaire. Multilevel regression analysis was applied, controlling for patient characteristics. RESULTS: Counselling skills of practice nurses were not associated with chronic illness care and patients' self-management scores. At follow-up, patients in the intervention group experienced less chronic illness care and were less activated in disease management than patients in the control group. The most important predictors were patients' age, gender and education level. CONCLUSIONS: The logic model underlying the implementation programme needs to be reconsidered, because patient perceptions were neither influenced by nurses' counselling skills nor by other components of the implementation programme.

Claims data-based analysis of the influence of individual and regional characteristics on the utilisation of long-term care by people with dementia in Baden-Wurttemberg, Germany.

BACKGROUND: Challenges of future dementia care include increasing shortage of qualified healthcare providers and decreasing potential of informal care by relatives. In order to meet those challenges, changes in dementia care are needed. These changes should be based on data of both care utilisation and care supply. The aim of this study was to provide insight into individual and regional characteristics that influence the utilisation of long-term care by people with dementia. METHODS: The study was a retrospective cross-sectional analysis of claims-based data and other available data referring to one index year. All data were aggregated for small geographic districts. The study population comprised people with a dementia diagnosis, 65 years and older in Baden-Wuerttemberg and insured by the largest health insurer. Utilisation of nursing home care, informal care, and respite care was analysed using binary coded logistic multilevel analyses. RESULTS: Seventy nine thousand three hundred forty-nine people with dementia were included in the analyses. Nursing home care was used by 20.4%, informal care by 30.6%, and respite care by 3.5% of people with dementia. Individual characteristics that influence care utilisation included age, sex and the level of care dependency. The utilisation of informal care (OR = 1.713) and respite care (OR = 2.036) was higher in rural districts than in city districts. Respite care supply had an effect on the utilisation of respite care (OR = 1.173). CONCLUSIONS: The study found differences between districts in the utilisation of long-term care for dementia. These differences were largely explained by the composition of the population within the districts. An exception was the utilisation of respite care, which was higher in districts which have higher supply. Individual characteristics that influenced care utilisation are age, sex, level of care dependency and, with regard to informal care, comorbidity. Further research should be conducted on a small-area level, include further individual characteristics as well as other care and living forms.

Patient-reported health outcomes after total hip and knee surgery in a Dutch University Hospital Setting: results of twenty years clinical registry.

BACKGROUND: Patient-Reported Outcome (PRO) measurement is a method for measuring perceptions of patients on their health and quality of life. The aim of this paper is to present the results of PRO measurements in total hip and knee replacement as routinely collected during 20 years of surgery in a university hospital setting. METHODS: Data of consecutive patients between 1993 and 2014 were collected. Health outcomes were measured pre-surgery and at 3, 6, and 12 months post-surgery. Outcomes for hip replacement were measured with the Harris Hip Score (HHS) and Oxford Hip Score (OHS). Outcomes for knee replacement were measured with the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the Knee Society Score (KSS). A Visual Analog Scale (VAS) for pain was used. Absolute and relative Minimal Clinically Important Differences (MCID) were estimated. Generalized estimating equation analysis was used for estimating mean outcomes. Trends over time were analyzed. RESULTS: The database contained 2,089 patients with hip replacement, and 704 patients with knee replacement. Mean HHS and OHS scores in primary hip replacement at 12 months post-surgery were 86.7 (SD: 14.5) and 41.1 (SD: 7.5) respectively. Improvements on the HHS based on absolute MCID was lower for revisions compared to primary hip replacements, with 72.4% and 87.0% respectively. Mean WOMAC and KSS scores in knee replacement at 12 months post-surgery were 21.5 (SD: 18.2) and 67.0 (SD: 26.4) respectively. Improvements based on absolute MCID were lowest for the KSS (62.6%) and highest for VAS pain (85.6%). Trend analysis showed a difference in 1 out of 24 comparisons in hip replacement and in 2 out of 9 comparisons in knee replacement. CONCLUSIONS: The functional status of a large cohort of patients significantly improved after hip and knee replacement based on routine data collection. Our study shows the feasibility of the routine collection of PRO data in patients with total hip and knee replacement. The use of PRO data provides opportunities for continuous quality improvement.

Dynamics and nature of support in the personal networks of people with type 2 diabetes living in Europe: qualitative analysis of network properties.

BACKGROUND: Living with and self-managing a long-term condition implicates a diversity of networked relationships. This qualitative study examines the personal communities of support of people with type 2 diabetes. METHODS: We conducted 170 biographical interviews in six European countries (Bulgaria, Greece, the Netherlands, Norway, Spain and UK) to explore social support and networks. Analysis was framed with reference to three predetermined social support mechanisms: the negotiation of support enabling engagement with healthy practices, navigation to sources of support and collective efficacy. Each interview was summarized to describe navigation and negotiation of participants' networks and the degree of collective efficacy. RESULTS: Analysis highlighted the similarities and differences between countries and provided insights into capacities of networks to support self-management. The network support mechanisms were identified in all interviews, and losses and gains in networks impacted on diabetes management. There were contextual differences between countries, most notably the impact of financial austerity on network dynamics. Four types of network are suggested: generative, diverse and beneficial to individuals; proxy, network members undertook diabetes management work; avoidant, support not engaged with; and struggling, diabetes management a struggle or not prioritized. CONCLUSIONS: It is possible to differentiate types of network input to living with and managing diabetes. Recognizing the nature of active, generative aspects of networks support is likely to have relevance for self-management support interventions either through encouraging continuing development and maintenance of these contacts or intervening to address struggling networks through introducing the means to connect people to additional sources of support.

Meso level influences on long term condition self-management: stakeholder accounts of commonalities and differences across six European countries.

BACKGROUND: European countries are increasingly adopting systems of self -care support (SMS) for long term conditions which focus on enhancing individual, competencies, skills, behaviour and lifestyle changes. To date the focus of policy for engendering greater self- management in the population has been focused in the main on the actions and motivations of individuals. Less attention has been paid to how the broader influences relevant to SMS policy and practice such as those related to food production, distribution and consumption and the structural aspects and economics relating to physical exercise and governance of health care delivery systems might be implicated in the populations ability to self- manage. This study aimed to identify key informants operating with knowledge of both policy and practice related to SMS in order to explore how these influences are seen to impact on the self-management support environment for diabetes type 2. METHODS: Ninety semi-structured interviews were conducted with key stakeholder informants in Bulgaria, Spain, Greece, Norway, Netherlands and UK. Interviews were transcribed and analysed using thematic and textual analysis. RESULTS: Stakeholders in the six countries identified a range of influences which shaped diabetes self-management (SM). The infrastructure and culture for supporting self- management practice is viewed as driven by political decision-makers, the socio-economic and policy environment, and the ethos and delivery of chronic illness management in formal health care systems. Three key themes emerged during the analysis of data. These were 1) social environmental influences on diabetes self-management 2) reluctance or inability of policy makers to regulate processes and environments related to chronic illness management 3) the focus of healthcare system governance and gaps in provision of self-management support (SMS). Nuances in the salience and content of these themes between partner countries related to the presence and articulation of dedicated prevention and self- management policies, behavioural interventions in primary care, drug company involvement and the impact of measures resulting from economic crises, and differences between countries with higher versus lower social welfare support and public spending on shaping illness management. CONCLUSIONS: The results suggest reasons for giving increasing prominence to meso level influences as a means of rebalancing and improving the effectiveness of implementing an agenda for SMS. There is a need to acknowledge the greater economic and policy challenging environment operating in some countries which act as a source of inequality between countries in addressing SMS for chronic illness management and impacts on people's capacity to undertake self-care activities.

Social support systems as determinants of self-management and quality of life of people with diabetes across Europe: study protocol for an observational study.

BACKGROUND: Long-term conditions pose major challenges for healthcare systems. Optimizing self-management of people with long-term conditions is an important strategy to improve quality of life, health outcomes, patient experiences in healthcare, and the sustainability of healthcare systems. Much research on self-management focuses on individual competencies, while the social systems of support that facilitate self-management are underexplored. The presented study aims to explore the role of social systems of support for self-management and quality of life, focusing on the social networks of people with diabetes and community organisations that serve them. METHODS: The protocol concerns a cross-sectional study in 18 geographic areas in six European countries, involving a total of 1800 individuals with diabetes and 900 representatives of community organisations. In each country, we include a deprived rural area, a deprived urban area, and an affluent urban area. Individuals are recruited through healthcare practices in the targeted areas. A patient questionnaire comprises measures for quality of life, self-management behaviours, social network and social support, as well as individual characteristics. A community organisations' survey maps out interconnections between community and voluntary organisations that support patients with chronic illness and documents the scope of work of the different types of organisations. We first explore the structure of social networks of individuals and of community organisations. Then linkages between these social networks, self-management and quality of life will be examined, taking deprivation and other factors into account. DISCUSSION: This study will provide insight into determinants of self-management and quality of life in individuals with diabetes, focusing on the role of social networks and community organisations.

The influence of social networks on self-management support: a metasynthesis.

BACKGROUND: There is increasing recognition that chronic illness management (CIM) is not just an individual but a collective process where social networks can potentially make a considerable contribution to improving health outcomes for people with chronic illness. However, the mechanisms (processes, activities) taking place within social networks are insufficiently understood. The aim of this review was to focus on identifying the mechanisms linking social networks with CIM. Here we consider network mechanisms as located within a broader social context that shapes practices, behaviours, and the multiplicity of functions and roles that network members fulfil. METHODS: A systematic search of qualitative studies was undertaken on Medline, Embase, and Web for papers published between 1st January 2002 and 1st December 2013. Eligible for inclusion were studies dealing with diabetes, and with conditions or health behaviours relevant for diabetes management; and studies exploring the relationship between social networks, self-management, and deprivation. 25 papers met the inclusion criteria. A qualitative metasynthesis was undertaken and the review followed a line of argument synthesis. RESULTS: The main themes identified were: 1) sharing knowledge and experiences in a personal community; 2) accessing and mediation of resources; 3) self-management support requires awareness of and ability to deal with network relationships. These translated into line of argument synthesis in which three network mechanisms were identified. These were network navigation (identifying and connecting with relevant existing resources in a network), negotiation within networks (re-shaping relationships, roles, expectations, means of engagement and communication between network members), and collective efficacy (developing a shared perception and capacity to successfully perform behaviour through shared effort, beliefs, influence, perseverance, and objectives). These network mechanisms bring to the fore the close interdependence between social and psychological processes in CIM, and the intertwining of practical and moral dilemmas in identifying, offering, accepting, and rejecting support. CONCLUSIONS: CIM policy and interventions could be extended towards: raising awareness about the structure and organisation of personal communities; building individual and network capacity for navigating and negotiating relationships and CIM environments; maximising the possibilities for social engagement as a way of increasing the effectiveness of individual and network efforts for CIM.

Implementing guidelines for depression on antidepressant prescribing in general practice: a quasi-experimental evaluation.

BACKGROUND: Internationally, guidelines for depression recommend a stepped care approach, implying that antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations on antidepressant prescribing. METHODS: A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for a stepped care approach to depression. The model consisted of self-help and psychological treatment options for patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant prescription rates of GPs were documented for a three-year period and compared to those in a control group of GPs, selected from an ongoing national registration network. RESULTS: A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group (50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92). CONCLUSIONS: An implementation program using stepped care principles for the allocation of depression interventions resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within the context of a QIC.

A counselling intervention for individual strategies to prevent complications and strengthen resources during pregnancy in gynaecological care (AOK-Family +): study protocol for a cluster-randomised controlled trial.

BACKGROUND: Lifestyle-related risk factors can increase complications during pregnancy and negatively impact the health of a mother and her child. Knowledge about these compliances among many pregnant women and women of childbearing age is lacking. In the study AOK-Family + , we propose the evaluation of a newly developed counselling intervention. The intervention aims to raise awareness and to provide relevant information about the impact of lifestyle-related risk factors during pregnancy. The aim of the proposed study is to evaluate the effect of this counselling intervention on women's knowledge of lifestyle-related risk factors during pregnancy and the concomitant healthy behaviours. METHODS: A cluster-randomised trial with three arms in Baden-Wuerttemberg, Germany, is proposed. Pregnant women and women of childbearing age will be allocated to one of three groups: online intervention, on-site intervention, or a waiting-list control. Trained counsellors from AOK Baden-Wuerttemberg, a German statutory health insurer, will conduct the counselling sessions. Data collection is conducted throughout validated questionnaires administered at three intervals: before counselling (t0), directly after counselling (t1), and at a 6-week follow-up (t2). The primary outcomes will be health knowledge and healthy behaviours relating to LRFFs during pregnancy. A process evaluation will examine the processes, used resources, and future implementations through additional quantitative questions and qualitative interviews and focus groups. DISCUSSION: Based on this study, an implementation strategy for future conduction of lifestyle consultation during pregnancy could be developed with the aim of reducing pre- and post-mortem mobility and mortality. TRIAL REGISTRATION: The German Clinical Trials Register DRKS00027804. Registered on 2022/01/12.

Strengthening crisis resilience in German primary care by using quality indicators: findings of a process evaluation in the RESILARE project.

BACKGROUND: In recent years, health systems worldwide have been confronted with several crises such as natural disasters or the COVID-19 pandemic, that affected lives and health of many people. In light of waves of infections and heat, climate change is considered to be the biggest health threat of the 21st century. Strengthening individual and organizational crisis resilience in healthcare settings thus becomes a crucial factor in maintaining care quality and protecting vulnerable patients during such crises. The RESILARE project therefore aimed to develop and evaluate quality indicators that support primary care practices in preparing for and adapting to crisis-related challenges. METHODS: In a three-phased process, indicator development was based on systematic literature research and qualitative data, a two-stage expert panel process, and pilot testing in a maximum of n = 35 ambulatory practices during an outreach visit. Practice-individual indicator-related status and benchmarking information were provided via feedback reports to complete the audit and feedback program. A mixed-methods process evaluation used semistructured interviews with participating General practitioners and nonphysician health professionals to explore support and challenges for the implementation of the derived set of quality indicators. Two online surveys were conducted to evaluate all indicators and the two-part feedback report. Qualitative data were analyzed inductively using a thematic analysis approach. Survey data were analyzed descriptively. RESULTS: A total of n = 32 indicators covered four domains: (1) individual resilience, (2) crisis prevention, (3) organizational resilience, and (4) climate resilience. N = 34 practices participated in the piloting and the process evaluation. Participants generally attributed a high relevance to the domains, and considered the indicator set suitable for implementation into existing quality management systems. Planning and implementation of measures that strengthen crisis resilience in practices were triggered or intensified by piloting the indicators and by the two-part feedback report. The identified challenges involved the volume of indicators and practice-individual implementation of renewable energy sources on rented premises. Participants expressed their desire for peer exchange regarding proven concepts for crisis resilience.

First insights into multidisciplinary and multispecialty long COVID networks-a SWOT analysis from the perspective of ambulatory health care professionals.

Introduction: Multidisciplinary and multispecialty approaches with central integration of primary care, individualized long-term rehabilitative care, and multidisciplinary care pathways are recommended by international consortia to face the challenges of care of long COVID. Two regional long COVID networks-Rhein-Neckar (RN) and Ludwigsburg (LU) have emerged as ad hoc examples of best practice in Southern Germany. The aim of the community case study is to provide first insights into the experiences of the networks. Methods: The exploratory observational study was conducted between April and June 2023, focusing on an observation period of just under 24 months and using a document analysis supported by MAXQDA and SWOT analysis with ambulatory health care professionals in two online group discussions. Results: The document analysis revealed that both networks have defined network participants who have agreed on common goals and patient pathways and have established ways of communicating, organizing, and collaborating. Both networks agreed on a primary care-based, multidisciplinary and multispecialty approach. The main differences in realization emerged in LU as a focus on the ambulatory setting and very concrete application to individual patients, while RN showed a focus on an intersectoral character with participation of the specialized university hospital sector, knowledge transfer and a supra-regional approach with the involvement of the meso and macro level. The SWOT analysis (n = 14 participants, n = 6 male, 7 physicians (4 disciplines), 7 therapists (5 professions)) showed strengths such as resulting collaboration, contribution to knowledge transfer, and improvement of care for individual patients. As barriers, e.g., lack of reimbursement, high efforts of care, and persistent motivation gaps became apparent. Potentials mentioned were, e.g., transferability to other diseases such as Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, promotion of addressing a "difficult topic" and promotion of intersectoral care concepts; risks mentioned were, e.g., limited network resources and negative effects on the development of other structures. Conclusion: Resulting implications for practice and research address a call to policy makers and funders to support further research to find out what generalizable results regarding usefulness, effectiveness, and efficiency including transferability to other post-infectious diseases can be derived.

The Effect of an Additional Structured Methods Presentation on Decision-Makers' Reading Time and Opinions on the Helpfulness of the Methods in a Quantitative Report: Nonrandomized Trial.

BACKGROUND: Although decision-makers in health care settings need to read and understand the validity of quantitative reports, they do not always carefully read information on research methods. Presenting the methods in a more structured way could improve the time spent reading the methods and increase the perceived relevance of this important report section. OBJECTIVE: To test the effect of a structured summary of the methods used in a quantitative data report on reading behavior with eye-tracking and measure the effect on the perceived importance of this section. METHODS: A nonrandomized pilot trial was performed in a computer laboratory setting with advanced medical students. All participants were asked to read a quantitative data report; an intervention arm was also shown a textbox summarizing key features of the methods used in the report. Three data-collection methods were used to document reading behavior and the views of participants: eye-tracking (during reading), a written questionnaire, and a face-to-face interview. RESULTS: We included 35 participants, 22 in the control arm and 13 in the intervention arm. The overall time spent reading the methods did not differ between the 2 arms. The intervention arm considered the information in the methods section to be less helpful for decision-making than did the control arm (scores for perceived helpfulness were 4.1 and 2.9, respectively, range 1-10). Participants who read the box more intensively tended to spend more time on the methods as a whole (Pearson correlation 0.81, P=.001). CONCLUSIONS: Adding a structured summary of information on research methods attracted attention from most participants, but did not increase the time spent on reading the methods or lead to increased perceptions that the methods section was helpful for decision-making. Participants made use of the summary to quickly judge the methods, but this did not increase the perceived relevance of this section.

Building resilience in German primary care practices: a qualitative study.

BACKGROUND: In recent years, healthcare has faced many different crises around the world such as HIV-, Ebola- or H1N1-outbrakes, opioid addiction, natural disasters and terrorism attacks). In particular, the current pandemic of Covid-19 has challenged the resilience of health systems. In many healthcare systems, primary care practices play a crucial role in the management of crises as they are often the first point of contact and main health care provider for patients. Therefore, this study explored which situations are perceived as crises by primary care practice teams and potential strategies for crisis management. METHODS: A qualitative observational study was conducted. Data were collected in interviews and focus groups with experts from primary care practices and stakeholders focusing on primary care practices in Germany such as physicians, medical assistants, practice managers, quality managers, hygiene managers and institutions on health system level (politics, research and health insurance). All interviews and focus groups were audio-recorded and transcribed verbatim. A qualitative content analysis was performed using a rapid qualitative analysis approach first, followed by a thematic analysis. RESULTS: Two focus groups and 26 interviews including 40 participating experts were conducted. Many different situations were perceived as crises, varying from issues in the practice organization to problems on health system level and international disasters. Distinct aspects associated with the perception of a crisis situation by interviewees were the presence of emotional reactions, a need for organizational changes and a lack of necessary resources. A broad spectrum of possible strategies was discussed that could help to cope with or even prevent the emergence of an actual crisis. In particular, strengthening communication within practice teams and resilience among employees was perceived to be fundamental for improving responses to crises or preventing them. CONCLUSIONS: The study provides perspectives of primary health care workers on crises in health, that could inform health policy regarding prevention and management of future crises in primary care facilities.

[Long COVID: Care and support needs from the perspective of "long-haul" patients and primary care practitioners - a mixed-methods study from Baden-Wuerttemberg]. / Versorgungsbedarfe zu Long-COVID aus Sicht von Betroffenen und Hausärzt*innen ­ eine Mixed-Methods-Studie aus Baden-Württemberg.

INTRODUCTION: The approaches to cope with the challenges of providing medical care to patients with symptoms of long COVID are multidisciplinary and involve primary care worldwide. The aim of this study was to explore the experiences and ideas for continued development of medical care of long COVID from the patients' (PAT) and primary care practitioners' (PCP) perspective. METHODS: Between the third and fourth COVID-19 wave in Germany (July to September 2021), a mixed methods study was conducted by inviting patients and PCPs in two neighboring districts (urban and rural) in Baden-Wuerttemberg to a paper-based questionnaire with both closed and open questions. On the part of the PCPs a written, anonymized, complete survey was conducted, on the part of symptomatic COVID long-haulers an anonymized online survey with announcement of the study by multiple recruiting processes. Qualitative content analysis was applied to free text entries. The quantitative results were analyzed mainly descriptively. RESULTS: The responses of n = 72 PCPs (response rate 12%) and n = 126 PAT showed a heterogeneous assessment regarding the satisfaction with medical care for long COVID as well as the perception of the attitude towards patients and their disease in both groups. Uncertainty and dealing with it played a relevant role in both groups as well. The professional medical knowledge was assessed by 3,1 (self-assessment PCPs) and 3,2 (PAT) on average using a five-point Likert scale (1 = not applicable; 5 = applicable). The request for a structured overall concept with competent contact points and coordination of medical care for long COVID patients emerged out of the statements of both groups. CONCLUSION: The results support an interdisciplinary, intersectoral and interprofessional stepped-care concept for long COVID in Germany with PCPs as the first contact persons, integration of specialized contact points and knowledge transfer. Therefore, it appears to be both reasonable and appropriate to establish regional networks with links between regional outpatient medical care structures and the university medical sector.