[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]

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.

Implementierung einer Secure Instant Messaging-App in der COVID-19 Pandemie: Nutzungserfahrungen von Hausärzt*innen und Mitarbeiter*innen von Gesundheitsämtern

Hintergrund

Insbesondere zu Beginn der COVID-19-Pandemie klagten hausärztliche Praxen über eine für sie unsichere Informationslage und in diesem Zusammenhang über einen unzureichenden Informationsfluss von den zuständigen Gesundheitsämtern. Secure Instant Messaging beschreibt eine digitale, chatbasierte Kommunikationsstruktur, die es Akteur*innen im Bereich der ambulanten Primärversorgung ermöglichen könnte, sich in Echtzeit zu vernetzen und niedrigschwellig über Sektorengrenzen hinweg Informationen auszutauschen. Das als Proof-of-Concept-Studie angelegte Projekt KomPan hat in zwei deutschen Modellregionen eine solche sichere Echtzeitkommunikationsstruktur implementiert, um in der Pandemiesituation einen zusätzlichen Kommunikationsweg zwischen Sektoren des Gesundheitssystems zu schaffen und insbesondere den Austausch zwischen Hausärzt*innen und den Gesundheitsämtern zu vereinfachen. An dieser Stelle werden die Ergebnisse der qualitativen Nutzer*innenbefragung vorgestellt.

Methode

Beginnend mit Dezember 2020 (2. COVID-19-Welle) wurde Hausärzt*innen (n = 43) und Gesundheitsamtsmitarbeitenden (n = 10) in zwei hessischen Modellregionen die Secure Instant Messaging-App „Famedly“ der Famedly GmbH zur Verfügung gestellt. Nach einer mehrmonatigen Nutzungszeit befragten wir Projektteilnehmer*innen in leitfadengestützten Telefoninterviews zu ihren Nutzungserfahrungen mit dem Messenger. Die leitgebende Fragestellung war dabei: Wie hat sich die Kommunikation zwischen den beteiligten Akteur*innen durch Secure Instant Messaging geändert? Die Interviews wurden wörtlich transkribiert und mittels thematischer Analyse ausgewertet.

Ergebnisse

Es wurden Interviews mit 10 Hausärzt*innen und 2 Mitarbeiter*innen aus den Gesundheitsämtern geführt. Die Nutzung einer auf Secure Instant Messaging basierenden Kommunikationsplattformbeförderte die interkollegiale Vernetzung zwischen Hausärzt*innen während der Pandemie. Auf die Kommunikation zwischen Gesundheitsämtern und Hausärzt*innen hatte die App demgegenüber nur wenig Einfluss. Die zum Teil entgegengesetzten Erwartungen und Nutzungsweisen der beiden Nutzungsgruppen (Hausärzt*innen und Gesundheitsamtsmitarbeiter*innen) führten (neben anderen Gründen) letztlich dazu, dass die Möglichkeit zur direkten transsektoralen Kommunikation mittels Secure Instant Messaging im Untersuchungsverlauf weitestgehend ungenutzt blieb.

Schlussfolgerung

Insbesondere in der Pandemiesituation stellt die Etablierung von Secure-Instant-Messaging-Gruppen mit regionalem Bezug für Hausärzt*innen eine willkommene Kommunikationsmöglichkeit dar, die dazu beitragen kann, interkollegiale Vernetzung zu befördern und dadurch die fluktuierende Pandemiesituation besser zu bewältigen. Es gibt Hinweise darauf, dass die effektive Anwendung von Secure Instant Messaging für die transsektorale Kommunikation demgegenüber erst im Rahmen umfassender Digitalisierungsbemühungen institutioneller Kommunikationsstrukturen mit dem Ziel einer stärkeren Vernetzung lokaler Versorgungsakteur*innen gelingt.

[Specialized outpatient palliative care for children, adolescents, and their families-the special needs of the target group. Results of the ELSAH study]

Hintergrund und Ziel

Lebenslimitierend erkrankte Kinder und Jugendliche mit komplexem Symptomgeschehen haben Anspruch auf eine spezialisierte ambulante Palliativversorgung (SAPV). In der Richtlinie zur SAPV heißt es lediglich: „Den besonderen Belangen von Kindern und Jugendlichen ist Rechnung zu tragen.“ Das Ziel der Studie ist es deshalb, diese besonderen Belange zu identifizieren und Empfehlungen zur Überarbeitung der SAPV-Richtlinie zu formulieren.

Methoden

Sequenzielles Mixed-Methods-Design mit Fragebogenerhebungen, qualitativen Interviews, teilnehmenden Beobachtungen und Fokusgruppendiskussionen mit Angehörigen, Patient*innen und Leistungserbringer*innen der SAPV in Hessen sowie der Auswertung von Dokumentationsdaten der hessischen SAPV-Teams.

Ergebnisse

Kinder und Jugendliche in der SAPV leiden an komplexen, oftmals seltenen Erkrankungen und bedürfen einer besonders aufwendigen Palliativversorgung durch ein Team mit pädiatrischer Expertise. Die SAPV muss die gesamte Familie einbeziehen und oftmals überregional verteilte Versorger*innen koordinieren. Zudem ist eine besonders aufwendige psychosoziale Versorgung von Patient*innen und Angehörigen notwendig. Die SAPV für Kinder und Jugendliche ist weniger bekannt als die SAPV für Erwachsene und der Zugang für die Familien deshalb oft schwierig. Für lebenslimitierend erkrankte Kinder und Jugendliche, die zwar einer aufsuchenden Palliativversorgung bedürfen, jedoch keinen Bedarf an einer so intensiven Betreuung wie in der SAPV haben, besteht eine Versorgungslücke.

Fazit

Die SAPV von Kindern und Jugendlichen sowie von volljährigen Patient*innen, die seit dem Kindes- und Jugendalter erkrankt sind, bedarf einer eigenständigen Versorgungsform mit Vergütungsmodalitäten, die den besonderen Versorgungsbedarf und -aufwand abbilden.

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.

Specialised outpatient paediatric palliative care team-parent collaboration: narrative interviews with parents

OBJECTIVE

In Germany, children with life-limiting conditions and complex symptoms are eligible for specialised outpatient palliative care (SOPC). In the federal state of Hesse, SOPC for children (SOPPC) is delivered by teams with paediatric expertise. While burdened by the life-limiting condition of their child, parents must also fulfill their roles as main care providers and decision makers. Collaboration between parents and SOPPC teams is important, as the intermittent care and uncertainty it entails often lasts for several months or years. We explored parents' experiences and their demands of collaboration with SOPPC teams.

METHODS

We conducted nine narrative interviews with 13 parents of children and adolescents with life-limiting conditions and used a grounded theory approach to analyse interview data.

RESULTS

Parents stressed the importance of paediatric expertise, honesty, psychosocial support, an individualised approach, experience of self-efficacy and the need to be recognised as experts for their children. The narrative interviews showed that collaboration between parents and SOPPC teams was characterised by parents' need for specialised professional assistance and their simultaneous empowerment by SOPPC teams.

CONCLUSIONS

Parents' perceptions of what good collaboration with SOPPC teams entails are manifold. To meet these complex needs, SOPPC requires time and specialised expertise.

Parents' Perspectives on Hospital Care for Children and Adolescents with Life-Limiting Conditions: A Grounded Theory Analysis of Narrative Interviews

Background: Guidelines on pediatric palliative care recommend to provide care for children and adolescents with life-limiting conditions at home. Since 2007, in Germany, palliative home care can be provided by specialized outpatient palliative care teams. However, teams with specific expertise for children are not available all over the country. Families without this support need to use the hospital to get specialists' assistance. Objective: To explore how parents of children and adolescents with life-limiting conditions think about the hospital as place of care. Design: We conducted narrative interviews with parents and analyzed these by using a grounded theory approach. Setting/Subjects: We interviewed 13 parents (4 fathers and 9 mothers) of 9 children with life-limiting conditions receiving or having received pediatric specialized outpatient palliative care (SOPPC) in Germany. Results: Parents reported feelings of vulnerability, heteronomy, and disablement associated with hospital care and were afraid that their children's needs were not adequately addressed. These perceptions resulted from hospitals' standardized care structures and over- and undertreatment, a lack of continuity of care, hospital pathogens, a lack of a palliative mindset, insensitive hospital staff, the exclusion of parents from the treatment and parental care of their children, the hospital stay as a permanent state of emergency, and a waste of limited life time. Conclusion: Pediatric hospital staff needs training in identifying and responding to palliative care needs. SOPPC structures should be expanded all over Germany to meet the needs of families of children with life-limiting conditions.

Treatment with Sulthiame (Ospolot) in benign partial epilepsy of childhood and related syndromes: an open clinical and EEG study

The effect of Sulthiame on the EEG and on clinical seizures was evaluated in an open uncontrolled study in 25 children with focal sharp waves on the EEG (FSW). 16 children had typical benign partial epilepsy with rolandic spikes (BPERS), 5 children with atypical forms and 4 children with no clinical seizures but cognitive disturbances possibly related to the FSW. The effect of Sulthiame in suppressing the EEG discharges was evaluated on the waking and sleep EEG before introduction of the drug, and at 3 - 6 months, 6 to 12 months and beyond while under therapy. The children were followed clinically for one to several years. The EEG discharges disappeared or decreased under Sulthiame in 13/21 cases at 3 to 6 months but reappeared in 3/13 cases beyond this period. No case had a worsening of the EEG or of clinical seizures under Sulthiame, and no cognitive stagnation was noted. Our data confirm the good tolerance and positive effects on the EEG and justify systematic trials of this drug in the partial "functional" epilepsies, especially when negative cognitive consequences of the epileptic discharges are suspected.

Analysis of immunoglobulins in sarcoidosis

BACKGROUND

Assessment of local immunoglobulin(Ig)-production in sarcoidosis may be indicative of disease activity. However, in interstitial lung disease an increase in protein leakage across the alveolar-capillary membrane complicates determination of local Ig-production. In order to overcome this problem, techniques successfully used for the evaluation of local Ig-production in cerebrospinal fluid were applied to bronchoalveolar lavage (BAL)-analysis.

METHODS

Ten patients with biopsy-proven sarcoidosis, seven patients with respiratory infections and ten patients as controls without any sign of interstitial lung disease or infection underwent BAL. Equal amounts of total protein (2 micrograms/lane) from BAL and serum samples were run on SDS-PAGE gradient-gel and blotted to a nitro-cellulose membrane. The blots were stained for total protein, IgA, IgM, IgG and IgG1-4-subgroups.

RESULTS

Densitometric analysis revealed a significant increase of the IgG/albumin-ratio in BAL of sarcoidosis patients compared to the control group. In all control patients a single IgG band of identical molecular weight was detected both in serum and BAL. In sarcoidosis and pneumonia the serum showed multiple bands distinct from the BAL-band in regard to molecular weight. Subclass analysis of this group revealed an increased band intensity and different molecular weight of IgG1, IgG2 and IgG4-bands in BAL compared to serum indicative of local production. IgA and IgM were detected in all samples without any significant differences between the three groups.

CONCLUSIONS

Molecular weight analysis of IgG-subgroups revealed local production of IgG1,2+4 in sarcoidosis and respiratory infection. This technique may prove useful with regard to the assessment of disease activity in sarcoidosis.

Postganglionic cholinergic dysautonomia with incomplete recovery: a clinical, neurophysiological and immunological case study

A 26-year-old man presented with signs and symptoms of marked postganglionic cholinergic autonomic dysfunction manifested by non-reacting dilated pupils, paresis of accommodation, decreased salivation, dry skin, atony of the bladder, erectile impotence and complete gastrointestinal paresis. Standard neurophysiological tests for myelinated sensory and motor fibre function and quantitative methods to examine unmyelinated parasympathetic, sympathetic and afferent fibres were performed: parasympathetic function was measured by heart rate variation tests. Sympathetic cutaneous vasoconstrictor responses induced by deep inspiration were examined with laser Doppler flowmetry. Cutaneous nociceptive C-fibre function was assessed by measurement of axon reflex vasodilatation and flare size induced by histamine iontophoresis. The findings confirmed that the abnormalities were restricted exclusively to the cholinergic postganglionic autonomic systems. All other functions were completely preserved. Modern neurophysiological methods of testing sympathetic and afferent small fibre function might help in the diagnosis of cholinergic postganglionic dysautonomia in the early stages. The specificity of the dysfunction argues in favour of an immunological pathogenesis. However, antibody screening including acetylcholine receptor antibodies and voltage-gated calcium channel antibodies gave negative results. Whatever autoimmunological mechanism might be involved, the postulated antibodies act highly specifically on unknown structures of the cholinergic postganglionic autonomic neurons.

[Lambert-Eaton myasthenia syndrome--review with case report]

The pathogenetic and therapeutic concepts in Lambert-Eaton Myasthenic Syndrome (=LEMS) are changing. The disease has been proved to be an autoimmune reaction to voltage-dependent calcium channels of the presynaptic membrane at the neuromuscular junction. As pointed out in a case report, autonomic dysfunction can be an early sign and symptom of LEMS. The update review of the literature deals with the diagnosis, aetiology and therapy of the often but not exclusively paraneoplastic induced disease.