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.

[Analysis of Sickness-Related Days of Absence among Soldiers of the German Armed Forces from 2008 to 2018 Part 1: Retrospective Analysis with Comparison to the Statutory Health Insurance System]. / Analyse der krankheitsbedingten Fehltage von Soldatinnen und Soldaten der Bundeswehr von 2008 bis 2018 Teil 1: Retrospektive Analyse mit Vergleich zur Gesetzlichen Krankenversicherung.

BACKGROUND: Sickness-related absences are of particular importance both in the German armed forces and in the civilian sector. THE AIM OF THIS STUDY: was to analyze the incidence of sick leave among soldiers in comparison to the working population covered by the statutory health insurance (SHI) system. METHOD: According to the systematics of the SHI, the key figures on incapacity to work in the period 2008-2018 are calculated in an age- and gender-standardized manner. Likewise, a list of the TOP 20 ICD-10 diagnoses in relation to incapacity to work was determined, and their average annual rates of change were calculated for trend analysis. RESULTS: The annual rate of sick leave among soldiers was between 1.5 and 2.3%, which was lower than that of the SHI (3.1 to 5.0%). The duration of illness (sick days per case) among soldiers was between 9.0-15.6 days per year, compared with 10.9-14.4 days in the SHI system. The sickness frequency (cases per 100 persons) was lower among soldiers (48.2-75.0 cases) than in the SHI (96.8-131.0 cases). Most days of absence among soldiers were due to "respiratory infections (J06)" with 13.2%, "stress reactions (F43)" with 8.7%, "other infectious gastroenteritis and colitis (A09)" with 6.5%, "back pain (M54)" with 4.4% and "depressive episode (F32)" with 4.0% of all days of absence and were comparable to the values in SHI. "Depressive episode (F32)", "injuries (T14)", sreactions (F43)", "respiratory infections (J06)" and "pregnancy complaints (O26)" showed the highest rates of increase of+6.1% to+3.6% of days off work. CONCLUSION: For the first time, it was possible to compare the sickness rate of soldiers with that of the general population in Germany, which may also provide indications for further measures for primary, secondary and tertiary prevention. The lower sickness rate among soldiers compared with the general population is mainly due to a lower incidence of illness, with a similar duration and pattern of illness, but with an overall upward trend. The ICD-10 diagnoses "Depressive episode (F32)," "injuries (T14)," "stress reactions (F43)," "acute upper respiratory tract infections (J06)" and "pregnancy complaints (O26)," which are increasing at an above-average rate in relation to the number of days absent, require further analysis. This approach seems promising, for example, to generate hypotheses and ideas for further improvement of health care.

[Acute respiratory tract infections and antibiotic prescriptions: What are patients' expectations?] / Akute Atemwegsinfekte und Antibiotikaverordnungen: Welche Erwartungen haben Patient*innen?

INTRODUCTION: The use of antibiotics in human medicine is partly responsible for the global increase in antibiotic resistance. Significant reductions in antibiotic prescribing were realised through educational campaigns, communication training and prescribing feedback. Based on data from the cluster-randomised CHANGE-3 trial, the present analysis focuses on the question of patient expectations for an antibiotic in acute respiratory infections. METHODS: 106 of 114 General Practitioner (GP) practices in Baden-Württemberg and Mecklenburg-Western Pomerania took part in the study. 4736 patients who visited the practices with acute respiratory infections from October 2018 to May 2019 filled out a questionnaire after the doctor's consultation. The analysis was descriptive. RESULTS: 16.7 % of patients with acute respiratory infections reported receiving antibiotics from their GP. 13.3 % of patients had hoped for an antibiotic and 5.5 % stated that they had asked their GP for an antibiotic prescription. The lowest prescription rate for antibiotics was reported by patients who had received a diagnosis of influenza from their GP. With specific diagnoses differentiated from uncomplicated respiratory tract infection, an increase in both the number of antibiotics hoped for and the number of antibiotics prescribed was observed. DISCUSSION: Patients still receive antibiotics more often than they actually hope for. On the part of GPs, prescriptions may still be written because of perceived pressure from patients, but this is not reflected in patient expectations. In addition to dealing openly with patients' expectations, strengthening patients' health literacy, mindful doctor-patient communication and offered opportunities for re-presentation in the case of specific diagnoses could further reduce the perceived pressure on GPs.

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.

Challenges and opportunities for general practice specific CME in Europe - a narrative review of seven countries.

BACKGROUND: Several changes have led to general practitioners (GPs) working in a more differentiated setting today and being supported by other health professions. As practice changes, primary care specific continuing medical education (CME) may also need to adapt. By comparing different primary care specific CME approaches for GPs across Europe, we aim at identifying challenges and opportunities for future development. METHODS: Narrative review assessing, analysing and comparing CME programs for general practitioners across different north-western European countries (UK, Norway, the Netherlands, Belgium (Flanders), Germany, Switzerland, and France). Templates containing detailed items across seven dimensions of country-specific CME were developed and used. These dimensions are role of primary care within the health system, legal regulations regarding CME, published aims of CME, actual content of CME, operationalisation, funding and sponsorship, and evaluation. RESULTS: General practice specific CME in the countries under consideration are presented and comparatively analysed based on the dimensions defined in advance. This shows that each of the countries examined has different strengths and weaknesses. A clear pioneer cannot be identified. Nevertheless, numerous impulses for optimising future GP training systems can be derived from the examples presented. CONCLUSIONS: Independent of country specific CME programs several fields of potential action were identified: the development of curriculum objectives for GPs, the promotion of innovative teaching and learning formats, the use of synergies in specialist GP training and CME, the creation of accessible yet comprehensive learning platforms, the establishment of clear rules for sponsorship, the development of new financing models, the promotion of fair competition between CME providers, and scientifically based evaluation.

[Transfer of Physicians' Tasks to Nurses in the Care of People with Dementia]. / Aufgabenübertragung ärztlicher Tätigkeiten in der Versorgung von Menschen mit Demenz auf Pflegefachpersonen in Substitution und Delegation.

THE AIM OF THE STUDY: A transfer of medical activities to nurses and thus the redistribution of tasks has been discussed for almost 15 years. A legal base for model projects has been enacted. However, clearly defined tasks for substitution are still lacking. The aim of this study was to solicit opinions of general practitioners, nurses, people with dementia (PwD) and their relatives about the possibility of a large number of specific General practitioner (GP) tasks being performed by nurses in outpatient dementia care. METHODS: A mixed-methods study with a sequential in-depth design was conducted. The analysis presented here refers to the quantitative survey of the four participant groups. 865 participants were asked about the acceptance of substitution of assessments, primary and follow-up prescriptions, health monitoring measures and other activities currently performed by physicians. RESULTS: Across all groups of subjects, the highest level of approval for substitution was achieved for the assessment of mobility restrictions, everyday competencies, nutritional abnormalities, prescription of transportation, nursing aids, home nursing services and drawing of blood samples. Among PwD and relatives, the level of acceptance for substitution was very high. 88% of the PwD and relatives indicated that many activities can be substituted while the general practitioner remained their first point of contact. More GPs (63.2%) than nurses (56.7%) would accept the substitution. CONCLUSION: The results indicate that a large number of GPs, nurses, patients and their relatives welcome substitution. However, PwD and relatives have a significantly more positive attitude towards substitution.

[Task sharing in outpatient dementia care - Focus groups with GPs and nurses]. / Aufgabenteilung in der ambulanten Versorgung von Menschen mit Demenz.

Task sharing in outpatient dementia care - Focus groups with GPs and nurses Abstract. Background: Caring for people with dementia (PWD) is challenging for the health system and family carers and can only be managed through interprofessional medical and nursing care. AIM: The AHeaD study investigated attitudes of general practitioners (GPs) and nurses towards the transfer of activities previously performed by GPs to advanced nurses in the outpatient care of PWDs. METHODS: In four focus group discussions with 10 GPs and 13 nurses, qualitative content analysis was used to investigate attitudes towards the transfer of certain tasks and to identify opportunities and barriers to their introduction. RESULTS: GPs primarily preferred the transfer of nursing activities such as blood sampling, assessments, their monitoring or follow-up prescriptions for nursing aids. "Classical" medical tasks (e. g. diagnosis of diseases, initial prescription of medication) are still seen in the hands of GPs. Nurses demanded more appreciation and recognition for the relationship between GPs and nurse and criticised the lack of trust and insufficient communication. Both sides pointed to tight time budgets that were hardly oriented towards the actual needs of the PWD. CONCLUSIONS: The implementation of a redistribution of tasks requires the creation of legal and financial framework conditions, time resources, concrete task descriptions as well as a stronger cooperation between the professional groups involved. Innovative concepts could contribute to the sensible use of the resources GP and nurses and strengthen the care of PWDs.

Shared decision making and patient-centeredness for patients with poorly controlled type 2 diabetes mellitus in primary care-results of the cluster-randomised controlled DEBATE trial.

BACKGROUND: We investigate whether an educational intervention of GPs increases patient-centeredness and perceived shared decision making in the treatment of patients with poorly controlled type 2 diabetes mellitus? METHODS: We performed a cluster-randomized controlled trial in German primary care. Patients with type 2 diabetes mellitus defined as HbA1c levels ≥ 8.0% (64 mmol/mol) at the time of recruitment (n = 833) from general practitioners (n = 108) were included. Outcome measures included subjective shared decision making (SDM-Q-9; scale from 0 to 45 (high)) and patient-centeredness (PACIC-D; scale from 1 to 5 (high)) as secondary outcomes. Data collection was performed before intervention (baseline, T0), at 6 months (T1), at 12 months (T2), at 18 months (T3), and at 24 months (T4) after baseline. RESULTS: Subjective shared decision making decreased in both groups during the course of the study (intervention group: -3.17 between T0 and T4 (95% CI: -4.66, -1.69; p < 0.0001) control group: -2.80 (95% CI: -4.30, -1.30; p = 0.0003)). There were no significant differences between the two groups (-0.37; 95% CI: -2.20, 1.45; p = 0.6847). The intervention's impact on patient-centeredness was minor. Values increased in both groups, but the increase was not statistically significant, nor was the difference between the groups. CONCLUSIONS: The intervention did not increase patient perceived subjective shared decision making and patient-centeredness in the intervention group as compared to the control group. Effects in both groups might be partially attributed to the Hawthorne-effect. Future trials should focus on patient-based intervention elements to investigate effects on shared decision making and patient-centeredness. TRIAL REGISTRATION: The trial was registered on March 10th, 2011 at ISRCTN registry under the reference ISRCTN70713571 .

Attitudes towards advanced nursing roles in primary dementia care - Results of an observational study in Germany.

AIMS: To demonstrate the attitudes of general practitioners (GPs), nurses, persons with dementia, and caregiver towards suitable tasks and qualification needs for and the acceptance and impact of advanced nursing roles in German dementia primary care. DESIGN: Observational study using a questionnaire survey with 225 GPs, 232 nurses, 211 persons with dementia, and 197 caregivers, conducted between December 2017-August 2018. METHODS: A questionnaire was generated that includes specific assessment, prescription, and monitoring tasks of advanced nursing roles in dementia primary care as well as qualification requirements for and the acceptance and the impact of advanced nursing roles. Data were analysed using descriptive statistics. Group differences were assessed using the Fisher's exact test. RESULTS: Advanced nursing roles were highly appreciated across all groups. Assessment and monitoring tasks were rated as highly suitable, and prescription authorities as moderately suitable. Nurses felt less confident in assessment and monitoring, but more confident in prescribing as practitioners expected. Patients and caregivers would appreciate a takeover of tasks by nurses; nurses and practitioners preferred a delegation. A dementia-specific qualification was rated as best suitable for advanced nursing roles, followed by 'no specific qualification' if medical tasks that only can be carried out by practitioners were delegated and an academic degree if tasks were substituted. Advanced nursing roles were rated as beneficial, strengthening the confidence in nursing care and improving the cooperation between professionals and the treatment. Practitioners assumed that advanced nursing roles would improve job satisfaction of nurses, which was not confirmed by nurses. CONCLUSION: There is an extended consensus towards the enlargement of advanced nursing roles, represented by high endorsement, acceptance, and willingness to reorganize tasks. IMPACT: Results debunk the common notion that German practitioners would be reluctant towards advanced nursing roles and a takeover of current practitioner tasks, supporting the implementation of advanced nursing roles in Germany.

Treatment Complexity in Primary Open-Angle Glaucoma (POAG): Perspectives on Patient Selection in Micro-Invasive Glaucoma Surgery (MIGS) Using Stents. / Versorgungskomplexität beim primären Offenwinkelglaukom (POWG): Perspektiven zur Patientenauswahl in der mikroinvasiven Glaukomchirurgie (MIGS) mit Stents.

BACKGROUND: Primary open-angle glaucoma (POAG) is still one of the most common causes of impaired vision worldwide, despite the further development of therapy options, and can lead to blindness. Micro-invasive glaucoma surgery (MIGS) using stents aims at reducing intraocular pressure (IOP), as it is the main risk factor. With regard to adherence and adverse drug reactions it also aims at reducing the drug burden on patients. The study investigates under everyday conditions the criteria according to which ophthalmologists in Germany select patients for MIGS using stents. In addition, it will be investigated which patients (could) benefit most from the therapy. MATERIAL AND METHODS: In this qualitative study, 11 narrative interviews were conducted between May 2017 and July 2018 with ophthalmologists working in the hospital or in a private practice. They were interviewed on their experiences in the treatment of POAG with microstents. The interviews were analysed by an interdisciplinary team using the qualitative content analysis. RESULTS: The stages of therapy escalation form the frame of reference for patient selection in MIGS using stents. Only if the IOP cannot be sufficiently reduced by drop therapy or when this causes drug-related side effects that are intolerable for the patients, stents are apparently used as the next higher escalation stage. The intensive post-operative medication and the frequent check-up appointments are perceived as barriers by the interviewees, especially for people with or without disabilities, who are dependent on external help and/or those living in rural areas. The active cooperation of the patients in the demanding aftercare seems to be indispensable for the ophthalmologists. In addition, necessary revisions are sometimes stressful for patients (physical/psychological) and doctors (work organisation/therapy). Against the background of the organisational and economic challenges in the outpatient spectrum of tasks, especially physicians in private practice seem to weigh up carefully for which patients microstent therapy would be reasonable. CONCLUSION: In view of the therapeutic requirements, the current microstent therapy seems to be used in a selected, adherent patient group. Further qualitative and quantitative studies (in other health care regions and structures) are necessary to verify and extend the available results.

Comparing stroke prevention therapy of direct oral anticoagulants and vitamin K antagonists in patients with atrial fibrillation: a nationwide retrospective observational study.

BACKGROUND: Direct oral anticoagulants (DOACs) are not only increasingly being used for the initial stroke prevention therapy but progressively also substitute vitamin K antagonist (VKA) treatment in patients with non-valvular atrial fibrillation (AF). DOACs have been compared regarding therapeutic efficacy and adverse outcomes to warfarin in several pivotal studies and showed non-inferiority in terms of stroke prevention and superiority in terms of bleeding complications. However, comprehensive comparative studies are lacking for phenprocoumon, a VKA prescribed frequently outside the USA and the UK and accounting for 99% of all VKA prescriptions in Germany. Patients treated with phenprocoumon seem to meet more often international normalized ratio values in the therapeutic range, which may have implications concerning their efficacy and safety. This study aims at comparing the risk of stroke and bleeding in phenprocoumon- and DOAC-treated patients with AF in an adequately powered observational study population. METHODS: Retrospective analysis of stroke and bleeding incidence of 837,430 patients (1.27 million patient years) treated with DOAC or phenprocoumon for stroke prevention in German ambulatory care between 2010 and 2017. Relative risks of stroke and bleeding were estimated by calculating cox regression-derived hazard ratios (HR) and 95% confidence intervals (CI) of propensity score-matched cohorts. RESULTS: Patients treated with DOAC had an overall higher risk for stroke (HR 1.32; CI 1.29-1.35) and a lower risk for bleeding (0.89; 0.88-0.90) compared to phenprocoumon. When analyzed separately, the risk for stroke was higher for dabigatran (1.93; 1.82-2.03), apixaban (1.52; 1.46-1.58), and rivaroxaban (1.13; 1.10-1.17) but not for edoxaban (0.88; 0.74-1.05). The risk for bleeding was lower for dabigatran (0.85; 0.83-0.88), apixaban (0.71; 0.70-0.73), and edoxaban (0.29; 0.17-0.51) but not for rivaroxaban (1.03; 1.01-1.04). CONCLUSIONS: This study provides a comprehensive view of the stroke and bleeding risks associated with phenprocoumon and DOAC use in Germany. Phenprocoumon may be preferable to DOAC treatment for the prevention of strokes in AF in a real-world population cared for in ambulatory care.

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.

Patient-centered communication and shared decision making to reduce HbA1c levels of patients with poorly controlled type 2 diabetes mellitus - results of the cluster-randomized controlled DEBATE trial.

BACKGROUND: Does an intervention designed to foster patient-centered communication and shared decision making among GPs and their patients with poorly controlled type 2 diabetes mellitus reduce the level of HbA1c. METHODS: The DEBATE trial is a cluster-randomized controlled trial conducted in German primary care and including patients with type 2 diabetes mellitus having an HbA1c level of 8.0% (64 mmol/mol) or above at the time of recruitment. Data was measured before intervention (baseline, T0), 6-8 months (T1), 12-14 months (T2), 18-20 months (T3), and 24-26 months (T4) after baseline. Main outcome measure is the level of HbA1c. RESULTS: In both, the intervention and the control group the decline of the HbA1c level from T0 to T4 was statistically significant (- 0.67% (95% CI: - 0.80,-0.54%; p < 0.0001) and - 0.64% (95% CI: - 0.78, - 0.51%; p < 0.0001), respectively). However, there was no statistically significant difference between both groups. CONCLUSIONS: Although the DEBATE trial was not able to confirm effectiveness of the intervention tested compared to care as usual, the results suggest that patients with poorly controlled type 2 diabetes are able to improve their blood glucose levels. This finding may encourage physicians to stay on task to regularly approach this cohort of patients. TRIAL REGISTRATION: The trial was registered at ISRCTN registry under the reference ISRCTN70713571 .

Satisfaction with general practice care in German patients with multimorbidity: a cross-sectional study.

Background: Little is known about the quality of general practice care received by patients suffering from multimorbidity. Objectives: To assess how patients with multimorbidity evaluate their General Practitioners (GPs') performance and to identify factors associated with high patient satisfaction levels. Methods: Cross-sectional study in Germany using the EUROPEP questionnaire consisting of 23 items with a five-point Likert scale and covering two dimensions: clinical performance of the GP and organisation of care. Mixed logistic regression was used in the analysis, with the EUROPEP score as a dependent variable. Results: The study included 651 patients (54.8% female), with a mean age of 73.7 ± 4.9 years. Of 22 of 23 questionnaire items, >80% of patients rated their satisfaction as 'good' or 'excellent'. The highest level of satisfaction (excellent) varied among items between 28.0 and 73.1%. Lower age and female sex of GPs were associated with better patient evaluations in 15 and 12 of the 23 items, respectively. Patient characteristics were not associated with their satisfaction with their GP. Conclusions: This study found high levels of satisfaction with primary care in patients with multimorbidity. However, since high levels of patient satisfaction are not necessarily equivalent to high quality of care, a broader view is necessary to integrate the subjective views of patients and objective quality indicators into a comprehensive concept of good quality of care.

Perceptions of interprofessional collaboration of general practitioners and community pharmacists - a qualitative study.

BACKGROUND: Despite numerous evidences for the positive effect of community pharmacists on health care, interprofessional collaboration of pharmacists and general practitioners is very often limited. Though highly trained, pharmacists remain an underutilised resource in primary health care in most western countries. This qualitative study aims at investigating pharmacists' and general practitioners' views on barriers to interprofessional collaboration in the German health care system. METHODS: A total of 13 narrative in-depth interviews, and two focus group discussions with 12 pharmacists and general practitioners in Mecklenburg-Western Pomerania, a predominantly rural region of North-Eastern Germany, were conducted. The interviews aimed at exploring general practitioners' and pharmacists' attitudes, views and experiences of interprofessional collaboration. At a second stage, two focus group discussions were performed. Fieldwork was carried out by a multi-professional team. All interviews and focus group discussions were audio taped and transcribed verbatim. The constant comparative method of analysis from grounded theory was applied to the data. RESULTS: There are three main findings: First, mutual trust and appreciation appear to be important factors influencing the quality of interprofessional collaboration. Second, in light of negative personal experiences, pharmacists call for a predefined, clear and straightforward way to communicate with physicians. Third, given the increasing challenge to treat a rising number of elderly patients with chronic conditions, general practitioners desire competent support of experienced pharmacists. CONCLUSIONS: On the ground of methodological triangulation the findings of this study go beyond previous investigations and are able to provide specific recommendations for future interprofessional collaboration. First, interventions and initiatives should focus on increasing trust, e.g. by implementing multi-professional local quality circles. Second, governments and health authorities in most countries have been and still are reluctant in advancing political initiatives that bring together physicians and pharmacists. Proactive lobbying and empowerment of pharmacists are extremely important in this context. In addition, future physician and pharmaceutical training curricula should focus on comprehensive pharmacist-physician interaction at early stages within both professional educations and careers. Developing and fostering a culture of continued professional exchange and appreciation is one major challenge of future policy and research.

[Approaches of general practitioners and patients to multimorbidity. Qualitative study]. / Multimorbidität aus Hausarzt- und Patientensicht. Qualitative Studie.

BACKGROUND: For general practioners (GP) the treatment of patients suffering from multimorbidity is an everyday challenge. For these patients guidelines which each focus on a specific chronic disease cannot be applied comprehensively and equally; therefore, it is necessary to prioritize. OBJECTIVE: Given this situation the study aimed at analyzing how GPs and patients deal with this challenge and what their priorities are. MATERIAL AND METHODS: Narrative interviews were conducted with 9 GPs and 19 of their multimorbid patients. The data were analyzed by means of content analysis. RESULTS: The majority of interviewed patients felt well or very well cared for by their GPs; however, GPs and multimorbid patients often had relatively different priorities. Whereas GPs mostly focused on the management of diseases that could lead to life-threatening situations, patients put an emphasis on maintaining autonomy and a social life. CONCLUSION: The results of this study suggest that there is room for development in the way GPs and multimorbid patients communicate with each other, particularly as far as shared priority setting is concerned.

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.

In-vivo-validation of a cardiovascular risk prediction tool: the arriba-pro study.

BACKGROUND: Calculation of individual risk is the cornerstone of effective cardiovascular prevention. arriba is a software to estimate the individual risk to suffer a cardiovascular event in 10 years. Prognosis and the absolute effects of pharmacological and lifestyle interventions help the patient make a well-informed decision. The risk calculation algorithm currently used in arriba is based on the Framingham risk algorithm calibrated to the German setting. The objective of this study is to evaluate and adapt the algorithm for the target population in primary care in Germany. METHODS/DESIGN: arriba-pro will be conducted within the primary care scheme provided by a large health care insurer in Baden-Württemberg, Germany. Patients who are counseled with arriba by their general practitioners (GPs) will be included in the arriba-pro cohort. Exposure data from the consultation with arriba such as demographic data and risk factors will be recorded automatically by the practice software and transferred to the study centre. Information on relevant prescription drugs (effect modifiers) and cardiovascular events (outcomes) will be derived from administrative sources. DISCUSSION: The study is unique in simulating a therapy naïve cohort, matching exactly research and application setting, using a robust administrative data base, and, finally, including patients with known cardiovascular disease who have been excluded from previous studies. TRIAL REGISTRATION: The study is registered with Deutsches Register Klinischer Studien (DRKS00004633).