[Medical care research based on family doctor routine data--are interface-communicated treatment data feasible?]

Designing and piloting a generic research architecture and workflows to unlock German primary care data for secondary use

Background

Medical data from family doctors are of great importance to health care researchers but seem to be locked in German practices and, thus, are underused in research. The RADAR project (Routine Anonymized Data for Advanced Health Services Research) aims at designing, implementing and piloting a generic research architecture, technical software solutions as well as procedures and workflows to unlock data from family doctor’s practices. A long-term medical data repository for research taking legal requirements into account is established. Thereby, RADAR helps closing the gap between the European countries and to contribute data from primary care in Germany.

Methods

The RADAR project comprises three phases: (1) analysis phase, (2) design phase, and (3) pilot. First, interdisciplinary workshops were held to list prerequisites and requirements. Second, an architecture diagram with building blocks and functions, and an ordered list of process steps (workflow) for data capture and storage were designed. Third, technical components and workflows were piloted. The pilot was extended by a data integration workflow using patient-reported outcomes (paper-based questionnaires).

Results

The analysis phase resulted in listing 17 essential prerequisites and guiding requirements for data management compliant with the General Data Protection Regulation (GDPR). Based on this list existing approaches to fulfil the RADAR tasks were evaluated—for example, re-using BDT interface for data exchange and Trusted Third Party-approach for consent management and record linkage. Consented data sets of 100 patients were successfully exported, separated into person-identifying and medical data, pseudonymised and saved. Record linkage and data integration workflows for patient-reported outcomes in the RADAR research database were successfully piloted for 63 responders.

Conclusion

The RADAR project successfully developed a generic architecture together with a technical framework of tools, interfaces, and workflows for a complete infrastructure for practicable and secure processing of patient data from family doctors. All technical components and workflows can be reused for further research projects. Additionally, a Trusted Third Party-approach can be used as core element to implement data privacy protection in such heterogeneous family doctor’s settings. Optimisations identified comprise a fully-electronic consent recording using tablet computers, which is part of the project’s extension phase.

[Prevalence of thyroid abnormality: a comparison of ambulatory claims data with data from a population-based study]

BACKGROUND

Billing diagnoses are used for quality assurance, estimates of prevalence and resource allocation. Validity studies showed relevant limitations. In Germany, there are no population-based data on the agreement of outpatient billing diagnoses with clinical data of thyroid disorders.

OBJECTIVES

The study investigated the agreement of ICD-diagnosed thyroid nodules, goitre, hyperthyroidism, hypothyroidism and thyroiditis with clinical and self-reported data from the population-based cohort study called the Study of Health in Pomerania (SHIP).

MATERIALS AND METHODS

Billing data from the Association of Statutory Health Insurance Physicians Mecklenburg-Vorpommern were linked on an individual level for the period from 2002-2016 with data from SHIP. The agreement was evaluated using sensitivity, specificity and positive and negative predictive value (PPW, NPW). Data were weighted to ensure population representativeness.

RESULTS

The data of 5746 participants were analysed (46% male, average age 55 years, SD [standard deviation] ± 15, min: 20 years, max: 93 years). Based on clinical data, 63% (3451/5511, missing values n = 235) and based on billing data 25% (1421/5746) of the participants had thyroid disorders. The sensitivity was 12-36%, the specificity was 84-98%, the PPW was highest for thyroid nodules (75%) and hypothyroidism (70%) and the NPW was between 63 and 94%, depending on the investigated thyroid disorder.

CONCLUSIONS

Thyroid disorders are common and often undiagnosed. Billing data have a low sensitivity to identify clinically relevant thyroid disorders.

[Prescribing practices in the treatment of upper respiratory tract infections in anthroposophic medicine]

BACKGROUND

Upper respiratory tract infections (URTI) are among the leading reasons for doctor consultations. This study investigates the prescribing practices of medical doctors specialized in anthroposophic medicine in the treatment of URTI with a special focus on the prescription of antibiotics, complications, recurrence rates and costs.

MATERIALS AND METHODS

Starting in May 2004 all prescriptions within a 1-year period by 35 primary care practitioners in Germany were analysed. Data were extracted from practice software with special interfaces with additional linking of medications and diagnoses by practitioners.

RESULTS

21,818 prescriptions for 12,081 patients (73.7%children) with 19,050 cases of URTI were analysed. The most common diagnosis was common cold (63.3%), followed by acute tonsillitis (12.9%). 63.0% were treated purely with complementary medicine. Antibiotics were given in 6.3% of cases (minimum: common cold 1.9%, maximum: tonsillitis 24.3%). Predictive factors for antibiotic prescribing were the diagnoses tonsillitis (odds ratio [OR]: 6.7; 95% confidence interval [CI]:4.5-9.9) and sinusitis (OR: 1.9; 95% CI: 1.1-3.1), concomitant disease (OR: 1.2; 95% CI: 1.0-1.4), complications (OR: 7.2; 95% CI:5.5-9.4) and the specialty paediatrics (OR: 2.1; 95% CI: 1.7-2.6). In cases that were initially treated with only complementary medicine, antibiotics were eventually prescribed in 0.7%. Overall complication rates were 2.9% and follow-up visits occurred in 6.3%. Patients had an average of 2.4 URTI/year (adults 1.7,children 2.7). Treatment costs did not differ between complementary care and antibiotics.

CONCLUSION

Prescription practices in the treatment of URTI by anthroposophic practitioners were documented through the processing of routine medical data with minimal additional data. The therapy was found to be in accordance with the guidelines, however, the prescription rate for antibiotics was well below the German average.

[Health services research in general practice. A new approach]

Competence networks in medicine, involving departments of general practice (www.kompetenznetze-medizin.de), as well as a large research support program "General Practice" funded by the German Federal Ministry of Education and Research (www.gesundheitsforschung-bmbf.de/de/439.php) mirror the increasing importance of academic general practice for health services research. The use and benefit of computerized medical records is exemplified by the classification of therapeutic measures and prevalence estimates of diseases. Computerized medical records from 134 practices could be extracted via the BDT (BehandlungsDatenTräger) interface. Using SQL (structured query language) queries, we identified patients with urinary tract infection (UTI), airway obstruction and chronic heart failure and the therapeutic management for these illnesses. Age and sex of the patients were nearly completely documented in the BDT data. Patients with UTI (6,239 consultations) received most often cotrimoxazole (69%) and fluoroquinolone (15%), less often trimethoprim (9%) and herbal UTI drugs (4%). About half of the 2,714 patients with asthma received inhaled steroids, to a somewhat lesser degree than patients suffering from chronic obstructive pulmonary disease (50 vs 53%). In a subsample of practices (n=44), we identified 4,120 patients with a diagnosis of chronic heart failure. Using refined analysis tools, computerized medical records from general practices may be helpful to answer relevant questions of health services research and contribute to quality assurance in ambulatory patient care.

Participation in a quality of care study and consequences for generalizability of general practice research

BACKGROUND

Non-participation of General Practitioners (GPs) hampers primary care research. Using existing network structures can improve participation, but may introduce sampling effects.

OBJECTIVES

To examine the role of network-based recruitment and other determinants of participation, and to estimate effects of sampling and non-participation on generalizability.

METHODS

For a study of quality of care assessment, we recruited GPs from a regionally defined population and a GP network. Effects of sampling and non-participation were analysed by comparing characteristics between participants, target samples, and reference data for all German GPs. Factors influencing study participation were assessed in multiple logistic regression.

RESULTS

Compared to the regional sample, network GPs were more likely to complete survey questionnaires (92% versus 69%) and to participate in the study (66% versus 23%). Compared to national reference data, study participants from both populations were younger, had a higher level of professional training, and included more men. These differences were already present in the network target sample, but were largely attributable to selective participation in the regional sample. Network membership remained the strongest determinant of participation in multiple logistic regression (odds ratio 5.01; 95% confidence interval 2.53-9.91). A younger age, higher professional training, and membership in the German Society of General Practice were also predictive of participation.

CONCLUSIONS

Although network-based recruitment of GPs increases participation rates, sample effects are similar in size and direction as effects of non-participation in the regionally defined population. Careful analysis of participants based on publicly available data is therefore crucial for the assessment of generalizability.