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Quality indicators to assess the quality of primary care have only been applied on a national or regional level in European countries, and there have been no comparisons between regions of different countries. In the interventional pre-post-study "Improvement of Quality by Benchmarking - IQuaB" (level of evidence: 3), we aimed to improve and compare quality of process care in 57 participating general practices in Salzburg, Austria, and South Tyrol, Italy.The intervention consisted of self-audit, benchmarking and quality circles. Quality indicators for eight common chronic diseases (e. g., diabetes) were extracted from the electronic health records in 2012, 2013 and 2014. Based on 19 quality indicators, a supra-regional quality score was calculated and compared using Mann-Whitney U tests.A relatively weak baseline performance was identified in both regions. In all three assessments, the median quality score increased in both regions and was significantly higher in South Tyrol than in Salzburg. During the study period the median supra-regional quality score increased from 20.00 to 38.00 in the Salzburg sample and from 47.00 to 79.50 in the South Tyrolian sample. The differences between the two regions were significant at baseline and after intervention (2012: p=0.015, 2014: p=0.001).Despite data extraction challenges in Austria, we are convinced that our data highlight real differences in (processual) quality of care between the two regions.The reasons underlying the persisting differences between the two regions may include: (1) different functions in electronic health records, (2) benchmarking as an integral part of the electronic health record, (3) gate-keeping system and use of registration lists, (4) state-supported quality initiatives.

Objective Due to the increasing concerns about polypharmacy, there is a growing need for clinical recommendations for drug discontinuation. This requires studies investigating the process on several levels. This paper addresses the methodological problems of drug discontinuation trials (DDTs). To that end, we offer a new typology of research aims and corresponding methodological recommendations for trials evaluating drug discontinuation. Study Design and Setting Multi-stage development process, including literature search and expert panels. Results Clinical trials are only required in cases of scientific uncertainty. We identified three situations of uncertainty associated with drug discontinuation from which we derived three study types: 1) Uncertainty regarding the effectiveness and/or safety of a drug; 2) Uncertainty regarding the procedure of discontinuing a previously taken drug; 3) Uncertainty regarding the effectiveness of complex strategies used to discontinue one or more drugs. We developed specific methodological recommendations for each study type. Conclusion We offer a comprehensive definition of research aims, study designs, and methodological recommendations regarding DDTs. The typology we propose can help investigators clarify their research aims and study design. The type-specific methodological recommendation should improve the quality of future drug discontinuation trials.

Zusammenfassung Hintergrund Ziel dieser Arbeit ist die exemplarische methodische Uberprufung der Qualitat eingeschlossener Studien zur medikamentosen Therapie alterer Menschen anhand einer publizierten Reihe von sechs systematischen Reviews (SRs). Diese sechs SRs inkludierten 48 systematische Ubersichtsarbeiten, 65 Interventions- und 33 Beobachtungsstudien. Die Reihe der SRs wurde im Rahmen des PRIMA-eDS-Projekts ( www.prima-eds.eu ) erstellt, um Empfehlungen zur Behandlung von alteren Menschen mit Polypharmazie zu entwickeln. Methode Wir gehen mit dieser Qualitatsanalyse der Frage nach, inwieweit sich Empfehlungen zur medikamentosen Behandlung alterer Menschen auf belastbare Studienevidenz grunden. Hierzu erfolgte eine Qualitatsbewertung aller eingeschlossenen Studien mittels AMSTAR fur systematische Ubersichtsarbeiten, CASP fur Beobachtungsstudien und dem Cochrane „Risk of Bias“-Tool fur Interventionsstudien. Ergebnisse Die Evidenzbasis fur haufig verschriebene Medikamente bei alteren Menschen ist schwach. Die in der Reihe von SRs identifizierten Publikationen offenbarten sowohl einen deutlichen Mangel an hochwertigen Studien hinsichtlich der Zielpopulation als auch einen Mangel an Studienqualitat. Unter den 33 Beobachtungsstudien blieb bei fast der Halfte aller Veroffentlichungen unklar, ob das Follow-up ausreichend lang und vollstandig war. Bei einem Drittel passten die Schlussfolgerungen nicht zur beobachteten Evidenz. Das groste Verzerrungsrisiko der Interventionsstudien fand sich bei der korrekten Gruppenzuteilung und der korrekten Verblindung. Qualitatsmangel der systematischen Ubersichtsarbeiten bestanden hinsichtlich der Bereitstellung einer vollstandigen Studienliste und der fehlenden Berucksichtigung eines moglichen Publikationsbias. Diskussion Insgesamt zeigten sich viele methodische Mangel, wodurch die Ableitung belastbarer Empfehlungen erschwert oder fast unmoglich gemacht wurde. Schlussfolgerung Unsere Arbeit verdeutlich zum einen den immensen Forschungsbedarf in der Behandlung alterer und hochbetagter Patientinnen und Patienten und zum anderen die Wichtigkeit, sowohl bei der Durchfuhrung von Primarstudien als auch bei der Erstellung systematischer Ubersichtsarbeiten auf hochste Qualitatsstandards zu achten.

Purpose It has been shown that morbidity and mortality, associated with falls in older persons, can be reduced by physical activity. Many previous programs for prevention of falls were too demanding to be implemented. We aimed to test the feasibility and acceptability of a program of regular lay people, assisted outdoor walking for nursing home residents including a possible impact on the prevention of falls. Patients and methods We included five nursing homes; whereof three were assigned for the intervention and two for the control group. Inclusion criteria were age above 65 years and increased risk of falls. The intervention group (n = 32) benefited from regular assisted outdoor walking, the control group (n = 20) did not practice physical activities. We evaluated participants at the start of the study (T0) and after 6 months (T1) for history of falls, physical and cognitive impairment. In addition, we performed qualitative interviews with nursing home managers. Results The program was evaluated positively by the participating nursing homes. Half of the participants reported an improvement in their general condition, general mood and walking ability. There was a slight intervention effect on depressive symptoms, but no differences between intervention and control group in the proportion of falls, in regard to risk of falls and functional status (daily activities). Conclusions This study shows the feasibility of implementing a simple program of outdoor walking for older people in nursing homes. A sufficiently powered randomized controlled trial is necessary to prove the effectiveness and safety of our approach.

Objective To assess the feasibility and outcome of measuring the theory of planned behaviour (TPB) in patients receiving routine counselling versus counselling with a decision aid (DA) during primary care consultation on cardiovascular risk prevention. Methods A DA was developed, based on models of shared decision-making (SDM) and the TPB. We evaluated the impact of the intervention in a randomized controlled trial. Main outcomes were previously reported. To assess the intermediate social cognitive processes and our theoretical framework, we evaluated the impact of the intervention on a TPB scale. Results The TPB scale showed satisfactory measurement properties. Factor analysis (main component analysis, confirmatory model) could mostly replicate the assumptions of the model. 44% of variance of the behavioural intention to adhere to the decision after counselling was explained in linear regression models. Of the TPB components, only attitude towards the decision and moral norm were significantly more positive in the intervention. No difference was found with regard to intention to adhere to the decision. High risk resulted in higher values of the TPB components in both groups. Conclusion Most DAs are developed and tested without explicitly referring to a theoretical model of psychosocial processes. The TPB may serve as a useful theoretical framework. Practice Implications Trials on DAs demonstrate positive effects on psychological outcomes of patients without leading to better objective health results. Our study might contribute to an explanation: DAs might not cause stronger adherence to decisions even though one's attitude towards the decision becomes more positive.