Verbesserung der ambulanten Versorgungssituation chronisch-entzündlicher Erkrankungen in Deutschland

In Deutschland besteht im ambulanten Bereich eine Unterversorgung für Patienten mit chronisch-entzündlichen Erkrankungen. In den Fachbereichen der Rheumatologie, Dermatologie und Gastroenterologie wurden die Behandlungserfolge in den letzten Jahren durch den Einsatz von verbesserten Therapieoptionen mit Biologika deutlich gesteigert, jedoch ist diese Therapie mit erheblichem Aufwand für Behandler und enormen Kosten für Kostenträger verbunden. Die Zahl der an chronisch-entzündlichen Erkrankung leidender Menschen steigt. Die Erkrankungen die in der vorliegenden Dissertation vornehmlich behandelt werden sind die Rheumatoide Arthritis, Psoriasis-Arthritis, Spondylarthrits, Psoriasis sowie chronisch-entzündliche Darmerkrankungen. Es besteht ein Fachärztemangel, der dazu führt, dass beispielsweise im Fachbereich Rheumatologie nur etwa die Hälfte des berechneten Bedarfs gedeckt werden kann. Die ärztlichen Ressourcen, die zur Verfügung stehen, werden häufig durch eine unzulängliche Patientensteuerung gebunden. Hinzu kommt die Allokation von Aufgaben, die ohne Qualitätsverluste durch nichtmedizinische Mitarbeitende übernommen werden könnten. Das Ziel dieser Dissertation liegt in der Untersuchung verschiedener Lösungsansätze, um der Unterversorgung von Patienten mit entzündlichen Erkrankungen entgegenzuwirken. Hierfür wird anhand von insgesamt acht Modulen zunächst der aktuelle Stand sowie der Veränderungsbedarf in Deutschland dargelegt. Darauffolgend werden drei sich potentiell ergänzende Ansätze vorgestellt, untersucht und methodische Aspekte für die Bewertung neuer Versorgungsformen aufgeführt. Das Modell „Vier Säulen der Delegation und Stand der Umsetzung“ (Hoeper et al., 2023 [1]) wird für die Einordnung der Module verwendet und erweitert. In den letzten Jahren wurde durch den Innovationsfonds des Gemeinsamen Bundesausschusses die Vorstellung und Untersuchung neuer Versorgungsformen ermöglicht. Zwei der geförderten Projekte sowie ein Sub-Projekt bilden den Hauptteil der vorliegenden Dissertation. Durch den Einsatz verschiedener Methoden und aufeinander aufbauende Projekte konnten erste Ergebnisse für Deutschland geliefert werden, die die Nicht-Unterlegenheit der Delegation ärztlicher Aufgaben an medizinische Fachangestellte im Fachbereich der Rheumatologie aufzeigen. Außerdem konnte durch Koordinationszentralen die Verbesserung der Patientensteuerung und daraus resultierend verkürzte Zeiten bis zur Diagnose und Therapie erreicht werden. Ergänzend ist die Verbesserung des eigenständigen Krankheitsmanagements von Patienten ein wichtiger Ansatz der auf partizipationsorientierte Ziele, die weiter als die medikamentöse Therapie reichen, eingeht. Die verschiedenen Ansätze sind gut miteinander zu verknüpfen. Dennoch ist in Zukunft unter anderem ein aktives Handeln der Politik sowie ein Blick in andere Länder notwendig, um langfristige Veränderungen erreichen zu können.In Germany, there is a lack of outpatient care for patients with chronic inflammatory diseases. In the fields of rheumatology, dermatology, and gastroenterology, treatment outcomes have significantly improved in recent years due to the use of enhanced therapeutic options with biologics. However, this treatment is associated with substantial effort for healthcare providers and enormous costs for payers. The number of people suffering from chronic inflammatory diseases is increasing. The main diseases addressed in this dissertation are rheumatoid arthritis, psoriatic arthritis, spondylarthritis, psoriasis, and chronic inflammatory bowel diseases. There is a shortage of specialist doctors, resulting in only about half of the calculated demand being met in fields such as rheumatology. The available medical resources are often tied up due to inadequate patient management. In addition, there is a potential for non-medical staff to assume tasks without compromising quality. The goal of this dissertation is to examine various approaches to counteracting the undersupply of patients with inflammatory diseases. To achieve this, the current situation and the need for change in Germany are first presented using a total of eight modules. Subsequently, three potentially complementary approaches are introduced, investigated, and methodological aspects for evaluating new forms of care are outlined. The "four pillars of delegation and implementation status" model (Hoeper et al., 2023 [1]) is used to classify and expand upon the modules. In recent years, the Innovation Fund of the Joint Federal Committee has facilitated the presentation and examination of new forms of care. Two of the funded projects, along with a sub-project, form the main part of this dissertation. Through the use of different methods and consecutive projects, initial results have been obtained for Germany, demonstrating the non-inferiority of delegating medical tasks to medical assistants in the field of rheumatology. Additionally, the implementation of coordination centers has improved patient management, resulting in shorter times to diagnosis and therapy. Furthermore, improving patients' independent disease management is an important approach that addresses participatory goals extending beyond medication therapy. These various approaches can be well integrated. However, in the future, proactive action by policymakers and an examination of other countries will be necessary to achieve longterm changes

Delegation ärztlicher Leistungen an rheumatologische Fachassistenten: Effekte auf Depression und Angst bei Patienten mit rheumatoider Arthritis

Background: At least 1 comorbidity occurs in 80% of patients with rheumatoid arthritis (RA). In addition to cardiovascular comorbidities psychological comorbid conditions are common. The prevalence of depression and anxiety is higher in patients than in the general population. Screening for comorbidities is crucial. A shortage of outpatient specialist care barely allows resources for this. The implementation of team-based care holds the potential to improve the standard of care while simultaneously working against the shortage of care. Objective: The aim of the study was to examine the effects of care on the course of depression and anxiety in patients with seropositive RA and active disease. Material and methods: A multicenter pragmatic randomized controlled trial was conducted over the course of 1 year with 224 patients. After baseline, five more visits followed. In the intervention group (IG), three were initially carried out by qualified rheumatological assistants. Depression, anxiety and patient satisfaction with outpatient care were looked at in detail. Results: In the IG the anxiety symptoms significantly improved over 12 months (p = 0.036). The proportions of patients with anxiety also significantly changed in the IG (p < 0.001), while there was no change in the control group between baseline and month 12. The values of the depression scale did not differ significantly (p = 0.866). In terms of the information dimension of the satisfaction questionnaire, patients in the IG felt significantly better informed after 6 months (p = 0.013) and 12 months (p = 0.003). Conclusion: A positive effect of team-based care on the course of depression and anxiety in patients with seropositive RA and active disease could be shown.Hintergrund: Bei 80 % der Patienten mit einer rheumatoiden Arthritis (RA) tritt mindestens eine Komorbidität auf. Neben kardiovaskulären Komorbiditäten sind psychische Erkrankungen häufig. Die Prävalenz von Depression und Angst ist bei Betroffenen höher als in der Allgemeinbevölkerung. Ein Screening auf Komorbidität ist hoch relevant. Die Unterversorgung im fachärztlichen Bereich lässt dies kaum zu. Die Implementierung einer Visite durch die rheumatologische Fachassistenz (RFA) bietet Potenzial, die Versorgung zu verbessern und der Unterversorgung zu begegnen. Fragestellung: Ziel ist, Auswirkungen einer teambasierten Versorgung auf den Verlauf von Depression und Angst bei Patienten mit einer seropositiven RA im Krankheitsschub zu untersuchen. Material und Methoden: Es handelt sich um eine multizentrische, pragmatische, randomisierte, kontrollierte Studie über 1 Jahr mit 224 Patienten. Nach Baseline folgen 5 Visiten. In der Interventionsgruppe (IG) fanden 3 zunächst bei der RFA statt. Depression, Angst und Behandlungszufriedenheit werden genauer betrachtet. Ergebnisse: In der IG hat sich die ängstliche Symptomatik über 12 Monate signifikant verbessert (p = 0,036). Auch die Anteile der Patienten mit Ängstlichkeit verändern sich signifikant in der Interventionsgruppe (p < 0,001), während es in der Kontrollgruppe im Vergleich zwischen Baseline und Monat 12 zu keiner Veränderung kam. Die Werte der Depressionsskala unterschieden sich nicht signifikant (p = 0,866). Bei der Dimension „Information“ des Zufriedenheitsfragebogens haben sich die Patienten in der IG nach 6 (p = 0,013) und 12 Monaten (p = 0,003) signifikant besser informiert gefühlt. Diskussion: Ein positiver Effekt der teambasierten Versorgung auf den Verlauf von Depression und Angst bei Patienten mit einer seropositiven RA im Krankheitsschub konnte gezeigt werden

Disseminating and assessing implementation of the EULAR recommendations for patient education in inflammatory arthritis:a mixed-methods study with patients' perspectives

OBJECTIVES: To explore patients' agreement and reasons for agreement or disagreement with the EULAR recommendations for patient education (PE) for people with inflammatory arthritis (IA). METHODS: This mixed-method survey collected data using snowball sampling. The survey had been translated into 20 languages by local healthcare professionals, researchers and patient research partners. It explored the degree to which patients with IA agreed with each recommendation for PE (0=do not agree at all and 10=agree completely) and their rationale for their agreement level in free text questions. Descriptive statistics summarised participants' demographics and agreement levels. Qualitative content analysis was used to analyse the free text data. Sixteen subcategories were developed, describing the reasons for agreement or disagreement with the recommendations, which constituted the categories. RESULTS: The sample comprised 2779 participants (79% female), with a mean (SD) age 55.1 (13.1) years and disease duration 17.1 (13.3) years. Participants strongly agreed with most recommendations (median 10 (IQR: 9-10) for most recommendations). Reasons for agreement with the recommendations included the benefit of using PE to facilitate collaborative care and shared decision making, the value of flexible and tailored PE, and the value of gaining support from other patients. Reasons for disagreement included lack of resources for PE, not wanting information to be tailored by healthcare professionals and a reluctance to use telephone-based PE. CONCLUSION: The EULAR recommendations for PE have been disseminated among patients with IA. Overall, agreement levels were very high, suggesting that they reflect patients' preferences for engaging in collaborative clinical care and using PE to facilitate and supplement their own understanding of IA. Reasons for not completely agreeing with the recommendations can inform implementation strategies and education of healthcare professionals

Investigating the effectiveness of a mindfulness-based sleep improvement app intervention

Mentale Gesundheit hat in den vergangenen Jahren deutlich mehr Aufmerksamkeit erlangt, ebenso wie die Möglichkeiten die mit Smartphones und ständigem online-sein verbunden sind. Daher wirkt es logisch, mentale Gesundheit anhand von online oder app-basierten Interventionen zu verbessern. Die eleMental App ist ein Beispiel solcher Interventionen. Die gegenwärtige Untersuchung hat das „Sleep Easy“ Modul, eins von vier Modulen, der App in einer Langzeitstudie in der Arbeitspopulation unter-sucht. 71 Leute haben über einen Zeitraum von insgesamt vier Wochen, einschließlich drei Interventionswochen, teilgenommen. Die Übungen der Intervention basieren auf Mindfulness, Entspannungsübungen, Hypnose und positiver Psychologie. Die Teil-nehmer haben insgesamt fünf Fragebogen erhalten, bestehend aus einem Pre-Test, drei wöchentlichen Interventionsfragebögen und einem Post-Test. Die Hauptvariablen die untersucht wurden sind Schlafqualität, Wohlbefinden, Erholungsbedarf und Le-bensqualität. Die Ergebnisse haben gezeigt, dass Schlafqualität Wohlergehen und Erholungsbedarf signifikant mediiert. Mindfulness mediiert Erholungsbedarf und Le-bensqualität signifikant. Häufigkeit der App Verwendung moderiert Schlafqualität und Erholungsbedarf signifikant. Diese Erkenntnisse erlauben die vorsichtige Tendenz, dass die Verwendung des Moduls „Sleep Easy“ positive Resultate erzielen kann.Mental health has received a lot more attention in the last years as have the possibilities that are associated with having a smart-phone and being online. There-fore, it seems to be a logical conclusion to work on improving mental health with online or app-based interventions. The eleMental app is one example of these interventions. The present research evaluated the “Sleep Easy” module, one of four modules, of the app in a longitudinal study in the working population. 71 people participated over the course of four weeks, including three intervention weeks. The exercises making up the intervention were based on mindfulness, relaxation-techniques, hypnosis and positive psychology. The participants received five questionnaires in total, consisting of one pre-test, three weekly intervention questionnaires and one post-test. Main outcomes were sleep quality, well-being, need for recovery and quality of life. The results showed that sleep quality was associated with well-being and need for recovery signif-icantly. Mindfulness significantly mediated need for recovery and quality of life. The frequency of app-usage significantly moderated sleep quality and need for recovery. These findings allow a careful suggestion that using the module “Sleep Easy” may have a positive impact on sleep quality and daily functions, pending confirmation by future studies

Effect of nurse-led care on outcomes in patients with ACPA/RF-positive rheumatoid arthritis with active disease undergoing treat-to-target: a multicentre randomised controlled trial

Objective To determine the non-inferiority of nurse-led care (NLC) in patients with anticitrullinated protein antibody (ACPA)-positive and/or rheumatoid factor (RF)-positive rheumatoid arthritis (RA) with active disease who are starting disease-modifying antirheumatic drug therapy, following treat-to-target (T2T) recommendations.Methods A multicentre, pragmatic randomised controlled trial was conducted to assess clinical effectiveness, anxiety, depression and patient satisfaction following a non-inferiority design. The participants were 224 adults with ACPA/RF-positive RA who were randomly assigned to either NLC or rheumatologist-led care (RLC). The primary outcome was the Disease Activity Score in 28 Joints measured with C reactive protein (DAS28-CRP) assessed at baseline and after 3, 6, 9 and 12 months. A DAS28-CRP difference of 0.6 was set as the non-inferiority margin. Mean differences between the groups were assessed following per-protocol and intention-to-treat strategies.Results Demographic data and baseline characteristics of patients in the NLC group (n=111) were comparable to those of patients in the RLC group (n=113). The improvement in disease activity (change in DAS28-CRP, primary outcome) over the course of 12 months was significant in both groups (p&lt;0.001). No significant differences were observed between the NLC and RLC groups (p=0.317). Non-inferiority of NLC was shown for the primary outcome and all secondary outcomes.Conclusion This study supported the non-inferiority of NLC in managing T2T and follow-up care of patients with RA with moderate to high disease activity and poor prognostic factors in addition to RLC.Trial registration number DRKS00013055

Disseminating and assessing implementation of the EULAR recommendations for patient education in inflammatory arthritis: a mixed-methods study with patients' perspectives

Objectives: To explore patients’ agreement and reasons for agreement or disagreement with the EULAR recommendations for patient education (PE) for people with inflammatory arthritis (IA). Methods: This mixed-method survey collected data using snowball sampling. The survey had been translated into 20 languages by local healthcare professionals, researchers and patient research partners. It explored the degree to which patients with IA agreed with each recommendation for PE (0=do not agree at all and 10=agree completely) and their rationale for their agreement level in free text questions. Descriptive statistics summarised participants’ demographics and agreement levels. Qualitative content analysis was used to analyse the free text data. Sixteen subcategories were developed, describing the reasons for agreement or disagreement with the recommendations, which constituted the categories. Results: The sample comprised 2779 participants (79% female), with a mean (SD) age 55.1 (13.1) years and disease duration 17.1 (13.3) years. Participants strongly agreed with most recommendations (median 10 (IQR: 9–10) for most recommendations). Reasons for agreement with the recommendations included the benefit of using PE to facilitate collaborative care and shared decision making, the value of flexible and tailored PE, and the value of gaining support from other patients. Reasons for disagreement included lack of resources for PE, not wanting information to be tailored by healthcare professionals and a reluctance to use telephone-based PE. Conclusion: The EULAR recommendations for PE have been disseminated among patients with IA. Overall, agreement levels were very high, suggesting that they reflect patients’ preferences for engaging in collaborative clinical care and using PE to facilitate and supplement their own understanding of IA. Reasons for not completely agreeing with the recommendations can inform implementation strategies and education of healthcare professionals