Herausforderungen, Ergebnisse und Reflexion

Derzeit sind fünf Millionen Menschen in Deutschland pflegebedürftig. Sie werden überwiegend in der eigenen Häuslichkeit versorgt oder in Einrichtungen der vollstationären Langzeitpflege betreut. Versorgungsforscher:innen bezeichnen den derzeitigen Stand der Forschung zur Versorgungssituation älterer pflegebedürftiger Menschen als nicht zufriedenstellend. Vor dem Hintergrund einer zunehmenden Zahl an pflegebedürftigen Menschen ist das übergeordnete Ziel dieser Habilitationsschrift setting- und zielgruppenspezifische Herausforderungen in der Versorgungsforschung mit dieser Zielgruppe zu bearbeiten, methodisch-methodologische Fragen zu beantworten und kritisch zu reflektieren. In der Diskussion wird zudem der Bezug zum aktuellen Diskurs der Versorgungsforschung hergestellt. Abschließend werden Implikationen für die zukünftige Forschung gegeben.Five million people in Germany are currently in need of care. Most of them are cared for in their own homes or in long-term inpatient care facilities. Health service researchers describe the current state of research on the care situation for older people receiving care as unsatisfactory. Against the background of an increasing number of people receiving care, the overarching aim of this habilitation thesis is to work on setting-related and target group-specific challenges in health service research with this target group, to answer questions concerning methods and methodological approaches and to reflect critically on them. The discussion is also extended to take account of the current discourse in health services research. Finally, implications for future research are presented

Deficits in pain medication in older adults with chronic pain receiving home care: A cross-sectional study in Germany

OBJECTIVE: To analyze the pattern and appropriateness of pain medications in older adults receiving home care. METHODS: We performed a prospective cross-sectional study in patients ≥65 years old having chronic pain and receiving home care in Berlin, Germany. Data on prescribed pain medications were collected using self-reported information, nursing documents, and medication plans during interviews at home. Pain intensity was determined with the numeric rating scale (NRS) and the Pain Assessment In Advanced dementia (PAINAD) scale. The Pain Medication Appropriateness Scale score (SPMAS) was applied to evaluate inappropriateness (i.e. a score ≤67) of pain medication. RESULTS: Overall 322 patients with a mean age of 82.1 ± 7.4 years (71.4% females) were evaluated. The average pain intensity scores during the last 24 hours were 5.3 ± 2.1 and 2.3 ± 2.3 on NRS and PAINAD scale (range 0-10, respectively). Sixty (18.6%) patients did not receive any pain medication. Among the treated patients, dipyrone was the most frequently prescribed analgesic (71.4%), while 50.8% and 19.1% received systemic treatment with opioids and non-steroidal anti-inflammatory drugs, respectively. The observed median SPMAS was 47.6 (range 0-100) with 58 (18.0%) of patients achieving appropriate values. Half of the patients were treated with scheduled, while 29.9% were only treated with on-demand medications. Cognitive status had no effect on appropriateness of pain treatment. CONCLUSIONS: We observed substantial deficits in dosing patterns and appropriateness of pain medication in older adults with pain receiving home care. This applied to both patients with and without severe cognitive impairment

Informal caregivers during the COVID-19 pandemic perceive additional burden: findings from an ad-hoc survey in Germany

Background: While the relation between care involvement of informal caregivers and caregiver burden is well-known, the additional psychosocial burden related to care involvement during the COVID-19 pandemic has not yet been investigated. Methods: A total of 1000 informal caregivers, recruited offline, participated in a cross-sectional online survey from April 21 to May 2, 2020. Questionnaires were used to assess COVID-19-specific changes in the care situation, negative feelings in the care situation, problems with implementation of COVID-19 measures, concerns/excessive demands, loss of support, change in informal caregivers' own involvement in care and problems with provision, comprehension & practicability of COVID-19 information, and to relate these issues to five indicators of care involvement (i.e., being the main caregiver, high expenditure of time, high level of care, dementia, no professional help). Binomial and multiple regression analyses were applied. Results: Across indicators of care involvement, 25.5-39.7% reported that the care situation rather or greatly worsened during the COVID-19 pandemic, especially for those caring for someone with dementia or those usually relying on professional help. In a multiple regression model, the mean number of involvement indicators met was associated with age (beta = .18; CI .10-.25), excessive demands (beta = .10, CI .00-.19), problems with implementation of COVID-19 measures (beta = .11, CI .04-.19), an increase in caregiving by the informal caregivers themselves (beta = .14, CI .03-.24) as well as with no change in the amount of caregiving (beta = .18, CI .07-.29) and loss of support (beta = -.08, CI -.16-.00). No significant associations with the mean number of involvement indicators met were found for gender, educational level, change in the care situation, negative feelings, and provision, comprehension & practicability of COVID-19 information. Conclusion: Those caregivers who perceived extensive care burden were those who suffered most during the pandemic, calling for structural support by the healthcare system now and in the future

Psychosocial burden and associated factors among nurses in care homes during the COVID-19 pandemic: findings from a retrospective survey in Germany

Background: Care homes were hit hard by the COVID-19 pandemic. Although high levels of psychosocial burden (i.e., anxiety, depression and stress) during the pandemic have been described for healthcare workers in hospitals, evidence on the psychosocial burden for nurses in care homes during the pandemic is scarce. Methods: A total of 811 nurses participated in a retrospective online survey between November 2020 and February 2021. Information about the COVID-19 situation (i.e., working demands, COVID-19 cases in their facility, and COVID-19-related burden) of nurses in German care homes during the first wave of the pandemic (March 2020 to June 2020) was gathered. The Stress Scale of the Depression Anxiety and Stress Scales (SDASS-21), the Generalized Anxiety Disorder Scale-2 (GAD-2), the Patients-Health-Questionnaire-2 (PHQ-2), and the Copenhagen Psychosocial Questionnaire (COPSOQ) were used to screen for psychosocial burden. Results: Among nurses, 94.2% stated that working demands since the COVID-19 pandemic increased. Further, 59.1% showed clinically relevant levels of either stress, anxiety, and/or depression. Multiple regression analysis showed significant associations between COVID-19-related burden and qualification (p < .01), dissatisfaction with COVID-19 management of care home manager (p < .05), COVID-19-related anxiety (p < .001), and dementia as a focus of care (p < .05). Stress, depression, and anxiety showed associations with COVID-19 related burden at work (p < .01), COVID-19-related anxiety (p < .001), social support (p < .01), and sense of community (p < .05). Stress was also associated with COVID-19 cases among residents (p < .05), and size of care home (p < .05). Conclusion: Short- and long-term strategies (i.e., psychosocial counseling, mandatory team meetings, more highly qualified nurses, additional training) in the work environment of nursing, in crises, but beyond, should be encouraged to reduce the burden on nursing staff in care homes

Health promotion for older family caregivers with special consideration of the problem of low uptake of health-promotion measures such as moderate physical activity

Hintergrund: Die steigende Zahl (älterer) pflegender Angehöriger sowie mit der häuslichen Pflege korrespondierende Belastungen für Pflegende prädestinieren diese Zielgruppe für Gesundheitsförderung beispielsweise durch moderate körperliche Aktivität. Trotz des hohen Bedarfs an Gesundheitsförderung werden pflegende Angehörige von Angeboten schwer erreicht („Präventionsdilemma“). Dies könnte auf die fehlende Bedarfsorientierung von Angeboten für diese Zielgruppe zurückzuführen sein. Ziel dieser Publikationspromotion war, einen Beitrag zur Gesundheitsförderung für ältere pflegende Angehörige zu leisten und dabei auch die Problematik der Nichtinanspruchnahme von gesundheitsförderlichen Angeboten zu untersuchen. Methode: Dazu wurde ein Assessment-Instrument (ARR) entwickelt und validiert, welches physische und psychische Ressourcen und Risiken älterer pflegender Angehöriger erfasst, um auf dieser Basis am Bedarf ausgerichtete Bewegungs- oder Entspannungsangebote zu unterbreiten. Pflegende Angehörige, die keines der Angebote nutzten, wurden zu ihren Gründen befragt. Der wahrgenommene Nutzen und die Barrieren moderater körperlicher Aktivität wurden mittels neu entwickelter und validierter Skalen analysiert. Ergebnisse: Die faktorielle Validität des ARR konnte an einer Stichprobe mit 202 pflegenden Angehörigen gezeigt werden. Trotz einer zugehenden und am Bedarf ausgerichteten Angebotsstruktur nutzten nur wenige pflegende Angehörige diese. Die Analyse spontan geäußerter Gründe stellt Erklärungsansätze dazu bereit. Zudem hatte die Mehrheit der Befragten entweder keine Absicht aktiv zu werden (42,7 %) oder war bereits regelmäßig aktiv (43,7 %). Das Aktivitätsniveau der pflegenden Angehörigen war mit dem Nutzen und den Barrieren hinsichtlich regelmäßiger Aktivität assoziiert, wobei der Nutzen einen stärkeren Effekt hatte. Schlussfolgerung: Interventionen zur Förderung der Gesundheit durch Bewegung sollten für diese Zielgruppe am Bedarf ausgerichtet sein und eher Strategien zur Maximierung des Nutzens von Aktivität berücksichtigen, als wahrgenommene Barrieren zu widerlegen.Background: Due to an increasing number of (elderly) family caregivers and various burdens related to home care, this target group is predestined for health promotion such as moderate physical activity. Despite a strong need for health promotion in general, elderly caregivers are rarely reached by activity offers. This might be explained by shortcomings in existing offers such as a lack of need orientation. The aim of this cumulative doctoral thesis was to contribute to health promotion for elderly family caregivers (50 years and older) in Germany and to explore the set of problems of disuse of moderate activity offers (exercise and/or relaxation). Methods: For this purpose an assessment-instrument (ARR) was developed (Publication1) and validated (Publication 2). The ARR encompasses physical and psychological resources and risks of elderly family caregivers. Based on results of the ARR need-oriented activity offers (exercise and/or relaxation) were provided. The utilization of these activity offers was low, however, semi-standardized interviews were conducted with caregivers to analyze reasons (Publication 3). Moreover, new scales were developed and validated to assess the perceived benefits of and barriers to moderate physical activity. Stages of change for activity were assessed to analyze different levels of motivation to activity (Publication 4). Results: Factorial validity for the ARR was confirmed. Psychometric qualities allow the conclusion that the ARR is a reliable and valid instrument (N = 202). Personal perceptions more than external circumstances inhibited the use of activity offers. Moreover, the majority of caregivers had either no intention to become active (precontemplation stage: 42.7 %) or had been exercising regularly for more than six months (maintenance stage: 43.7 %). While both perceived benefits and barriers were significantly related to stages of change for activity, perceived benefits showed a stronger positive relationship. Conclusion: Thus, interventions to promote moderate physical activity for elderly family caregivers should provide individual and need- oriented activity offers. Moreover, those interventions should consider strategies that maximize the perceived benefits of activity rather than refuting the barriers

Sekundärdatenanalyse initial vollstationär behandelter Patienten mit Schizophrenie in einem Berliner Modellprojekt (nach § 64b SGB V)

Ziel der Studie Schizophrenie zählt zu den schwersten psychiatrischen Erkrankungen. Das deutsche Versorgungssystem weist jedoch für diese und andere chronisch psychisch Erkrankte mit einem intensiven Behandlungsbedarf nach wie vor Lücken auf. Der vorliegende Beitrag fokussiert die Veränderung der Versorgung von initial vollstationär behandelten Patienten mit Schizophrenie, die an den St. Hedwig Kliniken in Berlin in einem Modellprojekt nach § 64b SGB V versorgt werden, im Vergleich zu Patienten in der Regelversorgung. Methodik Die Zielgrößen wurden mittels Routinedaten erfasst. Dabei wurden 3 Patientenkohorten analysiert. Mittels Propensity Score Matching wurde je Kohorte eine Vergleichsgruppe gebildet. Ergebnisse Es zeigt sich, dass im Modellprojekt die Anzahl der Krankenhausaufenthalte reduziert wurde, die Gesamtverweildauer gesenkt und Gesamtkosten teilweise gesenkt wurden. Zudem verlängerte sich die Dauer bis zur nächsten Rehospitalisierung, während sich die Gesamtzahl der Kontakte zum ambulanten Sektor erhöhte. Schlussfolgerung Die angestrebte Verlagerung der Versorgung in den ambulanten Bereich wurde für Patienten mit Schizophrenie in diesem Modellprojekt erreicht. Abstract Aim of the study Schizophrenia is one of the most severe psychiatric diseases. The German health care system still shows gaps in services for chronic psychiatric patients with intense need of treatment. The present article focused on changes in provision of health services for initially treated in-patients with schizophrenia in St. Hedwig hospitals in Berlin according to § 64b SGB V compared to patients receiving regular in-patient treatment. Methods By using statutory data, we analyzed target figures. We analyzed patients of 3 cohorts. Propensity Score Matching generated a control group in each cohort. Results The final analysis showed for schizophrenia patients treated in the model project that the number of hospital stays and overall length of stay decreased, but overall costs decreased only partially. Moreover, the period (in days) until next re-hospitalization was longer, while the sum of contacts to the outpatient sector increased. Conclusions The presented model project achieved the aimed shift of psychiatric health service into the outpatient sector for schizophrenia patients. Schlüsselwörter Schizophrenie - Evaluation - § 64b SGB V - Matching - Routinedaten Key words schizophrenia - evaluation - § 64b SGB V - matching - statutory dat

High Prevalence of Multimorbidity and Polypharmacy in Elderly Patients With Chronic Pain Receiving Home Care are Associated With Multiple Medication-Related Problems

Aim: To measure the extent of polypharmacy, multimorbidity and potential medication-related problems in elderly patients with chronic pain receiving home care. Methods: Data of 355 patients aged >= 65 years affected by chronic pain in home care who were enrolled in the ACHE study in Berlin, Germany, were analyzed. History of chronic diseases, diagnoses, medications including self-medication were collected for all patients. Multimorbidity was defined as the presence of >= 2 chronic conditions and levels were classified by the Charlson-Comorbidity-Index. Polypharmacy was defined as the concomitant intake of >= 5 medications. Potentially clinically relevant drug interactions were identified and evaluated; underuse of potentially useful medications as well as overprescription were also assessed. Results: More than half of the patients (55.4%) had moderate to severe comorbidity levels. The median number of prescribed drugs was 9 (range 0-25) and polypharmacy was detected in 89.5% of the patients. Almost half of them (49.3%) were affected by excessive polypharmacy (>= 10 prescribed drugs). Polypharmacy and excessive polypharmacy occurred at all levels of comorbidity. We detected 184 potentially relevant drug interactions in 120/353 (34.0%) patients and rated 57 (31.0%) of them as severe. Underprescription of oral anticoagulants was detected in 32.3% of patients with atrial fibrillation whereas potential overprescription of loop diuretics was observed in 15.5% of patients. Conclusion: Multimorbidity and polypharmacy are highly prevalent in elderly outpatients with chronic pain receiving home care. Medication-related problems that could impair safety of drug treatment in this population are resulting from potentially relevant drug interactions, overprescribing as well as underuse

Mortality, morbidity and health-related outcomes in informal caregivers compared to non-caregivers: a systematic review

A systematic overview of mental and physical disorders of informal caregivers based on population-based studies with good methodological quality is lacking. Therefore, our aim was to systematically summarize mortality, incidence, and prevalence estimates of chronic diseases in informal caregivers compared to non-caregivers. Following PRISMA recommendations, we searched major healthcare databases (CINAHL, MEDLINE and Web of Science) systematically for relevant studies published in the last 10 years (without language restrictions) (PROSPERO registration number: CRD42020200314). We included only observational cross-sectional and cohort studies with low risk of bias (risk scores 0–2 out of max 8) that reported the prevalence, incidence, odds ratio (OR), hazard ratio (HR), mean- or sum-scores for health-related outcomes in informal caregivers and non-caregivers. For a thorough methodological quality assessment, we used a validated checklist. The synthesis of the results was conducted by grouping outcomes. We included 22 studies, which came predominately from the USA and Europe. Informal caregivers had a significantly lower mortality than non-caregivers. Regarding chronic morbidity outcomes, the results from a large longitudinal German health-insurance evaluation showed increased and statistically significant incidences of severe stress, adjustment disorders, depression, diseases of the spine and pain conditions among informal caregivers compared to non-caregivers. In cross-sectional evaluations, informal caregiving seemed to be associated with a higher occurrence of depression and of anxiety (ranging from 4 to 51% and 2 to 38%, respectively), pain, hypertension, diabetes and reduced quality of life. Results from our systematic review suggest that informal caregiving may be associated with several mental and physical disorders. However, these results need to be interpreted with caution, as the cross-sectional studies cannot determine temporal relationships. The lower mortality rates compared to non-caregivers may be due to a healthy-carer bias in longitudinal observational studies; however, these and other potential benefits of informal caregiving deserve further attention by researchers