Investigating insomnia in United States deployed military forces: A topic modeling approach

STUDY OBJECTIVES

This retrospective study analyzed free-text clinical notes from medical encounters for insomnia among a sample of deployed US military personnel. Topic modeling, a natural language processing technique, was used to identify thematic patterns in the clinical notes that were potentially related to insomnia diagnosis.

METHODS

Clinical notes of patient clinical encounters coded for insomnia from the US Department of Defense Military Health System Theater Medical Data Store were analyzed. Following preprocessing of the free text in the clinical notes, topic modeling was employed to identify relevant underlying topics or themes in 32,864 unique patients. The machine-learned topics were validated using human-coded potential insomnia etiological issues.

RESULTS

A 12-topic model was selected based on quantitative metrics, interpretability, and coherence of terms comprising topics. The topics were assigned the following labels: personal/family history, stimulants, stress, family/relationships, other sleep disorders, depression, schedule/environment, anxiety, other medication, headache/concussion, pain, and medication refill. Validation of these topics (excluding the two medication topics) against their corresponding human-coded potential etiological issues showed strong agreement for the assessed topics.

CONCLUSIONS

Analysis of free-text clinical notes using topic modeling resulted in the identification of thematic patterns that largely mirrored known correlates of insomnia. These findings reveal multiple potential etiologies for deployment-related insomnia. The identified topics may augment electronic health record diagnostic codes and provide valuable information for sleep researchers and providers. As both civilian and military healthcare systems implement electronic health records, topic modeling may be a valuable tool for analyzing free-text data to investigate health outcomes.

Theories used to develop or evaluate social prescribing in studies: a scoping review

OBJECTIVE

This scoping review aims to provide an overview of how theories were used in the development or evaluation of social prescribing (SP) intervention studies.

BACKGROUND

SP describes a patient pathway where general practitioners (GPs) connect patients with community activities through referrals to link workers. This review seeks to understand the explanations provided for the outcomes and implementation process of SP.

INCLUSION CRITERIA

Studies using a defined theory to develop or evaluate a specific SP intervention in primary care and the community sector.

METHODS

This scoping review was conducted in accordance with JBI methodology. The following databases were searched on 8th of July 2022: PubMed, ASSIA, Cochrane, Cinahl, PsycINFO, Social Care Online, Sociological Abstracts, Scopus, and Web of Science. The search only considered English language texts. Additional literature was identified by searching relevant web pages and by contacting experts. The selection of sources and the data extraction was done by two reviewers independently.

RESULTS

The search resulted in 4240 reports, of which 18 were included in the scoping review. Of these, 16 were conducted in the UK, one in Canada and one in Australia. The majority of reports employed a qualitative approach (11/18). Three were study protocols. 11 distinct theories were applied to explain outcomes (4 theories), differences in outcomes (3 theories), and the implementation of the intervention (4 theories). In terms of practical application, the identified theories were predominantly used to explain and understand qualitative findings. Only one theory was used to define variables for hypothesis testing. All theories were used for the evaluation and none for the development of SP.

CONCLUSION

The theories influenced which outcomes the evaluation assessed, which causal pathway was expected to generate these outcomes, and which methodological approaches were used. All three groups of theories that were identified focus on relevant aspects of SP: fostering positive patient/community outcomes, addressing inequalities by considering the context of someone's individual circumstances, and successfully implementing SP by collaboratively working across professions and institutional boundaries. Additional insight is required regarding the optimal use of theories in practical applications.

Outcome of endovascular stroke therapy in a large mandatory stroke-registry

BACKGROUND

Endovascular stroke treatment (EST) has become the standard treatment for patients with stroke due to large vessel occlusion, especially in earlier time windows. Only few data from population-based registries on effectiveness of EST have been published.

METHODS

Baden-Wuerttemberg is the third largest state in Germany in terms of area and population and has a structured stroke concept since 1998 which includes mandatory collection of quality assurance data. In 2018 and 2019, 3820 of 39,168 ischemic stroke patients (9.8%) were treated by EST (age median 78 y, NIHSS median 14). We analyzed the clinical outcome of these patients determined with the modified Rankin Scale (mRS) at discharge from the hospital or with the initiation of palliative therapy using logistic regression analysis with adjustment for the mRS at admission, additive IVT, age, and NIHSS.

RESULTS

The probability of an excellent clinical outcome (mRS 0 or 1 at discharge) and for a good clinical outcome (mRS 0-2) were significantly higher in EST-patients (odds-ratio (OR) 1.27; 95% confidence interval (95% CI) 1.13-1.43, and OR of 1.15 (95% CI 1.04-1.28). Also, the regression model showed an advantage for EST-patients with less frequent 'decision for palliative care' (OR 0.87; 95% CI 0.78-0.98). Sensitivity analysis adjusting for intracranial vessel occlusion as further factor showed similar results.

CONCLUSION

Our data suggest that EST can be of benefit also for an area-wide unselected stroke population, in a large German federal state with sometimes long distance to the next thrombectomy center.

[PHARAO study: drug treatment of inflammatory rheumatic diseases : Guideline-conform treatment with biologics follows availability of biosimilars]

BACKGROUND

With the introduction of tumor necrosis factor (TNF) alpha inhibitors, the treatment of inflammatory rheumatic diseases (IRD) has undergone a fundamental change. Several of the originally high-priced biologics are now accessible as lower cost biosimilars, removing a significant impediment to prescription.

OBJECTIVE

The present study investigated whether the availability of biosimilars is associated with an improvement in the care of IRD. Moreover, the subjective acceptance of biosimilars by physicians and patients was investigated and compared with objectifiable parameters.

MATERIAL AND METHODS

Pseudonymized claims data of the Bavarian Association of Statutory Health Insurance Physicians from 2014 to 2019 as well as a paper and pencil survey of patients and rheumatologists formed the data basis of the study.

RESULTS

During the observation period, the proportion of diagnosed patients receiving drug therapy increased from 38.5% to 43.2%. Also, the care changed in terms of the prescribed agents. Conventional drug therapy declined overall and, in particular, glucocorticoid prescriptions decreased from 39.3% in 2014 to 34.3% in 2019. At the same time, the proportion of targeted treatments increased from 12.3% to 20.4%. The median duration of basic treatment before first-time bDMARD use dropped from 3.15 years in 2014 to 2.17 years in 2019.

CONCLUSION

Over the observation period, in which three biosimilars entered the market, the care of patients with IRD improved both quantitatively and qualitatively. The market share of biosimilars increased in parallel with this development. With an overall high acceptance of biosimilars, the assessment of the disease course by physicians and patients indicates a slight subjectively perceived advantage of therapy with originals compared to biosimilars, which, however, is not confirmed when standardized scores are applied. A possible explanation for this might be a nocebo effect, which could be minimized by suitable communication strategies.

Understanding the Perceptions of Healthcare Researchers Regarding ChatGPT: A Study Based on Bidirectional Encoder Representation from Transformers (BERT) Sentiment Analysis and Topic Modeling

In this study, we have used deep learning techniques to understand the perception of researchers in the healthcare sector about the recently introduced chat generative pre-trained transformer (ChatGPT). Ever since the launch of ChatGPT, there have been various debates over the usage of ChatGPT for research purposes. In this article, using the pre-trained BERT (Bidirectional Encoder Representations from Transformers) model, we performed sentiment analysis and topic modeling to analyze the social media posts of healthcare researchers to understand their emotions towards ChatGPT.

Prevalence of malocclusions in 8- and 9-year-old children in Germany-Results of the Sixth German Oral Health Study (DMS 6)

PURPOSE

Current population-wide data on the prevalence of malocclusions in 8‑ and 9‑year-old children in Germany are not available. Therefore, the primary objective of this study was to collect data on the prevalence of malocclusions in 8‑ and 9‑year-old children in Germany. The secondary objective of this study was to use this information to derive the need for orthodontic care provision.

METHODS

This is an oral-epidemiological investigation and social science survey at the national level with a focus on tooth and jaw misalignment. The investigation took place between January and March 2021 at 16 study centers across Germany. All relevant data were available for the 705 study participants and were included in the statistical analysis.

RESULTS

Overbite was the most common finding with 88.9%. Also widespread were crowding, with at least 60.9%, and lack of space, with a share of 30.9%. All other indication groups had a share below 10%. Rare (< 1%) were buccal and lingual occlusions and craniofacial abnormalities. The most severe forms of disease (Orthodontic Indication Group [Kieferorthopädische Indikationsgruppen, KIG] grade 5) were overbite (3.2%), open bite malocclusion (1.0%), undershot (0.6%), and craniofacial abnormalities (0.4%). The proportion of study participants who required orthodontic treatment, in accordance with statutory health insurance provider guidelines, was 40.4%. The proportion of study participants in principle requiring orthodontic treatment for medical reasons was 97.5%. Systemic differences in the need for orthodontic care provision relating to gender, region, or social status were not identified.

CONCLUSION

In general, the need for care provision identified in the orthodontic indication groups corresponds to that shown in previous studies. This suggests that the need for orthodontic treatment in Germany has remained stable over the years.

[Outpatient medical specialist care (ASV): A multiperspective study on status quo, challenges and perspectives]

BACKGROUND

In 2012, the so-called ambulatory medical specialist care (ASV) was implemented in accordance with para. 116b of Book V of the German Social Code (SGB V), enabling physicians in outpatient practices and hospitals to treat patients with rare diseases or complex courses of disease in a uniform framework. The implementation, however, is slow. The Joint Federal Committee (G-BA) has therefore commissioned an evaluation of the ASV with the aim to examine the reasons for this and to provide recommendations for further development.

METHODS

The health services research study "GOAL-ASV" (Innovation Fund, 01VSF19002) included a multi-perspective design with primary data collection as well as secondary data analyses. Data from the ASV service center and the central association of statutory health insurances and the notification forms of the extended state committees were analyzed. Data from the Robert Koch-Institute, the Federal Joint Committee, the National Association of Statutory Health Insurance Funds and a literature database analysis were used in order to estimate the proportion of insured persons qualifying for ASV. Care was examined by analyzing pseudonymized routine data from the statutory health insurances using selected indicators. Participating and not participating physicians were asked to complete an online survey.

RESULTS

Since the start of ASV, 615,531 insured persons have been treated in this form of care. At the time of analysis, 509 teams were operating, with 26,540 physicians treating 102,898 patients by the end of March 2021 in all indications. This comprises less than 9.8 %. of all approx. 1.05 million eligible patients. Especially in the case of rare diseases, a low willingness of participation can be seen. In addition, there was a relevant proportion of multiple uses of physicians within and outside ASV at 31 percent as well as indications of passive participation of doctors. We found significant regional differences in type and scope of the notification procedure as well as the implementation of teams with 13.4 teams per 1 million inhabitants in Schleswig-Holstein and no team in Mecklenburg-Vorpommern. Patient benefits (84 %), interdisciplinary (82 %) and cross-sectoral cooperation (75 %) were cited as motivations for participation. The main barriers reported by the respondents were the complex and laborious notification procedure (60 %), the administrative and documentation effort during participation (50 %), insufficient billing figures (49 %), and a small proportion of patients (32 %) with a consecutively unfavorable assessment of the cost to income ratio due to the current reimbursement system.

DISCUSSION

Nearly ten years after its introduction, the ASV has not become established nationwide. The reasons for this probably are the complex notification procedure and the reimburesement system for rare diseases. In the case of rare diseases, the risk of underuse is becoming apparent.

CONCLUSION

Strategies to further develop the ASV should, in particular, simplify the notification procedure and reduce the obstacles during participation. The remuneration system should take more account of the specific care required.

[Not Available]

Participation of patients and relatives in research means that those affected are involved in the research process in a partnership role. Despite the growing importance of participatory approaches and the large number of available concepts, many researchers and patients are faced with the question of how participatory research can be realized and organized in concrete terms. Here we report on our experiences with two different forms of patient participation in research in the context of pediatric health care research at a university hospital: (1) In a project for the development and evaluation of a case management for patients with spinal muscular atrophy, patient representatives have an consultative role. (2) In the patient advisory board, which is to accompany the research activities of the research group at the site continuously and systematically, i.e. in all phases, the participation currently corresponds to a contributory role (involvement) which, in the future, could be moved onto the collaborative stage. In both forms of participation, the essential questions include the selection of the participating patients, the type and extent of participation, and the evaluation of the effect of participation on the research that is carried out. In our experience, both forms of participation add value to research from the perspective of all participants. At the same time, they bring different opportunities and challenges. While in project-based participation the sphere of influence is already delineated by researchers, the context of the patient advisory board provides more room and openness to develop, for example, a research agenda and thus identify new research topics. In our experience, however, sufficient resources (in terms of time and money) are required from all participants, as well as good, trusting cooperation with jointly developed processes to realize both forms of participation.

Impact of the COVID-19 pandemic on delays in surgical procedures in Germany: a multi-center analysis of an administrative registry of 176,783 patients

Background

While extensive data are available on the postponement of elective surgical procedures due to the COVID-19 pandemic for Germany, data on the impact on emergency procedures is limited.

Methods

In this retrospective case–control study, anonymized case-related routine data of a Germany-wide voluntary hospital association (CLINOTEL association) of 66 hospitals was analyzed. Operation volumes, in-hospital mortality, and COVID-19 prevalence rates in digestive surgery procedure groups and selected single surgical procedures in the one-year periods before and after the outbreak of the COVID-19 pandemic were analyzed. The analysis was stratified by admitting department (direct admission or transfer to the general surgical department, i.e., primary or secondary surgical patients) and type of admission (elective/emergent).

Results

The total number of primary and secondary surgical patients decreased by 22.7% and 11.7%, respectively. Among primary surgical patients more pronounced reductions were observed in elective (-25.6%) than emergency cases (-18.8%). Most affected procedures were thyroidectomies (-30.2%), operations on the anus (-24.2%), and closure of abdominal hernias (-23.9%; all P’s < 0.001). Declines were also observed in colorectal (-9.0%, P = 0.002), but not in rectal cancer surgery (-3.9%, n.s.). Mortality was slightly increased in primary (1.3 vs. 1.5%, P < 0.001), but not in secondary surgical cases. The one-year prevalence of COVID-19 in general surgical patients was low (0.6%), but a significant driver of mortality (OR = 9.63, P < 0.001).

Conclusions

Compared to the previous year period, the number of patients in general and visceral surgery decreased by 22.7% in the first pandemic year. At the procedure level, a decrease of 14.8% was observed for elective procedures and 6.0% for emergency procedures. COVID-19 infections in general surgical patients are rare (0.6% prevalence), but associated with high mortality (21.8%).

Trial registration

The present study does not meet the ICMJE definition of a clinical trial and was therefore not registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13037-022-00331-y.

[Diagnosis of inherited retinal dystrophies. Relevance of molecular genetic testing from the patient's perspective]

BACKGROUND

The diagnostic process of inherited retinal dystrophies (IRD) is impeded by their low prevalence and the variability of the clinical presentations; however, for patients a valid diagnosis is vital for future planning and evaluating the potential of an appropriate early treatment to delay disease progression.

OBJECTIVE

Aim of the current study was to outline the patients' journeys until they receive the final diagnosis. This should help uncover diagnostic shortcomings and highlight potential for improvement with respect to the use of genetic diagnostic testing.

MATERIAL AND METHODS

Data were collected by questionnaires and an online survey conducted by the self-help association PRO RETINA Deutschland e. V. among patients with IRD. Data were analyzed by descriptive statistics.

RESULTS

From 15 March to 22 April 2021, 183 questionnaires were completed and 42 online interviews conducted. The surveyed population consisted of 48% female patients, mean age was 55 years and first symptoms occurred at a mean age of 22 years. On average about 14 years passed from first symptoms until final diagnosis. Only 66% of the patients reported that they had received at least 1 diagnostic genetic testing; less than half of the patients (47%) received genetic counseling. The huge majority of patients (85%) would be interested in gene therapy.

CONCLUSION

From the perspective of affected patients, a shortening of the time to diagnosis, the use of molecular genetic testing and the offer of genetic counseling are important to improve patient care for patients with IRD.

[Trends in uro-oncological surgery in Germany-comparative analyses from population-based data]

Obwohl urologische maligne Erkrankungen mit etwa 100.000 Neuerkrankungen pro Jahr eine relevante gesundheitsökonomische Aufgabe darstellen, existieren kaum Erkenntnisse über die Struktur und Entwicklung der entsprechenden tumorchirurgischen Eingriffe an den mehr als 400 urologisch-chirurgisch tätigen Kliniken in Deutschland. Somit erfassten wir mittels Datenbankabfrage der DRG-Datenbank („diagnosis related groups“) des statistischen Bundesamtes sämtliche Fälle von 5 großen tumorchirurgischen Eingriffen in Deutschland (Prostatektomie, Zystektomie, Nierentumoroperation, retroperitoneale Lymphadenektomie, penischirurgische Eingriffe) von 2006 bis 2013 (bzw. 2016) und untersuchten die Einflüsse von technischen Neuerungen sowie Leitlinienänderungen auf die Entwicklungen der Fallzahlen. Zudem analysierten wir die Zusammenhänge zwischen jährlicher Fallzahl und perioperativem Ergebnis. Die Ergebnisse zeigten eine deutliche Korrelation zwischen Fallzahlvolumen (und damit Expertise) einer Klinik und einem verbesserten perioperativen Ergebnis. Dennoch existiert kaum Tendenz zur Zentralisierung bei diesen uroonkologischen Eingriffen. Die Fallzahlentwicklungen scheinen vielmehr vom Werbeeffekt durch technische Innovationen oder auch vom regionalen Bezug der Patienten zu einer bestimmten Klinik abhängig zu sein. Zentral gesteuerte Versuche mittels Einführung von Mindestfallzahlen oder der freiwilligen Zertifizierung von Zentren hatten in der Vergangenheit nur geringen Einfluss auf die Fallzahlverteilungen.

Experiences, opinions and expectations of health care providers towards an intensive care unit follow-up clinic: Qualitative study and online survey

OBJECTIVES

Independent of the underlying disease, intensive care unit survivors often suffer from cognitive, physical and mental impairments, also known as post-intensive care syndrome (PICS). Specific follow-up services are recommended for these patients. This study aims to capture the perspectives of health care providers on the development of the first intensive care unit follow-up-clinic in Germany.

RESEARCH METHODOLOGY

A qualitative study with six focus groups (n = 41) and six expert interviews, followed by a quantitative survey was conducted, involving nine different professions. Qualitative and quantitative data were analysed using thematic analysis and descriptive statistics, respectively.

FINDINGS

Participants described aftercare of former intensive care unit patients as complex and appreciated the idea of an intensive care unit follow-up clinic to improve continuity of care and multidisciplinary collaboration. The favoured model combined diagnostics and targeted referral of patients to specialists and therapists with the provision of information. In the survey, participants disagreed on how to implement this referral system but agreed that assessments should be multidimensional.

CONCLUSION

The necessity of and important criteria for the design of an intensive care unit follow-up clinic were identified. We will integrate these data with further evidence to develop a concept for a complex intervention.

[Implications for health services research in GP practices using the example of an intervention study on palliative care]

INTRODUCTION

So far there has been little evidence of the extent to which project steps can affect the timing and successful implementation of research projects in general practitioner (GP) practices. Using the example of an intervention study on palliative care, the aim of this article is to report a) how the overall course of the project turned out compared to the original planning, and b) what recommendations can be derived to promote efficient implementation of intervention studies in GP practices.

METHODS

In two workshops each, GP practice teams selected specific measures to improve their palliative care and tested them during a four-month implementation phase. In order to track the progress of the project, the times at which the practice teams reported their participation in the study, the individual project steps and the contacts were documented and descriptively analysed using Microsoft Excel.

RESULTS

Due to a high willingness of practice teams to participate in the intervention study, recruitment was completed on time. The overall duration of the project was extended due to an increased workload for the preparation of an unexpectedly high number of selected measures to improve palliative care.

DISCUSSION

Conducting intervention studies in GP practices is promising if practice teams take an active and co-determining role during the entire research process. Research projects can best be implemented if they involve minimal time commitment for the practice teams, and if continuous personal support from the study team is ensured.

CONCLUSION

When planning future intervention studies with a high participatory share of GP practice teams, it is advisable to take into account potential additional work for the preparation and further development of intervention measures.

[Institutions of evidence-based medicine in Germany : Who is behind it and who does what?]

BACKGROUND

In recent decades, a number of institutions have been established to address the development, application, and dissemination of evidence-based medicine (EBM) in Germany.

OBJECTIVES

The aim of the paper is to give an overview of important EBM institutions in Germany and to determine their tasks and goals.

MATERIALS AND METHODS

Internet research was conducted to identify important German EBM institutions.

RESULTS

EBM institutions in Germany can be divided into institutions of self-administration and independent institutions in the health care system. Common tasks and goals are mainly the improvement of health care, the dissemination of evidence-based knowledge and the further development and teaching of EBM methods.

CONCLUSIONS

Both self-governing institutions and independent institutions have taken up EBM. They ensure that EBM becomes an integral part of everyday medical practice.

STARD Adherence in an Interventional Radiology Guideline for Diagnostic Arteriography

Objective: To assess the quality of reporting in diagnostic accuracy studies (DAS) referenced by the Quality Improvement Guidelines for Diagnostic Arteriography and their adherence to the Standards for Reporting of Diagnostic Accuracy (STARD) statement.Materials and Methods: Citations specific to the Society of Interventional Radiology's Quality Improvement Guidelines for Diagnostic Arteriography were collected. Using the 34-item STARD checklist, two authors in a duplicate and blinded fashion documented the number of items reported per diagnostic accuracy study. Authors met, and any discrepancies were resolved in a resolution meeting.Results: Of the 26 diagnostic accuracy studies included, the mean number of STARD items reported was 17.8 (SD ± 3.1). The median adherence was 18 (IQR, 17-19) items. Ten articles were published prior to 2003, the original date of STARD publication, and 16 articles were published after 2003. The mean number of reported items for the articles published prior to STARD 2003, and after STARD 2003 was 17.4 (SD ± 2.4) and 18.1 (SD ± 3.5), respectively. There were 14 STARD items that demonstrated an adherence of < 25%, and 13 an adherence > 75%.Conclusion: The dichotomous distribution of adherence to the STARD statement by DAS investigated demonstrates that areas of deficient reporting may be present and require attention to ensure complete and transparent reporting in the future.

[Health care reality of urological endoprosthetics in Germany from 2006 to 2016]

Hintergrund

Die Behandlung von Harninkontinenz und erektiler Dysfunktion verbessert die Lebensqualität vieler Patienten. Insbesondere die Endoprothetik mit Sphinkter- und Penisprothesen erzielt hierbei sehr gute Ergebnisse, wenn konservative Therapieoptionen ausgeschöpft sind. Ziel dieser Studie ist eine Darstellung der Entwicklung und aktuellen Versorgungslage der Sphinkter- und Penisprothesenimplantation in Deutschland.

Material und Methoden

Wir führten eine Analyse der Diagnosis-Related-Groups-Abrechnungsdaten in Deutschland im Zeitraum von 2006 bis 2016 durch. Die Versorgungslage im Jahr 2016 beschrieben wir auf Basis der Qualitätsberichtsdaten der deutschen Krankenhäuser.

Ergebnisse

Von 2006 bis 2012 stieg die Zahl der implantierten Sphinkterprothesen in Deutschland von 739 auf 1112 (p < 0,001) und die Zahl der implantierenden Kliniken von 129 auf 206 (p < 0,001). Von 2012 bis 2016 fielen die Fallzahlen auf 980 und die Zahl der Kliniken auf 198. Im Jahr 2016 implantierten 168 (88 %) urologische Kliniken 1–9 Sphinkterprothesen und 23 (12 %) Kliniken ≥ 10 Sphinkterprothesen. Die 10 Top-Kliniken (≥20 Sphinkter) implantierten 34 % (283/839) aller Sphinkter. Von 2006 bis 2013 stieg die Zahl der implantierten Penisprothesen kontinuierlich von 263 auf 503 (p < 0,001) sowie die Zahl der implantierenden Kliniken von 71 auf 107 (p < 0,001). Von 2013 bis 2016 stagnierte die Fallzahl (p = 0,9) und die Zahl der implantierenden Kliniken (p = 0,5). Der Anteil implantierter Penisprothesen im Rahmen von Geschlechtsumwandlungen stieg von 17 % im Jahr 2006 auf 25 % im Jahr 2016 (p = 0,03). Im Jahr 2016 implantierten 83 (85 %) urologische Kliniken 1–6 Penisprothesen und 14 (15 %) Kliniken ≥ 7 Prothesen. Die 7 Top-Kliniken (≥20 Prothesen/Jahr) implantierten 232/448 (52 %) der Prothesen.

Diskussion

Der Versorgungsstand der urologischen Endoprothetik in Deutschland zeigt eine deutliche Zentrenbildung, aber auch eine große Zahl von Kliniken mit geringer Fallzahl. Seit 2012/2013 zeigt sich eine Stagnation der Fallzahlen von Penis- und Sphinkterprothesenimplantationen, die in Zusammenschau mit den Prostatektomiefallzahlen eine Unterversorgung vermuten lässt.

Zusatzmaterial online

Die Online-Version dieses Artikels (10.1007/s00120-021-01444-5) enthält weitere Tabellen zu Fallzahlen von Sphinkterprothesen und Penisprothesenimplantationen. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Validation of the Spanish Wound-QoL Questionnaire

BACKGROUND AND AIMS

The Wound-QoL is a validated and feasible questionnaire for measuring disease-specific health-related quality of life in chronic wounds, originally developed for use in German. The objective of this study was to translate the Wound-QoL for use in clinical care and in clinical trials in Spain and to validate this version.

MATERIALS AND METHODS

Two independent fourth- and back translations of the Wound-QoL from the original German version were conducted, followed by an expert consensus of the resulting versions. After refinement, the final tool was piloted in N=10 patients and then used in the validation study.

RESULTS

A total of 115 patients were recruited. Mean age was 69.5 (SD 14.5) years, 60.0% were female. The Spanish version of Wound-QoL showed high internal consistency (Cronbach's alpha>0.8 in all scales). Factor analysis resulted in the same scales as the original version. There were satisfactory distribution characteristics of the global score and the subscales. Construct validity and convergent validity with other outcomes (generic QoL, healing rate) were satisfactory. The vast majority of patients considered the Wound-QoL a simple and feasible tool. Mean time needed for completing the questionnaire was 5minutes. Overall, 99.1% of the participants found it easy to understand the questions and 94.7% stated that the questionnaire suits the personal situation.

CONCLUSIONS

The Spanish version of the Wound-QoL shows good validity in clinical practice. It can be recommended for use in clinical routine and trials.

Acute neurological care in north-east Germany with telemedicine support (ANNOTeM): protocol of a multi-center, controlled, open-label, two-arm intervention study

Background

Both diagnosis and treatment of neurological emergencies require neurological expertise and are time-sensitive. The lack of fast neurological expertise in regions with underserved infrastructure poses a major barrier for state-of-the-art care of patients with acute neurological diseases and leads to disparity in provision of health care. The main purpose of ANNOTeM (acute neurological care in North East Germany with telemedicine support) is to establish effective and sustainable support structures for evidence based treatments for stroke and other neurological emergencies and to improve outcome for acute neurological diseases in these rural regions.

Methods

A “hub-and-spoke” network structure was implemented connecting three academic neurological centres (“hubs”) and rural hospitals (“spokes”) caring for neurological emergencies. The network structure includes (1) the establishment of a 24/7 telemedicine consultation service, (2) the implementation of standardized operating procedures (SOPs) in the network hospitals, (3) a multiprofessional training scheme, and (4) a quality management program. Data from three major health insurance companies as well as data from the quality management program are being collected and evaluated. Primary outcome is the composite of first time of receiving paid outpatient nursing care, first time of receiving care in a nursing home, or death within 90 days after hospital admission.

Discussion

Beyond stroke only few studies have assessed the effects of telemedically supported networks on diagnosis and outcome of neurological emergencies. ANNOTeM will provide information whether this approach leads to improved outcome. In addition, a health economic analysis will be performed.

Study registration

German Clinical Trials Register DRKS00013067, date of registration: November 16 th, 2017, URL: http://www.drks.de/DRKS00013068

Rare genital malformations in women's health research: sociodemographic, regional, and disease-related characteristics of patients with Mayer-Rokitansky-Küster-Hauser syndrome

BACKGROUND

The Mayer-Rokitansky-Küster-Hauser syndrome, MRKHS, is a rare (orphan) disease characterized by the aplasia or hypoplasia of the uterus and the vagina. In women's health research, little is known as to how much care provision for patients with MRKHS takes into account their socio-demographic together with their clinical characteristics. This work examines the patients' socio-demographic characteristics, highlighting issues of inappropriate and deficient provision of care.

METHODS

The study was carried out as part of the larger TransCareO project and included a group of N=129 MRKHS patients who underwent surgery between 2008 and 2012. Using a specially developed questionnaire, we analyzed MRKHS patients' data found both in the clinical documentation of the Department for Women's Health, University Hospital of Tübingen and the patient surveys of the Center for Rare Genital Malformations (CRGM/ ZSGF). Patients who took part in interviews were compared with non-respondents.

RESULTS

Patient respondents and non-respondents did not differ as to the parameters of interest. In most cases, primary amenorrhea was reported as an admission reason. In 24% of patients, a medical intervention (hymenal incision or hormone treatment) already occurred before admission to the Center in Tübingen and proper diagnosis of MRKHS. About one third received in advance inappropriate treatment. During the therapy, more than half of the patients were in a solid partnership. 10% of the family anamneses documented the occurrence of urogenital malformations.

CONCLUSIONS

Care provision for MRKHS patients is largely characterized by delayed proper diagnosis and in part, by inappropriate treatment attempts; there are also indications of regional differences. Anamnestic clues such as an asymptomatic amenorrhea or renal abnormalities of unclear origin still fail to result early enough in referral to a center on the basis of suspected MRKHS diagnosis. Urogenital malformations in the family are more common in patients than in the general population. For patients, a wide range of burdens are associated with the diagnosis. Abnormalities compared to their female peers occur, for instance, in the partnership status: MRKHS patients have more rarely a partner.

[Even low-acuity patients prefer hospital-based emergency care : A survey of non-urgent patients in an emergency department with unique regional position]

BACKGROUND

Besides increasing numbers of cases in German emergency departments (ED), the spectrum of attending patients is also changing. Patients with acute illnesses tend to prefer EDs to ambulatory care as primary contact point. This study examines the motives for use and use behavior of low-urgent ED-patients.

METHODS

Anonymous patient survey in the ED of Wolfsburg Hospital between 12/2015 and 03/2016 with descriptive analysis. All patients with low urgency (Manchester-Triage-System (MTS), levels blue and green) were eligible.

RESULTS

81.5% of respondents (729 evaluable out of 7000 questionnaires distributed) attended the ED between 8:00 a. m. and 5:00 p. m., 70.1 % of them were walk-in patients. The motive most frequently cited was that they would receive better care in the ED (48.3 %). Contrary to acuity assessment, 67.8 % of respondents considered themselves a medium to life-threatening emergency. As alternative option, 49.2 % would choose a nearby clinic in the region for their complaints.

CONCLUSION

Self-assessed urgency differs with acuity assessment according to MTS. Patients who fear an acute threat to their health do not use services provided in the ambulatory sector such as the emergency practice of the Association of Statutory Health Insurance Physicians in the immediate proximity sufficiently. Previous approaches for patient navigation do not seem to be successful in this setting. Strengthening of EDs as a single 24/7 access point for emergency care with simultaneous abolition of parallel care structures should be discussed.

Rheumatological care in rural areas : The Rheuma-Bus project 2018

OBJECTIVE

To explore the medical care of individuals in rural areas during a public health awareness project on musculoskeletal disorders (MSD).

METHODS

A tour bus was adapted to accommodate rheumatological consultations at widely accessible sites in 16 towns, providing individual medical advice with respect to MSD. The participating rheumatologists assessed the nature (e.g. inflammatory/non inflammatory), extent and duration of MSD and, where possible, made a tentative diagnosis and gave further advice on the course of action. In addition, age, sex and pre-existing care were recorded. All individuals were asked to assess their own severity of pain using a numeric ordinal scale from "no" (0) to "extreme" (10).

RESULTS

A total of 647 individuals visited the service. Median current pain intensity was 5 (interquartile range [IQR] 3-6), mean 4.9 (standard deviation [SD] 2.3). Osteoarthritis was suspected in 381 clients (59.6%), inflammatory rheumatic disease in 247 (38.7%), and in 104 (16.3%) other diseases. 307 (50%) were treated by a GP, 95 (15.5%) were under orthopaedic care, 204 (33.2%) under rheumatological care and 81 (13.1%) under supervision of other specialists. 104 clients (17%) had never consulted a physician for their MSD symptoms before. 27 (4.2%) of all the clients had a newly detected inflammatory rheumatic disease and 62 (9.6%) patients with suspected inflammatory rheumatic disease were not under previous rheumatological care.

CONCLUSION

The findings showed that there is still a lot of negligence in awareness and knowledge of rheumatic diseases, at least in rural areas.

Caring for frail older patients in the last phase of life : Challenges for general practitioners in the integration of geriatric and palliative care

BACKGROUND

The best possible care for frail older patients at the end of life can require the integration of geriatric and palliative approaches, possibly with different accentuations at different times. General practitioners (GP) are particularly important in this context: they provide patients with low-threshold primary care close to their homes and provide both general palliative care and geriatric services.

OBJECTIVE

What are the challenges for GPs in caring for frail older patients at the end of their lives?

MATERIAL AND METHODS

A secondary data analysis of 52 qualitative interviews was carried out, which were serially obtained at 4 points in time over a period of 18 months with 14 family doctors. In addition, one focus group with five GPs took place. The analysis was carried out according to the principles of grounded theory.

RESULTS

The results show that GPs see the care of frail older patients at the end of their lives through a) the growing number of older people, b) multimorbidity and complexity of the problem areas, c) the integration of geriatric and palliative approaches, d) the high average age of general practitioners and the lack of junior staff and e) the problem of ensuring care in rural areas as a major challenge. The practical transition between geriatric and palliative care is considered by GPs to be fluid and there is a desire for more integration of both disciplines.

CONCLUSION

In this study GPs perceived a large overlap between geriatric and palliative care. Both approaches should be offered for a selection of patients as a combined service. In the future a systematic network between GPs and geriatricians in practices, clinics, and day clinics will be necessary.

[Teledermatology for emergency patient care : Two-year experience with teledermatological emergency care]

BACKGROUND

Internationally telemedicine has become an important element of health care. Up to now it plays, however, a minor role in the German health care system. Taking skin diseases as an example we examined over a 2‑year period whether teledermatology is appropriate to care for patients presenting to the emergency department (ED) with symptomatic skin diseases.

METHODS

During 2016 and 2017, 190 patients aged between 18 and 88 years with skin diseases who presented to the ED of the University Medicine Greifswald (UMG) were cared for by a core team consisting of surgeons who were supported by the on-call dermatologist of the UMG via teledermatology (mSkin Doctor®, InfoKom, Neubrandeburg, Germany). Patients presented nearly exclusively outside the regular working hours: 59% on weekends and public holidays, 39% after 4 p.m. on working days. Furthermore, 33% of patients came from rural areas (<10,000 inhabitants), 41% from regional centres or mid-sized centres. Patients travelled 23 km (median) from their homes to the emergency department.

RESULTS

In all, 59 of the 190 patients immediately assessed the teledermatology-based care they received in the emergency department: 76% of the patients felt that they had received adequate care, 81% trusted the medical decisions. The teledermatologically based care outside normal working hours was deemed appropriate by 68% of the patients; 32% of the patients, however, wanted the dermatologist to be present at any time at day and night.

CONCLUSION

Patients with skin diseases were cared for safely by the core team of the ED which was supported by the on-call dermatologist via teledermatology. The use of teledermatology within the context of emergency-based care has gained a high degree of patients' acceptance and confidence.

[Urolithiasis research-big data and artificial intelligence : How we can use the new structures of the medical informatics initiative of the Federal Ministry of Education and Research]

BACKGROUND

The digital transformation of society has a tremendous impact on both medicine and healthcare. The generation and processing of continuously growing amounts of digital data can be used to facilitate new approaches in research, particularly for healthcare research of common diseases such as urolithiasis.

OBJECTIVE

Presentation of the design of the German medical informatics initiative (MI-I) and the resulting possibilities for healthcare research in the field of urolithiasis.

RESULTS

For a meaningful utilization patient data must be readily available for research purposes and suitable methods for the analysis, interpretation and utilization must be developed. The aim of the German MI‑I is to make patient data collected during hospitalization available for research. The formation of so-called data integration centers will create a digital network that will facilitate the utilization and exchange of data between institutions. Advanced artificial intelligence algorithms will be used for analysis of the immense amounts of data. In May 2019 the German Federal Ministry of Education and Research boosted funding for the set-up of a digital nationwide registry on urolithiasis where the data foundation is to be generated based on the digital infrastructure of the MI‑I. The registry is intended to answer questions from the three relevant areas: "impact of the disease on individuals and society" (e.g. limitations in the quality of life and ability to work, treatment costs), "identification of further risk factors" (e.g. personalized medicine, especially taking account of lifestyle and nutrition, development of a risk score) and "evaluation of various treatment approaches" (which is the best treatment for an individual patient?).

[Treatment reality with ranibizumab in clinical routine use for patients with diabetic macular edema : 1‑year results of the German POLARIS cohort]

BACKGROUND

Currently only few data are available on the treatment reality with ranibizumab in patients with diabetic macular edema (DME).

MATERIAL AND METHODS

POLARIS is an international observational study which included 983 patients who were treated with ranibizumab due to DME. The primary objective of the study was to investigate the influence of treatment and control intervals as well as resource utilization on the mean change in visual acuity. Secondary endpoints included the collation of disease activity monitoring in the clinical practice. This article describes the results of the German POLARIS population. The study was conducted in 8 European countries from October 2012 to January 2015.

RESULTS

In Germany 220 patients were included in the study. Visual acuity improved by 4.3 letters within the first 3 months of treatment. At 12 months, visual acuity increased on average by 4.1 (SD ± 12.4) letters (approximately 1 line) for 168 patients enrolled in the efficacy analysis. Patients received an average of 4.5 (SD ± 1.9) injections, 10.3 (SD ± 6.3) visual acuity tests and 3.3 (SD ± 3.1) optical coherence tomography (OCT) examinations during the first year. Patients with ≤3 injections showed an average improvement in visual acuity by 2.7 letters which was less improvement compared to patients with >3 injections, who achieved an average improvement of 5.4 letters. There was a correlation between the number of injections and the visual acuity achieved.

DISCUSSION

For Germany, the results of the POLARIS study indicate that despite a high number of visits, patients with DME are undertreated in clinical routine practice. The injection frequency in Germany was lower than in randomized clinical trials. Almost half of the patients received less than 4 injections in the first year of treatment and thus showed an undertreatment compared to the recommendations of German and international medical societies.

[Registry-based research in ophthalmology]

Medical registries and registry studies are frequently used for health services research as they represent a valuable means of capturing real-life data. Registry studies are particularly suitable for rare diseases for which epidemiological population-based or randomized controlled clinical studies are difficult. The are many examples of successful medical registries that have not only contributed to both epidemiological and clinical research, but which have also improved health service delivery. Only few ophthalmological medical registries are currently available. For non-infectious uveitis in children and adolescents with juvenile idiopathic arthritis (JIA), a rare disease entity, there is a need for data on, e.g., treatment, long-term outcomes, and risk factors for progression. The advantages for this disease of a registry with uveitis module from which numerous scientific publications and guidelines have been derived has been proven. Thus, we use the example of non-infectious uveitis to discuss the benefits of registries for other areas of ophthalmology.

LearnOvation: an intervention to foster exploration and exploitation behaviour in health care management in daily practice

Background

Innovation has been identified as an important engine for improving the quality, productivity and efficiency of health care. Little is known about how to stimulate innovation capacity in primary health care in general; even less is known about how specific interventions should be designed to support managements’ work with practice-based innovations. Research has shown that if managers and teams are excellent at handling the challenges of production (exploitation) and development (exploration), they are better at innovation. The aim of the study is to develop a dynamic management support programme to increase innovation leadership skills in daily practice.

Methods

The study has an interactive approach that allows the need for empirical and theoretical knowledge to emerge and merge, and a quasi-experimental cross-over design. Eight primary health care centres will participate in the study. In the first phase, the management teams at four health care centres will participate in the intervention, and the other four centres will serve as a control group. Thereafter, the units will switch places and the control group will experience the intervention. All staff at the 8 units will answer questionnaires at four points in time (before, during, after, 6 months later) to evaluate the effects of the intervention.

Discussion

The study will contribute to knowledge on how to organize processes of innovation and support exploitation and exploration behaviours by co-producing and testing a tailor-made management support programme for innovation work in primary health care. An expected long-term effect is that the support system will be disseminated to other centres both within and beyond the participating organizations.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4152-8) contains supplementary material, which is available to authorized users.

[German congress for healthcare research : Solutions and innovations for German health policy in the new legislative period]

The German congress for healthcare research reached a new historic record of 859 participants from healthcare research, practice, and policy who visited the congress from 4-6 October 2017 to discuss developments, results, and innovations in healthcare research.The German healthcare system will face key challenges over the coming years. As the German population is getting older and disease incidence will become more complex, the number of healthcare professionals will simultaneously decrease.The experts provided solutions and innovations in 322 lectures and in 239 poster presentations.Hot topics included innovative and cross-sectoral healthcare concepts, patient safety, new forms of division of labor, telemedicine, eHealth as well as projects of the innovation fund and the Federal Ministry for Education and Research.Healthcare experts state that healthcare research is a key partner of patients, health policy, and self-government. The experts declare that future healthcare should be regional, cross-sectoral, and should include all healthcare professions. They formulate several demands on health policy for the new legislative period.

The utilization of multidisciplinary tumor boards (MDT) in clinical routine: results of a health care research study focusing on patients with metastasized colorectal cancer

PURPOSE

Multidisciplinary tumor boards (MDT) have been advocated as standard of care in modern oncology. German guidelines for metastasized colorectal cancer (mCRC) recommend MDT discussion of colon cancer patients after completion of primary tumor therapy but stage IV colon cancer as well as rectal cancer patients prior to any therapy. In this health care research study, we evaluated application and decisional consequences of this approach in clinical routine.

METHODS

All major institutions providing oncological care in southern Lower Saxony and Northern Hesse (N = 11) were invited. Patients with mCRC diagnosed between 01/2011 and 12/2013 were eligible. Data were collected using a standardized patient report form and stored in a GCP-conform EDC-system (secuTrial®).

RESULTS

A university medical center, four teaching hospitals, one communal hospital, and three oncological focus practices participated in the study. In total, 470 patients with a median age of 70 years were enrolled. Guideline conform MDT discussion was performed in 63% of operated colon cancer patients, 38% of stage IV colon cancer patients and 47% of rectal cancer patients, respectively. Resection of metastases was performed in 41% of cases. Patients ≥70 years (n = 250) received significantly more often treatment following MDT discussion (86 versus 64%, p = 0.0002). Not the resection rate (48 versus 57%, p = 0.1574) but indication for preoperative chemotherapy (57 versus 33%, p = 0.0056) significantly differed when patients with single organ metastases experienced MDT discussion.

CONCLUSIONS

MDT discussion is not as established as advocated by national guidelines. Treatment decisions differ especially in older patients and those with single organ metastases.

[Questionnaire for the utilization of the Emergency Department : Implications for the patient survey]

BACKGROUND

For several years, Emergency Departments (ED) in Germany have observed increasing patient numbers, resulting in ED crowding. This leads to the question of whether patients with nonurgent conditions could also receive adequate treatment in primary care. Our objective was to develop a quantitative questionnaire to investigate in a larger patient group the reasons for this and to describe the implications for a patient survey in the ED.

METHODS

The development of the questionnaire was based on a literature search and the results of the qualitative EPICS-2 study. Two pretest surveys were conducted in three EDs at the Charité - Universitätsmedizin Berlin. We included patients aged ≥ 18 years with outpatient treatment and the categories blue (nonurgent), green (standard), or yellow (urgent) according to the Manchester Triage System (MTS).

RESULTS

In total, 189 patients were recruited in two surveys (pretest 1: n = 89, pretest 2 n = 100). The final questionnaire includes 24 items, which were evaluated and adapted during both pretests. The items evaluate basic clinical characteristics, reasons for choosing the ED, prior contacts in primary care, utilization of primary care after-hours services as well as sociodemographic characteristics. Data from the hospital information system were used to link the survey data with clinical characteristics.

CONCLUSIONS

The questionnaire is based on reasons for ED utilization. We recommend the written, self-applied questionnaire for patient surveys with plausibility checks conducted by staff. It is necessary to consider the heterogenic study surroundings in the ED, which requires a lot of flexibility during data collection.

Factors associated with general practitioners' awareness of depression in primary care patients with heart failure: baseline-results from the observational RECODE-HF study

Background

Depression is more prevalent in patients with heart failure (HF) than in those without, but its detection is complicated by the symptom overlap between the two diseases. General practitioners (GPs) are the first point of contact for patients with HF. Therefore, this study aims to investigate GPs’ awareness of depression in their HF patients and factors associated with this awareness.

Methods

In this cross-sectional, observational study 3224 primary care patients with HF were screened for depressive symptomatology using an algorithm based on the Hospital Anxiety and Depression Scale, the 9-item subscale on Depression of the Patient Health Questionnaire, and selected items from the PROMIS Depression and Anxiety scales. The 272 GPs of all patients involved in the study were interviewed by telephone regarding their patients’ somatic and psychological comorbidities. The awareness rates of depressive symptomatology by the patients’ GPs are analyzed using descriptive statistics. Logistic regression analyses are applied to investigate the patient- and GP-based factors associated with the GPs’ awareness of depressive symptomatology.

Results

GPs were aware of their patients’ depressive symptomatology in 35% of all cases. Factors associated with the awareness of depressive symptomatology were: higher patient education levels, a history of depression known to the GP, GP-consultations due to emotional distress within the last 6 months, a higher frequency of GP-contacts within the last 6 months, a higher New York Heart Association (NYHA) classification and more severe depressive symptomatology. The GPs’ characteristics, including further education in psychology/psychiatry, were not associated with GP awareness.

Conclusions

Many aspects, including the definition of awareness and the practical issues in primary care, may contribute to the unexpectedly low awareness rates of depressive symptomatology in HF patients in primary care. Awareness rates might increase, if GPs encouraged their patients to talk about emotional distress, held detailed medical interviews including a patient’s history of depression and payed special attention to HF patients with low education levels. However, it remains to be investigated whether GPs’ judgement of depressive symptomatology is a better or worse indicator for the future prognosis and quality of life of HF patients than psychiatry based diagnostic criteria.

[Standardized collection of presenting complaints in the emergency room : Integration of coded presenting complaints into the electronic medical record system of an emergency department and their value for health care research]

BACKGROUND

The point of entry of a patient in emergency care is a symptom or a complaint. To evaluate subsequent processes in an emergency department until a diagnosis is made, this information has to be taken into account.

OBJECTIVES

We report the introduction of coded presenting complaints into the electronic medical record system of an emergency department and describe the patients based on these data.

METHODS

The CEDIS presenting complaint list was integrated into the emergency department information system of an emergency department (38,000 patients/year). After 8 months, we performed an exploratory analysis of the most common presenting complaints. Furthermore, we identified the most frequent diagnoses for presenting complaint "shortness of breath" and the most frequent presenting complaints for the diagnosis of sepsis.

RESULTS

After implementing the presenting complaint list, a presenting complaint code was assigned to each patient. In our sample (26,330 cases), "extremity pain and injury" comprised the largest group of patients (29.5%). "Chest pain-cardiac features" (3.7%) and "extremity weakness/symptoms of cerebrovascular accident" (2.4%) were the main cardiac and neurologic complaints, respectively. They were mostly triaged as urgent (>80%) and hospitalized in critical care units (>50%). The main diagnosis for presenting complaint "shortness of breath" was heart failure (25.1%), while the main presenting complaint for the diagnosis sepsis was "shortness of breath" (18.1%).

CONCLUSIONS

Containing 171 presenting complaints, this classification was implemented successfully without providing extensive staff training. The documentation of coded presenting complaints enables symptom-based analysis of the health care provided in emergency departments.

Characteristics of adolescents frequently restrained in acute psychiatric units in Norway: a nationwide study

BACKGROUND

The use of restraints in adolescent psychiatric settings requires particular professional, ethical, and legal considerations. The purpose of this study was to investigate whether the number of restraint episodes per patient was related to any of several characteristics of the adolescents.

METHODS

In this nationwide study, we included all adolescents restrained during the period 2008-2010 (N = 267) in Norwegian adolescent acute psychiatric inpatient units. They constitute 6.5% of the adolescents hospitalized in these units in the same period of time. We collected data on the number of restraint episodes they experienced during the study period; Poisson regression was then used to analyze the impact of gender, social, mental health, and treatment characteristics on the frequency of restraint. We developed a risk index for the likelihood of experiencing multiple restraint episodes.

RESULTS

We found a skewed distribution of restraint episodes in which a small group (18%) of restrained adolescents experienced a majority (77%) of the restraint episodes. A large percentage of the restrained adolescents (36%) experienced only one restraint episode. Risk factors for multiple restraint episodes were female gender, lower psychosocial functioning (Children's Global Assessment Scale below 35), more and longer admissions, and concomitant use of pharmacological restraint. Except for gender, we used these variables to develop a risk index that was moderately associated with multiple restraint episodes.

CONCLUSIONS

As a small group of patients accounted for a large percentage of the restraint episodes, future research should further investigate the reasons for and consequences of multiple restraint episodes in patients at acute adolescent psychiatric units, and evaluate preventive approaches targeted to reduce their risk for experiencing restraint.

Improving patient flow of people with rheumatoid arthritis has the potential to simultaneously improve health outcomes and reduce direct costs

Background

In our current economic climate of scarce resources there is a lot of debate around the best - and most efficient - way of delivering care, which points patients towards the right physician at the earliest opportunity.

The aim of the study was to assess whether an improvement in the interdisciplinary management of rheumatoid arthritis (RA) has the potential to simultaneously improve health outcomes and reduce costs.

Methods

In a first step, we modelled the ways which lead patients with RA to the correct diagnosis, and the relevant specialist, respectively. On average, a patient experiences 3 GP visits before referral to a specialist. We compared this situation against a reconfiguration of current practice towards a more proactive identification and referral method with initiation of care by a rheumatologist early in the disease. We evaluated the impact of this reconfiguration on the number of RA patients diagnosed and the costs associated with the diagnostic process.

Result

Using data on epidemiology and Austrian practice patterns, we estimate a total of 5294 people with undifferentiated arthritis per year, of which 1765 suffer from RA. Modelling for diagnostic accuracy, we found that 1200 of these patients are initially misdiagnosed in a primary care setting and 95 at a rheumatologist. Our model found that a reconfiguration of current practice towards an approach of more integrated care has the potential to be not only cost-effective, but cost-saving: EUR 100,188 could be saved annually by exclusively adopting the new approach.

Conclusions

Our results show that by better directing the flow of people with RA, simultaneous clinical and economic benefits may be reaped:.

Effectiveness and efficiency of an 11-week exercise intervention for patients with hip or knee osteoarthritis: a protocol for a controlled study in the context of health services research

BACKGROUND

Osteoarthritis is the most common reason for pain in older adults, and the individual and economic burden of this disease is immense. The chronic character of osteoarthritis requires a long-term therapeutic treatment. In this regard life-style interventions such as physical exercises that can be carried out by the patient himself are recommended as first line treatment. There is evidence for the short-term benefit of exercise therapy in terms of pain reduction and physical functioning. Nonetheless research agendas highlight the need for multifaceted interventions that incorporate exercise strategies into patient care. Studies should be conducted with appropriate sample sizes and should allow statements on long-term effects as well as cost-utility and safety. These open questions are under the scope of this study.

METHODS/DESIGN

This is a controlled study in the context of health services research. The study population consists of n = 1400 subjects with hip or knee osteoarthritis. The intervention group will be recruited from participants of a country-wide health insurance offer for people with hip or knee osteoarthritis. Potential participants for the control group (ratio 10:1 (control vs. intervention) will be filtered out from the insurance data base according to pre-defined matching criteria and asked by letter for their participation. The final statistical twins from the responders (1:1) will be determined via propensity score matching. The progressive training intervention comprises 8 supervised group sessions, supplemented by home exercises (2/week over 11 weeks). Exercises include mobilization, strengthening and training of postural control. Primary outcomes are pain and function measured with the WOMAC Index immediately after the intervention period. Among other things, health related quality of life, self-efficacy, cost utility and safety will be evaluated as secondary outcomes. Participants will be followed up 6, 12 and 24 month after baseline.

DISCUSSION

Results of this trial will document the effects of clinical as well as economic outcomes in a regular health care setting on the basis of a large sample size. As such, results of this trial might have great impact on future implementations of group- and home-based exercises in hip or knee osteoarthritis.

TRAIL REGISTRATION

German Clinical Trial Register DRKS00009251 . Registered 10 September 2015.

[Users of regional dementia care networks in Germany : First results of the evaluation study DemNet-D]

BACKGROUND

In Germany a growing number of community-based support services for people with dementia (PwD) and their caregivers are organized in dementia care networks (DCN), which provide a single point of entry to social facilities and offer personal care and support.

OBJECTIVE

The aim of this study was to describe the health, functional and social characteristics of PwDs enrolled in DCNs throughout Germany because no data are currently available on this aspect.

MATERIAL AND METHODS

As part of the multi-center, multi-professional 12-month follow-up study DemNet-D, data on functional and psychological health, sociodemographic and dementia-specific factors and social inclusion were collected in standardized interviews with PwDs living at home.

RESULTS

A total of 560 PwDs with an average age of 80 years were enrolled in the study. Of the participants approximately 50 % had Alzheimer's dementia and more than 75 % demonstrated at least a challenging form of behavior. More than half of the participants lived together with a partner or relative. Instrumental activities of daily living (IADLs) were very limited; nevertheless, one in five PwDs showed no long-term care-dependency level. The participants reported having a relatively low feeling of loneliness and a high feeling of social inclusion, depending on the severity of dementia.

CONCLUSION

This is one of the very first studies generating data on PwDs who receive domiciliary care within DCNs in Germany. The results suggest that the regional DCNs make a successful contribution to overcoming the interface problem and can, therefore, contribute to a more stable care situation and better social integration of PwDs.

Diabetes outcomes within integrated healthcare management programs

AIM

The aim of this observational study was to assess mortality of patients with type 2 diabetes by type of healthcare delivery system, i.e. through specialist centers or generalist doctors, or integrated care.

METHODS

The study was conducted at the "Vicentino Ovest" Local Health District in the Veneto Region (north-eastern Italy) from January 1, 2008 to December 31, 2010. Patients with diabetes (≥ 20 years old) were identified using different public health databases. They were grouped as: patients followed up by specialists at diabetes clinics (DS); patients seen only by their own general practitioner (GP); and patients receiving integrated care (DS-GP). Cox's regression analysis was used to estimate adjusted hazard ratios for available potential predictors of death by level of care.

RESULTS

The crude mortality rate was highest in the GP group (26.1 per 1000 person-years), the difference being minimal when compared with the DS group (21.7 per 1000 person-years) and more marked when compared with the DS-GP group (8.8 per 1000 person-years). Patients followed up by their GPs had a 2.7 adjusted RR for mortality by comparison with the DS-GP group.

CONCLUSIONS

The findings of the present study could demonstrate that it is safe and cost-effective, after a first specialist assessment at a diabetes service, for low-risk diabetic patients to be managed by family physicians as part of a coordinated care approach, based on the specialist's clinical recommendations; GPs can subsequently refer patients to a specialist whenever warranted by their clinical condition.