Gaining information about home visits in primary care: methodological issues from a feasibility study

Background: Home visits are part of general practice work in Germany. Within the context of an expanding elderly population and a decreasing number of general practitioner (GPs), open questions regarding the organisation and adequacy of GPs’ care in immobile patients remain. To answer these questions, we will conduct a representative primary data collection concerning contents and organisation of GPs’ home visits in 2014. Because this study will require considerable efforts for documentation and thus substantial involvement by participating GPs, we conducted a pilot study to see whether such a study design was feasible. Methods: We used a mixed methods design with two study arms in a sample of teaching GPs of the University Halle. The quantitative arm evaluates participating GPs and documentation of home visits. The qualitative arm focuses on reasons for non-participation for GPs who declined to take part in the pilot study. Results: Our study confirms previously observed reasons for non-response of GPs in the particular setting of home visits including lack of time and/or interest. In contrast to previous findings, monetary incentives were not crucial for GPs participation. Several factors influenced the documentation rate of home visits and resulted in a discrepancy between the numbers of home visits documented versus those actually conducted. The most frequently reported problem was related to obtaining patient consent, especially when patients were unable to provide informed consent due to cognitive deficits. Conclusions: The results of our feasibility study provide evidence for improvement of the study design and study instruments to effectively conduct a documentation-intensive study of GPs doing home visits. Improvement of instructions and questionnaire regarding time variables and assessment of the need for home visits will be carried out to increase the reliability of future data. One particularly important methodological issue yet to be resolved is how to increase the representativeness of home visit care by including the homebound patient population that is unable to provide informed consent

Which Cost Components Influence the Cost of Palliative Care in the Last Hospitalization? A Retrospective Analysis of Palliative Care vs. Usual Care at a Swiss University Hospital.

CONTEXT Although the number of studies on the economic impact of palliative care (PC) is growing, the great majority report costs from North America. OBJECTIVES We aimed to provide a comprehensive overview of PC hospital cost components from the perspective of a European mixed funded health care system by identifying cost drivers of PC and quantifying their effect on hospital costs compared to usual care (UC). METHODS We performed a retrospective, observational analysis examining cost data from the last hospitalization of patients who died at a large academic hospital in Switzerland comparing patients receiving PC versus UC. RESULTS Total hospital costs were similar in PC and UC with a mean difference of CHF -2'777 [95% confidence interval (CI) -12'713 to 8'506, p=0.60]. Average costs per day decreased by CHF -3'224 [95% CI -3'811 to -2'631, p<0.001] for PC patients with significant reduction of costs for diagnostic intervention and medication. Higher cost components for PC patients were catering, room, nursing, social counselling and non-medical therapists. In sensitivity analyses, when we restricted PC exposure to 3 days from admission, total costs and average costs per day were significantly lower for PC. CONCLUSION Studies measuring the impact of PC on hospital costs should analyze various cost components beyond total costs in order to understand wanted and potentially unwanted cost-reducing effects. An international definition of a set of cost components, specific for cost-impact PC studies, may help avoid superficial and potentially dangerous cost discussions

Referral trajectories in patients with vertigo, dizziness and balance disorders and their impact on health-related quality of life and functioning: results from the longitudinal multicenter study MobilE-TRA

BACKGROUND: Due to reported barriers in the management of patients with vertigo, dizziness and balance problems (VDB), referral trajectories starting from primary care might be determined by other factors than medical necessity. The objective of this paper was to examine the impact of disease-related and other determinants on referral trajectories of older patients with VDB and to investigate, how these trajectories affect the patients’ functioning and health-related quality of life (HRQoL). METHODS: Data originate from the longitudinal multicenter study MobilE-TRA, conducted in two German federal states. Referrals to neurologists or ear-nose-throat (ENT) specialists were considered. Referral patterns were visualized using a state sequence analysis. Predictors of referral trajectories were examined using a multinomial logistic regression model. Linear mixed models were calculated to assess the impact of referral patterns on the patients’ HRQoL and functioning. RESULTS: We identified three patterns of referral trajectories: primary care physician (PCP) only, PCP and neurologist, and PCP and ENT. Chances of referral to a neurologist were higher for patients with a neurological comorbidity (OR = 3.22, 95%-CI [1.003; 10.327]) and lower for patients from Saxony (OR = 0.08, 95%-CI [0.013; 0.419]). Patients with a PCP and neurologist referral pattern had a lower HRQoL and lower functioning at baseline assessment. Patients with unspecific diagnoses also had lower functioning. CONCLUSION: Referral trajectories were determined by present comorbidities and the regional healthcare characteristics. Referral trajectories affected patients’ HRQoL. Unspecific VDB diagnoses seem to increase the risk of ineffective management and consequently impaired functioning. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00415-022-11060-8

Phosphoinositide 3-OH Kinase Regulates Integrin-Dependent Processes in Neutrophils by Signaling through Its Effector ARAP3

ARAP3, a GTPase activating protein for Rho and Arf family GTPases, is one of many phosphoinositide 3-OH kinase (PI3K) effectors. In this study, we investigate the regulatory input of PI3K upstream of ARAP3 by analyzing neutrophils from an ARAP3 pleckstrin homology (PH) domain point mutation knock-in mouse (R302, 303A), in which ARAP3 is uncoupled from activation by PI3K. ARAP3 PH domain point mutant neutrophils are characterized by disturbed responses linked to stimulation by either integrin ligands or immobilized immune complexes. These cells exhibit increased β2 integrin inside-out signaling (binding affinity and avidity), and our work suggests the disturbed responses to immobilized immune complexes are secondary to this. In vitro, neutrophil chemotaxis is affected in the mutant. In vivo, ARAP3 PH domain point mutant bone marrow chimeras exhibit reduced neutrophil recruitment to the peritoneum on induction of sterile peritonitis and also reduced inflammation in a model for rheumatoid arthritis. The current work suggests a dramatic regulatory input of PI3K into the regulation of β2 integrin activity, and processes dependent on this, by signaling through its effector ARAP3. Copyright © 2012 by The American Association of Immunologists, Inc

Quo vadis medicinae candidatus? Nemzetközi környezetben tanuló orvostanhallgatók szakirány-és munkahely-választási preferenciái

Faubl Nóra1, Balogh Erika2, Henna Riemenschneider3, Karen Voigt3, Kiss István2, Füzesi Zsuzsann

Exposure to Traffic Pollution and Increased Risk of Rheumatoid Arthritis

Background: Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease that affects approximately 1% of the adult population, and to date, genetic factors explain < 50% of the risk. Particulate air pollution, especially of traffic origin, has been linked to systemic inflammation in many studies. Objectives: We examined the association of distance to road, a marker of traffic pollution exposure, and incidence of RA in a prospective cohort study.Methods We studied 90,297 U.S. women in the Nurses’ Health Study. We used a geographic information system to determine distance to road at the residence in 2000 as a measure of traffic exposure. Using Cox proportional hazard models, we examined the association of distance to road and incident RA (1976–2004) with adjustment for a large number of potential confounders. Results: In models adjusted for age, calendar year, race, cigarette smoking, parity, lactation, menopausal status and hormone use, oral contraceptive use, body mass index, physical activity, and census-tract-level median income and house value, we observed an elevated risk of RA [hazard ratio (HR) = 1.31; 95% confidence interval (CI), 0.98–1.74] in women living within 50 m of a road, compared with those women living 200 m or farther away. We also observed this association in analyses among nonsmokers (HR = 1.62; 95% CI, 1.04–2.52), nonsmokers with rheumatoid factor (RF)-negative RA (HR = 1.77; 95% CI, 0.93–3.38), and nonsmokers with RF-positive RA (HR = 1.51; 95% CI, 0.82–2.77). We saw no elevations in risk in women living 50–200 m from the road. Conclusions: The observed association between exposure to traffic pollution and RA suggests that pollution from traffic in adulthood may be a newly identified environmental risk factor for RA