Sepsis incidence, suspicion, prediction and mortality in emergency medical services: a cohort study related to the current international sepsis guideline.

PURPOSE: Sepsis suspicion by Emergency Medical Services (EMS) is associated with improved patient outcomes. This study assessed sepsis incidence and recognition by EMS and analyzed which of the screening tools recommended by the Surviving Sepsis Campaign best facilitates sepsis prediction. METHODS: Retrospective cohort study of claims data from health insurances (n = 221,429 EMS cases), and paramedics' and emergency physicians' EMS documentation (n = 110,419); analyzed outcomes were: sepsis incidence and case fatality compared to stroke and myocardial infarction, the extent of documentation for screening-relevant variables and sepsis suspicion, tools' intersections for screening positive in identical EMS cases and their predictive ability for an inpatient sepsis diagnosis. RESULTS: Incidence of sepsis (1.6%) was similar to myocardial infarction (2.6%) and stroke (2.7%); however, 30-day case fatality rate was almost threefold higher (31.7% vs. 13.4%; 11.8%). Complete vital sign documentation was achieved in 8.2% of all cases. Paramedics never, emergency physicians rarely (0.1%) documented a sepsis suspicion, respectively septic shock. NEWS2 had the highest sensitivity (73.1%; Specificity:81.6%) compared to qSOFA (23.1%; Sp:96.6%), SIRS (28.2%; Sp:94.3%) and MEWS (48.7%; Sp:88.1%). Depending on the tool, 3.7% to 19.4% of all cases screened positive; only 0.8% in all tools simultaneously. CONCLUSION: Incidence and mortality underline the need for better sepsis awareness, documentation of vital signs and use of screening tools. Guidelines may omit MEWS and SIRS as recommendations for prehospital providers since they were inferior in all accuracy measures. Though no tool performed ideally, NEWS2 qualifies as the best tool to predict the highest proportion of septic patients and to rule out cases that are likely non-septic.

Heterogeneous Preferences for Colorectal Cancer Screening in Germany: Results of a Discrete Choice Experiment.

OBJECTIVES: Colorectal cancer (CRC) screening tests differ in benefits, harms, and processes, making individual informed decisions preference based. The objective was to analyze the preferences of insurees in Germany for characteristics of CRC screening modalities. METHODS: A generic discrete choice experiment with 2-alternative choice sets and 6 attributes (CRC mortality, CRC incidence, complications, preparation, need for transportation, and follow-up; 3 levels each) depicting characteristics of fecal testing, sigmoidoscopy, and colonoscopy was generated. Participants completed 8 choice tasks. Internal validity was tested using a within-set dominated pair. Between June and October 2020, written questionnaires were sent to a stratified random sample (n = 5000) of 50-, 55-, and 60-year-old insurees of the AOK (Allgemeine Ortskrankenkasse) Lower Saxony, who had previously received an invitation to participate in the organized screening program including evidence-based information. Preferences were analyzed using conditional logit, mixed logit, and latent-class model. RESULTS: From 1282 questionnaires received (26% [1282 of 4945]), 1142 were included in the analysis. Approximately 42% of the respondents chose the dominated alternative in the internal validity test. Three heterogeneous preference classes were identified. Most important attributes were preparation (class 1; n = 505, 44%), CRC mortality (class 2; n = 347, 30%), and CRC incidence (class 3; n = 290, 25%). Contrary to a priori expectations, a higher effort was preferred for bowel cleansing (class 1) and accompaniment home (classes 1 and 2). CONCLUSION: Internal validity issues of choice data need further research and warrant attention in future discrete choice experiment surveys. The observed preference heterogeneity suggests different informational needs, although the underlying reasons remained unclear.

Evaluation of a Digital Decision Support System to Integrate Type 2 Diabetes Mellitus and Periodontitis Care: Case-Vignette Study in Simulated Environments.

BACKGROUND: As highlighted by the recent World Health Organization Oral Health Resolution, there is an urgent need to better integrate primary and oral health care. Despite evidence and guidelines substantiating the relevance of integrating type 2 diabetes mellitus (T2DM) and periodontitis care, the fragmentation of primary and oral health care persists. OBJECTIVE: This paper reports on the evaluation of a prototype digital decision support system (DSS) that was developed to enhance the integration of T2DM and periodontitis care. METHODS: The effects of the prototype DSS were assessed in web-based simulated environments, using 2 different sets of case vignettes in combination with evaluation surveys among 202 general dental practitioners (GDPs) and 206 general practitioners (GPs). Each participant evaluated 3 vignettes, one of which, chosen at random, was assisted by the DSS. Logistic regression analyses were conducted at the participant and case levels. RESULTS: Under DSS assistance, GPs had 8.3 (95% CI 4.32-16.03) times higher odds of recommending a GDP visit. There was no significant impact of DSS assistance on GP advice about common risk factors for T2DM and periodontal disease. GDPs had 4.3 (95% CI 2.08-9.04) times higher odds of recommending a GP visit, 1.6 (95% CI 1.03-2.33) times higher odds of giving advice on disease correlations, and 3.2 (95% CI 1.63-6.35) times higher odds of asking patients about their glycated hemoglobin value. CONCLUSIONS: The findings of this study provide a proof of concept for a digital DSS to integrate T2DM and periodontal care. Future updating and testing is warranted to continuously enhance the functionalities of the DSS in terms of interoperability with various types of data sources and diagnostic devices; incorporation of other (oral) health dimensions; application in various settings, including via telemedicine; and further customization of end-user interfaces.

Apart from the Medical Complaints, Why do Patients Use Emergency Medical Services? Results of a Patient Survey.

INTRODUCTION: Many countries face an increased use of emergency medical services (EMS) with a decreasing percentage of life-threatening complaints. Though there is a broad discussion among experts about the cause, patients' self-perceived, non-medical reasons for using EMS remain largely unknown. METHODS: The written survey included EMS patients who had≥1 case of prehospital emergency care in 2016. Four German health insurance companies sent out postal questionnaires to 1312 insured patients. The response rate was 20%; 254 questionnaires were eligible for descriptive and interferential analyses (t-tests, chi2-tests, logistic models). RESULTS: The majority of respondents indicated that their EMS use was due to an emergency or someone else's decision (≥84%; multiple checks allowed); 56% gave need for a quick transport as a reason. Other frequently stated reasons addressed the health care system (e. g., complaints outside of physicians' opening hours) and insecurity/anxiety about one's state of health (>45% of the respondents). "Social factors" were similarly important (e. g., 42% affirming, "No one could give me a ride to the emergency department or doctor's office."). Every fifth person had contact with other emergency care providers prior to EMS use. Respondents negating an emergency as a reason were less likely to confirm wanting immediate medical care on site or quick transports compared to those affirming an emergency. Patients using EMS at night more often denied having an emergency compared to patients with access to care during the day. CONCLUSION: The study identified a bundle of reasons leading to EMS use apart from medical complaints. Attempts for needs-oriented EMS use should essentially include optimization of the health care and social support system and measures to reduce patients' insecurity.

Harms and Benefits of Cancer Screening.

In recommending and offering screening, health services make a health claim ('it's good for you'). This article considers ethical aspects of establishing the case for cancer screening, building a service programme, monitoring its operation, improving its quality and integrating it with medical progress. The value of (first) screening is derived as a function of key parameters: prevalence of the target lesion in the detectable pre-clinical phase, the validity of the test and the respective net utilities or values attributed to four health states-true positives, false positives, false negatives and true negatives. Decision makers as diverse as public regulatory agencies, medical associations, health insurance funds or individual screenees can legitimately come up with different values even when presented with the same evidence base. The main intended benefit of screening is the reduction of cause-specific mortality. All-cause mortality is not measurably affected. Overdiagnosis and false-positive tests with their sequelae are the main harms. Harms and benefits accrue to distinct individuals. Hence the health claim is an invitation to a lottery with benefits for few and harms to many, a violation of the non-maleficence principle. While a public decision maker may still propose a justified screening programme, respect for individual rights and values requires preference-sensitive, autonomy-enhancing educational materials-even at the expense of programme effectiveness. Opt-in recommendations and more 'consumer-oriented' qualitative research are needed.

Finding common (research) ground between general practitioners and neuroscientists: the vital role of knowledge circulation in closing the evidence-to-practice gap.

BACKGROUND: It may take 15 years or longer before research evidence is integrated into clinical practice. This evidence-to-practice gap has deleterious effects on patients as well as research and clinical processes. Bringing clinical knowledge into the research process, however, has the potential to close the evidence-to-practice gap. The NEUROTRANS-Project attempts to bring research and practice together by focusing on two groups that usually operate separately in their communities: general practitioners and neuroscientists. Although both groups focus on dementia as an area of work, they do so in different contexts and without opportunities to share their expertise. Finding new treatment pathways for patients with dementia will require an equal knowledge exchange among researchers and clinicians along with the integration of that knowledge into research processes, so that both groups will benefit from the expertise of the other. METHODS: The NEUROTRANS-Project uses a qualitative, multi-stage research design to explore how neuroscientists and general practitioners (GPs) approach dementia. Using a grounded theory methodology, it analyzes semi-structured interviews, case vignettes, focus groups with GPs in Saxony-Anhalt, Germany, and informal conversations with, and observations of, neuroscientists from the German Center for Neurodegenerative Diseases in Magdeburg. RESULTS: The NEUROTRANS-Project identified a clear division of labor between two highly specialized professional groups. Neuroscientists focus abstractly on nosology whereas general practitioners tend to patient care following a hermeneutic approach integrating the patients' perspective of illness. These different approaches to dementia create a barrier to constructive dialogue and the capacity of these groups to do research together with a common aim. Additionally, the broader system of research funding and health care within which the two groups operate reinforces their divide thereby limiting joint research capacity. CONCLUSIONS: Overcoming barriers to research collaboration between general practitioners and neuroscientists requires a shift in perspective in which both groups actively engage with the other's viewpoints to facilitate knowledge circulation (KC). Bringing 'art into science and science into art', i.e. amalgamating the hermeneutic approach with the perspective of nosology, is the first step in developing joint research agendas that have the potential to close the evidence-to-practice gap.

How do specialist surgeons treat the atrophic tooth gap? A vignette-based study among maxillofacial and oral surgeons.

BACKGROUND: There is little information available regarding the decision-making process of clinicians, especially in the choice of therapy for a severely atrophic tooth gap. The aim of this research was to use case vignettes to determine the influence of possible factors on the decision making of maxillofacial and oral surgeons. METHODS: A total of 250 maxillofacial (MFS) and oral (OS) surgeons in southern Germany were surveyed for atrophic single- or multiple-tooth gap with the help of case vignettes. The influence of different determinants on the therapy decision was investigated. Two case vignettes were designed for this purpose: vignette 1 with determinants "patient age" and "endocarditis prophylaxis" and vignette 2 with determinants "anxiety" and "bisphosphonate therapy". Furthermore, the specialist designation was assessed for both. The options available to achieve a sufficient implant site were "bone split", "bone block", "augmentation with bone substitute material" and "bone resection". Therapy was either recommended or rejected based on principle. RESULTS: A total of 117 participants returned the questionnaire: 68 (58%) were OS and 49 (42%) MFS. "Patient age" and "patient anxiety" were not significantly associated with any therapy decision. However, required "endocarditis prophylaxis" led to significantly higher refusal rates for "bone split", "bone block" and "bone replacement material" and to higher rates of general refusal of a therapy. "Bisphosphonate therapy" was significantly associated with general refusal of therapy, but with no significant correlation with different therapy options. In vignette 1, OS refused therapy significantly more often than MFS, though there was no association with the specialist designation for other therapy modalities. In vignette 2, specialty was not significantly associated with the therapy decision. CONCLUSION: "Patient age" as well as "patient anxiety" appear to have no or little influence on the treatment decision for severely atrophic single- or multiple-tooth gap by specialist surgeons. Surgeons more often refuse treatment for patients with endocarditis prophylaxis and bisphosphonate therapy.

[Manfred Pflanz (1923-1980), Health Services Researcher: his Early Contribution to the Medical Care Pattern of Appendectomy]. / Manfred Pflanz (1923­1980), Versorgungsforscher ­ sein früher Beitrag zur Versorgungsepidemiologie der Appendektomie.

This article is a reminder of an early example of health services research and quality assurance in Germany. The occasion for this was the 50th anniversary of the opening of the Institute of Social Medicine and Epidemiology at Hannover Medical School in 1968. The founding director of the institute, Prof. Dr. med. Manfred Pflanz, a board-certified internist, had gained reputation by publishing on psychosomatic and medico-social issues. In 1971, Sigrid Lichtner, a doctoral student, and Pflanz published a paper on the epidemiology and medical care pattern of appendectomy [1]. In the late 1960s certified appendicitis mortality in the Federal Republic of Germany used to be 3 times higher than in comparable countries. A regional analysis of all appendectomies in Hannover discovered further "odd" findings such as a weekly profile of operations not in line with an acute emergency condition and clear social as well as regional differences in the appendectomy rate. The most probable reason why the mortality from appendicitis was 3 times higher in the Federal Republic than in any other country, the authors conjectured, was that appendectomy was performed 3 times more frequently than elsewhere - questioning the doctrine of early surgical intervention in suspected appendicitis. Since then, management of appendicitis has changed, quality assurance has been implemented, evidence broadened, laparoscopic and non-operative treatment evaluated in RCTs. Appendicitis mortality has continued to decline with an acceleration of the falling trend in the early 1970s. Absolute numbers of deaths are now very low. Numbers of appendectomies are declining. In this respect, health services have become more effective and efficient.

Pre-implantological treatment routines for alveolar ridge atrophy - an investigation among maxillofacial and oral surgeons in southern Germany.

BACKGROUND: It is not well-known which pre-implantological procedures are preferred by maxillofacial (MFS) and oral surgeons (OS) for the narrow atrophic alveolar ridge under practice based conditions and, if different training paths in surgery lead to other pre-implantological techniques being preferred. This study aims to identify which procedures are preferred by the respective specialists in which indication. METHODS: A questionnaire was sent to a total of 300 MFS and OS in southern Germany. The questionnaire examined pre-implantological procedures (bone block, bone grafting material and/or particulate autogenous bone, titanium mesh, bone split, resection) in the edentulous severely atrophic mandible and in the severely atrophic single-tooth gap. Kendall's Tau-b test was used for statistical analyses. RESULTS: One hundred seventeen participants returned the questionnaire. 68 (58%) were OS and 49 (42%) were MFS. In the edentulous mandible, bone substitute material and resection were most preferred by both specialists. Bone blocks were statistically significantly more frequently associated with MFS and bone substitute materials with OS. Bone split was more frequently used in the atrophic single tooth gap than in the edentulous mandible. OS preferred bone blocks in the single tooth gap more often than in the edentulous mandible. MFS and OS preferred resection in the edentulous mandible significantly more frequently than in the single tooth gap. CONCLUSIONS: MFS in general prefer more invasive pre-implantological therapies with the same initial diagnosis than OS, which seems to be attributed to different training paths.

[Treatment, clinical course, and cross-sectoral information transmission in patients with acute-on-chronic kidney injury]. / Behandlung, klinischer Verlauf und sektorenübergreifende Informationsübermittlung bei Patienten mit akut-auf-chronischer Nierenschädigung.

BACKGROUND: Delayed diagnosis and undertherapy of acute-on-chronic kidney injury (AKI-on-CKD) may trigger multiple organ injury and worsen clinical outcome. OBJECTIVES: This study focused on description of in-hospital care and cross-sectoral information transmission of patients with AKI-on-CKD including subgroup analyses (under surgical vs. non-surgical and nephrology vs. non-nephrology care). MATERIALS AND METHODS: At a university clinic, we analysed clinical measures and documentation in patients with AKI-on-CKD. Cox regression was performed to identify independent risk factors for in-hospital-mortality and 180-day mortality. RESULTS: In 38 (25.3%) of 150 patients, progressing AKI-on-CKD was found. Nineteen patients (12.7%) received acute dialysis. Thirty patients (20.0%) died in hospital. Systemic hypotension (n = 76, 50.7%) and nephrotoxins (n = 26, 17.3%), both considered as causes for AKI-on-CKD, were treated in 36.8 and 19.2%, respectively, of affected patients. Fluid balance was documented in one third of patients. Nephrology referral was requested in 38 (25.3%) of patients (median 24.0 h after AKI-on-CKD start). Acute renal complications (n = 74, 49.3%) were an independent risk factor for in-hospital mortality (ExpB 6.5, p = 0.022) or 180-day mortality (ExpB 3.3, p = 0.034). Rarely, outpatient physicians were informed about AKI-on-CKD (n = 42, 28.0%) or renal function follow-up was recommended (n = 14, 11.7% of surviving patients). CONCLUSIONS: Care gaps in therapy and cross-sectoral information transmission in patients with AKI-on-CKD were identified.

[Award of the Salomon-Neumann-Medal 2017 - Speech of the Laureate Prof. Bernt-Peter Robra, 5 September 2017, St. Peter´s Church Lübeck]. / Verleihung der Salomon-Neumann-Medaille 2017 ­ Rede des Preisträgers Prof. Bernt-Peter Robra am 5. September 2017 in der St.-Petri-Kirche zu Lübeck.

The Salomon-Neumann-Medal 2017 of the German Society for Social Medicine and Prevention (DGSMP) was awarded to Bernt-Peter Robra, Institute for Social Medicine and Health Economics (ISMG) of the Otto von Guericke University Magdeburg. The person and scientific merits of Manfred Pflanz are valued and topics of the masterplan2020-process are highlighted, that offer chances for developments in medicine and public health.

[Responsibilities and concepts for undergraduate and postgraduate medical education in Germany : A plea for a reorientation]. / Zuständigkeiten und Konzepte zur ärztlichen Ausbildung und Weiterbildung : Ein Plädoyer für eine Neuorientierung.

BACKGROUND: Undergraduate medical education in Germany takes place in the medical faculties of universities, whereas postgraduate medical education takes place in nearly all hospitals under the aegis of medical associations. Both phases of the medical qualification process live on their own; the communication between the two responsible bodies is negligible. Previous reforms have always tackled undergraduate education only, whereas postgraduate education takes place without public attention. OBJECTIVE: This position paper discusses the origins and consequences of the complete separation between undergraduate and postgraduate medical education in Germany with regard to responsible bodies, learning objectives, and didactical concepts. On the basis of this critical analysis, proposals are presented to narrow the gap between the two phases. MATERIALS AND METHODS: This paper is based on several sources: data from historical documents, information retrieved from the internet on educational concepts in other OECD countries as well as intensive discussions among the authors. RESULTS AND DISCUSSION: The dissociation between under- and postgraduate education has historical reasons. Over a longer period of time the German Federal States reduced their responsibility for postgraduate education in favor of medical associations. The authors propose steps towards a better integration of both sequences, towards seeing the educational process as a continuum. In such a concept, medical associations would have a greater influence on undergraduate education and - vice versa - medical faculties on the postgraduate phase.

[Prospects of the German Academic Health Science and Health Care System]. / Perspektiven der Universitätsmedizin.

The German Council of Science and Humanities (Wissenschaftsrat) wants to strengthen the university health system at the interface of the science and the health care systems. Its recent future-proofing recommendations are 2-fold: a) integrated academic structures, called "profile centers", designed to support joint clinical and research opportunities as well as to offer sustainable career tracks to junior scientists (clinician as well as medical scientists) and b) better financing and negotiating power of university health centers and their respective outpatient departments as agents of innovation and providers in the health care system [1].

[How do asylum seekers experience access to medical care?] / Wie erleben Asylsuchende den Zugang zu medizinischer Versorgung?

BACKGROUND: In Germany basic medical care for asylum seekers is organized outside the statutory health insurance system. Currently there are few empirically based statements on how asylum seekers experience their access to healthcare. The aim is therefore to evaluate their experiences with healthcare focussing on subjective health, utilisation and access to medical care, and experiences with medical care. METHODS: Between August and November 2015, we performed 16 qualitative problem-oriented guided interviews with asylum seekers, who received or sought medical care in Saxony-Anhalt. The interpreter-assisted interviews were evaluated with content analysis. RESULTS: Access begins with a voucher for medical treatment issued by the social security office. Asylum seekers experience that procedure as onerous and incapacitating. These experiences influence subjective health and utilisation of medical help. If their efforts for treatment certificates are rejected, people increasingly resign. If medical treatment is achieved, they experience medical staff mostly as competent and friendly, in spite of language difficulties and time pressure. CONCLUSIONS: Reducing the "voucher bureaucracy" by uniform rules and practices may bring about a relief to access and utilisation of healthcare. Introducing an electronic health insurance card for asylum seekers would retransfer decision making about treatment needs from the welfare system into the medical system.

The regional myocardial infarction registry of Saxony-Anhalt (RHESA) in Germany - rational and study protocol.

BACKGROUND: In 2012 the age-standardized acute myocardial infarction (AMI) mortality rate was in the federal state Saxony-Anhalt 67 deaths per 100.000 whereas in Germany the AMI-rate was 47 deaths per 100.000. The rate in Saxony-Anhalt was therefore 43 % above the national average. Many factors may explain this above-average AMI mortality rate: First, the prevalence of cardiovascular risk factors (e.g. arterial hypertension, diabetes mellitus, smoking) in Saxony-Anhalt is the highest among all the Federal States of Germany. Second, structural health care for patients with AMI is potentially deficient (e.g. insufficient number of percutaneous coronary intervention-centers or deficits in the pre-hospital logistics of care). Third, the pre- and in-hospital process quality of health care for patients with AMI is possibly insufficient (e.g. time to reperfusion therapy). In July 2013 we established the regional myocardial infarction registry of Saxony-Anhalt (Regionales Herzinfarktregister in Sachsen-Anhalt, RHESA). RHESA is a population-based registry in the eastern part of Germany. Aims of RHESA are to calculate the AMI morbidity and mortality rates. Furthermore we study the factors that may potentially influence these rates in Saxony-Anhalt. METHODS: RHESA is a population-based registry of patients with fatal or non-fatal AMI that was established in July 2013. The registry population comprises inhabitants aged 25 years or more of the city of Halle (Saale) (n = 179.000) and inhabitants of the rural district Altmark (n = 165.000) in the federal state Saxony-Anhalt, Germany. DISCUSSION: The main objectives of RHESA are to provide detailed estimates of the burden of AMI in Saxony-Anhalt which is the federal state with the highest AMI mortality rate in Germany and to investigate factors that influence morbidity and mortality rates due to AMI. Data collected in RHESA enable us to assess different levels of quality of health care of patients with AMI (structural, process and outcome). RHESA provides for the first time estimates of the burden of AMI in Saxony-Anhalt, and therefore contributes considerably to an improvement of the German Health Monitoring that strives for a more valid extrapolation of the nationwide morbidity and mortality rates of AMI.

Case vignettes based on EQ-5D to elicit stated preferences for health services utilization from the insurees' perspective.

BACKGROUND: There is little evidence as to why or why not insurees decide to seek medical services. Steps prior to the entry of the insuree into the professional health care system have not been sufficiently examined and can only be partially described by secondary data of the statutory health insurance (SHI). We report the first investigation using case vignettes based on the generic health-related quality of life questionnaire EQ-5D as part of a choice study to assess insurees' stated preferences in health services utilization. METHODS: We invited 1500 randomly selected citizens (age 30 to 70 years) from the East German state of Saxony-Anhalt by postal mail to participate in the choice study. Attributes of the case vignettes involved in choice tasks were the five dimensions of the EQ-5D. We used multilevel mixed effects logit regression analysis with the dependent variables: preference to seek medical services (model 1) and preferred time until consultation (model 2) for the assessed case vignette. The EQ-5D attributes of the case vignettes and participant characteristics served as the independent variables. We also included the respondent's certainty of choosing from the choice set, and the order of questions of the questionnaire as control variables. RESULTS: Of the 1500 questionnaires 683 were evaluable (net response rate 48.0%). On the level of the case vignettes, problems in all five dimensions of the EQ-5D were statistically significant factors of the estimated likelihood to seek medical services (model 1). On the respondent level, there was a significant relationship between the preference for medical consultation for the assessed case vignette and the respondent's gender, age, educational level, the existence of a regular doctor, and the certainty of choosing from the choice set. Problems in four of the five dimensions of the EQ-5D (except anxiety/depression) of the case vignettes were significantly associated with the preferred time until consultation (model 2). On the respondent level, gender, educational level, the certainty of choosing from the choice set, and the order of questions of the questionnaire were significant determinants of the time until consultation. CONCLUSIONS: Our study offers a promising new approach for the national and cross-national study of preferences in health services utilization from the insurees' perspective.

"We never lived together either": Couples' housing (re-) arrangements in later life.

Social gerontology mainly addresses couples' housing arrangements in later life by focusing on partner's care, related adaptations in place, and changing role expectations within the couple relationship. Thereby, the resulting image does not fully represent today's diversity of couples' housing arrangements. This article considers housing arrangement and relationship orientation of older couples as entangled in social practice, providing a broader perspective on the diversity and dynamics of couples living arrangements in later life. In a qualitative study, we conducted joint in-depth interviews with ten couples from Germany aged 58 to 88 years. Couples talked about their shared biography and living together today. Data were merged with fieldnotes on housing constellations and analyzed following the documentary method. Couples co-constitute living together by using space in different ways. We found three relationship orientations of couples corresponding to practices of couples' housing arrangements: balancing physical and emotional presence by negotiating shared space, exploring presence by having a third common place, and reducing presence by separate housing. These orientation types which are linked with spatial (re-) arrangements reveal positioning to housing preferences in past relationships and point to societal concepts of coupledom as regards housing in later life. Space gives options for both being apart from and feeling close to the partner, partially at the same time. Diversity and dynamics of housing arrangements correspond to diversified and altering relationship orientations in later life. Considering couples' housing arrangements in later life as mutually constitutive broadens the options to examine the meaning of space in aging together. Moreover, this perspective can be combined with a critical approach towards stereotypical (hetero-) normative biases in research.

Attributes in stated preference elicitation studies on colorectal cancer screening and their relative importance for decision-making among screenees: a systematic review.

INTRODUCTION: The SIGMO study (Sigmoidoscopy as an evidence-based colorectal cancer screening test - a possible option?) examines screening eligible populations' preferences for colorectal cancer (CRC) screening in Germany using a discrete choice experiment (DCE). Attribute identification and selection are essential for the construction of choice tasks and should be evidence-based. As a part of the SIGMO study this systematic review provides an overview of attributes included in studies eliciting stated preferences for CRC screening tests and their relative importance for decision-making. METHODS: Systematic search (November 2021) for English-language studies published since January 2000 in PubMed, Embase, Web of Science, Biomedical Reference Collection: Corporate Edition, LIVIVO and PsycINFO. DCEs and conjoint analysis ranking or rating tasks on screening eligible populations' preferences for stool testing, sigmoidoscopy, and/or colonoscopy were included. Attributes were extracted and their relative importance was calculated and ranked. Risk of bias (RoB) of included studies was assessed using a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Study selection and RoB rating were carried out independently by two reviewers. Data were extracted by one reviewer and checked by another one. RESULTS: A total of 23 publications on 22 studies were included. Overall RoB was rated as serious/critical for 21 studies and as moderate for 2 studies. Main reasons for high RoB were non-random sampling, low response rates, lack of non-responder analyses, and, to a lesser extent, weaknesses in the measurement instrument and data analysis. Extracted attributes (n = 120) referred to procedure-related characteristics (n = 42; 35%), structural characteristics of health care (n = 24; 20%), test characteristics (n = 23; 19%), harms (n = 16; 13%), benefits (n = 13; 11%), and level of evidence (n = 2; 2%). Most important attributes were reduction in CRC mortality (and incidence) (n = 7), test sensitivity (n = 7), out-of-pocket costs (n = 4), procedure (n = 3), and frequency (n = 2). CONCLUSIONS: Health preference studies on CRC were found to have a high RoB. The composition of choice tasks revealed a lack of attributes on patient-important outcomes (like incidence reduction), while attributes not considered relevant for individual screening decisions (like sensitivity) were frequently used. Future studies eliciting stated preferences in cancer screening should apply the principles of informed decision-making in attribute identification and selection.

Feasibility assessment of patient-controlled EEG home-monitoring: More results from the HOMEONE study.

OBJECTIVE: The feasibility phase of the HOME (Home-Monitoing and Education) project aims to show the practical feasibility of Electroencephalography (EEG)home-monitoring using a patient-controlled mobile system. Its objective is to assess the potential diagnostic and therapeutic yields of home-monitoring compared to conventional healthcare. METHODS: 16 office-based practitioners chose 97 patients and recorded standard 20-minute EEGs using conventional recorders. After training, the same patients used a patient-controlled mobile dry electrode EEG system in their home environment. The practitioners in charge and two additional raters assessed all recordings. We conducted inter-rater and intra-rater comparisons between the diagnostic findings. RESULTS: 89 patients successfully conducted home-monitoring recordings. The intra-rater comparison results for the diagnostic findings of the conventional recordings and the patient-made recordings show a fair Cohen's kappa value (0.21). Additionally, we documented a change of patient management in 9 cases. CONCLUSIONS: The feasibility of EEG home-monitoring using a patient-controlled device is confirmed. The yield of EEG home-monitoring comprises information that can influence patient management. SIGNIFICANCE: Patient-controlled EEG home-monitoring is feasible as part of routine care for neurological outpatients as its technical efficacy and practical feasibility are shown and significantly positive effects on patient management are evidenced.

General populations' preferences for colorectal cancer screening: rationale and protocol for the discrete choice experiment in the SIGMO study.

INTRODUCTION: In Germany, the organised colorectal cancer (CRC) screening programme includes the immunologic faecal occult blood test and colonoscopy. The sigmoidoscopy is recommended for individuals rejecting colonoscopy but is not included into the screening programme. To examine whether the evidence based sigmoidoscopy should be additionally offered, the first objective of this study is to evaluate the demand for sigmoidoscopy by analysing the German general populations' preferences for CRC screening. METHODS AND ANALYSIS: Preference data will be collected using a discrete choice experiment (DCE). Identification and selection of the attributes and their levels will be supported by evidence resulting from a systematic literature search and focus groups. An efficient, fractional factorial choice design will be generated. In a cross-sectional study, the DCE will be administered as a written questionnaire to a random sample of 4000 members of the statutory health insurance company in Lower Saxony (AOK Lower Saxony). Insured persons 50-60 years of age without CRC or a chronic inflammatory bowel disease will be eligible. The collected choice data will be analysed by conducting a conditional logit regression model and latent class models. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the Ethics Committee of Hannover Medical School (reference number 8671_BO_K_2019). The study results will be disseminated via conference presentations, publications in peer-reviewed journals and, to participants, the membership magazine of the AOK Lower Saxony. TRIAL REGISTRATION NUMBER: DRKS00019010.