Fall-risk-increasing drugs in older patients: the role of guidelines and GP-centred health care in Germany.

BACKGROUND: fall-risk-increasing drugs (FRIDs) are a ubiquitous issue, especially for older patients. As part of a German guideline for pharmacotherapy, from 2019, a new quality indicator for this patient group was developed to measure the percentage of patients receiving FRIDs. METHODS: patients, aged at least 65 years in 2020, insured by the Allgemeine OrtsKrankenkasse statutory health insurance (Allgemeine Ortskrankenkasse, Baden-Wuerttemberg, Germany) with a particular general practitioner (GP) were observed from 1 January to 31 December 2020 cross-sectionally. The intervention group received GP-centred health care. Within GP-centred health care, GPs have the role of gatekeepers for patients within the health system and are-in contrast to regular care GPs in addition to other commitments-obliged to regularly attend training sessions on appropriate pharmacotherapy. The control group received regular GP care. For both groups, we measured the percentage of patients receiving FRIDs as well as the occurrence of (fall-related) fractures as the main outcomes. To test our hypotheses, we performed multivariable regression modelling. RESULTS: a total of 634,317 patients were eligible for analysis. Within the intervention group (n = 422,364), we could observe a significantly reduced odds ratio (OR) for obtaining a FRID (OR = 0.842, confidence interval [CI]: [0.826, 0.859], P < 0.0001) in comparison to the control group (n = 211,953). Moreover, we could observe a significantly reduced chance for (fall-related) fractures in the intervention group (OR: 0.932, CI: [0.889, 0.975], P = 0.0071). CONCLUSIONS: the findings point in the direction that the health care providers' awareness of the potential danger of FRIDs for older patients is higher in the GP-centred care group.

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.

Stroke Angel: Effect of Telemedical Prenotification on In-Hospital Delays and Systemic Thrombolysis in Acute Stroke Patients.

INTRODUCTION: Door-to-CT scan time (DCT) and door-to-needle time (DNT) are important process measures in acute ischemic stroke (AIS) patients undergoing intravenous thrombolysis (IVT). We examined the impact of a telemedical prenotification by emergency medical service (EMS) (called the "Stroke Angel" program) on DCT and DNT and IVT rate compared to standard of care. PATIENTS AND METHODS: Two prospective observational studies including AIS patients admitted via EMS from 2011 to 2013 (cohort I; n = 496) and from January 1, 2015 to May 31, 2018 (cohort II; n = 349) were conducted. After cohort I, the 4-Item Stroke Scale and a digital thrombolysis protocol were added. Multivariable logistic and linear regression analysis was performed. RESULTS: In cohort I, DCT was lower in the intervention group (13 vs. 26 min using standard of care; p < 0.001), but no significant difference in median DNT (35 vs. 39 min; p = 0.24) was observed. In cohort II, a reduction of DCT (8 vs. 15 min; p < 0.001) and DNT (25 vs. 29 min p = 0.003) was observed in the intervention group. Compared to standard of care, the likelihood of DCT ≤10 min or DNT ≤20 min in the intervention group was 2.7 (adjusted odds ratio [aOR] 2.7; 95% CI: 2.1-3.5) and 1.8 (aOR 1.8; 95% CI: 1.1-2.9), respectively. In cohort II, IVT rate was higher (aOR 1.4; 95% CI: 1.1-1.9) in the intervention group. CONCLUSION: Although the positive effects of Stroke Angel in AIS provided a rationale for implementation in routine care, larger studies of practice implementation will be needed. Using Stroke Angel in the prehospital management of AIS impacts on important process measures of IVT delivery.

Continuity in general practice and hospitalization patterns: an observational study.

BACKGROUND: High continuity of care is a key feature of strong general practice. This study aimed to assess the effect of a programme for enhancing strong general practice care on the continuity of care in Germany. The second aim was to assess the effect of continuity of care on hospitalization patterns. METHODS: We performed an observational study in Germany, involving patients who received a strong general practice care programme (n=1.037.075) and patients who did not receive this programme (n=723.127) in the year 2017. We extracted data from a health insurance database. The cohorts were compared with respect to three measures of continuity of care (Usual Provider Index, Herfindahl Index, and the Sequential Continuity Index), adjusted for patient characteristics. The effects of continuity in general practice on the rates of hospitalization, rehospitalization, and avoidable hospitalization were examined in multiple regression analyses. RESULTS: Compared to the control cohort, continuity in general practice was higher in patients who received the programme (continuity measures were 12.47 to 23.76% higher, P< 0.0001). Higher continuity of care was independently associated with lowered risk of hospitalization, rehospitalization, and avoidable hospitalization (relative risk reductions between 2.45 and 9.74%, P< 0.0001). Higher age, female sex, higher morbidity (Charlson-index), and home-dwelling status (not nursing home) were associated with higher rates of hospitalization. CONCLUSION: Higher continuity of care may be one of the mechanisms underlying lower hospitalization rates in patients who received strong general practice care, but further research is needed to examine the causality underlying the associations.

Surveillance and care for confirmed and suspected patients with COVID-19 in general practice (CovidCare): study protocol for an observational trial.

BACKGROUND: A SARS-CoV-2 infection can lead from asymptomatic through to critical disease in a dynamic and unpredictable course within a few days. The challenge in outpatient monitoring the highly contagious COVID-19 disease during the ongoing pandemic is to filter severe courses followed by admission to hospital with the aim of preventing an overburdening of clinics. However, little is known of the effect of risk factors on the course of the infection of outpatient patients. To support general practices in managing high risk patients, we designed a COVID-19 surveillance and care tool (CovidCare). It includes an initial assessment of yet known risk factors and symptoms and a continuous telephone monitoring of signs and symptoms. This study aims to investigate the effects of different risk factors on the course of the COVID-19 disease, utilisation of different health care services and to gain insights into the utilisation of CovidCare in general practices. METHODS: We will conduct a multi-centered prospective, longitudinal non-controlled observational trial of COVID-19 patients in general practices. Overall, 700 GPs who participate in general-practice centered care by the AOK Baden-Württemberg (large German sickness fund) are eligible and will be invited for study participation, including adult, outpatient COVID-19 patients (or urgent suspicion and ≥ 50 years) with at least one additional known risk factor, who participate in general-practice centered care. The primary outcome is hospitalisation due to COVID-19. Secondary outcomes are diagnosis of pneumonia, utilisation of palliative care, mortality rate, anxiety and identification of predictive risk factors. Quantitative data analysis will focus on valid descriptive figures and mixed regression models. The accompanying process evaluation is based on interviews and questionnaires from general practice staff and patients. The analysis of the process evaluation is descriptive and explorative. DISCUSSION: The use of the COVID-19 surveillance and care tool is expected to encourage the provision of structured quality of care during the ongoing pandemic. This trial will provide an understanding of the COVID-19-disease and the effect of several risk factors on the course of the disease and health care utilisation. The results can be used for a better management of the COVID-19 pandemic and its consequences. TRIAL REGISTRATION: German Clinical Trials Register DRKS00022054 .

[Retrospective cross-sectional study based on nationwide data of drug prescriptions and contractional data of outpatient offices regarding Morbus Wilson's disease]. / Retrospektive Querschnittsstudie von bundesweiten Arzneiverordnungsdaten und vertragsärztlichen Abrechnungsdaten von Morbus Wilson.

INTRODUCTION: In this article, the prevalence of the Morbus Wilson disease in Germany is determined. This is based on nationwide data of drug prescriptions and contractional data of outpatient offices. The prevalence is set in ratio to the found prevalence of prescriptions in Germany. METHOD: The descriptive evaluation is based on the database of the Central Research Institute of Ambulatory Health Care (Zi) in Germany. Additionally, data of the Federal Office of Statistics regarding inpatient treatment are available. RESULTS: It can be seen that there is a notable difference between the prevalence of patients undergoing therapy and the patients with verified diagnoses. In total, prevalence is increasing. The incidence on hand and the given dynamic of the patient population could indicate that, possibly, there is an increased rate of misdiagnosis in the first year of diagnosis. According to data, the hepatic form is the more often diagnosed form. The human genetic diagnostic increases, on average, are most distinct. ATTRIBUTES: Wilson Disease, Prevalence, Incidence, Trientine, Trientintetrahydrochlorid, D-Penicillamin, Zinc acetat, Zinc.

Anticholinergic and sedative medications and the risk of vertigo or dizziness in the German primary care setting-A matched case-control study from the CONTENT registry.

PURPOSE: To date, there is little information on the utilization of anticholinergic and sedative (AS) medications to vertigo or dizziness (VoD) patients in the German primary care setting. The objective of this study was to evaluate AS medication use and its association with VoD within the German primary care setting. METHODS: Cases with VoD from the CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork) database were 1:1 matched to controls on age, sex, and comorbidities by propensity score matching. AS medication was defined using the fourth level of Anatomical Therapeutic Chemical Classification (ATC) Codes. A prescription of AS medication any time within the study period formed the primary exposure. Multivariable conditional logistic regression examined the association between AS use and VoD. RESULTS: Of a total of N = 151 446 patients, 6971 (4.6%) cases and 6971 corresponding controls were analyzed (mean age (sd): 59.9 years (20.9), 64.2% female). Dizziness and giddiness (ICD-10 Code R42) were diagnosed most prominently (87.2%). AS medication was prescribed on 1072 of 10 552 (10.2%) consultation days with VoD diagnoses. After adjusting for covariates, AS use was significantly and independently associated with VoD, adjusted odds ratio (1.37; 95% CI: 1.18-1.58), compared with no AS use. CONCLUSION: Primary care practitioners should consider AS medication as a risk factor for VoD and avoid prescribing AS medications after a VoD diagnosis. Caution should also be taken when prescribing AS medications to older adults (≥65 years). Systematical calculations of AS medication burden for patients could help acknowledge this issue and raise awareness for prescription habits in primary care.

Novel oral anticoagulants in primary care in patients with atrial fibrillation: a cross-sectional comparison before and after their introduction.

BACKGROUND: Novel oral anticoagulation (NOAC) has been introduced in recent years, but data on use in atrial fibrillation (AF) in primary care setting is scarce. In Germany, General Practitioners are free to choose type of oral anticoagulation (OAC) in AF. Our aim was to explore changes in prescription-rates of OAC in German primary care before and after introduction of NOAC on the market. METHODS: Data of a representative morbidity registration project in primary care in Germany (CONTENT) were analysed. Patients with AF in 2011 or 2014 were included (before and after broad market authorization of NOAC, respectively). We defined three independent groups: patients from 2011 without follow-up (group A), patients from 2014 but without previous record in 2011 (group B) and patients with AF and records in 2011 and 2014 (group C). RESULTS: 2642 patients were included. Group A (n = 804) and B (n = 755) were comparable regarding patient characteristics. 87.3% of group A and 84.8% of group B had CHA2DS2-VASc-Score ≥ 2, indicating a need for oral anticoagulation (OAC). Prescription of OAC increased from 23.1% (n = 186) to 42.8% (n = 323, p < .01) with stable use of vitamin-k-antagonist (22.6-24.9%). NOAC increased from 0.6 to 19.2% (p < .01). Monotherapy with Acetylsalicylic acid (ASA) decreased from 15.3% (n = 123) to 8.2% (n = 62, p < .01). In group C (n = 1083), OAC increased from 35.3 to 55.4% (p < .01), with stable prescription rate of vitamin-k-antagonist (34.4-35.7%). NOAC increased from 0.9 to 21.5% (p < .01). CONCLUSIONS: In summary, our study showed a significant increase of OAC over time, which is fostered by the use of NOAC but with a stable rate of VKA and a sharp decrease of ASA. Patients on VKA are rarely switched to NOAC, but new patients with AF are more likely to receive NOAC.

Effects of a program to strengthen general practice care on hospitalisation rates: a comparative observational study.

OBJECTIVE: To determine the effect of a large-scale program to strengthen general practice on hospitalisation rates. METHODS: This observational study compared enrolled patients in the program and a sample of non-participating patients from non-participating GPs in the same geographic area in Germany. Key components of the program are: prompt access to care, comprehensiveness, continuity, empanelment, data-driven quality improvement, computerized decision support, and additional reimbursement of general practices. The outcomes in this study were hospitalisation, rehospitalisation, and avoidable hospital admission up to four years after patient inclusion. Poisson regression models and generalized estimating equations were used to estimate intervention effects. RESULTS: In the baseline year, 19.1% were hospitalised and 13.6% had a potentially avoidable hospitalisation, 14.5% were rehospitalised within 4 weeks. Across the four observed years, yearly hospitalisations were 9.8 to 14.9% lower in enrolled patients, yearly re-hospitalisations were 5.3 to 11.5% lower, and yearly avoidable hospitalisations were 6.8 to 8.6% lower compared to the control cohort (all differences were statistically significant). The trend in the between-group difference for hospitalisations and re-hospitalisations increased, while it remained stable for avoidable hospitalisations. CONCLUSION: This study provides strong indications for the positive impact of strong general practice care on population outcomes. Key points A program to strengthen general practice in Germany comprised of prompt access to care, comprehensiveness, continuity, empanelment, data-driven quality improvement, computerized decision support, and additional reimbursement of general practices. Patients who remained in the program during 4 years had increasingly lowered rates of hospitalisation and rehospitalisation compared to a control group of patients. Avoidable hospitalisations were also lower, but no trend of further lowering was found. This might suggest a ceiling effect to impact of strong general practice on hospitalisations.

[Prescription of Benzodiazepines and Z-Drugs by German General Practitioners: A Cross-Sectional Study]. / Verordnung von Benzodiazepinen und Z-Drugs in hausärztlichen Praxen ­ eine Querschnittanalyse.

BACKGROUND: Due to their addictive potential, benzodiazepine (BZ) and non-benzodiazepine-agonists (NBZ, so-called Z-drugs) should be taken no longer than 6 weeks. BZ and NBZ are primarily prescribed by general practitioners (GPs). Therefore, we aimed to analyze GPs' data on the patients collective, the amount of BZ/NBZ prescribed and the rate of private prescriptions. METHODS: We analyzed person years of 2-year intervals from 2009 to 2014 of the primary care CONTENT register that contains routine data from 31 general practitioners' practices. We classified BZ/NBZ prescriptions according to risk groups. The association of BZ/NBZ prescription and potential influencing factors was analyzed by calculating the odds ratio with 95% confidence interval (and corresponding p-value) on the basis of a multiple logistic regression model (adjusted by age, sex and type of health insurance). All patients with drug prescription with and without BZ/NBZ-prescription were compared. RESULTS: Almost 5% of patients with drug prescriptions received at least one prescription of BZ/NBZ during 1 year of observation. On average these patients were older (67.5 vs. 48 years respectively) and the proportion of women was higher than in the comparison group (69 vs. 58%). About one-third of these patients received more than 600 mg diazepam equivalent dose per person year (according to a 2-month daily intake of more than 10 mg diazepam). About one-third of the prescriptions were private prescriptions. A number of variables were significantly associated with the prescription of BZ/NBZ (e. g. age, gender, diagnosis codes, practices). CONCLUSION: The results provide valuable information about BZ/NBZ prescription routines in general practice. For continuous medical education as well as the development of interventions to reduce the use of BZ/NBZ, patient characteristics (e. g. sex, age, comorbidities, type of insurance) as well as different prescription routines (e. g. private prescriptions, reason and frequency of prescriptions, guideline orientation) should be considered.

Evaluation of a program to strengthen general practice care for patients with chronic disease in Germany.

BACKGROUND: A program to strengthen general practice care for patients with chronic disease was offered in Germany. Enrollment was a free individual choice for both patients and physicians. This study aimed to examine the long-term impact of this program. METHODS: Two comparative evaluations were done, at 4 and 5 years (T1 and T2) after start of the program. In each year, patients in the program were compared with patients in usual care. Measures were based on routinely collected data and concerned 11 aspects of primary care and hospital care. Study groups were compared, using regression analysis adjusted for confounders and clustering. RESULTS: Data on 1.187.597 and 1.591.017 eligible patients were available for the analysis for T1 and T2, respectively. Compared to usual care, the program was associated with more visits to the GP per patient (adjusted difference at T2: +1.98), more drugs prescribed per patient (+0.071), lower percentage of drugs that should be avoided (-0.699), and lower yearly medication costs per patient (-85.39 euro). The number of referrals to ambulatory specialists, either with or without referral from GP, was reduced at T2. In hospital care, the program was associated with fewer hospital admissions per patient per year (-0.017) and fewer avoidable hospital admissions of all admissions (-1.165%). Total hospital costs were slightly higher in T1, but lower in T2. Days in hospital and number of readmissions were lower at T2 only. CONCLUSION: The program has increased the role of general practice in healthcare for patients who chose to be included in the program of intensified general practice care.

[Integration of secondary data into national diabetes surveillance : Background, aims and results of the secondary data workshop at the Robert Koch Institute]. / Integration von Sekundärdaten in die Nationale Diabetes-Surveillance : Hintergrund, Ziele und Ergebnisse des Sekundärdaten-Workshops am Robert Koch-Institut.

Epidemiological data provide evidence that diabetes mellitus is a highly relevant public health issue in Germany as in many other countries. The Robert Koch Institute (RKI) is in the process of building a national diabetes surveillance system that is aimed at establishing indicator-based public health monitoring of diabetes population dynamics using primary and secondary data. The purpose of the workshop was to conduct an inventory of available secondary data sources and to discuss data contents, data access, data analysis examples in addition to the options for ongoing data use for diabetes surveillance.

Prescribing differences in family practice for diabetic patients in Germany according to statutory or private health insurance: the case of DPP-4-inhibitors and GLP-1-agonists.

BACKGROUND: The objective of this study was to analyze prescription decisions for family practice (FP) patients with Diabetes mellitus type 2 (DM2) using the case of the incretin mimetics Dipeptidyl peptidase-4 (DDP-4) inhibitors and Glucagon-like peptide-1 (GLP-1) agonists dependent on patients' health insurance status (statutory or private) in Germany. This study is important since the scientific debate is still open with regard to DPP-4-inhibitors and GLP-1-agonists, where some critics are raising questions on potential long-term risks for patients. METHODS: Data for this analysis were sourced from the German health services research register CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork), in which FP health services information, generated by family practitioners, is continuously collated, e.g. patients' health insurance status, morbidity and pharmacotherapy. Patients with Diabetes mellitus type 1 (DM1) were excluded from the study. RESULTS: From the family practices collaborating in the CONTENT research network, there were 7298 patients treated with pharmacotherapeutic agents for DM2 between 01.09.2009 and 31.08.2014. 586 (8.03 %) of these patients had private insurance. Prescriptions for the incretin mimetics were 40.6 % higher (9.7 vs. 6.9 %; p < 0.0001) for patients with private insurance compared to patients with statutory health insurance. This finding was confirmed with multivariable analyses. CONCLUSIONS: There was a statistically significant difference found in prescription patterns according to the patient's health insurance status for the incretin mimetics in this sample population of German patients with DM2. Obviously, these differences result from the eligibility for reimbursement according to patients' health insurance status. Whether incretin mimetics pose specific long term risks for particular patients is yet to be determined.

Identification of physicians with unusual performance in screening colonoscopy databases: a Bayesian approach.

BACKGROUND: The adenoma detection rate (ADR) is an important surrogate measure of performance quality for screening colonoscopies. OBJECTIVE: To demonstrate how physicians with unusual performance concerning the adenoma detection rate may be identified in screening colonoscopy databases. DESIGN: Bayesian random-effects modeling and Winsorization of potential outliers were applied to develop a robust model for the majority of providers. Divergence was assessed with adjustment for multiple testing. The steps in the analysis were visualized by using funnel plots. Additionally, minimum requirements for the number of colonoscopies with 1 or more detected adenomas were derived. SETTING: Data from 422 physicians offering screening colonoscopy and participating in a quality assurance program in Bavaria, Germany, were used. PATIENTS: A total of 69,738 asymptomatic individuals 55 to 79 years of age. INTERVENTION: Screening colonoscopy. MAIN OUTCOME MEASUREMENTS: Physician-specific ADRs. RESULTS: The overall ADR in the sample was 26%. From an initial model, 62 physicians (15%) were identified as potential outliers. A model with normally distributed random effects was then chosen as the robust null model. Of the potential outliers, 10 (16%) were confirmed as physicians with unusual performance at a false discovery rate of 5%. For all of them, the observed ADR was lower than expected, and together they accounted for 1.4% of all included colonoscopies. LIMITATIONS: Analysis of routine data. CONCLUSION: The applied statistical approach appears suitable to identify unusual performance in screening colonoscopy databases. Its application may help to evaluate and improve the quality of colonoscopy in population-based colorectal cancer screening programs.

[GP-centered health care in Baden-Württemberg, Germany: Results of a quantitative and qualitative evaluation]. / Hausarztzentrierte Versorgung in Baden-Württemberg : Ergebnisse einer qualitativen und querschnittlich quantitativen Evaluation.

BACKGROUND: GP-centered health care ("Hausarztzentrierte Versorgung", HzV)-the terms of which are described in § 73b of the Social Code Book V-came into effect in Baden-Württemberg, Germany, on 1 July 2008. The HzV is aimed at enhancing health care for patients with chronic diseases and complex health care needs (e.g., those requiring long-term care). OBJECTIVES: On the basis of four working packages (WP I-WP IV), the present paper examines the impact that GP-centered health care has had on patients insured by the "AOK" regional sickness fund and their GPs. WP I addresses the association between HzV participation and the corresponding health care utilization of patients on the basis of claims data. WP II looks at any changes that GPs and patients noticed were potentially attributable to HzV participation. WP III focuses on health care assistants in primary care ("Versorgungsassistenten in der Hausarztpraxis", VERAH). These assistants play a special role within the framework of the HzV. WP IV analyzes the quality of health care for patients aged 65 years and over, also on the basis of claims data. MATERIALS AND METHODS: A mixed methods design was used for this evaluation, and quantitative and qualitative approaches taken. This design enabled insights into the implementation of the HzV in regular health care to be obtained from different perspectives. RESULTS: Numerous positive associations between HzV participation and the variables of interest were observed for all WPs. These are presented in detail in the paper. CONCLUSION: The results obtained so far clearly support the continuation of HzV and associated evaluations.

The Use of Medical Services for Low-Acuity Emergency Cases in Germany: Protocol for a Multicenter Observational Pilot Study.

BACKGROUND: The increasing number of requests for help for acutely ill patients and their management is a major problem in the health systems of many countries, but especially in Germany. Rescue coordination centers and ambulances in Germany are increasingly overloaded. As a result, rides as a part of rescue operations have been increasing in length for years, yet a relevant proportion of these operations represent low-acuity calls (LACs). The basic objective of this pilot study is the quantitative analysis of the potential misuse of requests to the rescue control center. Indications for alternative treatment options and how to handle these treatment options in nonacute, non-life-threatening health conditions, such as minor injuries or minor infectious diseases, will be assessed. The identification of these LACs is vital in order to prevent health care resources in emergency medical care becoming inadequate. OBJECTIVE: The overarching goal of this study is to determine the percentage of unnecessary rescue missions on site and subsequently to obtain an impression of the paramedics' assessment of alternative treatment options or alternative methods of rescue transportation. METHODS: This will be an exploratory, noninterventional, cross-sectional study with a quantitative approach. The study is multicentric, with 21 ambulances in 12 different locations. The data for this study were collected via a questionnaire, newly developed for this study, for rescue personnel. Additionally, secondary data from the responsible control center will be linked and processed in an initial descriptive analysis. This descriptive analysis will form the basis for a subsequent variance analysis. RESULTS: Data collection started as projected on September 18, 2023, and was ongoing until end of November 2023. We expect the documentation of several thousand rescue operations. We expect the following study results: (1) many unnecessary rescue operations, (2) immediate on-site assessment of correct care and treatment, and (3) patients' reasons for calling a rescue coordination center. CONCLUSIONS: To our knowledge, this is the first observational study in which acute rescue operations are recorded on site. The focus of this study is on the trained paramedics' assessment of whether rescue operations are necessary or not. Additionally, alternative treatments, such as out-of-hours care service or primary care service, are shown for each individual case. The study also intends to cover the question of which factors are relevant and statistically significantly connected to the misuse of ambulances. TRIAL REGISTRATION: German Register for Clinical Studies (Deutsches Register für Klinische Studien) DRKS00032510; https://drks.de/search/en/trial/DRKS00032510. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54002.

Expenditure of chronic venous leg ulcer management in German primary care: results from a population-based study.

The aim of the study was to determine the demand on health service utilisation and to estimate the therapeutical costs caused by patients with chronic leg ulcer (CLU) in German primary care. A population-based case-control study was conducted using electronic medical records of 116 059 patients extracted from the CONTENT primary care database of Heidelberg, Germany, between April 2007 and March 2010. The drug and non drug prescription rates among patients with CLU were analysed by means of a unified German identification key and compared with those of patients with chronic venous insufficiency (CVI) without CLU. In the 3-year-contact group, CLU patients had significantly more patient-doctor encounters (55·9 versus 40·3; p < 0·0001), more referrals to home-care services (6·12 versus 3·08; p < 0·0001), and more admissions to hospitals (0·9 versus 0·4; p < 0·0001) than CVI patients, but no difference in referrals to specialists. The annual treatment costs for drugs and non drugs in CLU patients were substantially higher than in CVI patients (1645·75 € versus 1188·17 €; p < 0·0001). Wound dressings were identified as the most cost-enlarging factor. Summarising, CLU patients in primary care settings place a higher demand on health service utilisation and need nearly one-third higher therapeutical costs compared to venous patients without ulceration.

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.

Primary Care Disease Management for Venous Leg Ulceration in German Healthcare: Results of the Ulcus Cruris Care Pilot Study.

Despite proven effectiveness, compression therapy is applied in only 20-40% of patients with venous leg ulceration, leading to avoidable chronification and morbidity. The Ulcus Cruris Care project was established to develop a new disease-management concept comparable to existing programs for chronic diseases to support evidence-based treatment of venous leg ulceration. This prospective controlled study assessed its first implementation. Interventional elements comprised online training for general practitioner practices, software support for case management, and educational materials for patients. A total of 20 practices and 40 patients were enrolled in a 1:1 ratio to the intervention and control group. Guideline-conform compression therapy was applied more frequently in the intervention group (19/20 [95%] vs. 11/19 [58%]; p = 0.006). For patients with ulcers existing ≤ 6 months, the healing rate at 12 weeks was 8/11 [73%] (intervention) compared to 4/11 [36%] (control; p = 0.087). Patients after intervention had higher scores for self-help and education in the PACIC-5A questionnaire (42.9 ± 41.6 vs. 11.4 ± 28.8; p = 0.044). Treatment costs were EUR 1.380 ± 1.347 (intervention) and EUR 2.049 ± 2.748 (control; p = 0.342). The results of this study indicate that the Ulcus Cruris Care intervention may lead to a significant improvement in care. Consequently, a broader rollout in German healthcare seems warranted.

Varicose veins are a risk factor for deep venous thrombosis in general practice patients.

BACKGROUND: The role of varicose veins (VV) as a risk factor for development of deep venous thrombosis (DVT) is still controversial. The aim of this study in primary care was to determine the impact of varicosity as a potential risk factor for developing DVT. PATIENTS AND METHODS: During the observation period between 01-Jan-2008 and 01-Jan-2011, all cases with VV (ICD code I83.9) and DVT (ICD codes I80.1 - I80.9) were identified out of the CONTENT primary care register (Heidelberg, Germany). The exposure of VV and DVT was based solely on ICD coding without regarding the accuracy of the diagnosis. The covariates age, gender, surgery, hospitalization, congestive heart failure, malignancy, pregnancy, hormonal therapy, and respiratory infection were extracted for each patient. Multivariate binary logistic regression was performed in order to assess potential risk factors for DVT. The SAS procedure "PROC GENMOD" (SAS version 9.2, 64-bit) was parameterised accordingly. A potential cluster effect (patients within practices) was regarded in the regression model. RESULTS: There were 132 out of 2,357 (5.6 %) DVT episodes among patients with VV compared to 728 out of 80,588 (0.9 %) in the patient cohort without VV (p < 0.0001). An increased risk of DVT was associated with previous DVT (adjusted odds ratio (OR): 9.07, 95 % confidence interval (CI): 7.78 - 10.91), VV (OR 7.33 [CI 6.14 - 8.74]), hospitalization during the last 6 months (OR 1.69 [CI 1.29 - 2.22]), malignancy (OR 1.55 [CI 1.19 - 2.02]), and age (OR 1.02 [CI 1.01 - 1.03]). CONCLUSIONS: There are strong associations between VV and DVT in a general practice population with documented VV. Special medical attention is required for patients with VV, a history of previous venous thromboembolism, comorbid malignancy, and recent hospital discharge, particularly those with a combination of these factors.