Coordination of care for multimorbid patients from the perspective of general practitioners - a qualitative study

BACKGROUND: In Germany, a decreasing number of general practitioners (GPs) face a growing number of patients with multimorbidity. Whilst care for patients with multimorbidity involves various healthcare providers, the coordination of this care is one of the many responsibilities of GPs. The aims of this study are to identify the barriers to the successful coordination of multimorbid patient care and these patients' complex needs, and to explore the support needed by GPs in the care of multimorbid patients. Interviewees were asked for their opinion on concepts which involve the support by additional employees within the practice or, alternatively, external health care professionals, providing patient navigation. METHODS: Thirty-two semi-structured, qualitative interviews were conducted with 16 GPs and 16 medical practice assistants (MPAs) from 16 different practices in Berlin. A MPA is a qualified non-physician practice employee. He or she undergoes a three years vocational training which qualifies him or her to provide administrative and clinical support. The interviews were digitally recorded, transcribed and analysed using the framework analysis methodology. RESULTS: The results of this paper predominantly focus on GPs' perspectives of coordination within and external to general practice. Coordination in the context of care for multimorbid patients consists of a wide range of different tasks. Organisational and administrative obstacles under the regulatory framework of the German healthcare system, and insufficient communication with other healthcare providers constitute barriers described by the interviewed GPs and MPAs. In order to ensure optimal care for patients with multimorbidity, GPs may have to delegate responsibilities associated with coordinating tasks. GPs consider the deployment of an additional specifically qualified employee inside the general practice to take on coordinative and social and legal duties to be a viable option. CONCLUSIONS: The cross-sectoral cooperation between all involved key players working within the healthcare system, as well as the coordination of the whole care process, is seemingly challenging for GPs within the complex care system of multimorbid patients. GPs are generally open to the assignment of a person to support them in coordination tasks, preferably situated within the practice team

COMPARATIVE ANALYSIS OF FOREST PLANTATIONS CUTTING AGE BASED ON VOLUMETRIC AND GRAVIMETRIC UNITS

The objective of this work was to evaluate the technical and economic cutting age of forest plantations considering the wood market under volumetric and gravimetric measurement units. Volumetric production and wood basic density for Eucalyptus urophylla clones stands were obtained from a forest company in the Jequitinhonha’s region, Minas Gerais State, for ages of 3 to 9 years. It was estimated: mass per hectare; technical cutting age (TCA) for volume and mass; and economic viability at different interest rates. Data was divided by three clones, being the denser (C), passing through (B) median density, and less denser (A). The results showed that in alternating volumetric for gravimetric unit, the TCA occurs at least one year later. For the economic analysis, the results demonstrated that projects for wood commercialization by gravimetric measurement are economically viable when using high-density clones, due to the higher amount of mass per volume. For clones with low density and high volumetric productivity, the analysis must be done from a volumetric point of view, as the economic results were 23% higher than in the mass analysis. It was concluded that the adoption of the gravimetric unit of measure in the forest sector tends to cause significant changes in project management, improving wood characteristics for energy by postponing the cutting age and making more sensible the genetic material selection

Support for General Practitioners in the Care of Patients with Complex Needs: A Questionnaire Survey of General Practitioners in Berlin

OBJECTIVES Because of demographic changes, new models of care are important for supporting general practitioners in the care of patients with complex needs. This study addresses the question of the type of support that is requested by general practitioners working in Berlin. METHODS All general practitioners working in Berlin (n=2354) were asked between August and September 2018 to return a questionnaire by post which has been developed for this study. Questions addressed support needs as well as support models within the practice (delegation, substitution) and outside the practice (social worker, navigator, community care points). Data were analysed descriptively and by exploratory multivariate analysis to show the influence of practice and doctor characteristics on the preference of support models (age, gender, location of the practice, type of practice, working hours). RESULTS A total of 557 questionnaires (response rate 23.7%) were included in the analysis. Need for support was seen particularly for administrative, coordinative and organisational tasks and for advice on social issues. The majority of the study participants approved delegation and substitution. In their view, it was conceivable to get support from professionals or institutions outside their practice, such as mobile care services, community care points, social workers or navigators. Particularly younger and female doctors working in group practices were open for cooperative care models integrating other health professions. CONCLUSIONS There is unused potential for delegation and cooperation within existing structures. Further research should investigate the acceptance and feasibility of different support models.ZIEL Vor dem Hintergrund der demografischen Entwicklung werden zukünftig Versorgungsmodelle wichtig, die Hausärzte in der Versorgung von Patienten mit komplexem Bedarf unterstützen können. Die vorliegende Fragebogenstudie untersucht, welche Formen der Unterstützung sich Berliner Hausärzte wünschen. METHODIK Alle niedergelassenen Hausärzte Berlins (n=2354) wurden im Zeitraum August bis September 2018 postalisch gebeten, einen für die Fragestellung entwickelten Fragebogen auszufüllen. Die Fragen adressierten den Unterstützungsbedarf sowie verschiedene Unterstützungsmodelle. Es wurde zwischen Unterstützungsmöglichkeiten innerhalb (Delegation, Substitution) und außerhalb (Sozialarbeiter, Versorgungslotsen, Pflegestützpunkt) von Hausarztpraxen differenziert. Die Auswertung erfolgte deskriptiv, sowie explorativ multivariat in Bezug auf Zusammenhänge zwischen der Zustimmung zu Unterstützungsmodellen und Praxis- bzw. Arztcharakteristika (Alter, Geschlecht der Ärzte, Lage der Praxis, Praxisform, Arbeitszeit). ERGEBNISSE 557 Fragebögen (Response Rate 23,7%) wurden ausgewertet. Unterstützungsbedarf wurde v. a. für administrative, koordinative und organisatorische Tätigkeiten gesehen sowie für soziale und sozialrechtliche Fragestellungen. Ein Großteil der teilnehmenden hausärztlichen Praxen steht sowohl der Delegation als auch der Substitution ärztlicher Leistungen positiv gegenüber. Darüber hinaus ist für Hausärzte auch Unterstützung außerhalb der eigenen Praxis durch Mitarbeiter eines ambulanten Pflegedienstes, eines Pflegestützpunktes, oder durch Sozialarbeiter und Versorgungslotsen vorstellbar. Insbesondere jüngere und weibliche Hausärzte sowie diejenigen, die bereits in kooperativen Praxis-Strukturen tätig sind, sind offen für kooperative Ansätze unter Einbeziehung weiterer Gesundheitsberufe. SCHLUSSFOLGERUNG Es bestehen noch unzureichend genutzte Potenziale der Delegation und der Kooperation mit bestehenden Strukturen. Die hier befragten Berliner Hausärzte zeigten ein hohes Maß an Zustimmung zu Delegation und Substitution. Aber auch Gesundheitsberufe und Institutionen außerhalb der eigenen Praxis könnten die Hausärzte stärker unterstützen. Insbesondere für administrative und koordinative Tätigkeiten sowie für soziale und sozialrechtliche Fragestellungen wird Unterstützungsbedarf gesehen. In weiteren Untersuchungen sollte die Akzeptanz unter der Ärzteschaft und die Machbarkeit unterschiedlicher Modelle weiter untersucht werden

Measuring the burden of infodemics : summary of the methods and results of the fifth WHO infodemic management conference

Background: An infodemic is excess information, including false or misleading information, that spreads in digital and physical environments during a public health emergency. The COVID-19 pandemic has been accompanied by an unprecedented global infodemic that has led to confusion about the benefits of medical and public health interventions, with substantial impact on risk-taking and health-seeking behaviors, eroding trust in health authorities and compromising the effectiveness of public health responses and policies. Standardized measures are needed to quantify the harmful impacts of the infodemic in a systematic and methodologically robust manner, as well as harmonizing highly divergent approaches currently explored for this purpose. This can serve as a foundation for a systematic, evidence-based approach to monitoring, identifying, and mitigating future infodemic harms in emergency preparedness and prevention. Objective: In this paper, we summarize the Fifth World Health Organization (WHO) Infodemic Management Conference structure, proceedings, outcomes, and proposed actions seeking to identify the interdisciplinary approaches and frameworks needed to enable the measurement of the burden of infodemics. Methods: An iterative human-centered design (HCD) approach and concept mapping were used to facilitate focused discussions and allow for the generation of actionable outcomes and recommendations. The discussions included 86 participants representing diverse scientific disciplines and health authorities from 28 countries across all WHO regions, along with observers from civil society and global public health–implementing partners. A thematic map capturing the concepts matching the key contributing factors to the public health burden of infodemics was used throughout the conference to frame and contextualize discussions. Five key areas for immediate action were identified. Results: The 5 key areas for the development of metrics to assess the burden of infodemics and associated interventions included (1) developing standardized definitions and ensuring the adoption thereof; (2) improving the map of concepts influencing the burden of infodemics; (3) conducting a review of evidence, tools, and data sources; (4) setting up a technical working group; and (5) addressing immediate priorities for postpandemic recovery and resilience building. The summary report consolidated group input toward a common vocabulary with standardized terms, concepts, study designs, measures, and tools to estimate the burden of infodemics and the effectiveness of infodemic management interventions. Conclusions: Standardizing measurement is the basis for documenting the burden of infodemics on health systems and population health during emergencies. Investment is needed into the development of practical, affordable, evidence-based, and systematic methods that are legally and ethically balanced for monitoring infodemics; generating diagnostics, infodemic insights, and recommendations; and developing interventions, action-oriented guidance, policies, support options, mechanisms, and tools for infodemic managers and emergency program managers.peer-reviewe

Beyond interoperability to digital ecosystems: regional innovation and socio-economic development led by SMEs

This paper shows the early results of new research on how Digital Ecosystems can promote new modes of sustainable e-business practices, for Small and Medium-Sized Enterprises (SMEs), using an open architecture for content sharing and Business-to-Business (B2B) interactions in the knowledge economy, and within a framework of open standards. The current e-business practices and technologies do not always encourage openness but instead tend to promote established models of proprietary e-business development based on centralised network and service infrastructure. Governments can promote open developments by supporting opportunities for new entry through supporting and augmenting a market environment for the productive coexistence of large and small companies in the B2B e-commerce domain

External evaluation of the AGnES-Project in the State of Mecklenburg–Western Pomerania, German

Hintergrund: In Deutschland besteht durch eine ungünstige Verteilung zwischen ländlichen und städtischen Gebieten ein Ärztemangel, der von einer ebenso unproportionalen Verteilung zwischen alten und neuen Bundesländern begleitet wird. Die regionalen KVen der betroffenen Bundesländer erproben seit einigen Jahren entsprechende Maßnahmen, um Ärzte für defizitär versorgte Regionen zu gewinnen. Die Kassenärztliche Vereinigung Mecklenburg Vorpommern (KVMV) beauftragte das Institut für Allgemeinmedizin der Charité mit der unabhängigen Evaluierung der in Mecklenburg-Vorpommern (MV) realisierten „arztentlastenden, gemeindenahen, E-Health gestützten systemischen Intervention“ (AGnES-Projekt), um gemäß internationaler Empfehlungen zur Programmevaluierung die durch den Projektträger (Institut für Community Medicine der Universität Greifswald) vorgenommene interne Projektevaluierung zu ergänzen. Die unabhängige Evaluierung wurde als Spätevaluierung konzipiert. Methodik: In der Zeit vom 01.02.2008 bis 30.12.2008 wurden folgende Arbeitsbereiche realisiert: 1\. Quantitative Befragung aller Hausärzte MVs zur Einstellung gegenüber dem AGnES-Projekt; möglich-delegierbare Anteile der Hausbesuchstätigkeit; erforderliche Kompetenzen von Arzthelferinnen; Präferenzen und Selbstverständnis bezüglich berufsübergreifender Behandlungssteuerung, 2\. Fallbezogene Vorher-Nachher-Studie von Patienten-Outcomes bei über 75 jährigen Patienten mit Hochdruck und Diabetes, die im Hausbesuch ≥ fünf mal von AGnES- Schwestern in MV betreut wurden 3\. Qualitative Befragung der am AGnES-Projekt beteiligten Ärzte und Arzthelferinnen Ergebnisse: An der quantitativen Befragung beteiligten sich 515 von 1096 registrierten Hausärzten (47 %). Die Akzeptanz des AGnES-Konzeptes war bei der Hausärzteschaft MVs relativ hoch. Die Delegierung wurde vor allem von jüngeren Ärzten und Hausärztinnen befürwortet, die auch schon zum Zeitpunkt der Befragung Hausbesuche durch ihre medizinischen Fachangestellten (MFAs) durchführen ließen. Vor allem würden Hausärzte Tätigkeiten delegieren wie z. B. Temperaturmessung, Blutzuckerbestimmung, Blutdruckmessung und Blutentnahme (venös). Der Übernahme der erforderlichen Qualifizierung der MFAs für die Hausbesuchsdurchführung stand die Mehrzahl der Befragten ablehnend gegenüber. Im Rahmen der fallbezogenen Vorher-Nachher-Studie konnten 24 über 75-jährige Patienten mit Hochdruck und Diabetes eingeschlossen werden, die mindestens fünf Mal zusätzlich im Hausbesuch pro Jahr betreut wurden. Es resultierten bei ihnen häufigere Kontrollen und bessere Einstellungen der medizinischen Parameter (Blutdruck, Blutzucker, HbA1C, Kreatinin). Die Berufszufriedenheit der Hausärzte und der AGnES-Schwestern wurde positiv beeinflusst. Schlussfolgerung: Die Beteiligung der Hausärzte aus MV an der Befragung zum AGnES Projekt war überdurchschnittlich gut und kennzeichnet ihr großes Interesse an der Problematik. Die Meinung der Hausärzte sollte bei der Entwicklung zukünftiger arztentlastender Versorgungskonzepte stärker berücksichtigt werden, um die Attraktivität der strukturschwachen Regionen für den Nachwuchs zu erhöhen. Die Delegierung von Hausbesuchstätigkeiten an MFAs unterstützt die Anerkennung dieser Berufsgruppe. Zukünftig könnten komplexe populationsbezogene sektorenübergreifende Versorgungsnetze mögliche Lösungswege für eine optimierte Versorgung multimorbider älterer Patienten insbesondere in strukturschwachen ländlichen Regionen darstellen.Background: Germany’s crisis in ambulatory adult care is characterized by shortages in numbers and maldistribution of primary care practitioners (PCPs) particularly in rural areas and in the eastern states. Regional associations of statutory health insurance physicians (KV) in the affected states are trying out different measures to entice physicians. The KV of Mecklenburg Western Pomerania (MV) commissioned the Institute for General Medicine of the Charité-Universitätsmedizin Berlin to independently evaluate the AGnES project, in accordance with international guidelines for program evaluation. This evaluation was conducted independently from the project implementors (Institut für Community Medicine der Universität Greifswald). Methods: This study, conducted between February and December 2008, included three phases: 1\. quantitative postal survey of all PCPs working in MV, regarding their attitude towards the AGnES project, identification of home visit tasks they would delegate to a qualified practice assistant (MFA), their preferred profile, organizational and preventive skills expected of an MFA conducting home visits 2\. Before and after study on patient outcomes, of all patients aged ≥75 with hypertension and diabetes receiving at least five home visits from the MFA during the study period 3\. Qualitative interviews of all PCPs and MFAs participating in the AGnES project Results: 515 of 1096 (47 %) registered PCPs responded the survey. The acceptance of home visits delegation to qualified MFAs was high. Delegation was mainly supported by younger, female and those PCPs already informally delegating some home visits to their MFAs. Home visit tasks acceptable for delegation were identified (i.e. take temperature, measure blood sugar, take blood pressure and obtain venous blood samples). PCPs were finding it too expensive to cover costs of PAs’ training. The before and after study included 24 patients. They showed improved outcomes regarding the number of controls and medical parameters values (blood pressure, blood sugar, HbA1C, Creatinine). Participation in the AGnES project had a positive effect on the work satisfaction of PCPs and MFAs. Conclusions: The high response rate (almost 50%) shows the relevance of the topic to PCPs in MV. The opinion and perceptions of PCPs practicing in affected areas should be taken into account when introducing health care reforms and strategies aiming to attract young PCPs to rural areas. Delegation of home visits to MFAs supports the mutual recognition of cadres. Complex population based integrated interventions to improve health care delivery should include addressing solutions to improve the quality and delivery of care to older patients in rural regions

Reasons for women aged 50 years and older to seek gynaecological advice and treatment

PlatzhalterPeer Reviewe

Aplicando Investigación de Politicas y Systemas de Salud a la Atención Primaria en Medicina General y Familiar

Health policy defines health systems and health care provision, including specifying the role of primary care. Primary care can be understood as the first contact-point between the health care system and the served population. In some countries, like in Germany, Primary Care Practice can function as the bridge between health policy and Primary Care Physicians (PCPs). Primary Care Practice is responsible for the implementation of the rules and regulations established in health policy and for bridging policy with the needs of PCPs. When it comes to implementing new health policies, PCPs play a critical role as leaders of change. Their support can be instrumental in steering policy reforms, but they can also act as barriers to change. Resistance from PCPs may occur when they lack sufficient information about the new health regulations and policies proposed, when they don't see the need for reform, or when they have been excluded from the health policy development process. Therefore, it is important to engage and inform PCPs throughout the policy development process to ensure successful implementation and support. Currently, shortages and maldistribution of health workforces in PHC is a challenge not limited to Germany, but to our global health systems. The work focused on Germany´s context highlights the urgent need to address the issues of workforce maldistribution and unattractive working conditions, particularly in rural regions, which has persisted for years and gendersensitivity design of primary care. Primary Care Practice has a crucial leadership role in ensuring a high performing primary care. To encourage and support the next generation of General Practitioner (GPs), Primary Care Practice must be ready to innovate and find solutions that go beyond current rules and regulations. Health care reform and new heath policies is paramount to improve and maintain health care delivery. With this comes the evaluation, monitoring of progress, managing of change, and communication in a dynamic environment in midst of multiple, often diverging stakeholder interests. The ability of Primary Care Practice to innovate is a predictor of the resilience of the health system and its capacity to adapt and cope with performance challenges necessary for the health system to achieve its purpose. Through applying HPSR and systems thinking, this work assessed the introduction of health reforms in primary care and the design and proposal of a new model of care focusing on a patient-centered, share-care approach in ambulatory settings, This work evaluated the level of acceptance and uptake of introduced reforms on task-shifting and task-sharing (vertical collaboration, amongst PCPs and non-medical personnel), which addressed shortages of GPs in Germany, as well as evaluated the distribution of gender and labor wastage amongst health workforce in Mexico and exploring interprofessional collaboration (horizontal collaboration amongst PCPs). From these analyses, it was possible to identify challenges and opportunities for greater participatory methods, such as co-designing a new provision model of collaborative patient-centered-shared primary care by GPs and Gyns for women over 50 years that included a new financing mechanism. Beyond scientific publications, the communication strategy of these projects included policy briefs, fact sheets, briefs, and full policy reports to inform stakeholder groups who presented results at multiple national and international conferences as well as project specific meetings. It is crucial to understanding target groups and their power-relationships before formulating health policy recommendations for innovating Primary Care Practice in Germany. The introduction of a new health policy reform should be accompanied by a tailored information campaign. When evaluating health systems, the HPSR approach and systems thinking methods can bridge diverse paradigms of disciplines that can greatly aid in designing and introducing health policy reforms targeting PCPs to allow for participation and co-creation across all stakeholders. The work has shown that the application of HPSR in the design and implementation of health systems research efforts are an effective method to assess and address primary care challenges and propose innovations to Primary Care Practice and health policy. HPSR and systems thinking takes into account the complexity of the real-life-context in which PCPs provide services, which allows for more concrete, impactful recommendations for policy and practice (such as those pertaining to task-shifting), the uptake of reforms, collaboration on policy formulation, new models of care, and remuneration that reflect the pulse of primary care. Applying these approaches to Primary Care Practice can contribute to closing the gap between health policy and the practitioner’s realities in primary care service delivery, ultimately improving the function of health systems in upholding patients’ health. The higher specificity of the formulated solutions and the responsiveness of policy and practice to the pressing challenges of PCPs and patients facilitates the uptake of relevant, timely and needed reforms. HPSR has shown promise as a valuable tool for driving change and innovation in Primary Care Practice. It offers a suitable theoretical and methodological framework for the adoption of research findings by policymakers, PCPs, and society as a whole. By bridging the gap between policy regulations and the realities faced by PCPs and patients, HPSR has the potential to effectively translate research into tangible improvements in healthcare delivery

Collaboration amongst general practitioners and gynaecologists working in primary health care in Germany: a cross-sectional study

Aim: This cross-sectional study is the first one to explore the collaboration of the influencing factors thereof amongst general practitioners (GPs) and gynaecologists (Gyns) working in primary care in urban and rural settings in Germany. Background: The number of women aged >= 50 years is predicted to increase in the next years in Germany. This coincides with the ageing of primary care specialists providing outpatient care. Whereas delegation of tasks to nurses as a form of interprofessional collaboration has been the target of recent studies, there is no data regarding collaboration amongst physicians in different specialisations working in primary care. We explored collaboration amongst GPs and Gyn regarding the healthcare provision to women aged >= 50 years. Methods: A quantitative postal survey was administered to GPs and Gyns in three federal states in Germany, focusing on care provision to women aged >= 50 years. A total of 4545 physicians, comprising 3514 GPs (67% of the total GP population) randomly selected, and all 1031 Gyns practicing in these states received the postal survey in March 2018. A single reminder was sent in April 2018 with data collection ending in June 2018. Multiple logistic regressions were performed for collaboration, adjusted by age and sex, alongside descriptive methods. Findings: The overall response rate was 31% (1389 respondents): 861 GPs (25%) and 528 Gyns (51%), with the mean respondent age being 54.4 years. Seventy-two per cent were female. Key competencies of collaboration are associated with working in rural federal states and with network participation. Physicians from rural states [odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.2, 1.9] and physicians in networks (OR = 3.0, CI = 2.3, 3.9) were more satisfied with collaboration. Collaboration to deliver services for women aged >= 50 years is more systematic amongst GPs and Gyns who are members of a network; increased networking could improve collaboration, and ultimately, outcomes too