Primary care practice-based care management for chronically ill patients (PraCMan): study protocol for a cluster randomized controlled trial [ISRCTN56104508]

Background: Care management programmes are an effective approach to care for high risk patients with complex care needs resulting from multiple co-occurring medical and non-medical conditions. These patients are likely to be hospitalized for a potentially "avoidable" cause. Nurse-led care management programmes for high risk elderly patients showed promising results. Care management programmes based on health care assistants (HCAs) targeting adult patients with a high risk of hospitalisation may be an innovative approach to deliver cost-efficient intensified care to patients most in need. Methods: PraCMan is a cluster randomized controlled trial with primary care practices as unit of randomisation. The study evaluates a complex primary care practice-based care management of patients at high risk for future hospitalizations. Eligible patients either suffer from type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic heart failure or any combination. Patients with a high likelihood of hospitalization within the following 12 months (based on insurance data) will be included in the trial. During 12 months of intervention patients of the care management group receive comprehensive assessment of medical and non-medical needs and resources as well as regular structured monitoring of symptoms. Assessment and monitoring will be performed by trained HCAs from the participating practices. Additionally, patients will receive written information, symptom diaries, action plans and a medication plan to improve self-management capabilities. This intervention is addition to usual care. Patients from the control group receive usual care. Primary outcome is the number of all-cause hospitalizations at 12 months follow-up, assessed by insurance claims data. Secondary outcomes are health-related quality of life (SF12, EQ5D), quality of chronic illness care (PACIC), health care utilisation and costs, medication adherence (MARS), depression status and severity (PHQ-9), self-management capabilities and clinical parameters. Data collection will be performed at baseline, 12 and 24 months (12 months post-intervention). Discussion: Practice-based care management for high risk individuals involving trained HCAs appears to be a promising approach to face the needs of an aging population with increasing care demands. Trial registration: Current Controlled Trials ISRCTN5610450

Development of a primary care-based complex care management intervention for chronically ill patients at high risk for hospitalization: a study protocol

Background: Complex care management is seen as an approach to face the challenges of an ageing society with increasing numbers of patients with complex care needs. The Medical Research Council in the United Kingdom has proposed a framework for the development and evaluation of complex interventions that will be used to develop and evaluate a primary care-based complex care management program for chronically ill patients at high risk for future hospitalization in Germany. Methods and design: We present a multi-method procedure to develop a complex care management program to implement interventions aimed at reducing potentially avoidable hospitalizations for primary care patients with type 2 diabetes mellitus, chronic obstructive pulmonary disease, or chronic heart failure and a high likelihood of hospitalization. The procedure will start with reflection about underlying precipitating factors of hospitalizations and how they may be targeted by the planned intervention (pre-clinical phase). An intervention model will then be developed (phase I) based on theory, literature, and exploratory studies (phase II). Exploratory studies are planned that entail the recruitment of 200 patients from 10 general practices. Eligible patients will be identified using two ways of 'case finding': software based predictive modelling and physicians' proposal of patients based on clinical experience. The resulting subpopulations will be compared regarding healthcare utilization, care needs and resources using insurance claims data, a patient survey, and chart review. Qualitative studies with healthcare professionals and patients will be undertaken to identify potential barriers and enablers for optimal performance of the complex care management program. Discussion: This multi-method procedure will support the development of a primary care-based care management program enabling the implementation of interventions that will potentially reduce avoidable hospitalizations

The influence of age, gender and socio-economic status on multimorbidity patterns in primary care. first results from the multicare cohort study

Background: Multimorbidity is a phenomenon with high burden and high prevalence in the elderly. Our previous research has shown that multimorbidity can be divided into the multimorbidity patterns of 1) anxiety, depression, somatoform disorders (ADS) and pain, and 2) cardiovascular and metabolic disorders. However, it is not yet known, how these patterns are influenced by patient characteristics. The objective of this paper is to analyze the association of socio-demographic variables, and especially socio-economic status with multimorbidity in general and with each multimorbidity pattern. Methods: The MultiCare Cohort Study is a multicentre, prospective, observational cohort study of 3.189 multimorbid patients aged 65+ randomly selected from 158 GP practices. Data were collected in GP interviews and comprehensive patient interviews. Missing values have been imputed by hot deck imputation based on Gower distance in morbidity and other variables. The association of patient characteristics with the number of chronic conditions is analysed by multilevel mixed-effects linear regression analyses. Results: Multimorbidity in general is associated with age (+0.07 chronic conditions per year), gender (-0.27 conditions for female), education (-0.26 conditions for medium and -0.29 conditions for high level vs. low level) and income (-0.27 conditions per logarithmic unit). The pattern of cardiovascular and metabolic disorders shows comparable associations with a higher coefficient for gender (-1.29 conditions for female), while multimorbidity within the pattern of ADS and pain correlates with gender (+0.79 conditions for female), but not with age or socioeconomic status. Conclusions: Our study confirms that the morbidity load of multimorbid patients is associated with age, gender and the socioeconomic status of the patients, but there were no effects of living arrangements and marital status. We could also show that the influence of patient characteristics is dependent on the multimorbidity pattern concerned, i.e. there seem to be at least two types of elderly multimorbid patients. First, there are patients with mainly cardiovascular and metabolic disorders, who are more often male, have an older age and a lower socio-economic status. Second, there are patients mainly with ADS and pain-related morbidity, who are more often female and equally distributed across age and socio-economic groups

Erkundung (super) schwerer Elemente mittels des Skyrme-Hartree-Fock Modells

Motivated by the steadily increasing number of known nuclei and nuclear properties, theories of nuclear structure are presently a field of intense research. This work concentrates on the self-consistent description of nuclei in terms of the Skyrme-Hartree-Fock (SHF) approach. The extrapolation of nuclear shell structure to the region of super-heavy elements (SHE) using the SHF model, the dependence on different parameterization and the influence of collective correlation are studied. The general scope of this work are large scale calculation for a global survey of properties of SHE like binding energies, separation energies and decay characteristics and lifetimes. These calculations were done to develop a database of lifetimes and reaction rates for alpha-, beta-decay and spontaneous fission in a very wide range with proton numbers 86<Z<120 and neutron numbers up to N = 260 relevant for the astrophysical r-process.Motiviert von der stetig zunehmenden Anzahl an bekannten Kernen and deren Eigenschaften ist die theoretische Kernstrukturphysik ein aktuelles und intensives Forschungsgebiet. Die vorliegende Arbeit beschäftigt sich daher mit der selbst-konsistenten Beschreibung von Kernen unter Verwendung des Skyrme-Hartree-Fock (SHF) Ansatzes. Die Extrapolationsfähigkeit in das Gebiet super schwerer Elemente (SHE), die Abhängigkeit von verschiedenen Parameterisierungen und der Einfluss kollektiver Korrelationen werden untersucht. Im Mittelpunkt des Interesses dieser Arbeit stehen großangelegte Berechnungen mit dem Ziel einer globalen Übersicht der Eigenschaften von super schweren Elementen, wie zum Beispiel Bindungsenergien, Separationsenergien, Zerfallscharakteristiken und Zerfallslebenszeiten. Hierbei bestand das Ziel in einer umfassenden Datenbank von Halbwertszeiten and Reaktionsraten der drei konkurrierenden Zerfallsprozesse alpha-, beta-Zerfall und spontaner Spaltung in einem für den astrophysikalischen r-Prozess relevanten weiten Bereich mit der Protonzahl 86 < Z < 120 und bis zu einer Neutronenanzahl von N=260

The regulatory functions of ICAN and ICAO : a comparative study.

The term 'international organization' embraces two quite different kinds of institutions, the 'inter-governmental organization' and the 'non-governmental organization'. [...

Medical Assistant-based care management for high risk patients in small primary care practices:A cluster randomized clinical trial

BACKGROUND: Patients with multiple chronic conditions are at high risk for potentially avoidable hospitalizations, which may be reduced by care coordination and self-management support. Medical assistants are an increasingly available resource for patient care in primary care practices. OBJECTIVE: To determine whether protocol-based care management delivered by medical assistants improves care in patients at high risk for future hospitalization in primary care. DESIGN: Two-year cluster randomized clinical trial. (Current Controlled Trials: ISRCTN56104508). SETTING: 115 primary care practices in Germany. PATIENTS: 2076 patients with type 2 diabetes, chronic obstructive pulmonary disease, or chronic heart failure and a likelihood of hospitalization in the upper quartile of the population, as predicted by an analysis of insurance data. INTERVENTION: Protocol-based care management, including structured assessment, action planning, and monitoring delivered by medical assistants, compared with usual care. MEASUREMENTS: All-cause hospitalizations at 12 months (primary outcome) and quality-of-life scores (12-Item Short Form Health Survey [SF-12] and EuroQol instrument [EQ-5D]). RESULTS: Included patients had an average of 4 co-occurring chronic conditions. All-cause hospitalizations did not differ between groups at 12 months (risk ratio [RR], 1.01 [95% CI, 0.87 to 1.18]) and 24 months (RR, 0.98 [CI, 0.85 to 1.12]). Quality of life (differences, 1.16 [CI, 0.24 to 2.08] on SF-12 physical component and 1.68 [CI, 0.60 to 2.77] on SF-12 mental component) and general health (difference on EQ-5D, 0.03 [CI, 0.00 to 0.05]) improved significantly at 24 months. Intervention costs totaled $10 per patient per month. LIMITATION: Small number of primary care practices and low intensity of intervention. CONCLUSION: This low-intensity intervention did not reduce all-cause hospitalizations but showed positive effects on quality of life at reasonable costs in high-risk multimorbid patients. PRIMARY FUNDING SOURCE: AOK Baden-Wurttemberg and AOK Bundesverband

Götter und menschliche Willensfreiheit

Angefacht durch naturwissenschaftliche Erkenntnisse, wurde in den letzten Jahren die Diskussion um die Grenzen der menschlichen Selbstbestimmung in das Bewusstsein einer breiteren Öffentlichkeit zurückgerufen. Wesentliche Parameter der modernen Debatte liegen dabei in der antiken Auseinandersetzung mit dem Problemkreis der Willensfreiheit begründet. Ihm hat sich nicht nur die Philosophie, sondern auch die Epik des griechisch-römischen Altertums gewidmet. So sind Schicksal, göttlicher Wille und menschliches Tun die Koordinaten, in deren Spannungsfeld sich seit jeher die Handlung des antiken Erzählepos entwickelte. Jeder Autor hat ihr Verhältnis dem politischen, literarischen und philosophischen Horizont seiner Epoche entsprechend definiert und ausgestaltet. Im römischen Epos nach Vergil vollzieht sich dieser Prozess vor dem Hintergrund der Festigung des Prinzipats, einer Staatsform, welche die Frage nach den Handlungsmöglichkeiten des Einzelnen neu aufwarf. Der vorliegende Sammelband untersucht vor diesem Hintergrund die Wechselbeziehung von Schicksal, Gott und Mensch bei Lucan, Valerius Flaccus, Statius und Silius Italicus