Utilization and quality of palliative care in patients with hematological and solid cancers: a population-based study.

BACKGROUND: Palliative care (PC) contributes to improved end-of-life care for patients with hematologic malignancies (HM) and solid tumors (ST) by addressing physical and psychological symptoms and spiritual needs. Research on PC in HM vs. ST patients is fragmented and suggests less use. METHODS: We analyzed claims data of all deceased members of a large German health insurance provider for the year before death. First, we analyzed the frequency and the beginning of different types of PC and compared patients with HM vs. ST. Second, we analyzed the adjusted impact of PC use on several end-of-life quality outcomes in patients with HM vs. ST. We performed simple and multiple (logistic) regression analysis, adjusted for relevant covariates, and standardized for age and sex. RESULTS: Of the 222,493 deceased cancer patients from 2016 to 2020, we included 209,321 in the first analysis and 165,020 in the second analysis. Patients with HM vs. ST received PC less often (40.4 vs. 55.6%) and later (34 vs. 50 days before death). PC use significantly improved all six quality indicators for good end-of-life care. HM patients had worse rates in five of the six indicators compared with ST patients. Interaction terms revealed that patients with ST derived greater benefit from PC in five of six quality indicators than those with HM. CONCLUSION: The data highlight the need to integrate PC more often, earlier, and more effectively into the care of patients with HM.

[Attitudes of general practitioners and medical practice assistants towards the delegation of medical services: Results of a survey in Berlin, Brandenburg and Thuringia]. / Einstellungen von Hausärzt:innen und Medizinischen Fachangestellten zur Delegation ärztlicher Leistungen ­ Ergebnisse einer Befragung in Berlin, Brandenburg und Thüringen.

INTRODUCTION: The delegation of tasks and responsibilities from general practitioners (GPs) to medical practice assistants (MPAs) can contribute to ensuring primary care in Germany. The aim of the study was to collect and analyze attitudes and procedures of GPs and MPAs regarding the delegation of physician-related tasks and activities. METHODOLOGY: A self-designed, piloted questionnaire was sent to all GPs listed within the regional Associations of Statutory Health Insurance Physicians (KV) in Thuringia, Berlin, and Brandenburg (n=5,516) and their MPAs. Participants were asked to indicate which physician-related activities were already delegated and on which occasions further delegations could be considered. RESULTS: 890 GPs (response rate: 16.1%) and 566 MPAs participated in the written survey. The participants were predominantly female and most of them worked in urban areas. Numerous activities, such as medical history taking, triage, Disease Management Program (DMP) controls, vaccinations and home visits, have already been delegated. The willingness to delegate further tasks (e. g., follow-up prescriptions and referrals, independent takeover of simple consultations, assessing the necessity of physician consultation) was high. CONCLUSION: The survey showed a high level of willingness of both occupational groups to delegate physician-related activities to MFAs. An expansion seems possible under certain conditions. Many activities have already been delegated to MPAs in primary care practices. Our survey provides suggestions regarding further tasks suitable for delegation, some of which go beyond the delegation agreement valid in Germany.

[A regional comparison of outcomes quality and costs of general and specialized palliative care in Germany: a claims data analysis]. / Ergebnisqualität und Kosten der allgemeinen und spezialisierten Palliativversorgung in Deutschland im regionalen Vergleich: eine GKV-Routinedatenstudie.

BACKGROUND: The main framework conditions for palliative care are set at the regional level. The scope of the forms of care used (outpatient, inpatient, general, specialized) varies widely. What is the quality of outcomes achieved by the palliative care provided on a federal states level? What are the associated costs of care? METHOD: Retrospective observational study using BARMER claims data from 145,372 individuals who died between 2016 and 2019 and had palliative care in the last year of life. Regional comparison with regard to the following outcomes: proportion of palliative care patients who died in the hospital, potentially burdensome care in the last 30 days of life (ambulance calls, [intensive care] hospitalizations, chemotherapy, feeding tubes, parenteral nutrition), total cost of care (last three months), cost of palliative care (last year), and cost-effectiveness ratios. Calculation of patient/resident characteristic adjusted rates, costs, and ratios. RESULTS: Federal states vary significantly with respect to the outcomes (also adjusted) of palliative care. Palliative care costs vary widely, most strongly for specialized outpatient palliative care (SAPV). Across all indicators and the cost-effectiveness ratio of total cost of care to at-home deaths, Westphalia-Lippe shows favorable results. CONCLUSION: Regions with better quality and more favorable cost (ratios) can provide guidance for other regions. The extent to which the new federal SAPV agreement can incorporate the empirical findings should be reviewed. Patient-relevant outcome parameters should be given greater weight than parameters aiming at structures of care.

[Once vaccinated, always vaccinated? A claims data analysis on repeated influenza vaccinations among individuals aged ≥ 60 years]. / Einmal geimpft, immer geimpft? Routinedatenanalyse zur wiederholten Influenzaimpfung von ≥ 60-Jährigen.

BACKGROUND: The Standing Committee on Vaccination recommends the seasonal influenza vaccination as a standard vaccination for individuals aged ≥ 60 years and as an indication vaccination independent of age. Empirical data on repeated vaccination are not available for Germany. The aim of this study was therefore to investigate the frequency and influencing factors of repeated vaccinations. METHODS: We conducted a longitudinal retrospective observational study with claims data from ≥ 60­year-olds insured with the statutory health insurance AOK Plus in Thuringia between 2012 and 2018. The number of seasons with influenza vaccination was described and the association with various individual characteristics was analysed in a regression model. RESULTS: Included were 103,163 individuals with at least one influenza vaccination in the 2014/2015 season, of whom 75.3% had been vaccinated in ≥ 6 of 7 seasons. We found repeated vaccinations more frequently among nursing home residents (rate ratio (RR) 1.27), individuals with increased health risk due to underlying diseases (RR 1.21) and higher age groups (vs. 60-69 years: RR 1.17-1.25). With each additional year of participating in a disease management program, the number of vaccinations increased (RR 1.03). Women (RR 0.91), individuals with nursing care level 1 (vs. no nursing care level: RR 0.90) and people with a comorbidity (vs. no comorbidity: RR 0.97) were less likely to receive repeated vaccinations. DISCUSSION: A large proportion of individuals aged ≥ 60 years who have been vaccinated against influenza once is likely to repeatedly receive vaccinations. In accordance with vaccination recommendations, nursing home residents and in particular individuals with an increased health risk are vaccinated repeatedly. General practitioners play a central role: non-acute patient contacts should be used to offer vaccinations, especially to women and individuals in need of care who are living at home.

[General practitioners' palliative care activities in Westphalia-Lippe compared to other federal states - Secondary analysis of a survey]. / Hausärztliche Palliativversorgung in Westfalen-Lippe im Vergleich mit anderen Bundesländern ­ sekundäre Auswertung einer Befragungsstudie.

INTRODUCTION: In palliative home care frictional loss at the interface between primary palliative care (PPC) and specialised palliative home care (SPHC) is repeatedly pointed out. PPC and SPHC appear to be insufficiently interlinked. The model implemented in Westphalia-Lippe differs from others in Germany: it relies on close cooperation between general practitioners (GPs) and palliative consultancy services (PCS), an early start of the palliative care process and comprehensive/widespread collaboration. We hypothesize that the framework conditions applying in Westphalia-Lippe have positive effects on the uptake of palliative care activities by GPs. The objective of this study therefore is to compare GPs' attitudes and their willingness to provide palliative care between GPs in Westphalia-Lippe and GPs in other federal states/Associations of Statutory Health Insurance Physicians (ASHIPs) in order to empirically test our hypothesis. METHODS: Secondary evaluation of a nationwide paper-based survey from 2018 for national data acquisition of GPs' palliative care activities at the interface of SPHC. Answers of the participating GPs from Westphalia-Lippe (n=119) are contrasted with the answers of the GPs from seven other federal states (n=1,025). RESULTS: GPs from Westphalia-Lippe have a consistently higher self-perception of being responsible for palliative care of their patients, more often take responsibility for palliative care activities and feel more confident in carrying them out. GPs from Westphalia-Lippe are more likely to know other palliative care facilities/actors and they find them to be more likely available for GPs. They rate the quality of the overall palliative infrastructure higher. For GPs from Westphalia-Lippe the involvement of PCS/SPHC providers is less important than for GPs from other regional ASHIPs. If they are involved in the palliative treatment of a patient, GPs from Westphalia-Lippe feel more frequently involved in the course of treatment. DISCUSSION: Our study indicates that the special framework conditions for palliative care provided by GPs in Westphalia-Lippe have positive effects on their uptake of palliative care activities. An essential factor could be the PPC- and SPHC-integrated approach to palliative care in Westphalia-Lippe. CONCLUSION: Westphalia-Lippe may provide orientation for other regions regarding the involvement of GPs at the interface to specialized palliative care. Whether the type of palliative home care in Westphalia-Lippe also produces advantages in terms of quality and costs of care compared to the rest of Germany is something that needs to be investigated in the future.

[Utilization of palliative care at the end of life in Germany: temporal trend (2016-2019) and regional variability]. / Inanspruchnahme von Palliativversorgung am Lebensende in Deutschland: zeitlicher Verlauf (2016­2019) und regionale Variabilität.

BACKGROUND: In Germany, palliative care (PC) is provided on a homecare, inpatient, general, and specialized basis. Since little is currently known about the temporal course and regional differences in the forms of care, the present study was aimed to investigate this. METHOD: In a retrospective routine data study with 417,405 BARMER-insured persons who died between 2016 and 2019, we determined the utilization rates of primary PC (PPC), specially qualified and coordinated palliative homecare (PPC+), specialized palliative homecare (SPHC), inpatient PC, and hospice care on the basis of services billed at least once in the last year of life. We calculated time trends and regional variability and controlled for needs-related patient characteristics and access-related county of community characteristics. RESULTS: From 2016 to 2019, total PC increased from 33.8 to 36.2%, SPHC from 13.3 to 16.0% (max: Rhineland-Palatinate), and inpatient PC from 8.9 to 9.9% (max: Thuringia). PPC decreased from 25.8 to 23.9% (min: Brandenburg) and PPC+ came in at 4.4% (max: Saarland) in 2019. Hospice care remained constant at 3.4%. Regional variability in utilization rates remained high, increased for PPC and inpatient PC from 2016 to 2019, and decreased for SPHC and hospice care. The regional differences were also evident after adjustment. CONCLUSION: Increasingly more SPHC, less PPC, and high regional variability, which cannot be explained by demand- or access-related characteristics, indicate that the use of PC forms is oriented less to demand than to regionally available care capacities. In view of the growing need for palliative care due to demographic factors and decreasing personnel resources, this development must be viewed critically.

The role of recoding in implicit social cognition: Investigating the scope and interpretation of the ReAL model for the implicit association test.

The ReAL model is a multinomial processing tree model that quantifies the contribution of three qualitatively distinct processes-recoding, associations, and accuracy-to responses on the implicit association test (IAT), but has only been validated on a modified version of the IAT procedure. The initial goal of the present research was to validate an abbreviated version of the ReAL model (i.e., the Brief ReAL model) on the standard IAT procedure. Two experiments replicated previous validity evidence for the ReAL model on the modified IAT procedure, but did not produce valid parameter estimates for the Brief ReAL model on the standard IAT procedure. A third, pre-registered experiment systematically manipulated all of the task procedures that vary between the standard and modified IAT procedures-response deadline, number of trials, trial constraints-to determine the conditions under which the Brief ReAL model can be validly applied to the IAT. The Brief ReAL model estimated theoretically-interpretable parameters only under a narrow range of IAT conditions, but the ReAL model generally estimated theoretically-interpretable parameters under most IAT conditions. We discuss the application of these findings to implicit social cognition research, and their implications to social cognitive theory.

Predicting Behavior With Implicit Measures: Disillusioning Findings, Reasonable Explanations, and Sophisticated Solutions.

Two decades ago, the introduction of the Implicit Association Test (IAT) sparked enthusiastic reactions. With implicit measures like the IAT, researchers hoped to finally be able to bridge the gap between self-reported attitudes on one hand and behavior on the other. Twenty years of research and several meta-analyses later, however, we have to conclude that neither the IAT nor its derivatives have fulfilled these expectations. Their predictive value for behavioral criteria is weak and their incremental validity over and above self-report measures is negligible. In our review, we present an overview of explanations for these unsatisfactory findings and delineate promising ways forward. Over the years, several reasons for the IAT's weak predictive validity have been proposed. They point to four potentially problematic features: First, the IAT is by no means a pure measure of individual differences in associations but suffers from extraneous influences like recoding. Hence, the predictive validity of IAT-scores should not be confused with the predictive validity of associations. Second, with the IAT, we usually aim to measure evaluation ("liking") instead of motivation ("wanting"). Yet, behavior might be determined much more often by the latter than the former. Third, the IAT focuses on measuring associations instead of propositional beliefs and thus taps into a construct that might be too unspecific to account for behavior. Finally, studies on predictive validity are often characterized by a mismatch between predictor and criterion (e.g., while behavior is highly context-specific, the IAT usually takes into account neither the situation nor the domain). Recent research, however, also revealed advances addressing each of these problems, namely (1) procedural and analytical advances to control for recoding in the IAT, (2) measurement procedures to assess implicit wanting, (3) measurement procedures to assess implicit beliefs, and (4) approaches to increase the fit between implicit measures and behavioral criteria (e.g., by incorporating contextual information). Implicit measures like the IAT hold an enormous potential. In order to allow them to fulfill this potential, however, we have to refine our understanding of these measures, and we should incorporate recent conceptual and methodological advancements. This review provides specific recommendations on how to do so.

Identification with drug use among young adults who are at risk of transitioning to more serious use.

Understanding the drug use trajectories for at risk young adults can help reduce harms associated with serious drug use. This longitudinal study tracked young people to assess whether implicit and explicit identification with substance use predicts changes in use over time and whether patterns of use impacts identification with drugs. Two hundred and twenty-eight participants were initially recruited from homeless shelters, youth centers, drug health services, and parks where young people who use drugs are known to frequent. Over a 20-month period, 78 of these original participants were successfully recontacted and surveyed again. The survey assessed implicit and explicit identification with drug use, along with known risk factors, to determine if identification predicts changes in drug use over time as assessed by frequency, recency, and multiple drug use. Results revealed that implicit and explicit identification with drug use were stronger among participants who used more frequently, more recently, and used multiple drugs, although this finding only emerged cross-sectionally and not longitudinally. Overall, these results suggest that patterns of drug use are associated with the identity of the individual and that identification with drug use is a marker of drug-using behavior, but identification with drug use does not appear to be predictive of future behavior nor an outcome of prior drug use.

Implicit and Explicit Age Stereotypes for Specific Life Domains Across the Life Span: Distinct Patterns and Age Group Differences.

BACKGROUND/STUDY CONTEXT: Drawing on research that shows the importance of age stereotypes across the life span, the authors investigated domain-specific implicit and explicit age stereotypes in different age groups. METHODS: Implicit (Implicit Association Test [IAT]; Greenwald, McGhee, & Schwartz, 1998, Journal of Personality and Social Psychology, 74, 1464-1480) and explicit age stereotypes were assessed for the domains of family and health in a sample of N = 90 younger, middle-aged, and older adults. RESULTS: Overall, age stereotypes were negative for the health domain but not for the family domain. Distinct patterns of age group differences emerged depending on domain and assessment method. In the family domain, older participants held the least positive explicit age stereotypes, whereas implicit stereotypes in this domain were most positive for this age group compared with the young and middle-aged groups. For the health domain, implicit and explicit age associations indicated that middle-aged participants showed the most negative age-associations. CONCLUSIONS: These findings suggest that implicit and explicit age stereotypes in different life domains represent largely independent constructs. Differential age group effects are assumed to reflect the result of accommodative and assimilative processes that are used to cope with age-related changes. Implications for future studies of implicit and explicit age stereotypes and their influence on developmental regulation are discussed.

Estimating the contributions of associations and recoding in the Implicit Association Test: the ReAL model for the IAT.

We introduce the ReAL model for the Implicit Association Test (IAT), a multinomial processing tree model that allows one to mathematically separate the contributions of attitude-based evaluative associations and recoding processes in a specific IAT. The ReAL model explains the observed pattern of erroneous and correct responses in the IAT via 3 underlying processes: recoding of target and attribute categories into a binary representation in the compatible block (Re), evaluative associations of the target categories (A), and label-based identification of the response that is assigned to the respective nominal category (L). In 7 validation studies, using an adaptive response deadline procedure in order to increase the amount of erroneous responses in the IAT, we demonstrated that the ReAL model fits IAT data and that the model parameters vary independently in response to corresponding experimental manipulations. Further studies yielded evidence for the specific predictive validity of the model parameters in the domain of consumer behavior. The ReAL model allows one to disentangle different sources of IAT effects where global effect measures based on response times lead to equivocal interpretations. Possible applications and implications for future IAT research are discussed.