[Chronic cough in adult patients-evidence-based approach]. / Chronischer Husten bei erwachsenen Patienten ­ evidenzbasiertes Vorgehen.

Approximately 10% of the population suffer from a cough lasting longer than 8 weeks. Compared to acute cough, which usually occurs in the context of banal respiratory tract infections, the differential diagnoses of chronic cough require an increased use of diagnostic tests and thus a structured, evidence-based approach according to current international guidelines. A targeted history (smoking status, medication, previous diseases) and ENT status are always followed by chest x­ray and pulmonary function tests before extended diagnostics. In the case of angiotensin-converting enzyme (ACE) inhibitor use and unremarkable physical examination, a drug discontinuation test can be carried out first. In case of inconspicuous findings, a disease entity that can be treated empirically such as upper airway cough syndrome is most likely. If the cough remains unexplained, cough suppression techniques, physiotherapy or speech therapy should be sought before off-label-use of medication.

Exploring the views of low-acuity emergency department consulters on an educational intervention and general practitioner appointment service: a qualitative study in Berlin, Germany.

OBJECTIVES: Low-acuity patients presenting to emergency departments (EDs) frequently have unmet ambulatory care needs. This qualitative study explores the patients' views of an intervention aimed at education about care options and promoting primary care (PC) attachment. DESIGN: Qualitative telephone interviews were conducted with a subsample of participants of an interventional pilot study, based on a semi-structured interview guide. The data were analysed through qualitative content analysis. SETTING: The study was carried out in three EDs in the city centre of Berlin, Germany. PARTICIPANTS: Thirty-two low-acuity ED consulters with no connection to a general practitioner (GP) who had participated in the pilot study were interviewed; (f/m: 15/17; mean age: 32.9 years). INTERVENTION: In the pilot intervention, ED patients with low-acuity complaints were provided with an information leaflet on appropriate ED usage and alternative care paths and they were offered an optional GP appointment scheduling service. Qualitative interviews explored the views of a subsample of the participants on the intervention. RESULTS: Interviewees perceived both parts of the intervention as valuable. Receiving a leaflet about appropriate ED use and alternatives to the ED was viewed as helpful, with participants expressing the desire for additional online information and a wider distribution of the content. The GP appointment service was positively assessed by the participants who had made use of this offer and seen as potentially helpful in establishing a long-term connection to GP care. The majority of patients declining a scheduled GP appointment expected no personal need for further medical care in the near future or preferred to choose a GP independently. CONCLUSIONS: Low-acuity ED patients seem receptive to information on alternative acute care options and prevailingly appreciate measures to encourage and facilitate attachment to a GP. Promoting PC integration could contribute to a change in future usage behaviour. TRIAL REGISTRATION NUMBER: DRKS00023480.

Primary and secondary data in emergency medicine health services research - a comparative analysis in a regional research network on multimorbid patients.

BACKGROUND: This analysis addresses the characteristics of two emergency department (ED) patient populations defined by three model diseases (hip fractures, respiratory, and cardiac symptoms) making use of survey (primary) and routine (secondary) data from hospital information systems (HIS). Our aims were to identify potential systematic inconsistencies between both data samples and implications of their use for future ED-based health services research. METHODS: The research network EMANET prospectively collected primary data (n=1442) from 2017-2019 and routine data from 2016 (n=9329) of eight EDs in a major German city. Patient populations were characterized using socio-structural (age, gender) and health- and care-related variables (triage, transport to ED, case and discharge type, multi-morbidity). Statistical comparisons between descriptive results of primary and secondary data samples for each variable were conducted using binomial test, chi-square goodness-of-fit test, or one-sample t-test according to scale level. RESULTS: Differences in distributions of patient characteristics were found in nearly all variables in all three disease populations, especially with regard to transport to ED, discharge type and prevalence of multi-morbidity. Recruitment conditions (e.g., patient non-response), project-specific inclusion criteria (e.g., age and case type restrictions) as well as documentation routines and practices of data production (e.g., coding of diagnoses) affected the composition of primary patient samples. Time restrictions of recruitment procedures did not generate meaningful differences regarding the distribution of characteristics in primary and secondary data samples. CONCLUSIONS: Primary and secondary data types maintain their advantages and shortcomings in the context of emergency medicine health services research. However, differences in the distribution of selected variables are rather small. The identification and classification of these effects for data interpretation as well as the establishment of monitoring systems in the data collection process are pivotal. TRIAL REGISTRATION: DRKS00011930 (EMACROSS), DRKS00014273 (EMAAGE), NCT03188861 (EMASPOT).

Social Prescribing: Systematic Review of the Effectiveness of Psychosocial Community Referral Interventions in Primary Care.

Introduction: Social prescribing (SP) aims to provide targeted psychosocial support and close the gap between medical and non-medical services. This review assesses the effectiveness of community-based SP interventions. Methods: We performed a systematic review and qualitative synthesis of interventional studies of community referral interventions focused on facilitating psychosocial support. We considered health-related endpoints, other patient reported outcomes, or health care utilization. Six databases, grey literature, and additional trials registers were searched. Results were screened in a two-step process, followed by data extraction, each by two independent reviewers. If data permitted such, effect sizes were calculated. Risk of bias was assessed with the EPHPP and the Cochrane RoB2 tools. Results: We identified 68 reports from 53 different projects, three were controlled studies. Uncontrolled studies with shorter time frames frequently reported positive effects. This could largely not be seen in controlled settings and for longer follow-up periods. Designs, populations, and outcomes evaluated were heterogeneous with high risk of bias for most studies. Discussion and conclusion: Current evidence suggests positive effects of SP on a variety of relevant endpoints. Due to quality deficits in the available studies, scope for conclusions concerning clinical relevance and sustainability is limited. Further methodologically rigorous controlled trials are needed.

[Acute and chronic cough - differential diagnosis and treatment]. / Akuter und chronischer Husten ­ Differenzialdiagnose und Behandlung.

Cough is a frequent reason for consultation in the general practitioner's office. Most of the time, the symptom is harmless and self-limiting, as in the case of a banal cold cough, for example - however, serious diseases such as malignancies can also be the cause. Evaluation is therefore not always easy. This article presents a targeted and appropriate approach and discusses which treatments are recommended and effective.Acute and chronic cough are differentiated according to the duration of symptoms (up to 8 weeks/longer than 8 weeks). The most common cause of acute cough is a self-limiting viral infection of the upper respiratory tract; the most important differential diagnosis is community-acquired pneumonia. If there are no defined warning signs (red flags), the history and clinical examination are sufficient to establish the diagnosis in the case of an acute cough; medication is not necessary. In the case of a chronic cough, a chest X-ray is usually ordered and then further investigations are carried out in accordance with the most probable suspected diagnosis; probationary therapies are an important part of the workup. Coughs that are refractory to treatment or unexplained require individualised treatment (pharmacological, including off-label, non-pharmacological) and regular re-evaluation.

Redirecting emergency medical services patients with unmet primary care needs: the perspective of paramedics on feasibility and acceptance of an alternative care path in a qualitative investigation from Berlin, Germany.

BACKGROUND: Against the backdrop of emergency department (ED) overcrowding, patients' potential redirection to outpatient care structures is a subject of current political debate in Germany. It was suggested in this context that suitable lower-urgency cases could be transported directly to primary care practices by emergency medical services (EMS), thus bypassing the ED. However, practicality is discussed controversially. This qualitative study aimed to capture the perspective of EMS personnel on potential patient redirection concepts. METHODS: We conducted qualitative, semi-structured phone interviews with 24 paramedics. Interviews were concluded after attainment of thematic saturation. Interviews were transcribed verbatim, and qualitative content analysis was performed. RESULTS: Technical and organizational feasibility of patients' redirection was predominantly seen as limited (theme: "feasible, but only under certain conditions") or even impossible (theme: "actually not feasible"), based on a wide spectrum of potential barriers. Prominently voiced reasons were restrictions in personnel resources in both EMS and ambulatory care, as well as concerns for patient safety ascribed to a restricted diagnostic scope. Concerning logistics, alternative transport options were assessed as preferable. Regarding acceptance by stakeholders, the potential for releasing ED caseload was described as a factor potentially promoting adoption, while doubt was raised regarding acceptance by EMS personnel, as their workload was expected to conversely increase. Paramedics predominantly did not consider transporting lower-urgency cases as their responsibility, or even as necessary. Participants were markedly concerned of EMS being misused for taxi services in this context and worried about negative impact for critically ill patients, as to vehicles and personnel being potentially tied up in unnecessary transports. As to acceptance on the patients' side, interview participants surmised a potential openness to redirection if this would be associated with benefits like shorter wait times and accompanied by proper explanation. CONCLUSIONS: Interviews with EMS staff highlighted considerable doubts about the general possibility of a direct redirection to primary care as to considerable logistic challenges in a situation of strained EMS resources, as well as patient safety concerns. Plans for redirection schemes should consider paramedics' perspective and ensure a provision of EMS with the resources required to function in a changing care environment.

Emergency department consultations for respiratory symptoms revisited: exploratory investigation of longitudinal trends in patients' perspective on care, health care utilization, and general and mental health, from a multicenter study in Berlin, Germany.

BACKGROUND: Only few studies of emergency department (ED) consulters include a longitudinal investigation. The EMACROSS study had surveyed 472 respiratory patients in eight inner-city EDs in Berlin in 2017/2018 for demographic, medical and consultation-related characteristics. This paper presents the results of a follow-up survey at a median of 95 days post-discharge. We aimed to explore the post hoc assessment of ED care and identify potential longitudinal trends. METHODS: The follow-up survey included items on satisfaction with care received, benefit from the ED visit, potential alternative care, health care utilization, mental and general health, and general life satisfaction. Univariable between-subject and within-subject statistical comparisons were conducted. Logistic regression was performed for multivariable investigations of determinants of dropout and of retrospectively rating the ED visit as beneficial. RESULTS: Follow-up data was available for 329 patients. Participants of lower education status, migrants, and tourists were more likely to drop out. Having a general practitioner (GP), multimorbidity, and higher general life satisfaction were determinants of response. Retrospective satisfaction ratings were high with no marked longitudinal changes and waiting times as the most frequent reason for dissatisfaction. Retrospective assessment of the visit as beneficial was positively associated with male sex, diagnoses of pneumonia and respiratory failure, and self-referral. Concerning primary care as a viable alternative, judgment at the time of the ED visit and at follow-up did not differ significantly. Health care utilization post-discharge increased for GPs and pulmonologists. Self-reported general health and PHQ-4 anxiety scores were significantly improved at follow-up, while general life satisfaction for the overall sample was unchanged. CONCLUSIONS: Most patients retrospectively assess the ED visit as satisfactory and beneficial. Possible sex differences in perception of care and its outcomes should be further investigated. Conceivable efforts at diversion of ED utilizers to primary care should consider patients' views regarding acceptable alternatives, which appear relatively independent of situational factors. Representativeness of results is restricted by the study focus on respiratory symptoms, the limited sample size, and the attrition rate. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00011930 ); date: 2017/04/25.

[Acute Cough in Adult Patients]. / Akuter Husten bei erwachsenen Patient*innen.

Background: Acute cough (< 8 weeks) is a frequent complaint in family practice consultations. The most common cause are respiratory infections. The Guideline "Acute and chronic cough" of the German College of General Practitioners and Family Physicians (DEGAM) was updated in 2021 and contains recommendations for an evidence-based approach for the management of acute cough in primary care. Methods: The guideline has been updated in accordance with the findings of a systematic search of the literature for international guidelines and systematic reviews. All recommendations were developed by an interdisciplinary guideline committee and agreed by formal consensus. Results: History-taking, exclusion of red flags and a physical examination are the basis of diagnostic evaluation. If an acute, uncomplicated bronchitis is likely, no laboratory tests, sputum diagnostics, or chest x-rays should be performed, and antibiotics should not be administered. Evidence based strategies to avoid antibiotic therapy (delayed prescribing, shared decision making, point-of-care-tests) can be used. There is inadequate evidence for the efficacy of antitussive or expectorant drugs against acute cough. The state of the evidence for phytotherapeutic agents is heterogeneous; clinical importance is minimal. COVID-19 should currently be considered in cases of acute respiratory symptoms. If specific symptoms or red flags occur, further diagnoses in the context of acute cough such as community-acquired pneumonia, influenza disease and exacerbations of chronic respiratory diseases (bronchial asthma, COPD) should be taken into consideration. Conclusions: These evidence-based recommendations are intended to reduce the use of antibiotics to treat colds and acute bronchitis, for which they are not indicated. Further clinical trials of symptomatic treatments for cough should be performed in order to extend the evidence base.

Chronic Cough.

BACKGROUND: Chronic cough, i.e., cough lasting longer than eight weeks, affects approximately 10% of the population and is a common reason for outpatient medical consultation. Its differential diagnosis is extensive, and it is generally evaluated in poorly structured fashion with a variety of diagnostic techniques. The German Clinical Practice Guideline on Acute and Chronic Cough was updated in 2021 and contains a description of the recommended stepwise, patient-centered, and evidencebased procedure for the management of chronic cough. METHODS: The guideline has been updated in accordance with the findings of a systematic search of the literature for international guidelines and systematic reviews. All recommendations were developed in an interdisciplinary manner and agreed upon by formal consensus. The target group consists of adult patients with cough. RESULTS: History-taking, after the exclusion of red flags, should include questioning about smoking status, medications, and relevant present and past illnesses (COPD, asthma). Subsequent diagnostic testing should include a chest x-ray and pulmonary function tests. If the patient is taking an ACE inhibitor, a test of drug discontinuation can be carried out first. Radiologically detected pulmonary masses or evidence of rare diseases (interstitial lung diseases, bronchiectasis) are an indication for chest CT or for direct referral to an appropriate specialist. If the imaging studies and pulmonary function tests are normal, the patient is most likely suffering from a disease entity that can be treated empirically, such as upper airway cough syndrome or cough variant asthma. Any patient with an unexplained or refractory cough must receive proper patient education; individual therapeutic trials of physiotherapeutic or speech-therapeutic methods are possible, as is the off-label use of gabapentin or morphine. CONCLUSION: Chronic cough should be evaluated according to an established diagnostic algorithm in collaboration with specialists. Treatments such as inhaled corticosteroids should be tested exhaustively in accordance with the guidelines, and the possibility of multiple causes as well as the role of patient compliance should be kept in mind before a diagnosis of unexplained or intractable cough is assigned.

[Am I an emergency patient? Emergency perception and decision-making competence in acute situations: a qualitative study of ED patients]. / Bin ich ein Notfall? Notfallempfinden und Entscheidungskompetenz in akuten Situationen: eine qualitative Erhebung bei Notaufnahmepatient*innen.

BACKGROUND: The number of patients visiting emergency departments (ED) due to acute but less than urgent treatment needs is increasing. A deeper understanding of emergency perception and decision-making competencies of patients is fundamentally important for developing strategies to reduce ED utilization. The aim of this study was to assess ED patients' subjective understanding of an emergency in general as well as relating to their own specific consultation. Additionally, the patients' perspective on the ability to make appropriate decisions in acute situations should be explored. METHODS: Seventeen qualitative semi-structured patient interviews were conducted and analyzed using qualitative content analysis. RESULTS: The majority of participants attributed their ED consultation to a subjectively perceived emergency situation. Interviewees mostly understood an emergency as a serious or life-threatening constellation associated with impending long-term health damage. They believed that uncertainty concerning the interpretation of their symptoms and associated anxiety may particularly promote situations in which referring to an ED appears to be the only alternative. Patients' health competencies were assessed negatively by a majority of interviewees with regard to assessment of complaints and decision-making in acute situations ("insecure patients"). In contrast, few patients, including those with chronic disease and experience in dealing with health problems, were considered to have a high level of competence ("confident patients"). CONCLUSION: Improving patients' health literacy skills to strengthen their assessment of acute situations and their decision-making is important in order to promote appropriate ED utilization.

Self-reported health and life satisfaction in older emergency department patients: sociodemographic, disease-related and care-specific associated factors.

BACKGROUND: Self-reported health (SRH) and life satisfaction (LS) are patient-reported outcomes (PROs) that independently predict mortality and morbidity in older adults. Emergency department (ED) visits due to serious health problems or accidents might pose critical life events for patients. This study aimed (a) to characterize older patients' SRH and LS during the distinct event of an ED stay, and (b) to analyze concomitant associations of PROs with ED patients' sociodemographic, disease-specific and care-related variables. METHODS: Study personnel recruited mostly older ED patients from three disease groups during a two-year period (2017-2019) in eight EDs in central Berlin, Germany, in the context of the health services research network EMANet. Cross-sectional data from the baseline patient survey and associated secondary data from hospital information systems were analyzed. Multilevel linear regression models with random intercept were applied to assess concomitant associations with SRH (scale: 0 (worst) to 100 (best)) and LS (scale: 0 (not at all satisfied) to 10 (completely satisfied)) as outcomes, including sensitivity analyses. RESULTS: The final sample comprised N = 1435 participants. Mean age was 65.18 (SD: 16.72) and 50.9% were male. Mean ratings of SRH were 50.10 (SD: 23.62) while mean LS scores amounted to 7.15 (SD: 2.50). Better SRH and higher LS were found in patients with cardiac symptoms (SRH: ß = 4.35, p = .036; LS: ß = 0.53, p = .006). Worse SRH and lower LS were associated with being in need of nursing care (SRH: ß = - 7.52, p < .001; LS: ß = - 0.59, p = .003) and being unemployed (SRH: ß = - 8.54, p = .002; LS: ß = - 1.27, p < .001). Sex, age, number of close social contacts, and hospital stays in the previous 6 months were additionally related to the outcomes. Sensitivity analyses largely supported results of the main sample. CONCLUSIONS: SRH and LS were associated with different sociodemographic and disease-related variables in older ED patients. Nursing care dependency and unemployment emerged as significant factors relating to both outcomes. Being able to identify especially vulnerable patients in the ED setting might facilitate patient-centered care and prevent negative health outcomes. However, further longitudinal research needs to analyze trajectories in both outcomes and suitable intervention possibilities in the ED setting. TRIAL REGISTRATION: EMANet sub-studies were registered separately: German Clinical Trials Register (EMAAge: DRKS00014273, registration date: May 16, 2018; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014273; EMACROSS: DRKS00011930, registration date: April 25, 2017; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011930); ClinicalTrials.gov (EMASPOT: NCT03188861, registration date: June 16, 2017; https://clinicaltrials.gov/ct2/show/NCT03188861?term=NCT03188861&draw=2&rank=1).

Diverting less urgent utilizers of emergency medical services to primary care: is it feasible? Patient and morbidity characteristics from a cross-sectional multicenter study of self-referring respiratory emergency department consulters.

OBJECTIVE: Diversion of less urgent emergency medical services (EMS) callers to alternative primary care (PC) is much debated. Using data from the EMACROSS survey of respiratory ED patients, we aimed to characterize self-referred EMS patients, compare these with non-EMS patients, and assess scope and acceptability of a potential redirection to alternative PC. RESULTS: Of n = 292 self-referred patients, n = 99 were transported by EMS. Compared to non-EMS patients, these were older, triaged more urgently and arrived out-of-hours more frequently. The share of chronically and severely ill patients was greater. Out-of-hours ED visit, presence of a chronic pulmonary condition as well as a hospital diagnosis of respiratory failure were identified as determinants of EMS utilization in a logistic model, while consultation for access and quality motives as well as migrant status decreased the probability. EMS-transported lower urgency outpatients visiting during regular physicians' hours were defined as potential PC cases and evaluated descriptively (n = 9). As a third was medically complex and potentially less suitable for PC, redirection potential could be estimated at only 6% of EMS cases. This would be reduced to 2% if considering patients' judgment concerning the appropriate setting. Overall, the scope for PC diversion of respiratory EMS patients seems limited.

Ivy leaf (Hedera helix) for acute upper respiratory tract infections: an updated systematic review.

PURPOSE: Acute cough due to viral upper respiratory tract infections (URTIs) and bronchitis is a common reason for patients to seek medical care. Non-antibiotic over-the-counter cough medications such as ivy leaf extract are frequently used but their efficacy is uncertain. Our purpose was to update our previous systematic review and evaluate the effectiveness and tolerability of ivy leaf in the treatment of acute URTIs in adult and pediatric populations. METHODS: We searched MEDLINE, EMBASE, the Cochrane Library, and clinical trial registries from December 2009 to January 2020. Randomized controlled trials (RCTs), controlled clinical trials (CCTs), and observational studies (OSs) investigating ivy leaf mono- or combination preparations were included. Two independent reviewers assessed records for eligibility and risk of bias and performed data extraction. RESULTS: Six RCTs, 1 CCT, and 4 OSs were identified. Since the publication of our previous review, the number of RCTs has increased. All studies concluded that ivy leaf extract is an effective and safe option for the treatment of cough due to URTIs and bronchitis. Three RCTs reported a more rapid reduction in cough severity and/or frequency under ivy leaf treatment. The clinical significance of these effects appears to be minimal. No serious adverse effects were reported. The overall quality of reporting was low and the risk of bias was high. CONCLUSIONS: Ivy leaf preparations are safe for use in cough due to acute URTIs and bronchitis. However, effects are minimal at best and of uncertain clinical importance.

Self-referred walk-in patients in the emergency department - who and why? Consultation determinants in a multicenter study of respiratory patients in Berlin, Germany.

BACKGROUND: Emergency department (ED) consultations are on the rise, and frequently consultations by non-urgent patients have been held accountable. Self-referred walk-in (SRW) consulters supposedly represent a predominantly less urgent patient population. The EMACROSS study aimed to explore consultation determinants and motives in SRW patients with respiratory symptoms. METHODS: Multicenter survey of adult ED patients with respiratory complaints in eight emergency departments in central Berlin, Germany. Secondary hospital records data including diagnoses was additionally assessed. Characteristics of SRW and non-SRW patients were compared. Determinants of SRW consultation were evaluated by binary logistic regression. Consultation motives were analyzed descriptively. As a supplemental approach, network analysis (lasso-regularized mixed graphical model) was performed to explore connections between consultation determinants, consultation features and motives. RESULTS: Between June 2017 and November 2018, n = 472 participants were included, the median age was 55 years (range 18-96), 53.2% of patients were male and n = 185 cases (39.2%) were SRW consulters. The SRW group showed lower proportions of potentially severe (pneumonia and respiratory failure, p < 0.001, χ2 test) and chronic pulmonary conditions. Determinants of SRW consultation identified by logistic regression were younger age (p < 0.001), tertiary education (p = 0.032), being a first-generation migrant (p = 0.002) or tourist (p = 0.008), having no regular primary care provider (p = 0.036) and no chronic pulmonary illness (p = 0.017). The area under the curve (AUC) for the model was 0.79. Personal distress and access problems in ambulatory care were stated most frequently as consultation motives in the SRW group; network analysis showed the scarcity of associations between demographic and medical SRW determinants and motives triggering the actual decision to consult. CONCLUSIONS: As to "who" consults, this study identified demographic and medical predictors of SRW utilization. The said markers seem only remotely connected to "why" people decide for SRW visits. To alleviate ED crowding by addressing frequent SRW consultation motives, interventions focused on the ability for symptom self-assessment and at better-accessible alternative care seem sensible. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00011930 ); date: 2017/04/25.

What role does the GP play for emergency department utilizers? A qualitative exploration of respiratory patients' perspectives in Berlin, Germany.

BACKGROUND: While motives for emergency department (ED) self-referrals have been investigated in a number of studies, the relevance of general practitioner (GP) care for these patients has not been comprehensively evaluated. Respiratory symptoms constitute an important utilization trigger in both EDs and in primary care. In this qualitative study, we aimed to explore the role of GP care for patients visiting EDs as outpatients for respiratory complaints and the relevance of the relationship between patient and GP in the decision making process leading up to an ED visit. METHODS: Qualitative descriptive study. Semi-structured, face-to-face interviews with a sample of 17 respiratory ED patients in Berlin, Germany. Interviews were recorded and transcribed verbatim. Qualitative content analysis was performed. The study was embedded into the EMACROSS (Emergency and Acute Care for Respiratory Diseases beyond Sectoral Separation) cohort of ED patients with respiratory symptoms, which is part of EMANet (Emergency and Acute Medicine Network for Health Care Research). RESULTS: Three patterns of GP utilization could be differentiated: long-term regular consulters, sporadic consulters and patients without GP. In sporadic consulters and patients without GP, an ambivalent or even aversive view of GP care was prevalent, with lack of confidence in GPs' competence and a deficit in trust as seemingly relevant influencing factors. Regardless of utilization or relationship type, patients frequently made contact with a GP before visiting an ED. CONCLUSIONS: With regard to respiratory symptoms, our qualitative data suggest a hypothesis of limited relevance of patients' primary care utilization pattern and GP-patient relationship for ED consultation decisions.

How to decide adequately? Qualitative study of GPs' view on decision-making in self-referred and physician-referred emergency department consultations in Berlin, Germany.

OBJECTIVES: Patients with acute symptoms present not only to general practitioners (GPs), but also frequently to emergency departments (EDs). Patients' decision processes leading up to an ED self-referral are complex and supposed to result from a multitude of determinants. While they are key providers in primary care, little is known about GPs' perception of such patients. This qualitative study explores the GPs' view regarding motives and competences of patients self-referring to EDs, and also GPs' rationale for or against physician-initiated ED referrals. DESIGN: Qualitative study with semi-structured, face-to-face interviews; qualitative content analysis. SETTING: GP practices in Berlin, Germany. PARTICIPANTS: 15 GPs (female/male: 9/6; mean age 53.6 years). RESULTS: The interviewed GPs related a wide spectrum of factors potentially influencing their patients' decision to visit an ED, and also their own decision-making in potential referrals. Considerations go beyond medical urgency. Statements concerning patients' surmised rationale corresponded to GPs' reasoning in a variety of important areas. For one thing, the timely availability of an extended spectrum of diagnostic and therapeutic options may make ED services attractive to both. Access difficulties in the ambulatory setting were mentioned as additional triggers for an ED visit initiated by a patient or a GP. Key patient factors like severity of symptoms and anxiety also play a major role; a desire for reassurance may lead to both self-referred and physician-initiated ED visits. Patients' health competence was prevailingly depicted as limited, with the internet as an important influencing factor. Counselling efforts by GP were described as crucial for improving health literacy. CONCLUSIONS: Health education could hold promise when aiming to reduce non-urgent ED consultations. Primary care providers are in a key position here. Amelioration of organisational shortages in ambulatory care, for example, limited consultation hours, might also make an important impact, as these trigger both self-referrals and GP-initiated ED referrals. TRIAL REGISTRATION NUMBER: DRKS00011930.

'Managing scarcity'- a qualitative study on volunteer-based healthcare for chronically ill, uninsured migrants in Berlin, Germany.

OBJECTIVES: In Germany, healthcare for people lacking legal residency status and European Union citizens without health insurance is often provided by non-governmental organisations. Scientific studies assessing the situation of the patients with chronic diseases in this context are scarce. We aimed to characterise medical care for chronically ill migrants without health insurance and outline its possibilities and limitations from the treating physicians' perspective. DESIGN: Qualitative semi-structured interviews; qualitative content analysis. SETTING: Organisations and facilities providing healthcare for uninsured migrants: free clinics, medical practices and public health services. PARTICIPANTS: 14 physicians working regularly in healthcare for uninsured migrants. RESULTS: Delayed contact to the healthcare system was frequently addressed in the interviews. Care was described as constrained by a scarcity of resources that often impedes adequate treatment for many conditions, most pronounced in the case of oncological diseases or chronic viral infections (HIV, hepatitis). For other chronic conditions such as cardiovascular diseases or diabetes, some diagnostics and basic medications were described as partially available, while management of complications or rehabilitative measures are frequently unfeasible. For the patients with mental health problems, attainability of psychotherapeutic treatment is reported as severely limited. Care is predominantly described as fragmented with limitations to information flow and continuity. Which level of care a patient receives appears to depend markedly on the respective non-governmental organisation and the individual commitment, subjective decisions and personal connections of the treating physician. CONCLUSIONS: Restrictions in medical care for uninsured migrants have even more impact on chronically ill patients. Volunteer-based care often constitutes an inadequate compensation for regular access to the healthcare system, as it is strongly influenced by the limitation of its resources and its arbitrariness.

[EMANet: A regional network for health services research in emergency and acute medicine]. / EMANET - Regionales Netzwerk für Versorgungsforschung in der Notfall- und Akutmedizin.

The number of patients seeking help in emergency departments is steadily increasing. In part, this is due to patients who have acute symptoms, but do not require emergency care, as well as multimorbid patients needing complex medical care. Emergency departments serve as an interface between primary care and in-patient as well as out-patient care. The ongoing public discussion about the need to readjust emergency care structures in Germany does not adequately address this aspect. The knowledge of characteristics and needs of patients seeking help in emergency departments is insufficient. In order to develop interventions matching these needs it is necessary to gain deeper insight into these characteristics and needs. EMANet is a health services research project funded by the Federal Ministry of Education and Research. Its aim is to collect representative data on the course of medical care of emergency patients with ambulatory care sensitive conditions in all eight emergency departments in Mitte, the inner city district of Berlin. The EMANet project focuses on three patient groups: a) patients with cardiac symptoms and possible psychiatric comorbidities, b) ambulatory patients with acute or chronic diseases of the respiratory tract, and c) geriatric patients with hip fractures. The collected data shall be used to gain a better understanding of health care utilization patterns, patient-perceived satisfaction and risk factors for potentially avoidable medical conditions or worsening of chronic disease. The mixed methods design of EMANet includes quantitative data of 1,650 patients at two time points and corresponding secondary (i. e. routine) data from hospital information systems. In addition, qualitative interviews with patients and health care professionals shall reveal unmet needs for medical care. The results will give us more in-depth insight into the perceived current capacity overload and help implement structural changes in the health care system.