Delegation of medical services to specially trained medical practice assistants

Background

Germany is one of the countries most affected by demographic change. Meaning the shift towards the population being older is growing. At the same time, the number of doctors is declining. In order to ensure adequate care in Germany, the delegation of medical services to specially trained medical practice assistants (MPAs) is currently discussed. The aim of this study was to assess the attitudes of the German population towards medical delegation.

Methods

The analysis was based on a population survey of 6.105 German-speaking residents aged 18 years and over. Associations between respondents’ attitudes towards the delegation and social determinants (age, gender, education, employment status, region, self-rated health) were assessed using standardised questionnaires. Bi- and multivariate (logistic regression) analyses were performed.

Results

In case of a chronic disease half of the German-speaking population (51. 8%) would accept getting treated by a MPA. More older participants (65 years and above) than younger participants (18 to 34 years old) (OR: 1,64; KI [1,24-2,18]), more lower than higher educated participants (OR: 1,20; KI [1,04-1,39]) and more non-German than German participants (OR: 1,61; KI [1,24-2,10]) are significantly more likely to not accept medical delegation in case of a chronic disease. Discussion: In the debate on delegation models the present results should be taken into account in order to be able to address relevant target-groups. Further qualitative studies that investigate the reasons for the critical view on delegation are recommended.

Key messages

Approximately 50% of the German-speaking study population would accept treatment by a MPA for chronic disease. Especially older study participants, lower educated people and non-German participants would not accept medical delegation in case of a chronic disease.

Is there an association between social determinants and care dependency risk?

Background

Despite a growing body of knowledge about the morbidities and functional impairment which frequently lead to care dependency, the role of social determinants is not yet well understood. The purpose of this study was 1) to examine the effect of social determinants on care dependency onset and progression, and 2) to analyse the effect of social determinants on various levels of care dependency.

Methods

We used data from the Berlin Initiative Study (BIS), a prospective, longitudinal, population-based cohort study including 2069 older participants (≥70 years of age) with visits in 2009, 2011 and 2013. Care dependency was assessed if participants require substantial assistance in at least two activities of daily living for 90 minutes daily (level 1) or three hours+ daily (level 2). Social determinants were defined as partnership status, education, income, age and gender. Data were analysed with multi-state time to event regression modeling which simultaneously model several competing events, as well as not only first but also second or third event in one model.

Results

During the study period, 556 participants (27.5%) changed their status of care dependency. Persons who reported having no partner at baseline were care-dependent more often than participants with a partner (43.7% ’no partner’ / 27.1% ’with partner’). In the multiple model having no partner compared to having a partner was associated with a higher risk of transition from no care dependency to level 1 (HR: 1.25, 95%CI: 0.97-1.64), however failed significance. The significant association between care dependency and income and between care dependency and education ceased as well after adjustment for co-morbidities.

Conclusions

Results indicate that older people without a partner tend to be on a higher risk of care dependency onset but not on a higher risk of care dependency progression. Inequality between education and income groups can be explained in terms of morbidity.

Key messages

The significant association between care dependency and income and between care dependency and education can be explained in terms of morbidity. Results indicate that older people without a partner tend to be on a higher risk of care dependency onset but not on a higher risk of care dependency progression.

[Skin health promotion in the elderly]

BACKGROUND

Skin aging is associated with anatomical and physiological changes. These changes are not pathological; nevertheless, reduced functional skin capacity increases the susceptibility to skin diseases and functional disorders. Especially in old age, the clinical manifestation of skin changes differs greatly between individuals.

PURPOSE

This contribution focuses on a critical reflection of the concept of preventative skin care and skin health promotion in the aged.

RESULTS

Preventive skin care in the aged includes all activities to cleanse and care for the skin which contribute to health promotion and which reduce the probability developing skin disorders or diseases. Preventive skin care in the aged can be classified into primary, secondary, and tertiary prevention, but the empirical evidence supporting individual interventions is heterogeneous.

CONCLUSION

There are no formally developed guidelines or recommendations for basic skin care in the aged. Thus, preventive skin care in the elderly is very likely to be underused.

[Residential mobility in old age. Age-appropriate housing as a primary preventive strategy]

BACKGROUND

Unfavorable living conditions in old age have negative physical, psychological and social implications and increase the risk of institutionalization. The aim of this study is to examine older adults’ readiness to relocate to age-appropriate housing versus the wish to stay where they are.

METHODS

A total of 103 older men and women were questioned prospectively, face-to-face, regarding their readiness to relocate. In addition to assessing several established predictors of residential mobility, data on objective living situations were collected. The data were subjected to bi- and multivariate analysis.

RESULTS

At 70.9%, the proportion of respondents who are not willing to move (stayers) far exceeds the proportion of those who are (movers, 29.1%). Older respondents are more satisfied with their living situation and less likely to move. This study provides empirical evidence for the "satisfaction paradox" with respect to living conditions and for the importance of the subjective standard of living for quality of life in old age.

CONCLUSION

Modern housing counseling should more strongly reflect the variety of needs, requirements and living situations of older people today than it has done in the past. It is therefore recommended that the currently dominating paradigm of "aging in place" be critically re-evaluated.

[Delegation of Medical Treatment to Non-physician Health Care Professionals: The Medical Care Structure agneszwei in Brandenburg - A Qualitative Acceptance Analysis]

Backround: To address the increasing shortage of primary care physicians in rural regions, pilot model projects were tested, where general practitioners delegate certain physician tasks including house calls to qualified physician assistants. Evaluations show a high level of acceptance among participating physicians, medical assistants and patients. This study aims to measure the quality of cooperation among professionals participating in an outpatient health care delegation structure agnes^zwei with a focus on case management in Brandenburg. Methods: We conducted 10 qualitative semi-structured expert interviews among 6 physicians and 4 physician's assistants. Results: Physicians and physicians' assistants reported the cooperative action to be successful and as an advantage for patients. The precondition for successful cooperation is that non-physician health care professionals strictly respect the governance of the General Practitioners. Physicians report that the delegation of certain medical tasks reduces their everyday workload. Physician assistants derive professional satisfaction from the confidential relationship they have with the patients. All physician assistants are in favor of medical tasks being delegated to them in regular medical outpatient care, while most physicians are skeptical or reluctant despite their reported positive experience. Conclusion: Despite the high level of acceptance of delegating some medical tasks to physician assistants, the negotiation process of introducing cooperative working structures in the outpatient health care system is still at the beginning.

[Physio- and occupational therapy pathways of stroke patients and stroke mortality]

AIMS

This study examines the relationship between adherence to clinical guidelines and survival time in the first year after stroke.

METHODS

The sample comprises all clients of the Deutsche BKK, a large German health insurance company, who received acute inpatient care for stroke in 2007, who survived the hospital stay by at least 14 days, and who had motor deficits at the end of their acute treatment (n=1 791). 3 types of treatment that differ in the degree of adherence to clinical guidelines are identified ("Frühreha-Plus">"Standard-Plus">"Nur Akut").

RESULTS

There is a positive relationship between adherence to clinical guidelines and survival time, even when relevant covariates are controlled. The hazard-ratios are 0.49 for "Frühreha-Plus" and 0.65 for "Standard-Plus" compared to "Nur Akut".

CONCLUSIONS

Healthcare processes should be organized on the basis of cross-sector collaboration and in line with the recommendations of the guidelines.

[A cross-sectorial analysis of physio and occupational therapy pathways after stroke]

PURPOSE

This article examines the provision of physiotherapy and occupational therapy for stroke patients from a cross-sectorial perspective, from acute to rehabilitative care to outpatient services.

METHODS

The sample comprises all clients of the Deutsche BKK, a large German health insurance company, who received acute care for stroke in 2007, who survived the initial hospital stay, and who had a secondary diagnosis of motor deficits (n = 1 929).

RESULTS

For 60.4% of these stroke patients, no further treatment was provided after acute care. The odds of receiving early rehabilitation treatment while in hospital stay decreased by 1% with each year of life. Only 18.8% of patients received a form of treatment that was largely in line with current recommendations for stroke care, beginning with early rehabilitation and including further treatment in the context of rehabilitation measures or outpatient care. Patients who were in long-term nursing care before stroke were at increased risk of not being placed on this treatment pathway, which has been positively evaluated. 20.7% of patients did not receive any early rehabilitation treatment, but received further rehabilitation treatment and/or outpatient services after hospital discharge.

CONCLUSIONS

We recommend that receipt of long-term nursing care should routinely be regarded as a risk factor for underprovision of treatment after stroke (yellow flag).

[Temporal and structural differences in the care of obese and non-obese people in nursing homes]

Obesity is a common disease in Germany. Although care facilities are confronted with an increasing number of obese people, the care of them in nursing homes is barely investigated. The present study examines the amount of work using the example of the activity of dressing obese and non-obese nursing home residents and discloses with its temporal and structural differences. In five nursing homes in Berlin a fully structured observational study based on a convenience sample was conducted. 48 nurses were observed while performing the activity of dressing 70 residents aged 65 years and older. The residents' demographic data and medical diagnoses were taken from the nursing records. Information about the functional/cognitive status and pain events were collected by using the interRAI Contact Assessment. Further data regarding the nurses were obtained through face-to-face interviews. The results show a significant correlation between Body Mass Index and the required time of dressing. No correlations exist between age, qualifications and nurses' level of education and the time of dressing. Structural differences in the care of obese and non-obese residents appear by changes of, single activity sequences. The care of the obese residents is associated with increased time requirements and structurally differs from the care of the non-obese residents. This should lead to further research because it has implications for staffing in nursing homes.

[Health care research to improve the quality of health care provision for older people]

This article addresses the contribution that health care research can make to facilitating appropriate health care provision for older adults. First, the major risks in this age group are described. These include multiple illnesses, the increasing need for nursing care with age, but also the growing numbers of older adults with psychological disorders, primarily dementia. The second section of the article presents a critical assessment of the current health care situation in light of the risks identified. On this basis, the third section specifies the areas of health care research that can contribute to improving the quality of the health care provision for this population. The article is based on a presentation made by the author at the 2010 Berlin Talks on Social Medicine: "The New Old--Health Care Research for a Changed Society."

[Autonomy despite multimorbidity in old age--the Berlin-based AMA research consortium]

The proportion of the population with multiple illnesses increases with age and growing numbers of people are now living to a very old age. Despite medical progress and improved living conditions, many old people have to deal with physical, psychological, and social impairments. It is a crucial challenge for health and social policy to support the elderly with health-related impairments in their desire to lead as independent a life as possible. Against this background the research consortium Autonomy Despite Multimorbidity in Old Age (AMA I) examined the extent to which the self-determined life style of multimorbid old and very old persons can be supported and maintained. In order to reflect the diversity of life worlds of the elderly, the study sample included participants who were not notably impaired in their everyday functioning, participants in need of nursing care and participants with cognitive impairments. Moreover, the sample comprised both older persons who were still living in their own homes and nursing home residents. The studies conducted within the AMA framework focused on the resources available to old persons living in different situations and on how these resources can be strengthened. This article presents findings from the first phase of funding of the AMA research consortium. In a second phase of funding (2011-2013, AMA II), sustainable practice-based interventions are being developed to mobilize resources which can help multimorbid older persons to maintain their autonomy and the practical viability of these interventions will be tested.

[Do gatekeeping programs increase equality of health care in Germany? A comparison of the health care situation of participants and nonparticipants]

This article compares the health care situation of participants in programs of general practitioner-centered health care (gatekeeping) in Germany (participants) with that of statutory health insurance holders who are not participating in such programs (nonparticipants). Because a key objective of the general practitioner model is to reduce the number of visits to specialists, the article also examines factors influencing frequent utilization of specialists in both groups. The analysis draws on a survey conducted by the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, 2010) based on a sample representative of the German population. In this context, 5,232 holders of statutory health insurance aged between 18 and 79 years were interviewed on health care policy issues. The results show that regulating the utilization of specialists through the gatekeeping function of general practitioners succeeds in facilitating similar utilization rates across educational levels, between cities and towns, and between men and women. Thus, gatekeeping programs contribute to the reduction of health care inequalities.

[Use of health insurance data to analyse pain management practices in the nursing-home setting]

Pain is the most common health-related complaint in older persons. International estimations mention up to 80% of nursing home residents suffering from pain. In the meantime, no reliable epidemiological data on pain in nursing home residents are available for Germany, because of restricted access to the nursing-home population. This pilot study aimed to evaluate whether routine data from a German statutory health insurance fund can be used to generate data on pain prevalence and analgesic therapy in nursing home residents. To this end, data of all insured persons of Deutsche BKK who received long-term care insurance benefits for nursing-home care between April and June 2007 were selected anonymously. These data were combined with data on diagnoses and analgesic prescriptions. 3 pain-related diagnoses were selected: R 52 (pain, not elsewhere classified), M 16 (coxarthrosis) and G 53.0 (postherpetic neuralgia) and analysed for corresponding prescriptions. The study sample shows similar characteristics regarding age distribution and care needs in terms of long-term care insurance benefits compared to the official data on nursing-home residents for Germany in 2007. The rate of dementia was within the expected range, too. Therefore, external validity of the sample is assumed. One of the 3 selected diagnoses had been documented in 15% of the sample. About 58% of those received an analgesic prescription. Deficits were discovered regarding the documentation of postherpetic neuralgia, the combination of different analgesics and prescriptions for adjuvant drugs. Prevalence rate and numbers of prescriptions were as frequent as expected. The routine method for this analysis proved to be practicable and reliable. Data quality is deemed sufficient so that the main study will proceed to include a longer period of time and additional data.

[Special care requirements of elderly and old people: as reflected in the new Council of Experts Report]

This contribution refers to the 2009 Council of Experts Report on health system development and discusses the special care requirements of old people. This includes the geriatric phenomenon of multimorbidity, polypharmacy in old people with multiple diseases, and the need for care. The probability and complexity of multiple diseases increase with age. About half the German citizens who are over 65 have three or more relevant chronic diseases. Multimorbity often causes elderly people to concomitantly consume many different pharmaceuticals. Twenty percent of the insurance holders aged 70-99 who were prescribed drugs in 2005 received 13 or more pharmaceutical agents. However, multimorbidity also has a negative effect on the quality of life, subjective state of health and physical functioning. As a result, particularly people over 80 will eventually need help and care. At present, 2.13 million German citizens are considered to be in need of care in terms of Social Code Book XI. The Council of Experts predicts that the number will increase to 4.35 million by 2050. Finally, the discussion also focuses on the steps health policy makers must take to cope with these requirements. Apart from expanding prevention, these include improving the quality of outpatient treatment and care, upgrading case and care management, and modernizing institutional care.

Is grading of breast fibrosis with mammography feasible?

PURPOSE

To establish a grading system for mammographic fibrosis and correlate it with clinical fibrosis.

PATIENTS AND METHODS

Analogous to the LENT/SOMA scale a four-tiered scoring scale of breast fibrosis in mammography (G0 = absent, G1 = barely increased density, G2 = definitely increased density to G3 = very marked density) was established by two observers in a group of 16 patients. Reference mammograms were selected. Independently and blinded to clinical results, three observers scored the fibrosis in mammograms of further 31 patients examined by one radiation oncologist in a cross-sectional follow-up study. Pretreatment parenchyma density was judged according to the American College of Radiology (ACR). Interobserver correlation of mammography scoring as well as correlation of mammography and clinical findings were calculated with Cohen's weighted kappa. All patients had breast-conserving surgery and axillary resection for breast carcinoma T1-2N0-1. The breast was irradiated to a median reference dose of 55 Gy (range 50-60 Gy) with 2 Gy five times weekly or 2.5 Gy four times weekly. Two patients received chemotherapy, 14 patients tamoxifen. Median age was 55 years, median follow-up 8 years (4-15 years).

RESULTS

14 of 31 patients had clinical fibrosis, twelve G1 and two G2. In mammography, mild fibrosis (G1) was seen in 12/12/18 patients (observer 1/2/3) and moderate fibrosis (G2) in 9/10/2 patients. Interobserver correlation for observers 1 and 2 who had developed the score was fair (Cohen's weighted kappa 0.64, 95% confidence interval 0.4-0.88). However, it was weak for observer 3 (0.36 and 0.42, respectively) who relied on reference mammograms only. Independent interobserver correlation of pretreatment breast density was good for all observers (Cohen's weighted kappa 0.73-0.8). The correlation of fibrosis by mammography and palpation was weak (Cohen's weighted kappa 0.32-0.42).

CONCLUSION

Grading fibrosis as depicted by mammography is possible, especially if observers prepare by jointly analyzing a training group. It may be useful to study treatment effects, e. g., of fractionation or drugs, because retrospective and repeated analysis is possible. The correlation of mammography with clinical grading should be further evaluated with more objective clinical reference tools.

[Outpatient and inpatient medical care of the elderly]

This contribution discusses the outpatient and inpatient medical care of elderly patients in Germany. The paper first focuses on the increasing utilization of the two care sectors especially by the very old in the sense of a "geriatrization" of the system followed by a detailed analysis of the costs associated with a higher frequency of contact with the medical care system. On the one hand, the determining factor for outpatient treatment costs is more likely to be the patient's age rather than the type of disease. On the other hand it was found that inpatient treatment costs are associated more with closeness to death than with patient's age. A third central point beside these quantitative aspects continues to be the discussion about current deficits in the care of elderly patients. While the discussion on the outpatient medical care centers on physician-related factors and their influence on the quality of care exemplified by depression and dementia, the discussion on inpatient care focuses on structural problems. This is followed by the discussion of central organizational and research needs in the medical care of the elderly.

[The PhD program "Multimorbidity in Old Age and Selected Care Problems" Center for Human and Health Sciences of the Charité-Universitätsmedizin Berlin]

The PhD Program concerns the care of multimorbid geriatric patients. It takes a multidisciplinary approach in combining different perspectives on delivering care to the elderly. Students have completed courses of studies such as nursing, social education, sociology, psychology, or public health. Likewise, doctoral projects are overseen by members of various disciplines including medicine. These disciplines are represented in the Center for Human and Health Sciences of the Charité-Universitätsmedizin Berlin, where the PhD Program is located. The doctoral projects are grouped into three main topics--Care Problems and Interventions, Quality of Life and Self-Determination, and Care Structures and Quality.

[Quality assurance and total quality management in residential home care]

Quality, quality assurance, and quality management have been important topics in residential care homes for several years. However, only as a result of reform processes in the German legislation (long-term care insurance, care quality assurance) is a systematic discussion taking place. Furthermore, initiatives and holistic model projects, which deal with the assessment and improvement of service quality, were developed in the field of care for the elderly. The present article gives a critical overview of essential developments. Different comprehensive approaches such as the implementation of quality management systems, nationwide expert-based initiatives, and developments towards professionalizing care are discussed. Empirically based approaches, especially those emphasizing the assessment of outcome quality, are focused on in this work. Overall, the authors conclude that in the past few years comprehensive efforts have been made to improve the quality of care. However, the current situation still requires much work to establish a nationwide launch and implementation of evidence-based quality assurance and quality management.

Individual radiosensitivity measured with lymphocytes may be used to predict the risk of fibrosis after radiotherapy for breast cancer

BACKGROUND AND PURPOSE

To analyse the relationship of individual cellular radiosensitivity and fibrosis after breast conserving therapy. A new model was used describing the percentage of patients developing fibrosis per year and per patient at risk.

PATIENTS AND METHODS

In a retrospective study, 86 patients were included, who had undergone breast conserving surgery and irradiation of the breast with a median dose of 55 Gy (54-55 Gy) given at 2.5 Gy/fraction (n=57) or 2 Gy/fraction (n=29). Median age was 62 years (range 44-86) and median follow-up was 7.5 years (range 5-17). Patients were examined for fibrosis according to the LENT/SOMA score. For analysis, fibrosis was classified as grade 0 and grade 1 (G0-1) or present grade 2 and grade 3 (G2-3). The time to complete development of fibrosis was determined by analysis of yearly mammograms. Individual cellular radiosensitivity was determined by scoring lethal chromosomal aberrations in in vitro irradiated (6 Gy) lymphocytes using metaphase technique. Patients with low/intermediate cellular radiosensitivity were compared with patients with high cellular radiosensitivity using actuarial methods.

RESULTS

Ten patients developed fibrosis at 1-8 years after radiotherapy. Individual cellular radiosensitivity was described by normal distribution of lethal chromosomal aberrations, the average was 5.47 lethal aberrations per cell (standard deviation (SD) 0.71). Cellular radiosensitivity was defined as low/intermediate (< or =6.18 lethal aberrations) in 73 patients and high (>6.18 lethal aberrations; mean+SD) in 13 patients. In both groups, the actuarial rate of fibrosis-free patients decreased exponentially with time after radiotherapy. Patients with high cellular radiosensitivity showed a 2.3-fold higher annual rate for fibrosis than patients with intermediate and low radiosensitivity (3.6 versus 1.6% per year).

CONCLUSIONS

In breast cancer patients, high individual cellular radiosensitivity as determined by the number of lethal chromosome aberrations in in vitro irradiated lymphocytes might be associated with an enhanced annual rate of fibrosis.

Cosmesis from the patient's and the doctor's view

PURPOSE

Long-term cosmesis from the patient's perspective is compared to the doctor's appraisal. Factors that determine judgment of cosmesis are analyzed. Also, a patient questionnaire was designed to screen for normal tissue reactions and is evaluated.

METHODS AND PATIENTS

With structured questions, patients rated their satisfaction considering cosmesis, the difference in overall appearance, and specific changes of the breast. Two doctors rated cosmesis and radiation late effects (LENT/SOMA). Ratings were compared, and the relative impact of single items was studied. Two hundred eighty-seven patients with unilateral breast carcinoma were examined after a median follow-up of 8 years. They were treated between 1981 and 1995 with lumpectomy and radiotherapy of the breast with 1.8-2.5 Gy fractions with a median total dose of 55 Gy (range: 50-65 Gy).

RESULTS

One hundred sixty-one patients rated cosmesis as satisfying, 73 patients rated it as acceptable, and 25 patients as poor. Eighty-nine patients noted severe changes of appearance. Severe firmness and extensive scars were the most frequent complaint; the most important single item for judging cosmesis as poor was highly visible scars. Generally, doctors rated cosmesis less favorably (satisfactory, 150 patients; poor, 43 patients). Severe fibrosis was more important than discoloration of the breast or scars. Correlation between patients' and doctors' rating of cosmesis was modest (Cohen's weighted kappa 0.29), whereas the doctor's rating correlated well (0.55). Specificity and sensitivity of the questionnaire item for severe fibrosis (using doctors' judgments as gold standard) was 0.8; Cohen's weighted kappa was 0.34 (95% confidence interval: 0.21-0.48).

CONCLUSION

Rating of cosmesis is subjective. Patients' satisfaction with cosmesis is greater than the doctors' and is determined not only by radiation late effects, but also by factors unrelated to the appearance of the breast. Severe fibrosis may be detected by a patient questionnaire.