‘We can do only what we have the means for’ general practitioners’ views of primary care for older people with complex health problems

Background: Due to demographic change, general practitioners (GPs) are increasingly required to care for older people with complex health problems. Little is known about the subjective appraisals of GPs concerning the demanded changes. Our objective is to explore how general practitioners view their professional mandates and capacities to provide comprehensive care for older people with complex health problems. Do geriatric training or experience influence viewpoints? Can barriers for the implementation of changes in primary care for older people with complex health problems be detected? Methods: Preceding a controlled intervention study on case management for older patients in the primary care setting (OMAHA II), this qualitative study included 10 GPs with differing degrees of geriatric qualification. Semi structured interviews were conducted and audio-taped. Full interview transcripts were analyzed starting with open coding on a case basis and case descriptions. The emerging thematic structure was enriched with comparative dimensions through reiterated inter-case comparison and developed into a multidimensional typology of views. Results: Based on the themes emerging from the data and their presentation by the interviewed general practitioners we could identify three different types of views on primary care for older people with complex health problems: ‘maneuvering along competence limits’, ‘Herculean task’, and ‘cooperation and networking’. The types of views differ in regard to role-perception, perception of their own professional domain, and action patterns in regard to cooperation. One type shows strong correspondence with a geriatrician. Across all groups, there is a shared concern with the availability of sufficient resources to meet the challenges of primary care for older people with complex health problems. Conclusions: Limited financial resources, lack of cooperational networks, and attitudes appear to be barriers to assuring better primary care for older people with complex health problems. To overcome these barriers, geriatric training is likely to have a positive impact but needs to be supplemented by regulations regarding reimbursement. Most of all, general practitioners’ care for older people with complex health problems needs a conceptual framework that provides guidance regarding their specific role and contribution and assisting networks. For example, it is essential that general practice guidelines become more explicit with respect to managing older people with complex health problems

who is missed and why?

Background Public health monitoring depends on valid health and disability estimates in the population 65+ years. This is hampered by high non- participation rates in this age group. There is limited insight into size and direction of potential baseline selection bias. Methods We analyzed baseline non-participation in a register-based random sample of 1481 inner-city residents 65+ years, invited to a health examination survey according to demographics available for the entire sample, self-report information as available and reasons for non-participation. One year after recruitment, non- responders were revisited to assess their reasons. Results Five groups defined by participation status were differentiated: participants (N = 299), persons who had died or moved (N = 173), those who declined participation, but answered a short questionnaire (N = 384), those who declined participation and the short questionnaire (N = 324), and non-responders (N = 301). The results confirm substantial baseline selection bias with significant underrepresentation of persons 85+ years, persons in residential care or from disadvantaged neighborhoods, with lower education, foreign citizenship, or lower health-related quality of life. Finally, reasons for non-participation could be identified for 78 % of all non-participants, including 183 non- responders. Conclusion A diversity in health problems and barriers to participation exists among non-participants. Innovative study designs are needed for public health monitoring in aging populations

The German version of the Anorectic Behavior Observation Scale (ABOS)

Objective: To assess the performance of the German version of the Anorectic Behavior Observation Scale (ABOS) as a parent-report screening instrument for eating disorders (ED) in their children. Methods: Parents of 101 ED female patients (80 with Anorexia Nervosa; 21 with Bulimia Nervosa) and of 121 age- and socioeconomic status (SES)-matched female controls completed the ABOS. Results: Confirmatory factor analysis supported the original three-factor structure model of the ABOS. Cronbach’s alpha coefficients indicated good internal consistency for the three factors and the total score in the total sample. The best cut-off point (100% sensitivity and specificity) in the German version was ≥23. Conclusion: The ABOS may be a useful additional instrument for assessing ED

Design and usability testing of an in-house developed performance feedback tool for medical students

Background: Feedback is essential in a self-regulated learning environment such as medical education. When feedback channels are widely spread, the need arises for a system of integrating this information in a single platform. This article reports on the design and initial testing of a feedback tool for medical students at Charite-Universitatsmedizin, Berlin, a large teaching hospital. Following a needs analysis, we designed and programmed a feedback tool in a user-centered approach. The resulting interface was evaluated prior to release with usability testing and again post release using quantitative/qualitative questionnaires. Results: The tool we created is a browser application for use on desktop or mobile devices. Students log in to see a dashboard of "cards" featuring summaries of assessment results, a portal for the documentation of acquired practical skills, and an overview of their progress along their course. Users see their cohort's average for each format. Learning analytics rank students' strengths by subject. The interface is characterized by colourful and simple graphics. In its initial form, the tool has been rated positively overall by students. During testing, the high task completion rate (78%) and low overall number of non-critical errors indicated good usability, while the quantitative data (system usability scoring) also indicates high ease of use. The source code for the tool is open-source and can be adapted by other medical faculties. Conclusions: The results suggest that the implemented tool LevelUp is well-accepted by students. It therefore holds promise for improved, digitalized integrated feedback about students' learning progress. Our aim is that LevelUp will help medical students to keep track of their study progress and reflect on their skills. Further development will integrate users' recommendations for additional features as well as optimizing data flow

Clinically relevant depressive symptoms in young stroke patients - results of the sifap1 study

BACKGROUND Although post-stroke depression is widely recognized, less is known about depressive symptoms in the acute stage of stroke and especially in young stroke patients. We thus investigated depressive symptoms and their determinants in such a cohort. METHODS The Stroke in Young Fabry Patients study (sifap1) prospectively recruited a large multinational European cohort (n = 5,023) of patients with a cerebrovascular event aged 18-55. For assessing clinically relevant depressive symptoms (CRDS, defined by a BDI-score ≥18) the self-reporting Beck Depression Inventory (BDI) was obtained on inclusion in the study. Associations with baseline parameters, stroke severity (National Institutes of Health Stroke Scale, NIHSS), and brain MRI findings were analyzed. RESULTS From the 2007 patients with BDI documentation, 202 (10.1%) had CRDS. CRDS were observed more frequently in women (12.6 vs. 8.2% in men, p < 0.001). Patients with CRDS more often had arterial hypertension, diabetes mellitus, and hyperlipidemia than patients without CRDS (hypertension: 58.0 vs. 47.1%, p = 0.017; diabetes mellitus: 17.9 vs. 8.9%, p < 0.001; hyperlipidemia: 40.5 vs. 32.3%, p = 0.012). In the subgroup of patients with ischemic stroke or TIA (n = 1,832) no significant associations between CRDS and cerebral MRI findings such as the presence of acute infarcts (68.1 vs. 65.8%, p = 0.666), old infarctions (63.4 vs. 62.1%, p = 0.725) or white matter hyper-intensities (51.6 vs. 53.7%, p = 0.520) were found. CONCLUSION Depressive symptoms were present in 10.1% of young stroke patients in the acute phase, and were related to risk factors but not to imaging findings

Operationalizing multimorbidity and autonomy for health services research in aging populations - the OMAHA study

<p>Abstract</p> <p>Background</p> <p>As part of a Berlin-based research consortium on health in old age, the OMAHA (Operationalizing Multimorbidity and Autonomy for Health Services Research in Aging Populations) study aims to develop a conceptual framework and a set of standardized instruments and indicators for continuous monitoring of multimorbidity and associated health care needs in the population 65 years and older.</p> <p>Methods/Design</p> <p>OMAHA is a longitudinal epidemiological study including a comprehensive assessment at baseline and at 12-month follow-up as well as brief intermediate telephone interviews at 6 and 18 months. In order to evaluate different sampling procedures and modes of data collection, the study is conducted in two different population-based samples of men and women aged 65 years and older. A geographically defined sample was recruited from an age and sex stratified random sample from the register of residents in Berlin-Mitte (Berlin OMAHA study cohort, n = 299) for assessment by face-to-face interview and examination. A larger nationwide sample (German OMAHA study cohort, n = 730) was recruited for assessment by telephone interview among participants in previous German Telephone Health Surveys. In both cohorts, we successfully applied a multi-dimensional set of instruments to assess multimorbidity, functional disability in daily life, autonomy, quality of life (QoL), health care services utilization, personal and social resources as well as socio-demographic and biographical context variables. Response rates considerably varied between the Berlin and German OMAHA study cohorts (22.8% vs. 59.7%), whereas completeness of follow-up at month 12 was comparably high in both cohorts (82.9% vs. 81.2%).</p> <p>Discussion</p> <p>The OMAHA study offers a wide spectrum of data concerning health, functioning, social involvement, psychological well-being, and cognitive capacity in community-dwelling older people in Germany. Results from the study will add to methodological and content-specific discourses on human resources for maintaining quality of life and autonomy throughout old age, even in the face of multiple health complaints.</p

Acute Cerebrovascular Disease in the Young The Stroke in Young Fabry Patients Study

Background and Purpose-Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients. Methods-Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol. Results-Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%-0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18-24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%). Conclusions-Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies

Construction of a measurement tool for quality of life in multimorbid elderly without cognitive impairment

Titelseite, Inhaltsverzeichnis, Danksagung, Abbildungsverzeichnis 1\. Einleitung und theoretischer Hintergrund 1 2\. Methodisches Vorgehen 78 3\. Ergebnisse 95 4\. Diskussion 129 5\. Literaturverzeichnis 157 6\. Anhänge 179 Erklärung 305Die Zahl multimorbide erkrankter älterer Menschen wächst stetig. Für diesen Personenkreis mit vielfach chronifizierten, nicht im traditionellen Sinne heilbaren Erkrankungen wird häufig Lebensqualität als Indikator von Therapie- und Rehabilitationserfolg sowie zur Evaluation des Wohlergehens genutzt. Obwohl weitgehende Einigkeit darüber besteht, dass Lebensqualität eine multidimensionale Struktur aufweist, besteht kein Konsens, welcher Natur ein pragmatisch reduziertes Set von Indikatoren sein sollte. Multimorbide ältere Menschen weisen eine große Heterogenität der Krankheits- und Beschwerdeprofile auf, mit großer Variationsbreite individueller Grenzen und Möglichkeiten. Dies erfordert ein inhaltlich sehr heterogenes und flexibles Messinstrument, um differenzielle Vorstellungen über ein gutes Leben zu reflektieren. Ziel dieser Arbeit ist es, ein Messinstrument für die Lebensqualität multimorbider älterer Menschen zu entwickeln, welches diesen Anforderungen gerecht wird. Zunächst wurden in einer qualitativen Vorstudie individuelle Strukturelemente der Lebensqualität im Alter eruiert. Die Konstruktion des Fragebogen zur Lebensqualität multimorbider älterer Menschen (FLQM) rekurriert strukturell auf das Modell der Lebenszufriedenheit von Campbell et al. (1976) und folgt dem Prinzip der individualisierten Messung : Die Befragten benennen selbst die für ihre Lebensqualität bedeutsamen Lebensbereiche. Anschließend werden die einzelnen Bereiche nach Zufriedenheit bewertet und nach Bedeutsamkeit gewichtet. Aus diesen Angaben wird als Gesamtscore eine individuell gewichtete Produktsumme gebildet. Der Fragebogen wurde im Rahmen einer Pilotstudie mit N = 44 mehrfach körperlich erkrankten Personen über 65 Jahren einer explorativen Konstruktvalidierung unterzogen. Es fanden sich hohe und mittlere Zusammenhänge zwischen dem FLQM- Gesamtscore und globaler Lebenszufriedenheit, dem allgemeinen subjektiven Wohlbefinden (PGCMS; Lawton, 1975), den PGCMS-Subskalen Alterszufriedenheit und Lebenszufriedenheit , positivem Affekt (PANAS; Watson et al., 1988) sowie der subjektiven Einschätzung körperlicher und psychischer Gesundheit (SF-36; Ware & Sherbourne, 1992). Es wurden keine Alters- oder Geschlechtereffekte beobachtet. Eine begleitende Befragung (n = 21) zur Verständlichkeit des Fragebogens spricht für die Angemessenheit von Form und Inhalt des FLQM. Diese Ergebnisse werden als vorläufige Bestätigung der Validität des FLQM als Fragebogen zur Lebensqualität multimorbider älterer Menschen gewertet. Inhaltlich zeigte sich, dass mit zunehmendem Alter die Reichhaltigkeit der individuell benannten bedeutsamen Lebensbereiche deutlich abnahm. Trotz dieser Verengung des Spektrums behielten die älteren Studienteilnehmer eine hohe Lebenszufriedenheit bei. Die inhaltlichen Befunde werden im Rahmen des SOK- Modells (Baltes & Baltes, 1990a) und des zwei-Prozess-Modells der Entwicklungs¬regulation (Brandtstädter & Rothermund, 2002) diskutiert.The number of older people with multiple health affections increases steadily. For these people with often chronic diseases, not curable in the traditional sense, quality of life is often utilized as an indicator of success in therapy, rehabilitation or general well-being. Although there is an overall consensus on the multidimensional structure of quality of life, no general agreement on the nature of a pragmatically reduced set of indicators has been made. There is a vast heterogeneity of profiles of illnesses and impairments with a wide variety of individual options and restrictions in old age multimorbidity. This calls for a very heterogeneous and flexible measurement tool to reflect differential views on the good life . It is the aim of this study to develop a tool to measure quality of life in old age that fits these prerequisites. First, individual content and structural elements of quality of life in old age were inquired in a qualitative study. Construction of the FLQM is structurally founded on the model of global and domain-specific satisfaction with life by Campbell et al. (1976) and stands in the tradition of individualized measurement : Participants themselves generate the domains in life that are important for their quality of life. Subsequently these domains are rated for satisfaction and weighted according to their relative importance. The overall-index of quality of life is calculated as an individually weighted sum-of-products. In a pilot-study with N = 44 elderly aged 65 years and older, suffering from multiple morbidity the questionnaire underwent an exploratory construct-validation. There were high to medium correlations between the FLQM overall score and global life satisfaction, general well-being (PGCMS; Lawton, 1975), PGCMS-subscales satisfaction with aging und life satisfaction , positive affect (PANAS; Watson et al., 1988), and subjective ratings of physical and mental health (SF-36; Ware & Sherbourne, 1992). There were neither age- nor gender-effects. Additional structured interviews (n = 21) regarding the instrument s comprehensibility support the appropriateness of the FLQM s form and content. These results are interpreted as a preliminary confirmation of the FLQM s validity as an index of quality of life in old age multimorbidity. Content analyses showed that with increasing age the richness of individually generated domains decreased markedly. Despite this narrowing of the spectrum the older participants still maintained a high global satisfaction with life. These results are discussed in the context of the SOC-model (Baltes & Baltes, 1990a) and the two-process- framework of developmental regulation (Brandtstädter & Rothermund, 2002)

Baseline participation in a health examination survey of the population 65 years and older: who is missed and why?

Background: Public health monitoring depends on valid health and disability estimates in the population 65+ years. This is hampered by high non-participation rates in this age group. There is limited insight into size and direction of potential baseline selection bias. Methods: We analyzed baseline non-participation in a register-based random sample of 1481 inner-city residents 65+ years, invited to a health examination survey according to demographics available for the entire sample, self-report information as available and reasons for non-participation. One year after recruitment, non-responders were revisited to assess their reasons. Results: Five groups defined by participation status were differentiated: participants (N = 299), persons who had died or moved (N = 173), those who declined participation, but answered a short questionnaire (N = 384), those who declined participation and the short questionnaire (N = 324), and non-responders (N = 301). The results confirm substantial baseline selection bias with significant underrepresentation of persons 85+ years, persons in residential care or from disadvantaged neighborhoods, with lower education, foreign citizenship, or lower health-related quality of life. Finally, reasons for non-participation could be identified for 78 % of all non-participants, including 183 non-responders. Conclusion: A diversity in health problems and barriers to participation exists among non-participants. Innovative study designs are needed for public health monitoring in aging populations