Parents' and neonatal healthcare professionals' views on barriers and facilitators to parental presence in the neonatal unit: a qualitative study.

BACKGROUND: Parent and infant separation in the neonatal unit is associated with adverse health outcomes. Family-integrated care has several advantages and the potential to reduce these adverse outcomes but requires parental presence. This study aimed to explore the views of parents and neonatal healthcare professionals (nHCPs) on barriers and facilitators to parental presence in a Swiss neonatal unit and to identify possible differences between nHCPs and parents, and between mothers and fathers. METHODS: Data were collected through semi-structured interviews with parents and focus group discussions with nHCPs. Inductive content analysis was used to identify barriers and facilitators to parental presence in the neonatal unit. RESULTS: Twenty parents (10 mothers and 10 fathers) and 21 nHCPs (10 nurses and 11 physicians) participated in the study. Parents and nHCPs experienced barriers and facilitators related to: (1) Structural factors of the institution, such as infrastructure or travel and distance to the neonatal unit. (2) Organization and time management of parental presence, daily activities, and work. (3) Resources, which include factors related to the legal situation, support services, family, and friends. (4) Physical and psychological aspects, such as pain, which mainly affected mothers, and aspects of emotional distress, which affected both parents. Self-care was an important physical and psychological facilitator. (5) Parent-professional interaction. Parental presence was influenced by communication, relationship, and interaction in infant care; and (6) Cultural aspects and language. Some perspectives differed between mothers and fathers, while the overall views of parents and nHCPs provided complementary rather than conflicting insights. Using visit plans to support the organization, educating nHCPs in knowledge skills and available resources to improve encouragement and information to parents, strengthening parent self-care, and improving nHCPs' attitudes towards parental presence were seen as possible improvements. CONCLUSIONS: Multifactorial barriers and facilitators determine parental presence and experience in the neonatal unit. Parents and nHCPs made specific recommendations to improve parental presence.

Attitudes and values towards decisions at the margin of viability among expectant mothers at risk for preterm birth.

AIM: To explore how expectant mothers at risk for preterm birth would like to be involved in decision-making at the margin of viability and what they would base their decisions on. METHODS: This cross-sectional observational study included a mixed-methods post-hoc analysis alongside a previously reported randomised clinical trial. Expectant mothers between 280/7 and 366/7 weeks' gestation who were hospitalised for risk of preterm birth responded to written case vignettes of an impending preterm birth at the margin of viability. Participants responded to closed and open-ended questions that were theoretically coded for attitudes and values towards shared decision-making. RESULTS: Sixty-four expectant mothers were included in the analysis, 36 provided written perspectives. Decision-making was perceived as an enormous burden and a potential source of guilt and regret. Weighing personal values in terms of 'fighting for the baby' and 'quality of life' were used to inform the decision-making process. Explicitly stating that any decision is a good decision, empowerment through co-constructing shared decisions rather than simply presenting choices, sharing the clinicians' personal views, and honest, and empathetic counselling were perceived as supportive. CONCLUSION: Mothers at risk for preterm birth provided specific insights into their decision-making patterns that may be helpful to clinicians.

Influence of Cooperation Work on Management Continuity of Ambulatory Cardiovascular Care: A Cross-Sectional Exploratory Study in Germany.

Introduction: A wide range of factors influence coordination and continuity of care. The aim of this study was to explore how management continuity of cardiovascular-related ambulatory care is influenced by the following network characteristics: presence of a case coordinator, network reciprocity, network composition and team climate. Methods: This cross-sectional observational study included three written surveys. The primary outcome management continuity of cardiovascular care was measured with the team/cross-boundary scale in the Nijmegen Continuity Questionnaire. The final analysis comprised a multivariate linear multilevel model with the predictors: presence of a case coordinator, network reciprocity, network composition and team climate. Results: Eighteen general practices with 83 health workers and 340 patients participated. The linear multilevel regression analysis showed a positive influence of team climate on cross-boundary continuity of care (b-coefficient 0.44, 95% confidence interval 0.09-0.78, p = 0.02). No statistically significant influence was measured for the other predictors. Discussion: To improve integrated care, therefore, emphasis should also be placed on promoting the team climate within individual practices. Regarding network characteristics, further research is needed, especially in larger practices. Conclusion: This study showed that team climate had an independent, relevant and statistically significant association with cross-boundary continuity of cardiovascular ambulatory care.

Development of individual competencies and team performance in interprofessional ward rounds: results of a study with multimodal observations at the Heidelberg Interprofessional Training Ward.

Introduction: Interprofessional training wards (IPTW) aim to improve undergraduates' interprofessional collaborative practice of care. Little is known about the effects of the different team tasks on IPTW as measured by external assessment. In Heidelberg, Germany, four nursing and four medical undergraduates (= one cohort) care for up to six patients undergoing general surgery during a four-week placement. They learn both professionally and interprofessionally, working largely on their own responsibility under the supervision of the medical and nursing learning facilitators. Interprofessional ward rounds are a central component of developing individual competencies and team performance. The aim of this study was to evaluate individual competencies and team performance shown in ward rounds. Methods: Observations took place in four cohorts of four nursing and four medical undergraduates each. Undergraduates in one cohort were divided into two teams, which rotated in morning and afternoon shifts. Team 1 was on morning shift during the first (t0) and third (t1) weeks of the IPTW placement, and Team 2 was on morning shift during the second (t0) and fourth (t1) weeks. Within each team, a tandem of one nursing and one medical undergraduate cared for a patient room with three patients. Ward round observations took place with each team and tandem at t0 and t1 using the IP-VITA instrument for individual competencies (16 items) and team performance (11 items). Four hypotheses were formulated for statistical testing with linear mixed models and correlations. Results: A total of 16 nursing and medical undergraduates each were included. There were significant changes in mean values between t0 and t1 in individual competencies (Hypothesis 1). They were statistically significant for all three sum scores: "Roles and Responsibilities", Patient-Centeredness", and "Leadership". In terms of team performance (Hypothesis 2), there was a statistically significant change in mean values in the sum score "Roles and Responsibilities" and positive trends in the sum scores "Patient-Centeredness" and "Decision-Making/Collaborative Clinical Reasoning". Analysis of differences in the development of individual competencies in the groups of nursing and medical undergraduates (Hypothesis 3) showed more significant differences in the mean values of the two groups in t0 than in t1. There were significant correlations between individual competencies and team performance at both t0 and t1 (Hypothesis 4). Discussion: The study has limitations due to the small sample and some sources of bias related to the external assessment by means of observation. Nevertheless, this study offers insights into interprofessional tasks on the IPTW from an external assessment. Results from quantitative and qualitative analysis of learners self-assessment are confirmed in terms of roles and responsibilities and patient-centeredness. It has been observed that medical undergraduates acquired and applied skills in collaborative clinic reasoning and decision-making, whereas nursing undergraduates acquired leadership skills. Within the study sample, only a small group of tandems remained constant over time. In team performance, the group of constant tandems tended to perform better than the group of random tandems. The aim of IPTW should be to prepare healthcare team members for the challenge of changing teams. Therefore, implications for IPTW implementation could be to develop learning support approaches that allow medical and nursing undergraduates to bring interprofessional competencies to team performance, independent of the tandem partner or team.

[Measuring individual competencies and team performance in clinical learning settings of interprofessional collaborative practice: Empirical development of the Interprofessional Ward Round Individual and Team Assessment Tool (IP-VITA)]. / Individuelle Kompetenzen und Team-Performance in klinischen Lernsettings der interprofessionellen Zusammenarbeit erfassen: Die empirische Entwicklung des Interprofessionelle Visiten Individual und Team Assessment Tools (IP-VITA).

BACKGROUND: Interprofessional training wards (IPTW) can contribute to the development of interprofessional competencies. In order to evaluate the acquisition of competencies, instruments are needed that record both team performance and individual competencies in the clinical teaching setting in third-party assessment. This paper describes the Interprofessional Ward Round Individual and Team Assessment-Tool, IP-VITA ("Interprofessionelle Visiten Individual und Team Assessment Tool") and its development. METHOD: Based on the empirical exploration of the three observation instruments "Teamwork Assessment Scale" (TAS), "McMaster-Ottawa Scale" and "Individual Teamwork Observation and Feedback Tool" (iTOFT) in at least four rounds each at the HIPSTA (with n=8 students and trainees each), a preliminary version of the IP-VITA was created. This preliminary version was then refined in subsequent empirical steps: a consensual validation in the research team was followed by a "member check" with the clinical colleagues of the HIPSTA, the input from external experts and an empirical test in an alternative setting. RESULTS: The IP-VITA is an empirically developed multimodal instrument to assess the interprofessional competencies of trainees and students as well as their team performance in clinical settings with patient interaction. It comprises three parts. In part A, structural data, the persons involved and the essential patient characteristics are recorded. Part B consists of 12 items and a free-text field for recording behaviour at the individual level. Part C also consists of 12 items and evaluates behaviour at team level. DISCUSSION: The IP-VITA instrument was developed specifically for the context of evaluating interprofessional ward rounds in a clinical educational setting. The instrument takes into account the ambiguous position of the assessment of interprofessional collaboration between individual competence and team performance. Beyond the HIPSTA, it can be used as a formative assessment instrument, and it may also be useful for summative assessments.

Keeping up with evidence-based recommendations - a qualitative interview study with general practitioners in Germany on information-seeking behaviour in cardiovascular care.

BACKGROUND: Due to the nature of their work, general practitioners (GPs) need to be up to date with evidence in various medical domains. While much synthesised research evidence is easily accessible nowadays, in practice, the time to search for and review this evidence proposes a challenge. In German primary care, the knowledge infrastructure is rather fragmented, leaving GPs with relatively few primary care specific resources of information and many resources from other medical fields. This study aimed to explore GPs information-seeking behaviour regarding evidence-based recommendations in cardiovascular care in Germany. METHODS: To explore views of GPs a qualitative research design was chosen. Data was collected through semi-structured interviews. In total, 27 telephone interviews with GPs were conducted between June and November 2021.Verbatim transcript interviews were then analysed using thematic analysis, deriving at themes inductively. RESULTS: Two broad strategies of information-seeking behaviour in GP could be distinguished: (a) generic information-seeking behaviour and (b) casuistic information-seeking. The first referring to strategies GPs apply to keep up with medical developments such as new medication and the second referring to purposeful information exchange regarding individual patients, such as referral letters. The second strategy was also used to keep up with medical developments in general. CONCLUSION: In a fragmented information landscape, GPs used information exchange on individual patients to remain informed about medical developments in general. Initiatives to implement recommended practices need to take this into account, either by using these sources of influence or by making GPs aware of possible bias and risks. The findings also emphasize the importance of systematic evidence-based sources of information for GPs. TRAIL REGISTRATION: We registered the study prospectively on 07/11/2019 at the German Clinical Trials Register (DRKS, www.drks.de ) under ID no. DRKS00019219.

The Influence of Provider Connectedness on Continuity of Care and Hospital Readmissions in Patients With COPD: A Claims Data Based Social Network Study.

Background: Hospital readmission rates are very high in patients with chronic obstructive pulmonary disease (COPD). Continuity of care (CoC) with general practitioners (GPs) and ambulatory specialists can impact readmission rates. This study aimed to identify shared patient networks of ambulatory care physicians and to examine the effect of provider connectedness on CoC and hospital readmissions. Methods: A retrospective observational study was conducted in claims data from the years 2016 to 2018 in patients with COPD (aged 40 years or older; hospital stay in 2017). Linkages between GPs, pneumologists, and cardiologists were determined on the basis of shared patients. Multilevel regression models were used to analyze the impact of provider connectedness, operationalized by several social network characteristics, on continuity of care (sequential continuity [SECON] index) and hospital readmission rates. Results: A total of 7294 patients linked to 3673 GPs were available for analysis. Closeness centrality (ß=- 0.029) and the external-internal (EI)-index (ß =0.037) impacted on the SECON index. The EI-index (odds ratio [OR]=1.25) and degree centrality (OR=1.257) impacted 30-day readmission. Network density (OR=0.811) and the SECON index (OR=1.121) affected the likelihood of a 90-day readmission. None of the predictors had a significant impact on 180-day and 365-day readmissions. Conclusions: Ambulatory care providers' connectedness showed some effects on hospital readmissions and CoC in patients with COPD up to 90 days after hospital discharge, but the additional predictive power is limited.

Parental perceptions of informed consent in a study of tracheal intubations in neonatal intensive care.

Background and objective: Obtaining informed consent in neonatal emergency research is challenging. The aim of this study was to assess parental perceptions of informed consent following participation in a clinical trial in neonatal emergency care. Methods: This was a supplementary analysis of a randomised controlled trial comparing video and direct laryngoscopy for neonatal endotracheal intubation in the delivery room and neonatal intensive care unit. After obtaining informed consent for the clinical trial, parents were asked to answer a series of self-administered questions about their perceptions of clinical trial participation and the consent process. Informed consent had been given either before birth, after birth but before inclusion in the trial, or after inclusion in the trial. Results: We received responses from 33 mothers and 27 fathers (n = 60) of the 63 preterm and term infants who participated in the study. Fifty-three (89.8%, n = 59) parents agreed that infants should participate in clinical trials, and 51 (85%, n = 60) parents agreed that parents should be asked for informed consent. Fifty-three (89.8%, n = 59) parents felt that their infant's participation in this particular trial would be beneficial. Fifty-two (86.7%, n = 60) parents felt that the informed consent process was satisfactory. One parent (100%, n = 1) approached before birth, 23 parents (82.1%, n = 28) approached after birth but before enrolment and 26 (83.9%, n = 31) parents approached after enrolment were satisfied with the timing of the consent process. Eight (13.3%, n = 60) parents felt some pressure to provide informed consent. Of these, two (25%) were approached before enrolment and six (75%) were approached after enrolment. Conclusion: Parents valued their infant's participation in an emergency neonatal clinical trial and considered it important to be asked for consent. In this study, it seemed less important whether consent was obtained before or after the intervention. Future studies may need to investigate which form of consent is most acceptable to parents for the individual study in question.

Nurses' competence in recognition and management of delirium in older patients: development and piloting of a self-assessment tool.

BACKGROUND: Delirium is a common condition in elderly inpatients. Health care professionals play a crucial role in recognizing delirium, initiating preventive measures and implementing a multicomponent treatment strategy. Yet, delirium often goes unrecognized in clinical routine. Nurses take an important role in preventing and managing delirium. This study assesses clinical reasoning of nurses using case vignettes to explore their competences in recognizing, preventing and managing delirium. METHODS: The study was conducted as an online survey. The questionnaire was based on five case vignettes presenting cases of acutely ill older patients with different subtypes of delirium or diseases with overlapping symptoms. In a first step, case vignettes were developed and validated through a multidisciplinary expert panel. Scoring of response options were summed up to a Geriatric Delirium Competence Questionnaire (GDCQ) score including recognition and management tasks The questionnaire was made available online. Descriptive analyses and group comparisons explores differences between nurses from different settings. Factors explaining variance in participants' score were evaluated using correlations and linear regression models. RESULTS: The questionnaire demonstrated good content validity and high reliability (kappa = 0.79). The final sample consisted of 115 nurses. Five hundred seventy-five case vignettes with an accuracy of 0.71 for the correct recognition of delirium presence or absence were solved. Nurses recognized delirium best in cases describing hyperactive delirium (79%) while hypoactive delirium was recognized least (44%). Nurses from geriatric and internal medicine departments had significantly higher GDCQ-score than the other subgroups. Management tasks were correctly identified by most participants. CONCLUSIONS: Overall, nurses' competence regarding hypoactive delirium should be strengthened. The online questionnaire might facilitate targeting training opportunities to nurses' competence.

Opinion seeking behaviour of healthcare providers in ambulatory cardiovascular care in Germany: a cross-sectional study.

BACKGROUND: Healthcare providers' inclination to seek or lead other providers' opinions on clinical topics may influence healthcare practices, particularly regarding their alignment across different providers in controversial domains. This study aimed to explore opinion-seeking behaviours of general practitioners and their impacts on clinical opinions in ambulatory cardiovascular care in Germany. METHODS: Between 2019 and 2021, we performed a written survey in two samples of general practitioners and one sample of self-employed cardiologists in three German states. The general practitioners were asked to identify a person they deemed influential on their views on cardiovascular conditions. Their self-perceived opinion leadership and opinion seeking behaviours were then measured, using a validated 12-item-questionnaire. General practitioners and cardiologists were requested to indicate their agreement with three potentially controversial aspects of cardiovascular ambulatory care. Potential impacts on the general practitioners' views, including local cardiologists' opinions, were examined using multi-level linear regression models. RESULTS: A total of 129 general practitioners and 113 cardiologists returned the questionnaire. 68.50% of general practitioners named an opinion leader, mainly cardiologists outside of their practice. General practitioners perceived themselves as opinion seeking and as opinion leading at the same time. Views on the presented controversial topics were mixed among both general practitioners and cardiologists. Self-reported opinion leadership behaviour of general practitioners was associated with their views on one of the three topics. No such associations were found for opinion seeking behaviours and the views of local cardiologists. CONCLUSION: While most general practitioners named a cardiovascular opinion leader and saw themselves as opinion seeking regarding cardiovascular issues, they simultaneously perceived themselves as opinion leading, suggesting that opinion leadership and opinion seeking are not mutually exclusive concepts. The views of local cardiologists were not associated with the general practitioners' view, suggesting that local medical specialists do not necessarily influence the surrounding opinion seekers' views per se. 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.

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.

Patient-reported continuity of care and the association with patient experience of cardiovascular prevention: an observational study in Germany.

BACKGROUND: Cardiovascular diseases are often accompanied by comorbidities, which require good coordination of care. Especially in fragmented healthcare systems, it is important to apply strategies such as case management to achieve high continuity of care. The aim of this study was to document continuity of care from the patients' perspective in ambulatory cardiovascular care in Germany and to explore the associations with patient-reported experience of cardiovascular prevention. METHODS: This cross-sectional observational study was performed in primary care practices in Germany. The study included patients with three recorded chronic diseases, including coronary heart disease. Continuity of care was measured with the Nijmegen Continuity Questionnaire, which addresses personal/relational and team/cross-boundary continuity. From aspects of medical care and health-related lifestyle counselling a patient-reported experience of cardiovascular prevention index was formed with a range of 0-7. The association between continuity of care within the family practice and patient-reported experience of cardiovascular prevention was examined, using a linear multilevel regression model that adjusted for sociodemographics, structured care programme and numbers of contacts with the family practice. RESULTS: Four hundred thirty-five patients from 26 family practices participated. In a comparison between general practitioners (GPs) and cardiologists, higher values for relational continuity of care were given for GPs. Team/cross-boundary continuity for 'within the family practice' had a mean of 4.0 (standard deviation 0.7) and continuity between GPs and cardiologists a mean of 3.8 (standard deviation 0.7). Higher personal continuity of care for GPs was positively associated with patient-reported experience (b = 0.75, 95% CI 0.45-1.05, P < 0.001). CONCLUSIONS: Overall, there was high patient-reported continuity, which positively influenced the experience of cardiovascular prevention. Nevertheless, there is potential for improvement of personal continuity of the cardiologists and team/cross-boundary continuity between GPs and cardiologists. Structured care programs may be able to support this. TRIAL REGISTRATION: We registered the study prospectively on 7 November 2019 at the German Clinical Trials Register (DRKS) under ID no. DRKS00019219 .

Contextual factors influencing physicians' perception of antibiotic prescribing in primary care in Germany - a prospective observational study.

BACKGROUND: Antimicrobial resistance is a worldwide challenge for health services and systems alike. To reduce the overuse of antibiotics, multifaceted interventions are often used to achieve sustainable effects. It can be assumed that these effects are influenced by contextual factors. Embedded in the cluster randomized trial ARena (Sustainable reduction of antibiotic-induced antimicrobial resistance), the aim of this present study was to identify contextual factors associated with practitioners' perceptions of antibiotic prescribing in German primary health care. METHODS: In a prospective observational study, data were generated in a three-wave survey study between January 2018 and July 2019. Analysis was performed using logistic regression models. The outcome of interest was the physician perceived impact of participating in the ARena project on decision-making regarding antibiotic prescribing, the independent variables of interest included individual characteristics, intervention arm allocation, primary care network (PCN) environment and characteristics of the medical practice. RESULTS: Forty Six point eight percent (n = 126) of participants indicated to have perceived an impact on their decision-making regarding antibiotic prescribing by participating in the ARena project. Bivariate logistic regression analyses indicated that work experience (odds ratio (OR) 1.05, 95% confidence interval (CI) 1.006-1.103), PCN environment (OR 2.06, 95% CI 1.256-3.363), structural conditions (OR 1.66, 95% CI 1.161-2.371), environment of existing processes (OR 1.46, 95% CI 1.011-2.094), and externally defined general conditions (OR 1.57, 95% CI 1.035-2.378) were associated with physicians' perceived impact of participating in the ARena project on decision-making regarding antibiotic prescribing. In the multivariable logistic regression analysis, only work experience OR 1.05 (95% CI 1.001-1.104) continuously showed a significant influence. CONCLUSIONS: This study indicates that contextual factors at individual, practice, and system level influence physicians' perceptions of antibiotic prescribing. Longer work experience appeared to be a significant influencing factor to be considered in antimicrobial stewardship programs. TRIAL REGISTRATION: ISRCTN, ISRCTN58150046 (registered 13.09.2017).

Information exchange networks for chronic diseases in primary care practices in Germany: a cross-sectional study.

BACKGROUND: Coordination of care requires information exchange between health workers. The structure of their information exchange networks may influence the quality and efficiency of healthcare delivery. The aim of this study was to explore and classify information exchange networks in primary care for patients with chronic diseases in Germany. METHODS: A cross-sectional study was carried out between 2019 and 2021. As part of a larger project on coordination of care, this study focused on information exchange in practice teams regarding patients with type 2 diabetes (DM), coronary heart disease (CHD) and chronic heart failure (CHF). Social network analysis was applied to determine the number of connections, density and centralization for each of the health conditions for each of the practices. On the basis of the descriptive findings, we developed typologies of information exchange networks in primary care practices. RESULTS: We included 153 health workers from 40 practices, of which 25 practices were included in the social network analysis. Four types of information exchange structures were identified for the three chronic diseases: highly connected networks with low hierarchy, medium connected networks with medium hierarchy, medium connected networks with low hierarchy and lowly connected networks. Highly connected networks with low hierarchy were identified most frequently (18 networks for DM, 17 for CHD and 14 for CHF). Of the three chronic conditions, information sharing about patients with DM involved the most team members. Information exchange outside the family practice took place mainly with nurses and pharmacists. CONCLUSIONS: This study identified four types of information exchange structures, which provides a practical tool for management and improvement in primary care. Some practices had few information transfer connections and could hardly be considered a network. 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.

Analysis of the Localization of NLRs upon Shigella flexneri Infection Exemplified by NOD1.

NOD-like receptors (NLRs) are a family of pattern recognition receptors, able to respond to conserved microbial structures and endogenous danger signals. The NLR NOD1 responds to bacterial peptidoglycan, leading to recruitment of RIPK2, following activation of NFκB and MAPK pathways. In this chapter, we describe a fluorescent light microscopic approach to analyze the subcellular distribution of NOD1 upon infection with the invasive, Gram-negative bacterial pathogen Shigella flexneri. This method is based on exogenously expressed EGFP-tagged NOD1 and describes a protocol to obtain inducible cell lines with functional NOD1 signaling. The described protocol is useful to study NOD1 function, also in living cells, using live cell imaging and can be adopted for the study of other NLR proteins.

Effects of personalized invitation letters on research participation among general practitioners: a randomized trial.

BACKGROUND: Participation of general practitioners is crucial for health care studies. However, recruiting them is an ongoing challenge and participation rates of general practitioners around the globe are often low. One feasible and cost-efficient approach to potentially enhance participation rates among general practitioners are personalized invitation letters, since they may increase one's attention to and appreciation of a study. Still, evidence whether this method actually affects participation is scarce and ambiguous in relation to physicians. METHODS: We undertook a randomized trial in a sample of general practitioners from three German states in the context of a large, observational study on physicians' coordination and uptake of recommended cardiovascular ambulatory care. An intervention group (n = 757 general practitioners) received a personalized invitation to participate in the observational study, the control group (n = 754 general practitioners) received a generic invitation. Both groups were blinded to group assignment. Eventual participation rates as well as the number and types of responses overall were compared between arms. Besides the main intervention, sociodemographic and geographical context factors were considered as well. RESULTS: The overall participation rate among physicians was 2.6% (2.8% in the intervention group and 2.4% in the control group). No statistically significant effect of personalization on participation of physicians was found (relative risk to participate when receiving a personalized invitation of 1.17 [95%-CI: 0.62, 2.21]). However, the number of responses to the invitation varied significantly between the geographical regions. CONCLUSIONS: Personalization of first written contact alone did not improve research participation among general practitioners, which was overall very low. TRIAL REGISTRATION: The study in which the trial was embedded has been registered prospectively at the German Clinical Trials Register (DRKS) under registration number DRKS00019219 .

Influence of physician networks on prescribing a new ingredient combination in heart failure: a longitudinal claim data-based study.

BACKGROUND: Since 2016, the combination of sacubitril/valsartan, which combines an angiotensin receptor and neprilysin inhibitor (ARNI), has been recommended in the guidelines for the treatment of heart failure. The adoption of new drugs may be influenced by collaboration and exchange between physicians. We aimed to determine whether characteristics of the professional networks of prescribing physicians were associated with the prescribing of ARNI in Germany. METHODS: We conducted a longitudinal analysis based on claims data in 2016-2018 in Germany. The characteristics of ambulatory care physicians' networks were determined in the analysis of the patient-sharing networks of physicians in 2017. Binary logistic regression analysis with the outcome 'prescribes ARNI in 2018' (present or absent) was carried out, using network characteristics as predictors, adjusted for specialty and sociodemographic characteristics of physicians. RESULTS: The network analysis included 8370 physicians, who had 144,636 connections. Prescribers had more connections to other physicians compared to non-prescribers (median 31 vs. 23). Regression analysis showed that the numbers of linkages to prescribers of ARNI were positively associated with prescribing ARNI. For 6-10 connections, the average marginal effect (AME) was 0.04 (confidence interval [CI] 95% 0.01-0.06) and for > 10 links the AME 0.07 (CI 95% 0.05-0.10) compared to 0-5 connections to prescriber. CONCLUSION: Physicians who shared patients with many other physicians were more likely to prescribe ARNI, independent of physicians' specialty. This suggested that collaboration and exchange on the basis of patient-sharing with other physicians influenced their medication prescribing decisions.

Cellular stress promotes NOD1/2-dependent inflammation via the endogenous metabolite sphingosine-1-phosphate.

Cellular stress has been associated with inflammation, yet precise underlying mechanisms remain elusive. In this study, various unrelated stress inducers were employed to screen for sensors linking altered cellular homeostasis and inflammation. We identified the intracellular pattern recognition receptors NOD1/2, which sense bacterial peptidoglycans, as general stress sensors detecting perturbations of cellular homeostasis. NOD1/2 activation upon such perturbations required generation of the endogenous metabolite sphingosine-1-phosphate (S1P). Unlike peptidoglycan sensing via the leucine-rich repeats domain, cytosolic S1P directly bound to the nucleotide binding domains of NOD1/2, triggering NF-κB activation and inflammatory responses. In sum, we unveiled a hitherto unknown role of NOD1/2 in surveillance of cellular homeostasis through sensing of the cytosolic metabolite S1P. We propose S1P, an endogenous metabolite, as a novel NOD1/2 activator and NOD1/2 as molecular hubs integrating bacterial and metabolic cues.

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 .

Exploring early interprofessional socialization: a pilot study of student's experiences in medical history taking.

Traditional hierarchies and structures in healthcare, as well as traditional professional socialization practices, continue to create barriers to effective interprofessional collaboration. Nevertheless, some studies indicate that early socialization with other health professionals can build bridges and improve understanding of each other's roles and contributions to patient care. This pilot study aimed to gain insights into the nursing and medical students' experiences of interprofessional medical history taking during a collective learning activity. A descriptive case study was conducted using modified interviews based on the speed-dating (SD) technique to explore participants' reasons for the choice of profession (SD1) and experiences of interprofessional history taking (SD2). Data were digitally captured using audio-recordings. An inductive-deductive approach to qualitative content analysis of transcribed responses was undertaken. Eighteen students (medicine n = 6; nursing n = 12) participated. Two main categories with sub-themes emerged from the inductive SD1 analysis: (a) reasons for choosing a career and (b) knowledge about professions. The SD2 deductive analysis identified three major categories with sub-themes: (a) breaking down barriers, (b) interprofessional role learning - interprofessional collaboration and (c) dual-identity development. Our findings showed that early interprofessional socialization of students supported their learning about the complementary roles of doctors and nurses and enabled them to gain early experiences of interprofessional teamwork.