Search

Zusammenfassung Hintergrund Seit etwa 15 Jahren wird eine Übertragung ärztlicher Tätigkeiten an Pflegefachpersonen und damit eine Aufgabenneuverteilung zwischen beiden Professionen diskutiert. Für Modellvorhaben wurde bereits eine rechtliche Grundlage geschaffen. Jedoch fehlen bis heute klar definierte Tätigkeiten. Ziel der AHeaD-Studie war es, die Meinungen von Hausärzt*innen, Pflegefachpersonen, Menschen mit Demenz (MmD) und deren Angehörigen zur Möglichkeit der Substitution und Delegation spezifischer ärztlicher Tätigkeiten durch Pflegefachpersonen und ihrer Akzeptanz in der ambulanten Demenzversorgung zu erfassen. Methodik Durchgeführt wurde eine Mixed-Methods-Studie mit einem sequentiellen Vertiefungsdesign. Die hier vorgestellte Auswertung bezieht sich auf die quantitative Befragung der vier Teilnehmer*innengruppen. Es wurden 865 Teilnehmer*innen zur Akzeptanz der Substitution von Assessments, Primär- und Folgeverschreibungen, Maßnahmen des gesundheitlichen Monitorings und weiteren, bislang ausschließlich ärztlichen Tätigkeiten befragt. Ergebnisse Über alle Probandengruppen hinweg erzielten das Assessment von Mobilitätseinschränkungen, der Alltagskompetenz und von Ernährungsauffälligkeiten, die Verschreibung von Fahrtdiensten, Pflegehilfsmitteln und häuslicher Krankenpflege sowie die Durchführung von Blutentnahmen die höchste Zustimmung zur Substitution. MmD und Angehörige gaben durchweg eine sehr hohe Akzeptanz der Substitution an, wobei Hausärzt*innen auch bei einer Substitution von Tätigkeiten weiterhin erste*r Ansprechpartner*in blieben (88%). Bei den Hausärzt*innen (63,2%) war im Vergleich zu den Pflegefachpersonen (56,7%) im Mittel die Akzeptanz der Substitution höher. Schlussfolgerung Ein Großteil der Hausärzt*innen, Pflegefachpersonen, MmD und Angehörigen begrüßte eine Substitution ärztlicher Tätigkeiten. Dabei stehen MmD und Angehörige einer Substitution deutlich positiver gegenüber.

Currently, there is a lack of interaction between research and healthcare practice. As a result, research findings reach healthcare practice only late, and topics relevant to practice are often not known in research. Involving people living with dementia (PlwD), their relatives and healthcare providers in dementia care research can accelerate this process. For inclusion, firm and reliable structures are needed, which are to be established with the help of the Translational Network for Dementia Care Research in Germany. However, there is only limited knowledge about the priorities, expectations and conditions of stakeholders (healthcare providers and dementia researchers) for such cooperation within a network.The aim is to gather stakeholders' views on (i) future research topics to be addressed within the dementia care research network, (ii) the nature of collaboration within the network and (iii) the facilitating and hindering factors for establishing such a network.Within an exploratory sequential mixed-method study, we interviewed 87 stakeholders within eleven semistructured focus group interviews. The interviews were transcribed, pseudonymized and analyzed using qualitative content analysis. The qualitative data were analyzed with MAXQDA. Based on the qualitative results found in the focus group interviews, a supplementary online questionnaire was developed to prioritise and rank these findings afterwards.Stakeholders prioritized a comprehensible transfer of research results into practice, increased involvement of PlwD and their relatives (additionally marginalized groups such as people with a migrant background) in research and exchange between researchers. Cooperation should preferably occur in a regional context with local contacts, and the latest research results should be made available via an online database. The stakeholders' time, finances and human resources should be considered.Stakeholders have partly similar preferences and goals for cooperation and involvement, emphasizing that such interaction in a network offers the possibility of long-term, effective collaboration and added value for practice and research.For this study, dementia healthcare providers and dementia care researchers were asked about their perspectives. Their involvement is further elucidated in the manuscript text.

IntroductionThe EQ-5D is a widely used health-related quality of life (HRQoL) instrument. The recall period “today” may miss out on recurrent health fluctuations often observed in people with dementia (PlwD). Thus, this study aims to assess the frequency of health fluctuations, affected HRQoL dimensions and the impact of the health fluctuations on the assessment of health today using the EQ-5D-5L.Methods and analysisThis mixed-methods study will base on n=50 patient and caregiver dyads and four main study phases: (1) Baseline assessment of patients' socio-demographic and clinical characteristics; (2) caregivers self-completion of a daily diary for 14 days, documenting patient's today's health compared to yesterday, the affected HRQoL dimensions, and events that could have caused the fluctuations; (3) administration of the EQ-5D-5L as self- and proxy-rating at baseline, day seven and day 14; (4) interviewing caregivers on patient's health fluctuation, the consideration of past fluctuations in the assessment of health today using the EQ-5D-5L, and the appropriateness of recall periods to capture health fluctuations on day 14. Qualitative semi-structured interview data will be analyzed thematically. Quantitative analyses will be used to describe the frequency and intensity of health fluctuations, affected dimensions, and the association between health fluctuation and its consideration in the assessment of health today.DiscussionThis study aims to reveal insights into the health fluctuation in dementia, the affected dimensions, and underlying health events, as well as whether individuals adhere to the recall period of health today using the EQ-5D-5L. This study will also provide information about more appropriate recall periods that could better capture health fluctuations.Trial registrationThis study is registered in the German Clinical Trials Register (DRKS00027956).

Background: Person-centered care (PCC) requires knowledge about patient preferences. Among people living with cognitive impairments (PlwCI), evidence on quantitative, choice-based preferences, which allow to quantify, weigh, and rank care elements, is limited. Furthermore, data on the congruence of patient preferences with physicians’ judgements for PCC are missing. Such information is expected to support the implementation of PCC; state-of-the-art medical care aligned with patients’ preferences. Objective: To elicit patient preferences and physicians’ judgements for PCC and their congruence. Methods: Data from the mixed-methods PreDemCare study, including a cross-sectional, paper-and-pencil, interviewer-assisted analytic hierarchy process (AHP) survey conducted with n = 50 community-dwelling PlwCI and n = 25 physicians. Individual AHP weights (preferences/judgements) were calculated with the principal eigenvector method and aggregated per group by aggregation of individual priorities mode. Individual consistency ratios (CRs) were calculated and aggregated per group. Group differences in preferences/judgements were investigated descriptively by means and standard deviations (SDs) of AHP weights, resulting ranks, and boxplots. Additionally, differences between groups were investigated with independent paired t-test/Mann Whitney U-test. Sensitivity of AHP results was tested by inclusion/exclusion of inconsistent respondents, with an accepted threshold at CR≤0.3 for patients, and CR≤0.2 for physicians, due to better cognitive fitness of the latter group. Results: Patient preferences and physicians’ judgements did not differ significantly, except for the criterion Memory Exercises (AHP weights (mean (SD)): 0.135 (0.066) versus 0.099 (0.068), p = 0.01). We did not see rank-reversals of criteria after exclusion of inconsistent participants. Mean CR for patients at the criteria level was 0.261, and 0.181 for physicians. Conclusion: Physicians’ judgements in our setting aligned well with patients’ preferences. Our findings may be used to guide the implementation of preference-based PCC.

This study aimed to analyze the impact of low-value medications (Lvm), that is, medications unlikely to benefit patients but to cause harm, on patient-centered outcomes over 24 months.This longitudinal analysis was based on baseline, 12 and 24 months follow-up data of 352 patients with dementia. The impact of Lvm on health-related quality of life (HRQoL), hospitalizations, and health care costs were assessed using multiple panel-specific regression models.Over 24 months, 182 patients (52%) received Lvm at least once and 56 (16%) continuously. Lvm significantly increased the risk of hospitalization by 49% (odds ratio, confidence interval [CI] 95% 1.06-2.09; p = 0.022), increased health care costs by €6810 (CI 95% -707€-14,27€; p = 0.076), and reduced patients' HRQoL (b = -1.55; CI 95% -2.76 to -0.35; p = 0.011).More than every second patient received Lvm, negatively impacting patient-reported HRQoL, hospitalizations, and costs. Innovative approaches are needed to encourage prescribers to avoid and replace Lvm in dementia care.Over 24 months, more than every second patient received low-value medications (Lvm). Lvm negatively impact physical, psychological, and financial outcomes. Appropriate measures are needed to change prescription behaviors.

Background: Person-centered care (PCC) is an important concept in many countries’ national guidelines and dementia plans. Key intervention categories, i.e., a taxonomy of person-centered (PC)-interventions, to provide person-centered dementia care, are difficult to identify from literature. Objective: This systematic review aimed to identify and categorize published PC-interventions into key intervention categories to guide the provision of person-centered dementia care. Methods: Conduct of this systematic review followed Cochrane guidelines. A search of the dimensions ‘Dementia’, ‘Person-Centered Care’, and ‘Intervention’ combined was performed in PubMed, EMBASE, and Web of Science. Study selection was based on 2-stage screening against eligibility criteria, limited to controlled study designs. Information about interventions and outcomes was extracted into an “Effects Table”. The identified PC-interventions were categorized in intervention categories to provide person-centered dementia care. Results: Searches identified 1,806 records. 19 studies were included. These covered a range of psychosocial interventions, oftentimes multi-component interventions, which followed heterogeneous approaches. Studies were conducted in long-term care/hospital settings. Nine key intervention categories were identified: social contact, physical activities, cognitive training, sensory enhancement, daily living assistance, life history oriented emotional support, training and support for professional caregivers, environmental adjustments, and care organization. Conclusion: Our findings provide a current overview of published PC-interventions in dementia, which followed heterogeneous approaches under the PCC-concept. The heterogeneity made it challenging to identify a well-defined concept of PCC and common key intervention categories. An effectiveness-evaluation of “PC” - including “relationship-centered”-interventions may be valuable, to assess whether an explicit focus on relationships around PCC-interventions yields an added benefit. PROSPERO-ID: CRD42021225084.

The increasing prevalence of dementia with the constant availability of general practitioners is a significant challenge for healthcare systems worldwide. Advanced nursing practice (ANP) was implemented in several countries as one possible solution to overcome this challenge. However, this concept of care is not yet implemented in Germany. The InDePendent study (“Advanced nursing practice and interprofessional dementia care”) is the first study in Germany, aiming to implement and evaluate a model of ANP for persons with dementia (PwDs) living at home and their caregivers where tasks were reorganized between dementia-specific qualified nurses and physicians.MethodsThe Independent study is a multi-center, cluster-randomized, controlled, crossover interventional trial. Whereas the waiting-control group receive care as usual, the InDePendent intervention of the intervention group aims to provide optimum care for PwD and their caregivers by integrating multimodal strategies of an individualized care within the framework of the German healthcare system by a reorganization of tasks between general practitioners and nurses. Dementia-specific qualified nurses, who passed a specific state exam, conduct the interventions. Based on evidence-based guidelines a comprehensive set of 115 intervention modules were defined. Each module consists of predefined trigger conditions and recommendations of actions. The intervention starts with a set of assessment instruments for PwD to identify the unmet needs, individual situation and resources of PwD and caregiver. Subsequently, an intervention tasks list was generated to address each of the identified unmet needs. The tasks lists were carried out by the dementia-specific nurse in close cooperation with general practitioners. For the first time in Germany, nurses were able to carry out tasks that are usually carried out by general practitioners, like prescription of care aids and outpatient care.Expected results: We expect statistically significant differences between waiting-control-group and intervention-group across the primary (unmet needs) and secondary outcomes (quality of life, caregiver burden, acceptance, cost-effectiveness). This study can provide evidence concerning the safety, efficacy, and cost-effectiveness of ANP in Germany, supporting the implementation of the ANP concept into German routine care.

Recent studies have demonstrated the efficiency of collaborative dementia care, which aim to improve post-diagnostic support. However, tasks carried out of such models are currently unknown, hindering its implementation.ObjectivesTo describe the tasks of an efficient collaborative dementia care management and analyze the association of these tasks with patients’ characteristics.MethodsThe analysis was based on 183 persons screened positive for dementia (PwD), who received dementia care management conducted by nurses with a dementia-specific qualification. A standardized computer-assisted assessment, patients’ and caregivers’ unmet needs were identified, based on these, pre-specified algorithms generated an individual list of intervention tasks for each PwD. Tasks performed to meet unmet needs were documented and categorized and descriptively analyzed. We used multivariate regression models to identify socio-demographic and clinical factors that are associated with a specific subgroup of tasks or a higher number of tasks.ResultsOn average 22.7 tasks were carried out per dyad (PwD and caregiver). 38%, 19% and 13% of tasks could be categorized to cooperation with other healthcare providers, medical and nursing care, and social and legal support, respectively. A lower mental and physical health-related quality of life, age of PwD, lower education, higher deficits in daily living activities, higher depressive symptoms, and a higher number of drugs taken of the PwD, as well as female sex of the caregiver were associated with a significantly higher number of tasks carried out.ConclusionsSocio-demographic and clinical characteristics and the subjective perception of health determine the intensity of intervention needed to address unmet needs of PwDs. A variability of the intensity of collaborative care should be considered in the development of future intervention studies and in the implementation into routine care.

Person-centered care (PCC) requires knowledge about patient preferences. An analytic hierarchy process (AHP) is one approach to quantify, weigh and rank patient preferences suitable for People living with Dementia (PlwD), due to simple pairwise comparisons of individual criteria from a complex decision problem. The objective of the present study was to design and pretest a dementia-friendly AHP survey. Methods: Two expert panels consisting of n = 4 Dementia Care Managers and n = 4 physicians to ensure content-validity, and “thinking-aloud” interviews with n = 11 PlwD and n = 3 family caregivers to ensure the face validity of the AHP survey. Following a semi-structured interview guide, PlwD were asked to assess appropriateness and comprehensibility. Data, field notes and partial interview transcripts were analyzed with a constant comparative approach, and feedback was incorporated continuously until PlwD had no further comments or struggles with survey completion. Consistency ratios (CRs) were calculated with Microsoft® Excel and ExpertChoice Comparion®. Results: Three main categories with sub-categories emerged: (1) Content: clear task introduction, (sub)criteria description, criteria homogeneity, (sub)criteria appropriateness, retest questions and sociodemography for heterogeneity; (2) Format: survey structure, pairwise comparison sequence, survey length, graphical design (incl. AHP scale), survey procedure explanation, survey assistance and response perspective; and (3) Layout: easy wording, short sentences and visual aids. Individual CRs ranged from 0.08 to 0.859, and the consolidated CR was 0.37 (0.038). Conclusions: Our formative qualitative study provides initial data for the design of a dementia-friendly AHP survey. Consideration of our findings may contribute to face and content validity in future quantitative preference research in dementia.

Background: Person-centered care (PCC) requires knowledge about patient preferences. This formative qualitative study aimed to identify (sub)criteria of PCC for the design of a quantitative, choice-based instrument to elicit patient preferences for person-centered dementia care. Method: Interviews were conducted with n = 2 dementia care managers, n = 10 People living with Dementia (PlwD), and n = 3 caregivers (CGs), which followed a semi-structured interview guide including a card game with PCC criteria identified from the literature. Criteria cards were shown to explore the PlwD’s conception. PlwD were asked to rank the cards to identify patient-relevant criteria of PCC. Audios were verbatim-transcribed and analyzed with qualitative content analysis. Card game results were coded on a 10-point-scale, and sums and means for criteria were calculated. Results: Six criteria with two sub-criteria emerged from the analysis; social relationships (indirect contact, direct contact), cognitive training (passive, active), organization of care (decentralized structures and no shared decision making, centralized structures and shared decision making), assistance with daily activities (professional, family member), characteristics of care professionals (empathy, education and work experience) and physical activities (alone, group). Dementia-sensitive wording and balance between comprehensibility vs. completeness of the (sub)criteria emerged as additional themes. Conclusions: Our formative study provides initial data about patient-relevant criteria of PCC to design a quantitative patient preference instrument. Future research may want to consider the balance between (sub)criteria comprehensibility vs. completeness.

BackgroundA redistribution of tasks between specialized nurses and primary care physicians, i.e., models of advanced nursing practice, has the potential to improve the treatment and care of the growing number of people with dementia (PwD). Especially in rural areas with limited access to primary care physicians and specialists, these models might improve PwD’s quality of life and well-being. However, such care models are not available in Germany in regular healthcare. This study examines the acceptance, safety, efficacy, and health economic efficiency of an advanced nursing practice model for PwD in the primary care setting in Germany.MethodsInDePendent is a two-arm, multi-center, cluster-randomized controlled intervention study. Inclusion criteria are age ≥70 years, cognitively impaired (DemTect ≤8) or formally diagnosed with dementia, and living in the own home. Patients will be recruited by general practitioners or specialists. Randomization is carried out at the physicians’ level in a ratio of 1:2 (intervention vs. waiting-control group). After study inclusion, all participants will receive a baseline assessment and a follow-up assessment after 6 months. Patients of the intervention group will receive advanced dementia care management for 6 months, carried out by specialized nurses, who will conduct certain tasks, usually carried out by primary care physicians. This includes a standardized assessment of the patients’ unmet needs, the generation and implementation of an individualized care plan to address the patients’ needs in close coordination with the GP. PwD in the waiting-control group will receive routine care for 6 months and subsequently become part of the intervention group. The primary outcome is the number of unmet needs after 6 months measured by the Camberwell Assessment of Need for the Elderly (CANE). The primary analysis after 6 months is carried out using multilevel models and will be based on the intention-to-treat principle. Secondary outcomes are quality of life, caregiver burden, acceptance, and cost-effectiveness. In total,n=465 participants are needed to assess significant differences in the number of unmet needs between the intervention and control groups.DiscussionThe study will provide evidence about the acceptance, efficacy, and cost-effectiveness of an innovative interprofessional concept based on advanced nursing care. Results will contribute to the implementation of such models in the German healthcare system. The goal is to improve the current treatment and care situation for PwD and their caregivers and to expand nursing roles.Trial registrationClinicalTrials.govNCT04741932. Registered on 2 February 2021.

BackgroundLow-value medications (Lvm) provide little or no benefit to patients, may be harmful, and waste healthcare resources and costs. Although evidence from the literature indicates that Lvm is highly prevalent in dementia, evidence about the financial consequences of Lvm in dementia is limited. This study analyzed the association between receiving Lvm and healthcare costs from a public payers’ perspective.MethodsThis analysis is based on data of 516 community-dwelling people living with dementia (PwD). Fourteen Lvm were extracted from dementia-specific guidelines, the German equivalent of the Choosing Wisely campaign, and the PRISCUS list. Healthcare utilization was retrospectively assessed via face-to-face interviews with caregivers and monetarized by standardized unit costs. Associations between Lvm and healthcare costs were analyzed using multiple linear regression models.ResultsEvery third patient (n = 159, 31%) received Lvm. Low-value antiphlogistics, analgesics, anti-dementia drugs, sedatives and hypnotics, and antidepressants alone accounted for 77% of prescribed Lvm. PwD who received Lvm were significantly less cognitively impaired than those not receiving Lvm. Receiving Lvm was associated with higher medical care costs (b = 2959 €; 95% CI 1136–4783; p = 0.001), particularly due to higher hospitalization (b = 1911 €; 95% CI 376–3443; p = 0.015) and medication costs (b = 905 €; 95% CI 454–1357; p

Background: Treatment decisions based on guidelines rather than patients’ preferences determine adherence to and compliance with treatment, which, in turn, could improve health-related outcomes. Objectives: To summarize the stated treatment and care preferences of people with dementia (PwD). Methods: A systematic review was conducted to assess the stated preferences of PwD. The inclusion criterion was the use of quantitative methods to elicit stated preferences, enabling a ranking of preferences. Results: Eleven studies revealed preferences for diagnostics, treatment decisions, patient-related outcomes, care services, end-of-life care, leisure activities, and digital life story work. PwDs prefer accurate, pain-free, and comfortable diagnostic procedures without radioactive markers as well as being accompanied by a caregiver. PwD’s quality of life (QoL), self-efficacy, and depression were equally most important for PwD and caregivers. However, PwD memory was only important for caregivers but not for PwD, and caregiver QoL was moderately important for PwD but least important for caregivers. Additionally, comfort and family involvement were most important for patients’ end-of-life care, whereas caregivers most preferred good communication and pain management. Also, preferences depend on the living situation: Patients living not alone prefer a regular care provider most, whereas those living alone only want to live nearby the caregiver. Preferences for leisure activities did not differ between past and present ratings, indicating that PwD prefer activities that have always been carried out. Conclusion: Only a few studies have applied quantitative methods to elicit the preferences of PwD. More research is needed to capture the stated preferences for the treatment, care, and support of PwD to improve health-related outcomes and the allocation of healthcare resources.

HintergrundSeit Jahren wird eine Aufgabenneuverteilung und damit eine Übertragung ärztlicher Tätigkeiten an Pflegefachpersonen mit erweiterten Kompetenzen in Deutschland diskutiert und aktuell von Seiten der Bundesregierung konkretisiert.Ziel dieser Arbeit war es, die Meinungen von Hausärzt*innen und Pflegefachpersonen zum Qualifikationsbedarf von möglichen delegierbaren und substituierbaren ärztlichen Tätigkeiten an Pflegefachpersonen am Beispiel der ambulanten Versorgung von Menschen mit Demenz zu erfassen.MethodeIm Rahmen einer quantitativen Befragung wurde der Qualifikationsbedarf zu einer Aufgabenübertragung von 30 verschiedenen Tätigkeiten an Pflegefachpersonen von Hausärzt*innen und Pflegefachpersonen erhoben. Insgesamt wurden 1634 Fragebögen verschickt bzw. ausgegeben. Die Rücklaufquote betrug 28,0% (Hausärzt*innen (n = 225) und Pflegefachpersonen (n = 232). Die Analysen erfolgten deskriptiv mittels der Software SPSS (Version 25, IBM Corp., 2017).Ergebnisse45,1% der Befragten äußerten die Notwendigkeit einer Qualifikation für eine Aufgabenübertragung. Dieser Qualifikationsbedarf bezieht sich vorrangig auf eine Weiterbildung (37,3%). Wird eine Hochschulausbildung (36,2%) favorisiert, wird der Qualifikationsbedarf primär auf Masterniveau (Bachelor 15,6%; Master 20,6%) verortet.SchlussfolgerungDie Ergebnisse dieser Studie können in die Definition von Tätigkeitsprofilen akademisch qualifizierter Pflegefachpersonen und in die Entwicklung von Curricula für deren hochschulische Ausbildung einfließen. Darüber hinaus kann ein Bedarf für die Weiterentwicklung der gesetzlichen Rahmenbedingungen abgeleitet werden.

Background: Collaborative care models for people living with dementia (PwD) have been developed and evaluated, demonstrating safety, efficacy, and cost-effectiveness. However, these studies are based on heterogeneous study populations and primary care settings, limiting the generalizability of the results. Therefore, this study aims to implement and evaluate collaborative care across various healthcare settings and patient populations. Objective: To describe the study design of this multicenter implementation trial. Methods: This single-arm, multicenter, longitudinal implementation study will be conducted in five different healthcare settings, including 1) physicians’ networks, 2) dementia networks, 3) counselling centers, 4) hospitals, and 5) ambulatory care services. Eligibility criteria are: having a formal dementia diagnosis or having been screened positive for dementia and living community-dwelling. The staff of each healthcare setting identifies patients, informs them about the study, and invites them to participate. Participants will receive a baseline assessment followed by collaborative individualized dementia care management, comprising proven safe, effective, and cost-effective modules. Over six months, specially-qualified nurses will assess patients’ unmet needs, transfer them to individualized care plans, and address them, cooperating with various healthcare providers. A follow-up assessment is conducted six months after baseline. Approximately 60–100 PwD per setting per year are expected to participate. Differences across settings will be assessed regarding acceptability, demand, implementation success and barriers, efficacy, and cost-effectiveness. Results: We expect that acceptability, demand, implementation success and barriers, efficacy, and cost-effectiveness will vary by patients’ sociodemographic and clinical characteristics and unmet needs in each setting. Conclusion: The results will provide evidence highlighting differences in the implementation of collaborative care in various healthcare settings and demonstrating the settings with the highest need, best conditions for a successful implementation, and highest (cost-)effectiveness, as well as the population group that benefits most from collaborative care. Trial registration: German Clinical Trials Register: DRKS00025074. Registered 16 April 2021-retrospectively registered.

Task sharing in outpatient dementia care - Focus groups with GPs and nurses Abstract. Background: Caring for people with dementia (PWD) is challenging for the health system and family carers and can only be managed through interprofessional medical and nursing care.The AHeaD study investigated attitudes of general practitioners (GPs) and nurses towards the transfer of activities previously performed by GPs to advanced nurses in the outpatient care of PWDs.In four focus group discussions with 10 GPs and 13 nurses, qualitative content analysis was used to investigate attitudes towards the transfer of certain tasks and to identify opportunities and barriers to their introduction.GPs primarily preferred the transfer of nursing activities such as blood sampling, assessments, their monitoring or follow-up prescriptions for nursing aids. 'Classical' medical tasks (e. g. diagnosis of diseases, initial prescription of medication) are still seen in the hands of GPs. Nurses demanded more appreciation and recognition for the relationship between GPs and nurse and criticised the lack of trust and insufficient communication. Both sides pointed to tight time budgets that were hardly oriented towards the actual needs of the PWD.The implementation of a redistribution of tasks requires the creation of legal and financial framework conditions, time resources, concrete task descriptions as well as a stronger cooperation between the professional groups involved. Innovative concepts could contribute to the sensible use of the resources GP and nurses and strengthen the care of PWDs.

Zusammenfassung Ziel Beschreibung von Versorgungserwartungen von Patienten mit leichten kognitiven Störungen (PmMCI). Methoden Befragung von 51 PmMCI in einer fachärztlichen Versorgerpraxis. Fragebogen in Anlehnung an die CANE-Beurteilungsskala. Kontrollvariablen u. a. MMST und GDS. Ergebnisse 35 % bzw 8 % erlebten die Gedächtnisstörungen als mittelschwer bzw. schwerwiegend und 27 % bzw. 8 % fühlten sich im Alltag häufig bzw. andauernd beeinträchtigt. Über 70 % waren trotz der Gedächtnisprobleme ausgeglichener Stimmung. Arztbezogene Erwartungen: Verlaufskontrolle (96 %), Demenz-Risikoabschätzung (73 %), Gedächtnistraining (55 %), medikamentöse Behandlung (33 %). Medikamentenbezogene Erwartungen: spürbare Wirkung (41 %), Bereitschaft, Nebenwirkungen zu ertragen (29 %), Bevorzugung pflanzlicher Medikation (59 %). Nichtmedikamentöse Therapieerwartungen: sportliche Aktivierung (63 %), Gedächtnistraining (51 %) und Ernährungsberatung (37 %). Der Wunsch nach psychotherapeutischen Gesprächen (27 %) war mit höheren Depressionswerten der GDS assoziiert. Schlussfolgerung PmMCI erlebten Gedächtnisstörungen als Belastung und Beeinträchtigung und erwarteten diagnostische und therapeutische Maßnahmen. PmMCI mit depressiver Symptomatik erwarteten zusätzlich psychotherapeutische Gespräche.

Background: Low-value care (LvC) is defined as care unlikely to provide a benefit to the patient regarding the patient’s preferences, potential harms, costs, or available alternatives. Avoiding LvC and promoting recommended evidence-based treatments, referred to as high-value care (HvC), could improve patient-reported outcomes for people living with dementia (PwD). Objective: This study aims to determine the prevalence of LvC and HvC in dementia and the associations of LvC and HvC with patients’ quality of life and hospitalization. Methods: The analysis was based on data of the DelpHi trial and included 516 PwD. Dementia-specific guidelines, the “Choosing Wisely” campaign and the PRISCUS list were used to indicate LvC and HvC treatments, resulting in 347 LvC and HvC related recommendations. Of these, 77 recommendations (51 for LvC, 26 for HvC) were measured within the DelpHi-trial and finally used for this analysis. The association of LvC and HvC treatments with PwD health-related quality of life (HRQoL) and hospitalization was assessed using multiple regression models. Results: LvC was highly prevalent in PwD (31%). PwD receiving LvC had a significantly lower quality of life (b = –0.07; 95% CI –0.14 – –0.01) and were significantly more likely to be hospitalized (OR = 2.06; 95% CI 1.26–3.39). Different HvC treatments were associated with both positive and negative changes in HRQoL. Conclusion: LvC could cause adverse outcomes and should be identified as early as possible and tried to be replaced. Future research should examine innovative models of care or treatment pathways supporting the identification and replacement of LvC in dementia.

To demonstrate the attitudes of general practitioners (GPs), nurses, persons with dementia, and caregiver towards suitable tasks and qualification needs for and the acceptance and impact of advanced nursing roles in German dementia primary care.Observational study using a questionnaire survey with 225 GPs, 232 nurses, 211 persons with dementia, and 197 caregivers, conducted between December 2017-August 2018.A questionnaire was generated that includes specific assessment, prescription, and monitoring tasks of advanced nursing roles in dementia primary care as well as qualification requirements for and the acceptance and the impact of advanced nursing roles. Data were analysed using descriptive statistics. Group differences were assessed using the Fisher's exact test.Advanced nursing roles were highly appreciated across all groups. Assessment and monitoring tasks were rated as highly suitable, and prescription authorities as moderately suitable. Nurses felt less confident in assessment and monitoring, but more confident in prescribing as practitioners expected. Patients and caregivers would appreciate a takeover of tasks by nurses; nurses and practitioners preferred a delegation. A dementia-specific qualification was rated as best suitable for advanced nursing roles, followed by 'no specific qualification' if medical tasks that only can be carried out by practitioners were delegated and an academic degree if tasks were substituted. Advanced nursing roles were rated as beneficial, strengthening the confidence in nursing care and improving the cooperation between professionals and the treatment. Practitioners assumed that advanced nursing roles would improve job satisfaction of nurses, which was not confirmed by nurses.There is an extended consensus towards the enlargement of advanced nursing roles, represented by high endorsement, acceptance, and willingness to reorganize tasks.Results debunk the common notion that German practitioners would be reluctant towards advanced nursing roles and a takeover of current practitioner tasks, supporting the implementation of advanced nursing roles in Germany.目的: 证明全科医师 (GP) 、护士、痴呆症患者和照料人员对德国痴呆症初级护理中高级护理角色的合适任务和资质需求、接受程度和影响的态度。 设计: 2017年12月至2018年8月期间, 采用问卷调查的方式, 对225名全科医师、232名护士、211名痴呆症患者和197名照料人员进行了观察性研究。 方法: 生成问卷调查表, 其内容包括痴呆症初级护理中高级护理角色的具体评价、处方和监测任务, 以及高级护理角色的资质要求、接受程度和影响。采用描述性统计进行数据分析。采用费希尔精确检验方式来评估组间差异。 结果: 所有群组均高度支持高级护理角色。评价和监测任务被评为高度合适, 且开处方权限被评为中等合适。在评价和监测方面, 护士缺乏信心, 但对医师所期望的处方工作更有信心。患者和照料人员对护士接管任务表示支持; 护士和执业医师更喜欢授权。对于高级护理角色, 特定于痴呆症的资格被评为最适合, 其次是‘无特定资格’ (如果医疗任务只能由执业医师执行, 则进行委托; 如果任务被替代, 则涉及学术学位) 。高级护理角色被评价为是有益的, 其增强了护理方面的信心, 提高了专业人员与治疗之间的协作。执业医师认为高级护理角色可以提高护士的工作满意度, 但这一点没有得到护士的证实。 结论: 我们对高级护理角色的扩大化有一个广泛共识, 这代表着我们对高级护理角色的高度认可、接受、以及重新安排任务的意愿。 影响: 研究结果推翻了德国执业医师不愿意从事高级护理角色和接管现有执业医师任务的普遍观念, 支持执行德国高级护理角色。.

BACKGROUND Dementia care management (DCM) aims to provide optimal treatment for people with dementia (PwD). Treatment and care needs are dependent on patients' sociodemographic and clinical characteristics and thus, economic outcomes could depend on such characteristics. OBJECTIVE To detect important subgroups that benefit most from DCM and for which a significant effect on cost, QALY, and the individual cost-effectiveness could be achieved. METHODS The analysis was based on 444 participants of the DelpHi-trial. For each subgroup, the probability of DCM being cost-effective was calculated and visualized using cost-effectiveness acceptability curves. The impact of DCM on individual costs and QALYs was assessed by using multivariate regression models with interaction terms. RESULTS The probability of DCM being cost-effective at a willingness-to-pay of 40,000€ /QALY was higher in females (96% versus 16% for males), in those living alone (96% versus 26% for those living not alone), in those being moderately to severely cognitively (100% versus 3% for patients without cognitive impairment) and functionally impaired (97% versus 16% for patients without functional impairment), and in PwD having a high comorbidity (96% versus 26% for patients with a low comorbidity). Multivariate analyses revealed that females (b = -10,873; SE = 4,775, p = 0.023) who received the intervention had significantly lower healthcare cost. DCM significantly improved QALY for PwD with mild and moderate cognitive (b = +0.232, SE = 0.105) and functional deficits (b = +0.200, SE = 0.095). CONCLUSION Patients characteristics significantly affect the cost-effectiveness. Females, patients living alone, patients with a high comorbidity, and those being moderately cognitively and functionally impaired benefit most from DCM. For those subgroups, healthcare payers could gain the highest cost savings and the highest effects on QALYs when DCM will be implemented.

Background Drug-related problems (DRP) are common in the elderly population, especially in people living with dementia (PwD). DRP are associated with adverse outcomes that could result in increased costs. Objective The objective of the study was to analyze the association between DRP and healthcare costs in PwD. Methods The analysis was based on the cross-sectional data of 424 PwD. Compliance, adverse effects, and drug administration of prescribed and over-the-counter drugs taken were assessed. DRP were identified and classified by pharmacists using an adapted German version of "PIE-Doc®". Healthcare utilization was assessed retrospectively used to calculated costs from a public payer perspective using standardized unit costs. The associations between DRP and healthcare costs were analyzed using multiple linear regression models. Results 394 PwD (93%) had at least one DRP. An inappropriate drug choice was significantly associated with increased total costs (b = 2,718€; CI95% 1,448-3,988) due to significantly higher costs for hospitalization (b = 1,936€; 670-3,202) and for medications (b = 417€; 68-765). Problems with medication dosage and drug interactions were significantly associated with higher medication costs (b = 679€; 31-1,328; and b = 630€; 259-1,001, respectively). Conclusions DRP could significantly lead to adverse outcomes for PwD and healthcare payers, reflected by a higher hospitalization and costs, respectively. Further research is needed to clarify on interventions and approaches efficiently avoiding DRP and on the effect on patient-reported and economic outcomes.

* OBJECTIVES: Collaborative dementia care aim to provide optimal treatment for people with dementia (PwD). Treatment and care needs are dependent on patients’ sociodemographic and clinical characteristics. We conduct a cost-effectiveness analysis under consideration of such characteristics to detect subgroups that benefits most from the intervention and for those a significant cost-effectiveness could be achieved.* METHODS: Data were retrieved from the DelpHi-trial and analysis was based on 444 participants. Healthcare resource use, costs, QALY and incremental cost per QALY gained were measured over 24-month. Subgroup cost-effectiveness analysis was used to assess differences in variables. The probability of cost-effective was calculated at a wide range of willingness-to-pay margins and displayed using cost-effectiveness acceptability curves. The impact of dementia care management (DCM) on costs, QALYs and individual net-monetary-benefit was assessed by using multivariate regression models and interaction terms between PwD characteristics and intervention.* RESULTS: The probability of DCM being cost-effective for the entire sample was 86% at the willingness-to-pay threshold of 40,000€/QALY gained after 24 month. The probability of cost-effectiveness was higher in older PwD than in younger PwD (87% vs. 48%), in females than in males (96% vs. 16%) and in those living alone compared to those living with a caregiver (96% vs. 26%). The probability of the DCM being cost-effectiveness was much higher for PwD with a high functional (97%) and cognitive impairment (99%) compared to mild functional or cognitive deficits (69% and 76%) as well as in those having a high compared to a low comorbidity (96% vs. 27%).* CONCLUSIONS: The significant interactions indicated that for some subgroups a collaborative DCM is highly cost-effective. Especially, patients being female and living alone benefits most of such approaches. For those PwDs, healthcare payers could gain the highest cost savings and the highest effects by improving QALYs when such approaches will be implemented.

Ziel Beschreibung von Versorgungserwartungen von Patienten mit leichten kognitiven Storungen (PmMCI). Methoden Befragung von 51 PmMCI in einer facharztlichen Versorgerpraxis. Fragebogen in Anlehnung an die CANE-Beurteilungsskala. Kontrollvariablen u. a. MMST und GDS. Ergebnisse 35 % bzw 8 % erlebten die Gedachtnisstorungen als mittelschwer bzw. schwerwiegend und 27 % bzw. 8 % fuhlten sich im Alltag haufig bzw. andauernd beeintrachtigt. Uber 70 % waren trotz der Gedachtnisprobleme ausgeglichener Stimmung. Arztbezogene Erwartungen: Verlaufskontrolle (96 %), Demenz-Risikoabschatzung (73 %), Gedachtnistraining (55 %), medikamentose Behandlung (33 %). Medikamentenbezogene Erwartungen: spurbare Wirkung (41 %), Bereitschaft, Nebenwirkungen zu ertragen (29 %), Bevorzugung pflanzlicher Medikation (59 %). Nichtmedikamentose Therapieerwartungen: sportliche Aktivierung (63 %), Gedachtnistraining (51 %) und Ernahrungsberatung (37 %). Der Wunsch nach psychotherapeutischen Gesprachen (27 %) war mit hoheren Depressionswerten der GDS assoziiert. Schlussfolgerung PmMCI erlebten Gedachtnisstorungen als Belastung und Beeintrachtigung und erwarteten diagnostische und therapeutische Masnahmen. PmMCI mit depressiver Symptomatik erwarteten zusatzlich psychotherapeutische Gesprache.