Sustainable reduction of antibiotic-induced antimicrobial resistance (ARena) in German ambulatory care: study protocol of a cluster randomised trial

Background: Despite many initiatives to enhance the rational use of antibiotics, there remains substantial room for improvement. The overall aim of this study is to optimise the appropriate use of antibiotics in German ambulatory care in patients with acute non-complicated infections (respiratory tract infections, such as bronchitis, sinusitis, tonsillitis and otitis media), community-acquired pneumonia and non-complicated cystitis, in order to counter the advancing antimicrobial resistance development. Methods: A three-armed cluster randomised trial will be conducted in 14 practice networks in two German federal states (Bavaria and North Rhine-Westphalia) and an added cohort that reflects standard care. The trial is accompanied by a process evaluation. Each arm will receive a different set of implementation strategies. Arm A receives a standard set, comprising of e-learning on communication with patients and quality circles with data-based feedback for physicians, information campaigns for the public, patient information material and performance-based additional reimbursement. Arm B receives this standard set plus e-learning on communication with patients and quality circles with data-based feedback tailored for non-physician health professionals of the practice team and information material for tablet computers (culture sensitive). Arm C receives the standard set as well as a computerised decision support system and quality circles in local multidisciplinary groups. The study aims to recruit 193 practices which will provide data on 23,934 patients each year (47,867 patients in total). The outcome evaluation is based on claims data and refers to established indicators of the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). Primary and secondary outcomes relate to prescribing of antibiotics, which will be analysed in multivariate regression models. The process evaluation is based on interviews with surveys among physicians, non-physician health professionals of the practice team and stakeholders. A patient survey is conducted in one of the study arms. Interview data will be qualitatively analysed using thematic framework analysis. Survey data of physicians, non-physician health professionals of the practice team and patients will use descriptive and exploratory statistics for analysis. Discussion: The ARena trial will examine the effectiveness of large scale implementation strategies and explore their delivery in routine practice. Trial registration: ISRCTN, ISRCTN58150046 . Registered 24 August 2017

Questionnaire of chronic illness care in primary care-psychometric properties and test-retest reliability

<p>Abstract</p> <p>Background</p> <p>The Chronic Care Model (CCM) is an evidence-based approach to improving the structure of care for chronically ill patients with multimorbidity. The Assessment of Chronic Illness Care (ACIC), an instrument commonly used in international research, includes all aspects of the CCM, but cannot be easily extended to the German context. A new instrument called the "Questionnaire of Chronic Illness Care in Primary Care" (QCPC) was developed for use in Germany for this reason. Here, we present the results of the psychometric properties and test-retest reliability of QCPC.</p> <p>Methods</p> <p>A total of 109 family doctors from different German states participated in the validation study. Participating physicians completed the QCPC, which includes items concerning the CCM and practice structure, at baseline (T0) and 3 weeks later (T1). Internal consistency reliability and test-retest reliability were evaluated using Cronbach's alpha and Pearson's r, respectively.</p> <p>Results</p> <p>The QCPC contains five elements of the CCM (decision support, delivery system design, self-management support, clinical information systems, and community linkages). All subscales demonstrated moderate internal consistency and moderate test-retest reliability over a three-week interval.</p> <p>Conclusions</p> <p>The QCPC is an appropriate instrument to assess the structure of chronic illness care. Unlike the ACIC, the QCPC can be used by health care providers without CCM training. The QCPC can detect the actual state of care as well as areas for improvement of care according to the CCM.</p

Herbal Medicine in Primary Healthcare in Germany: The Patient's Perspective

Herbal medicine (HM) is one of the most widely used Complementary and Alternative Medicine (CAM) therapies throughout the world. The WHO has recognized HM as an essential component of primary healthcare. The aim of this study was to explore patients' attitudes towards using HM, their sources of information and the role of costs. Within a qualitative research approach, semi-standardized interviews with 18 patients using HM were conducted and analyzed according to Mayring's content analysis. Patients highlighted their active role and perceived autonomy choosing HM. Most interviewees experienced HM as better, with more sustainable effects and fewer side effects compared to conventional medicine. All media, family, friends, and healthcare professionals were reported as sources of information. Some patients complained that doctors and pharmacists have insufficient knowledge of HM. Most patients expressed their regret that HM is not reimbursed by statutory health insurances but also their general willingness to pay extra for HM. The main challenge for German primary care, besides the reintroduction of reimbursement, is the promotion of knowledge and skill development in HM. This is to ensure patient safety and work in partnership with patients. Appropriate strategies for education must be tailored to the specific needs of health professional groups

Findings from a three-round Delphi study: essential topics for interprofessional training on complementary and integrative medicine

BACKGROUND: Integrating complementary medicine into medical care promotes patient-oriented care. A well-informed and collaborative professional healthcare team is essential for effective and patient-safe implementation of these methods. At present, the skills for patient counseling, therapy and care regarding complementary medicine vary among the professional groups involved. Professionals generally feel that they are not sufficiently qualified in this area. Curricular concepts for Complementary and Integrative Medicine (CIM) are virtually non-existent in undergraduate interprofessional training. The aim of this study is to initiate a consensus-building process between various experts (professionals, students, patient and faculty representatives) in order to identify which topics should be the focus of such a curriculum. METHODS: A three-round Delphi study was carried out from March 2018 to March 2019 to compile the experience and knowledge of experts in the field of integrative patient care and interprofessional education. Sixty-five experts from Germany and German-speaking Switzerland with various professional backgrounds and experiences were asked to name general content, therapy methods and treatment reasons which should be addressed in interprofessional seminars. In the subsequent rounds these were rated on a seven-point Likert scale. The ratings were assigned to relevance groups and discussed in a final workshop in July 2019. RESULTS: The response rates for the three rounds were 76% (n = 50), 80% (n = 40) 90% (n = 36); and 21% (n = 11) for the final workshop. The experts suggested that topics could be aligned along the most common treatment reasons such as insomnia, generalized pain, fatigue and back pain. However, it is important that students also receive an overview of the evidence base for different therapeutic concepts, especially in the field of classical natural medicine, acupuncture and mind-body medicine, and that they get an overview of the effects and interactions of frequently used procedures. CONCLUSION: Consensus was reached among the various experts on the most important topics for an interprofessional CIM curriculum. The systematic evaluation of the topics in this study can help to create a curriculum that achieves a high level of acceptance among teachers, lecturers and students, and thus facilitates implementation at universities and medical faculties

Applying Digital Information Delivery to Convert Habits of Antibiotic Use in Primary Care in Germany: Mixed-Methods Study

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