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Objectives The aims of our study were to describe the effect of the COVID-19 pandemic and lockdown on primary care in Germany regarding the number of consultations, the prevalence of specific reasons for consultation presented by the patients, and the frequency of specific services performed by the GP. Methods We conducted a longitudinal observational study based on standardised GP interviews in a quota sampling design comparing the time before the COVID-19 pandemic (12 June 2015 to 27 April 2017) with the time during lockdown (21 April to 14 July 2020). The sample included GPs in urban and rural areas 120 km around Hamburg, Germany, and was stratified by region type and administrative districts. Differences in the consultation numbers were analysed by multivariate linear regressions in mixed models adjusted for random effects on the levels of the administrative districts and GP practices. Results One hundred ten GPs participated in the follow-up, corresponding to 52.1% of the baseline. Primary care practices in 32 of the 37 selected administrative districts (86.5%) could be represented in both assessments. At baseline, GPs reported 199.6 ± 96.9 consultations per week, which was significantly reduced during COVID-19 lockdown by 49.0% to 101.8 ± 67.6 consultations per week (p p Conclusions We observed a dramatic reduction of the number of consultations in primary care. This effect was independent of age, sex and specialty of the GP and independent of the practice location in urban or rural areas. Consultations for complaints like low back pain, gastrointestinal complaints, vertigo or fatigue and services like house calls/calls at nursing homes, wound treatments, pain therapy or screening examinations for the early detection of chronic diseases were particularly affected.

Background In most countries, the general practitioner (GP) is the first point of contact in the healthcare system and coordinator of healthcare. However, in Germany it is possible to consult an outpatient specialist even without referral. Coordination by a GP might thus reduce health expenditures and inequalities in the healthcare system. The study describes the patients’ willingness/commitment to use the GP as coordinator of healthcare and identifies regional and patient-related factors associated with the aforementioned commitment to the GP. Methods Cross-sectional observational study using a standardised telephone patient survey in northern Germany. All counties and independent cities within a radius of 120 km around Hamburg were divided into three regional categories (urban areas, environs, rural areas) and stratified proportionally to the population size. Patients who had consulted the GP within the previous three months, and had been patients of the practice for at least three years were randomly selected from medical records of primary care practices in these districts and recruited for the study. Multivariate linear regression models adjusted for random effects at the level of federal states, administrative districts and practices were used as statistical analysis methods. Results Eight hundred eleven patients (25.1%) from 186 practices and 34 administrative districts were interviewed. The patient commitment to a GP attained an average of 20 out of 24 possible points. Significant differences were found by sex (male vs. female: + 1.14 points, p p = 0.043), education (high vs. low: − 1.74, p p = 0.004), regional category (urban areas: − 0.85, p = 0.022; environs: − 0.80, p = 0.045) and healthcare utilisation (each GP contact: + 0.30, p p = 0.018). Professional situation and age were not significantly associated with the GP commitment. Conclusion On average, the patients’ commitment to their GP was relatively strong, but there were large differences between patient groups. An increase in the patient commitment to the GP could be achieved through better patient information and targeted interventions, e.g. to women or patients from regions of higher urban density. Trial registration The study was registered in ClinicalTrials.gov (NCT02558322).

BackgroundPrevalence of people with multimorbidity rises. Multimorbidity constitutes a challenge to the healthcare system, and treatment of patients with multimorbidity is prone to high-quality variations. Currently, no set of quality indicators (QIs) exists to assess quality of care, let alone incorporating the patient perspective. We therefore aim to identify aspects of quality of care relevant to the patients’ perspective and match them to a literature-based set of QIs.MethodsWe conducted eight focus groups with patients with multimorbidity and three focus groups with patients’ relatives using a semistructured guide. Data were analysed using Kuckartz’s qualitative content analysis. We derived deductive categories from the literature, added inductive categories (new quality aspects) and translated them into QI.ResultsWe created four new QIs based on the quality aspects relevant to patients/relatives. Two QIs (patient education/self-management, regular updates of medication plans) were consented by an expert panel, while two others were not (periodical check-ups, general practitioner-coordinated care). Half of the literature-based QIs, for example, assessment of biopsychosocial support needs, were supported by participants’ accounts, while more technical domains regarding assessment and treatment regimens were not addressed in the focus groups.ConclusionWe show that focus groups with patients and relatives adding relevant aspects in QI development should be incorporated by default in QI development processes and constitute a reasonable addition to traditional QI development. Our QI set constitutes a framework for assessing the quality of care in the German healthcare system. It will facilitate implementation of treatment standards and increase the use of existing guidelines, hereby helping to reduce overuse, underuse and misuse of healthcare resources in the treatment of patients with multimorbidity.Trial registration numberGerman clinical trials registry (DRKS00015718), Pre-Results.

Background Low health literacy is believed to be associated with behaviours that increase the risk of type 2 diabetes. But there is limited knowledge on the relation between health literacy (HL) and diabetes risk, and whether improving HL could be a potential prevention strategy. Therefore, the main purpose of this study was to examine the link between HL and diabetes risk among non-diabetic adults. Methods We used data from the Hamburg Diabetes Prevention Survey, a population-based cross-sectional study in Germany. One thousand, two hundred and fifty-five non-diabetic subjects aged 18–60 years were eligible. The German Diabetes Risk Score (GDRS, ranging 0 to 123 points) was used to determine the individual risk of type 2 diabetes. The short version of the European Health Literacy Questionnaire (HLS-EU-Q16, ranging 0 to 16 points) was applied to assess the individual self-reported HL. Subjects were asked to self-estimate their diabetes risk, which was then compared with the calculated GDRS. Descriptive statistics were calculated to investigate group differences in the GDRS and self-estimated diabetes risk. Linear as well as logistic regression models were performed to analyse potential influencing variables of the GDRS as well as incorrect self-estimated diabetes risk. In three nested statistical models for each outcome, these analyses were adjusted for age, gender, educational level and the presence of chronic conditions. Results According to the criteria of the GDRS, 996 (79.4%) subjects showed “low risk”, 176 (14.0%) “still low risk”, 53 (4.2%) “elevated risk”, and 30 (2.4%) “high to very high risk” to develop type 2 diabetes within the next 5 years. In the statistical models including all control variables, subjects with “inadequate HL” scored 2.38 points higher on the GDRS (95% CI 0.378 to 4.336; P = 0.020) and had a 2.04 greater chance to estimate their diabetes risk incorrectly (OR 2.04; 95% CI 1.33 to 3.14; P = 0.001) compared to those with “sufficient HL”. Conclusion The risk of type 2 diabetes is increased in people with inadequate self-reported HL. People with high diabetes risk and inadequate HL might be provided with educational programs to improve diabetes knowledge and reduce behavioural risk factors.

Background It is almost unknown whether the driving status is associated with HRQOL among individuals in highest age. Aims Based on a multicenter prospective cohort study, the objective of this study was to examine whether the driving status is associated with health-related quality of life (HRQOL) among the oldest old in Germany. Methods Cross-sectional data from follow-up wave 9 (n = 544) were derived from the “Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)” (AgeQualiDe). Average age was 90.3 years (± 2.7; 86 to 101 years). The current driver status (no; yes) was used in our analysis. The EuroQoL EQ-5D questionnaire was used to assess HRQOL in this study. Results Regression analysis showed that being a current driver was associated with the absence of problems in ‘self-care’ [OR 0.41 (95%-CI 0.17 to 0.98)], and ‘usual activities’ [OR 0.48 (0.26 to 0.90)], whereas it was not significantly associated with problems in ‘pain/discomfort’ [OR 0.82 (0.47 to 1.45)] and ‘anxiety/depression’ [OR 0.71 (0.36 to 1.39)]. Being a current driver was marginally significantly associated with the absence of problems in ‘mobility’ [OR 0.60 (0.34 to 1.06)]. While being a current driver was not associated with the EQ-VAS in the main model, it was positively associated with the driving status (β = 5.00, p Discussion Our findings provide first evidence for an association between driving status and HRQOL among the oldest old. Conclusions Future longitudinal studies are required to evaluate a possible causal relationship between driving status and HRQOL in very old individuals.

ObjectivesThe aims of our study were to describe the disease spectrum of refugees, to analyse to what extent their healthcare needs could be met in an outpatient primary care walk-in clinic and which cases required additional services from secondary care (ie, outpatient specialists or hospitals).DesignRetrospective longitudinal observational study.SettingThe study was based on routine data from a walk-in clinic in the largest central first reception centre in Hamburg, Germany between 4 November 2015 and 21 July 2016.Participants1467 asylum seekers with 4006 episodes of care (ie, distinctive health problems) resulting in 5545 consultations. The patients were 60% men and had a mean age of 23.2 years. About 90% of the patients were from Central Asia or from the Middle East and North Africa.Primary and secondary outcome measuresThe endpoint of our analyses was referral to secondary care. Time to event was defined as days under treatment until the first referral. Predictor variables were the patients’ diagnoses grouped in 46 categories. The data set was analysed by Cox regression allowing for multiple failure times per patient. This analysis was adjusted for age, sex and country of origin.ResultsReferrals to secondary care occurred in 15.5% of the episodes. The diagnosis groups with the highest referral rates were ‘eye’ (HR 4.9; 95% CI 3.12 to 7.8; p≤0.001), ‘teeth/gum symptom/complaint or disease’ (3.51; 2.52 to 4.9; p≤0.001) and ‘urological system/female or male genital’ (2.50; 1.66 to 3.77; p≤0.001). Age, sex and country of origin had no significant effect on time until referral.ConclusionsIn most cases, the walk-in clinic physicians could provide first-line medical care for the health problems of patients not integrated in the German healthcare system. Additional resources were needed particularly not only for visual impairment and dental problems but also for psychological disorders, antenatal care and certain infections and injuries.

Background From 2015 to 2016 Germany faced an influx of 1.16 million asylum seekers. In the state of Hamburg Primary Care walk-in clinics (PCWC) were commissioned at refugee camps because the high number of residents (57,000 individuals) could not be provided with access to regular healthcare services. Our study aims were (1) to describe the utilization of a PCWC by camp residents, (2) to compare episodes of continuous care with shorter care episodes and (3) to analyse which diagnoses predict episodes of continuous care in this setting. Methods A retrospective longitudinal observational study was conducted by reviewing all anonymized electronic medical records of a PCWC that operated from 4th November 2015 to 22nd July 2016 at a refugee camp in Hamburg. Episodes of care (EOC) were extracted based on the international classification of primary care-2nd edition (ICPC-2). Outcome parameters were episode duration, principal diagnoses, and medical procedures. Results We analysed 5547 consultations of 1467 patients and extracted 4006 EOC. Mean patient age was 22.7 ± 14.8 years, 37.3% were female. Most common diagnoses were infections (44.7%), non-communicable diseases (22.2%), non-definitive diagnoses describing symptoms (22.0%), and injuries (5.7%). Most patients (52.4%) had only single encounters, whereas 19.8% had at least one EOC with a duration of ≥ 28 days (defined as continuous care). Several procedures were more prevalent in EOC with continuous care: Blood tests (5.2 times higher), administrative procedures (4.3), imaging (3.1) and referrals to secondary care providers (3.0). Twenty prevalent ICPC-2-diagnosis groups were associated with continuous care. The strongest associations were endocrine/metabolic system and nutritional disorders (hazard ratio 5.538, p Conclusion A wide spectrum of acute and chronic health conditions could be treated at a GP-led PCWC with few referrals or use of medical resources. But we also observed episodes of continuous care with more use of medical resources and referrals. Therefore, we conclude that principles of primary care like continuity of care, coordination of care and management of symptomatic complaints could complement future healthcare concepts for refugee camps.

To describe health status and health state utilities measured by the EQ-5D-3L in a population-based sample of individuals aged 85 + in Germany, and to analyze associations with basic socio-demographic variables. Cross-sectional data from follow-up wave 7 (n = 761) of the German AgeCoDe Study were used. The EQ-5D-3L questionnaire was used to record problems in five health dimensions, its visual analogue scale (EQ VAS) was used to record self-rated health status, and the German EQ-5D-3L index was used to derive health state utilities. Mean age of respondents was 88.9 years (SD 2.9; range 85 to 100), 67.4% were female. 81.9% reported problems in at least one of the EQ-5D dimensions, with 15.3% reporting extreme problems. Most frequent were problems with pain/discomfort (64.8%), followed by mobility (62.5%), usual activities (42.6%), self-care (28.2%), and anxiety/depression (20.5%). Mean EQ VAS score was 62.4 (SD 18.8), and mean EQ-5D index was 0.77 (SD 0.24). Multiple regression analysis showed associations of problem frequency in various EQ-5D dimensions with age, gender, living situation, marital status, and education. The EQ VAS score was negatively associated with age (β = − 0.56; p

Background Among other factors, the patients’ consultation reasons and GPs’ spectrum of services determine the process and outcome of the medical treatment. So far, however, there has been little information on differences in reasons for consultation and GPs’ services between urban and rural areas. Our study’s goal was thus to investigate these factors in relation to the regional location of GPs’ practices. Methods We conducted a cross-sectional observational study based on standardised GP interviews in a quota sampling design. All counties and independent cities within a radius of 120 km around Hamburg were divided into three regional categories (urban area, environs, rural area) and stratified proportionally to the population size. Differences in the number of reasons for consultation and services were analysed by multivariate linear regressions in mixed models adjusted for random effects on the levels of the German federal states and administrative districts. Differences in individual consultation reasons and services were identified by logistic regression via stepwise forward and backward selection. Results Primary care practices in 34 of the 37 selected administrative districts (91.9%) were represented in the dataset. In total, 211 GPs were personally interviewed. On average, GPs saw 344 patients per month with a slightly higher number of patients in rural areas. They reported 59.1 ± 15.4 different reasons for consultation and 30.3 ± 3.9 different services. There was no statistically significant regional variation in the number of different consultation reasons, but there was a broader service spectrum by rural GPs (ß = − 1.42; 95% confidence interval − 2.75/− 0.08; p = 0.038) which was statistically explained by a higher level of medical training. Additionally, there were differences in the frequency of individual consultation reasons and services between rural and urban areas. Conclusion GPs in rural areas performed more frequently services usually provided by medical specialists in urban areas. This might be caused by a low availability of specialists in rural areas. The association between medical training and service spectrum might imply that GPs compensate the specific needs of their patients by completing advanced medical training before or after setting up a medical practice. Trial registration The study was registered in ClinicalTrials.gov (NCT02558322).

Introduction: There is a lack of studies investigating the link between time-varying factors associated with changes in frailty scores in very old age longitudinally. This is important because the level of frailty is associated with subsequent morbidity and mortality. Objective: To examine time-dependent predictors of frailty among the oldest old using a longitudinal approach. Methods: Longitudinal data were drawn from the multicentre prospective cohort study “Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)” (AgeQualiDe), covering primary care patients aged 85 years and over. Three waves were used (from follow-up, FU, wave 7 to FU wave 9 [with 10 months between each wave]; 1,301 observations in the analytical sample). Frailty was assessed using the Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS). As explanatory variables, we included sociodemographic factors (marital status and age), social isolation as well as health-related variables (depression, dementia, and chronic diseases) in a regression analysis. Results: In total, 18.9% of the individuals were mildly frail, 12.4% of the individuals were moderately frail, and 0.4% of the individuals were severely frail at FU wave 7. Fixed effects regressions revealed that increases in frailty were associated with increases in age (β = 0.23, p < 0.001), and dementia (β = 0.84, p < 0.01), as well as increases in chronic conditions (β = 0.03, p = 0.058). Conclusion: The study findings particularly emphasize the importance of changes in age, probably chronic conditions as well as dementia for frailty. Future research is required to elucidate the underlying mechanisms. Furthermore, future longitudinal studies based on panel regression models are required to confirm our findings.

Zusammenfassung Ziel der Studie Analyse der Beziehung zwischen depressiven Symptomen und funktionellen Beeinträchtigungen bei Hochaltrigen (85+) im Längsschnitt. Methodik Drei Wellen der multizentrischen prospektiven Kohortenstudie AgeQualiDe wurden genutzt (n = 1272 Beobachtungen). Die Geriatrische Depressionsskala wurde zur Erfassung depressiver Symptome verwendet. Die Instrumental Activities of Daily Living von Lawton und Brody wurde zur Messung funktioneller Beeinträchtigungen eingesetzt. Ergebnisse Anfängliche Steigerungen in depressiven Symptomen gehen mit späteren Steigerungen funktioneller Beeinträchtigungen einher. Hingegen hängen anfängliche Steigerungen funktioneller Beeinträchtigungen nicht mit späteren Steigerungen in depressiven Symptomen zusammen. Schlussfolgerung Unsere Ergebnisse deuten darauf hin, dass anfängliche Steigerungen depressiver Symptome mit einer Zunahme funktioneller Beeinträchtigungen bei Hochaltrigen zusammenhängen.

Background Initiatives such as “Choosing Wisely” in the USA and “Smarter Medicine” in Switzerland have published lists of widely overused health care services. The German initiative “Choosing Wisely Together (Gemeinsam Klug Entscheiden)” follows this example. The goal of our study was to prioritize important recommendations against the overuse and underuse of health care services. The final list of recommendations will be published in the German guideline “Protection against the overuse and underuse of health care”. Methods First, a multidisciplinary expert panel established a catalogue of prioritization criteria. Second, we extracted all the recommendations from evidence- and consensus-based German College of General Practice and Family Medicine (DEGAM) guidelines and National Health Care Guidelines (NVL). Third, the recommendations were rated by two independent panels (general practitioners and other health care professionals involved/not involved in guideline development). The prioritization process was finalized in a consensus conference held by DEGAM’s Standing Guideline Committee (SLK). Results Eleven prioritization criteria were established. A total of 782 recommendations were extracted and rated by 98 physicians and other health care professionals in a survey. In the voting process, more than 80% of the recommendations were eliminated. After the final consensus conference, twelve recommendations from DEGAM guidelines, nine DEGAM addenda and 17 NVL recommendations were chosen for inclusion in the guideline, for a total of 38 recommendations. Conclusion The selection procedure proved helpful in identifying the highest priority recommendations with which to combat the overuse and underuse of health care services. To date, in Germany there has been no attempt to compile such a list by using a systematic and transparent methodology. Hence, the guideline that results from this process can fill an important gap.

ObjectivesAim of this study was to analyse if subjectively perceived treatment urgency of patients in emergency departments is associated with self-reported health literacy and the willingness to use the general practitioner (GP) as coordinator of treatment.DesignA multicentre, cross-sectional, observational study.SettingEmergency departments in five hospitals. Each hospital was visited 14 times representing two 8-hour shifts on each day of the week. Calendar dates were randomly assigned.ParticipantsAll patients of legal age registered at the emergency department or hospital reception desk. Exclusion criteria included immediate or very urgent need of treatment, high level of symptom burden and severe functional impairments in terms of hearing, vision and speech. We conducted standardised personal interviews. Additionally, clinical data were extracted from patient records.Primary and secondary outcome measuresOur target variable was subjectively perceived treatment urgency. Predictor variables included age, sex, education, health-related quality of life (EuroQol Five-Dimension Scale, value set UK), anxiety and depression (Hospital Anxiety and Depression Scale), somatic symptoms (Patient Health Questionnaire, 15 items version), self-reported health literacy (European Health Literacy Questionnaire, 16 questions version) and the commitment to the GP (Fragebogen zur Intensität der Hausarztbindung, ‘F-HaBi’). Data were analysed by multilevel, multivariable linear regression adjusted for random effects at the hospital level.ResultsOur sample comprised 276 patients with a mean age of 50.1 years and 51.8% women. A low treatment urgency (defined as 0–5 points on a Numerical Rating Scale) was reported by 111 patients (40.2%). In the final model, lower subjective treatment urgency was associated with male sex (β=0.84; 95% CI 0.11/1.57, p=0.024), higher health-related quality of life (−2.27 to –3.39/−1.15, pConclusionsA lower level of subjectively perceived treatment urgency was predicted by a lower willingness to use the GP as coordinator of treatment. Self-reported health literacy did not predict the patients’ urgency rating.

Background Dementia is a major economic challenge for societies worldwide. One approach of cost-of-illness studies focuses on the excess costs of people with dementia compared to costs in people without dementia. Yet, excess costs of dementia have rarely been examined. Objective To contribute to the existing evidence on excess costs of dementia by adding information regarding the oldest-old. Methods We used cross-sectional data from the AgeQualiDe study. This multicenter cohort study considers exclusively participants with a minimum age of 85 years. We included 856 primary care patients with (n = 154) and without (n = 702) dementia into the analysis. By using the reweighting method of entropy balancing, excess costs from the societal perspective were estimated as mean cost differences between both groups for each cost category of different healthcare sectors. Results In our primary analysis, total costs were 2.5 times higher for people with dementia (n = 154) compared with people without dementia (n = 702). People with dementia showed significant total excess costs of € 11,789 (95% CI € 8,343–15,234) compared with people without the disease in a 6-month period. Excess costs of informal care represented the highest cost category in both primary and sensitivity analyses. Conclusions Our results emphasize the economic and practical value of informal carers in dementia care, as it is generally unpaid care provision saving expenditures for formal care. Health policy strategies are needed to foster community-based dementia care in order to relieve social security systems and to support informal carers of people with dementia.

Purpose To investigate the association between health-related quality of life and ego integrity among the oldest old. Materials and methods Cross-sectional data were taken from follow-up wave 9 of the multicenter prospective cohort study “Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)” (AgeQualiDe). Our analytical sample comprised n = 495 observations. Mean age was 90.2 years (SD: 2.7 years). Health-related quality of life was quantified using the EQ-5D-3L questionnaire (including the visual analogue scale EQ-VAS). Ego integrity was measured using the Ego Integrity Scale. Results Regressions showed an association between decreased ego integrity and problems with ‘usual activities’, ‘pain/discomfort’ and ‘anxiety/depression’. Furthermore, regressions showed a marginally significant association between decreased ego integrity and problems with ‘mobility’ and a decreased EQ-VAS score. Ego integrity was not significantly associated with problems with ‘self-care’. Conclusions Findings stress the importance of health-related quality of life for ego integrity among the oldest old. Future studies are required to clarify the underlying mechanisms.

Zusammenfassung Ziel der Studie Analyse möglicher Unterschiede in Kognition, depressiven Symptomen und gesundheitsbezogener Lebensqualität zwischen GKV- und PKV-Versicherten im hohen Alter. Methodik N = 854 (nGKV = 773, nPKV = 81) Hausarztpatienten (Alter ≥ 85 Jahre) wurden mittels Global Deterioration Scale, Geriatric Depression Scale und EQ-VAS untersucht. Ergebnisse Leichte deskriptive Unterschiede in den betrachteten Maßen erwiesen sich in multiplen Regressionsanalysen nicht als statistisch signifikant. Schlussfolgerung Zwischen GKV- und PKV-Versicherten bestehen keine Unterschiede in den untersuchten Maßen.

To determine the prevalence of overweight and obesity, and to identify factors associated with obesity, among the oldest old.For this study, data from follow-up (FU) wave 7 and FU wave 8 of the 'Study on Needs, Health Service Use, Costs and Health-Related Quality of Life in a Large Sample of Oldest-Old Primary Care Patients (85+)' (AgeQualiDe) were used. At FU wave 7, the mean age was 88.9 years (SD: 2.9; 85-100 years). Body-mass-index (BMI) categories were defined according to the World Health Organization (WHO) thresholds: underweight (BMI < 18.5 kg/m²), normal weight (18.5 kg/m² ≤ BMI < 25 kg/m²), overweight (25 kg/m² ≤ BMI < 30 kg/m²), and obesity (BMI ≥ 30 kg/m²). Longitudinal regression analysis was used to determine factors associated with obesity.At FU wave 7, 3.0 % were underweight, 48.9 % were normal weight, 37.9 % were overweight, and 10.2 % were obese. Regressions showed that the probability of obesity decreased with age (OR: 0.77 [95 % CI: .593-.999]) and less chronic conditions (OR: 1.32 [95 % CI: 1.11-1.57]). The probability of obesity was not associated with sex, educational level, marital status, social isolation, visual impairment, hearing impairment, depression, and dementia.Nearly half of the individuals in very late life had excess weight. Thus, excess weight remains a major challenge, even in very old age. Given the demographic ageing in upcoming decades, this is an issue which we should be aware of.

ObjectivesThe aim of our study was to explore patient types in general practitioner (GP) practices and to quantify the regional differences of the frequencies of these patient types in northern Germany.Design and settingWe conducted a mixed-methods study based on focus groups and standardised interviews with GPs. All counties and independent cities within a radius of 120 km around Hamburg were assigned one of three regional categories (urban areas, environs, rural areas). The focus groups were analysed using qualitative content analysis. Relative frequencies of consultations by patient types and differences between the regions were calculated. Logistic regression analyses were used to identify differences among regions.ParticipantsNine focus groups with 65 GPs (67.7% male). From the 280 initially recruited GPs 211 (65.4% male) could be personally interviewed.ResultsFour themes with 27 patient types were derived from the focus groups: patients classified by morbidity, sociodemographic characteristics, special care needs and patient behaviour. Five patient characteristics were significantly more prevalent in urban areas than rural areas: patients with migration background and culturally different disease concepts (OR 1.23; 95% CI 1.06 to 1.42), privately insured patients (OR 1.17; 95% CI 1.05 to 1.31), educationally disadvantaged patients with low health literacy (OR 1.11; 95% CI 1.04 to 1.19), patients with psychiatric disorders (OR 1.07; 95% CI 1.02 to 1.12) and senior citizens living on their own without caregivers (OR 1.05; 95% CI 1.05 to 1.31). Three patient types were significantly less prevalent in urban areas: minors accompanied by their parents (OR 0.71; 95% CI 0.61 to 0.83), patients with poor therapy adherence (OR 0.87, 95% CI 0.80 to 0.95) and patients with dementia (OR 0.90; 95% CI 0.82 to 0.99).ConclusionsGPs could compensate the specific needs of their patients with medical training aligned with the requirements of their region. Urban GPs need skills treating patients with psychiatric, social and cultural problems, rural GPs regarding the care for children or noncompliant patients.Trial registration numberNCT02558322

Background The number of patients in emergency departments has risen steadily in recent years, with a particular increase in patients not requiring urgent treatment. The aim of this study is to characterize this group of patients with respect to their sociodemographic features, health status, and reasons for attending an emergency department. Methods PiNo Nord is a cross-sectional observational study representing two full working weeks in five different hospitals. Patients were questioned in personal interviews, and medical diagnoses were documented. The data were analyzed with multivariate logistic regressions in mixed multilevel models. Predictors for the subjectively perceived treatment urgency were identified by stepwise backward selection. Results The 1175 patients questioned had an average age of 41.8 years and 52.9% were male. 54.7% said the degree of their treatment urgency was low. 41.3% had visited the emergency department on their own initiative, 17.0% on the advice or referral of their primary care physician, and 8.0% on the advice or referral of a specialist. The strongest predictors for low subjective treatment urgency were musculoskeletal trauma (odds ratio [OR] 2.18), skin conditions (OR 2.15), and the momentary unavailability of a primary care physician (OR 1.70). Conclusion More than half of the patients do not think their condition requires urgent treatment and thus do not meet the definition of a medical emergency. Patients' reasons for visiting the emergency department are varied; aside from the treatment urgency of the health condition itself, the reason may lie in perceived structural circumstances and individual preferences.

Objective The purpose of this study was to examine the impact of falls on depressive symptoms among the oldest old in Germany longitudinally. Methods Data were used from 2 waves of the multicenter prospective cohort "Study on needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe). This study covers primary care patients ≥85 years (at baseline: n = 547, average age of 88.9 ± 3.0 years; ranging from 85 to 100 years). General practitioner-diagnosed falls were used as explanatory variable. The Geriatric Depression Scale was used as outcome measure. Results Linear fixed effects regressions showed that the occurrence of falls is associated with an increase in depressive symptoms (β = .60, P = .02), whereas changes in marital status, ageing, social support, functional decline (instrumental activity of daily living), cognitive impairment, and an increase in chronic diseases did not affect depressive symptoms. In sensitivity analysis, an increase in depressive symptoms was associated with functional impairment (basic activities of daily living; Barthel index; β = -.04, P = .005). Conclusions Based on a large, population-based longitudinal study, this study underlined the impact of falls on depressive symptoms and consequently extended previous knowledge about an association between falls and depressive symptoms in the oldest old. Developing strategies to prevent falls might also help to prevent depressive symptoms.

To investigate how visual impairment affects social ties in late life longitudinally. Population-based prospective cohort study. Individuals in old age were recruited via general practitioners’ offices (at six study centers) in Germany. They were interviewed every 18 months. Individuals aged 75 years and above at baseline. Follow-up wave 2 (36 months after baseline, n=2,443) and wave 4 (72 months after baseline, n=1,618) were used for the analyses presented here. Social ties were assessed using the 14-item form of the questionnaire for social support (F-SozU K-14). Visual impairment was self-rated on a three level Likert scale (no impairment, mild visual impairment, or severe/profound visual impairment). Adjusting for sociodemographic factors, hearing impairment and comorbidity, fixed effects regressions revealed that the onset of mild visual impairment decreased the social support score, in particular the emotional support score. Additionally, the onset of mild hearing impairment decreased the social support score in men. Moreover, increasing age decreased the social support score in the total sample and in both sexes. Loss of spouse and increasing comorbidity did not affect the social support score. Our results highlight the importance of visual impairment for social ties in late life. Consequently, appropriate strategies in order to delay visual impairment might help to maintain social ties in old age.

Background:Most of the previous studies attempted to disentangle the relationship between disability and depressive symptoms were limited to observation periods of only few years. Moreover, evidence is missing regarding the complex co-occurrence of disability and depressive symptoms in old age in Germany. In order to close the research gap, we aimed at disentangling the complex co-occurrence of disability and depressive symptoms in old age in Germany over a longer time frame.Methods:Based on data from a representative survey of the German general population aged 75 years and older, the course of disability as well as depressive symptoms was observed every 1.5 years over six waves. While disability was quantified by the Lawton and Brody Instrumental Activities of Daily Living scale, the Geriatric Depression Scale was used to measure depressive symptoms. Taking into account the complex co-occurrence of depressive symptoms and disability, a panel vector autoregressive model was used. By taking the first differences, unobserved heterogeneity was taken into account.Results:In the total sample and in both sexes, we revealed a robust positive association between an initial change in depressive symptoms and subsequent changes in disability. No robust association between an initial change in disability and a subsequent change in depressive symptoms was detected.Conclusion:Our findings highlight the importance of changes in depressive symptoms for future changes in disability in old age.

Background: In the future, an increase in health care needs in the elderly is expected. Reports on unmet care needs of the oldest old with cognitive disorders are pending. This study aims at exploring unmet needs in the oldest old primary care patients with mild cognitive impairment (MCI) and dementia. Furthermore, the association between sociodemographic and clinical factors and unmet needs ought to be analyzed. Methods: Based on the study “Needs, Health Service Use, Costs and Health-Related Quality of Life in a Large Sample of Oldest-Old Primary Care Patients (85+)” (AgeQualiDe), 749 patients (unimpaired, MCI, and dementia) aged 85 years and older, their relatives (n = 421), and general practitioners (GPs) (n = 607) were assessed. Descriptive, inferential, and regression analyses were run. Results: Most unmet needs were observed in dementia patients, although needs were less frequently rated as unmet by dementia patients themselves as compared to relatives and GPs. Unmet needs were associated with MCI and dementia; other risk factors were age, education, and marital status. Conclusion: This study provides first data on unmet needs according to different perceptions in the elderly with MCI and dementia in Germany. Need assessments should be part of medical examinations to ensure a high-quality health care in the elderly.

Zusammenfassung Einleitung Disease-Management-Programme (DMP) sind strukturierte Behandlungsprogramme fur chronisch Kranke, welche die Versorgungsqualitat fordern sollen. Die Anforderungen an DMP werden im Wesentlichen auf der Grundlage von evidenzbasierten Leitlinien entwickelt. Um den kontinuierlichen Fortschritten in der Versorgung Rechnung zu tragen, mussen sie regelmasig uberarbeitet werden. Ziel unserer Untersuchungen war es, potenziellen Erganzungs- und Aktualisierungsbedarf (im Folgenden als „Uberarbeitungsbedarf“ bezeichnet) fur die Anforderungen an das DMP-Modul „Chronische Herzinsuffizienz“ zu ermitteln. Dazu galt es diejenigen Empfehlungen aus evidenzbasierten Leitlinien zu identifizieren, die Uberarbeitungsbedarf bedingen. Methode Die Suche nach Leitlinien erfolgte in Leitliniendatenbanken sowie Medline und EMBASE. Es wurden Leitlinien in den Sprachen Deutsch, Englisch oder Franzosisch eingeschlossen und ihre methodische Qualitat bewertet. Relevante Empfehlungen wurden extrahiert. Aus dem Abgleich der Leitliniensynopse mit den bestehenden DMP-Anforderungen folgte die Identifizierung von Uberarbeitungsbedarf. Ergebnisse Insgesamt wurden 27 Leitlinien eingeschlossen. Es konnten Empfehlungen zum gesamten Versorgungsprozess der chronischen Herzinsuffizienz extrahiert, synoptisch gegenubergestellt und mit den bestehenden DMP-Anforderungen abgeglichen werden. Die Leitlinienempfehlungen waren haufig ausfuhrlicher formuliert als die Anforderungen. Es fanden sich daruber hinaus einige Leitlinienempfehlungen ohne Entsprechungen in den DMP-Anforderungen. Schlussfolgerungen Wesentliche fur das DMP-Modul relevante Neuerungen in der Versorgung der chronischen Herzinsuffizienz wurden auf der Grundlage dieser Leitliniensynopse nicht identifiziert. Fur einzelne Aspekte kann jedoch Uberarbeitungsbedarf angeregt werden.

Introduction Inappropriate supply and an increasing demand on the healthcare system have been of concern for health policy in Germany for at least 15 years. In the primary care setting, this especially relates to an undersupply of general practitioners (GPs) in the countryside. In addition, there seem to be other regional differences, for example, a difference in accessing primary and secondary care between rural and urban areas. Despite these findings, regional differences in health services have not been studied extensively in Germany. Therefore, this study aims to explore regional variations of patient populations and reasons for accessing primary medical care. Methods and analysis We will conduct a cross-sectional observational study based on standardised interviews with 240 GPs and ∼1200 patients. Data collection started on 10 June 2015 and will probably be completed by 31 October 2016. We will include all districts and cities within 100 km from Hamburg and assign them according to the type of regions: rural, urban and environs. All eligible GPs will be invited to participate. Each practice will recruit up to 15 patients, aged 18 years or older. Questionnaires are based on a preliminary qualitative study and were pretested. Data will be analysed with descriptive statistics and regression modelling strategies adjusted for confounders and the GP-induced cluster structure. Ethics and dissemination Our study was approved by the Ethics Committee of the Medical Association of Hamburg and is conducted in accordance with the Declaration of Helsinki. Study participants give written informed consent before data collection and data is pseudonymised. Survey data and person identifiers are stored separately in locked cabinets and have restricted availability. The results of our study will be presented at conferences and published in peer-reviewed journals. Trial registration number NCT02558322; Pre-results.

Objective The study aimed to develop a comprehensive algorithm (meta-algorithm) for primary care encounters of patients with multimorbidity. We used a novel, case-based and evidence-based procedure to overcome methodological difficulties in guideline development for patients with complex care needs. Study design Systematic guideline development methodology including systematic evidence retrieval (guideline synopses), expert opinions and informal and formal consensus procedures. Setting Primary care. Intervention The meta-algorithm was developed in six steps:1. Designing 10 case vignettes of patients with multimorbidity (common, epidemiologically confirmed disease patterns and/or particularly challenging health care needs) in a multidisciplinary workshop.2. Based on the main diagnoses, a systematic guideline synopsis of evidence-based and consensus-based clinical practice guidelines was prepared. The recommendations were prioritised according to the clinical and psychosocial characteristics of the case vignettes.3. Case vignettes along with the respective guideline recommendations were validated and specifically commented on by an external panel of practicing general practitioners (GPs).4. Guideline recommendations and experts’ opinions were summarised as case specific management recommendations (N-of-one guidelines).5. Healthcare preferences of patients with multimorbidity were elicited from a systematic literature review and supplemented with information from qualitative interviews.6. All N-of-one guidelines were analysed using pattern recognition to identify common decision nodes and care elements. These elements were put together to form a generic meta-algorithm. Results The resulting meta-algorithm reflects the logic of a GP9s encounter of a patient with multimorbidity regarding decision-making situations, communication needs and priorities. It can be filled with the complex problems of individual patients and hereby offer guidance to the practitioner. Contrary to simple, symptom-oriented algorithms, the meta-algorithm illustrates a superordinate process that permanently keeps the entire patient in view. Conclusion The meta-algorithm represents the back bone of the multimorbidity guideline of the German College of General Practitioners and Family Physicians. This article presents solely the development phase; the meta-algorithm needs to be piloted before it can be implemented.

For decades various pressure ulcer risk assessment scales (PURAS) have been developed and implemented into nursing practice despite uncertainty whether use of these tools helps to prevent pressure ulcers. According to current methodological standards, randomised controlled trials (RCTs) are required to conclusively determine the clinical efficacy and safety of this risk assessment strategy. In these trials, PURAS-aided risk assessment has to be compared to nurses' clinical judgment alone in terms of its impact on pressure ulcer incidence and adverse outcomes. However, RCTs evaluating diagnostic procedures are prone to specific risks of bias and threats to the statistical power which may challenge their validity and feasibility. This discussion paper critically reflects on the rigour and feasibility of experimental research needed to substantiate the clinical efficacy of PURAS-aided risk assessment. Based on reflections of the methodological literature, a critical appraisal of available trials on this subject and an analysis of a protocol developed for a methodologically robust cluster-RCT, this paper arrives at the following conclusions: First, available trials do not provide reliable estimates of the impact of PURAS-aided risk assessment on pressure ulcer incidence compared to nurses' clinical judgement alone due to serious risks of bias and insufficient sample size. Second, it seems infeasible to assess this impact by means of rigorous experimental studies since sample size would become extremely high if likely threats to validity and power are properly taken into account. Third, means of evidence linkages seem to currently be the most promising approaches for evaluating the clinical efficacy and safety of PURAS-aided risk assessment. With this kind of secondary research, the downstream effect of use of PURAS on pressure ulcer incidence could be modelled by combining best available evidence for single parts of this pathway. However, to yield reliable modelling results, more robust experimental research evaluating specific parts of the pressure ulcer risk assessment-prevention pathway is needed.

Health technology assessment (HTA) is the multidisciplinary study of the implications of the development, diffusion and use of health technologies. It supports health-policy decisions by providing a joint knowledge base for decision-makers. To increase its policy relevance, HTA tries to extend beyond effectiveness and costs to also considering the social, organizational and ethical implications of technologies. However, a commonly accepted method for analysing the ethical aspects of health technologies is lacking. This paper describes a model for ethical analysis of health technology that is easy and flexible to use in different organizational settings and cultures. The model is part of the EUnetHTA project, which focuses on the transferability of HTAs between countries. The EUnetHTA ethics model is based on the insight that the whole HTA process is value laden. It is not sufficient to only analyse the ethical consequences of a technology, but also the ethical issues of the whole HTA process must be considered. Selection of assessment topics, methods and outcomes is essentially a value-laden decision. Health technologies may challenge moral or cultural values and beliefs, and their implementation may also have significant impact on people other than the patient. These are essential considerations for health policy. The ethics model is structured around key ethical questions rather than philosophical theories, to be applicable to different cultures and usable by non-philosophers. Integrating ethical considerations into HTA can improve the relevance of technology assessments for health care and health policy in both developed and developing countries.

Objective We aimed to evaluate and compare the efficacy of the bicaval and the biatrial standard techniques in orthotopic heart transplantation. Methods A systematic review with meta-analysis was performed. As data sources, we used the electronic databases EMBASE and Medline (1966–August 2006), hand searching in 4 journals, expert consultation, and reference lists of reviews. Observational and randomized and prospective and retrospective controlled trials that reported outcomes on the 2 techniques of heart transplantation were considered. Results A total of 23 retrospective and 18 prospective studies were included. Meta-analyses of prospective trials including between 228 and 472 patients revealed significant superiority of the bicaval technique in comparison with the biatrial procedure for early atrial pressure (weighted mean difference, −3.95; 95% confidence interval, −6.50 to −1.40), perioperative mortality (odds ratio, 0.41; 95% confidence interval, 0.17 to 0.98), tricuspid valve regurgitation (odds ratio, 0.23; 95% confidence interval, 0.15 to 0.36), and sinus rhythm (odds ratio, 7.01; 95% confidence interval, 2.57 to 19.13). The latter also showed a significant difference in the analysis of retrospective studies (odds ratio, 2.69; 95% confidence interval, 1.55 to 4.66). Conclusion In summary, this systematic review and meta-analysis provides evidence of clinically relevant beneficial effects of the bicaval technique in comparison with those of the standard technique. Nevertheless, the longer-term beneficial effects of the bicaval technique remain to be evaluated.

Background Adherence to current monomorbidity-focused, mono-disciplinary guidelines may result in undesirable effects for persons with several comorbidities, in adverse interactions between drugs and diseases, conflicting management strategies, and polypharmacy. As yet no satisfactory approaches exist to address multimorbidity (MM) in clinical guidelines since this patient group is too heterogeneous as to be met by guideline recommendations. Objectives to develop a set of case-based (N = 1) guidelines for common disease combinations identified through epidemiological research and expert (GP) consultations. Methods We followed a new 5-step, mixed methods approach comprising: (1) review of epidemiological data on MM patterns; (2) interdisciplinary focus groups developed case vignettes according to both internal evidence and the results of step 1; (3) development of case-based recommendations according to case vignettes (N of one guidelines); (4) informal consensus of recommendations; (5) formal consensus. Results Step one revealed three different approaches for the selection criteria of case vignettes: first, cases addressing MM disease patterns from epidemiological studies (MM clusters); second, cases addressing triads of the 6 most prevalent chronic conditions; third, cases according to a problem-oriented prioritisation of focus group participants. All in all 10 N-of-one guidelines according to 10 cases could be developed according to the new 5-step-process. Discussion We present a new approach in order to capture the complex and heterogeneous problems of MM through evidence-based and case-based recommendations. This set of N-of-one-guidelines may serve as a framework of evidence-based recommendations for MM patients as the base for the development of meta-tools for both guideline developers and clinicians.