Big data analysis techniques to address polypharmacy in patients - a scoping review.

BACKGROUND: Polypharmacy is a key challenge in healthcare especially in older and multimorbid patients. The use of multiple medications increases the potential for drug interactions and for prescription of potentially inappropriate medications. eHealth solutions are increasingly recommended in healthcare, with big data analysis techniques as a major component. In the following we use the term analysis of big data as referring to the computational analysis of large data sets to find patterns, trends, and associations in large data sets collected from a wide range of sources in contrast to using classical statistics programs. It is hypothesized that big data analysis is able to reveal patterns in patient data that would not be identifiable using conventional methods of data analysis. The aim of this review was to evaluate whether there are existing big data analysis techniques that can help to identify patients consuming multiple drugs and to assist in the reduction of polypharmacy in patients. METHODS: A computerized search was conducted in February 2019 and updated in May 2020, using the PubMed, Web of Science and Cochrane Library databases. The search strategy was defined by the principles of a systematic search, using the PICO scheme. All studies evaluating big data analytics about patients consuming multiple drugs were considered. Two researchers assessed all search results independently to identify eligible studies. The data was then extracted into standardized tables. RESULTS: A total of 327 studies were identified through the database search. After title and abstract screening, 302 items were removed. Only three studies were identified as addressing big data analysis techniques in patients with polypharmacy. One study extracted antipsychotic polypharmacy data, the second introduced a decision support system to evaluate side-effects in patients with polypharmacy and the third evaluated a decision support system to identify polypharmacy-related problems in individuals. CONCLUSIONS: There are few studies to date which have used big data analysis techniques for identification and management of polypharmacy. There may be a need to further explore interdisciplinary collaboration between computer scientists and healthcare professionals, to develop and evaluate big data analysis techniques that can be implemented to manage polypharmacy.

[Diabetes treatment 2.0: telemedicine]. / Diabetestherapie 2.0 ­ Telemedizin.

BACKGROUND: The prevalence of diabetes mellitus in Germany is between 5.8% and 9.5%. Telemedical applications (TA) can provide meaningful approaches in diabetes care. So far, however, TA have seldom undergone a structured research evaluation. This deficiency is considered to be one of the reasons why TA have rarely been implemented in routine care as yet. OBJECTIVES: What information about research evaluation can be identified in current TA that address diabetes therapy? MATERIALS AND METHODS: In order to identify the accompanying evaluation approaches of telemedical diabetes projects, the "vesta" information portal of the German Society for Telematics Applications for the Health Card (Gesellschaft für Telematikanwendungen der Gesundheitskarte mbH), the websites of the Innovation Fund at the Federal Joint Committee, PubMed, and gray literature were searched. Prevention projects were not included. RESULTS: Twelve projects were identified. For four of the projects, data from the accompanying research could be found, which refers to parameters such as HbA1c, quality of life and economic aspects. One of these four projects stated that it was based on an established model for the evaluation of TA. No information on accompanying evaluations was found for the other eight projects, but three of these are still in the data collection phase. CONCLUSIONS: As the results suggest, most of the telemedically supported diabetes projects are not being evaluated in a structured way as yet. Established instruments for the accompanying evaluation of TA are now being used.

Procedures performed by general practitioners and general internal medicine physicians - a comparison based on routine data from Northern Germany.

BACKGROUND: In response to a rising shortage of general practitioners (GPs), physicians in general internal medicine (GIM) have become part of the German primary care physician workforce. Previous studies have shown substantial differences in practice patterns between both specialties. The aim of this study was to analyse and compare the application of procedures by German GPs and GIM physicians based on routine data. METHODS: The Association of Statutory Health Insurance Physicians in the federal state Schleswig-Holstein (Northern Germany) provided invoicing data of the first quarters of 2013 and 2015. Differences between GPs and GIM physicians in the implementation rate of 46 selected primary care procedures were examined by means of the Pearson χ2-test. The selection of procedures was based on international and own preliminary studies on primary care procedures. RESULTS: In the first quarter of 2013/2015 respectively, 1228/1227 GPs and 447/484 GIM physicians provided services in Schleswig-Holstein. Significant differences were found for 20 of the 46 procedures. GPs had higher application rates of procedures concerning health screening (e.g. adolescent health examination, well-child visits) and minor surgery. GIM physicians more often applied technology-oriented procedures, such as ultrasound scans, electrocardiograms (ECG), and 24-h ambulatory blood pressure measurements. The treatment patterns of both specialities did not vary much during the study period. Cardiac stress testing was the only significantly increased GP procedure in that time. CONCLUSIONS: Our results suggest substantial differences in the application of procedures between GPs and GIM physicians with potential consequences for the overall primary healthcare provision. The findings could foster a discussion about training needs for procedures in primary care to ensure its comprehensiveness. The results reflect scope for changes in vocational training in the future for an effective and efficient re-allocation of primary healthcare.

[Procedures Performed in General Practice - a Cross-sectional Study]. / Prozeduren, die in der Allgemeinmedizin durchgeführt werden ­ eine Querschnittstudie.

OBJECTIVE: General practice offers basic medical care to patients. Therefore, general practitioners (GPs) perform a variety of medical procedures. In order to estimate GPs array of services from the perspective of health services research, it is indispensable to know the procedures that are carried out by GPs and identify relevant influencing factors. METHODS: Based on the results of a selective literature search, the Medical Association's regulations on specialty training and experiences gained so far in developing the competence-based curriculum for general practice, a questionnaire covering 89 procedures was developed and sent to 1 576 general practitioners all over Germany. RESULTS: The response rate was 42%; 42 of 89 procedures were carried out by at least 50% of the participants. These procedures include the anatomical areas skin, eyes, ears, nose, gastrointestinal tract, urological tract and musculoskeletal system. Significant differences were shown in 25 of the most frequent procedures regarding practices in urban and rural areas, in 9 procedures with regard to the participant's length of occupation in general practice and in 19 procedures regarding male and female participants. CONCLUSION: This is the first survey that shows which procedures are performed by German GPs and how often they are performed. Factors such as practice location in either rural or urban area, physician's gender and years practiced as GP have been identified as important influences on the spectrum of services provided.

[Projection of General Practitioner Care Demand at the Community Level]. / Projektion des Bedarfs an hausärztlicher Versorgung auf Gemeindeebene.

BACKGROUND: Within the next 8 years about 2 000 general practitioners (GPs) will be seeking a successor in the federal state of Baden-Württemberg, Germany. Both the small number of newly qualified GPs and the wish to work as an employee or in a group practice will lead to a situation in which about 500 practices will likely not find a successor. Using a single administrative district, the aim of this analysis was to develop a projection of the demand for GP health care at the community level. METHODS: Using the administrative district of Rottweil with its 21 communities, a community-based demographic forecast on the basis of current birth and death probabilities was performed. From the projected population structure, the demand for GP care in the year 2023 was derived under the assumption of unchanged age- and gender-specific numbers of GP visits. The anticipated deficit or, respectively, overrun of GPs at the community level was calculated as the difference between expected demand and number of GPs not retiring for age-related reasons. RESULTS: Until the year 2023 the demographic change will cause a shrinking population. However, with unchanged age- and gender-specific numbers of GP visits, a slightly higher demand of 0.6 GPs will occur as a result of population-aging. The expected age-related retirement of physicians will have a stronger impact on primary care demand than demography. Up to 32 (37%) GPs might need a successor. In addition to 4 communities today, this would result in another 5 communities not having a GP in 10 years. CONCLUSION: Communities that are at higher risk of GP shortage based on demographic changes and age of practicing GPs, can be identified by the approach described and applied here in order to implement targeted comprehensive community models of care.

[Oversupplied? Undersupplied? - The Perspective of Local Governments of the Federal State of Baden-Württemberg: A Contribution to the Discussion of Close-to-Home Health Care]. / Überversorgt? Unterversorgt? - die Sicht von Bürgermeistern in Baden-Württemberg: Ein Beitrag zur Diskussion um die wohnortnahe medizinische Versorgung.

BACKGROUND: The ageing of physicians working in ambulatory care make regional health planning a challenging task. This study examines the current supply of general practitioners (GP) within the communities from the perspective of mayors. The information gained on a community level can be used when discussing over- and undersupply as well as future health care planning. METHODS: A questionnaire was sent to all 1101 mayors of the Federal state of Baden-Württemberg (BW) in May 2011. For the evaluation of the location of the communities, subjective ratings by the mayors were compared with official criteria, provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR). RESULTS: The participation rate was 63% (n=698). According to the mayors about 70% (n=468) were located in a rural area, according to BBSR criteria were about 26% (n=177) of answers given by rural communities. Of the participating mayors about 54% (n=355) stated that their community is cared for merely by GPs. From this information there was a locally experienced undersupply of GPs calculated for 13.5% (n=86) of the communities. This affected rural as well as non-rural communities. In communities up to 20 000 inhabitants, the ratio between GPs and other specialists seems to be 60:40 whereas in bigger cities the proportion of other specialists appears to be much higher. CONCLUSION: Half of the participating communities seem to not have a practicing specialised physician. An accumulation of specialised physicians in larger cities was reported. The GP shortage appears to mainly be experienced subjectively. Regarding the location (urban vs. rural) of the community, subjective views differ distinctly from the BBSR criteria. This discrepancy could influence a community's marketing strategy when competing for new physicians.

[Joint replacement quality index: the perspective of resident physicians]. / "Qualitätsindex Endoprothetik" aus Sicht von niedergelassenen Ärzten.

BACKGROUND AND AIM: Joint replacement is an established therapy for arthrosis. The quality index for joint replacement (knee and hip) should include screening for quality of patient-centred care in hospitals providing replacements, on the basis of administrative data. The quality index summarizes 16 inpatient and posthospital complications (indicators). The aim of the study was to evaluate this quality index from the medical practitioner's viewpoint. METHODS: Four semistructured focus groups with 11 family physicians and 8 orthopaedic/trauma surgeons were conducted. The discussions were recorded, transcribed and analysed qualitatively according to Mayring. RESULTS: Infections and the revision of a total joint arthroplasty have been weighted as the most important indicators from the existing quality indicators. Between the participants some differences regarding the relevance of the indicators thrombosis and pulmonary embolism occurred. These indicators were weighted as more important by family physicians than orthopedic/trauma surgeons. For eight of the indicators, imprecision in words/meaning was criticized. In an open-ended second section, 20 new indicators within the areas complications, management and overall sector communication were identified. CONCLUSION: Major amendments of the quality index for the joint replacement are necessary. The knowledge gained from this study may serve as a basis for this development.

[Perceptions of the local government about the primary care physicians shortage - a survey among mayors in the Federal State of Baden-Wuerttemberg]. / Die Sichtweise der kommunalen Ebene über den Hausärztemangel - eine Befragung von Bürgermeistern in Baden-Württemberg.

BACKGROUND: Local governments have a crucial role in dealing with the primary care physicians shortage (PS). The aim of this study is to evaluate the perspectives and experiences of the local mayors on this issue. METHODS: In May 2011, all 1101 mayors in the Federal State of Baden-Wuerttemberg (BW) were invited to participate in the study by filling out a survey developed by the authors. Data were analysed descriptively. RESULTS: Of the contacted mayors in BW, 63% (n=698) responded. More than 90% of the participants consider it their duty to ensure future primary care. 16% experienced local practice closures due to PS. The infrastructure provided by the communities seems to be at a high level, whereas emergency practices exist in only 15% of the communities at present. Supportive actions to attract new GPs are evaluated as appropriate by almost half of the participants. CONCLUSIONS: The PS topic is of high relevance for communities in BW. In order to gain future physicians for their region, the majority of the communities are maintaining a high level of infrastructure and are willing to offer more actions. The young generation physicians need to be informed about these existing conditions. Innovative ideas should be implemented in individual communities as pilot projects.

[Manual medicine in Germany. A descriptive analysis]. / Manuelle Medizin in Deutschland. Eine deskriptive Analyse.

BACKGROUND: In Germany manual medicine (MM) is widely used by physicians. The purpose of this study was to give a first description of relevant health service research aspects of MM. METHODS: A structured questionnaire was placed online between April 2009 and March 2010 after pilot testing. Cooperating MM schools invited their members to take part in the study through different media. RESULTS: A total of 60 female and 241 male physicians participated in this survey. The most common indication for MM is the ileosacral joint syndrome, 73% stated that from their experience a single therapy does change symptoms and 47% stated that there are average to severe unspecific effects involved in MM therapy. Factors most influencing current MM treatment are time pressure and own wellbeing. There were no differences between the schools or specialties with respect to experienced effects of MM and frequency of therapy. CONCLUSION: Future study research can be planned to cover all schools of MM.

[Challenges and potentials of primary care in a multicultural society]. / Herausforderungen und Potenziale hausärztlicher Versorgung in einer multikulturellen Gesellschaft.

The greatest proportion of basic health care for patients with a migrational background living in Germany is provided by general practitioners. There is evidence that patients with a migrational background see a general practitioner as a gate keeper in case of physical or mental complaints even more frequently than the native German population. In contrast, the impact of migration-specific tasks in general practice appears to be relatively low in the medical and public discourse. This article analyzes the current situation of medical care for migrant patients in general practice and shows its potential to offer low-threshold high quality health care services to migrant patients and the whole population. In addition, an overview on migration-specific issues in research, teaching, and continuous medical education of general practitioners is provided. Finally, the implications of these findings for future research questions on migration-sensitive interventions are discussed.

Process evaluation of five tailored programs to improve the implementation of evidence-based recommendations for chronic conditions in primary care.

BACKGROUND: Although there is evidence that tailored implementation strategies can be effective, there is little evidence on which methods of tailoring improve the effect. We designed and evaluated five tailored programs (TPs) each consisting of various strategies. The aim of this study was to examine (a) how determinants of practice prioritized in the design phase of the TPs were perceived by health care professionals who had been exposed to the TPs and whether they suggested other important determinants of practice and (b) how professionals used the offered strategies and whether they suggested other strategies that might have been more effective. METHODS: We conducted a mixed-method process evaluation linked to five cluster-randomized trials carried out in five European countries to implement recommendations for five chronic conditions in primary care settings. The five TPs used a total of 28 strategies which aimed to address 38 determinants of practice. Interviews of professionals in the intervention groups and a survey of professionals in the intervention and control groups were performed. Data collection was conducted by each research team in the respective national language. The interview data were first analyzed inductively by each research team, and subsequently, a meta-synthesis was conducted. The survey was analyzed descriptively. RESULTS: We conducted 71 interviews; 125 professionals completed the survey. The survey showed that 76 % (n = 29) of targeted determinants of practice were perceived as relevant and 95 % (n = 36) as being modified by the implementation interventions by 66 to 100 % of professionals. On average, 47 % of professionals reported using the strategies and 51 % considered them helpful, albeit with substantial variance between countries and strategies. In the interviews, 89 determinants of practice were identified, of which 70 % (n = 62) had been identified and 45 % (n = 40) had been prioritized in the design phase. The interviewees suggested 65 additional strategies, of which 54 % (n = 35) had been identified and 20 % (n = 13) had been prioritized, but not selected in the final programs. CONCLUSIONS: This study largely confirmed the perceived relevance of the targeted determinants of practice. This contrasts with the fact that no impact of the trials on the implementation of the recommendations could be observed. The findings suggest that better methods for prioritization of determinants and strategies are needed. TRIAL REGISTRATION: Each of the five trials was registered separately in recognized trial registries. Details are given in the respective trial outcome papers.

[What do medical students think of family medicine? Results of an online cross-sectional study in the federal state of Baden-Wuerttemberg]. / Wie sehen Medizinstudierende die Allgemeinmedizin? Ergebnisse einer onlinebasierten Querschnittstudie in Baden-Württemberg.

BACKGROUND: In the context of physician shortages, critical factors influencing career choice need to be better understood. The aim of this study was to explore experiences students have had with family medicine in order to develop additional strategies for recruiting family medicine trainees. METHODS: Students from the five medical faculties in the federal state of Baden-Wuerttemberg were invited to participate in an online-survey via email. A purpose-built questionnaire was used. In addition to descriptive statistics, analysis included linear partial correlations controlled for age, gender, and semester, which were calculated between the variable "I believe family medicine is an attractive job" and the 31 variables of the survey. Linear regression was used to analyze the influence of experiences with family medicine and statements about family medicine to the perception of family medicine as an attractive specialty. RESULTS: 1299 students participated in the survey. About half of the participants (49.7 %) considered working as a primary care physician to be attractive or partly attractive. 49.6 % of students reported positive experiences with family medicine as a patient and 33.1 % as a family member. 24.3 % reported positive experiences during the compulsory 1-2 weeks general practice internship and 18.1 % during a four weeks elective placement. For 302 participants (23.3 %), family medicine is presented positively in the media. 178 (13.7 %) consider family medicine to have high importance in both undergraduate and postgraduate education. Positive influences on judging attractiveness of family medicine were: own experience with family medicine as a clinical elective (rpart= + 0.450), own experience with family medicine as a patient (rpart= + 0.218), perception that family medicine offers a diversified working day (rpart= + 0.259), and perception that family medicine offers a good salary (rpart= + 0.242). CONCLUSION: To enable students during undergraduate studies to have practical experience with family medicine seems to be an important influence on judging family medicine attractive.

[Approaches to reduce shortage of general practitioners in rural areas--results of an online survey of trainee doctors]. / Lösungsansätze gegen den Allgemeinarztmangel auf dem Land--Ergebnisse einer Online-Befragung unter Ärzten in Weiterbildung.

BACKGROUND: In times of shortage of general practitioners (GPs), especially in rural areas, it is of particular interest to explore expectations and interests of GP trainees relating to their future work. The aim of this study was, to survey the willingness of trainee doctors to work in or open a general practice, as well as their expectations and plans concerning future work as a GP in a rural area. METHODS: The survey was conducted online between April to October 2010 with trainee doctors. The questionaire contained 25 questions about the trainees' sociodemographic status, expectations and conception of their future work, factors influencing setting up a GP practice and their ideas about working in a rural area. RESULTS: 528 trainee doctors from across Germany responded. More than half of them were female, more than 40% older than 35 years. 89% could image themselves settling in a GP practice, 77% in a rural area. The three most important factors influencing working in a rural practice were family friendly surrounding, the rural village itself and cooperation with colleagues. Most trainees would accepted having to travel 30 minutes to work. CONCLUSION: As the basic willingness to set up practice in rural areas is quite high, relevant influencing factors such as family friendly surroundings, out-of-hour services arrangements und working models offering the opportunity to work in group handed practices should be emphasized in recruitment.

[Aspirations of medical students: "planning for a secure career" - results of an online-survey among students at five medical schools in Germany]. / Berufswunsch "planungssicherer Arbeitsplatz" - Ergebnisse einer Online-Befragung unter Medizinstudierenden.

BACKGROUND: In times of shortage of doctors, expectations and interests of the future generation of doctors towards their career aspiration is of major importance. The aim of this study was to analyze expectations of medical students at the five medical schools in the State of Baden-Wuerttemberg (Germany) concerning their career choice and factors influencing it. METHODS: Between January and February 2010, 1299 medical students (out of 12 062 medical students at the five medical schools) participated in an online-survey. In addition to sociodemographic items, career choice and aspects of planning reliability were raised. RESULTS: Three quarters of the students assign a medical profession for their future occupation. There is a dominance of internal medicine (n = 152), gynaecology (n = 127), paediatrics (n = 125), surgery (n = 115), anaesthesiology (n = 101), and family medicine (n = 88). The time point of decision varies between the different undergraduate years of medical school and specialty. Students at the beginning of their studies seem to be interested mostly in surgery. During medical school the interests towards internal medicine grows. Regarding planning dependability important aspects for medical students were to work in a job that has a future (61.2 % fully agree), to have a safe job (57.7 %), and to have a safe income (57.1 %). Less important seems to be to have good opportunity to earn money (29.6 %). CONCLUSIONS: Interest in a certain specialty changes markedly at during medical school. Factors such as economical guarantee, good future prospects and also the studies itself have an essential impact for students on choosing a specific career. Strategies to face physicians' shortage in different specialties need to be close to the needs and expectations of future physicians. This is not only valid for the undergraduate time period but also for the work circumstances of their future.

[As to the traumatic etiology of the Freiberg-Köhler's epiphyseonecrosis (author's transl)]. / Zur Frage der traumatischen Entstehung des Morbus Köhler II. (Freiberg's Disease).

There is demonstrated the case of a Freiberg-Köhler's epiphyseonecrosis developing without any doubt after a direct massive contusion of the forefoot by hit against the edge of a swimmingpool. While the X-ray from the date of accident only showed a tiny osseus avulsion fracture out of the base of the proximal phalanx II--in spite of the immediately taken accurate therapeutical provisions (by fixation with plaster and later on paviment dressing)--there took place a massive epiphyseonecrosis of the capitulum II within only three months.--The etiology of the necrosis--direct trauma of the nutritive arteries passing through the collateral ligaments--is discussed. There is given a reference to the particular problems arising by critical examination of similar cases for instance at medical reports.

[Modification of the operative technics for the ventralisation of the tuberositas tibiae (Maquet-Bandi) (author's transl)]. / Operationstechnische Modifikation für die Ventralverlagerung der Tuberositas tibiae (Maquet-Bandi).

UNLABELLED: There is given a modification of operative technics for ventralisation of the tuberosity of the tibia (Maquet-Bandi-Operation). Similar to a sand-glass two triangular cortical/spongious bone grafts are taken from the medial side of the tibia, just beside the tuberosity. Their size can be determined exactly. After having chiseled the proximal part of the tuberosity from both sides and lifted it up, the bone grafts are put under it, one from the medial, the other one from the lateral side by the way, that the top of the triangle is looking in distal, the base in proximal direction. The cortical surfaces of the grafts, showing to the medial and lateral side, make sure the stable keeping place, while their spongious surfaces, showing to the internal side, by direct contact to the spongious backside of the tuberosity and its spongious bed guarantee the quick osseous consolidation. A minimal osteosynthesis by drilling 2 Kirschner-wires in ventro-dorsal direction through the tuberosity, the cortical part of the bone grafts up to the opposite cortex of the tibia finishes the operation. ADVANTAGES: 1. The bone graft can be taken directly at the field of operation. 2. The bone material is homogenous. 3. The cortical part of the grafts guarantee stable keeping place. 4. Their spongious parts make sure the quick osseous consolidation. 5. Minimal osteosynthesis is necessary.

[Large cyst of the ulnar head and simultaneous lunatomalacia]. / Ausgedehnte Zyste im Ulnaköpfchen und Lunatummalazie.

The correlations between symptoms at the distal end of the ulna and lunatomalacia are discussed by demonstration of a case with large subchondral bone cyst within the head of the ulna and simultaneous lunatomalacia. The possible common factors with regard to the etiology are discussed.

["Dislocation osteotomy" in the treatment of large juvenile bone cysts (author's transl)]. / Zur "Verschiebeosteotomie" in der Therapie grosser jugendlicher Knochenzysten.

Dislocation osteotomy with subpositioning of the distal fragment - without additional implantation of bone material (!) - yields excellent results in the treatment of large juvenile bone cysts of the coxal end of the femur (Imhäuser), as confirmed by the author's own experience. The advantages of this procedure compared with other methods are described. Taking into consideration the two cases successfully treated by Imhäuser at the shaft of the upper arm in the same manner, it is demonstrated by describing the case of a patient with extended juvenile bone cyst in the region of the proximal humerus that here, too, dislocation osteotomy leads to complete cure within a short time, so that its increasing use appears justified.

[Bilateral necrosis of the lunate bone. A pathogenic study]. / Doppelseitige Mondbeinnekrose. Ein Beitrag zur Pathogenese.

The incidence of clinically and roentgenologically manifest Kienböck disease was checked on the basis of a thorough analysis of 85 patients suffering from the condition. Apart from sex distribution and age at onset, particular importance was attached to certain "constitutional factors". The fact in all bilaterally affected patients the ulnar was smaller than average at the wrist, and the advanced signs of arthrosis were radiologically demonstrated in 81.8% of the patients, once again confirms that certain constitutional factors play a decisive role in the Pathogenesis of Kienböch disease. Their importance for treatment, and also for possible assessments for insurance purpose, is emphasized.