Community care coordination for stroke survivors: results of a complex intervention study

Background: Outpatient follow-up care for stroke survivors is often inadequate and mostly self-organized by the patients themselves. In the German health care system, there are no standard care programs for patients after they are discharged from the hospital to support them with their multifaceted and heterogeneous health care needs. The objective of this complex intervention study was to evaluate the effectiveness of a post-stroke care coordination program in comparison to standard care in the first year after a stroke. Methods: Patients aged 55 and older who had survived a stroke or a transient ischemic attack (TIA) within the last 6 months before enrollment were included. Participants received care coordination either by telephone or face-to-face for up to 1 year. Patients’ health insurance claims data were used to measure outcomes. The control group consisted of stroke survivors receiving standard care and was constructed by exact matching based on six criteria. Outcome measures were health services utilization, rate of recurrent events, readmissions and accompanying costs, and mortality. Outcomes were tested using different multiple models. Results: In total, N = 361 patients were included in the analyses. Intervention participants had seen an outpatient neurologist more often (OR = 4.75; 95% CI: 2.71–8.31) and were readmitted to a hospital less frequently (IRR = 0.42; 95% CI: 0.29–0.61), resulting in lower hospital costs (IQR = €0–1910 in the intervention group, IQR = €0–4375 in the control group). There were no substantial group differences in the rate of recurrent events and mortality. Conclusion: This study showed the beneficial potential of care coordination for a vulnerable patient population: the utilization rate of important health services was increased, and the rate of hospital readmissions decreased as a result. Future research should focus on the risk of recurrent strokes and the long-term effects of improved care. Trial registration: DRKS00017526 on DRKS – German Clinical Trials Register (retrospectively registered: 21 June 2019)

Self-reported health and life satisfaction in older emergency department patients: sociodemographic, disease-related and care-specific associated factors

Background: Self-reported health (SRH) and life satisfaction (LS) are patient-reported outcomes (PROs) that independently predict mortality and morbidity in older adults. Emergency department (ED) visits due to serious health problems or accidents might pose critical life events for patients. This study aimed (a) to characterize older patients' SRH and LS during the distinct event of an ED stay, and (b) to analyze concomitant associations of PROs with ED patients' sociodemographic, disease-specific and care-related variables. Methods: Study personnel recruited mostly older ED patients from three disease groups during a two-year period (2017-2019) in eight EDs in central Berlin, Germany, in the context of the health services research network EMANet. Cross-sectional data from the baseline patient survey and associated secondary data from hospital information systems were analyzed. Multilevel linear regression models with random intercept were applied to assess concomitant associations with SRH (scale: 0 (worst) to 100 (best)) and LS (scale: 0 (not at all satisfied) to 10 (completely satisfied)) as outcomes, including sensitivity analyses. Results: The final sample comprised N =1435 participants. Mean age was 65.18 (SD: 16.72) and 50.9% were male. Mean ratings of SRH were 50.10 (SD: 23.62) while mean LS scores amounted to 7.15 (SD: 2.50). Better SRH and higher LS were found in patients with cardiac symptoms (SRH: beta =4.35, p =.036; LS: beta =0.53, p =.006). Worse SRH and lower LS were associated with being in need of nursing care (SRH: beta=-7.52, p =-0.59, p =.003) and being unemployed (SRH: beta=-8.54, p =.002; LS: beta=-1.27, p <.001). Sex, age, number of close social contacts, and hospital stays in the previous 6 months were additionally related to the outcomes. Sensitivity analyses largely supported results of the main sample. Conclusions: SRH and LS were associated with different sociodemographic and disease-related variables in older ED patients. Nursing care dependency and unemployment emerged as significant factors relating to both outcomes. Being able to identify especially vulnerable patients in the ED setting might facilitate patient-centered care and prevent negative health outcomes. However, further longitudinal research needs to analyze trajectories in both outcomes and suitable intervention possibilities in the ED setting. Trial registration: EMANet sub-studies were registered separately: German Clinical Trials Register (EMAAge: DRKS00014273, registration date: May 16, 2018; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014273; EMACROSS: DRKS00011930, registration date: April 25, 2017; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011930); ClinicalTrials.gov (EMASPOT: NCT03188861, registration date: June 16, 2017; https://clinicaltrials.gov/ct2/show/NCT03188861?term=NCT03188861&draw=2&rank=1)

Health-related quality of life and associated factors after hip fracture. Results from a six-month prospective cohort study

Background: Hip fractures are a major public health problem with increasing relevance in aging societies. They are associated with high mortality rates, morbidity, and loss of independence. The aim of the EMAAge study was to determine the impact of hip fractures on patient-reported health-related quality of life (HRQOL), and to identify potential risk factors for worse outcomes. Methods: EMAAge is a multicenter, prospective cohort study of patients who suffered a hip fracture. Patients or, if necessary, proxies were interviewed after initial treatment and after six months using standardized questionnaires including the EQ-5D-5L instrument, the Oxford Hip Score, the PHQ-4, the Short Nutritional Assessment Questionnaire, and items on patients living situation. Medical data on diagnoses, comorbidities, medications, and hospital care were derived from hospital information systems. Results: A total of 326 patients were included. EQ-5D index values decreased from a mean of 0.70 at baseline to 0.63 at six months. The mean self-rated health on the EQ-VAS decreased from 69.9 to 59.4. Multivariable linear regression models revealed three relevant associated factors with the six-months EQ-5D index: symptoms of depression and anxiety, pre-fracture limitations in activities of daily living, and no referral to a rehabilitation facility had a negative impact. In addition, the six-months EQ-VAS was negatively associated with polypharmacy, living in a facility, and migration background. Conclusions: Hip fractures have a substantial negative impact on patients HRQOL. Our results suggest that there are modifying factors that need further investigation including polypharmacy and migration background. Structured and timely rehabilitation seems to be a protective factor

Malnutrition is associated with six-month mortality in older patients admitted to the emergency department with hip fracture

Background: Hip fractures in older people are a common health problem often associated with malnutrition that might affect outcomes. Screening for malnutrition is not a routine examination in emergency departments (ED). This analysis of the EMAAge study, a prospective, multicenter cohort study, aimed to evaluate the nutritional status of older patients (>= 50 years) with hip fracture, factors associated with malnutrition risk, and the association between malnutrition and the six-months mortality. Methods: Risk of malnutrition was evaluated using the Short Nutritional Assessment Questionnaire. Clinical data as well as data on depression and physical activity were determined. Mortality was captured for the first six months after the event. To assess factors associated with malnutrition risk we used a binary logistic regression. A Cox proportional hazards model was used to assess the association of malnutrition risk with six-month survival adjusted for other relevant risk factors. Results: The sample consisted of N = 318 hip fracture patients aged 50 to 98 (68% women). The prevalence of malnutrition risk was 25.3% (n = 76) at the time of injury. There were no differences in triage categories or routine parameters measured in the ED that could point to malnutrition. 89% of the patients (n = 267) survived for six months. The mean survival time was longer in those without malnutrition risk (171.9 (167.1-176.9) days vs. 153.1 (140.0-166.2) days). The Kaplan Meier curves and the unadjusted Cox regression (Hazard Ratio (HR) 3.08 (1.61-5.91)) showed differences between patients with and patients without malnutrition risk. In the adjusted Cox regression model, risk of death was associated with malnutrition risk (HR 2.61, 1.34-5.06), older age (70-76 years: HR 2.5 (0.52-11.99); 77-82 years: HR 4.25 (1.15-15.62); 83-99 years: HR 3.82 (1.05-13.88)) and a high burden of comorbidities (Charlson Comorbidity Index >= 3: HR 5.4 (1.53-19.12)). Conclusion: Risk of malnutrition was associated with higher mortality after hip fracture. ED parameters did not differentiate between patients with nutritional deficiencies and those without. Therefore, it is particularly important to pay attention to malnutrition in EDs to detect patients at risk of adverse outcomes and to initiate early interventions

Outcome after resection of Adrenocortical Carcinoma liver metastases: a retrospective study

Background: Metastatic Adrenocortical Carcinoma (ACC) is a rare malignancy with a poor 5-year-survival rate (<15%). A surgical approach is recommended in selected patients if complete resection of distant metastasis can be achieved. To date there are only limited data on the outcome after surgical resection of hepatic metastases of ACC. Methods: A retrospective analysis of the German Adrenocortical Carcinoma Registry was conducted. Patients with liver metastases of ACC but without extrahepatic metastases or incomplete tumour resection were included. Results: Seventy-seven patients fulfilled these criteria. Forty-three patients underwent resection of liver metastases of ACC. Complete tumour resection (R0) could be achieved in 30 (69.8%). Median overall survival after liver resection was 76.1 months in comparison to 10.1 months in the 34 remaining patients with unresected liver metastases (p < 0.001). However, disease free survival after liver resection was only 9.1 months. Neither resection status (R0/R1) nor extent of liver resection were significant predictive factors for overall survival. Patients with a time interval to the first metastasis/recurrence (TTFR) of greater than 12 months or solitary liver metastases showed significantly prolonged survival. Conclusions: Liver resection in the case of ACC liver metastases can achieve long term survival with a median overall survival of more than 5 years, but disease free survival is short despite metastasectomy. Time to recurrence and single versus multiple metastases are predictive factors for the outcome

Health services research on stroke: analyses of disparities in care and effects of a complex intervention based on routine data of statutory health insurances

Der Schlaganfall stellt mit seiner hohen Mortalitätsrate und oft schwerwiegenden Folgen für die Überlebenden sowohl Patient*innen als auch Gesundheitsversorger vor große Herausforderungen. Die Versorgungssituation in westlichen Industrieländern ist einerseits durch Fortschritte in der Akuttherapie und andererseits eine weitgehend unstrukturierte, poststationäre Nachsorge gekennzeichnet. Die vorliegende Dissertation verfolgt zwei Zielsetzungen: 1) im Rahmen einer Ist-Analyse gruppenspezifische Disparitäten in der Akutversorgung zu analysieren und 2) Effekte einer komplexen Intervention für Schlaganfallbetroffene in der poststationären Phase zu evaluieren. Datengrundlage bildeten Routinedaten gesetzlicher Krankenversicherungen. Die Analysen der Ist-Situation basierten auf einer Schlaganfallkohorte der Deutschen BKK (N=4.843); die Evaluation der poststationären Intervention auf Daten teilnehmender Patient*innen aus vier Krankenkassen sowie einer Quasi-Kontrollgruppe, die per Matching-Verfahren konstruiert wurde. Fokus der Ist-Analysen zur Akutversorgung waren gruppenspezifische Disparitäten a) hinsichtlich des Zugangs zur Stroke Unit und b) bezüglich funktioneller Outcomes nach Akutbehandlung. Hierbei zeigte sich a), dass vor allem ältere Patient*innen, weibliche Schlaganfallbetroffene und durch einen vorherigen Schlaganfall oder Pflegebedürftigkeit vorbelastete Patient*innen überproportional häufig eine unspezifische Diagnose (ICD-10-GM I64) erhielten. Dies deutet auf eine Versorgung außerhalb der Stroke Unit-Strukturen hin. Die Analysen der funktionellen Outcomes ergab b), dass der Anteil der Frauen, die mit dem Schlaganfall pflegeabhängig wurden, mit 31,2 % fast 10 Prozentpunkte höher lag als jener der Männer (21,3 %). Weitere mit Pflegebedürftigkeit assoziierte Faktoren waren Alter, Dysphagie, Hemiparese, Demenz und Harninkontinenz. Durch den Einbezug dieser Adjustierungsvariablen reduzierte sich der Geschlechtereffekt deutlich (unadjustiertes OR=1,67; adjustiertes OR=1,18). Die Intervention für Schlaganfallbetroffene in der Nachsorge umfasste ein individuelles Case Management sowie eine optimierte Kooperation der Versorger durch Zusammenschluss in einem regionalen Versorgungsnetzwerk. Inwiefern die Patient*innenversorgung erfolgreich verbessert werden konnte, wurde u.a. anhand der Inanspruchnahme neurologischer Fachärzt*innen sowie der Rezidiv- und der allgemeinen Rehospitalisierungsraten untersucht. Zur Evaluation der Intervention konnten Krankenkassendaten von n=91 Teilnehmenden in die Analysen einbezogen werden. Die Quasi-Kontrollgruppe mit bis zu drei Matching-Partner*innen bestand aus n=270 Schlaganfallbetroffenen, die Gesamtstichprobe damit aus N=361. In der Interventionsgruppe lag die Rate der Inanspruchnahme neurologischer Fachärzt*innen signifikant höher und die Rehospitalisierungsrate signifikant niedriger als in der Kontrollgruppe. Keine Unterschiede zwischen Interventions- und Kontrollgruppe zeigten sich hinsichtlich der Rezidive innerhalb eines Jahres.With its high mortality rates and severe health consequences for survivors, stroke depicts a major challenge for patients and healthcare providers. To date, stroke care in high-income countries is characterized by advances in acute treatment on the one hand, and largely unstructured follow-up care on the other hand. This dissertation pursues two objectives: 1) analyzing the status quo of acute stroke care regarding group-specific disparities, and 2) evaluating the effects of a complex intervention for outpatient stroke survivors. The data basis was formed by routine data from statutory health insurance funds. The analyses of the status quo were based on a stroke cohort of the Deutsche BKK (N=4,843); the evaluation of the intervention utilized data of participating patients from four health insurance funds and a quasi-control group, which was constructed by matching. The analyses of the present acute care provision focused on a) group-specific disparities in access to stroke unit care and b) functional outcomes after acute treatment. Results revealed a) that older patients, female stroke patients, and patients with a previous stroke or long-term care dependency had disproportionately often received an unspecific diagnosis (ICD-10-GM I64). This indicates the provision of healthcare outside the stroke unit structures. Analyses of functional outcomes showed b) that the proportion of women who became care-dependent after stroke was almost 10 percentage points higher (31.2%) compared to men (21.3%). Furthermore, care dependency was associated with age, dysphagia, hemiparesis, dementia, and urinary incontinence. By including these variables into the regression model, the sex effect decreased considerably. The intervention for stroke survivors in the community included an individual case management and an optimized cooperation among healthcare providers. The extent to which the intervention successfully improved post-acute stroke care was measured by the rates of utilization of neurological specialists, recurrent strokes, and readmissions. For the evaluation of the intervention, data of n=91 participants were included for analyses. The quasi-control group with up to three matching partners consisted of n=270 individuals, the total sample of N=361. In the intervention group, the utilization of neurological specialists was significantly higher and the readmission rate significantly lower compared to the control group. No differences regarding recurrent strokes within 12 months were found. Future health services research on stroke needs to systematically assess disparities in care and take this into account when designing and implementing interventions. The evaluation of complex interventions requires complex study designs to assess effectiveness and understand the mechanisms behind

Entre "jugar al doctor", "balance empleo-vida" y "medicina de lujo": ¿Desafían los médicos jóvenes la "masculinidad hegemónica" en el campo de la medicina?

Wir diskutieren die Frage, ob eine sogenannte "Feminisierung" bestehende "maskuline" Machtstrukturen in der Medizin herausfordert. Die Rede von der "Feminisierung der Medizin" setzt sowohl die "Maskulinität" voraus als auch deren Veränderung durch die Erhöhung des Frauenanteils. Wir stellen die Kontrastanalyse zweier Gruppendiskussionen aus der Längsschnittstudie Karriereverläufe und Karrierebrüche bei Ärztinnen und Ärzten während der fachärztlichen Weiterbildung (KarMed) vor; eine Diskussion mit angehenden Ärztinnen und eine mit angehenden Ärzten. Als manifestes Thema wurde Geschlechtlichkeit in beiden Diskussionen im diskursiven Kontext der sogenannten "Feminisierung" eingeführt – bezeichnenderweise im Kontrast zur gleichsam mythisch aufgeladenen Maskulinität der Chirurgie. Das Material unserer Gruppendiskussionen verweist auf eine nach wie vor maskuline Norm im Selbstverständnis der angehenden Ärztinnen und Ärzte. Die Männerrunde konstituierte sich als Gruppe der Ärzteschaft bei allen Differenzen wie selbstverständlich als männliche Norm. Die Frauengruppe konstituierte sich über eine geteilte Identifikation als "Frauen in der Medizin". Das Material wurde mit Methoden der psychoanalytischen Sozialforschung interpretiert und wird in diesem Beitrag im Hinblick auf die Begriffe der Feminisierung und der hegemonialen Männlichkeit diskutiert.URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs1601159In this contribution we discuss the question of whether the so-called "feminization" of medicine challenges persisting power structures in the field. The notion of the "feminization of medicine" implies both the "masculinity" of the field and its change due to the increasing number of female medical doctors. We present the comparative analysis of two group discussions from the longitudinal study "Career Paths and Career Breaks of Medical Doctors During Residency" (KarMed).  One discussion was held with women, one discussion with men, all of whom had just completed their medical studies. In both discussions the theme of gender came up manifestly in the discursive context of the so-called "feminization of medicine." The discussants contrasted this "feminization" with the mythologically laden "masculinity" of surgery. The material of our group discussions indicates a persistent masculine norm in the perception of both female and male doctors. Despite all differences between their members, the group of men constituted itself as a group of medical doctors representing the masculine norm. The group of women constituted itself through shared identifications as "women in medicine." We analyzed the material with psychoanalytic methods in social research and we discuss our interpretations in relation to the notions of "feminization" and of "hegemonic masculinity."URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs1601159En esta contribución se discute la pregunta sobre si la llamada "feminización" de la medicina desafía las estructuras de poder que persisten en el campo. La noción de "feminización de la medicina" implica tanto la "masculinidad" del campo como sus cambios debido al creciente número de doctoras de sexo femenino. Se presenta el análisis comparativo de dos discusiones grupales en el marco del estudio longitudinal "Trayectorias profesionales e interrupciones en la carrera de medicina durante la residencia" (KarMed). Un grupo de discusión se llevó a cabo con mujeres y otro con varones, ambos acababan de completar sus estudios en medicina. En ambos grupos de discusión el tema de género surgió evidentemente en el contexto discursivo de la llamada "feminización de la medicina". Los ponentes contrastaron esta "feminización" con la "masculinidad" mitológicamente asignada a la práctica de la cirugía. El material de nuestras discusiones grupales indica una norma masculina persistente en la percepción de médicos de ambos sexos. A pesar de todas las diferencias entre sus miembros, el grupo de varones se constituyó como un grupo de médicos que representa la norma masculina. El grupo de mujeres se constituyó a través de identificaciones compartidas como "mujeres en medicina." Analizamos el material utilizando métodos psicoanalíticos de investigación social y discutimos nuestras interpretaciones con relación a las nociones de "feminización" y "masculinidad hegemónica".URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs160115

Zwischen "Arzt spielen", "Work-Life-Balance" und "Highend-Medizin". Wird "hegemoniale Männlichkeit" in der Medizin herausgefordert?

Wir diskutieren die Frage, ob eine sogenannte "Feminisierung" bestehende "maskuline" Machtstrukturen in der Medizin herausfordert. Die Rede von der "Feminisierung der Medizin" setzt sowohl die "Maskulinität" voraus als auch deren Veränderung durch die Erhöhung des Frauenanteils. Wir stellen die Kontrastanalyse zweier Gruppendiskussionen aus der Längsschnittstudie Karriereverläufe und Karrierebrüche bei Ärztinnen und Ärzten während der fachärztlichen Weiterbildung (KarMed) vor; eine Diskussion mit angehenden Ärztinnen und eine mit angehenden Ärzten. Als manifestes Thema wurde Geschlechtlichkeit in beiden Diskussionen im diskursiven Kontext der sogenannten "Feminisierung" eingeführt – bezeichnenderweise im Kontrast zur gleichsam mythisch aufgeladenen Maskulinität der Chirurgie. Das Material unserer Gruppendiskussionen verweist auf eine nach wie vor maskuline Norm im Selbstverständnis der angehenden Ärztinnen und Ärzte. Die Männerrunde konstituierte sich als Gruppe der Ärzteschaft bei allen Differenzen wie selbstverständlich als männliche Norm. Die Frauengruppe konstituierte sich über eine geteilte Identifikation als "Frauen in der Medizin". Das Material wurde mit Methoden der psychoanalytischen Sozialforschung interpretiert und wird in diesem Beitrag im Hinblick auf die Begriffe der Feminisierung und der hegemonialen Männlichkeit diskutiert. URN: http://nbn-resolving.de/urn:nbn:de:0114-fqs160115