Who Benefited the Most? Effectiveness of a Lifestyle Intervention Against Cognitive Decline in Older Women and Men - Secondary Analysis of the AgeWell.de-trial.

INTRODUCTION: Differences between women and men matter in the prevalence and risk factors of dementia. We aimed to examine potential sex differences regarding the effectiveness by running a secondary analysis of the AgeWell.de trial, a cluster-randomized multicenter multi-domain lifestyle intervention to reduce cognitive decline. METHODS: Intention-to-treat analyses of women (n=433) and men (n=386) aged 60 to 77 years were used for models including interactions between intervention group allocation and sex followed by subgroup analysis stratified by sex on primary and secondary outcomes. Further, the same procedure was repeated for age groups (60-69 vs. 70-77) within sex-specific subgroups to assess the effectiveness in different age groups. TRIAL REGISTRATION: German Clinical Trials Register (ref. number: DRKS00013555). RESULTS: No differences were found between women and men in the effectiveness of the intervention on cognitive performance. However, women benefitted from the intervention regarding depressive symptoms while men did not. Health-related quality of life was enhanced for younger intervention participants (60-69 years) in both women and men. CONCLUSION: The AgeWell.de intervention was able to improve depressive symptoms in women and health-related quality of life in younger participants. Female participants between 60 and 69 years benefited the most. Results support the need of better individually targeted lifestyle interventions for older adults.

Depressive primary care patients' assessment of received collaborative care.

The "Patient Assessment of Chronic Illness Care" (PACIC) is a tool for evaluating outpatient health service for patients with chronic diseases. Our aim was to analyze the association between PACIC scores of primary care patients with depression and patients' or patients' general practitioners' (GPs) characteristics. In a data set including depressive primary care patients (N = 280) the association of patient characteristics (sex, age, depressive symptom severity, suicidal ideation) with PACIC scores were assessed by linear regression models. The association between GPs' characteristics (type, location of practice; age, qualification of practitioner) and PACIC scores was assessed by linear mixed models with individual practices as random effects. Patient Health Questionnaire (PHQ-9) scores at 12 months follow up and changes in PHQ-9 scores from baseline to follow up were significantly positive associated with higher PACIC scores (beta = 0.67, 95%-CI [0.02, 1.34]). PACIC scores were not associated with patients' sex (p = 0.473) or age (p = 0.531). GP's age was negatively associated with PACIC scores (p = 0.03). In conclusion, in patients with depression, the PACIC is independent from patients' and GPs' characteristics. The PACIC may be appropriate to assess patient-perspective on depression services in primary care.

Predictors and outcomes in primary depression care (POKAL) - a research training group develops an innovative approach to collaborative care.

BACKGROUND: The interdisciplinary research training group (POKAL) aims to improve care for patients with depression and multimorbidity in primary care. POKAL includes nine projects within the framework of the Chronic Care Model (CCM). In addition, POKAL will train young (mental) health professionals in research competences within primary care settings. POKAL will address specific challenges in diagnosis (reliability of diagnosis, ignoring suicidal risks), in treatment (insufficient patient involvement, highly fragmented care and inappropriate long-time anti-depressive medication) and in implementation of innovations (insufficient guideline adherence, use of irrelevant patient outcomes, ignoring relevant context factors) in primary depression care. METHODS: In 2021 POKAL started with a first group of 16 trainees in general practice (GPs), pharmacy, psychology, public health, informatics, etc. The program is scheduled for at least 6 years, so a second group of trainees starting in 2024 will also have three years of research-time. Experienced principal investigators (PIs) supervise all trainees in their specific projects. All projects refer to the CCM and focus on the diagnostic, therapeutic, and implementation challenges. RESULTS: The first cohort of the POKAL research training group will develop and test new depression-specific diagnostics (hermeneutical strategies, predicting models, screening for suicidal ideation), treatment (primary-care based psycho-education, modulating factors in depression monitoring, strategies of de-prescribing) and implementation in primary care (guideline implementation, use of patient-assessed data, identification of relevant context factors). Based on those results the second cohort of trainees and their PIs will run two major trials to proof innovations in primary care-based a) diagnostics and b) treatment for depression. CONCLUSION: The research and training programme POKAL aims to provide appropriate approaches for depression diagnosis and treatment in primary care.

Management of COVID-19 ICU-survivors in primary care: - a narrative review.

Many survivors of critical illness suffer from long-lasting physical, cognitive, and mental health sequelae. The number of affected patients is expected to markedly increase due to the COVID-19 pandemic. Many ICU survivors receive long-term care from a primary care physician. Hence, awareness and appropriate management of these sequelae is crucial. An interdisciplinary authorship team participated in a narrative literature review to identify key issues in managing COVID-19 ICU-survivors in primary care. The aim of this perspective paper is to synthesize important literature to understand and manage sequelae of critical illness due to COVID-19 in the primary care setting.

Frequency and risk factors of post-intensive care syndrome components in a multicenter randomized controlled trial of German sepsis survivors.

BACKGROUND: Post-intensive care syndrome (PICS) is a combination of cognitive, psychiatric and physical impairments in survivors of critical illness and intensive care. There is little data on long-term co-occurrence of associated impairments. METHODS: Analysis of data from 289 sepsis survivors from a German multicenter RCT. Impairments associated with PICS (depression, PTSD, cognitive impairment, chronic pain, neuropathic symptoms, dysphagia) during 24 months follow-up are used to explore the frequency and risk factors of PICS components in three classification models. RESULTS: The majority of participants showed impairments in 2-3 of 6 domains during follow-up. The overall frequency of PICS according to the classification models ranged from 32.9% to 98.6%. In regression analyses, there were no significant effects in selected ICU-related exposures or covariates for PICS classification models. Regarding individual components, only higher age and longer duration of ICU treatment and mechanical ventilation showed significant positive associations with the occurrence of cognitive impairment during follow-up, as did male gender and higher age for dysphagia. CONCLUSIONS: Almost all study participants showed impairments associated with PICS in at least one domain. The proposed classification models for PICS appear to be too broad to identify specific risk factors beyond its individual components.

Illness behaviour of general practitioners-a cross-sectional survey.

BACKGROUND: International guidelines recommend that physicians should be registered with a general practitioner (GP) and should avoid self-treatment. Adherence to these recommendations is mixed. AIMS: To describe illness behaviour and chronic medical conditions of GPs in Germany. METHODS: Cross-sectional, observational questionnaire study. We contacted 1000 GPs by mail in April 2014. We asked about registration with a GP, chronic conditions and self-treatment. We undertook descriptive statistical analysis and analysed associations using t-tests and chi-square test. RESULTS: Two hundred and eighty-five responses (29%) were eligible for analysis. Nineteen per cent of GPs were registered as patients of a GP, 58% reported at least one chronic condition, 68% disclosed self-diagnosis and 60% self-treatment. Self-therapy for chronic conditions was inversely correlated with subjective severity of the disease (r = -0.159; P < 0.05). CONCLUSIONS: The high rates of self-treatment and the low rate of registration with a GP of German GPs are in contrast to international guideline recommendations. Further research is needed to analyse specific reasons.

[Use and potential risks of over-the-counter analgesics]. / Gebrauch und potenzielle Risiken durch nicht verschreibungspflichtige Schmerzmittel.

BACKGROUND AND AIM: We investigated the use of prescription and non-prescription (over-the-counter, OTC) analgesics and the associated risks in elderly patients with multiple morbidities. METHODS: Pain medication use was evaluated from the baseline data (2008/2009) of the MultiCare cohort enrolling elderly patients with multiple morbidities who were treated by primary care physicians (trial registration: ISRCTN89818205). We considered opioids (N02A), other analgesics, and antipyretics (N02B) as well as nonsteroidal anti-inflammatory drugs (NSAIDs; M01A). OTC use, duplicate prescription, dosages, and interactions were examined for acetylsalicylic acid, diclofenac, (dex)ibuprofen, naproxen, and acetaminophen. RESULTS: Of 3,189 patients with multiple morbidities aged 65-85 years, 1,170 patients reported to have taken at least one prescription or non-prescription analgesic within the last 3 months (36.7 %). Of these, 289 patients (24.7 % of 1,170) took at least one OTC analgesic. Duplicate prescription was observed in 86 cases; 15 of these cases took the analgesics regularly. In two cases, the maximum daily dose of diclofenac was exceeded due to duplicate prescription. In 235 cases, patients concurrently took a drug with a potentially clinically relevant interaction. In 43 cases (18.3 % of 235) an OTC analgesic, usually ibuprofen, was involved. DISCUSSION: About one third of the elderly patients took analgesics regularly or as needed. Despite the relatively high use of OTC analgesics, the proportions of duplicate prescription, medication overdoses, and adverse interactions due to OTC products was low.

General and abdominal obesity parameters and their combination in relation to mortality: a systematic review and meta-regression analysis.

Epidemiological studies assessing general and abdominal obesity measures or their combination for mortality prediction have shown inconsistent results. We aimed to systematically review the associations of body mass index (BMI), waist-to-hip ratio (WHR), waist circumference (WC) and waist-to-height ratio (WHtR) with all-cause mortality in prospective cohort studies. In this systematic review, which includes a meta-regression analysis, we analysed the associations with all-cause mortality of BMI, WHR, WC and WHtR in prospective cohort studies available in Medline, Embase, the Cochrane Database of Systematic Reviews and Esbiobase from inception through 7 May 2010. A total of 18 studies met the inclusion criteria, comprising 689, 465 participants and 48, 421 deaths during 5-24 years of follow-up. The studies were heterogeneous, mainly due to differences in categorization of anthropometric parameters (AP) and different approaches to statistical analysis. Both general and abdominal obesity measures were significantly associated with mortality. In analyses using categorical variables, BMI and WC showed predominantly U- or J-shaped associations with mortality, whereas WHR and WHtR demonstrated positive relationships with mortality. All measures showed similar risk patterns for upper quantiles in comparison to reference quantiles. The parameters of general and abdominal obesity each remained significantly associated with mortality when adjusted for the other. This evidence suggests that abdominal obesity measures such as WC or WHR, show information independent to measures of general obesity and should be used in clinical practice, in addition to BMI, to assess obesity-related mortality in adults.

Evaluating frequency, diagnostic quality, and cost of Lyme borreliosis testing in Germany: a retrospective model analysis.

BACKGROUND: Data on the economic impact of Lyme borreliosis (LB) on European health care systems is scarce. This project focused on the epidemiology and costs for laboratory testing in LB patients in Germany. MATERIALS AND METHODS: We performed a sentinel analysis of epidemiological and medicoeconomic data for 2007 and 2008. Data was provided by a German statutory health insurance (DAK) company covering approx. 6.04 million members. In addition, the quality of diagnostic testing for LB in Germany was studied. RESULTS: In 2007 and 2008, the incident diagnosis LB was coded on average for 15,742 out of 6.04 million insured members (0.26%). 20,986 EIAs and 12,558 immunoblots were ordered annually for these patients. For all insured members in the outpatient sector, a total of 174,820 EIAs and 52,280 immunoblots were reimbursed annually to health care providers (cost: 2,600,850€). For Germany, the overall expected cost is estimated at 51,215,105€. However, proficiency testing data questioned test quality and standardization of diagnostic assays used. CONCLUSION: Findings from this study suggest ongoing issues related to care for LB and may help to improve future LB disease management.

[The diabetes traffic light scheme - development of an instrument for the case management in patients with diabetes mellitus in primary care]. / Das Diabetes-Ampelschema - Entwicklung eines Instruments für das hausärztliche Case Management bei Patienten mit Diabetes mellitus.

In order to sustain the continuity and quality of treatment in diabetic primary care patients, it is necessary to introduce structured and regularly performed monitoring system into the practice team. The monitoring aims at early and valid recognition of potential complications resulting from a chronic disease. Ideally the practice nurse is in charge of the case management. The central element of the case management is a colour coded instrument, the diabetes traffic light scheme, by which means the most important clinical parameters and patient adherence can be screened in regular intervals. Additionally, the instrument regulates in-practice communication by means of stratified action plans and enables ideal treatment continuity also in larger teams. The experiences resulting from the development of this diabetes-specific traffic light scheme can be beneficial for the future development of similar instruments in other chronic diseases.

Practice-based depression case management in primary care: a qualitative study on family doctors' perspectives.

BACKGROUND: Case management provided by health care assistants (HCAs) is effective in improving primary care for depressive patients. Little is known on the implementation-related aspects of case management performed in small family practices. OBJECTIVE: To explore family doctors' perspectives on clinical and organizational aspects of implementation of case management and perceived practice-related aspects associated with patient care after 1 year's experience of HCAs providing case management for depressive patients in their practices. METHODS: This qualitative study was nested in a cluster-randomized trial on case management provided by practice-based HCAs for patients with major depression in Germany. We used semi-structured interview guides and performed audio-taped interviews with family doctors. Full transcription and thematic content analysis were carried out. RESULTS: Twenty-three family doctors were interviewed. The family doctors perceived case management as beneficial to patients and reported that it improved their consultation styles and doctor-patient relationships. They implemented case management elements into their everyday day work using 'concrete', 'subsumed' or 'progressive' implementation styles. CONCLUSIONS: Family doctors perceived practice-based case management by HCAs as beneficial for patient care. Different implementation styles may be appropriate, depending on the health care setting, and this requires further evaluation.

Interventions in primary care to improve cardiovascular risk factors and glycated haemoglobin (HbA1c) levels in patients with diabetes: a systematic review.

Most patients with diabetes are treated in primary care (PC). We performed a systematic review to assess the effect of single and combined interventions on cardiovascular risk factors (CVRFs) and glycated haemoglobin (HbA1c) levels in patients with diabetes in PC settings. We searched the MEDLINE database from January 1990 to October 2008. According to the Cochrane Effective Practice and Organization of Care Group (EPOC) criteria, (cluster-)randomized control studies and controlled before-and-after studies were selected and reviewed. Identified interventions were classified according to a modified EPOC intervention taxonomy. We included 68 studies. Forty-five studies evaluated the effect of any intervention on HbA1c. Seventeen studies presented a significant improvement in HbA1c. Nine out of 27 studies evaluating CVRFs [cholesterol, blood pressure (BP)] and HbA1c showed a significant improvement in at least two of these factors. Audit and feedback on performance, clinical decision support systems, multi-professional teams and patient education seemed to be successful strategies. The increasing evidence regarding the treatment of persons with chronic illnesses, summarized in the Chronic Care Model (CCM), is not reflected in most recent studies about diabetes treatment in PC. Most interventions still seem only partly adapted to the CCM. The methodological quality of many studies is still poor and often the pivotal outcomes, CVRFs and HbA1c, are not appropriately addressed. As a consequence, the potential of PC in the care of patients with diabetes may still be underestimated.

The Patient Assessment of Chronic Illness Care questionnaire: evaluation in patients with mental disorders in primary care.

The Chronic Care Model provides evidence-based recommendations to improve the care for patients with chronic conditions. The Patient Assessment of Chronic Illness Care questionnaire (PACIC) is an instrument to evaluate the patient's perspective on receipt of care delivered in the five domains patient activation, delivery system, goal setting, problem solving, and follow-up. The aim of this study was to assess the psychometric characteristics of the PACIC in 442 primary care patients with major depression. The psychometric properties were good. We found possible ceiling effects in the two subscales 'patient activation' (12.9%) and 'problem solving/contextual' (8.9%), as well as floor effects in 'goal setting/tailoring' (4.6%). The Cronbach's α coefficient for the total scale was excellent (0.91). We found two major factors, which we labeled according to the PACIC domains as composite factors 'patient activation and problem solving' as well as 'goal setting and coordination'. The perspective of patients with mental disorders, such as depression, on primary chronic illness care can be assessed adequately by the PACIC.

[Evidence-based therapy of depression: S3 guidelines on unipolar depression]. / Evidenzbasierte Therapie der Depression: Die S3-Leitlinie unipolare Depression.

Unipolar depressive disorders are among the most frequent reasons for utilizing the health care system. Although efficacious treatments are available and further advances have recently been made there is still a need for improving diagnostic and therapeutic procedures. Alignment of treatment on evidence-based treatment guidelines establishes an essential mainstay. The new S3 and National Health Care guidelines on unipolar depression, the compilation of which was coordinated by the German Society of Psychiatry, Psychotherapy and Neurology (DGPPN) and which were approved by 29 scientific and professional associations, is the ambitious effort to present state of the art evidence and clinical consensus for the treatment of depression. For pharmacotherapy of depression differentiated recommendations can be given, also separate from and in addition to psychotherapy.

"Every error counts": a web-based incident reporting and learning system for general practice.

BACKGROUND: Incident reporting systems have been established primarily in the inpatient setting. Their goal is the identification of safety risks in healthcare as a precondition for improvements in the overall quality of care. Knowledge about medical errors in general practice is sparse, as are reporting systems for patient safety in this setting. This article describes the development, structure and initial results of an incident reporting system for general practices in German-speaking countries. METHODS: Jeder Fehler Zaehlt (JFZ; www.jeder-fehler-zaehlt.de) is a web-based reporting system that receives incident reports from anonymous German-speaking users. Reports are fed into a database, classified and analysed by a team of experts. Exemplary reports are published on the internet and in journals, and the reporting system provides the opportunity for users to comment on and learn from these incidents. RESULTS: The incident reporting system received 199 reports in the 17 months following its launch, of which 188 were classifiable. Of these, 72.9% were classified as process errors and 26.1% as knowledge/skills errors. The most frequently reported process errors were treatment errors (32.2%), communication errors (12.6%) and investigation errors (8.5%). Of the classified errors, 41.5% were associated with harm to the patient. More than 300 comments were made, mostly by anonymous users of the system. CONCLUSIONS: JFZ is a well-functioning and growing incident reporting system. Future efforts to improve the benefits of incident reporting will concentrate on increasing the utilisation of the system and broadening the spectrum of reported incidents.

Case management to improve major depression in primary health care: a systematic review.

BACKGROUND: Deficits in the care of depression lead to poor medication adherence, which increases the risk of an unfavourable outcome for this care. This review evaluates effects on symptoms and medication adherence of case management in primary health care. METHOD: A systematic literature search was performed. The quality of the studies was rated according to the Cochrane Effective Practice and Organization of Care Group (EPOC) criteria. To conduct a subgroup analysis interventions were classified as either 'standard' or 'complex' case management. RESULTS: Thirteen studies met the inclusion criteria. In a meta-analysis we calculated a standard mean difference/effect size on symptom severity after 6-12 months of -0.40 (95% CI -0.60 to -0.20). Patients in the intervention groups were more likely to achieve remission after 6-12 months [relative risk (RR) 1.39, 95% CI 1.30-1.48]. The relative risk for clinical response was 1.82 (95% CI 1.68-2.05). Patients in intervention groups had better medication adherence than the control group (RR 1.5, 95% CI 1.28-1.86). We found heterogeneous results when assessing effects of different types of intervention. CONCLUSIONS: We conclude that case management improves management of major depression in primary health-care settings.