Primary healthcare in transition – a qualitative study of how managers perceived a system change

BACKGROUND: Primary healthcare in Sweden has undergone widespread reforms in recent years, including freedom of choice regarding provider, freedom of establishment and increased privatisation. The key aims of the reforms were to strengthen the role of the patient and improve performance in terms of access and responsiveness. The aim of this study was to explore how managers at publicly owned primary healthcare centres perceived the transition of the primary healthcare system and the impact it has had on their work. METHODS: In this qualitative study, 24 managers of publicly owned primary healthcare centres in the metropolitan region of Gothenburg were recruited. Semi-structured interviews were conducted and data were analysed using content analysis inspired by Silverman. RESULTS: The analysis revealed two core themes: The transition is perceived as a rapid change, enforced mainly through financial incentives and Prioritisation conflicts arise between patient groups with different needs, demands and levels of empowerment. The transition has produced powerful and rapid effects that were considered to be both positive and negative. While the new financial incentives were seen as a driving force and a tool for change, they also became a stress factor due to uncertainty, competition with other primary healthcare centres and negative feelings associated with staff cutbacks. The shift in power towards the patient improved access and service but also led to more patients with unreasonable demands. Managers found it difficult to prioritise correctly between patient groups with different needs, demands and levels of empowerment and they were concerned about potentially negative effects on less empowered patients, e.g. multi-morbid patients. Managers also experienced shortcomings in their change management skills. CONCLUSIONS: This qualitative study shows the complexity of the system change and describes the different effects and perceptions of the transition from a manager’s perspective. This suggests a need for improved follow-up and control in order to monitor and govern system changes and ensure development towards a more effective and sustainable primary healthcare system

Online insomnia treatment-a review

Spiegelhalder K, Acker J, Baumeister H, et al. Digitale Behandlungsangebote für Insomnie – eine Übersichtsarbeit. SOMNOLOGIE. 2020;24(4):106-114.Zusammenfassung Digital angebotene psychologische Interventionen gegen Schlafstörungen sind aktuell ein sehr intensiv bearbeitetes Forschungsthema. In dieser Übersichtsarbeit werden Originalarbeiten und Metaanalysen zu diesem Thema zusammengefasst. Hierbei zeigt sich, dass die internetbasierte kognitive Verhaltenstherapie für Insomnie (KVT-I) bei Erwachsenen durchweg sehr effektiv ist mit allenfalls leicht geringeren Effektstärken als die gleiche Behandlung mit physischer Präsenz von Therapeuten und Patienten. Behandlungseffekte zeigen sich dabei auch für sekundäre Outcome-Parameter wie Depressivität, Angst, Fatigue und Lebensqualität. Hingegen lassen die Forschung zur Wirksamkeit der internetbasierten KVT‑I bei Erwachsenen mit komorbiden psychischen Störungen oder körperlichen Erkrankungen sowie die Forschung zur Frage, wieviel Therapeutenkontakt in die Behandlung integriert werden sollte, anscheinend noch keine abschließenden Antworten zu. In diesen Bereichen scheint weitere Forschung notwendig zu sein scheint.Digitally provided psychological interventions for sleep disorders are currently a very intensively researched topic. In this review, original work and meta-analyses are summarized. Thus, it was shown that internet-based cognitive behavioral therapy for insomnia (CBT-I) in adults is consistently very effective, with only slightly reduced effects compared with the same treatment with the physical presence of therapists and patients. Treatment effects are also shown for secondary outcome parameters such as depression, anxiety, fatigue, and quality of life. On the other hand, research on the effectiveness of internet-based CGT-I in adults with comorbid mental disorders or physical illnesses, and on the issue of how much contact with therapists should be integrated into treatment, does not seem to provide any conclusive answers. Further research seems to be needed in these areas

Approaches to ensure and improve quality at primary healthcare centres - a study of the effects of a structured patient-sorting system and a healthcare reform

Background: Primary healthcare in Sweden meets increased demands from an aging population concerning quality and accessibility while dealing with a growing shortage of general practitioners and imperfect efficiency. Initiatives in the delivery and governance of primary care services attempt to improve quality and performance, but frequently do not attain the targeted results. Aim: The thesis studies the effects of i) an initiative for improved health service delivery – the structured patient-sorting system (PSS) – and ii) a healthcare reform aiming to strengthen the patient’s role and to improve access and responsiveness through freedom of choice and establishment. Methods: A Swedish primary healthcare centre (PHCC) developed and implemented the PSS using improvement science methods. Changes in access rates and questionnaires on patients’ and staff members’ perceptions were analyzed quantitatively (Paper I). In a qualitative study (phenomenography) 11 staff members’ conceptions of the PSS were analyzed (Paper II). In another qualitative study (content analysis) the perceptions of 24 managers of publicly owned PHCCs about the changes through the healthcare reform in Region Västra Götaland were analyzed (Paper III). In an observational study the differences between privately and publicly owned PHCCs in Region Västra Götaland were quantitatively analyzed concerning the listed populations, the patient perceived quality, the prescription rates of antibiotics and benzodiazepines, and the rate of follow-up for certain chronic conditions (Paper IV). Results: The introduction of the PSS resulted in a 13% increase in the access rate on average, mainly through improved accessibility to physiotherapists and psychologists. More than 90% of the surveyed patients (n=96) were satisfied with both accessibility and treatment. 92% of staff members (n=36) were satisfied with the working situation. Staff members conceptualized the PSS as an appropriate platform for the transformation into an effective patient-centred team. Improvement of health service delivery, professional development and team development took place concurrently. Managers perceived the healthcare reform as a rapid change, enforced through financial incentives and leading to prioritization conflicts between patient groups with different care needs. In comparison with publicly owned PHCCs (n=114), privately owned PHCCs (n=86) were characterized by: urban overrepresentation (54%); smaller population sizes (avg. 5932 vs. 9432 individuals); overrepresentation of individuals of working age (62% vs. 56%) and belonging to the second most affluent socioeconomic quintile (26% vs. 14%); better results in perceived patient quality (82.4 vs. 79.6 points); higher 3-month prescription rates of antibiotics per 100 individuals (6.0 vs. 5.1 prescriptions) with a larger variance (SD 2.78 vs. 1.50); lower prescription rates of benzodiazepines; lower rates for follow-ups of chronic disease. While antibiotic use decreased, the use of benzodiazepines increased on average for all PHCCs over time. Conclusions: The findings indicate a more efficient use of all competences at the PHCC and the transformation into an effective team through the PSS. Prioritization conflicts between patient groups emerged after the healthcare reform and the question of the effect of the ownership type on quality could not be answered unambiguously. Further research is necessary to improve health service delivery and health system governance

Analysis of the key themes in the healthcare of older people with multimorbidity in Germany: a framework analysis as part of the LoChro trial

Objectives Multimorbidity challenges healthcare systems. In Germany, coordination of healthcare for older multimorbid patients remains unstructured.This study aims to identify key themes in the healthcare of these patients and the inter-relationships between them.Design Framework analysis of six cases based on 1-year data of primary and secondary care, patient-answered questionnaires and video material.Setting Southern Germany.Participants Six multimorbid older patients participating in a randomised controlled trial that compared usual care with a local, collaborative, stepped and personalised care management approach for older people with chronic diseases (LoChro-trial). The LoChro care intervention involved a care manager who assisted participants in self-management. The primary outcome was a composite of functional health and depressive symptoms at 12 and 18 months. The LoChro-intervention had no effect on the primary outcome.Primary outcome measure Key themes in the healthcare of older patients with multimorbidity and the inter-relationships between them.Methods One-year data included diagnoses, treatment plans, examinations, assessments and discharge reports. Patient perspectives were assessed using the Patient Assessment of Chronic Illness Care. In three cases, videos of the LoChro intervention showed patients describing their health needs. These data were evaluated by three doctors and public health researchers. Using framework analysis, recurring themes influencing the healthcare situation of multimorbid older patients and their inter-relationships were identified.Results Participants had an average age of 77, with 13 diagnoses, taking eight medications regularly. The five key themes describing the healthcare situation of these multimorbid patients were as follows: insufficient coordination, overuse and underuse of medical care, doctor and patient roles. Each theme covered three to four subcategories. The most significant inter-relationships between these themes were a lack of coordination leading to overuse and underuse of medical care. These were characterised by redundant inpatient stays, potential prescribing omissions and missed examinations. Deficiencies in vaccinations and secondary prevention were also demonstrated.Conclusion Coordination of care for multimorbid older patients in Germany is still deficient. Future healthcare arrangements should be explored with the participation of physicians and patients.Trial registration number LoChro trial: DRKS00013904

Integriertes Versorgungsmanagement für chronisch erkrankte ältere Menschen in der eigenen Häuslichkeit: Evidenz aus Cochrane-Reviews

Hintergrund Die Anzahl multipel chronisch erkrankter Älterer steigt, und Multimorbidität geht mit hoher Inanspruchnahme von Gesundheitsleistungen einher. Um Selbstständigkeit und Verbleib in der Häuslichkeit zu erhalten, wird zunehmend ein integriertes Versorgungsmanagement eingesetzt. Zur Wirksamkeit in der Zielgruppe der multipel chronisch erkrankten Älteren liegen aber kaum belastbare Daten vor. Ziel der Arbeit Bewertung der Wirksamkeit von integriertem Versorgungsmanagement bei Erwachsenen und Abschätzung der Übertragbarkeit auf ältere, multimorbide Personen in Deutschland. Methoden Systematische Literaturrecherche in der Cochrane Library mit Einschluss von Cochrane-Reviews (CR) zu (a) den 13 häufigsten Gesundheitsproblemen im Alter, mit (b) Komponenten des integrierten Versorgungsmanagements bei (c) Erwachsenen jeden Alters. Experten schätzten die Übertragbarkeit der eingeschlossenen CR auf multipel chronisch erkrankte Ältere in Deutschland ein. Ergebnisse Aus 1412 Treffern wurden 126 CR eingeschlossen. Zur Endpunktkategorie Selbstständigkeit und funktionale Gesundheit zeigten 25 CR klinisch relevante Ergebnisse mit moderater Evidenzqualität. Folgende Interventionskomponenten wurden – unter Berücksichtigung identifizierter Barrieren – als übertragbar eingeschätzt und könnten für ein effektives, indikationsspezifisch integriertes Versorgungsmanagement multipel chronisch erkrankter Älterer herangezogen werden: (1) körperliche Aktivierung, (2) multidisziplinäre Interventionen, (3) das Selbstmanagement verstärkende Interventionen, (4) kognitive Therapieverfahren, (5) telemedizinische Interventionen und (6) Disease-Management-Programme. Schlussfolgerungen Die identifizierten Komponenten sollten in versorgungs- und patientennahen randomisierten kontrollierten Studien auf Wirksamkeit bei gebrechlichen Älteren geprüft werden

Fluvoxamine for the treatment of COVID-19

Background Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI) that has been approved for the treatment of depression, obsessive compulsive disorder, and a variety of anxiety disorders; it is available as an oral preparation. Fluvoxamine has not been approved for the treatment of infections, but has been used in the early treatment of people with mild to moderate COVID-19. As there are only a few effective therapies for people with COVID-19 in the community, a thorough understanding of the current evidence regarding the efficacy and safety of fluvoxamine as an anti-inflammatory and possible anti-viral treatment for COVID-19, based on randomised controlled trials (RCTs), is needed. Objectives To assess the efficacy and safety of fluvoxamine in addition to standard care, compared to standard care (alone or with placebo), or any other active pharmacological comparator with proven efficacy for the treatment of COVID-19 outpatients and inpatients. Search methods We searched the Cochrane COVID-19 Study Register (including Cochrane Central Register of Controlled Trials, MEDLINE, Embase, ClinicalTrials.gov, WHO ICTRP, medRxiv), Web of Science and WHO COVID-19 Global literature on COVID-19 to identify completed and ongoing studies up to 1 February 2022. Selection criteria We included RCTs that compared fluvoxamine in addition to standard care (also including no intervention), with standard care (alone or with placebo), or any other active pharmacological comparator with proven efficacy in clinical trials for the treatment of people with confirmed COVID-19, irrespective of disease severity, in both inpatients and outpatients. Co-interventions needed to be the same in both study arms. We excluded studies comparing fluvoxamine to other pharmacological interventions with unproven efficacy. Data collection and analysis We assessed risk of bias of primary outcomes using the Cochrane Risk of Bias 2 tool for RCTs. We used GRADE to rate the certainty of evidence to treat people with asymptomatic to severe COVID-19 for the primary outcomes including mortality, clinical deterioration, clinical improvement, quality of life, serious adverse events, adverse events of any grade, and suicide or suicide attempt. Main results We identified two completed studies with a total of 1649 symptomatic participants. One study was conducted in the USA (study with 152 participants, 80 and 72 participants per study arm) and the other study in BraziE (study with 1497 high-risk participants for progression to severe disease, 741 and 756 participants per study arm) among outpatients with mild COVID-19. Both studies were double-blind, placebo controlled trials in which participants were prescribed 100 mg fluvoxamine two or three times daily for a maximum of 15 days. We identified five ongoing studies and two studies awaiting classification (due to translation issues, and due to missing published data). We found no published studies comparing fluvoxamine to other pharmacologica interventions of proven efficacy. We assessed both included studies to have an overall high risk of bias. Fluvoxamine for the treatment of COVID-19 in inpatients We did not identify any completed studies of inpatients. Fluvoxamine for the treatment of COVID-19 in outpatients Fluvoxamine in addition to standard care may slightly reduce all-cause mortality at day 28 (RR 0.69, 95% Cl 0.38 to 1.27; risk difference (RD) 9 per 1000; 2 studies, 1649 participants; low-certainty evidence), and may reduce clinical deterioration defined as all-cause hospital admission or death before hospital admission (RR 0.55, 95% CI 0.16 to 1.89; RD 57 per 1000; 2 studies, 1649 participants; low-certainty evidence). We are very uncertain regarding the effect of fluvoxamine on serious adverse events (RR 0.56, 95% CI 0.15 to 2.03; RD 54 per 1000; 2 studies, 1649 participants; very low-certainty evidence) or adverse events of any grade (RR 1.06, 95% CI 0.82 to 1.37; RD 7 per 1000; 2 studies, 1649 participants; very low-certainty evidence). Neither of the studies reported on symptom resolution (clinical improvement), quality of life or suicide/suicide attempt. Authors' conclusions Based on a low-certainty evidence, fluvoxamine may slightly reduce all-cause mortality at day 28, and may reduce the risk of admission to hospital or death in outpatients with mild COVID-19. However, we are very uncertain regarding the effect of fluvoxamine on serious adverse events, or any adverse events. In accordance with the living approach of this review, we will continually update our search and include eligible trials as they arise, to complete any gaps in the evidence

REDuction of Antibiotic RESistance (REDARES) in urinary tract infections using treatments according to national clinical guidelines: study protocol for a pragmatic randomized controlled trial with a multimodal intervention in primary care

Background: Urinary tract infections (UTIs) are a common cause of prescribing antibiotics in family medicine. In Germany, about 40% of UTI-related prescriptions are second-line antibiotics, which contributes to emerging resistance rates. To achieve a change in the prescribing behaviour among family physicians (FPs), this trial aims to implement the guideline recommendations in German family medicine. Methods/design: In a randomized controlled trial, a multimodal intervention will be developed and tested in family practices in four regions across Germany. The intervention will consist of three elements: information on guideline recommendations, information on regional resistance and feedback of prescribing behaviour for FPs on a quarterly basis. The effect of the intervention will be compared to usual practice. The primary endpoint is the absolute difference in the mean of prescribing rates of second-line antibiotics among the intervention and the control group after 12 months. To detect a 10% absolute difference in the prescribing rate after one year, with a significance level of 5% and a power of 86%, a sample size of 57 practices per group will be needed. Assuming a dropout rate of 10%, an overall number of 128 practices will be required. The accompanying process evaluation will provide information on feasibility and acceptance of the intervention. Discussion: If proven effective and feasible, the components of the intervention can improve adherence to antibiotic prescribing guidelines and contribute to antimicrobial stewardship in ambulatory care

Encouragement of patients’ self-management in primary care for the prevention of cardiovascular diseases (DECADE): protocol for a cluster randomised controlled trial

Introduction Cardiovascular diseases are the most common cause of death in Germany and among the most frequent reasons for encounters in primary care. Most patients with cardiovascular risks (CVRs) have difficulties implementing health-promoting behavioural changes. In this study, a complex intervention containing evidence-based patient materials and structured follow-up consultations are intended to strengthen patients’ self-management to improve health behaviour.Methods and analysis In this cluster randomised controlled trial, we investigate the effects of the intervention Decision aid, action planning and follow-up support for patients to reduce the 10-year risk of cardiovascular diseases (DECADE) using a 2×2 design. All patients, including the control group (CG), receive a CVR calculation. Three intervention groups (IGs) receive one or both of two different components of the DECADE intervention: IG1 (patient materials), IG2 (follow-up consultations) and IG3 (patient materials and follow-up consultations). The study was planned to be conducted with 77 general practitioners in 3 German regions and a target sample size of 924 patients. The observation period for each patient amounts to 12 months with three patient surveys: baseline (t0), after 6 and 12 months (t1 and t2). The primary outcome is patient activation (Patient Activation Measure 13 (PAM13-D)) at t1. Secondary outcomes include PAM13-D at t2 and further patient-reported and clinical outcomes at t1 and t2. We will also analyse the cost-effectiveness of the intervention, the degree of usage and satisfaction with the intervention.Ethics and dissemination The study was first approved by the lead ethics committee of the University of Freiburg on 15 April 2021 (vote number: 21-1078) and subsequently by the other ethics committees in the study regions (Ethics committee of medical association Baden-Württemberg (B-F-2021-078), Ethics Committee of the Technische Universität Dresden, Dresden (BO-EK-251052021), Ethics Committee of the State Chamber of Physicians of Saxony (EK-BR-92/21-1), Ethics Committee of the Hamburg Medical Association (2021-200013-BO-bet)). Informed consent is required for patients to participate in the study. The results of this study will be published in peer-reviewed journals and presented at congresses by the DECADE team. The DECADE lead management will communicate the results to the funder of this study.Trial registration number German Clinical Trials Register, DRKS00025401 (registration date: 21 June 2021); International Clinical Trials Registry Platform, DRKS00025401