Converting habits of antibiotic use for respiratory tract infections in German primary care (CHANGE-3) - process evaluation of a complex intervention.

BACKGROUND: Antimicrobial resistance remains a global challenge. In Germany, the national health agenda supports measures that enhance the appropriate, guideline-oriented use of antibiotics. The study "Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3)" aimed at a sustainable reduction of antimicrobial resistance through converting patterns of prescribing practice and use of antibiotics and an increase in health literacy in primary care patients, practice teams, and in the general public. Embedded in a cluster-randomized trial of a multifaceted implementation program, a process evaluation focused on the uptake of program components to assess the fidelity of the implementation program in the CHANGE-3 study and to understand utilization of its educational components. METHODS: A mix of qualitative and quantitative methods was used. Semi-structured telephone interviews were conducted with General Practitioners, Medical Assistants, patients treated for respiratory tract infection and outreach visitors who had carried out individual outreach visits. A two-wave written survey (T1: 5 months after start, T2: 16 months after start) was conducted in general practitioners and medical assistants. Qualitative data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze survey data. RESULTS: Uptake of intervention components was heterogenous. Across all components, the uptake reported by General Practitioners varied from 20 to 88% at T1 and 31 to 63% at T2. Medical Assistants reported uptake from 22 to 70% at T1 and 6 to 69% at T2. Paper-based components could by and large be integrated in daily practice (64 to 90% in T1; 41 to 93% in T2), but uptake of digital components was low. A one-time outreach visit provided thematic information and feedback regarding actual prescribing, but due to time constraints were received with reluctance by practice teams. Patients were largely unaware of program components, but assumed that information and education could promote health literacy regarding antibiotics use. CONCLUSIONS: The process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics. Future research efforts need to identify the best mode of delivery to reach the targeted population. TRIAL REGISTRATION: ISRCTN, ISRCTN15061174 . Registered 13 July 2018 - Retrospectively registered.

[Patients' perspectives beyond sectoral borders between inpatient and outpatient care - patients' experiences and preferences along cross-sectoral episodes of care]. / Die Patientenperspektive jenseits ambulant-stationärer Sektorengrenzen - Was ist Patientinnen und Patienten in der sektorenübergreifenden Versorgung wichtig?

AIM: Patient perspective is crucial concerning health care and quality improvement. During episodes of care, patients come into contact with multidisciplinary health-care providers in inpatient and outpatient settings and are in a unique position to describe processes throughout the entire chain of care. The aim of this study was to identify patients' experiences and preferences with fragmented cross-sectoral care to develop a patient-centred cross-sectoral quality-assessment instrument. METHOD: Patient perspective was analysed using qualitative focus-group methods. Patients were recruited from general practices if they had experienced cross-sectoral care. Focus group discussions were audiotaped, transcribed and analysed using ATLAS.ti software. Categories were extracted deductively according to a previously developed focus group guide and supplemented by inductive analyses. RESULTS: Patients identified quality gaps mainly concerning communication and coordination of care mostly along the cross-sectoral interfaces. Referrals and hospitalisations were characterised by redundant examinations and deficits in forwarding clinical findings. Support and organisation of follow-up care was rated to be improvable mainly during inpatient care and discharge. Patients identified also quality deficits concerning inpatient hygiene factors and changes of medication. Lack of transparency and responsibility within the entire chain of care caused anxiety and unstableness of patients. CONCLUSION: Patients' experiences provide important information to identify quality gaps along the entire chain of care. Study results can be used to develop a cross-sectoral patient-centred quality assessment instrument.