Collaborative Ambulatory Orthopaedic Care in Patients with Hip and Knee Osteoarthritis: A Retrospective Comparative Cohort Study on Health Utilisation and Economic Outcomes.

Objective: To evaluate a novel healthcare programme for the treatment of patients with hip and knee osteoarthritis in southern Germany in terms of clinical and health economic outcomes. The study is based on claims data from 2014 to 2017. Methods: We conducted a retrospective comparative cohort study of 9768 patients with hip and knee osteoarthritis, of whom 9231 were enrolled in a collaborative ambulatory orthopaedic care programme (intervention group), and 537 patients received usual orthopaedic care (control group). Key features of the programme are coordinated care, morbidity-adapted reimbursement and extended consultation times. Multivariable analysis was performed to determine effects on health utilisation outcomes. The economic analysis considered annual costs per patient from a healthcare payer perspective, stratified by healthcare service sector. Besides multivariable regression analyses, bootstrapping was used to estimate confidence intervals for predicted mean costs by group. Results: Musculoskeletal-disease-related hospitalisation was much less likely among intervention group patients than control group patients [odds ratio (OR): 0.079; 95% CI: 0.062-0.099]. The number of physiotherapy prescriptions per patient was significantly lower in the intervention group (RR: 0.814; 95% CI: 0.721-0.919), while the likelihood of participation in exercise programmes over one year was significantly higher (OR: 3.126; 95% CI: 1.604-6.094). Enrolment in the programme was associated with significantly higher ambulatory costs (€1048 vs. €925), but costs for inpatient care, including hospital stays, were significantly lower (€1003 vs. €1497 and €928 vs. €1300 respectively). Overall annual cost-savings were €195 per patient. Conclusions: Collaborative ambulatory orthopaedic care was associated with reduced hospitalisation in patients with hip and knee osteoarthritis. Health costs for programme participants were lower overall, despite higher costs for ambulatory care.

General practitioner-centred paediatric primary care reduces risk of hospitalisation for mental disorders in children and adolescents with ADHD: findings from a retrospective cohort study.

BACKGROUND: General practitioners (GPs) play an essential role in the sustainable management of attention-deficit/hyperactivity disorder (ADHD). To our knowledge, the healthcare programme described here is the first integrated care programme for paediatric ambulatory care embedded in GP-centred-healthcare in Germany. OBJECTIVES: To compare the health-service-utilisation of patients with ADHD enrolled in a GP-centred-paediatric-primary-care-programme with usual care in terms of disease-related hospitalisation, pharmacotherapy and psychotherapy. METHODS: In 2018, we conducted a retrospective cohort study of 3- to 18-year-old patients with ADHD in Baden-Wuerttemberg, southern Germany. The intervention group (IG) comprised patients enrolled in a GP-centred-paediatric-primary-healthcare-programme and consulted a participating GP for ADHD at least once. GP-centred-paediatric-primary-care provides high continuity of care, facilitated access to specialist care, extended routine examinations and enhanced transition to adult healthcare. Patients in the control group (CG) received usual care, meaning they consulted a non-participating GP for ADHD at least once. Main outcomes were disease-related hospitalisation, pharmacotherapy and psychotherapy. Multivariable logistic regression was performed to compare groups. RESULTS: A total of 2317 patients were included in IG and 4177 patients in CG. Mean age was 8.9 ± 4.4. The risk of mental-disorder-related hospitalisations was lower in IG than CG (odds ratio (OR): 0.666, 95% confidence interval (CI): 0.509-0.871). The prescription rate for stimulants was lower in IG (OR: 0.817; 95% CI: 0.732-0.912). There was no statistically significant difference in the participation rate of patients in cognitive behavioural therapy between groups (OR: 0.752; 95% CI: 0.523-1.080). CONCLUSION: Children and adolescents with ADHD enrolled in GP-centred-paediatric-primary-care are at lower risk of mental-disorder-related hospitalisation and less likely to receive stimulants.

Providing an interactive undergraduate elective on safety culture online - concept and evaluation.

BACKGROUND: The COVID-19 pandemic has made it more difficult to maintain high quality in medical education. As online formats are often considered unsuitable, interactive workshops and seminars have particularly often been postponed or cancelled. To meet the challenge, we converted an existing interactive undergraduate elective on safety culture into an online event. In this article, we describe the conceptualization and evaluation of the elective. METHODS: The learning objectives of the safety culture elective remained unchanged, but the teaching methods were thoroughly revised and adapted to suit an online setting. The online elective was offered as a synchronous two-day course in winter semester 2020/21 during the "second wave" of the COVID-19 pandemic in Germany. At the end of each day, participating students evaluated the elective by completing an online survey. Items were rated on a six-point Likert scale. We used SPSS for data analysis. RESULTS: Twenty medical undergraduates completed the elective and rated it extremely positively (1.1 ± 0.2). Students regard safety culture as very important and felt the learning objectives had been achieved. Moreover, they were very satisfied with the design and content of the elective, and especially with interactive elements like role-play. Around 55% of participants would recommend continuing to offer the online elective after the pandemic. CONCLUSIONS: It makes sense to offer undergraduate medical students online elective courses on safety culture, especially during a pandemic. The elective described here can serve as a best practice example of how to teach safety culture to undergraduates, especially when physical presence is unfeasible. Electives requiring a high degree of interaction can also function well online.

[Secondary Data-based Trend Analysis of How Quality Differences in Two Forms of Healthcare Develop Over Time]. / Eine Trendanalyse zur zeitlichen Entwicklung von Qualitätsunterschieden zweier Versorgungsformen auf Basis von Sekundärdaten.

AIM OF THE STUDY: The evaluation of complex interventions such as different forms of healthcare are methodologically challenging. The aim of this study was to use generalized estimating equations (GEE) to investigate how quality differences between family practitioner-based healthcare (HZV) and standard care develop over time. METHODS: A longitudinal secondary data analysis for 2011-2018 was conducted using routine data from the AOK Baden Wuerttemberg health insurer. A dynamic cohort of insured persons that fulfilled the inclusion criteria were included in the analysis at the beginning of each year of observation, so the size and composition of the cohorts varied from year to year. Quality differences between HZV and standard care were investigated, whereby an autoregressive covariance structure (AR1) was assumed for multiple measurements. Under observation were a group variable for healthcare type, a variable for year of observation, and any interaction between the two. The resulting estimates provided information on the relationship between the two groups at the beginning of the observation period, and on how the groups developed both individually and in relation to one another over time. RESULTS: The GEE were used exemplarily on the quality indicator prescription of potentially inappropriate medication (PIM) in elderly insured patients. At the beginning of the observation period, the chance of PIM in those over 65 years of age (year 2018; N=628,523) was significantly lower in the HZV group than in the group receiving standard care (odds ratio 0.978; 95% confidence interval: 0.968-0.987). The chance of a PIM in the following seven years declined in both groups, but faster in the HZV group than the group receiving standard care. CONCLUSION: A secondary data-based trend analysis with GEE of quality differences in comparison groups over time has considerable potential in the evaluation of new and existing forms of healthcare.

[Patient perspectives on patient safety: Results of a population-based survey in Germany]. / Subjektive Informiertheit von Patient*innen zum Thema Patientensicherheit: Ergebnisse einer Bevölkerungsbefragung in Deutschland.

INTRODUCTION: The growing number of people with multimorbidity and polypharmacy in Germany has led to increasing complexity in health care and risks to patient safety. A high priority should therefore be placed on identifying and preventing avoidable adverse events. The patient perspective plays an important role in improving patient safety. In this study, we conducted a representative, population-based survey of knowledge, perceptions and experiences of patient safety, especially of subjectively experienced errors in health care. Our aim was, in particular, to assess patient safety from the patients' point of view, and to analyze differences in assessments of risk and preventability between persons that felt well or poorly informed about patient safety topics. METHODS: In 2019, computer-assisted telephone interviews were conducted nationwide as part of the "TK-Monitor Patient Safety" project. Recruitment was carried out by using multistage selection and forming a stratified random sample. Adults (18 years and older) with sufficient knowledge of German were included. The survey was conducted using a structured guideline containing 21 questions concerning perceptions and experiences of patient safety, and 12 questions on sociodemographic factors. The results were analyzed both descriptively and using inferential statistical methods. RESULTS: Of a total of 1,000 respondents (51% female), approx. half (52%) were gainfully employed, and 57% rated their state of health as "very good" or "good". The patients regarded data protection, medication errors, hospital infections and diagnostic (un)certainty as of major relevance to patient safety. Overall, 55% of the respondents rated their knowledge of patient safety as "very good" or "good". The results showed that subjective knowledge was negatively associated with important outcome parameters such as having experience of medication errors or suspecting errors had been made in a medical examination or treatment. Patients that considered themselves well-informed also reckoned they could contribute towards increasing safety in health care. DISCUSSION: The respondents considered diagnostic uncertainty to be one of the greatest risks to their person. This shows that they recognized a need for further information and felt this need was inadequately satisfied in the German research landscape. With regard to the correlation between subjective knowledge and outcome parameters, it is also necessary to analyze whether the respondents' subjective knowledge reflects their actual knowledge, as this would be necessary for preventive measures to be effective. This question will be the subject of further studies. CONCLUSION: The patient perspective is an important addition to the study of the safety of medical care in Germany. Factors influencing subjective knowledge should be investigated. Furthermore, regular surveys would be desirable in order to gain greater insight into the topic.

Clinical and economic outcomes of a collaborative cardiology care program.

OBJECTIVES: We evaluated a collaborative care program aimed at improving cooperation among general practitioners (GPs) and cardiologists in Baden-Wuerttemberg, Germany. The program focused on improving care for patients with chronic cardiac conditions. STUDY DESIGN: We conducted a retrospective cohort study. The observation period was 2 years. METHODS: The study was based on claims data and compared groups of patients who participated in the collaborative care program (GP-centered care and the cardiology contract) with patients receiving usual care. The evaluation focused on care coordination, quality, health service utilization, and costs in patients with heart failure, coronary heart disease, heart rhythm disorders, and/or valvular heart disease (disease cohorts). Multivariable regression models were used to adjust for differences in patient characteristics between the groups. RESULTS: Across all disease cohorts, participation in the collaborative care program was associated with better care coordination and improved quality in a broad range of indicators (pharmacotherapy and vaccination). Results showed lower emergency service utilization and hospitalizations, lower consultation frequencies with GPs and specialists, and a shift from inpatient to outpatient procedures. Program participation resulted in higher costs for outpatient cardiologist treatment, but disease-specific costs were lower overall. CONCLUSIONS: The results underline evidence that health care service programs that strengthen collaboration between GPs and cardiologists can substantially improve the care of patients with chronic cardiac conditions while simultaneously reducing costs.

Strong and sustainable primary healthcare is associated with a lower risk of hospitalization in high risk patients.

In 2004, Germany introduced a program based on voluntary contracting to strengthen the role of general practice care in the healthcare system. Key components include structured management of chronic diseases, coordinated access to secondary care, data-driven quality improvement, computerized clinical decision-support, and capitation-based reimbursement. Our aim was to determine the long-term effects of this program on the risk of hospitalization of specific categories of high-risk patients. Based on insurance claims data, we conducted a longitudinal observational study from 2011 to 2018 in Baden-Wuerttemberg, Germany. Patients were assigned to one or more of four open cohorts (in 2011, elderly, n = 575,363; diabetes mellitus, n = 163,709; chronic heart failure, n = 82,513; coronary heart disease, n = 125,758). Adjusted for key patient characteristics, logistic regression models were used to compare the hospitalization risk of the enrolled patients (intervention group) with patients receiving usual primary care (control group). At the start of the study and throughout long-term follow-up, enrolled patients in the four cohorts had a lower risk of all-cause hospitalization and ambulatory, care-sensitive hospitalization. Among patients with chronic heart failure and coronary heart disease, the program was associated with significantly reduced risk of cardiovascular-related hospitalizations across the eight observed years. The effect of the program also increased over time. Over the longer term, the results indicate that strengthening primary care could be associated with a substantial reduction in hospital utilization among high-risk patients.

[Design and evaluation of a preclinical medical elective titled "Safety culture in healthcare: Every error counts!"] / Konzeption und Evaluation eines vorklinischen medizinischen Wahlpflichtfaches "Sicherheitskultur in der Medizin: Jeder Fehler zählt!".

INTRODUCTION: The World Health Organization has called for more importance to be attached to the subject of patient safety in medical studies. However, teaching staff are unsure when the right time is to include this topic in existing medical school curricula. The aim of this article is to present the learning objectives, design and evaluation of a two-day elective on patient safety offered in the preclinical phase of medical studies at the Faculty of Medicine, University of Frankfurt am Main. To the best of our knowledge, no existing elective on safety culture has been provided at such an early stage of medical studies in Germany. METHODS: After defining learning objectives and teaching methods, the safety culture elective was offered in the winter term 2019/20. Based on a questionnaire, a quantitative and qualitative evaluation of the students' acceptance of the elective was carried out. We also sought to investigate whether group role-play was considered an effective means of communicating the teaching content. Acceptance and rejection of the elective were evaluated on a six-point Likert scale. RESULTS: The resulting elective, consisting of topical input via film, an introductory speech, role-play and discussions, is presented. Nineteen students in the preclinical phase of their medical studies took part. Overall, the quantitative and qualitative evaluation delivered positive results (1.2±0.5), and the topic was perceived to very important. The students considered the didactic implementation and the learning objectives to be very good, and they became acquainted with different sources of error. DISCUSSION: The preclinical elective would appear to be suitable for demonstrating the importance of medical safety to medical students and teaching them how to deal with the topic constructively. It can be viewed as a best-practice example for the development of comparable learning formats at medical faculties. CONCLUSION: The results show that the preclinical phase is a suitable time to illustrate the importance of the subject of patient safety during medical studies.

Intensified ambulatory cardiology care: effects on mortality and hospitalisation-a comparative observational study.

Since 2010, an intensified ambulatory cardiology care programme has been implemented in southern Germany. To improve patient management, the structure of cardiac disease management was improved, guideline-recommended care was supported, new ambulatory medical services and a morbidity-adapted reimbursement system were set up. Our aim was to determine the effects of this programme on the mortality and hospitalisation of enrolled patients with cardiac disorders. We conducted a comparative observational study in 2015 and 2016, based on insurance claims data. Overall, 13,404 enrolled patients with chronic heart failure (CHF) and 19,537 with coronary artery disease (CAD) were compared, respectively, to 8,776 and 16,696 patients that were receiving usual ambulatory cardiology care. Compared to the control group, patients enrolled in the programme had lower mortality (Hazard Ratio: 0.84; 95% CI: 0.77-0.91) and fewer all-cause hospitalisations (Rate Ratio: 0.94; 95% CI: 0.90-0.97). CHF-related hospitalisations in patients with CHF were also reduced (Rate Ratio: 0.76; 95% CI: 0.69-0.84). CAD patients showed a similar reduction in mortality rates (Hazard Ratio: 0.81; 95% CI: 0.76-0.88) and all-cause hospitalisation (Rate Ratio: 0.94; 95% CI: 0.91-0.97), but there was no effect on CAD-related hospitalisation. We conclude that intensified ambulatory care reduced mortality and hospitalisation in cardiology patients.

Interpregnancy weight change and adverse pregnancy outcomes: a systematic review and meta-analysis.

OBJECTIVES: To evaluate the effect of interpregnancy body mass index (BMI) change on pregnancy outcomes, including large-for-gestational-age babies (LGA), small-for-gestational-age babies (SGA), macrosomia, gestational diabetes mellitus (GDM) and caesarean section (CS). DESIGN: Systematic review and meta-analysis of observational cohort studies. DATA SOURCES: Literature searches were performed across Cochrane, MEDLINE, EMBASE, CINAHL, Global Health and MIDIRS databases. STUDY SELECTION: Observational cohort studies with participants parity from 0 to 1. MAIN OUTCOME MEASURES: Adjusted ORs (aORs) with 95% CIs were used to evaluate the association between interpregnancy BMI change on five outcomes. RESULTS: 925 065 women with singleton births from parity 0 to 1 were included in the meta-analysis of 11 studies selected from 924 identified studies. A substantial increase in interpregnancy BMI (>3 BMI units) was associated with an increased risk of LGA (aOR 1.85, 95% CI 1.71 to 2.00, p<0.001), GDM (aOR 2.28, 95% CI 1.97 to 2.63, p<0.001), macrosomia (aOR 1.54, 95% CI 0.939 to 2.505) and CS (aOR 1.72, 95% CI 1.32 to 2.24, p<0.001) compared with the reference category, and a decreased risk of SGA (aOR 0.83, 95% CI 0.70 to 0.99, p=0.044). An interpregnancy BMI decrease was associated with a decreased risk of LGA births (aOR 0.70, 95% CI 0.55 to 0.90, p<0.001) and GDM (aOR 0.80, 95% CI 0.62 to 1.03), and an increased risk of SGA (aOR 1.31, 95% CI 1.06 to 1.63, p=0.014). Women with a normal BMI (<25kg/m2) at first pregnancy who have a substantial increase in BMI between pregnancies had a higher risk of LGA (aOR 2.10, 95% CI 1.93 to 2.29) and GDM (aOR 3.10, 95% CI 2.74 to 3.50) when compared with a reference than women with a BMI ≥25 kg/m2 at first pregnancy. CONCLUSIONS: Gaining weight between pregnancies increases risk of developing GDM, CS and LGA, and reduces risk of SGA in the subsequent pregnancy. Losing weight between pregnancies reduces risk of GDM and LGA and increases risk of SGA. Weight stability between first and second pregnancy is advised in order to reduce risk of adverse outcomes. TRIAL REGISTRATION NUMBER: CRD42016041299.

Where Public Health Meets Human Rights: Integrating Human Rights into the Validation of the Elimination of Mother-to-Child Transmission of HIV and Syphilis.

In 2014, the World Health Organization (WHO) initiated a process for validation of the elimination of mother-to-child transmission (EMTCT) of HIV and syphilis by countries. For the first time in such a process for the validation of disease elimination, WHO introduced norms and approaches that are grounded in human rights, gender equality, and community engagement. This human rights-based validation process can serve as a key opportunity to enhance accountability for human rights protection by evaluating EMTCT programs against human rights norms and standards, including in relation to gender equality and by ensuring the provision of discrimination-free quality services. The rights-based validation process also involves the assessment of participation of affected communities in EMTCT program development, implementation, and monitoring and evaluation. It brings awareness to the types of human rights abuses and inequalities faced by women living with, at risk of, or affected by HIV and syphilis, and commits governments to eliminate those barriers. This process demonstrates the importance and feasibility of integrating human rights, gender, and community into key public health interventions in a manner that improves health outcomes, legitimizes the participation of affected communities, and advances the human rights of women living with HIV.

Biomechanical analysis of screw fixation vs. K-wire fixation of a slipped capital femoral epiphysis model.

INTRODUCTION: Previous data have shown that due to the technical ease, low-morbidity, and lower complication rates, the in situ single-implant fixation is the current standard for stabilization of slipped capital femoral epiphysis (SCFE) fixation. Multiple-implant fixation is thought to be combined with a higher incidence of serious complications. The purpose of the current study was to evaluate single- vs. multiple-implant fixation regarding strength and stiffness. Furthermore, different screw designs, including telescopic screw, were evaluated regarding the stiffness, strength, and especially fixation failure. METHODS: Forty porcine proximal femurs were sectioned through the physeal line using a gigli saw and stabilized with a 7.3-mm stainless steel AO screw, a dynamic telescopic screw, three 1.6-mm Kirschner wires (K-wires), and three 2.0-mm K-wires. The femurs were biomechanically tested to determine failure load (N) and stiffness (N/mm). RESULTS: No significant differences were found regarding failure load and stiffness between the two screw groups. The 2.0-mm K-wire construct was significantly the strongest and stiffest fixation. The 1.6-mm K-wire fixation had the lowest values, but not statistically significant. Regarding the fixation failure, no femoral shaft fracture occurred. CONCLUSION: SCFE stabilization with three 2.0-mm K-wires leads to increased stability over single-screw fixation and 1.6-mm K-wire fixation. However, none of the two screws seemed to be superior in fixation stability and fixation failure.