Identifying gaps in healthcare: a qualitative study of Ukrainian refugee experiences in the German system, uncovering differences, information and support needs.

BACKGROUND: The 5.8 million Ukrainian refugees arriving in European countries must navigate varying healthcare systems and different and often unknown languages in their respective host countries. To date, there has been little exploration of the experiences, perceived differences, information and support needs of these refugees regarding the use of healthcare in Germany. METHODS: We conducted ten qualitative interviews with Ukrainian refugees living in Germany from February to May 2023, using Ukrainian, English and German language. The transcribed interviews were analysed using the qualitative content analysis method according to Kuckartz and Rädiker with the MAXQDA software. RESULTS: In general, participants consistently had a positive experience of the German healthcare system, particularly regarding the quality of treatments and insurance. Differences have been reported in the structure of the healthcare systems. The Ukrainian healthcare system is divided into private and state sectors, with no mandatory insurance and frequent out-of-pocket payments. Pathways differ and tend to focus more on clinics and private doctors. General practitioners, often working in less well-equipped offices, have only recently gained prominence due to healthcare system reforms. Initiating contact with doctors is often easier, with much shorter waiting times compared to Germany. Interviewees often found the prescription requirements for many medications in Germany to be unusual. However, the mentioned differences in healthcare result in unmet information needs among the refugees, especially related to communication, navigating the healthcare system, health insurance, waiting times and medication access. These needs were often addressed through personal internet research and informal (social media) networks because of lacking official information provided during or after their arrival. CONCLUSIONS: Despite the positive experiences of Ukrainian refugees in the German healthcare system, differences in the systems and language barriers led to barriers using healthcare and information needs among refugees. The dissemination of information regarding characteristics of the German health care system is crucial for successful integration but is currently lacking. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00030942, date of registration: 29.12.2022.

Opioid Use Disorder: A Qualitative Exploratory Analysis of Potential Misunderstandings in Patients with Chronic Non-Cancer Pain.

Purpose: Substance use disorders (SUD) are a challenging comorbidity in patients with chronic non-cancer pain (CNCP) as they complicate diagnosis and therapy, especially when opioids are part of the therapeutic regimen. A definite diagnosis of opioid use disorder (OUD) in patients with CNCP on long-term opioid therapy (LTOT) is a prerequisite for effective and targeted therapy but may be complicated as some criteria of OUD might be attributed to the desire of the patient to relieve the pain. For instance, the desire to increase the dose can be based on both a SUD as well as inadequate pain therapy. Many scientific studies use standardized questions. Therefore, potential misunderstandings due to possible diagnostic overlaps often cannot be clarified. Methods: 14 qualitative guided interviews were conducted and analyzed (Kuckartz content analysis), with the intention to verify if patient's initial response to simple questions based on the wording of the DSM-5, as commonly used in research and practice, were consistent with the results of a more in-depth inquiry. Results: The results suggest that without in-depth investigation, there is a particular risk of false-positive assessment of the DSM-5 criteria for OUD when opioids are prescribed, especially when the questions are considered independently of chronic pain. The risk of a false-negative assessment has also been shown in isolated cases. Conclusion: Only after asking for and describing specific situations it was possible to determine whether the patient's positive or negative answers were based on a misunderstanding of the question. To avoid misdiagnosis, staff conducting DSM-5 interviews should be trained in pain-specific follow-up questions that may help to uncover diagnostic confounding.

[Multimorbidity and its Importance in Future Health Care in Germany: a Secondary Data Analysis Based on 67 Million Health Insurance Policy Holders]. / Multimorbidität in Deutschland und ihre Bedeutung für die Versorgung der Zukunft ­ eine Sekundärdatenanalyse basierend auf 67 Mio. Versichertendaten.

BACKGROUND: Multimorbidity is a particular challenge for health care systems. In Germany, epidemiological findings are primarily sample-based. The estimated prevalence among adults in Germany is high, but there are methodological problems, such as a lack of a uniform definition. METHOD: Statutory health insurance data from the information system for health care data ("Informationssystem Versorgungsdaten") of the former German Institute for Medical Documentation and Information were analyzed. A total of 67.3 million people with statutory health insurance in 2014 were included. Multimorbidity was defined by the presence of at least three chronic diseases from a list of 46 diseases per ICD-10. RESULTS: A total of 21,157,937 individuals, or 31.4% of the total cohort, were defined as multimorbid. In men, progression of multimorbidity occurred at the age of about 40 years, whereas the increase was seen at the age of about 35 years in women. The different disease burden varied in different age and sex groups. CONCLUSION: A better understanding of complex disease interactions in relation to age and sex is needed. Interdisciplinary approaches with specific care concepts for multimorbidity, adapted to the chronic care model, should be explored in order to achieve an ideal care situation in Germany.

[Primary care of Ukrainian refugees]. / Hausärztliche Versorgung ukrainischer Geflüchteter: Evaluation von Herausforderungen und Informationsbedarfen (RefUGe-Studie).

Background: Since the beginning of the war in Ukraine, more than 7.6 million people from Ukraine have been registered as refugees in European countries. In Germany, the number is estimated to be more than 1 million. These refugees may have different health needs than German patients due to differences in the health care system, disease prevalence, preventive measures, health behavior, and experiences of flight. However, general practitioners (GPs) have hardly been prepared for the contact. Objectives: For the first time, challenges in the treatment of Ukrainian refugees and support needs of German GPs were determined. Materials and methods: In July and August 2022, a cross-sectional study among GPs in Germany was conducted using an online survey. Results: A total of 82 GPs participated with a response rate of 16.0%; 52 of the participating GPs had treated Ukrainian refugees in the previous 2 weeks. In all, 75.0% of them reported difficulties or peculiarities in care, especially in communication (61.5%), due to lack of information about previous illnesses (34.6%), and expectations of services to be provided (30.8%). Of the 82 participants, 59.8% reported a need for multilingual information for patients, especially about the German health care system, help with mental health problems, contact points, and differences in the use of medications. Information for the practice team is needed in 37.8% of cases, especially on possibilities in case of language barriers, vaccination coverage in Ukraine, and dealing with missing vaccination records as well as drug lists. Conclusions: Due to the new situation of Ukrainian refugees in Germany and the mentioned barriers, GPs should be supported in care. Information for practice teams as well as their networking with psychotherapeutic offers, contact points, drug databases, and regional interpreter services are urgently needed. However, multilingual information for Ukrainian patients should be disseminated in order to relieve the burden on practices, which have been under great strain, and to ensure continuity and quality of care.

[Changes in Prescription Patterns of Oral Anticoagulants in Family Practices after Marketing Approval of Direct Oral Anticoagulants]. / Änderungen bei der Verordnung oraler Antikoagulation in Hausarztpraxen nach Einführung der direkten oralen Antikoagulanzien.

AIM OF THE STUDY: Since 2011, non-vitamin-K-dependent oral anticoagulants (NOAC) have extended the spectrum of anticoagulation therapy. Initially, the approval of NOAC was limited to the prophylaxis of postoperative thrombosis, but in the course of time the spectrum was extended to the therapy of thrombosis and embolism as well as anticoagulation in non-valvular atrial fibrillation. The study was designed to examine how the approval of NOAC had affected the prescribing behaviour of general practitioners in the first years of their approval. METHODS: In a retrospective longitudinal study, the prescriptions of anticoagulants between 2012 and 2017 were analysed in 3 general practitioners' practices in the Bonn area. The study included all patients for whom at least one prescription from a NOAC or a vitamin K antagonist (VKA) was documented in the administrative system of the practices during this period. RESULTS: A total of n=579 patient files were evaluated (47% female; median age 75 years). Of these, 47% received a VKA, and 40% a NOAC (59% rivaroxaban, 29% apixaban, 9% dabigatran and 3% edoxaban). During the period under examination, the share of VKA prescriptions decreased from 45% to 14% and the share of NOAC increased from 28% to 87%. Anti-coagulation was changed in 12%. The most frequent change was from a VKA to a NOAC (70%). CONCLUSION: After marketing approval, the use of NOAC in the initial prescriptions increased steadily. This trend can also be seen in other European studies. VKA are mainly prescribed to patients with stable oral anticoagulation. As recommended in the guidelines, anticoagulation is changed mainly when problems occur during therapy. If the trend in the prescription of anticoagulants continues, in the medium term, VKA will only be prescribed for patients who have been stable for many years and for patients with artificial heart valves.

Specialized Outpatient Palliative Care­Clinical Course and Predictors for Living at Home Until Death

BACKGROUND: Specialized outpatient palliative care (SOPC) is an important component of the palliative medicine care concept in Germany. Its purpose is to improve the out-of-hospital care of patients who cannot be adequately cared for by their primary care physicians and in the setting of general outpatient palliative care (GOPC). METHODS: In this retrospective analysis of anonymized routine treatment data, we analyzed the characteristics of SOPC patients overall and with specific diseases, and depicted them both numerically and graphically. We also carried out a regression analysis of the factors affecting whether or not patients will be able to die in a home environment. RESULTS: The analysis included data from 14 460 patients who were treated by 14 different SOPC teams in the North Rhine area of Germany in 2017 and 2018. The majority of patients who died were able to live at home until death (85.9%); only a small percentage died as inpatients (7.7%). The symptom burden shortly before death was less than at the beginning of treatment. The factors displaying a statistically significant association with dying at home were: more advanced age (aOR 0.96; 95% CI: [0.95; 0.96]), female sex (aOR 0.85; 95% CI: [0.74; 0.98]), and house calls at night (aOR 0.60; 95% CI: [0.51; 0.71]). CONCLUSION: SOPC met its declared objectives of limiting distressing symptoms and enabling patients to live at home until death.

[General practitioners' perception of integrated care using communication technologies: a secondary analysis of a focus group of the Horizon 2020 funded project POLYCARE]. / Einschätzung deutscher Hausärztinnen und Hausärzte zur integrierten Versorgung mittels Kommunikationstechnologien : Sekundäranalyse einer Fokusgruppe des Horizont-2020-geförderten Projektes POLYCARE.

BACKGROUND: Integrated healthcare models (IC) have the objective of reducing the costs of an increased use of health service as well as the strong sectoral fragmentation of the German health care system. However, no national approach has been implemented in primary care to date. METHOD: Ten GPs from the Cologne/Bonn district (60% male; Ø age = 52 years [35-65]) were invited to a focus group in 2016. The interview was part of the Horizon 2020 funded POLYCARE study. A semi-structured guideline was used to assess feasibility of the POLYCARE study protocol. GPs also provided information about previous experience with and attitudes toward IC models and the relevant information and communication technologies (ICT), such as home-monitoring or communication software. This information was analyzed using a transcending secondary analysis to evaluate conditions for their successful implementation. RESULTS: Participants reported little experience with IC and ICT. However, they reported being open to both and seeing potential for time savings, better networking opportunities, and increased quality of care for their patients. The integration of social services was considered as a chance of alleviating the burden of socio-medical tasks. Barriers to the introduction of IC and ICT were seen in the initial time investment, the lack of legal structures, the concern about overabundant data, and the susceptibility to failure. CONCLUSION: The nationwide expansion of social services as well as ICT that is easy to use, less susceptible to failure, and compatible with existing structures show great potential for relieving GPs. Future research should address the concerns - such as financial and time expenses of introducing IC and ICT - of GPs by systematic investigation in long-term studies. The provision of an additional legal basis that is regulating the respective remuneration models as well as the rights and obligations of all parties, IC and ICT can play a greater role in future patient care.

Patients' perspective on supposedly patient-relevant process and outcome parameters: a cross-sectional survey within the 'PRO patients study'.

BACKGROUND: To be able to make informed choices based on their individual preferences, patients need to be adequately informed about treatment options and their potential outcomes. This implies that studies measure the effects of care based on parameters that are relevant to patients. In a previous scoping review, we found a wide variety of supposedly patient-relevant parameters that equally addressed processes and outcomes of care. We were unable to identify a consistent understanding of patient relevance and therefore aimed to develop an empirically based concept including a generic set of patient-relevant parameters. As a first step we evaluated the process and outcome parameters identified in the scoping review from the patients' perspective. METHODS: We conducted a cross-sectional survey among German general practice patients. Ten research practices of Witten/Herdecke University supported the study. During a two-week period in the fall of 2020, patients willing to participate self-administered a short questionnaire. It evaluated the relevance of the 32 parameters identified in the scoping review on a 5-point Likert scale and offered a free-text field for additional parameters. These free-text answers were inductively categorized by two researchers. Quantitative data were analyzed using descriptive statistics. Bivariate analyses were performed to determine whether there are any correlations between rating a parameter as highly relevant and patients' characteristics. RESULTS: Data from 299 patients were eligible for analysis. All outcomes except 'sexuality' and 'frequency of healthcare service utilization' were rated important. 'Confidence in therapy' was rated most important, followed by 'prevention of comorbidity' and 'mobility'. Relevance ratings of five parameters were associated with patients' age and gender, but not with their chronic status. The free-text analysis revealed 15 additional parameters, 12 of which addressed processes of care, i.e., 'enough time in physician consultation'. CONCLUSION: Patients attach great value to parameters addressing processes of care. It appears as though the way in which patients experience the care process is not less relevant than what comes of it. Relevance ratings were not associated with chronic status, but few parameters were gender- and age-related. TRIAL REGISTRATION: Core Outcome Measures in Effectiveness Trials Initiative, registration number: 1685.

Telemedical Diabetic Retinopathy Screening in a Primary Care Setting: Quality of Retinal Photographs and Accuracy of Automated Image Analysis.

BACKGROUND: Screening for diabetic eye disease (DED) and general diabetes care is often separate, which leads to delays and low adherence to DED screening recommendations. Thus, we assessed the feasibility, achieved image quality, and possible barriers of telemedical DED screening in a point-of-care general practice setting and the accuracy of an automated algorithm for detection of DED. METHODS: Patients with diabetes were recruited at general practices. Retinal images were acquired using a non-mydriatic camera (CenterVue, Italy) by medical assistants. Images were quality assessed and double graded by two graders. All images were also graded automatically using a commercially available artificial intelligence (AI) algorithm (EyeArt version 2.1.0, Eyenuk Inc.). RESULTS: A total of 75 patients (147 eyes; mean age 69 years, 96% type 2 diabetes) were included. Most of the patients (51; 68%) preferred DED screening at the general practice, but only twenty-four (32%) were willing to pay for this service. Images of 63 patients (84%) were determined to be evaluable, and DED was diagnosed in 6 patients (8.0%). The algorithm's positive/negative predictive values (95% confidence interval) were 0.80 (0.28-0.99)/1.00 (0.92-1.00) and 0.75 (0.19-0.99)/0.98 (0.88-1.00) for detection of any DED and referral-warranted DED, respectively.Overall, the number of referrals was 18 (24%) for manual telemedical assessment and 31 (41%) for the artificial intelligence (AI) algorithm, resulting in a relative increase of referrals by 72% when using AI. CONCLUSIONS: Our study shows that achieved overall image quality in a telemedical GP-based DED screening was sufficient and that it would be accepted by medical assistants and patients in most cases. However, good image quality and integration into existing workflow remain challenging. Based on these findings, a larger-scale implementation study is warranted.

Burden Associated with Telephone Calls on COVID-19: Results of a Flash Mob Study in Family Practices.

Background: Family practices are the primary contact for inquiries relating to COVID-19. This study reveals the reasons why German family practices are called during the pandemic and which burden is associated with patients' inquiries related to COVID-19 among practice assistants (PAs). Methods: On April 28, 2021 a cross-sectional flash mob study was conducted in family practices across Germany. The study material and invitation were disseminated via social media and postal or electronic mails. During half a day, participating practices counted every incoming call. For calls addressing COVID-19, the reason, duration, and perceived stress level were documented. Descriptive statistics and regression analyses were performed using SPSS. Results: 5,646 calls, 1,826 of which were related to COVID-19 (32.3%), were documented by 73 practices (practice average: 25.0 ± 17.7) within a single Wednesday morning. Most calls addressed vaccination (n = 1,050, 59.0%). During 22.0% (n = 388) of COVID-19-related calls, PAs felt stressed, which was mainly influenced by the call duration (calls of 5 minutes and longer were perceived significantly more stressful [OR 8.94, 95% CI 6.47-12.37]). Feeling well-prepared to meet patients' inquiries relating to COVID-19 was a protective factor for the average stress perceived per PA. Overall, less than 10% of calls on COVID-19 were transferred to a physician. Conclusions: Family practice teams experience a high volume of partly stressful phone calls about COVID-19 but are often able to handle the pandemic challenges. PAs play a central role in advising the practice population on issues related to COVID-19. This deserves greater recognition.