Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home

Objectives

For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home.

Methods

Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting.

Results

A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study.

Conclusion

The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT.

Innovation

Adapting family conferences to primary care for frail patients with polypharmacy.

Converting habits of antibiotic use for respiratory tract infections in German primary care (CHANGE-3) - process evaluation of a complex intervention

BACKGROUND

Antimicrobial resistance remains a global challenge. In Germany, the national health agenda supports measures that enhance the appropriate, guideline-oriented use of antibiotics. The study "Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3)" aimed at a sustainable reduction of antimicrobial resistance through converting patterns of prescribing practice and use of antibiotics and an increase in health literacy in primary care patients, practice teams, and in the general public. Embedded in a cluster-randomized trial of a multifaceted implementation program, a process evaluation focused on the uptake of program components to assess the fidelity of the implementation program in the CHANGE-3 study and to understand utilization of its educational components.

METHODS

A mix of qualitative and quantitative methods was used. Semi-structured telephone interviews were conducted with General Practitioners, Medical Assistants, patients treated for respiratory tract infection and outreach visitors who had carried out individual outreach visits. A two-wave written survey (T1: 5 months after start, T2: 16 months after start) was conducted in general practitioners and medical assistants. Qualitative data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze survey data.

RESULTS

Uptake of intervention components was heterogenous. Across all components, the uptake reported by General Practitioners varied from 20 to 88% at T1 and 31 to 63% at T2. Medical Assistants reported uptake from 22 to 70% at T1 and 6 to 69% at T2. Paper-based components could by and large be integrated in daily practice (64 to 90% in T1; 41 to 93% in T2), but uptake of digital components was low. A one-time outreach visit provided thematic information and feedback regarding actual prescribing, but due to time constraints were received with reluctance by practice teams. Patients were largely unaware of program components, but assumed that information and education could promote health literacy regarding antibiotics use.

CONCLUSIONS

The process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics. Future research efforts need to identify the best mode of delivery to reach the targeted population.

TRIAL REGISTRATION

ISRCTN, ISRCTN15061174 . Registered 13 July 2018 - Retrospectively registered.

Die Erfahrung zeigt, dass man mit ganz Einfachem recht gut klar kommt

Ziel: Mit der Durchführung eines Praxistests der S3-Leitlinie zu Diagnostik und Therapie des Ulcus cruris venosum der DGP sollen Akzeptanz und Praktikabilität der Empfehlungen unter Bedingungen der phlebologischen Praxis untersucht und Erkenntnisse über mögliche Barrieren bei der Implementierung in die Regelversorgung erforscht werden.Methoden: Praxisanwendung bei vertragsärztlich tätigen Phlebologen. Qualitativer Ansatz mit Fokusgruppen und Telefoninterviews, die nach Protokollierung bzw. Transkribierung von zwei Forschern unabhängig inhaltsanalytisch unter der globalen Fragestellung des Projektes systematisch ausgewertet wurden. Ergebnisse: Die Phlebologen betrachten die Leitlinie als theoretischen Goldstandard in Abweichung zur eigenen praktischen Tätigkeit. Hemmende Faktoren bei der Umsetzung im Alltag sehen sie in unzureichenden Vergütungsstrukturen, den Patienten selbst sowie verschiedenen Rahmenbedingungen. Evidenzbasiertes Handeln scheint im Alltag nur eine untergeordnete Rolle zu spielen. Schlussfolgerung: Implementierungshindernisse sowie detaillierte Anregungen der Nutzer könnten für eine Überarbeitung der Leitlinie herangezogen werden.

Risk factors for incident mild cognitive impairment--results from the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)

OBJECTIVES

To provide age- and gender-specific incidence rates of MCI among elderly general practitioner (GP) patients (75+ years) and to identify risk factors for incident MCI.

METHOD

Data were derived from the longitudinal German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe). Incidence was calculated according to the 'person-years-at-risk' method. Risk factors were analysed using multivariate logistic regression models.

RESULTS

During the 3-year follow-up period, 350 (15.0%) of the 2331 patients whose data were included in the calculation of incidence developed MCI [person-years (PY) = 6198.20]. The overall incidence of MCI was 56.5 (95% confidence interval = 50.7-62.7) per 1000 PY. Older age, vascular diseases, the apoE epsilon4 allele and subjective memory complaints were identified as significant risk factors for future MCI.

CONCLUSION

Mild cognitive impairment is frequent in older GP patients. Subjective memory complaints predict incident MCI. Especially vascular risk factors provide the opportunity of preventive approaches.

[Discrimination of Blacks on account of their skin colour? Results of focus group discussions with victims in the German health-care system]

BACKGROUND

In spite of a number of researches on immigrants in the German Health System, there has hardly been any research on immigrant's experiences with General Practitioners or research on Black patients. As an example the experiences of Black People (1) with an immigration background from the Democratic Republic of Congo (RDC) with German White GPs was investigated.

METHODS

Two focus groups with a total of 33 participants from the DRC were held and the discussions documented and transcribed. The authors performed a content analysis and developed inductively the categorical system on the basis of the transcription.

RESULTS

The participants underlined their self-competences in health and diseases. Language was mentioned as a problem in communication, but had no priority except for the lack of documents in French. However, they underlined the hectic and unfriendliness of German medical staff as well as lack of respect towards them. They also criticised the insufficient medical competence of German medical doctors concerning diseases, which are common in Africa and the increasing social injustice, bureaucracy and economic efficiency. Experiences with discrimination and racism were clearly expressed and illustrated in its intermingled structure with other forms of discrimination.

CONCLUSIONS

The concept concerning health and diseases of the African immigrants was a Western medical concept, other concepts like, e.g., "African" formed medical concepts did not occur. The many-sided experienced discriminations of Black immigrants in White Surgeries and in the German Health System presumably also correspond to experiences in other areas of German society. A number of critical remarks of the participants corresponded with what we expect from White patients, especially when speaking about communicative abilities of doctors. Better communicative abilities and a better knowledge of the so-called "tropical diseases" are required. But to the same degree it is mandatory to develop the ability of reflecting on discrimination at all levels including racism and "intercultural" opening of the German Health System.