Establishing a standing patient advisory board in family practice research: A qualitative evaluation from patients' and researchers' perspectives.

INTRODUCTION: Patient and public involvement is vital for high-quality research. Integrating patients' and providers' perspectives early in research enhances the feasibility and relevance of study results. Within our family practice-based research network ForN, we established a standing patient advisory board (PAB) to include patients with diverse conditions and experiences. In this paper, we aim to describe the establishment and functioning of a standing PAB in family medicine research from patients' and researchers' perspectives. METHODS: After each PAB meeting, patients and researchers were asked to name anonymously positive and challenging moments in a feedback form with open questions. Researchers were also asked to reflect on how they implemented the discussion content in their research projects. The responses from both groups were transferred to MAXQDA 2018 and analyzed separately using thematic analysis. RESULTS: We analyzed 40 feedback forms from patients and 14 feedback forms from researchers. The dominant theme in the patients' feedback was 'exchange': They positively emphasized the 'exciting and open discussions' and the exchange of perspectives with one another and researchers. The clarity of the researchers' presentations and the research topics were appreciated. Researchers also positively highlighted the open atmosphere of the discussions. Presenting their research to the PAB helped most researchers reflect on their research topics from patients' perspectives and implement changes. However, researchers also mentioned several barriers to the implementation of PAB members' feedback. CONCLUSION: The establishment of a standing PAB in family practice research is feasible and productive both from patients' and researchers' perspectives. PATIENT OR PUBLIC CONTRIBUTION: This study reports the evaluation of the establishment of a standing PAB in family practice research. Board members are involved in the design of studies, the co-production of interventions and information material, and the interpretation of data.

Gender Differences in Perceived Working Conditions of General Practitioners During the COVID-19 Pandemic-a Cross-Sectional Study.

BACKGROUND: The ongoing COVID-19 pandemic has revealed gender-specific differences between general practitioners in adapting to the posed challenges. As primary care workforce is becoming increasingly female, in many countries, it is essential to take a closer look at gender-specific influences when the global health care system is confronted with a crisis. OBJECTIVE: To explore gender-specific differences in the perceived working conditions and gender-specific differences in challenges facing GPs at the beginning of the COVID-19 pandemic in 2020. DESIGN: Online survey in seven countries. PARTICIPANTS: 2,602 GPs from seven countries (Austria, Australia, Switzerland, Germany, Hungary, Italy, Slovenia). Of the respondents, 44.4% (n = 1,155) were women. MAIN MEASURES: Online survey. We focused on gender-specific differences in general practitioners' perceptions of working conditions at the beginning of the COVID-19 pandemic in 2020. KEY RESULTS: Female GPs rated their skills and self-confidence significantly lower than male GPs (f: 7.1, 95%CI: 6.9-7.3 vs. m: 7.6, 95%CI 7.4-7.8; p < .001), and their perceived risk (concerned about becoming infected or infecting others) higher than men (f: 5.7, 95%CI: 5.4-6.0 vs. m: 5.1, 95%CI: 4.8-5.5; p = .011). Among female GPs, low self-confidence in the treatment of COVID-19 patients appear to be common. Results were similar in all of the participating countries. CONCLUSIONS: Female and male GPs differed in terms of their self-confidence when dealing with COVID-19-related issues and their perceptions of the risks arising from the pandemic. To ensure optimal medical care, it is important that GPs realistically assess their own abilities and overall risk.

[SaxoForN-a transregional primary care research network in Dresden and Frankfurt am Main : Design of a practice-based research infrastructure]. / SaxoForN ­ Transregionales allgemeinmedizinisches Forschungspraxennetz Dresden und Frankfurt am Main : Konzept einer innovativen Forschungspraxeninfrastruktur.

Establishing primary care research networks (PCRNs) makes it easier to conduct clinical trials and health services research in a general-practice setting. Since February 2020, the German Federal Ministry of Education and Research (BMBF) has sponsored the development of six PCRNs and a coordination unit throughout Germany, with the aim of setting up a sustainable outpatient research infrastructure to raise the quantity and quality of primary care.The present article describes the design of a PCRN in Dresden and Frankfurt am Main - SaxoForN - and explains its structure and how it operates. The network is a transregional alliance between the two regional PCRNs named "SaxoN" (Dresden/Saxony) and "ForN" (Frankfurt am Main/Hesse), both of which run transregional and local research projects. For this purpose, joint standards and harmonized structures, for example with respect to the data infrastructure, qualifications, participation, and accreditation, were agreed upon and implemented at both sites.A critical success factor will be whether and to what extent the standards and structures, as well as resource planning, can be designed sustainably enough to permit the PCRNs to carry out high-quality research over the long term. To achieve this, the PCRNs will have to attract new practices and build up lasting relationships with them, qualify the research practices in order to standardize processes as far as possible, and regularly document their basic information and healthcare data.

The moderating effects of social support and depressive symptoms on pain among elderly multimorbid patients-data from the multicentre, prospective, observational cohort study MultiCare.

OBJECTIVES: Depressive symptoms and chronic pain are common among patients with multimorbidity creating a complex medical condition for both the patient and the general practitioner. Perceived social support may function as a protective measure.To examine the impact of perceived social support as a potential moderator between depressive symptoms and pain intensity and pain disability in daily activities in multimorbid patients aged 75+. METHOD: Data from 3,189 patients of the German longitudinal cohort study MultiCare were obtained at baseline and follow-ups during 5 years. Multilevel linear mixed-effects analyses were conducted for pain intensity (model 1) and pain disability in daily activities (model 2). The interaction term social support by depression score was included to test for moderation. RESULTS: The interaction between social support and depressive symptoms was significantly associated with the pain intensity score 0.41 (SE=.17; 95-CI[.08;.74]) but not with the pain disability score 0.35 (SE=.19; 95-CI[-.01;.72]). Additionally, men and individuals with medium or higher educational level showed reduced pain intensity and disability scores. Pain disability scores increased with age and depressive symptoms. Increased pain scores were also found for body mass index and burden of multimorbidity. CONCLUSION: Perceived social support amplified the association of depressive symptoms on pain intensity and did not show a protective function. The high scores of perceived social support among the participants may point to the practice of secondary gain due to the patients immense health burden.

Predictors of change in depressive symptoms in older and multimorbid patients: a longitudinal analysis of the multicare cohort.

BACKGROUND: Depression in older adults is becoming an increasing concern. As depressive symptoms change over time, it is important to understand the determinants of change in depressive symptoms. The aim of our study is to use a longitudinal study design to explore the predictors of change, remission and incident depression in older patients with multimorbidity. METHODS: Data from the MultiCare cohort study were used. The cohort studied 3,189 multimorbid general practice patients aged 65-85. Data were collected during personal interviews. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS-15). Predictors of change in depressive symptoms were determined using multivariate linear regression, while multivariate logistic regression was used to analyze predictors of remission and incident depression. Models included depressive symptoms at baseline and follow-up, socio-demographics and data on health status and social support. RESULTS: Overall, 2,746 participants with complete follow-up data were analyzed. Mean age was 74.2 years, 59.2% were female, and 11.3% were classified as depressed at baseline. Burden of multimorbidity and social support were statistically significant predictors in all regression analyses. Further predictors of change in depressive symptoms were: income, pain, nursing grade, self-rated health and self-efficacy. LIMITATIONS: The sample size for prediction of remission limited statistical certainty. Assessment of depressive symptoms using GDS-15 differs from routine clinical diagnoses of depression. CONCLUSIONS: Predictors of change in depressive symptoms in older multimorbid patients are similar to those predicting remission and incident depression, and do not seem to differ significantly from other older patient populations with depressive symptoms.

RubiN - continuous care in regional networks: a study protocol for a prospective controlled trial.

BACKGROUND: The health care situation of geriatric patients is often multifaceted, complex and often overlaps with social living conditions. Due to the lack of cross-sectoral and interprofessional health care geriatric patients often, receive insufficient care. Only a holistic view enables a comprehensive evaluation of the complex health risks, but also the potential to preserve the health of geriatric patients. The implementation of cross-sectoral, multi-professional case management could reduce the gaps in care, improve the autonomy of the geriatric patients in their own homes, and allow them to retain it as long as possible. The "RubiN" project examines the effects of multi-professional, cross-sectoral and assessment-based case management on the quality of the care of geriatric patients. The results of the study aim to show whether geriatric patients receive better care using case management than patients who receive standard health care. In addition, data on the effects of case management on practices of general practitioners (GP), the satisfaction with the care concept amongst the case managers, patients and relatives will be collected. Furthermore, a health economic analysis will be carried out. METHODS: The project is designed as a prospective controlled study and compares geriatric patients from practice networks in different regions in Germany. Inclusion criteria are: Age ≥ 70 years and care requirements from two different care complexes (identified with the screening instrument 'Angelina'-questionnaire). The intervention is the use of a geriatric case management, where health care is organised based on patient-specific care requirements. Five practice networks of physicians will implement the intervention (n = 3200 patients) and three practice networks will serve as the control group (n = 1200 patients). The primary endpoint is the ability to manage activities of daily living, measured using the Barthel Index. The patients in the intervention group receive geriatric case management and the patients in the control networks receive standard care ("care as usual"). The analysis of the primary data, which is pseudonymised, occurs according to the intention-to-treat principle. For this purpose, the endpoints will be analysed using a group comparison after 12 months. For the health economic analysis, secondary data from the statutory health insurance providers will be included in the analysis, in addition to the primary data. Data for the analysis of the effects the concept has on the GP practices as well as on the satisfaction of the project participants will be collected with questionnaires and interviews with experts. DISCUSSION: The implementation of cross-sectoral and interdisciplinary geriatric case management has been a topic of discussion for years, whereby positive effects have already been-shown. This planned study will be the first evaluation of the effect of case management for geriatric patients with a very large sample. In addition, the effects of case management on the GP practices and also on the relatives of the geriatric patients will be shown. It is intended that the study results pave the way for a widespread implementation of this concept. TRIAL REGISTRATION: German Clinical Trials Register, ID: DRKS00016642 . Registered on 29 October 2019 - Retrospectively registered.

[Interprofessional Care of Patients with Rheumatoid Arthritis from the Perspective of a General Practitioner Perspective: Results of a Cross-sectional Study]. / Interprofessionelle Versorgung von Patienten mit rheumatoider Arthritis aus hausärztlicher Sicht: Ergebnisse einer Querschnittserhebung.

BACKGROUND: General practitioners, specialists, occupational and physical therapists, nursing services and other professional groups are all involved in the treatment of patients with rheumatoid arthritis. This study aims to describe interprofessional cooperation in daily ambulatory care from the perspective of a general practitioner. METHODS: The cross-sectional study investigated cooperation between general practitioners (n=121 in 68 medical practices) and several other health care providers in Hesse and Rhineland Palatinate, Germany, from February to September 2017. It was part of the prospective cohort study PANORA (Prevalence of anti-cyclic citrullinated peptide (anti-CCP) positivity in patients with new onset of non-specific musculoskeletal symptoms). The questionnaire that was used contained closed-ended questions on socio-demographics and frequency of contact, and asked physicians to assess and weigh existing collaboration. Descriptive statistics were used for data analysis. RESULTS: When caring for patients with rheumatoid arthritis, 70%, of the physicians often took responsibility for synchronizing medications, and discussing diagnoses and test results. The most frequent cooperation was with rheumatologists and was considered as highly important but the least satisfactory. The second most frequent cooperation was with physical therapists and this was also rated as very important. Physicians had highest level of satisfaction with their collaboration with the nursing services. CONCLUSION: This study shows that general practitioners perform several medical tasks when treating patients with rheumatoid arthritis. During the process, they work together with several health care providers to various degrees. Cooperation with rheumatologists and physical therapists is particularly important to general practitioners; cooperation with rheumatologists is considered inadequate and in need of improvement.

Differences in the quality of oral anticoagulation therapy with vitamin K antagonists in German GP practices - results of the cluster-randomized PICANT trial (Primary Care Management for Optimized Antithrombotic Treatment).

BACKGROUND: In Germany, patients receiving oral anticoagulation (OAC) are often treated by general practitioners (GPs), and large proportions of patients receive vitamin K antagonists (VKAs). The quality of OAC in German GP practices, differences between various practices, and improvement potential through implementation of case management, have not yet been investigated satisfactorily. Based on results of a cluster-randomized controlled trial, we aimed to assess whether OAC quality can be improved, any variations between practices exist and determine practice- and patient-level factors. METHODS: The PICANT trial (2012-2015) was performed in 52 GP practices in Hesse, Germany. Adult patients with long-term indication for OAC received best practice case management in the intervention group. International normalized ratio (INR) values were recorded from anticoagulation passes. The Rosendaal method was used to calculate Time in Therapeutic Range (TTR) at patient level, and mean pooling to obtain center-specific TTR (cTTR) at practice level. The quality of OAC was assessed by TTR and cTTR. Linear model analyses were used to investigate associations between practice-/ patient-level factors and TTR. RESULTS: Inclusion of 736 patients (49.6% intervention and 50.4% control patients); 690 (93.8%) received phenprocoumon. Within 24 months, the TTR was 75.1% (SD 17.6) in the intervention versus 74.3% (SD 17.8) in the control group (p = 0.670). The cTTR averaged 75.1% (SD 6.5, range: 60.4 to 86.7%) in the intervention versus 74.3% (SD 7.2, range: 52.7 to 85.7%) in the control group (p = 0.668). At practice level, the TTR was significantly lower in practices with a male physician and certification in quality management. At patient level, the TTR was significantly higher in patients with moderate to high compliance, in men, and in patients that performed self-management. The TTR was significantly lower in patients with certain comorbidities, and who were hospitalized. CONCLUSIONS: The intervention did not effectively improve OAC quality compared to routine care. Quality of INR control was generally good, but considerable variation existed between GP practices. The variability indicates optimization potential in some practices. The demonstrated association between patient-level factors and TTR highlights the importance of considering patient characteristics that may impede achieving high quality therapeutic outcomes. TRIAL REGISTRATION: ISRCTN registry, ISRCTN41847489 , registered 27 February 2012.

Does a complex intervention increase patient knowledge about oral anticoagulation? - a cluster-randomised controlled trial.

BACKGROUND: Oral anticoagulation therapy (OAT) is a challenge in general practice, especially for high-risk groups such as the elderly. Insufficient patient knowledge about safety-relevant aspects of OAT is considered to be one of the main reasons for complications. The research question addressed in this manuscript is whether a complex intervention that includes practice-based case management, self-management of OAT and additional patient and practice team education improves patient knowledge about anticoagulation therapy compared to a control group of patients receiving usual care (as a secondary objective of the Primary Care Management for Optimised Antithrombotic Treatment (PICANT) trial). METHODS: The cluster-randomised controlled PICANT trial was conducted in 52 general practices in Germany, between 2012 and 2015. Trial participants were patients with a long-term indication for oral anticoagulation. A questionnaire was used to assess knowledge at baseline, after 12, and after 24 months. The questionnaire consists of 13 items (with a range of 0 to 13 sum-score points) covering topics related to intervention. Differences in the development of patient knowledge between intervention and control groups compared to baseline were assessed for each follow-up by means of linear mixed-effects models. RESULTS: Seven hundred thirty-six patients were included at baseline, of whom 95.4% continued to participate after 12 months, and 89.3% after 24 months. The average age of patients was 73.5 years (SD 9.4), and they mainly suffered from atrial fibrillation (81.1%). Patients in the intervention and control groups had similar knowledge about oral anticoagulation at baseline (5.6 (SD 2.3) in both groups). After 12 months, the improvement in the level of knowledge (compared to baseline) was significantly larger in the intervention group than in the control group (0.78 (SD 2.5) vs. 0.04 (SD 2.3); p = 0.0009). After 24 months, the difference between both groups was still statistically significant (0.6 (SD 2.6) vs. -0.3 (SD 2.3); p = 0.0001). CONCLUSION: Since this intervention was effective, it should be established in general practice as a means of improving patient knowledge about oral anticoagulation. TRIAL REGISTRATION: Current controlled trials ISRCTN41847489 ; Date of registration: 13/04/2012.

Association between multimorbidity patterns and chronic pain in elderly primary care patients: a cross-sectional observational study.

BACKGROUND: Multimorbidity is a highly prevalent health problem, which may reduce adherence, produce conflicts in treatment, and is not yet supported by evidence-based clinical recommendations. Many older people suffer from more than one chronic disease as well as from chronic pain. There is some evidence that disease management can become more complex if multimorbid patients suffer from chronic pain. In order to better consider the patients' comorbidity spectrum in clinical pain treatment recommendations, evidence is needed regarding which disease combinations are frequently related with the presence of chronic pain. Therefore, our aim is to identify diseases and disease combinations in a multimorbid population, which are associated with the patient-reported presence of chronic pain. METHODS: Analyses are based on cross-sectional data of the MultiCare Cohort Study, an observational cohort study based on interviews with 3189 multimorbid patients aged 65+, randomly selected from 158 practices, and their GPs. The response rate was 46.2 %. Data were collected in GP interviews and comprehensive patient interviews. Diseases and disease combinations associated with chronic pain were identified by CART (classification and regression tree) analyses performed separately for both genders. 46 chronic conditions were used as predictor variables and a dichotomized score from the Graded Chronic Pain Scale was used as outcome variable. RESULTS: About 60 % of the study participants were female. Women more often reported chronic pain than men. The most important predictor of a higher pain level in the female population was chronic low back problems, especially if combined with chronic gastritis, hyperuricemia/gout, cardiac insufficiency, neuropathies or depression. Regarding the pain level the male population was also divided best by chronic low back problems, especially if combined with intestinal diverticulosis, neuropathies or chronic ischemic heart disease. CONCLUSIONS: Our analyses are a first step in identifying diseases and disease combinations that are related to chronic pain. The most important condition seems to be low back problems. Back pain and pain in other body regions seems to be interrelated with cardiometabolic conditions. In women, psychosocial issues like depression also seem to be relevant. TRIAL REGISTRATION: ISRCTN89818205 .

Social inequalities in patient-reported outcomes among older multimorbid patients--results of the MultiCare cohort study.

INTRODUCTION: In this article three research questions are addressed: (1) Is there an association between socioeconomic status (SES) and patient-reported outcomes in a cohort of multimorbid patients? (2) Does the association vary according to SES indicator used (income, education, occupational position)? (3) Can the association between SES and patient-reported outcomes (self-rated health, health-related quality of life and functional status) be (partly) explained by burden of disease? METHODS: Analyses are based on the MultiCare Cohort Study, a German multicentre, prospective, observational cohort study of multimorbid patients from general practice. We analysed baseline data and data from the first follow-up after 15 months (N = 2,729). To assess burden of disease we used the patients' morbidity data from standardized general practitioner (GP) interviews based on a list of 46 groups of chronic conditions including the GP's severity rating of each chronic condition ranging from marginal to very severe. RESULTS: In the cross-sectional analyses SES was significantly associated with the patient-reported outcomes at baseline. Associations with income were more consistent and stronger than with education and occupational position. Associations were partly explained (17% to 44%) by burden of disease. In the longitudinal analyses only income (but not education and occupational position) was significantly related to the patient-reported outcomes at follow-up. Associations between income and the outcomes were reduced by 18% to 27% after adjustment for burden of disease. CONCLUSIONS: Results indicate social inequalities in self-rated health, functional status and health related quality of life among older multimorbid patients. As associations with education and occupational position were inconsistent, these inequalities were mainly due to income. Inequalities were partly explained by burden of disease. However, even among patients with a similar disease burden, those with a low income were worse off in terms of the three patient-reported outcomes under study.

Implementation of chronic illness care in German primary care practices--how do multimorbid older patients view routine care? A cross-sectional study using multilevel hierarchical modeling.

BACKGROUND: In primary care, patients with multiple chronic conditions are the rule rather than the exception. The Chronic Care Model (CCM) is an evidence-based framework for improving chronic illness care, but little is known about the extent to which it has been implemented in routine primary care. The aim of this study was to describe how multimorbid older patients assess the routine chronic care they receive in primary care practices in Germany, and to explore the extent to which factors at both the practice and patient level determine their views. METHODS: This cross-sectional study used baseline data from an observational cohort study involving 158 general practitioners (GP) and 3189 multimorbid patients. Standardized questionnaires were employed to collect data, and the Patient Assessment of Chronic Illness Care (PACIC) questionnaire used to assess the quality of care received. Multilevel hierarchical modeling was used to identify any existing association between the dependent variable, PACIC, and independent variables at the patient level (socio-economic factors, weighted count of chronic conditions, instrumental activities of daily living, health-related quality of life, graded chronic pain, no. of contacts with GP, existence of a disease management program (DMP) disease, self-efficacy, and social support) and the practice level (age and sex of GP, years in current practice, size and type of practice). RESULTS: The overall mean PACIC score was 2.4 (SD 0.8), with the mean subscale scores ranging from 2.0 (SD 1.0, subscale goal setting/tailoring) to 3.5 (SD 0.7, delivery system design). At the patient level, higher PACIC scores were associated with a DMP disease, more frequent GP contacts, higher social support, and higher autonomy of past occupation. At the practice level, solo practices were associated with higher PACIC values than other types of practice. CONCLUSIONS: This study shows that from the perspective of multimorbid patients receiving care in German primary care practices, the implementation of structured care and counseling could be improved, particularly by helping patients set specific goals, coordinating care, and arranging follow-up contacts. Studies evaluating chronic care should take into consideration that a patient's assessment is associated not only with practice-level factors, but also with individual, patient-level factors. TRIAL REGISTRATION: Current Controlled Trials ISRCTN89818205.

Anticoagulant treatment in German family practices - screening results from a cluster randomized controlled trial.

BACKGROUND: Oral anticoagulation (OAC) with coumarins and new anticoagulants are highly effective in preventing thromboembolic complications. However, some studies indicate that over- and under-treatment with anticoagulants are fairly common. The aim of this paper is to assess the appropriateness of treatment in patients with a long-term indication for OAC, and to describe the corresponding characteristics of such patients on the basis of screening results from the cluster randomized PICANT trial. METHODS: Randomly selected family practices in the federal state of Hesse, Germany, were visited by study team members. Eligible patients were screened using an anonymous patient list that was generated by the general practitioners' software according to predefined instructions. A documentation sheet was filled in for all screened patients. Eligible patients were classified into 3 categories (1: patients with a long-term indication for OAC and taking anticoagulants, 2: patients with a long-term indication for OAC but not taking anticoagulants, 3: patients without a long-term indication for OAC but taking an anticoagulant on a permanent basis). IBM SPSS Statistics 20 was used for descriptive statistical analysis. RESULTS: We screened 2,036 randomly selected, potentially eligible patients from 52 family practices. 275 patients could not be assigned to one of the 3 categories and were therefore not considered for analysis. The final study sample comprised 1,761 screened patients, 1,641 of whom belonged to category 1, 78 to category 2, and 42 to category 3. INR values were available for 1,504 patients of whom 1,013 presented INR values within their therapeutic ranges. The majority of screened patients had very good compliance, as assessed by the general practitioner. New antithrombotic drugs were prescribed in 6.1% of cases. CONCLUSIONS: The screening results showed that a high proportion of patients were receiving appropriate anticoagulation therapy. The numbers of patients with a long-term indication for OAC therapy that were not receiving oral anticoagulants, and without a long-term indication that were receiving OAC, were considerably lower than expected. Most patients take coumarins, and the quality of OAC control is reasonably high. TRIAL REGISTRATION: Current Controlled Trials ISRCTN41847489.

Depressive mood mediates the influence of social support on health-related quality of life in elderly, multimorbid patients.

BACKGROUND: It is not well established how psychosocial factors like social support and depression affect health-related quality of life in multimorbid and elderly patients. We investigated whether depressive mood mediates the influence of social support on health-related quality of life. METHODS: Cross-sectional data of 3,189 multimorbid patients from the baseline assessment of the German MultiCare cohort study were used. Mediation was tested using the approach described by Baron and Kenny based on multiple linear regression, and controlling for socioeconomic variables and burden of multimorbidity. RESULTS: Mediation analyses confirmed that depressive mood mediates the influence of social support on health-related quality of life (Sobel's p < 0.001). Multiple linear regression showed that the influence of depressive mood (ß = -0.341, p < 0.01) on health-related quality of life is greater than the influence of multimorbidity (ß = -0.234, p < 0.01). CONCLUSION: Social support influences health-related quality of life, but this association is strongly mediated by depressive mood. Depression should be taken into consideration in research on multimorbidity, and clinicians should be aware of its importance when caring for multimorbid patients. TRIAL REGISTRATION: ISRCTN89818205.

Informational continuity of medication management in transitions of care: Qualitative interviews with stakeholders from the HYPERION-TransCare study.

BACKGROUND: The transition of patients between inpatient and outpatient care can lead to adverse events and medication-related problems due to medication and communication errors, such as medication discontinuation, the frequency of (re-)hospitalizations, and increased morbidity and mortality. Older patients with multimorbidity and polypharmacy are particularly at high risk during transitions of care. Previous research highlighted the need for interventions to improve transitions of care in order to support information continuity, coordination, and communication. The HYPERION-TransCare project aims to improve the continuity of medication management for older patients during transitions of care. METHODS AND FINDINGS: Using a qualitative design, 32 expert interviews were conducted to explore the perspectives of key stakeholders, which included healthcare professionals, patients and one informal caregiver, on transitions of care. Interviews were conducted between October 2020 and January 2021, transcribed verbatim and analyzed using content analysis. We narratively summarized four main topics (stakeholders' tasks, challenges, ideas for solutions and best practice examples, and patient-related factors) and mapped them in a patient journey map. Lacking or incomplete information on patients' medication and health conditions, inappropriate communication and collaboration between healthcare providers within and across settings, and insufficient digital support limit the continuity of medication management. CONCLUSIONS: The study confirms that medication management during transitions of care is a complex process that can be compromised by a variety of factors. Legal requirements and standardized processes are urgently needed to ensure adequate exchange of information and organization of medication management before, during and after hospital admissions. Despite the numerous barriers identified, the findings indicate that involved healthcare professionals from both the inpatient and outpatient care settings have a common understanding.

Effects of multiple chronic conditions on health care costs: an analysis based on an advanced tree-based regression model.

BACKGROUND: To analyze the impact of multimorbidity (MM) on health care costs taking into account data heterogeneity. METHODS: Data come from a multicenter prospective cohort study of 1,050 randomly selected primary care patients aged 65 to 85 years suffering from MM in Germany. MM was defined as co-occurrence of ≥3 conditions from a list of 29 chronic diseases. A conditional inference tree (CTREE) algorithm was used to detect the underlying structure and most influential variables on costs of inpatient care, outpatient care, medications as well as formal and informal nursing care. RESULTS: Irrespective of the number and combination of co-morbidities, a limited number of factors influential on costs were detected. Parkinson's disease (PD) and cardiac insufficiency (CI) were the most influential variables for total costs. Compared to patients not suffering from any of the two conditions, PD increases predicted mean total costs 3.5-fold to approximately € 11,000 per 6 months, and CI two-fold to approximately € 6,100. The high total costs of PD are largely due to costs of nursing care. Costs of inpatient care were significantly influenced by cerebral ischemia/chronic stroke, whereas medication costs were associated with COPD, insomnia, PD and Diabetes. Except for costs of nursing care, socio-demographic variables did not significantly influence costs. CONCLUSIONS: Irrespective of any combination and number of co-occurring diseases, PD and CI appear to be most influential on total health care costs in elderly patients with MM, and only a limited number of factors significantly influenced cost. TRIAL REGISTRATION: Current Controlled Trials ISRCTN89818205.

[Coordinated primary care of older patients with complex needs. The perspective of family doctors in the light of a case management project within practice networks of independent physicians in Germany]. / Koordinierte Versorgung geriatrischer Patientinnen und Patienten aus ärztlicher Sicht: Erfahrungen aus einem kontrollierten Modellversuch in zertifizierten Praxisnetzen.

BACKGROUND: Cross-sectoral and interdisciplinary care and case management can contribute to an improved integration of the primary care for patients with geriatric characteristics. Following this approach, the pilot study RubiN (Regional ununterbrochen betreut im Netz / Continuous Care in Regional Networks) implemented a specific geriatric Care and Case Management (CCM) in five certified practice networks of independent physicians in different regions in Germany. As part of the accompanying process-based evaluation of the project, a survey was conducted among general practitioners and other specialists from these networks in order to find out how, in their view, collaboration with case managers can improve medical care of geriatric patients and contribute to closing possible gaps in primary care structures. METHODS: The overall project RubiN, which was designed as a pragmatic controlled trial, compared patients from five practice networks where CCM has been implemented (intervention networks), with patients from three networks where the intervention was not taking place (control networks). Physicians of all eight participating practice networks were included in the present survey. The survey was conducted via a self-developed questionnaire. RESULTS: A total of 111 physicians participated in the survey, 76 of whom were part of an intervention network and 35 part of a control network. The calculated response rate was 15.4% (networks reported a total of approx. 720 members). 91,1% of the participants from intervention networks, who had joined RubiN with their patients, reported satisfaction with their collaboration with case managers (n=41 of 45). 87.0% of the physicians from intervention networks stated that care for geriatric patients had improved as a result of their participation in the pilot study (n=40 of 46). When asked about the overall quality of care provided for their geriatric patients, the assessments of participants from intervention networks were more positive than those of the participants from control networks (MV 3.48 vs. 3.27 on a scale of 1=poor to 5=very good). Agreement with whether external case managers could provide certain services was higher among participants from intervention networks compared to participants from control networks. This was the case, in particular, of services related to medical data collection and test procedures. Overall, both comparison groups showed a high level of willingness to delegate tasks to a CCM. DISCUSSION: Delegation of tasks to geriatric case managers seems to be more readily accepted by physicians in intervention networks than by their colleagues from the control networks, especially as regards medical assessment methods and advanced advisory tasks. The results suggest that interventions in this domain were able to convince physicians of the value that case managers can bring to medical practice and help resolve reservations and skepticism. Especially, the implemented CCM seemed to be an effective way of generating geriatric anamnestic data and fostering the flow of general patient-centered information. CONCLUSION: From the point of view of general practitioners and other specialists participating in the intervention, CCM has been successfully implemented in their practice networks and seems to be a worthwhile approach that will help provide better coordinated and more team-oriented care to their geriatric patients.

Implementation and evaluation of a complex intervention to improve information availability at the interface between inpatient and outpatient care in older patients with multimorbidity and polypharmacy (HYPERION-TransCare) - study protocol for a pilot and feasibility cluster-randomized controlled trial in general practice in Germany.

BACKGROUND: Despite attempts to improve the cross-sectoral flow of information, difficulties remain in routine healthcare. The resulting negative impact on continuity of care is often associated with poor health outcomes, especially in older patients. Our intervention aims to increase information availability with respect to medications and health conditions at the interface between inpatient and outpatient care and to contribute towards improving the quality of care in older patients. This pilot study focuses on feasibility and implementability. METHODS: The idea of the complex intervention has been developed in a previous study. This intervention will be tested in a prospective, multicenter, cluster-randomized (via web tool), controlled pilot trial with two parallel study arms (intervention and control group). The pilot study will be conducted in 20 general practices in Hesse and Saxony (Germany) and include 200 patients (≥ 65 years of age with multimorbidity and polypharmacy) recruited by the practices. Practice staff and patients will be blinded. We will use qualitative and quantitative methods to assess the feasibility and implementability of the intervention and the study design in a process evaluation covering topics ranging from expectations to experiences. In addition, the feasibility of proposed outcome parameters for the future definitive trial will be explored. The composite endpoint will include health-related patient outcomes (hospitalization, falls, and mortality using, e.g., the FIMA questionnaire), and we will assess information on medications (SIMS questionnaire), symptoms and side effects of the medication (pro-CTCAE questionnaire), and health literacy (HLQ questionnaire). Data will be collected at study begin (baseline) and after 6 months. Furthermore, the study will include surveys and interviews with patients, general practitioners, and healthcare assistants. DISCUSSION: The intervention was developed using a participatory approach involving stakeholders and patients. It aims to empower general practice teams as they provide patient-centered care and play a key role in the coordination and continuity of care. We aim to encourage patients to adopt an active role in their health care. Overall, we want to increase the availability of health-related information for patients and healthcare providers. The results of the pilot study will be used in the design and implementation of the future definitive trial. TRIAL REGISTRATION: The study was registered in DRKS-German Clinical Trials Register: registration number DRKS00027649 (date: 19 January 2022). Date and version identifier 10.07.2023; Version 1.3.

COVI-Prim Longitudinal Survey: Experiences of Primary Care Physicians During the Early Phase of the COVID-19 Pandemic.

Background: General practitioners (GPs) are the mainstay of primary care and play a critical role in pandemics. During the first wave of the COVID-19 pandemic, this international study aimed to explore changes in the workload of general practitioners, as well as their interactions with patients and colleagues, and their self-confidence and concerns. Methods: An online survey was conducted among GPs in Austria and Germany. Participants were asked to answer a basic questionnaire and participate in a subsequent longitudinal survey containing closed and open-ended items. All data were pseudonymized. Results: Overall, 723 general practitioners from Austria and Germany took part in the longitudinal survey over a period of 12 weeks (April 3-July 2, 2020). The majority of GPs had less direct contact with patients at the beginning of the survey (96 vs. 49% at the end of the study period). At first, doctors were mainly concerned with pandemic-related issues and had to care for the patients of GP colleagues that were in quarantine, which meant they had less time for routine work such as screenings and treating chronic diseases. Over the survey period, GPs' self-confidence increased and their concerns about income loss decreased. Conclusions: Following a difficult initial phase when protective equipment and information were lacking, physicians in primary care adapted quickly to new situations. Experience with telemedicine should help them face future challenges and may help prevent a decline in the delivery of routine health care and care for chronically ill patients. Registration: Trial registration at the German Clinical Trials Register: DRKS00021231.

Digital participatory workshops with patients and health professionals to develop an intervention for the management of polypharmacy: results from a mixed-methods evaluation and methodological conclusions.

BACKGROUND: In the COVID-19 pandemic, numerous researchers postponed their patient and public involvement (PPI) activities. This was mainly due to assumptions on patients' willingness and skills to participate digitally. In fact, digital PPI workshops differ from in-person meetings as some forms of non-verbal cues and body language may be missing and technical barriers may exist. Within our project HYPERION-TransCare we adapted our PPI workshop series for intervention development to a digital format and assessed whether these digital workshops were feasible for patients, health care professionals and researchers. METHODS: We used a digital meeting tool that included communication via audio, video and chat. Discussions were documented simultaneously on a digital white board. Technical support was provided via phone and chat during the workshops and with a technical introduction workshop in advance. The workshop evaluation encompassed observation protocols, participants' feedback via chat after each workshop on their chance to speak and the usability of the digital tools, and telephone interviews on patients' and health professionals' experiences after the end of the workshop series. RESULTS: Observation protocols showed an active role of moderators in verbally encouraging every participant to get involved. Technical challenges occurred, but were in most cases immediately addressed and solved. Participants median rating of their chance to speak and the usability of the digital tool was "very good". In the evaluation interviews participants reported a change of perspective and mutual understanding as a main benefit from the PPI workshops and described the atmosphere as inclusive and on equal footing. Benefits of the digital format such as overcoming geographical distance, saving time and combining workshop participation with professional or childcare obligations were reported. Technical support was stressed as a pre-condition for getting actively involved in digital PPI. CONCLUSIONS: Digital formats using different didactic and documentation techniques, accompanied by technical support, can foster active patient and public involvement. The advantages of digital PPI formats such as geographical flexibility and saving time for participants as well as the opportunity to prepare and hold workshops in geographically stretched research teams persists beyond the pandemic and may in some cases outweigh the advantages of in-person communication.

Digital patient and public involvement (PPI) activities differ from in-person meetings. For example, some forms of non-verbal cues and body language are limited and technical barriers may exist. Therefore, some research teams were hesitant to switch to a digital PPI format during the COVID-19 pandemic and postponed their PPI activities.In this paper, we aim to describe, how we adapted a PPI workshop series to a digital format, how patients and health care professionals experienced these digital workshops, and which conclusions we have drawn for future digital PPI activities. The workshop evaluation encompassed workshop observation protocols, participants' feedback via chat on their chance to speak and the feasibility of the digital tools, and telephone interviews on participants' experiences.The study results showed that moderators had an active role in verbally encouraging every participant to get involved. Technical challenges occurred, but were in most cases immediately addressed and solved. Most participants rated their chance to speak and the feasibility of the digital format as "very good". They described the atmosphere as inclusive and on equal footing without hierarchy between different stakeholder groups. Participants reported benefits of the digital format such as overcoming geographical distance, saving time and combining workshop participation with professional or childcare obligations. They stressed technical support as a condition for getting actively involved in digital PPI.We conclude that some advantages of digital PPI may persist beyond the pandemic. Therefore, we encourage research teams to discuss the question of digital or in-person PPI with the involved patients and health professionals and decide on a case-by-case basis.