Sex differences in cardiologic medication provision for adults with coronary heart disease: an analysis of health claims data from 2018 to 2020 in Saxony-Anhalt, Germany.

BACKGROUND: Coronary heart diseases (CHDs) have experienced the largest increase worldwide as a cause of death, accounting for 16% of all deaths. In Saxony-Anhalt, a federal state in Germany, both CHD morbidity and acute myocardial infarction mortality rates are particularly high. Several risk factors associated with CHDs have been studied in Saxony-Anhalt, but sex differences in service use and medication have not been investigated. This study therefore aimed to investigate sex differences in the quality and quantity of cardiological care provided to adults with CHD. METHODS: This study used health claims data from 2018 to 2020 to analyse the utilisation of healthcare services and adherence to medication-related guideline recommendations in primary and specialist care. The sample included 133,661 individuals with CHD from a major statutory health insurance company (Germany). RESULTS: Almost all CHD patients (> 99%) received continuous primary care. Continuous cardiologist utilisation was lower for females than for males, with 15.0% and 22.2%, respectively, and sporadic utilisation showed greater differences, with 33.5% of females and 43.4% of males seeking sporadic cardiologist consultations. Additionally, 43.1% of the identified CHD patients participated in disease management programmes (DMPs). The study also examined the impact of DMP participation and cardiologist care on medication uptake and revealed that sex differences in medication uptake, except for statin use, were mitigated by these factors. Statins were prescribed to 42.9% of the CHD patients eligible for statin prescription in accordance with the QiSA indicator for statin prescription eligibility. However, there were significant sex differences in statin utilisation. Female CHD patients were less likely to use statins (35.2%) than male CHD patients were (50.1%). The difference in statin utilisation persisted after adjustment for DMP participation and cardiologist consultation. CONCLUSIONS: This study highlights sex differences in the utilisation of cardiological healthcare services for patients with CHD in the Saxony-Anhalt cohort. These findings underscore the continuing need for interventions to reduce sex inequalities in accessing healthcare and providing health care for patients with CHD. Factors at the health care system, patient, and physician levels should be further investigated to eventually improve statin prescription in people with CHD, especially women.

Measuring patients' experience of nursing quality in acute hospitals: review of existing scales and development and psychometric validation of a new scale.

OBJECTIVE: To provide an overview of existing instruments measuring patient-perceived quality of nursing care and to develop and psychometrically evaluate a new multidimensional scale applicable to the German acute care sector. DESIGN: We conducted a scale development and validation study involving the following phases: (1) performing a structured literature search to identify existing scales, (2) generating an initial pool of items using the results of the literature search and expert interviews, (3) coding/categorising the item pool, (4) organising a peer researcher workshop to select relevant items, (5) drafting the survey questionnaire and conducting cognitive pretesting, (6) pilot testing the survey questionnaire, (7) administering the survey to a large sample of hospital patients and (8) conducting a psychometric evaluation comprising exploratory factor analysis using the survey results, followed by confirmatory factor analysis and reliability and validity assessment of the resulting draft scale. SURVEY PARTICIPANTS: 17 859 recently hospitalised patients discharged from non-intensive care in non-paediatric and non-psychiatric hospital units in Germany between May and October 2019. RESULTS: We identified 32 instruments comprising 635 items on nursing care quality. Alongside 135 indicators derived from expert interviews, these formed our initial item pool, which we coded into 15 categories. From this pool, 36 items were selected in the peer researcher workshop for pretesting and psychometric evaluation. Based on the results of our exploratory and confirmatory factor analyses, we propose a second-order scale to measure Patients' Experience of Nursing Quality in Acute Hospitals (PENQuAH), including the two higher-order dimensions 'patients' perception of direct nursing care activities' and 'patients' perception of guidance provided by nurses'. The results of various tests suggest the scale has sufficient goodness of fit, reliability and validity. CONCLUSIONS: The PENQuAH scale is promising in terms of its psychometric properties, the plausibility and meaningfulness of its dimensions, and its ease of use.

Avoidable Care Transitions: A Consensus-Based Definition Using a Delphi Technique.

Background and Objectives: Older adults are at increased risk of frequent transitions between care settings, even though some care transitions are avoidable. The term "avoidable care transitions" is not clearly defined in the research literature. This study aimed to find a consensus-based definition for "avoidable care transitions." Research Design and Methods: This study was conducted as part of the TRANS-SENIOR research network. A 4-round Delphi survey was based on a literature review that identified existing definitions of "avoidable care transitions." Articles in MEDLINE via PubMed and CINAHL were searched. In total 95 references were included, and 106 definitions were identified. Definitions were coded to find themes, resulting in 3 themes with 2 codes for each. Results: In total, 99 experts from 9 countries were invited, and the response rates in Delphi Rounds 1, 2, 3, and 4 were 37.5%, 19.1%, 33.3%, and 23.3%, respectively. Upon reaching the predefined minimum of 90% agreement, the following definition was declared as final: "Avoidable care transitions (a) are without significant patient-relevant benefits or with a risk of harm outweighing patient-relevant benefits and/or (b) are when a comparable health outcome could be achieved in lower resource settings using the resources available in that place/health care system, and/or (c) violate a patient's/informal caregiver's preference or an agreed care plan." Discussion and Implications: Consensus on a definition for "avoidable care transitions" was reached by a multidisciplinary and international panel of experts comprising researchers and providers. The resulting definition consists of 3 distinct dimensions relating to the balance of benefit and harm to a patient, resource consumption, and a patient's or informal caregiver's preferences. The new definition might enhance the common understanding of avoidable care transitions and is now ready for application in research and quality and safety management in health care.

Challenges, strategies and consequences from the perspective of German nursing home managers during the first wave of the COVID-19 pandemic - a qualitative interview study.

BACKGROUND: The first wave of the COVID-19 pandemic reached Germany between March and May 2020. In order to contain the spread of the virus and particularly protect vulnerable people, the government imposed a lockdown in March 2020. In addition to infection control measures, such as hygiene and social distancing requirements, a general ban on access to nursing homes for relatives and external service providers was issued. METHODS: To investigate the challenges and consequences of the enacted infection prevention measures and specific strategies for nursing homes in Germany, a multicentre cross-sectional qualitative interview study with nursing home managers and ward managers was conducted. Recorded audio data were transcribed, analysed using thematic framework analysis and reflected in peer debriefings. RESULTS: Seventy-eight interviews with 40 nursing home managers and 38 ward managers from 43 German nursing homes were conducted. At organisational level, the following six themes were identified: Appointing a multi-professional crisis task force, reorganizing the use of building and spatial structures, continuous adaption and implementation of hygiene plans, adapting staff deployment to dynamically changing demands, managing additional communicative demands and relying on and resorting to informal networks. To deal with the pandemic challenges also six themes can be described for the direct care level: Changed routines, taking over non-nursing tasks, increased medical responsibility, increased documentation demands, promoting social participation and increased communication demands. Also various negative consequences were identified (four themes): Psychological stress, negative emotional consequences, permanent feeling of responsibility and increased potential for conflicts. Positive emotional consequences were also reported (two themes): resources for the challenges and positive emotional consequences for home managers and staff. CONCLUSIONS: The results of the described challenges, strategies and consequences allow recommendations as basis for possible approaches and successful adaptation processes in nursing home care in the future. In particular, there is a need for local networks to act in a coordinated way and a need for quantitative and qualitative support for nurses, such as staff support as well as advanced nursing practice, to cope with the challenges of the pandemic.

Family Conferences to Facilitate Deprescribing in Older Outpatients With Frailty and With Polypharmacy: The COFRAIL Cluster Randomized Trial.

Importance: For older adults with frailty syndrome, reducing polypharmacy may have utility as a safety-promoting treatment option. Objective: To investigate the effects of family conferences on medication and clinical outcomes in community-dwelling older adults with frailty receiving polypharmacy. Design, Setting, and Participants: This cluster randomized clinical trial was conducted from April 30, 2019, to June 30, 221, at 110 primary care practices in Germany. The study included community-dwelling adults aged 70 years or older with frailty syndrome, daily use of at least 5 different medications, a life expectancy of at least 6 months, and no moderate or severe dementia. Interventions: General practitioners (GPs) in the intervention group received 3 training sessions on family conferences, a deprescribing guideline, and a toolkit with relevant nonpharmacologic interventions. Three GP-led family conferences for shared decision-making involving the participants and family caregivers and/or nursing services were subsequently held per patient at home over a period of 9 months. Patients in the control group received care as usual. Main Outcomes and Measures: The primary outcome was the number of hospitalizations within 12 months, as assessed by nurses during home visits or telephone interviews. Secondary outcomes included the number of medications, the number of European Union list of the number of potentially inappropriate medication (EU[7]-PIM) for older people, and geriatric assessment parameters. Both per-protocol and intention-to-treat analyses were conducted. Results: The baseline assessment included 521 individuals (356 women [68.3%]; mean [SD] age, 83.5 [6.17] years). The intention-to-treat analysis with 510 patients showed no significant difference in the adjusted mean (SD) number of hospitalizations between the intervention group (0.98 [1.72]) and the control group (0.99 [1.53]). In the per-protocol analysis including 385 individuals, the mean (SD) number of medications decreased from 8.98 (3.56) to 8.11 (3.21) at 6 months and to 8.49 (3.63) at 12 months in the intervention group and from 9.24 (3.44) to 9.32 (3.59) at 6 months and to 9.16 (3.42) at 12 months in the control group, with a statistically significant difference at 6 months in the mixed-effect Poisson regression model (P = .001). After 6 months, the mean (SD) number of EU(7)-PIMs was significantly lower in the intervention group (1.30 [1.05]) than in the control group (1.71 [1.25]; P = .04). There was no significant difference in the mean number of EU(7)-PIMs after 12 months. Conclusions and Relevance: In this cluster randomized clinical trial with older adults taking 5 or more medications, the intervention consisting of GP-led family conferences did not achieve sustainable effects in reducing the number of hospitalizations or the number of medications and EU(7)-PIMs after 12 months. Trial Registration: German Clinical Trials Register: DRKS00015055.

[Utilization of pre-hospital emergency medical services: Secondary data analysis of health insurance data from Saxony-Anhalt]. / Inanspruchnahme der bodengebundenen Notfallrettung ­ Sekundärdatenanalyse der Versichertenkohorte AOK Sachsen-Anhalt.

BACKGROUND: Utilization of emergency care is subject to demographic changes. In Germany, there was an increase of 4% to 6% annually between the years 2000 and 2017. Studies revealed that age and regional structures were related to utilization. The aim of this cross-sectional study was to analyze utilization of pre-hospital emergency medical services in Saxony-Anhalt and to identify associated factors. METHOD: Based on data from the AOK Saxony-Anhalt for 2019, transportation with ground ambulances of insured persons living in Saxony-Anhalt were identified and recorded. Insured time of all AOK insured persons living in Saxony-Anhalt was used to determine incidence rates. For the multivariate analysis of associated factors, a Poisson regression model was adapted. RESULTS: 112,575 transportations of patients were identified; an average of 1.53 events per person or 149.6 per 1,000 person years. Inpatient hospital treatment was provided for 53.2% of emergency patients and outpatient hospital treatment for 37.1%. Frequent users represented 14.6% of the events. The incidence rate was highest for older persons and those with care dependency. In addition, the risk of using emergency services was higher among men and in suburban and urban regions (compared with rural regions), even after adjustment. CONCLUSIONS: Utilization is higher in the cohort studied compared to that found in other studies. The high proportion where inpatient hospital treatment is not necessary, as well as the clear association with care dependency and age, offer possible angles of approach for interventions to relieve the burden on emergency services.

Factors influencing the implementation of person-centred care in nursing homes by practice development champions: a qualitative process evaluation of a cluster-randomised controlled trial (EPCentCare) using Normalization Process Theory.

BACKGROUND: Person-centred care (PCC) has been suggested as the preferred model of dementia care in all settings. The EPCentCare study showed that an adapted PCC approach was difficult to implement and had no effect on prescription of antipsychotics in nursing home residents in Germany. This paper reports the qualitative process evaluation to identify facilitators and barriers of the implementation of PCC in German nursing homes from the perspective of participating practice development champions. METHODS: Five individual and 14 group interviews were conducted with 66 participants (staff and managers) from 18 nursing homes. The analysis was based on inductive coding to identify factors influencing the PCC implementation process. Identified factors were systematised and structured by mapping them to the four constructs (coherence, cognitive participation, collective action, reflexive monitoring) of the Normalization Process Theory (NPT) as a framework that explains implementation processes. RESULTS: Facilitating implementation factors included among others broadening of the care perspective (coherence), tolerance development within the care team regarding challenging behaviour (cognitive participation), testing new approaches to solutions as a multi-professional team (collective action), and perception of effects of PCC measures (reflexive monitoring). Among the facilitating factors reported in all the NPT constructs, thus affecting the entire implementation process, were the involvement of relatives, multi-professional teamwork and effective collaboration with physicians. Barriers implied uncertainties about the implementation and expectation of a higher workload (coherence), concerns about the feasibility of PCC implementation in terms of human resources (cognitive participation), lack of a person-centred attitude by colleagues or the institution (collective action), and doubts about the effects of PCC (reflexive monitoring). Barriers influencing the entire implementation process comprised insufficient time resources, lack of support, lack of involvement of the multi-professional team, and difficulties regarding communication with the attending physicians. CONCLUSIONS: The findings provide a comprehensive and detailed overview of facilitators and barriers structured along the implementation process. Thus, our findings may assist both researchers and clinicians to develop and reflect more efficiently on PCC implementation processes in nursing homes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02295462 ; November 20, 2014.

[What patients judge as important regarding nursing quality: Content analysis of patients' responses to an open-ended question within an online survey]. / Was Patient_innen an Pflegequalität noch wichtig ist.

What patients judge as important regarding nursing quality: Content analysis of patients' responses to an open-ended question within an online survey Abstract. Introduction: In a cross-sectional study with people insured by a health insurance company the association between the quality of care assessed by patients and nurse staffing in acute care hospitals has been investigated. A systematically developed online questionnaire registered the patients' assessments of nursing care, nursing behavior and nursing outcomes. The questionnaire included an open-ended question that was designed to supplement other important aspects where appropriate. Research question: Which aspects of the experienced care were particularly important for the patients but were -from their point of view- not yet covered by the questionnaire? Can additional indicators of care quality be derived? Method: Online survey following hospital discharge. Content analysis of the free text entries to the open-ended question. Results: A total of 212554 insured people were contacted; 30209 participated in the survey (14,2%) and 12507 (41,4%) of them answered to the open-ended question. A random selection of free text replies (n=2000) was finally coded and analyzed. Altogether, 45,1% of all codes covered the aspects of care quality included in the questionnaire. Of the remaining codes, 35,1% contained statements about non-nursing quality aspects of hospitalization and 19,8% contained statements about working conditions. No additional indicators of quality of care could be identified. Conclusion/Outlook: The statements about the working conditions will be explored in a further analysis. The expectations of patients towards nursing care need to be investigated in future studies.

Gewalt und Gewaltprävention in der stationären Altenpflege während der COVID-19-Pandemie.

Violence and Violence Prevention in Nursing Homes during the COVID-19 Pandemic - A partial analysis of Interviews with Managers or Team Leaders Abstract. Background: During the first wave of the COVID-19 pandemic, strict infection control measures were in force in long-term residential care in Germany that burdened staff and isolated residents socially. Both are considered risk factors for violence in long-term residential care. Questions: How does violence develop in nursing homes under pandemic conditions from the point of view of managers and how do strategies for preventing violence change? Methods: Semi-structured telephone interviews were conducted with staff in 43 nursing homes: 25 with service managers, 15 with nurse managers, 28 with nursing team leaders and 10 with registered nurses with extended tasks. The interviews were recorded as audio, transcribed and analysed in five steps following the "Thematic Framework Analysis". Results: The infection control measures were partly perceived as deprivation of freedom. Residents, relatives and staff partly reacted most with verbal violence. Nevertheless, the issue of violence was not a major concern for management and preventive measures were not carried out. Conclusions: The results show that strategies to prevent violence might not be sufficiently established in the institutions involved and would have to be adapted to the conditions of the pandemic. Further research is needed to evaluate infection control measures in their potential to increase the incidence of violence.

Staffing levels and nursing-sensitive patient outcomes: Umbrella review and qualitative study.

OBJECTIVE: To derive a comprehensive list of nursing-sensitive patient outcomes (NSPOs) from published research on nurse staffing levels and from expert opinion. DATA SOURCES/STUDY SETTING: Published literature reviews and their primary studies analyzing the link between nurse staffing levels and NSPOs and interviews with 16 experts on nursing care. STUDY DESIGN: Umbrella review and expert interviews. DATA COLLECTION/EXTRACTION METHODS: We screened three electronic databases for literature reviews on the association between nurse staffing levels and NSPOs. After screening 430 potentially relevant records, we included 15 literature reviews, derived a list of 22 unique NSPOs from them, and ranked these in a systematic fashion according to the strength of evidence existing for their association with nurse staffing. We extended this list of NSPOs based on data from expert interviews. PRINCIPAL FINDINGS: Of the 22 NSPOs discussed in the 15 included literature reviews, we rated the strength of evidence for four as high, for five as moderate, and for 13 outcomes as low. Four additional NSPOs that have not been considered in literature were identified through expert interviews. CONCLUSIONS: We identified strong evidence for a significant association between nurse staffing levels and NSPOs. Our results may guide researchers in selecting NSPOs they might wish to prioritize in future studies. In particular, rarely studied NSPOs as well as NSPOs that were only identified through expert interviews but have not been considered in literature so far should be subject to further research.

Die COVID-19-Pandemie im akutstationären Setting aus Sicht von Führungspersonen und Hygienefachkräften in der Pflege - Eine qualitative Studie

The COVID-19-pandemic in acute inpatient setting from nursing managers' and hygiene specialists' perspective - A qualitative study Abstract. Background: The COVID-19-pandemic is an unprecedented, exceptional situation and necessitates numerous adaptations of structures and processes in the acute inpatient setting. AIM: The aim of this study was to explore how acute inpatient care was influenced by the pandemic and which implications may result for the future from nursing managers' and hygiene specialists' point of view. METHODS: Qualitative study based on semi-structured interviews with five nursing managers and three hygiene specialists in four German acute care hospitals. Interviews were interpreted by using content analysis. RESULTS: Interviewees described how everyday routines in their hospitals were adapted to the prioritized care for COVID-19 patients. Main challenges were uncertainty and anxiety among staff, relative scarcity of equipment and workforce resources and rapid implementation of new requirements for treatment capacities. This was addressed by targeted communication and information, large efforts to ensure resources and coordinated control of all processes by cross-department, interprofessional task forces. CONCLUSIONS: Adaptations made to the structures and procedures of care delivery during the pandemic hold potential for future improvements of routine care, e. g. new workplace and skill mix models. To identify detailed practical implications, a renewed and deepened data analysis is needed at a later point of time, with a larger distance to the period of the pandemic.

Computerized clinical decision system and mobile application with expert support to optimize management of vertigo in primary care: study protocol for a pragmatic cluster-randomized controlled trial.

Vertigo and dizziness are amongst the most common symptoms in medicine and often have a major impact on activities of daily life. Although many causes of vertigo and dizziness can easily be recognized, patients often receive inappropriate and ineffective treatment. The reasons for this are various. Because vertigo/dizziness is an interdisciplinary symptom and there is a lack of standardised diagnostic tools, it is easy to lose the overview of the possible differential diagnoses. There is evidence though, that the management of patients with vertigo/dizziness can be optimized using standardized care pathways with digital support. The present study (within the framework of "PoiSe-prevention, online feedback, and interdisciplinary therapy of acute vestibular syndromes by e-health") aims to evaluate the implementation of a program with several interlocking components. The three main components are a computerized clinical decision system, a mobile application, a counselling and interdisciplinary educational program developed by the German Center for Vertigo and Balance Disorders (DSGZ). The study is a cluster-randomized controlled trial with a parallel-group design, as well as a detailed process evaluation. Clusters comprise of primary care physician practices in Bavaria, Germany. In the scope of the study the effectiveness, acceptability and efficiency of the intervention will be evaluated. It is anticipated that the intervention will improve the quality and efficiency of the management of dizzy patients. A higher diagnostic accuracy, optimized treatment, and disease progression monitoring is expected to improve patient-relevant outcomes and reduce health-care costs.

Agreement between the Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW) interview and a paper-administered adaption.

BACKGROUND: The Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW) is a prevalent face-to-face interview method for measuring quality of life by integrating respondent-generated dimensions. To apply this method in clinical trials, a paper-administered alternative would be of interest. Therefore, our study aimed to analyze the agreement between the SEIQoL-DW and a paper questionnaire version (SEIQoL-PF/G). METHODS: In a crossover design, both measures were completed in a random sequence. 104 patients at a heart surgery hospital in Germany were randomly assigned to receive either the SEIQoL-DW or the SEIQoL-PF/G as the first measurement in the sequence. Patients were approached on their earliest stable day after surgery. The average time between both measurements was 1 day (mean 1.3; SD 0.8). Agreement regarding the indices, ratings, and weightings of nominated life areas (cues) was explored using Bland-Altman plots with 95% limits of agreement (LoA). Agreement of the SEIQoL indices was defined as acceptable if the LoA did not exceed a threshold of 10 scale points. Data from n = 99 patients were included in the agreement analysis. RESULTS: Both measures led to similarly nominated cues. The most frequently nominated cues were "physical health" and "family". In the Bland-Altman plot, the indices showed a mean of differences of 2 points (95% CI, - 1 to 6). The upper LoA showed a difference of 36 points (95% CI, 30 to 42), and the lower LoA showed a difference of - 31 points (95% CI, - 37 to - 26). Thus, the LoAs and confidence intervals exceeded the predefined threshold. The Bland-Altman plots for the cue levels and cue weights showed similar results. The SEIQoL-PF/G version showed a tendency for equal weighting of cues, while the weighting procedure of the SEIQoL-DW led to greater variability. CONCLUSIONS: For cardiac surgery patients, use of the current version of the SEIQoL-PF/G as a substitute for the SEIQoL-DW is not recommended. The current questionnaire weighting method seems to be unable to distinguish weighting for different cues. Therefore, the further design of a weighting method without interviewer support as a paper-administered measure of individual quality of life is desirable.

[Improving psychosocial health of nursing home residents: a systematic review of interventions for prevention and health promotion]. / Stärkung der psychosozialen Gesundheit von Bewohnerinnen und Bewohnern der stationären Langzeitpflege: Systematische Übersicht zu Interventionen der Prävention und Gesundheitsförderung.

BACKGROUND: Long-term care insurance funds have been mandated by the German Prevention Act to support long-term care facilities in the implementation of health-promoting structures. One area of action is the promotion of the nursing home residents' psychosocial health. The objective of this systematic review was to describe and analyze interventions and intervention components related to the psychosocial health of nursing home residents. METHODS: First, we conducted a search for systematic reviews and meta-analyses in Medline via PubMed, the Cochrane Library, CINAHL, Gerolit, Embase, Psyndex, and Livivo, and hand-searched additional sources. Second, references of all relevant randomized controlled trials (n=86) were extracted from the identified systematic reviews (n=27). The original articles of the included primary studies were then analyzed using criteria for the evaluation of complex interventions. The GRADE approach was used to assess the quality of the evidence. RESULTS: Seventeen interventions for promoting the psychosocial health of nursing home residents were identified. The majority of the study participants were nursing home residents with dementia. Since the underlying evidence was predominantly very low, it was not possible to draw clear conclusions concerning the efficacy of the interventions for psychosocial health outcomes. The best indications of positive effects were found for reminiscence, mealtime interventions, music therapy, and special care staff training. CONCLUSION: The diversity and heterogeneity of the interventions made both classification and consistent judgments of the quality of the evidence difficult. From the perspective of promoting the psychosocial health of nursing home residents, the identified interventions should only be considered as suggestions or proposals for prevention and health promotion measures, and future studies should evaluate their implementation.

Effect of person-centred care on antipsychotic drug use in nursing homes (EPCentCare): a cluster-randomised controlled trial.

BACKGROUND: antipsychotic drugs are regularly prescribed as first-line treatment for neuropsychiatric symptoms in persons with dementia although guidelines clearly prioritise non-pharmacological interventions. OBJECTIVE: we investigated a person-centred care approach, which has been successfully evaluated in nursing homes in the UK, and adapted it to German conditions. DESIGN: a 2-armed 12-month cluster-randomised controlled trial. SETTING: nursing homes in East, North and West Germany. METHODS: all prescribing physicians from both study arms received medication reviews for individual patients and were offered access to 2 h of continuing medical education. Nursing homes in the intervention group received educational interventions on person-centred care and a continuous supervision programme. Primary outcome: proportion of residents receiving at least one antipsychotic prescription after 12 months of follow-up. Secondary outcomes: quality of life, agitated behaviour, falls and fall-related medical attention, a health economics evaluation and a process evaluation. RESULTS: the study was conducted in 37 nursing homes with n = 1,153 residents (intervention group: n = 493; control group: n = 660). The proportion of residents with at least one antipsychotic medication changed after 12 months from 44.6% to 44.8% in the intervention group and from 39.8 to 33.3% in the control group. After 12 months, the difference in the prevalence was 11.4% between the intervention and control groups (95% confidence interval: 0.9-21.9; P = 0.033); odds ratio: 1.621 (95% confidence interval: 1.038-2.532). CONCLUSIONS: the implementation of a proven person-centred care approach adapted to national conditions did not reduce antipsychotic prescriptions in German nursing homes. TRIAL REGISTRATION: ClinicalTrials.gov NCT02295462.

[Improving cognitive resources of nursing home residents: a systematic review of prevention and health promotion interventions]. / Stärkung kognitiver Ressourcen von Bewohnerinnen und Bewohnern der stationären Langzeitpflege: Systematische Übersicht zu Interventionen der Prävention und Gesundheitsförderung.

BACKGROUND: The German Prevention Act mandated long-term care insurance funds to support long-term care facilities in designing health-promoting structures. One area of action is the promotion of the cognitive resources of nursing home residents. The objective of this systematic review was to describe and analyze interventions and intervention components that improve cognitive resources of nursing home residents. METHODS: First, we conducted a search for systematic reviews to identify relevant randomised controlled trials in Medline via PubMed, the Cochrane Library, CINAHL, Gerolit, Embase, Psyndex, and Livivo; additional sources were hand-searched. Second, references of all relevant randomized controlled trials (n=43) were extracted from the identified systematic reviews (n=26). The original articles of the primary studies included were then considered and data extracted using criteria for the evaluation of complex interventions. The quality of evidence was assessed using the GRADE approach. RESULTS: Nine interventions to promote cognitive resources were identified: cognitive stimulation, cognitive training, physical training, art and music interventions, bright light, multicomponent stimulation, multisensory stimulation, care staff training and reminiscence. The quality of the underlying evidence in the inpatient long-term care setting was predominantly low, therefore, it was not always possible to draw clear conclusions regarding the efficacy of the interventions. The low quality of evidence was mainly due to the high heterogeneity as well as the low number and limited methodological quality of the primary studies. CONCLUSION: In general, a wide range of nonpharmacological interventions were reported. Due to the limited evidence, however, these may be regarded as ideas only or possible options for promoting the cognitive resources of nursing home residents.

Inter-rater agreement of the Quality of Life-Alzheimer's Disease (QoL-AD) self-rating and proxy rating scale: secondary analysis of RightTimePlaceCare data.

BACKGROUND: To assess the quality of life of people with dementia, measures are required for self-rating by the person with dementia, and for proxy rating by others. The Quality of Life in Alzheimer's Disease scale (QoL-AD) is available in two versions, QoL-AD-SR (self-rating) and QoL-AD-PR (proxy rating). The aim of our study was to analyse the inter-rater agreement between self- and proxy ratings, in terms of both the total score and the items, including an analysis specific to care setting, and to identify factors associated with this agreement. METHODS: Cross-sectional QoL-AD data from the 7th Framework European RightTimePlaceCare study were analysed. A total of 1330 cases were included: n = 854 receiving home care and n = 476 receiving institutional long-term nursing care. The proxy raters were informal carers (home care) and best-informed professional carers (institutional long-term nursing care). Inter-rater agreement was investigated using Bland-Altman plots for the QoL-AD total score and by weighted kappa statistics for single items. Associations were investigated by regression analysis. RESULTS: The overall QoL-AD assessment of those with dementia revealed a mean value of 33.2 points, and the proxy ratings revealed a mean value of 29.8 points. The Bland-Altman plots revealed a poor agreement between self- and proxy ratings for the overall sample and for both care settings. With one exception (item 'Marriage' weighted kappa 0.26), the weighted kappa values for the single QoL-AD items were below 0.20, indicating poor agreement. Home care setting, dementia-related behavioural and psychological symptoms, and the functional status of the person with dementia, along with the caregiver burden, were associated with the level of agreement. Only the home care setting was associated with an increase larger than the predefined acceptable difference between self- and proxy ratings. CONCLUSIONS: Proxy quality of life ratings from professional and informal carers appear to be lower than the self-ratings of those with dementia. QoL-AD-SR and QoL-AD-PR are therefore not interchangeable, as the inter-rater agreement differs distinctly. Thus, a proxy rating should be judged as a complementary perspective for a self-assessment of quality of life by those with dementia, rather than as a valid substitute.

Effect of person-centred care on antipsychotic drug use in nursing homes (EPCentCare): study protocol for a cluster-randomised controlled trial.

BACKGROUND: The majority of nursing home residents with dementia experience behavioural and psychological symptoms like apathy, agitation, and anxiety. According to analyses of prescription prevalence in Germany, antipsychotic drugs are regularly prescribed as first-line treatment of neuropsychiatric symptoms in persons with dementia, although guidelines clearly prioritise non-pharmacological interventions. Frequently, antipsychotic drugs are prescribed for inappropriate reasons and for too long without regular reviewing. The use of antipsychotics is associated with adverse events like increased risk of falling, stroke, and mortality. The aim of the study is to investigate whether a person-centred care approach, successfully evaluated in nursing homes in the United Kingdom, can be implemented in German nursing homes and, in comparison with a control group, can result in a clinically relevant reduction of the proportion of residents with antipsychotic prescriptions. METHODS/DESIGN: The study is a cluster-randomised controlled trial comparing an intervention group (two-day initial training on person-centred care and ongoing training and support programme) with a control group. Both study groups will receive, as optimised usual care, a medication review by an experienced psychiatrist/geriatrician providing feedback to the prescribing physician. Overall, 36 nursing homes in East, North, and West Germany will be randomised. The primary outcome is the proportion of residents receiving at least one antipsychotic prescription (long-term medication) after 12 months of follow-up. Secondary outcomes are residents' quality of life, agitated behaviour, as well as safety parameters like falls and fall-related medical attention. A health economic evaluation and a process evaluation will be performed alongside the study. DISCUSSION: To improve care, a reduction of the current high prescription rate of antipsychotics in nursing homes by the intervention programme is expected. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02295462.

Cost-utility analysis of a preventive home visit program for older adults in Germany.

BACKGROUND: Most older adults want to live independently in a familiar environment instead of moving to a nursing home. Preventive home visits based on multidimensional geriatric assessment can be one strategy to support this preference and might additionally reduce health care costs, due to the avoidance of costly nursing home admissions. The purpose of this study was to analyse the cost-effectiveness of preventive home visits from a societal perspective in Germany. METHODS: This study is part of a multi-centre, non-blinded, randomised controlled trial aiming at the reduction of nursing home admissions. Participants were older than 80 years and living at home. Up to three home visits were conducted to identify self-care deficits and risk factors, to present recommendations and to implement solutions. The control group received usual care. A cost-utility analysis using quality-adjusted life years (QALY) based on the EQ-5D was performed. Resource utilization was assessed by means of the interview version of a patient questionnaire. A cost-effectiveness acceptability curve controlled for prognostic variables was constructed and a sensitivity analysis to control for the influence of the mode of QALY calculation was performed. RESULTS: 278 individuals (intervention group: 133; control group: 145) were included in the analysis. During 18 months follow-up mean adjusted total cost (mean: +4,401 EUR; bootstrapped standard error: 3,019.61 EUR) and number of QALY (mean: 0.0061 QALY; bootstrapped standard error: 0.0388 QALY) were higher in the intervention group, but differences were not significant. For preventive home visits the probability of an incremental cost-effectiveness ratio <50,000 EUR per QALY was only 15%. The results were robust with respect to the mode of QALY calculation. CONCLUSIONS: The evaluated preventive home visits programme is unlikely to be cost-effective. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT00644826.

[Potential analysis for research on Advanced Practice Nursing (APN) for persons with dementia living in long-term care facilities]. / Potenzialanalyse zu "Advanced Practice Nursing (APN)" für Bewohner mit dementiellen Erkrankungen in deutschen Einrichtungen der stationären Langzeitpflege.

HEALTH PROBLEM: The nursing Minimum Data Set 3.0 (MDS 3.0) and other nursing quality indices summarise relevant health and nursing outcomes for long-term care that are recommended as quality measures. These are measures like "Percent of High-Risk Residents with Pressure Ulcers", "Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder", "Percent of Residents Experiencing One or More Falls with Major Injury", "Percent of Residents Who Lose Too Much Weight" etc. Analyses of healthcare data in Germany showed a substantial higher risk for negative outcomes in the long-term care setting in persons with dementia compared to persons without dementia. There already exist evidence-based guidelines and recommendations for most of the quality measures and underlying health problems (e.g., the German "Expertenstandards in der Pflege"). Implementation and translation of evidence have not been systematically researched yet, and there is uncertainty about structures and processes that support implementation and eventually lead to improved nursing outcomes in people with dementia in long-term care. CORPUS OF EVIDENCE: Studies showed a potential benefit of master-level geriatric advanced practice nurses (GAPNs) concerning the implementation of evidence-based guidelines. This corresponds to the expectation that academic nursing staff positively influences research utilisation in practice. A systematic review identified four controlled trials that evaluated the effectiveness of GAPN on select quality measures. Both the internal and external validity of the trials require a thorough investigation into the intervention before translation and effectiveness research in Germany can be recommended. IMPLICATION FOR RESEARCH: In accordance with national and international recommendations on the development and clinical evaluation of complex interventions, we recommend a multistage model. Such a model comprises the conceptualisation and adaptation of the original intervention. In this way, the original concept of a GAPN has to be translated into the context of the German healthcare system. Furthermore, feasibility of the intervention in general has to be investigated. This includes acceptance of GAPNs in practice and the necessary prerequisites, especially concerning a comprehensive commitment of one APN to more than one long-term care facility.