Quality of care transition, patient safety incidents, and patients' health status: a structural equation model on the complexity of the discharge process.

BACKGROUND: The transition of patients between care contexts poses patient safety risks. Discharges to home from inpatient care can be associated with adverse patient outcomes. Quality in discharge processes is essential in ensuring safe transitions for patients. Current evidence relies on bivariate analyses and neglects contextual factors such as treatment and patient characteristics and the interactions of potential outcomes. This study aimed to investigate the associations between the quality and safety of the discharge process, patient safety incidents, and health-related outcomes after discharge, considering the treatments' and patients' contextual factors in one comprehensive model. METHODS: Patients at least 18 years old and discharged home after at least three days of inpatient treatment received a self-report questionnaire. A total of N = 825 patients participated. The assessment contained items to assess the quality and safety of the discharge process from the patient's perspective with the care transitions measure (CTM), a self-report on the incidence of unplanned readmissions and medication complications, health status, and sociodemographic and treatment-related characteristics. Statistical analyses included structural equation modeling (SEM) and additional analyses using logistic regressions. RESULTS: Higher quality of care transition was related to a lower incidence of medication complications (B = -0.35, p < 0.01) and better health status (B = 0.74, p < 0.001), but not with lower incidence of readmissions (B = -0.01, p = 0.39). These effects were controlled for the influences of various sociodemographic and treatment-related characteristics in SEM. Additional analyses showed that these associations were only constant when all subscales of the CTM were included. CONCLUSIONS: Quality and safety in the discharge process are critical to safe patient transitions to home care. This study contributes to a better understanding of the complex discharge process by applying a model in which various contextual factors and interactions were considered. The findings revealed that high quality discharge processes are associated with a lower likelihood of patient safety incidents and better health status at home even, when sociodemographic and treatment-related characteristics are taken into account. This study supports the call for developing individualized, patient-centered discharge processes to strengthen patient safety in care transitions.

Development and validation of a short clinical risk management implementation (Short CRiMI) questionnaire.

Clinical Risk Management (CRM) is an important instrument to continuously improve safety of health care delivery. In Germany, hospitals are required by law to implement CRM and incidence reporting systems. Since 2010, nation-wide surveys have been conducted periodically to evaluate implementation of CRM in hospitals. The instrument used in these surveys is constantly being updated to reflect previous experiences, as well as to adapt to ongoing trends and developments in CRM practices. The survey instrument used in 2022 consisted of up to 200 items and took up to an hour to complete. In this study, we aimed to develop a short instrument to measure the level of CRM implementation in hospitals, evaluate its psychometric properties, and to offer benchmarking data for health care facilities of different sizes. We used data collected in 2022 as part of KHaSiMiR study, employing a cross-sectional self-reported online survey. The hospital administrations were invited to designate one CRM manager to participate in the study. Out of 1,411 general hospitals invited, 401 responses were collected (response rate of 28%). After removing the cases with excessive missings, we imputed remaining missing values using multiple imputation, and split the resulting sample (n=362) in two halves (i.e., exploratory and testing subsamples). A principal component analysis was applied on the first subsample. We validated the resulting model using confirmatory factor analysis in the testing subsample. We evaluated internal consistency, and tested external validity of the established instrument using correlation analysis with two single-item measures: subjective evaluation of CRM implementation compared to similar organizations and compared to own ideal level. The principal component analysis included 45 items from the full instrument. The analysis resulted in a three-factor model with 26 items. In the confirmatory factor analysis, the model demonstrated acceptable fit with the data according to the commonly used fit indices: Chi2/df=1.36, CFI=0.941, TLI=0.930, RMSEA=0.045 (90% CI=0.032-0.056), SRMR=0.049. Cronbach's alpha of all three factors was good (>0.70). All three factors had statistically significant positive correlations with each other (0.359-0.497) and with the two single items (0.282-0.532). None of the correlations were high enough (>0.7) to indicate multicollinearity. The proposed short clinical risk management implementation (Short CRiMI) questionnaire is psychometrically valid and can be used to rapidly evaluate CRM implementation in hospitals. Further research can provide evidence of its external validity and association with quality and safety outcomes. Benchmarking data can be used to compare the results with the data from the most recent Germany-wide survey.

Association between eHealth literacy and health outcomes in German athletes using the GR-eHEALS questionnaire: a validation and outcome study.

BACKGROUND: Athletes face various sports-related stressors, which may increase their risk for physical and mental health symptoms. With the internet as an important source of (health) information, it is important for athletes to have eHealth literacy, i.e. the ability to access, understand and use electronic health information and services. However, it is presently uncertain whether eHealth literacy of athletes is linked to better health outcomes such as reduced injury frequency and behaviours like decreased substance abuse. METHODS: A cross-sectional study was conducted with N = 373 German athletes (229 females) from different types of sport (e.g., ball sports and water sports) who were included in the statistical analyses. The survey included medical, socio-demographic, eHealth- and sports-related data as well as the eHealth Literacy Scale (GR-eHEALS) questionnaire, which measures eHealth literacy. Confirmatory factor analyses and correlational analyses were performed to determine the convergent and discriminant (compared to the 8-item Impulsive Behavior-8 Scale) validity of the GR-eHEALS and to assess the relation between eHealth literacy scores and health outcomes. RESULTS: The more frequently athletes had sustained minor or moderate injuries in the past, the higher the level of eHealth literacy they reported. Furthermore, consumption frequency of painkillers (r = .18, p = .002), sedatives (r = .12, p = .040), and cannabis (r = .29, p = .000) was significantly correlated with eHealth literacy scores. The confirmatory factor analysis of the GR-eHEALS showed an acceptable model fit with a 2-factor solution (information seeking and information appraisal). The GR-eHEALS showed good discriminant (r = - .09, p = .21) and convergent validity (digital confidence; r = .28, p < .001). CONCLUSION: The GR-eHEALS is a valid instrument to assess eHealth literacy within the cohort of German athletes. Potential dangers of dealing with injury and psychological strain without reaching out for professional help should be considered.

Assessing Electronic Health Literacy in Individuals With the Post-COVID-19 Condition Using the German Revised eHealth Literacy Scale: Validation Study.

BACKGROUND: The eHealth Literacy Scale (eHEALS) is a widely used instrument for measuring eHealth literacy (eHL). However, little is known so far about whether the instrument is valid for the assessment of eHL in persons who are affected by the post-COVID-19 condition. This is particularly important as people with the post-COVID-19 condition are frequently affected by false information from the internet. OBJECTIVE: The objective of our study was to evaluate the validity and reliability of the German Revised eHealth Literacy Scale (GR-eHEALS) in individuals with the post-COVID-19 condition. METHODS: A cross-sectional study was conducted from January to May 2022. The self-assessment survey consisted of the GR-eHEALS, health status- and internet use-related variables, sociodemographic data, and (post)-COVID-19-related medical data. Confirmatory factor analysis (CFA), correlational analyses, and tests of measurement invariance were deployed. RESULTS: In total, 330 participants were included in the statistical analyses. CFA revealed that the 2-factor model reached an excellent model fit (comparative fit index=1.00, Tucker-Lewis index=0.99, root mean square error of approximation=0.036, standardized root mean square residual=0.038). Convergent validity was confirmed by significant positive correlations between eHL and knowledge of internet-based health promotion programs, experience in using these programs, and the duration of private internet use. In addition, a significantly negative relationship of eHL with internet anxiety supported convergent validity. Further, significant relationships of eHL with mental health status and internal health locus of control confirmed the criterion validity of the instrument. However, relationships of eHL with physical health status and quality of life could not be confirmed. The 2-factor model was fully measurement invariant regarding gender. Regarding age and educational level, partial measurement invariance was confirmed. The subscales as well as the overall GR-eHEALS reached good-to-excellent reliability (Cronbach α≥.86). CONCLUSIONS: The GR-eHEALS is a reliable and largely valid instrument for assessing eHL in individuals with the post-COVID-19 condition. Measurement invariance regarding gender was fully confirmed and allows the interpretation of group differences. Regarding age and educational level, group differences should be interpreted with caution. Given the high likelihood that individuals with the post-COVID-19 condition will be confronted with misinformation on the Internet, eHL is a core competency that is highly relevant in this context, in both research and clinical practice. Therefore, future research should also explore alternative instruments to capture eHL to overcome shortcomings in the validity of the GR-eHEALS.

[Discharge management strategies in German general hospitals : A nationwide survey of professionals responsible for clinical risk management]. / Strategien des Entlassmanagements in deutschen Allgemeinkrankenhäusern : Deutschlandweite Befragung von Verantwortlichen des klinischen Risikomanagements.

BACKGROUND: Transitions from inpatient care are associated with risks for the safety of patients. In 2017, the framework agreement on discharge management was legally defined. There is currently a lack of empirical data in Germany on the implementation of measures to ensure safe transitions of patients after inpatient care. The aim of this study is to provide an overview of the discharge management strategies implemented by German general hospitals. METHODS: Between March and May 2022, specific discharge management strategies as well as structural and organizational characteristics were assessed in a nationwide survey of 401 general hospitals, and descriptive statistics and group comparisons were performed. RESULTS: Seven of nine strategies surveyed were implemented in > 95% of all hospitals. The evaluation of discharge planning was only implemented in 61% of the hospitals, and systematic documentation, analysis, and evaluation of readmissions in 54%. Hospitals with a higher number of hospital beds reported significantly less often about "early contact with follow-up care providers" and "organization of a seamless transition to follow-up care." DISCUSSION: A large part of the strategies in discharge management from inpatient treatment is implemented in German general hospitals. However, measures for evaluation and the systematic analysis of discharge processes and readmissions of patients have only been partially implemented. However, these are necessary to systematically evaluate and potentially improve the discharge processes.

Measuring transitional patient safety: Adaptation and validation of the German version of the Care Transitions Measure.

INTRODUCTION: The transition between different care contexts, especially during discharge from inpatient treatment to home, is associated with risks for patient safety. Internationally established, the Care Transitions Measure (CTM) is used to assess the quality and safety of this transition from the patients' perspective. A systematic and standardized assessment of quality and safety in the discharge process from the patients' perspective has not been possible in German-speaking countries due to the lack of a German adaptation and validation of the CTM. This study aims to translate, adapt, and validate the CTM for use in German-speaking countries METHODS: The German version of the CTM was developed based on internationally accepted recommendations for translating and adapting questionnaires. Patients of all departments (except pediatric departments) of a German university hospital who were discharged home after at least three days of inpatient treatment received the questionnaire by mail between May and August 2022. A total of 806 patients participated in the survey. The validity of the CTM was tested by factor analyses. For this purpose, different factor models were compared. In addition, the measurement invariance of the instrument was examined. RESULTS: The construct validity of the long version of the CTM (15items) with a two-factorial model structure was confirmed with good model fit indices. The two subscales had excellent internal consistency. In addition, the one short version with four items achieved excellent model fit indices and high internal consistency. For the long version of the CTM, measurement invariance was confirmed for all sociodemographic, care-related, and survey response characteristics examined. The measurement invariance of the short version was only partially confirmed. DISCUSSION: The validity and reliability of the German version of the CTM were confirmed. In its long version, the instrument is measurement invariant across various characteristics and thus allows valid interpretation of group differences. The short version is partially measurement invariant and is suitable as a screening instrument for assessing the quality and safety of discharge processes due to its high validity and reliability. CONCLUSIONS: With a validated and standardized German version of the CTM, an instrument is now available to assess the quality and safety of the discharge process from the patients' perspective. Thus, this study provides an essential tool for systematically investigating and optimizing patient safety in the discharge process.

Psychometric properties of the German revised version of the eHealth literacy scale in individuals with cardiac diseases: Validation and test of measurement invariance.

Background: The internet is most people's primary source of (health) information. However, no validated instrument exists to assess eHealth literacy in the group of patient with cardiac diseases. Objective: The objective of this study was the evaluation of the psychometric properties of the German revised version of the eHealth literacy scale (GR-eHEALS) in individuals with coronary artery disease (CAD) and congestive heart failure (CHF). Methods: A cross-sectional study was conducted. N = 455 were included in the statistical analyses. The assessment compromised the GR-eHEALS, medical history, sociodemographic data, and technology-related data. Confirmatory factor analyses, correlational analyses, and tests of measurement invariance were performed. Results: The two-factorial model reached a good model fit. The sub-scales information seeking and information appraisal, as well as the eHealth literacy total score, reached high reliability coefficients. Construct and criterion validity was fully confirmed For the two-factorial model, measurement invariance up to the scalar level could be confirmed regarding the sociodemographic characteristics sex, age, and educational level. Conclusions: This study confirmed the two-factor structure, construct, and criterion validity as well as measurement invariance at the scalar level for sex, age, and educational level of the GR-eHEALS scale in a sample of individuals with CAD and CHF.

Exploring the Applicability of General Dietary Recommendations for People Affected by Obesity.

(1) Obesity has emerged as a major public health challenge with increasing prevalence globally. The General Dietary Behavior Inventory (GDBI) was developed based on official dietary recommendations. However, little is known about whether general dietary recommendations also apply to people affected by obesity and whether the GDBI can be used appropriately. (2) A cross-sectional study was conducted. A total of 458 people meeting the inclusion criteria participated in the study. The assessment consisted of the GDBI and behavioral, dietary, and health-related variables. We used descriptive analysis to examine the item characteristics of the GDBI and inferential statistics to investigate the associations between the GDBI score and behavioral, dietary, and health-related outcomes. (3) Several items of the GDBI were concerned by ceiling effects. A higher GDBI score (indicating a higher adherence to dietary recommendations) was related to higher age, higher nutrition knowledge, more restrained eating behavior, lower impulsivity, and higher body mass index. There were no associations between the GDBI score and reported physical and mental health or quality of life. (4) The GDBI showed inconsistent relationships with the study outcomes. General dietary recommendations do not appear to be applicable to people with obesity. Hence, there is an urgent need for specific recommendations and subsequent assessments of behavioral adherence for people affected by obesity.

Quality of Care Transition During Hospital Discharge, Patient Safety, and Weight Regain After Bariatric Surgery: a Cross-Sectional Study.

PURPOSE: Bariatric surgery is established as the gold standard in the treatment of severe obesity. However, a significant proportion of patients experience a substantial weight regain afterwards. Previous research focused predominantly on patients' personal factors. Yet, critical discharge process factors that contribute to patient's adherence after surgical interventions are rarely examined. This study investigated whether high quality of care transitions in discharge management influences weight regain and the likelihood of experiencing adverse patient safety incidents. MATERIALS AND METHODS: A cross-sectional study with 578 patients after bariatric surgery was conducted. Participants answered a standardized assessment on the quality of care transition from hospital to home-, surgery-, and nutrition-related characteristics as well as patient safety incidents. RESULTS: Significant weight regain was observed 24 months after surgery. The association between time since surgery and weight regain was weaker in patients with high quality of care transitions (B = 2.27, p < .001). Higher quality of care transition was also significantly related to a lower likelihood of unplanned hospital readmissions (OR = 0.67) and fewer medication complications (OR = 0.48) after surgery. CONCLUSION: This study sheds first light on the key influence of high quality of care transitions after bariatric surgery. Improvement efforts into effective discharge processes may establish smoother care transitions and help patients to assume responsibility and compliance with behavioral recommendations after surgery. Moreover, adverse patient safety incidents are less frequent after high quality care transitions indicating both high quality of health services for patients and reducing costs for the health care system.

Development and Validation of Dietary Behavior Inventory-Surgery (DBI-S) in the Scope of International Post-Bariatric Surgery Guidelines and Recommendations.

(1) Dietary behavior is highly relevant for patients after bariatric surgery. No instrument exists assessing adherence to medical guidelines concerning the dietary behavior of patients after bariatric surgery. The aim of this study was to develop and validate such an instrument. (2) Data from patients after bariatric surgery (n = 543) were collected from March to May 2022. The development of the DBI-S was theory-based and interdisciplinary. Items' and content validity of the DBI-S were examined. (3) The final version of the DBI-S consists of 13 items. Convergent validation was confirmed by significant correlations between DBI-S score and attitude towards healthy food (r = 0.26, p = <0.001) and impulsivity (r = −0.26, p = <0.001). Criterion validity was confirmed by significant correlations between DBI-S score and pre-/post-surgery BMI difference (r = −0.14, p = 0.002), pre-/post-surgery weight difference (r = 0.13, p = 0.003), and quality of life (r = 0.19, p = <0.001). Cluster analysis confirmed the ability to distinguish between two dietary behavior clusters (rather healthy and rather unhealthy). (4) The DBI-S is an economic and valid instrument to assess the adherence of post-bariatric surgery patients to the relevant dietary behavior recommendations and guidelines and can distinguish between rather unhealthy and healthy dietary behavior.

Validation of the English Version of the General Dietary Behavior Inventory (GDBI-E).

In medical science and practice, dietary behavior is mostly assessed by item-extensive questionnaires (e.g., food-frequency-questionnaires) or by questionnaires focusing on psychological aspects of dietary behavior neglecting dietary quality or quantity. In consequence, these questionnaires do not capture the full bandwidth of dietary behavior or are less effective in the assessment of dietary behavior because of the large item pools. Therefore, the aim of this validation study was to translate the existing General Dietary Behavior Inventory (GDBI), which was constructed as a behavior-related, as well as effective, instrument, and verifying its construct and criterion validity. This inventory is based on the general nutrition recommendations of the World Health Organization (WHO). Our English-speaking convenience sample consisted of 263 participants. The study results confirmed convergent, as well as criterion validity of the English version of the GDBI (GDBI-E). Discriminant validity of the GDBI-E could mainly be verified. Different dietary behavior clusters were identified in a cluster analysis. The found clusters represented a rather healthy and a rather unhealthy dietary behavior in the sample according to the recommendations of the WHO. The results underpinned the validity of the GDBI-E. The GDBI-E is applicable in research and clinical practice to assess dietary behavior in the English-speaking population.

Measuring Electronic Health Literacy: Development, Validation, and Test of Measurement Invariance of a Revised German Version of the eHealth Literacy Scale.

BACKGROUND: The World Wide Web has become an essential source of health information. Nevertheless, the amount and quality of information provided may lead to information overload. Therefore, people need certain skills to search for, identify, and evaluate information from the internet. In the context of health information, these competencies are summarized as the construct of eHealth literacy. Previous research has highlighted the relevance of eHealth literacy in terms of health-related outcomes. However, the existing instrument assessing eHealth literacy in the German language reveals methodological limitations regarding test development and validation. The development and validation of a revised scale for this important construct is highly relevant. OBJECTIVE: The objective of this study was the development and validation of a revised German eHealth literacy scale. In particular, this study aimed to focus on high methodological and psychometric standards to provide a valid and reliable instrument for measuring eHealth literacy in the German language. METHODS: Two internationally validated instruments were merged to cover a wide scope of the construct of eHealth literacy and create a revised eHealth literacy scale. Translation into the German language followed scientific guidelines and recommendations to ensure content validity. Data from German-speaking people (n=470) were collected in a convenience sample from October to November 2020. Validation was performed by factor analyses. Further, correlations were performed to examine convergent, discriminant, and criterion validity. Additionally, analyses of measurement invariance of gender, age, and educational level were conducted. RESULTS: Analyses revealed a 2-factorial model of eHealth literacy. By item-reduction, the 2 factors information seeking and information appraisal were measured with 8 items reaching acceptable-to-good model fits (comparative fit index [CFI]: 0.942, Tucker Lewis index [TLI]: 0.915, root mean square error of approximation [RMSEA]: 0.127, and standardized root mean square residual [SRMR]: 0.055). Convergent validity was comprehensively confirmed by significant correlations of information seeking and information appraisal with health literacy, internet confidence, and internet anxiety. Discriminant and criterion validity were examined by correlation analyses with various scales and could partly be confirmed. Scalar level of measurement invariance for gender (CFI: 0.932, TLI: 0.923, RMSEA: 0.122, and SRMR: 0.068) and educational level (CFI: 0.937, TLI: 0.934, RMSEA: 0.112, and SRMR: 0.063) were confirmed. Measurement invariance of age was rejected. CONCLUSIONS: Following scientific guidelines for translation and test validation, we developed a revised German eHealth Literacy Scale (GR-eHEALS). Our factor analyses confirmed an acceptable-to-good model fit. Construct validation in terms of convergent, discriminant, and criterion validity could mainly be confirmed. Our findings provide evidence for measurement invariance of the instrument regarding gender and educational level. The newly revised GR-eHEALS questionnaire represents a valid instrument to measure the important health-related construct eHealth literacy.

Validation and Test of Measurement Invariance of the Adapted Health Consciousness Scale (HCS-G).

The objective of this study was the translation and validation of a health consciousness scale in order to provide an economically and empirically confirmed measurement of health consciousness, which is associated with health-related behavior. We evaluated this translation on the basis of psychometric testing in a German convenience sample. A cross-sectional online survey (n = 470) was carried out using a translated version of the health consciousness scale, oriented on the basis of international guidelines. As previous studies have not consistently confirmed the factorial structure of the health consciousness scale, we conducted a Confirmatory Factor Analysis to verify its factorial structure. Furthermore, we cross-validated the questionnaire with other scales in order to verify convergent and discriminant validity. The results indicated a two-factor solution for the Health Consciousness Scale-German (HCS-G). The criterion validity was confirmed on the basis of a significantly positive correlation between the HCS-G and health literacy. Furthermore, strict measurement invariance was able to be verified, indicating that the HCS-G is an applicable measurement, regardless of gender. In practical research, this questionnaire can help to assess health consciousness and its influence on health-related constructs. Future studies should consider possible mediating variables between health consciousness and health outcomes.

Development and Validation of the General Dietary Behavior Inventory (GDBI) in Scope of International Nutrition Guidelines.

Unhealthy eating is associated with various diseases, such as cardiovascular, neurodegenerative, or oncological. There are neither economical nor behavior-related questionnaires available in the German language to assess general dietary behavior. Therefore, the aim of this validation study was to develop an instrument considering these aspects and verifying its construct and criterion validity. The new questionnaire is based on the general nutrition recommendations of the World Health Organization and the German Nutrition Society. It consists of 16 items that contrast dietary behaviors on a semantic differential scale. Our German-speaking convenience sample consisted of 428 participants. The construct validity of the General Dietary Behavior Inventory (GDBI) could be confirmed by examining convergent and discriminant validity. Furthermore, criterion validity was confirmed (significant negative correlations with body weight, Body Mass Index, and positive correlations with physical/mental health as well as life satisfaction). A cluster analysis revealed two different dietary behavior clusters representing a rather healthy and a rather unhealthy dietary behavior cluster. The results indicate that the GDBI is a validated and economical instrument to assess general dietary behavior. In practical research, this questionnaire helps to assess dietary behavior and to derive interventions for a healthy dietary behavior in concordance with international nutrition recommendations.