Physicians' experiences with indications and prescriptions of foot orthoses-A cross-sectional study in northern Germany.

Background: Foot orthoses (FOs) are prescribed by general practitioners (GPs) and orthopedic surgeons for various complaints. As there are very limited medical guidelines and checklists, the prescription of FOs is often inconsistent. Therefore, our study to evaluate the general prescription behavior and indication experiences with FOs from the perspective of GPs and orthopedists. Methods: A survey was carried out using a questionnaire from October to December 2021. GPs and orthopedic surgeons in northern Germany were included. The focus of the survey was to examine which foot problems would lead GPs and orthopedic surgeons to prescribe FOs and to evaluate what factors these physicians included in their diagnostic analysis. Apart from descriptive analyses, a stepwise linear regression analysis was performed to explore potential associations of the primary outcome variable 'specific effect on the prescription of FOs', which was introduced to shed light upon the estimated added value of the prescription of FOs. Results: Out of the 790 questionnaires distributed, 184 questionnaires were returned by GPs (n = 95) and orthopedic surgeons (n = 74) (response rate 23 %). FOs were most frequently prescribed for talipes valgus (96 %) and heel spur (54 %). Diagnostic analysis was mainly carried out clinically. Custom-made FOs (82 %) were prescribed more frequently than prefabricated FOs (6 %). Regular interaction within the prescription process was most commonly with orthopedic technicians (61 %). The estimation of the specific effect on FO prescription was assessed by a mean of 66 % of the participants, 82 % recommended self-exercises as an additional therapy. Conclusions: FOs are a specific and well-established aid prescribed by many GPs and orthopedic surgeons for a variety of foot complaints. Despite being one of the most frequently prescribed orthopedic devices, the utilization of FOs is predominantly explorative due to a growing but nevertheless still deficient body of well-researched evidence. There is a clear need for a uniform approach to the indication and prescription of FOs among physicians.

Ethical issues in dental education-A cross-sectional study with pre-clinical and clinical dental students.

INTRODUCTION: Although ethics is an indispensable part of dental education, it has not yet played a relevant role in the dental curriculum in Germany. The study aimed at assessing their prior knowledge of ethical aspects, and their expectations of and wishes for ethics course of dental students, preclinical vs. clinical, at the dental school Kiel, Germany by means of a validated questionnaire. METHODS: A descriptive cross-sectional study design was used. The study population consisted of dental students, from pre-clinical (n = 105) and clinical semesters (n = 110). In January 2019, each student completed a validated questionnaire to identify semester-specific ethical teaching content. Besides descriptive analyses, Mann-Whitney U test was used to compare pre-clinical and clinical students. RESULTS: A total of 215 dental students, with a mean age of 25.3 (SD 4.1), participated in the study, of which 150 were female (69.8%) and 65 were male students (30.2%). The results in the areas of 'previous knowledge of ethical issues' and 'expectations and desires in terms of teaching medical ethics' showed similarities and differences between pre-clinical and clinical students. Both groups stated that they need training in ethics. Moreover, especially clinical students recognize that more ethical competence is needed if the first patient contact will start. CONCLUSION: The study indicates that there is a clear need for ethics education. Student awareness of the relevance of ethical competences and the perception of ethical problems increased progressively during the course of their studies. Overall, the study provides good support for the development of specific ethics courses.

Job satisfaction and work stress among physicians in Norway and Germany-A cross-sectional study.

PURPOSE: Physicians' health and wellbeing are important albeit often neglected quality indicators of health care systems. The aims of the study were to compare job satisfaction and work stress among doctors in Germany and Norway, and to identify predictors for job satisfaction. METHODS: All active physicians in Schleswig-Holstein, Germany (N = 13,304) and a nationwide sample of Norwegian physicians (N = 2,316) were surveyed in a cross-sectional design in 2021. Response rates of German and Norwegian physicians were n = 4,385 (33%) and n = 1,639 (70.8%), respectively. In addition to age, sex, and work-hours, the main outcome measures were the validated Job Satisfaction Scale (JSS) and the short form of the Effort-Reward Imbalance Questionnaire (ERI). RESULTS: There were significant differences between Norwegian and German physicians in job satisfaction but with small effect sizes. All effort scores of German physicians were significantly higher and four of seven reward scores significantly lower than for their Norwegian colleagues. The proportion of German physicians in the state of a gratification crisis was significantly higher (67%) than in their Norwegian colleagues (53%). In both countries, physicians with a gratification crisis scored significantly lower on all items of job satisfaction. There were only minor gender differences in job satisfaction and effort-reward balance. Age, effort, and reward accounted for 46% of the explained variance of job satisfaction. CONCLUSIONS: Lower job satisfaction and reward in some areas and higher perceived effort of physicians in Germany than in Norway are still in favor of Norwegian working conditions, but the differences seem to diminish. The high proportions of gratification crises in both countries warrants appropriate measures for prevention and health promotion.

The influence of fears of perceived legal consequences on general practitioners' practice in relation to defensive medicine - a cross-sectional survey in Germany.

BACKGROUND: Medical decisions are influenced by a variety of factors also by legal requirements and feelings of uncertainty, which results in the term defensive medicine. The aim of the study was to evaluate the influence of fears of perceived legal consequences on the practice of defensive medicine from the perspective of German general practitioners (GPs). METHODS: A cross-sectional study was performed from April to May 2022. GPs were invited via an e-mail newsletter of the Institute for Continuing Education in Family Medicine in the German Association of General Practitioners and via an online platform of the German College of General Practitioners and Family Physicians. The evaluation of legal fears, the general assessment of defensive medicine and reasons for and the frequency of defensive medical measures were surveyed in this study. Beside descriptive analyses, a stepwise linear regression analysis was used to explore potential associations between for the primary outcome variable 'fears of legal consequences' on the practice of defensive medicine. RESULTS: 413 general practitioners with an average age of 50 years (51% female) responded. The majority rated their fears of legal consequences as low to average whereas for almost a third (27%, n = 113) the fears were strong to very strong. Regarding legal fears, the physician-patient-relationship played a fairly to very large role for 48% (n = 198) of the respondents. One third estimated the probability of being sued civilly in the next 10 years as rather high to very high. 47% (n = 193) of the participants assumed that the risk of being sued could mostly to very much be reduced by defensive medicine. Legal self-protection was for 38% of the responders (n = 157) quite frequently to very frequently a reason for acting defensively. Consequently, half of the respondents stated that they performed unnecessary laboratory tests at least once per week and 40% indicated that they referred patients for radiological diagnostics without medical indication once per month. CONCLUSIONS: As legal fears have an influence on medical practice and legal self-protection being a frequent reason for defensive behaviour, understanding and knowledge of the law should be improved by legal education at university and further training of post-graduate trainees and practicing physicians should be implemented. Additionally, a more in-depth enlightenment of society about the phenomenon of Protective and Defensive Medicine and its consequences could be a possibility to decrease the perceived fears of legal consequences on the physicians' side.

The impact of the COVID-19 pandemic on professional life and well-being in German physicians: A cross-sectional study.

This study assessed perceptions of German physicians' regarding the impact of the COVID-19 pandemic on work-related issues as well as mental and physical health. Almost three quarters of the physicians felt stressed by the increased quantity (69%) and quality (73%) of the work and felt physically (68%) or mentally exhausted (71%). Also about three-quarters of physicians reported the pandemic having a strong impact on family life. A higher proportion feared to infect their family more than being infected themselves (66% vs 50%). Mental health scores were significantly lower in physicians compared to the general population. In female physicians, these findings were even more pronounced. Stressful work conditions and feelings of isolation were the most important predictors for mental health scores (R2 = 0.37), and also for motivation to work (R2 = 0.20). Preventive measures to strengthen resilience and optimize work organization are warranted to alleviate the toll of the pandemic on physicians.

Determinants of the implementation of artificial intelligence-based screening for diabetic retinopathy-a cross-sectional study with general practitioners in Germany.

Objective: Diabetic retinopathy (DR) may lead to irreversible damage to the eye and cause blindness if diagnosed in its advanced stages. Artificial intelligence (AI) may support screening and contribute to a timely diagnosis. The aim of this study was to evaluate factors that might influence the success of implementing AI-supported devices for DR screenings in general practice. Methods: A questionnaire with modules on attitudes toward digital solutions, technical factors, perceived patient perspectives, and sociodemographic data was constructed and 2100 general practitioners (GPs) in Germany were invited to participate via a personal letter. Results: Two hundred nine physicians participated in the survey (10% response rate, mean age = 54 years, 46% women). Acquisition costs (mean = 1.37), remuneration (mean = 1.46), and running costs (mean = 1.40) were considered particularly relevant in the context of AI-based screening tools. GPs indicated that a mean of €27.00 (SD = 19) was considered to be an appropriate reimbursement for an AI-based screening for DR in their practice. Less relevant factors were availability of a smartphone used in the practice (mean = 2.53) and time until the examination result was available (mean = 2.29). Important technical factors were practicability of the device (mean = 1.27), unproblematic installation of any necessary software (mean = 1.34), and the integrability into the practice information system (mean = 1.44). Considering the patient welfare, physicians rated the accuracy of the examination, omission of pupil dilation, and the duration of the examination as the most important factors. Participants ranked the factors broadening the scope of care, strengthening the primary care (PC) range, and signs of modern medical practice as the most important factors for making an AI-based screening tool attractive for their practice. Conclusions: These findings serve as a basis for a successful implementation of AI-assisted screening devices in PC and might facilitate early screenings for ophthalmological diseases in general practice. The most relevant barriers that need to be overcome for a successful implementation of such tools include clarification of the costs and reimbursement policies.

Experiences with long-term care for geriatric patients by an interprofessional outpatient care approach - a qualitative study.

BACKGROUND: Outpatient care for geriatric patients is complex and requires the collaboration of different professions for supporting long-term care. Care and case management (CCM) could provide support with that. The long-term care of geriatric patients could be optimized with an interprofessional, cross-sectoral CCM. Therefore, the aim of the study was to evaluate the experiences and attitudes of those involved in the care with regard to the interprofessional design of the care for geriatric patients. METHODS: A qualitative study design was used. Focus group interviews were conducted with those involved in the care (general practitioners (GP), health care assistants (HCA) as well as care and case managers (CM)). The interviews were digitally recorded, transcribed and analysed by qualitative content analysis. RESULTS: Overall, ten focus groups were conducted in the five practice networks with n = 46 participants (n = 15 GP, n = 14 HCA and n = 17 CM). The participants evaluated the care they received from a CCM positively. The HCA and the GP were the primary points of contact for the CM. The close collaboration with the CM was experienced to be rewarding and relieving. Through their home-visitations, the CM gained a deep insight into the homelives of their patients and were thus able to accurately reflect the gaps in the care back to the family physicians. CONCLUSIONS: The different health care professionals involved in this type of care experience that an interprofessional and cross-sectoral CCM is able to optimally support the long-term care of geriatric patients. The different occupational groups involved in the care benefit from this type of care arrangement as well.

Certainty in Uncertain Times: Dental Education during the COVID-19 Pandemic-A Qualitative Study.

BACKGROUND: The restrictions concerning social contact due to the COVID-19 pandemic implied a rethinking of teaching methods at universities in general, and for practice-oriented teaching such as dental education in particular. This qualitative study aimed to assess aspects of feelings of certainty and uncertainty during this specific education process, incorporating the perspectives of teaching staff and dental students. METHODS: Qualitative methods based on interviews were used for data collection. Dental students from different academic years (second, third, fourth, and fifth) and teaching staff responsible for the content and implementation of courses within the dental curriculum were recruited. The data analysis was performed by qualitative content analysis. RESULTS: A total of 39 dental students and 19 teaching staff participated. When students and staff dealt positively with this specific situation, certainty was achieved. The availability of presentations and clear communication enhanced feelings of certainty. The participants often felt unsure about how to handle such a challenging situation and felt insecure when planning for the semester. The students missed contact with other students and argued that the information policy on their dental studies was not transparent enough. In addition, dental students and teaching staff were nervous about the risk of infection from COVID-19, especially in practical courses with patient contact. CONCLUSIONS: The COVID-19 pandemic situation leads to a rethinking of dental education. Feelings of certainty can be strengthened by clear and transparent communication as well as training in online teaching methods. To reduce uncertainty, it is crucial to establish channels for information exchange and feedback.

How Do Health Care Professionals Perceive a Holistic Care Approach for Geriatric Patients? A Focus Group Study.

BACKGROUND: Geriatric patients require holistic care in order to meet their complex care needs. The project RubiN (Continuous Care in a Regional Network) provides case and care management (CCM) for older people to address these needs in a primary care setting in Germany. This study aimed to explore the experiences of health care professionals who provided CCM for geriatric patients. METHODS: Focus group interviews with general practitioners (GPs), health care assistants (HCAs), and case managers (CMs) were conducted. Transcribed data were analyzed by using qualitative content analysis. RESULTS: Ten focus group discussions (n = 15 GPs, n = 14 HCAs, n = 17 CMs) were conducted. The different health care professionals emphasized the importance of a holistic care approach to geriatric care. Moreover, the GPs stated that the CMs supported the patients in organizing their care. A CCM could help encourage patients to remain at their own homes, which would have an effect on patients' quality of life and satisfaction. CONCLUSION: A well-functioning and effective cooperation between those health professionals involved is a prerequisite for a trustful relationship in the holistic care of older people. This creates a feeling of security for all people involved in the care process.

Encountering uncertainty and complexity in decision-making: an observational study of clinical reasoning among medical and interprofessional groups of health care students.

Poor teamwork and clinical decisions have a major impact on patient outcomes and safety. Clinical decision-making rarely occurs under ideal conditions, but complex health care environments make this particularly challenging for new graduate health professionals as beginner practitioners. Recent evidence indicates that effective collaboration also enhances quality of clinical decisions for patients with complex needs. However, collaborative decision-making is not standard in educational curricula, where clinical decision-making is usually taught in profession-specific courses emphasizing individual rationality and cognition. The aim of this study was to gain detailed insights into the practice of clinical decision-making by small groups of medical and other health care students. A qualitative observational study design was used. Students (n = 45) took part in a short role-play of a hospital clinical ethics committee meeting discussing three complex patient cases, considering clinical and ethical aspects of care, and made a group decision about priorities for treatment. Audio-recorded data were transcribed verbatim and inductively analyzed based on Strauss's "Theoretical Coding" approach. Coding and interpretation of transcripts resulted in three key themes: a) values/beliefs as a basis for negotiation; b) encountering obstacles; c) overcoming obstacles. All groups benefited from shared knowledge, assisting each other in dealing with uncertainty and perceived emotional burden. In small groups, they were able to overcome challenges and fulfil a goal potentially beyond many of them as individuals. Provision of learning opportunities where students learn to share expertise and decision-making responsibilities has the potential to optimize their learning in preparation for challenges in future practice.

Covid-19: teaching and learning in practical courses under special regulations - a qualitative study of dental students and teachers.

BACKGROUND: The coronavirus pandemic led to a lockdown of public life. For universities, this meant suspensions or corresponding adaptations of practical courses. In Germany, Kiel Dental Clinic received special permission to start practical courses under appropriate hygiene conditions. The study aimed at recording the experiences and associated challenges of course implementation under the special regulations from the perspective of students and teachers. METHODS: Qualitative guided interviews were conducted with students and teachers at Kiel in the summer semester 2020. Students (4th, 6th, 8th, 10th semesters) were recruited and lecturers responsible for conducting the practical courses within the dental clinic's four departments. Evaluation was carried out by means of qualitative content analysis, whereby deductive procedures were supplemented by inductive ones. RESULTS: Thirty-nine students and 19 lecturers took part. The flow of information at the start of the course was welcomed by students and teachers across the board. The lack of or limited adjustment to the scope tended to be assessed positively by students. The majority of both groups suspected there had been no reduction in learning, and learning had been improved due to the smaller group sizes. Regarding the necessary conditions for conducting the course, positive and negative aspects became apparent. CONCLUSION: Students and teachers felt very relief to start the practical courses under special conditions although the implementation was very challenging for both groups. The structural and content-related course adaptations required a high degree of flexibility on the part of students and lecturers alike, but also meant that courses were able to be conducted without serious deficits in learning gains.

Bridging the Gap Between Competencies and Uncertainties in Postgraduate Training in Family Medicine: Results and Psychometric Properties of a Self-Assessment Questionnaire.

Purpose: One of the reasons for postgraduate trainees not to choose working in a rural area is uncertainty related to the lack of competencies. The aim of this study was to investigate the concept of uncertainty by measuring competencies and to examine the psychometric properties of an instrument that measures competencies related to uncertainty in the self-assessment of postgraduate trainees in family medicine. Patients and Methods: A questionnaire was created based on pre-existing instruments. It was distributed to participants of postgraduate training seminars in the federal states of Baden-Württemberg and Schleswig-Holstein, Germany in 2016. Descriptive statistics and a partial correlation analysis were calculated for measuring the degree of association between year of postgraduate training and items' responses. Psychometric properties were assessed by calculating descriptive item analysis, factor analysis and internal consistency. Results: The response rate was 85% (105/124). More than one-fifth of the participants stated to show only seldom or sometimes the following skills: ability to balance work and life (N=25, 24%), letting a mild disorder run its own way (N=24, 23%) and ability to conduct interventions that decreased aggression from the patient (N=22, 21%). More than half of the participants felt (very) insecure in performing routine child check-ups, the application of a below elbow backslab and the partial removal of a toenail. Nine out of 21 items showed positive statistically significant correlation between level of competence and progress in training. Factor analysis led to a final instrument with 12 items (Cronbach's α=0.736) and a three-factor-structure: "doctor well-being and resilience", "communication" and "skills". Conclusion: In order to reduce uncertainty with all its consequences, a focus on teaching of competencies regarding the physicians' well-being and resilience, communication and skills has to be continued in postgraduate training.

The predictive validity of admission criteria for the results of clinical competency assessment with an emphasis on family medicine in the fifth year of medical education: an observational study.

BACKGROUND: In many countries, the number of applicants to medical schools exceeds the number of available places. This offers the need, as well as the opportunity to medical schools to select those applicants most suitable for later work as a doctor. However, there is no generally accepted definition of a 'good doctor'. Clinical competencies may serve as surrogates. The aim of this study was to compare medical students in Germany selected based either on their pre-university grade point average alone or based on the result of a university-specific selection procedure regarding their clinical competencies with an emphasis on family medicine in the later years of training. METHODS: We used the 'Allgemeinarztbarometer Ausbildung' (Undergraduate Family Medicine Barometer), an instrument developed to assess clinical competencies with an emphasis on family medicine, to compare students in the pre-university grade point average admission-quota and the university-specific selection procedure admission-quota in the fifth year of training. Students were judged by their supervising general practitioners after a two-week practical course. Competencies were rated on a five-point Likert-scale (1 = 'totally agree' i.e. the student is very competent to 5 = 'totally disagree' i.e. the student is not competent at all). RESULTS: We included 94 students (66% female). Students in the university-specific selection procedure quota (n = 80) showed better mean scores in every item of the Undergraduate Family Medicine Barometer. We found a statistically significant difference between the two groups for the item assessing communication skills (M [university-specific selection procedure quota] = 1.81, SD = 0.84 vs. M [pu-GPA quota] = 2.38, SD = 0.96; t[91] = -2.23, p = .03; medium effect size). Logistic regression revealed no statistically significant age or gender contribution. CONCLUSIONS: Despite the small sample-size, our results indicate, that students selected via an university-specific selection procedure show better communicative competencies in the later years of training.

Suspension of face-to-face teaching and ad hoc transition to digital learning under Covid-19 conditions - a qualitative study among dental students and lecturers.

BACKGROUND: In mid-March 2020, the coronavirus pandemic led to a national lockdown in Germany. Face-to-face teaching was cancelled in universities for the 2020 summer semester. Teaching moved online with no prior IT testing and lecturer training. The study analyses experiences of the suspension of face-to-face teaching and the move to digitalised learning for students and lecturers of dentistry at Kiel. METHODS: In summer 2020, qualitative guided interviews were conducted with students (4th, 6th, 8th, and 10th semesters), and lecturers. Deductive and inductive qualitative content analysis of the results was carried out. RESULTS: Thirty-nine students (69% female) and 19 lecturers (32% female) were interviewed. Reactions to the changes in teaching were observed. Feelings ranged from an essentially positive attitude, through insecurity and uncertainty to a failure to fully appreciate the situation. The loss of social contact was lamented. Digitalisation was associated with technological challenges and additional work. However, it also fostered learning independent of time and place, and encouraged autonomy. Negative aspects of digitalisation included a lack of feedback and loss of interaction. CONCLUSION: The introduction of ad hoc digitalisation challenged both students and lecturers alike. Dealing with lockdown and the changes in teaching and studying required significant flexibility.

Experiences of family caregivers regarding a community-based care- and case-management intervention. A qualitative study.

Family caregivers play an essential role in healthcare for elderly people in primary care settings. The complexity of geriatric patients as well as the fragmentation of healthcare systems can lead to a burden for family caregivers, which can affect their physical and psychological health as well as social relationships, economic productivity and quality of caregiving. Care- and case-management offers a possibility to support, empower and navigate family caregivers through healthcare systems in order to reduce their own burden. The project RubiN (Continuous care in a regional network) was developed to provide regional care- and case-management for outpatient care of the elderly (age >70 years) in a primary care setting in Germany. The aim of this qualitative study was to explore experiences and attitudes of family caregivers of geriatric patients regarding the community-based care- and case-management intervention RubiN. Telephone interviews with a purposeful sample of 21 family caregivers enlisted in all RubiN networks were conducted between March and May 2020 and were followed by qualitative content analysis. The main categories, which emerged were namely: (1) current healthcare situation and (2) experiences with RubiN. Main findings suggest that participants in this study valued the provided support and experienced a sense of relief. However, some participants were disappointed with RubiN and the included support by care- and case-managers. A care- and case-management affected caregiving per se as well as the patient's and family caregiver's well-being. Important aspects contributing to these findings were a continuous relationship, training and expertise of the care- and case-managers. Establishing networks between the patients, family caregivers, care- and case-managers and healthcare providers were key components as well as a good explanation about RubiN itself for family caregivers. Therefore, a community-based care- and case-management can play an important role in detecting, facilitating and preventing family caregiver burden.

Short report: coaching as an intervention to treat mild form of fear of flying.

Fear of flying can lead to restrictions in private but also in professional life. Different treatment approaches are available to handle fear of flying. Of these, coaching could be one possible treatment method. However, evidence is rare and the aim of this study was to evaluate descriptive effect of wingwave® coaching on a mild form of fear of flying. Coaching was delivered twice before the first flight and once after the first flight. The interventions were conducted between December 2016 and May 2017. Four people with fear of flying participated in the study. As measurement tools, satisfaction with life scale and 'Fear of Flying Scale' (FFS) were used at each of the measurement points. The measurement of fear of flying using the FFS measures showed a reduction in all four individuals. The participants also revealed a benefit in the sub-scales Anticipation, Flying and Turbulence. Our study indicates a positive impact of wingwave® coaching on dealing with a mild form of fear of flying.

Measuring care coordination in German primary care - adaptation and psychometric properties of the Medical Home Care Coordination Survey.

BACKGROUND: Continuity of care is associated with many benefits for patients and health care systems. Therefore measuring care coordination - the deliberate organization of patient care activities between two or more participants - is especially needed to identify entries for improvement. The aim of this study was the translation and cultural adaptation of the Medical Home Care Coordination Survey (MHCCS) into German, and the examination of the psychometric properties of the resulting German versions of the MHCCS-P (patient version) and MHCCS-H (healthcare team version). METHODS: We conducted a paper-based, cross-sectional survey in primary care practices in three German federal states (Schleswig-Holstein, Hamburg, Baden-Württemberg) with patients and health care team members from May 2018 to April 2019. Descriptive item analysis, factor analysis, internal consistency and convergent, discriminant and predictive validity of the German instrument versions were calculated by using SPSS 25.0 (Inc., IBM). RESULTS: Response rates were 43% (n = 350) for patients and 34% (n = 141) for healthcare team members. In total, 300 patient questionnaires and 140 team member questionnaires could be included into further analysis. Exploratory factor analyses resulted in three domains in the MHCCS-D-P and seven domains in the MHCCS-D-H: "link to community resources", "communication", "care transitions", and additionally "self-management", "accountability", "information technology for quality assurance", and "information technology supporting patient care" for the MHCCS-D-H. The domains showed acceptable and good internal consistency (α = 0.838 to α = 0.936 for the MHCCS-D-P and α = 0.680 to α = 0.819 for the MHCCS-D-H). As 77% of patients (n = 232) and 63% of health care team members denied to have or make written care plans, items regarding the "plan of care" of the original MHCCS have been removed from the MHCCS-D. CONCLUSIONS: The German versions of the Medical Home Care Coordination Survey for patients and healthcare team members are reliable instruments in measuring the care coordination in German primary care practices. Practicability is high since the total number of items is low (9 for patients and 27 for team members).

Facilitators and barriers for the implementation of telemedicine from a local government point of view - a cross-sectional survey in Germany.

BACKGROUND: Telemedicine offers additional ways of delivering medical care, e.g., in primary care in rural areas. During the last decades, projects including telemedicine are being implemented worldwide. However, implementation of telemedicine is in some countries, e.g., Germany somewhat slower compared to northern European countries. One important part of successful implementation is to include the citizen perspective. The aims of this study were to explore the perception of representatives of the local government regarding telemedicine in the context of a perceived GP shortage and to tailor future telemedicine offers according to these perceived needs. METHODS: Considering the multidisciplinary assessment suggested by the Model for Assessment of Telemedicine a questionnaire with 19 questions was developed by identifying determinants of telemedicine out the literature. After pre-testing, the questionnaire was sent to all 2199 mayors from the federal states of Schleswig-Holstein (North Germany) and Baden-Württemberg (South Germany) as representatives of the citizens (cross- sectional study; full population survey). The final questionnaire contained sections for socio-demographic data, telemedicine and perceived GP shortage. All responses from November 2018 until 2019 were included and analyzed descriptively. RESULTS: The response rate was 32% (N = 699), of which 605 were included in the analysis. A majority of the participants stated they live in a rural area and 46% were in the office for up to 8 years. The mayors had predominantly a positive perception about telemedicine (60%) and 76% of them stated, their community would benefit from telemedicine. A GP shortage was reported by 39% of the participants. The highest risk of telemedicine was seen in misdiagnosing. In case of an emergency situation 291 (45%) of the participants considered data privacy as not as relevant. Mayors from a community with a perceived GP shortage had a more negative perception regarding telemedicine. CONCLUSION: The acceptance of telemedicine is rapidly rising compared to former studies. Communities with a perceived GP shortage had a more negative perception. Barriers like data security concerns were seen as less important in case of an emergency. The highest risk of telemedicine was seen in misdiagnosing. These findings need to be considered in designing future telemedicine offers.

RubiN - continuous care in regional networks: a study protocol for a prospective controlled trial.

BACKGROUND: The health care situation of geriatric patients is often multifaceted, complex and often overlaps with social living conditions. Due to the lack of cross-sectoral and interprofessional health care geriatric patients often, receive insufficient care. Only a holistic view enables a comprehensive evaluation of the complex health risks, but also the potential to preserve the health of geriatric patients. The implementation of cross-sectoral, multi-professional case management could reduce the gaps in care, improve the autonomy of the geriatric patients in their own homes, and allow them to retain it as long as possible. The "RubiN" project examines the effects of multi-professional, cross-sectoral and assessment-based case management on the quality of the care of geriatric patients. The results of the study aim to show whether geriatric patients receive better care using case management than patients who receive standard health care. In addition, data on the effects of case management on practices of general practitioners (GP), the satisfaction with the care concept amongst the case managers, patients and relatives will be collected. Furthermore, a health economic analysis will be carried out. METHODS: The project is designed as a prospective controlled study and compares geriatric patients from practice networks in different regions in Germany. Inclusion criteria are: Age ≥ 70 years and care requirements from two different care complexes (identified with the screening instrument 'Angelina'-questionnaire). The intervention is the use of a geriatric case management, where health care is organised based on patient-specific care requirements. Five practice networks of physicians will implement the intervention (n = 3200 patients) and three practice networks will serve as the control group (n = 1200 patients). The primary endpoint is the ability to manage activities of daily living, measured using the Barthel Index. The patients in the intervention group receive geriatric case management and the patients in the control networks receive standard care ("care as usual"). The analysis of the primary data, which is pseudonymised, occurs according to the intention-to-treat principle. For this purpose, the endpoints will be analysed using a group comparison after 12 months. For the health economic analysis, secondary data from the statutory health insurance providers will be included in the analysis, in addition to the primary data. Data for the analysis of the effects the concept has on the GP practices as well as on the satisfaction of the project participants will be collected with questionnaires and interviews with experts. DISCUSSION: The implementation of cross-sectoral and interdisciplinary geriatric case management has been a topic of discussion for years, whereby positive effects have already been-shown. This planned study will be the first evaluation of the effect of case management for geriatric patients with a very large sample. In addition, the effects of case management on the GP practices and also on the relatives of the geriatric patients will be shown. It is intended that the study results pave the way for a widespread implementation of this concept. TRIAL REGISTRATION: German Clinical Trials Register, ID: DRKS00016642 . Registered on 29 October 2019 - Retrospectively registered.

Regional differences in general practitioners' behaviours regarding influenza vaccination: a cross-sectional study.

BACKGROUND: The World Health Organization recommends vaccination rates of 75% against seasonal influenza for patients over 65 years old. In the 2013/2014 season, the German vaccination rates ranged between 14 and 65%. This study aimed to compare the attitudes, personal characteristics and vaccination behaviours of general practitioners (GPs) in regions with high and low vaccination rates in Germany. METHODS: In May 2016, a questionnaire was sent to 1594 GPs practising in 16 districts with the highest and the lowest vaccination rates in Western and Eastern Germany as described by the Central Research Institute of Ambulatory Health Care in Germany for the 2013/2014 season. Descriptive statistics and multiple regression analyses were computed to identify potential factors associated with high vaccination rates. RESULTS: A total response rate of 32% (515/1594 participants) was observed in the study. GPs reported their attitudes towards vaccination in general and vaccination against influenza as mostly 'very positive' (80%, n = 352 and 65%, n = 288, respectively). GPs practising in regions with low vaccination rates reported their attitudes towards vaccinations in general (p = 0.004) and towards influenza vaccination (p = 0.001) more negatively than their colleagues from regions with high vaccination rates. Multiple logistic regression identified an increasing influence of year-dependent changing efficiency on GPs' influenza rates as the strongest factor for predicting GPs from highly vaccinating regions (OR = 4.31 [1.12-16.60]), followed by the patient's vaccination refusal despite GP advice due to already receiving a vaccination from another physician (OR = 3.20 [1.89-5.43]) and vaccination information gathering through medical colleagues (OR = 2.26 [1.19-4.29]). CONCLUSIONS: The results of this study suggest a correlation between GPs' attitudes and regional vaccination rates. Beneath GPs' individual attitudes, the regional attitude patterns of patients, colleagues and medical assistants surrounding those GPs seem decisive and should be integrated into future campaigns to increase vaccination rates at a regional level.