A Qualitative Analysis of Cancer Patients' Perceptions of an Interprofessional Counseling Service on Complementary and Integrative Healthcare.

Medical guidelines recommend actively addressing patients' information needs regarding complementary and integrative healthcare (CIH). Within the CCC-Integrativ study, an interprofessional counseling program on CIH was developed and implemented at four comprehensive cancer centers (CCCs) in Germany. As part of the process evaluation, this study examines cancer patients' experiences with interprofessional CIH counseling sessions conducted by a physician and a nurse. Forty problem-centered interviews were conducted using a semi-structured interview guide. All interviews were audio-recorded, transcribed verbatim, and analyzed using deductive-inductive content analysis based on Kuckartz and Rädiker's approach. Findings revealed that most participants had prior experience with CIH approaches and were burdened by physiological and psychological symptoms. Counseling sessions focused on cancer- and treatment-related symptoms and appropriate CIH recommendations (e.g., herbal poultice against anxieties and acupressure against nausea). Participants appreciated the mutual exchange and integration of perspectives from different healthcare professions within the interprofessional approach. They noted that the counseling team comprehensively addressed their healthcare and CIH information needs. Suggestions for improvement included the specificity of the CIH recommendations. As the participants only received counseling and no CIH treatments, information about reputable CIH providers was particularly important to many seeking advice. Patients with cancer receiving tailored CIH counseling from two healthcare professionals experienced benefits in CIH counseling for symptom management. The interprofessional teams offered a comprehensive perspective on patients' needs, proposing personalized recommendations for symptom control. These insights may foster collaboration between healthcare professionals interested in CIH counseling, enabling them to expand and consolidate their counseling services.

How can competencies in minor surgery in general practice be increased? Assessing the effect of a compact intervention in postgraduate training: a mixed-methods study.

OBJECTIVES: We aimed to assess general practice (GP) trainees' self-perception of surgical competencies and to explore longitudinal effects of a compact intervention. DESIGN: We performed a mixed-methods study including a before and after comparison in the intervention group (IG), a comparison of attendees and non-attendees (control group (CG)) and a qualitative evaluation of the intervention. Competencies were self-assessed through surveys. Semi-structured interviews were performed after 9 months. SETTING: In 2019, a 2-day voluntary seminar focussing on minor surgery/injuries was offered on 13 occasions by educators from KWBW Verbundweiterbildungplus (Competence Centre for Postgraduate Medical Education Baden-Württemberg). PARTICIPANTS: All enrolled GP trainees were offered participation. GP trainees who did not attend a seminar (non-attendees) were recruited for CG after the 13th intervention. INTERVENTION: Attendees took part in an interactive, GP-oriented short course incorporating 270 min of focused minor surgery/injuries training (compact intervention) on the second day of the 2-day seminar. RESULTS: 326 GP trainees (IG: n=257; CG: n=69) participated in the study. 17 attendees were interviewed. CG had more often experienced a surgical rotation (p=0.03) and reported higher interest in performing minor surgery in future practice (p=0.03). GP trainees self-rated their all-round competency in minor surgery as average (IG: 3.0±1.0, CG: 3.2±0.9, IG:CG p=0.06). After the intervention, attendees felt that surgical skills should be a core component of GP vocational training (p=0.05). After 9 months, attendees remembered a variety of content and valued the interactive, case-oriented, peer-to-peer approach in a mixed learning group. Some attendees reported they had started to overcome competency gaps in minor surgery. CONCLUSIONS: A compact intervention in minor surgery provides an 'intense' stimulus which could foster positive attitudes towards minor surgery and promote longitudinal personal development of related competencies in GP trainees, including those with little interest in surgery. Such measures appear crucial to support individual progress of GP trainees to provide comprehensive primary care.

Need for nursing care after laparoscopic and open colorectal cancer surgery: a claims data analysis in German primary care.

PURPOSE: Our study analyzes the influence of minimally invasive vs. open surgery on the postoperative need for nursing care in patients with colorectal carcinoma. Colorectal cancer is an age-related disease, and oncologic surgery is increasingly performed in elderly patients. Long-term effects of the procedural choice on patients' self-sufficiency and autonomy have not been scientifically addressed so far. METHODS: Multivariable logistic regression models based on claims data from a statutory health insurer (AOK, Baden-Württemberg, Germany) were applied to assess potential risk factors for assignment patients to a nursing care level, a German scale to categorize individual need for nursing care, at 12 and 36 months after colorectal cancer surgery. RESULTS: A total of 3996 patients were eligible to be included in the analysis. At 36 months postoperatively, 44 of 427 (10.3%) patients after minimally invasive colon cancer surgery and 231 of 1287 (17.9%) patients after open procedure were newly graded into a nursing care level (OR = 0.62, 95%CI = 0.44-0.90, p = 0.010). Thirty-four of 251 (13.5%) patients receiving minimally invasive rectal cancer surgery compared to 142 of 602 (23.6%) patients after open approach were newly assigned to a nursing care level (OR = 0.53, 95%CI = 0.34-0.81, p = 0.003). CONCLUSIONS: Laparoscopically assisted resection of colorectal cancer seems to be superior in preserving physical autonomy of elderly patients with colorectal cancer.

Protocol for the process evaluation of a counselling intervention designed to educate cancer patients on complementary and integrative health care and promote interprofessional collaboration in this area (the CCC-Integrativ study).

BACKGROUND: Conducting a process evaluation is essential to understand how health interventions work in different healthcare settings. Particularly in the case of complex interventions, it is important to find out whether the intervention could be carried out as planned and which factors had a beneficial or hindering effect on its implementation. The aim of this study is to present the detailed protocol of the process evaluation embedded in the controlled implementation study CCC-Integrativ aiming to implement an interprofessional counselling program for cancer patients on complementary and integrative health care (CIH). METHODS: This mixed methods study will draw upon the "Consolidated Framework for Implementation Research" (CFIR) combined with the concept of "intervention fidelity" to evaluate the quality of the interprofessional counselling sessions, to explore the perspective of the directly and indirectly involved healthcare staff, as well as to analyze the perceptions and experiences of the patients. The qualitative evaluation phase consists of analyzing audio-recorded counselling sessions, as well as individual and group interviews with the involved persons. The quantitative evaluation phase applies questionnaires which are distributed before (T0), at the beginning (T1), in the middle (T2) and at the end (T3) of the intervention delivery. DISCUSSION: This protocol provides an example of how a process evaluation can be conducted parallel to a main study investigating and implementing a complex intervention. The results of this mixed methods research will make it possible to identify strengths and weaknesses of the team-based intervention, and to target more specifically the key factors and structures required to implement healthcare structures to meet patients' unmet needs in the context of CIH. To our knowledge, this study is the first applying the CFIR framework in the context of interprofessional CIH counselling, and its results are expected to provide comprehensive and multidisciplinary management of cancer patients with complex supportive healthcare needs.

Prevalence and patient-rated relevance of complexity factors in medication regimens of community-dwelling patients with polypharmacy.

PURPOSE: To describe the prevalence of complexity factors in the medication regimens of community-dwelling patients with more than five drugs and to evaluate the relevance of these factors for individual patients. METHODS: Data were derived from the HIOPP-6 trial, a controlled study conducted in 9 general practices which evaluated an electronic tool to detect and reduce complexity of drug treatment. The prevalence of complexity factors was based on the results of the automated analysis of 139 patients' medication data. The relevance assessment was based on the patients' rating of each factor in an interview (48 patients included for analysis). RESULTS: A median of 5 (range 0-21) complexity factors per medication regimen were detected and at least one factor was observed in 131 of 139 patients. Almost half of these patients found no complexity factor in their medication regimen relevant. CONCLUSION: In most medication regimens, complexity factors could be identified automatically, yet less than 15% of factors were indeed relevant for patients as judged by themselves. When assessing complexity of medication regimens, one should especially consider factors that are both particularly frequent and often challenging for patients, such as use of inhalers or tablet splitting. TRIAL REGISTRATION: The HIOPP-6 trial was registered retrospectively on May 17, 2021, in the German Clinical Trials register under DRKS-ID DRKS00025257.

Self-Efficacy, Social Activity, and Spirituality in the Care of Elderly Patients with Polypharmacy in Germany-A Multicentric Cross-Sectional Study within the HoPES3 Trial.

About one third of Europe's elderly population takes ≥5 drugs. Polypharmacy increases their risk of adverse drug reactions. To ensure drug safety, innovative approaches are needed. The aim of this cross-sectional study was to explore the relationship between psychosocial factors and medication-related beliefs and behaviors. Medication lists of 297 patients were recorded according to the ATC classification. Correlations between the dependent variables, Medication Adherence (MARS) and Beliefs about Medicines (BMQ), and independent variables, General Self-Efficacy (GSE), self-efficacy for managing chronic diseases (SES6G), spiritual needs (SpNQ), patient activity (PAM), loneliness (DJG), and social networks (LSNS), were measured. Patients with higher self-efficacy (OR: 1.113; 95% CI [1.056-1.174]; p < 0.001) or self-confidence in managing their chronic condition (OR: 1.188; 95% CI [1.048-1.346]; p < 0.007) also showed higher adherence. Lonely patients (OR: 0.420; 95% CI [0.267-0.660]; p < 0.001) and those with a need for inner peace (OR: 0.613; 95% CI [0.444-0.846], p = 0.003) were more likely nonadherent. Stronger positive beliefs about medications' usefulness weakly correlated with higher scores on the SES6G (ρ = 0.178, p = 0.003) and GSES scale (ρ = 0.121, p = 0.042), patient activity (ρ = 0.155, p = 0.010) and functioning social networks scale (ρ = 0.159, p = 0.008). A weak positive correlation was found between loneliness and the belief that drugs were harmful (ρ = 0.194, p = 0.001). Furthermore, interesting correlations were detected regarding the number of medications and overuse beliefs. Psychosocial factors, such as self-efficacy, loneliness, and spiritual needs and medication-related beliefs and behaviors seem to interrelate. Addressing these factors may improve medication management and drug safety.

Early integration of palliative care for outpatients with advanced cancer in general practice: how is the situation?-a cohort study.

BACKGROUND: Compared with standard care alone, early integration of specialist palliative care in the treatment of patients with advanced cancer offers significant benefit with respect of symptom control, healthrelated quality of life and survival. The early integration of specialist palliative care means that patients receive palliative care concurrent with, or shortly after, the diagnosis of advanced cancer. METHODS: Using data from 2015 compiled from a large German statutory health insurance company (AOK Baden-Wuerttemberg) which insures 3.87 million people, we evaluated how many patients were identified with advanced metastatic cancer and at what point in time, if ever, general practitioners referred them to a specialist palliative home care team. The data were collected exclusively from general practices in the BadenWürttemberg province of Germany. Patients with advanced cancer where identified using all ICD-10 codes for cancer and the ICD-10 codes for metastases. Patients receiving care from a palliative care team were identified using the codes 01425 or 01426 of the German medical fee schedule. RESULTS: We identified 3,535 patients diagnosed with advanced cancer as having palliative care needs. 669 (18.9%) of these were referred to a specialist home care team. Of these, 302 (45.1%) where referred to a palliative care team on the day they were diagnosed but 367 (54.9%) were referred only at a later point in time. Two hundred and six (30.8%) patients had a delayed referral after 8 weeks or more and 153 (22.9%) after more than 12 weeks. CONCLUSIONS: Over half of the cancer patients in general practice who are referred for specialist palliative care are done so very late. General practitioners appear to need encouragement for the early integration of palliative care for patients with advanced cancer and to initiate early referrals to palliative care teams.

A New Method for Structured Integration of User Needs in Two Health Technology Development Projects: Action Sheets.

An early integration of users and stakeholders is needed for a successful innovation process. Nonetheless, the integration of users is often hard to realize - especially when dealing with persons with chronic diseases. In addition, patients or users in general often are not able to formulate the requirements in a technical manner. Therefore, even if user requirements are collected, it is not certain that the developers know or understand 'what is really wanted'. To overcome these 'gaps', we have developed so-called Action Sheets (AS). This article presents the use of AS in two projects: the development of health technologies for people with cancer (INFOPAT) and dementia (QuartrBack). Depending on the project context, group sessions were conducted with different stakeholders to identify the needs of (potential) users. Within the INFOPAT project, ten focus groups were conducted with patients, physicians and other healthcare professionals. In QuartrBack stakeholders like e.g. care professionals, technical assistance organizations and citizens participated in two focus groups and three world cafés. Their requirements were then 'fed' into the technology development by the use of AS. AS appear to be a promising tool to make user needs based on social values more tangible and implementable into technology development processes. In addition, it shows up that four phases seem to be necessary for transferring identified user and stakeholder needs into AS, which can therefore be seen as essential to translate non-technically formulated requirements into technically feasible ones. The case study shows as lessons learned that despite the successful integration of user needs, context-sensitive adjustments are still necessary.

Caregivers' role in using a personal electronic health record: a qualitative study of cancer patients and caregivers in Germany.

BACKGROUND: Particularly in the context of severe diseases like cancer, many patients wish to include caregivers in the planning of treatment and care. Many caregivers like to be involved but feel insufficiently enabled. This study aimed at providing insight into patients' and caregivers' perspectives on caregivers' roles in managing the patient portal of an electronic personal health record (PHR). METHODS: A descriptive qualitative study was conducted comprising two study phases: (1) Usability tests and interviews with patients with cancer and caregivers (2) additional patient interviews after a 3-month-pilot-testing of the PHR. For both study parts, a convenience sample was selected, focusing on current state of health and therapy process and basic willingness to participate and ending up with a mixed sample as well as saturation of data. All interviews were audio-recorded, pseudonymized, transcribed verbatim and qualitatively analyzed. RESULTS: Two main categories emerged from qualitative data: 'Caregivers' role' and 'Graduation of access rights' - consisting of four subcategories each. The interviewed patients (n = 22) and caregivers (n = 9) felt that the involvement of caregivers is central to foster the acceptance of a PHR for cancer patients. However, their role varied from providing technical support to representing patients, e.g. if the patient's state of health made this necessary. Heterogeneous opinions emerged regarding the question whether caregivers should receive full or graduated access on a patient's PHR. CONCLUSIONS: In order to support the patient and to participate in the care process, caregivers need up-to-date information on the patient's health and treatment. Nevertheless, some patients do not want to share all medical data with caregivers, which might strain the patient-caregiver relationship. This needs to be considered in development and implementation of personal health records. Generally, in the debate on patient portals of a personal health record, paying attention to the role of caregivers is essential. By appreciating the important relationship between patients and caregivers right from the beginning, implementation, of a PHR would be enhanced. TRIAL REGISTRATION: ISRCTN85224823 . Date of registration: 23/12/2015 (retrospectively registered).

Development of an algorithm to detect and reduce complexity of drug treatment and its technical realisation.

BACKGROUND: The increasing complexity of current drug therapies jeopardizes patient adherence. While individual needs to simplify a medication regimen vary from patient to patient, a straightforward approach to integrate the patients' perspective into decision making for complexity reduction is still lacking. We therefore aimed to develop an electronic, algorithm-based tool that analyses complexity of drug treatment and supports the assessment and consideration of patient preferences and needs regarding the reduction of complexity of drug treatment. METHODS: Complexity factors were selected based on literature and expert rating and specified for integration in the automated assessment. Subsequently, distinct key questions were phrased and allocated to each complexity factor to guide conversation with the patient and personalize the results of the automated assessment. Furthermore, each complexity factor was complemented with a potential optimisation measure to facilitate drug treatment (e.g. a patient leaflet). Complexity factors, key questions, and optimisation strategies were technically realized as tablet computer-based application, tested, and adapted iteratively until no further technical or content-related errors occurred. RESULTS: In total, 61 complexity factors referring to the dosage form, the dosage scheme, additional instructions, the patient, the product, and the process were considered relevant for inclusion in the tool; 38 of them allowed for automated detection. In total, 52 complexity factors were complemented with at least one key question for preference assessment and at least one optimisation measure. These measures included 29 recommendations for action for the health care provider (e.g. to suggest a dosage aid), 27 training videos, 44 patient leaflets, and 5 algorithms to select and suggest alternative drugs. CONCLUSIONS: Both the set-up of an algorithm and its technical realisation as computer-based app was successful. The electronic tool covers a wide range of different factors that potentially increase the complexity of drug treatment. For the majority of factors, simple key questions could be phrased to include the patients' perspective, and, even more important, for each complexity factor, specific measures to mitigate or reduce complexity could be defined.

Interventions to Improve Hospital Admission and Discharge Management: An Umbrella Review of Systematic Reviews.

BACKGROUND: The aim of this umbrella review was to summarize the research evidence on programs to improve the transition between ambulatory and hospital care. METHODS: The MEDLINE database and the Cochrane library were searched. Systematic reviews of randomized controlled trials published between January 2000 and September 2018 in English or German were included. Studies were eligible if an assessment or coordination intervention had been evaluated and if patients had been transferred between hospital (defined as internal medicine, surgery, or unspecified hospital setting) and home (defined as any permanent residence). Risk of bias was assessed using the AMSTAR criteria. Results are presented descriptively and in table format. RESULTS: Thirty-nine systematic reviews comprising 492 different studies were included. More than half of these studies were conducted in the United States, the United Kingdom, Canada, and Australia. All studies evaluated strategies to improve discharge management (introduced after patients' arrival at the hospital); no study assessed strategies to improve admission management (initiated in primary care before patients' transition to hospital). The reviews included focused on a specific patient group, a specific intervention type, or a specific outcome. Overall, interventions focusing on elderly patients and high-intensity interventions seemed to be most effective. An overview of classifications of care transition strategies is provided. CONCLUSIONS: Future research should focus on hospital admission management programs.

Medication beliefs and use of medication lists - is there a connection? Results from a before-and-after study in Germany.

BACKGROUND: Despite increasing digitalisation the paper-based medication list remains one of the most important instruments for the documentation and exchange of medication-related information. However, even elderly patients with polypharmacy who are at high risk for medication errors and adverse drug events, frequently do not receive or use a complete and comprehensible medication list. Increasing the use of medication lists would be a great contribution to medication safety and facilitate the work of health care providers. METHODS: This study is related to the project MeinPlan (MyPlan) which comprised an information campaign on safe drug administration in the Rhine-Neckar region in South Germany. The campaign was evaluated in a before-and-after study based on a survey among two independent, representative samples of citizens over 65 years. In total, 5034 questionnaires were analysed. While the effects of the primary outcome (the percentage of citizens using a medication list) have been reported elsewhere, this analysis focusses on the effects of the campaign on citizens' medication beliefs and assesses whether medication beliefs are associated with the use of medication lists, the use of over-the-counter drugs and the use of the tools offered by the campaign. Medication beliefs were assessed with the German version of the General Beliefs About Medicines Questionnaire (BMQ) which results in subscales for "General Overuse", "General Usefulness" and "General Harm". The use of medication lists and over-the-counter drugs was assessed with self-developed questionnaire items. RESULTS: No statistically significant change in citizens' medication beliefs before and after the campaign could be detected. Likewise, no association between medication beliefs and the use of medication lists, the use of over-the-counter drugs or the use of the tools offered by the campaign could be shown. CONCLUSIONS: A campaign focussing on the risks of drug administration did not change the medication beliefs of the targeted population. Moreover, citizens' general medication beliefs do not seem to be crucial for their decision to use a medication list or over-the-counter drugs. Strategies to improve the use of medication lists by patients should focus on other influential factors, such as individual benefits and barriers and socio-psychological factors.

Holistic care program for elderly patients to integrate spiritual needs, social activity, and self-care into disease management in primary care (HoPES3): study protocol for a cluster-randomized trial.

BACKGROUND: Strategies to improve the care of elderly, multimorbid patients frequently focus on implementing evidence-based knowledge by structured assessments and standardization of care. In Germany, disease management programs (DMPs), for example, are run by general practitioners (GPs) for this purpose. While the importance of such measures is undeniable, there is a risk of ignoring other dimensions of care which are essential, especially for elderly patients: their spiritual needs and personal resources, loneliness and social integration, and self-care (i.e., the ability of patients to do something on their own except taking medications to increase their well-being). The aim of this study is to explore whether combining DMPs with interventions to address these dimensions is feasible and has any impact on relevant outcomes in elderly patients with polypharmacy. METHODS: An explorative, cluster-randomized controlled trial with general practices as the unit of randomization will be conducted and accompanied by a process evaluation. Patients aged 70 years or older with at least three chronic conditions receiving at least three medications participating in at least one DMP will be included. The control group will receive DMP as usual. In the intervention group, GPs will conduct a spiritual needs assessment during the routinely planned DMP appointments and explore whether the patient has a need for more social contact or self-care. To enable GPs to react to such needs, several aids will be provided by the study: a) training of GPs in spiritual needs assessment and training of medical assistants in patient counseling regarding self-care and social activity; b) access to a summary of regional social offers for seniors; and c) information leaflets on nonpharmacological interventions (e.g., home remedies) to be applied by patients themselves to reduce frequent symptoms in old age. The primary outcome is health-related self-efficacy (using the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SES-6G)). Secondary outcomes are general self-efficacy (using the General Self-Efficacy Scale (GSES)), physical and mental health (using the Short-Form Health Survey (SF-12)), patient activation (using the Patient Activation Measure (PAM)), medication adherence (using the Medication Adherence Report Scale (MARS)), beliefs in medicine (using the Beliefs About Medicines Questionnaire (BMQ)), satisfaction with GP care (using selected items of the European Project on Patient Evaluation of General Practice (EUROPEP)), social contacts (using the 6-item Lubben Social Network Scale (LSNS-6)), and loneliness (using the 11-item De-Jong-Gierveld Loneliness Scale (DJGS-11)). Interviews will be conducted to assess the mechanisms, feasibility, and acceptability of the interventions. DISCUSSION: If the interventions prove to be effective and feasible, large-scale implementation should be sought and evaluated by a confirmatory design. TRIAL REGISTRATION: German Clinical Trials Register (DRKS), DRKS00015696 . Registered on 22 January 2019.

The effects of an integrated supportive care intervention on quality of life outcomes in outpatients with breast and gynecologic cancer undergoing chemotherapy: Results from a randomized controlled trial.

The aim of the Complementary Nursing in Gynecologic Oncology study was to investigate the effects of a complex, nurse-led, supportive care intervention using Complementary and Integrative Medicine (CIM) on patients' quality of life (QoL) and associated patient-reported outcomes. In this prospective, pragmatic, bicentric, randomized controlled trial, women with breast or gynecologic cancer undergoing a new regimen of chemotherapy (CHT) were randomly assigned to routine supportive care plus intervention (intervention group, IG) or routine care alone (control group, CG). The intervention consisted of CIM applications and counseling for symptom management, as well as CIM information material. The primary endpoint was global QoL measured with the EORTC-QLQ-C30 before and after CHT. Mixed linear models considering fixed and random factors were used to analyze the data. In total, 126 patients were randomly assigned into the IG and 125 patients into the CG (median age 51 years). The patients' medical and socio-demographic characteristics were homogenous at baseline and at follow-up. No group effects on QoL were found upon completion of CHT (estimate -1.04 [-4.89; 2.81]; P = 0.596), but there was a significant group difference in favor of the IG 6 months later (estimate 6.643 [1.65; 11.64]; P = 0.010). IG patients did also experience significant better emotional functioning (P = 0.007) and less fatigue (P = 0.027). The tested supportive intervention did not improve patients' QoL outcomes directly after CHT (T3), but was associated with significant QoL improvements when considering the change from baseline to the time point T4, which could be assessed 6 months after patients' completion of CHT. This delayed effect may have resulted due to a strengthening of patients' self-management competencies.

Using country of origin to inform targeted tuberculosis screening in asylum seekers: a modelling study of screening data in a German federal state, 2002-2015.

BACKGROUND: Screening programmes for tuberculosis (TB) among immigrants rarely consider the heterogeneity of risk related to migrants' country of origin. We assess the performance of a large screening programme in asylum seekers by analysing (i) the difference in yield and numbers needed to screen (NNS) by country and WHO-reported TB burden, (ii) the possible impact of screening thresholds on sensitivity, and (iii) the value of WHO-estimated TB burden to improve the prediction accuracy of screening yield. METHODS: We combined individual data of 119,037 asylum seekers screened for TB in Germany (2002-2015) with TB estimates of the World Health Organization (WHO) (1990-2014) for their 81 countries of origin. Adjusted rate ratios (aRR) and 95% credible intervals (CrI) of the observed yield of screening were calculated in Bayesian Poisson regression models by categories of WHO-estimated TB incidence. We assessed changes in sensitivity depending on screening thresholds, used WHO TB estimates as prior information to predict TB in asylum seekers, and modelled country-specific probabilities of numbers needed to screen (NNS) conditional on different screening thresholds. RESULTS: The overall yield was 82 per 100,000 and the annual yield ranged from 44.1 to 279.7 per 100,000. Country-specific yields ranged from 10 (95%- CrI: 1-47) to 683 (95%-CrI: 306-1336) per 100,000 in Iraqi and Somali asylum seekers, respectively. The observed yield was higher in asylum seekers from countries with a WHO-estimated TB incidence > 50 relative to those from countries ≤50 per 100,000 (aRR: 4.17, 95%-CrI: 2.86-6.59). Introducing a threshold in the range of a WHO-estimated TB incidence of 50 and 100 per 100,000 resulted in the lowest "loss" in sensitivity. WHO's TB prevalence estimates improved prediction accuracy for eight of the 11 countries, and allowed modelling country-specific probabilities of NNS. CONCLUSIONS: WHO's TB data can inform the estimation of screening yield and thus be used to improve screening efficiency in asylum seekers. This may help to develop more targeted screening strategies by reducing uncertainty in estimates of expected country-specific yield, and identify thresholds with lowest loss in sensitivity. Further modelling studies are needed which combine clinical, diagnostic and country-specific parameters.

Converting habits of antibiotic use for respiratory tract infections in German primary care - study protocol of the cluster-randomized controlled CHANGE-3 trial.

BACKGROUND: The overuse of antibiotics is a major cause for the worldwide rise of antibiotic resistance. Although it is well known that acute respiratory tract infections (ARTI) are mainly caused by viruses and are often self limiting, antibiotics are too frequently prescribed in primary care. CHANGE-3 examines whether a complex intervention focusing on improving communication and provision of prescribing feedback reduces antibiotic use in patients suffering from ARTI. METHODS/DESIGN: The CHANGE-3 trial is a cluster-randomized controlled trial nested within a web-based public campaign conducted in two regions in Germany. A total of 114 medical practices will be included. Practices randomized to the intervention will receive a practice-specific antibiotic-prescription feedback and an educational outreach visit. During the visit the whole practice team will receive an introduction to e-learning modules addressing patient-centered communication on antibiotics. Furthermore, the practices will receive tablet PCs with information on antibiotics and the treatment of ARTI to be presented to patients. Practices randomized to the control will provide care as usual. The primary outcome measure is the antibiotic prescribing rate for patients with a history of ARTI. Data collected before the intervention, during the intervention and after the intervention will be compared. The use of narrow- vs. broad-spectrum antibiotics will be analyzed as a secondary outcome. A process evaluation is also part of the trial. DISCUSSION: This study should contribute to the growing body of research on reducing antibiotic prescription. TRIAL REGISTRATION: ISRCTN, ISRCTN15061174 . Registered retrospectively on 13 July 2018.

Challenges in supporting lay carers of patients at the end of life: results from focus group discussions with primary healthcare providers.

BACKGROUND: Family caregivers (FCGs) of patients at the end of life (EoL) cared for at home receive support from professional and non-professional care providers. Healthcare providers in general practice play an important role as they coordinate care and establish contacts between the parties concerned. To identify potential intervention targets, this study deals with the challenges healthcare providers in general practice face in EoL care situations including patients, caregivers and networks. METHODS: Focus group discussions with general practice teams in Germany were conducted to identify barriers to and enablers of an optimal support for family caregivers. Focus group discussions were analysed using content analysis. RESULTS: Nineteen providers from 11 general practices took part in 4 focus group discussions. Participants identified challenges in communication with patients, caregivers and within the professional network. Communication with patients and caregivers focused on non-verbal messages, communicating at an appropriate time and perceiving patient and caregiver as a unit of care. Practice teams perceive themselves as an important part of the healthcare network, but also report difficulties in communication and cooperation with other healthcare providers. CONCLUSION: Healthcare providers in general practice identified relational challenges in daily primary palliative care with potential implications for EoL care. Communication and collaboration with patients, caregivers and among healthcare providers give opportunities for improving palliative care with a focus on the patient-caregiver dyad. It is insufficient to demand a (professional) support network; existing structures need to be recognized and included into the care.

[Assessment of the severity of postoperative complications from the patient and doctor perspective]. / Einschätzung des Schweregrads postoperativer Komplikationen aus der Sicht von Patienten und Ärzten.

AIM OF THE STUDY: This study compares doctors' and patients' assessments of the severity of postoperative complications reported by patients. Within the context of quality assurance and patient safety, the study aims to contribute to developing instruments to include patients' views for measuring postoperative complications. METHODS: In a questionnaire development study 474 patients who had undergone different kinds of surgery were given a questionnaire and asked whether postoperative complications occurred, and if so, to describe these complications in free text and assesses their severity as "slight, temporary" or "extensive". In an additional study, the patients' written descriptions of their complications were presented independently to two doctors (general practitioner [GP], orthopaedic surgeon) who were asked to assess the severity from their point of view. The physicians were not aware of the patients' or the other physician's assessments. RESULTS: 23.5 % of the patients participating in the survey reported postoperative complications in the questionnaire. Feedback from 80 of these patients included sufficient information for data analysis concerning the study's aim, including the description of their complication in free text. 47 (58.7 %) of these patients assessed their postoperative complications as being "slight, temporary", 33 (41.3 %) as being "extensive". The doctors, on the other hand, assessed the severity of the complications described by the patients much less often as "extensive" (GP: 20.0 %, orthopaedic surgeon: 11.3 %). In only 4 (12.0 %) of the 33 cases where the patient chose "extensive" both doctors also chose the assessment item "extensive". In 10 cases (30.3 %), one doctor's "extensive" assessment matched the patient's assessment, and in 19 cases (57.6 %) the patients but none of the doctors assessed the complications as being "extensive". There was a higher correlation between the GP's and the patients' assessments than between the orthopaedic surgeon's and the patients' ratings. Examples of patients' descriptions of their postoperative complications in free text as well as the corresponding assessments of patients and doctors are presented. CONCLUSIONS: Patients' views and assessments of postoperative complications are different from doctors' views. Adequate instruments for measuring the occurrence and severity of postoperative complications should be developed bringing the patients' perspectives into the doctors' assessments. Also, it might be useful to include questions addressing information received pre- and postoperatively about the expected postoperative course as well as communication with patients in the case of complications.

Sustainable reduction of antibiotic-induced antimicrobial resistance (ARena) in German ambulatory care: study protocol of a cluster randomised trial.

BACKGROUND: Despite many initiatives to enhance the rational use of antibiotics, there remains substantial room for improvement. The overall aim of this study is to optimise the appropriate use of antibiotics in German ambulatory care in patients with acute non-complicated infections (respiratory tract infections, such as bronchitis, sinusitis, tonsillitis and otitis media), community-acquired pneumonia and non-complicated cystitis, in order to counter the advancing antimicrobial resistance development. METHODS: A three-armed cluster randomised trial will be conducted in 14 practice networks in two German federal states (Bavaria and North Rhine-Westphalia) and an added cohort that reflects standard care. The trial is accompanied by a process evaluation. Each arm will receive a different set of implementation strategies. Arm A receives a standard set, comprising of e-learning on communication with patients and quality circles with data-based feedback for physicians, information campaigns for the public, patient information material and performance-based additional reimbursement. Arm B receives this standard set plus e-learning on communication with patients and quality circles with data-based feedback tailored for non-physician health professionals of the practice team and information material for tablet computers (culture sensitive). Arm C receives the standard set as well as a computerised decision support system and quality circles in local multidisciplinary groups. The study aims to recruit 193 practices which will provide data on 23,934 patients each year (47,867 patients in total). The outcome evaluation is based on claims data and refers to established indicators of the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). Primary and secondary outcomes relate to prescribing of antibiotics, which will be analysed in multivariate regression models. The process evaluation is based on interviews with surveys among physicians, non-physician health professionals of the practice team and stakeholders. A patient survey is conducted in one of the study arms. Interview data will be qualitatively analysed using thematic framework analysis. Survey data of physicians, non-physician health professionals of the practice team and patients will use descriptive and exploratory statistics for analysis. DISCUSSION: The ARena trial will examine the effectiveness of large scale implementation strategies and explore their delivery in routine practice. TRIAL REGISTRATION: ISRCTN, ISRCTN58150046 . Registered 24 August 2017.