Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure.

BACKGROUND: The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study. METHODS: General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis. RESULTS: Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees. CONCLUSIONS: Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.

["The Show Must Go on": Medical Assistants and Their Experience Managing Vaccination during the Covid-19 Pandemic]. / "Es muss laufen" ­ Medizinische Fachangestellte und ihre Erfahrungen im Impfmanagement während der Covid-19-Pandemie.

BACKGROUND: With the beginning of the Covid-19 vaccinations in primary care, a new and work-intensive responsibility arose for medical assistants (MA). In addition to their existing duties and the challenges posed by Covid-19, they had to organize, plan, and in some cases carry out the vaccinations and follow up on the documentation. METHODS: A total of 21 semi-structured interviews were conducted with MA between April and September 2021. Particularly considering the timing of the interview, questions were asked about the daily work routine and the associated vaccine organization. The interviews were then analyzed using MAXQDA software based on Kuckartz's qualitative content analysis. RESULTS: The MA criticized a lack of organization and transparency in the planning and implementation of vaccinations. Each vaccination had to be pre- and post-processed, resulting in an immense bureaucratic effort. Additional work and stress were the results. Also, MA had to deal with difficult patients. CONCLUSION: The experience of MA must be taken into consideration in the future to create guidance for dealing with an increased demand for vaccinations. The guidelines for the future must ensure that MA are relieved and supported by a meaningful organization during such events.

["You have to take it that way." A study of the subjective experience of the corona pandemic by older people in need of help and care living at home]. / "Das muss man so nehmen." Eine Studie zum subjektiven Erleben der Coronapandemie älterer hilfe- und pflegebedürftiger Menschen in der Häuslichkeit.

BACKGROUND: As older people are at increased risk of severe and fatal courses of SARS-CoV­2 infection, they receive special attention, which, however, often refers one-sidedly to their need for protection. What is needed is a discussion that considers the subjective reality and resources as well as risks. OBJECTIVE: The study focused on the perspectives of older people. The aim was to shed light on their subjective experience of the corona pandemic. The questions were how they experienced the pandemic, the risks, consequences and protective measures, to what extent these affected their everyday life and how they dealt with it. MATERIAL AND METHODS: A total of 12 guideline-based telephone interviews were conducted in May and June 2020 with 9 women and 3 men between 77 and 91 years of age, who lived in their own homes, had impaired health and needed help and care. The data were evaluated by structuring content analysis. RESULTS: The respondents were generally concerned about the corona pandemic but considered their own risk to be low. They saw themselves as hardly affected by the immediate consequences of the crisis or severely restricted in their everyday lives. They experienced insecurity in social life and fear of loneliness was central. Overall, they considered the protective measures to be appropriate but criticized early cancelling, family contact restrictions and dealing with the dying. CONCLUSION: A moderate degree of direct personal involvement, acceptance and adaptability characterized the experience and handling of the corona pandemic. Resources and skills in dealing with the crisis become visible.

[Closing care gaps after hospitalization: Study results [intersec-CM] on discharge and transfer management according to sect. 39 SGB V for people with cognitive impairments associated with dementia]. / Versorgungslücken nach dem Krankenhausaufenthalt schließen: Studienergebnisse [intersec-CM] zum Entlass- und Überleitungsmanagement nach § 39 SGB V für Menschen, die im Krankenhaus kognitive demenzielle Beeinträchtigungen zeigen.

In Germany, there are 1.8 million people currently living with dementia, and the trend is rising. In particular, the health system at the transition from hospital to outpatient care is facing major challenges given the high increase in a difficult patient clientele. Legal efforts have been undertaken (sect. 39a of the Fifth Social Code Book [SGB V]) to close the care gaps in the discharge and transfer process. This article aims to provide an overview of the documentation process of the discharge and transfer management for people with cognitive impairments in everyday clinical practice according to SGB V sect. 39 para. 1a after the Discharge Management Act came into force. Furthermore, the manuscript answers the research question "How is the statutory discharge management of people with cognitive impairments (MmkB) aged 65 and over documented" and highlights further characteristics of the discharge documentation for MmkB starting with the transition from the inpatient setting to other care settings. In order to answer the research question(s), a qualitative content analysis of all discharge documents available at the time of discharge was carried out as part of the intervention study on cross-sector care management to support cognitively impaired people during and after a hospital stay [intersec-CM], which was funded by the Federal Ministry of Education and Research. The results of the analysis show that, despite legal efforts, there are currently no standardized, unified processes of discharge management for people with cognitive impairments that can be traced in writing. However, departments with a large proportion of vulnerable patient groups were able to offer valuable insights: for example, their discharge documents included a short social history. Further evidence-based research and development in the domain of discharge management for people with cognitive impairments remains essential.

Improve Mental Health (Improve-MH) in refugee families using a culturally adapted, general practitioner-delivered psychotherapeutic intervention combined with Triple P Online parenting programme: study protocol of a multicentre randomised controlled trial.

INTRODUCTION: Germany and the European Union have experienced successive waves of refugees since 2014, resulting in over 1.6 million arrivals, including families with young children. These vulnerable populations often face xenophobia, discrimination, substandard living conditions and limited healthcare access, contributing to a high prevalence of mental health problems (MHP). Our primary goal is to proactively address MHP in refugee parents and prevent its potential impact on their children through effective early interventions. Using a low-threshold, primary care-based approach, we aim to enhance parenting skills and address parental psychopathology, creating a supportive environment for parents and children. METHODS AND ANALYSIS: In this randomised controlled trial, 188 refugee parents of 6-year-old children or younger who meet the clinical cut-off on the MHP scale will participate. They are randomly assigned to either the experimental psychotherapeutic intervention, delivered by general practitioners (10-week Improve intervention), or treatment as usual, in a ratio of 1:1. The randomisation will be masked only for outcome assessors. Improve includes face-to-face sessions with general practitioners, an interactive online parenting programme (Triple P Online) and regular protocol-based telephone calls by psychologists. Primary outcomes will assess the intervention's effects on parental and child MHP and parenting skills, with secondary outcomes including psychosocial and physical health indicators. Outcomes will be assessed at pre, post and at 3-month and 6-month follow-ups. The study is scheduled to run from February 2019 to July 2025. ETHICS AND DISSEMINATION: The project Improve-MH (application number 602) was approved by the local ethics committee of Ruhr-University of Bochum and is being conducted in accordance with the Declaration of Helsinki. The study is also conducted in full accordance with the German Data Protection Act, and the Good Clinical Practice guideline (GCP) and is sensitive to specific ethical considerations. Results will be disseminated at scientific conferences, published in peer-reviewed journals and provided to consumers of healthcare. TRIAL REGISTRATION NUMBER: The trial was prospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien, DRKS-ID: DRKS00019072) on 16 March 2020.

"I Needed to Know, No Matter What I Do, I Won't Make It Worse"-Expectations and Experiences of Last Aid Course Participants in Germany-A Qualitative Pilot Study.

BACKGROUND: The need to care for a loved one in a palliative state can lead to severe physical as well as psychological stress. In this context, Last Aid courses have been developed to support caring for relatives and to stimulate the public discussion on death and dying. The purpose of our pilot study is to gain an understanding of the attitudes, values, and difficulties of relatives caring for a terminally ill person. METHODS: A qualitative approach was used in form of five semi-structured guided pilot interviews with lay persons who recently attended a Last Aid course. The transcripts of the interviews were analyzed following Kuckartz's content analysis. RESULTS: Overall, the interviewed participants have a positive attitude toward Last Aid courses. They perceive the courses as helpful as they provide knowledge, guidance, and recommendations of action for concrete palliative situations. Eight main topics emerged during analysis: expectations regarding the course, transfer of knowledge, reducing fear, the Last Aid course as a safe space, support from others, empowerment and strengthening of own skills, and the improvement needs of the course. CONCLUSIONS: In addition to the expectations before participation and the knowledge transfer during the course, the resulting implications for its application are also of great interest. The pilot interviews show initial indications that the impact, as well as supportive and challenging factors regarding the ability to care for relatives to cope, should be explored in further research.

[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.

Intersectoral care management for older people with cognitive impairment during and after hospital stays [intersec-CM]: study protocol for a process evaluation within a randomised controlled trial.

BACKGROUND: In the healthcare system in Germany, different institutions and actors play specific roles in the discharge and transition of patients from hospitals into primary care (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen, Wettbewerb an der Schnittstelle zwischen ambulanter und stationärer Gesundheitsversorgung, 2012). However, there are shortcomings in these intersectoral transitions. Especially in older people with cognitive impairment (PCI), discharge management often lacks coordination and cooperation between healthcare providers. This frequently results in higher rates of unscheduled readmission. The project intersec-CM is a randomised controlled trial (RCT) that aims to explore up to what extent an intersectoral care management (ICM) can improve this transition. This ICM is delivered by nurses with special training in care management. The objective of this paper is to describe a mixed-methods process evaluation of the intersectoral care management intervention and the factors that facilitate and inhibit its implementation. METHODS: Different study designs for process evaluations from previous literature were collected and analysed according to the dimension implementation fidelity, satisfaction with the intervention, feasible transfer into routine care, optimum point of time, frequency and execution of the intervention, and context factors. RESULTS: The actor-network theory was chosen as the theoretic framework for the process evaluation. Based on this theory, a mixed-methods design was developed to combine and integrate qualitative and quantitative evaluation methods. The qualitative part includes semi-structured interviews using topic guides (phase 1) and later in-depth interviews with narrative portions (phase 3), which will be analysed by using the qualitative content analysis according to Kuckartz. The quantitative survey (phase 2) is conducted with standardised questionnaires. DISCUSSION: Challenges in data collection include the development of interview guidelines, which require different terminologies depending on every specific actor targeted in the intervention. Conducting the interviews, there is a risk of misunderstanding the older PCI by the interviewer and vice versa. However, the combination of qualitative and quantitative approaches as different techniques of process evaluation may help to capture, integrate and analyse data on different dimensions of the intervention. CONCLUSIONS: The results of our process evaluation may serve as an implementation guideline for intersectoral care management in the German healthcare system. Furthermore, the approach to evaluate the process of a complex intervention in health care for older PCI may serve as a stimulus to broaden the evidence base also of other complex intervention studies to improve health care for this vulnerable group. The study was ethically approved by the Ethics Committee of the Ernst-Moritz-Arndt University of Greifswald. The study has been registered at the U.S. National Library of Medicine. TRIAL REGISTRATION: ClinicalTrials.gov NCT03359408 . Registered on 2 December 2017. The approximate date when recruitment to the process evaluation of the study will be completed is 31 May 2021.