Outpatient geriatric health care in the German federal state of Mecklenburg-Western Pomerania: a population-based spatial analysis of claims data.

BACKGROUND: Due to unidentified geriatric needs, elderly patients have a higher risk for developing chronic conditions and acute medical complications. Early geriatric screenings and assessments help to identify geriatric needs. Holistic and coordinated therapeutic approaches addressing those needs maintain the independence of elderly patients and avoid adverse effects. General practitioners are important for the timely identification of geriatric needs. The aims of this study are to examine the spatial distribution of the utilization of outpatient geriatric services in the very rural Federal State of Mecklenburg-Western Pomerania in the Northeast of Germany and to identify regional disparities. METHODS: Geographical analysis and cartographic visualization of the spatial distribution of outpatient geriatric services of patients who are eligible to receive basic geriatric care (BGC) or specialized geriatric care (SGC) were carried out. Claims data of the Association of Statutory Health Insurance Physicians in Mecklenburg-Western Pomerania were analysed on the level of postcode areas for the quarter periods between 01/2014 and 04/2017. A Moran's I analysis was carried out to identify clusters of utilization rates. RESULTS: Of all patients who were eligible for BGC in 2017, 58.3% (n = 129,283/221,654) received at least one BCG service. 77.2% (n = 73,442/95,171) of the patients who were eligible for SGC, received any geriatric service (BGC or SGC). 0.4% (n = 414/95,171) of the patients eligible for SGC, received SGC services. Among the postcode areas in the study region, the proportion of patients who received a basic geriatric assessment ranged from 3.4 to 86.7%. Several regions with statistically significant Clusters of utilization rates were identified. CONCLUSIONS: The widely varying utilization rates and the local segregation of high and low rates indicate that the provision of outpatient geriatric care may depend to a large extent on local structures (e.g., multiprofessional, integrated networks or innovative projects or initiatives). The great overall variation in the provision of BGC services implicates that the identification of geriatric needs in GPs' practices should be more standardized. In order to reduce regional disparities in the provision of BGC and SGC services, innovative solutions and a promotion of specialized geriatric networks or healthcare providers are necessary.

Effects of Closure of the Paediatric Department of a District Hospital on Regional Care: Analysis of Patient Flows. / Auswirkungen der Schließung der pädiatrischen Abteilung eines Kreiskrankenhauses auf die regionale Versorgung ­ Analyse der Patientenflüsse.

BACKGROUND: The consequences of economization and staff shortage in the German health care system strongly affect paediatric care structures, especially in rural regions. It is not known how closures of paediatric departments influence patient flows of surrounding hospitals. Here, we investigate the quantitative effects of closure of the paediatric department of a district hospital and the subsequent opening of an alternative inpatient service on the utilisation of inpatient and outpatient care services of the two neighboring hospitals and the emergency services of the region. METHODOLOGY: In the observation period from 2015 to 2019, patient-related data from the three hospitals in the study region as well as data from the rescue service were evaluated. RESULTS: In the year after the paediatric department of the district hospital was closed in 2016, the total number of inpatient cases in the region decreased by 33% (2015: n=1,787; 2016: n=1,193) and then decreased by an additional 11% (2019: n=1,005). The number of outpatient cases decreased by further 8% (2015: n=6,250; 2019: n=5,770). In the last observation year, emergency services were used much more frequently than in the year before the closure (2015: n=398; 2019: n=572). This means an increase of 44%. CONCLUSION: After the closure of the paediatric department, the total number of inpatient cases in the region fell sharply. However, actual gaps in care apparently did not arise. Before closing, the consequences for the surrounding hospitals should be assessed more precisely. Real gaps in care must be counteracted, e. g. through alternative outpatient services.

Population-Based, Spatial Analysis of Specialised Ambulatory Palliative Care in Mecklenburg-Western Pomerania, Germany, on the Basis of Reimbursement Data.

In rural areas, healthcare providers, patients and relatives have to cover long distances. For specialised ambulatory palliative care (SAPV), a supply radius of max. 30 km is recommended. The aim of this study was to analyse whether there are regional disparities in the supply of SAPV and whether it is associated with the distance between the SAPV team's site and the patient's location. Therefore, anonymised data of the Association of Statutory Health Insurance Physicians of the Federal State of Mecklenburg-Western Pomerania (M-V) were retrospectively analysed for the period of 2014-2017. Identification as a palliative patient was based on palliative-specific items from the ambulatory reimbursement catalogue. In total, 6940 SAPV patients were identified; thereof, 48.9% female. The mean age was 73.3 years. For 28.3% of the identified SAPV patients (n = 1961), the SAPV teams had a travel distance of >30 km. With increasing distance, the average number of treatment days per patient increased. It was found that there are regional disparities in the provision of SAPV services in M-V and that local structures have an important impact on regional supply patterns. The distance between the SAPV team's site and the patient's location is not the only determining factor; other causes must be considered.

[Tandem Practices: Pediatric Consultation Hours in General Practitioners' Practices in Rural Areas in Germany - a Collaborative Project]. / Tandem-Praxen ­ Pädiatrische Sprechstunden in Hausarzt-Praxen in ländlichen Regionen: ein Kooperations-Experiment.

BACKGROUND: In Germany, patients under the age of 18 receive medical care from pediatricians. In sparsely populated regions, general practitioners often have to do the job of pediatricians and offer medical care to children, which in most cases is adequate. However, it does not meet the goal of demand planning namely, every patient should have equal access to care regardless of their place of residence. One option to help achieve this is the implementation of consultation hours with pediatricians in general practitioners' practices (tandem practices). The aim of this study was to investigate the feasibility and acceptance of this cooperation and whether this improved access to pediatric care. METHODS: First, general practitioners willing to participate were identified, where the nearest pediatrician's practice was more than 20 kilometers away. The second step was to find suitable pediatricians willing to offer regular weekly pediatric consultations in the practice of a general practitioner. For the evaluation, various data collection methods were used: one-off parent questionnaires at the time of study inclusion, questionnaires filled out by the pediatricians for each consultation, and data from the practice information systems in the participating practices. The distance between the patients' place of residence and the next regular outpatient pediatrician's practice were calculated and compared to the distance to a tandem practice. RESULTS: In April 2019, in two practices tandem consultation hours were implemented. During 12 months, 192 children and adolescents (50.2% female) were included. They attended the consultation hours a total of 387 times. Of 482 reasons given in the doctor's questionnaire, 36.9% were vaccinations (n=178), 14.9% were preventive examinations (n=72), the most frequently coded ICD-10 diagnostic groups were diseases of the respiratory system (J00-J99: 8.5%, n=41) and mental/behavioral disorders (F00-F99: 7.7%, n=37). Before the project, the patients had an average of 20.2 kilometers (min 0.3; max 34.8) to the next regular outpatient pediatrician's practice; within the project, the distance decreased to 5.1 kilometers (min 0.1; max 26.7). CONCLUSION: All doctors involved wanted to continue the tandem consultations after the end of the test phase. The project results showed the feasibility and a high level of acceptance of tandem practices, both for the doctors involved and for the patients and their parents.

Diagnostic delay in children with inflammatory bowel disease in the German-Austrian patient registry CEDATA-GPGE 2014-2018.

The incidence and prevalence of pediatric-onset inflammatory bowel disease (PIBD) are on the rise worldwide. Initial symptoms are often recognized with a delay, which reduces the quality of life and may lead to an increased rate of complications. The aim of this study was to determine the diagnostic delay in PIBD and to identify potential influencing factors. Therefore, data from the German-Austrian patient registry CEDATA-GPGE for children and adolescents with PIBD were analyzed for the period January 2014 to December 2018. There were 456 children identified in the data, thereof 258 children (57%) with Crohn's disease (CD) and 198 children (43%) with Ulcerative colitis (UC). The median age was 13.3 years (interquartile range (IQR) = 10.9-15.0), and 44% were females. The median diagnostic delay was 4.1 months (IQR = 2.1-7.0) in CD and 2.4 months (IQR = 1.2-5.1) in UC (p = 0.01). UC was associated with earlier diagnosis than CD (p < 0.001). Only a few factors influencing the diagnostic delay have been verified, e.g., abdominal pain at night and if video capsule endoscopy was performed. Diagnostic delay improved over the years in participating centers, but the level of awareness needs to be high even in common symptoms like abdominal pain.

Triage through telemedicine in paediatric emergency care-Results of a concordance study.

BACKGROUND: In the German health care system, parents with an acutely ill child can visit an emergency room (ER) 24 hours a day, seven days a week. At the ER, the patient receives a medical consultation. Many parents use these facilities as they do not know how urgently their child requires medical attention. In recent years, paediatric departments in smaller hospitals have been closed, particularly in rural regions. As a result of this, the distances that patients must travel to paediatric care facilities in these regions are increasing, causing more children to visit an ER for adults. However, paediatric expertise is often required in order to assess how quickly the patient requires treatment and select an adequate treatment. This decision is made by a doctor in German ERs. We have examined whether remote paediatricians can perform a standardised urgency assessment (triage) using a video conferencing system. METHODS: Only acutely ill patients who were brought to a paediatric emergency room (paedER) by their parents or carers, without prior medical consultation, have been included in this study. First, an on-site paediatrician assessed the urgency of each case using a standardised triage. In order to do this, the Paediatric Canadian Triage and Acuity Scale (PaedCTAS) was translated into German and adapted for use in a standardised IT-based data collection tool. After the initial on-site triage, a telemedicine paediatrician, based in a different hospital, repeated the triage using a video conferencing system. Both paediatricians used the same triage procedure. The primary outcome was the degree of concordance and interobserver agreement, measured using Cohen's kappa, between the two paediatricians. We have also included patient and assessor demographics. RESULTS: A total of 266 patients were included in the study. Of these, 227 cases were eligible for the concordance analysis. In n = 154 cases (68%), there was concordance between the on-site paediatrician's and telemedicine paediatrician's urgency assessments. In n = 50 cases (22%), the telemedicine paediatrician rated the urgency of the patient's condition higher (overtriage); in 23 cases (10%), the assessment indicated a lower urgency (undertriage). Nineteen medical doctors were included in the study, mostly trained paediatric specialists. Some of them acted as an on-site doctor and telemedicine doctor. Cohen's weighted kappa was 0.64 (95% CI: 0.49-0.79), indicating a substantial agreement between the specialists. CONCLUSIONS: Telemedical triage can assist in providing acute paediatric care in regions with a low density of paediatric care facilities. The next steps are further developing the triage tool and implementing telemedicine urgency assessment in a larger network of hospitals in order to improve the integration of telemedicine into hospitals' organisational processes. The processes should include intensive training for the doctors involved in telemedical triage. TRIAL REGISTRATION: DRKS00013207.

Comparison of survival between patients receiving general outpatient palliative care and patients receiving other palliative care - analysis of data of a statutory health insurance data.

BACKGROUND: The care of palliative patients takes place as non-specialized and specialized care, in outpatient and inpatient settings. However, palliative care is largely provided as General Outpatient Palliative Care (GOPC). This study aimed to investigate whether the survival curves of GOPC patients differed from those of the more intensive palliative care modalities and whether GOPC palliative care was appropriate in terms of timing. METHODS: The study is based on claims data from a large statutory health insurance. The analysis included 4177 patients who received palliative care starting in 2015 and who were fully insured 1 year before and 1 year after palliative care or until death. The probability of survival was observed for 12 months. Patients were classified into group A, which consisted of patients who received palliative care only with GOPC, and group B including patients who received inpatient or specialized outpatient palliative care. Group A was further divided into two subgroups. Patients who received GOPC on only 1 day were assigned to subgroup A1, and patients who received GOPC on two or more days were assigned to subgroup A2. The survival analysis was carried out using Kaplan-Meier curves. The median survival times were compared with the log-rank test. RESULTS: The survival curves differed between groups A and B, except in the first quartile of the survival distribution. The median survival was significantly longer in group A (137 days, n = 2763) than in group B (47 days, n = 1424, p < 0.0001) and shorter in group A1 (35 days, n = 986) than in group A2 (217 days, n = 1767, p < 0.0001). The survival rate during the 12-month follow-up was higher in group A (42%) than in group B (11%) and lower in group A1 (38%) than in group A2 (44%). CONCLUSIONS: The results of the analysis revealed that patients who received the first palliative care shortly before death suspected insufficient care, especially patients who received GOPC for only 1 day and no further palliative care until death or 12-month follow-up. Palliative care should start as early as necessary and be continuous until the end of life.

Telemedical care and quality of life in patients with schizophrenia and bipolar disorder: results of a randomized controlled trial.

BACKGROUND: Schizophrenia and bipolar disorder are serious psychiatric disorders with a high disease burden, a high number of years of life lived with disability and a high risk for relapses and re-hospitalizations. Besides, both diseases are often accompanied with a reduced quality of life (QoL). A low level of quality of life is one predictor for relapses. This study examines whether a telemedical care program can improve QoL. METHODS: Post stationary telemedical care of patients with severe psychiatric disorders" (Tecla) is a prospective controlled randomized intervention trial to implement and evaluate a telemedical care concept for patients with schizophrenia and bipolar disorder. Participants were randomized to an intervention or a control group. The intervention group received telemedical care including regular, individualized telephone calls and SMS-messages. QoL was measured with the German version of the WHOQOL-BREF. Effects of telemedicine on QoL after 6 months and treatment*time interactions were calculated using linear regressions (GLM and linear mixed models). RESULTS: One hundred eighteen participants were recruited, thereof 57.6% men (n = 68). Participants were on average 43 years old (SD 13). The treatment*time interaction was not significant. Hence, treatment had no significant effect either. Instead, gender is an influencing factor. Further analysis showed that social support, the GAF-level and QoL-values at baselines were significant determinants for the improvement of QoL. CONCLUSION: The telemedicine care concept Tecla was not significant for QoL in patients with severe psychiatric disorders. More important for the QoL is the general social support and the level of global functioning of the patients. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00008548, registered 21 May 2015 - retrospectively registered, https://www.drks.de/drks_web/setLocale_EN.do.

Association between body mass index and macronutrients differs along the body mass index range of German adults: results from the German National Nutrition Survey II.

The aim of the present study was to determine whether the association between body mass index (BMI) and the intake of macronutrients varies along the BMI distribution of German adults. Based on a sample of 9214 men and women aged 18-80 years from the representative cross-sectional German National Nutrition Survey (NVS) II, quantile regression was used to investigate the association between BMI and the intake of macronutrients independent of energy intake and other predictors. In both sexes, BMI was positively associated with the intake of total protein and animal protein over its entire range and negatively associated with vegetable protein. A negative association between BMI and the intake of polysaccharides was found along the entire range of BMI in men. There was a weak negative association between BMI and the intake of total fat and saturated fatty acids observed in normal-weight-range women only. In conclusion, the association between BMI and the intake of macronutrients varies along the BMI range. Animal protein intake is positively associated with BMI independent of energy intake in both sexes whereas only in men an inverse association of polysaccharide intake with BMI was shown.

Continuity in palliative care - analysis of intersectoral palliative care based on routine data of a statutory health insurance.

BACKGROUND: The goal of palliative care is to prevent and alleviate a suffering of incurable ill patients. A continuous intersectoral palliative care is important. The aim of this study is to analyse the continuity of palliative care, particularly the time gaps between hospital discharge and subsequent palliative care as well as the timing of the last palliative care before the patient's death. METHODS: The analysis was based on claims data from a large statutory health insurance. Patients who received their first palliative care in 2015 were included. The course of palliative care was followed for 12 months. Time intervals between discharge from hospital and first subsequent palliative care as well as between last palliative care and death were analysed. The continuity in palliative care was defined as an interval of less than 14 days between palliative care. Data were analysed using descriptive statistics and Chi-Square. RESULTS: In 2015, 4177 patients with first palliative care were identified in the catchment area of the statutory health insurance. After general inpatient palliative care, 415 patients were transferred to subsequent palliative care, of these 67.7% (n = 281) received subsequent care within 14 days. After a stay in a palliative care ward, 124 patients received subsequent palliative care, of these 75.0% (n = 93) within 14 days. Altogether, 147 discharges did not receive subsequent palliative care. During the 12-months follow-up period, 2866 (68.7%) patients died, of these 78.7% (n = 2256) received palliative care within the last 2 weeks of life. Of these, 1223 patients received general ambulatory palliative care, 631 patients received specialised ambulatory palliative care, 313 patients received their last palliative care at a hospital and 89 patients received it in a hospice. CONCLUSIONS: The majority of the palliative care patients received continuous palliative care. However, there are some patients who did not receive continuous palliative care. After inpatient palliative care, each patient should receive a discharge management for a continuation of palliative care. Readmissions of patients after discharge from inpatients palliative care can be an indication for a lack of support in the ambulatory health care setting and for an insufficient discharge management. Palliative care training and possibilities for palliative care consultations by specialists should strengthen the GPs in palliative care.

[Palliative Care from the Perspective of Providers of General and Specialised Palliative Care - A Cross-Sectional Survey]. / Die allgemeine und spezialisierte Palliativversorgung aus Sicht von Leistungserbringern der Hospiz- und Palliativversorgung ­ eine Querschnittserhebung.

BACKGROUND: Palliative care is a particular challenge in rural regions with low population density. Every patient should have access to palliative care regardless of age, diagnosis, prognosis, place of residence and economic aspects. The aim was to identify problem areas in palliative care in rural regions and to find possible solutions from the perspective of health service providers. METHODS: A standardised written survey was conducted among providers of general and specialised palliative care in the federal state of Mecklenburg-Western Pomerania. In total, 489 service providers were sent a questionnaire. A random sample of general palliative care providers and all specialised palliative care providers in Mecklenburg-Western Pomerania were contacted. For the evaluation of the structure of palliative care and to identify problem areas, the German school grading system was used (1=very good, 6=insufficient). The results of the survey were descriptively analysed. RESULTS: The response rate was 19% (n=93). Identified problems were the interface between outpatient and inpatient care as well as between general and specialised palliative care. The cooperation between specialised outpatient palliative care teams and hospital with a palliative care unit was rated with an average of 1.9. The cooperation between specialised outpatient palliative care teams and hospitals without a palliative care unit was rated with an average of 3.6. The knowledge of palliative care of nurses in nursing homes was graded 4.0; 54.8% (n=51) of the participants could consider providing telemedicine care to palliative patients in addition to conventional care. The establishment of a palliative care coordination unit was rated as highly important by 34.4% of the participants. CONCLUSIONS: The results indicate infrastructural, organisational and quality-related problems in providing palliative care. The provision of palliative care in rural areas could be strengthened through targeted training, outpatient consultation services, coordination units and the integration of telemedicine functionalities.

Predictors of BMI Vary along the BMI Range of German Adults - Results of the German National Nutrition Survey II.

OBJECTIVE: The objective of the study was to identify predictors of BMI in German adults by considering the BMI distribution and to determine whether the association between BMI and its predictors varies along the BMI distribution. METHODS: The sample included 9,214 adults aged 18-80 years from the German National Nutrition Survey II (NVS II). Quantile regression analyses were conducted to examine the association between BMI and the following predictors: age, sports activities, socio-economic status (SES), healthy eating index-NVS II (HEI-NVS II), dietary knowledge, sleeping duration and energy intake as well as status of smoking, partner relationship and self-reported health. RESULTS: Age, SES, self-reported health status, sports activities and energy intake were the strongest predictors of BMI. The important outcome of this study is that the association between BMI and its predictors varies along the BMI distribution. Especially, energy intake, health status and SES were marginally associated with BMI in normal-weight subjects; this relationships became stronger in the range of overweight, and were strongest in the range of obesity. CONCLUSIONS: Predictors of BMI and the strength of these associations vary across the BMI distribution in German adults. Consequently, to identify predictors of BMI, the entire BMI distribution should be considered.

Food consumption of adults in Germany: results of the German National Nutrition Survey II based on diet history interviews.

The second German National Nutrition Survey (NVS II) aimed to evaluate food consumption and other aspects of nutritional behaviour of a representative sample of the German population, using a modular design with three different dietary assessment methods. To assess usual food consumption, 15,371 German speaking subjects 14-80 years of age completed a diet history interview between November 2005 and November 2006. With reference to the guidelines of the German Nutrition Society (DGE), NVS II observed that the German population did not eat enough foods of plant origin, especially vegetables and consumed too much of meat and meat products. While generally similar food consumption is observed in other European countries, consumption of bread, fruit juices/nectars and beer is higher in Germany. On average, men consumed two times more meat and soft drinks as well as six times more beer than women did, whereas the consumption of vegetables, fruit as well as herbal/fruit tea was higher in women. Older participants showed a lower consumption of meat, fruit juice/nectars, soft drinks and spirits as well as a higher consumption of fish, vegetables, fruit, and herbal/fruit tea than adolescents and younger adults did. There are also differences in food consumption with regard to socio-economic status (SES). Persons with higher SES consumed more vegetables, fruit, fish, water, coffee/tea and wine, while persons with lower SES consumed more meat and meat products, soft drinks and beer. In general, the food consumption of women, the elderly and the higher SES group tends to be closer to the official dietary guidelines in Germany.