[General practitioners' palliative care activities in Westphalia-Lippe compared to other federal states - Secondary analysis of a survey]. / Hausärztliche Palliativversorgung in Westfalen-Lippe im Vergleich mit anderen Bundesländern ­ sekundäre Auswertung einer Befragungsstudie.

INTRODUCTION: In palliative home care frictional loss at the interface between primary palliative care (PPC) and specialised palliative home care (SPHC) is repeatedly pointed out. PPC and SPHC appear to be insufficiently interlinked. The model implemented in Westphalia-Lippe differs from others in Germany: it relies on close cooperation between general practitioners (GPs) and palliative consultancy services (PCS), an early start of the palliative care process and comprehensive/widespread collaboration. We hypothesize that the framework conditions applying in Westphalia-Lippe have positive effects on the uptake of palliative care activities by GPs. The objective of this study therefore is to compare GPs' attitudes and their willingness to provide palliative care between GPs in Westphalia-Lippe and GPs in other federal states/Associations of Statutory Health Insurance Physicians (ASHIPs) in order to empirically test our hypothesis. METHODS: Secondary evaluation of a nationwide paper-based survey from 2018 for national data acquisition of GPs' palliative care activities at the interface of SPHC. Answers of the participating GPs from Westphalia-Lippe (n=119) are contrasted with the answers of the GPs from seven other federal states (n=1,025). RESULTS: GPs from Westphalia-Lippe have a consistently higher self-perception of being responsible for palliative care of their patients, more often take responsibility for palliative care activities and feel more confident in carrying them out. GPs from Westphalia-Lippe are more likely to know other palliative care facilities/actors and they find them to be more likely available for GPs. They rate the quality of the overall palliative infrastructure higher. For GPs from Westphalia-Lippe the involvement of PCS/SPHC providers is less important than for GPs from other regional ASHIPs. If they are involved in the palliative treatment of a patient, GPs from Westphalia-Lippe feel more frequently involved in the course of treatment. DISCUSSION: Our study indicates that the special framework conditions for palliative care provided by GPs in Westphalia-Lippe have positive effects on their uptake of palliative care activities. An essential factor could be the PPC- and SPHC-integrated approach to palliative care in Westphalia-Lippe. CONCLUSION: Westphalia-Lippe may provide orientation for other regions regarding the involvement of GPs at the interface to specialized palliative care. Whether the type of palliative home care in Westphalia-Lippe also produces advantages in terms of quality and costs of care compared to the rest of Germany is something that needs to be investigated in the future.

[The general practitioner perspective of a multimodal intervention for the adequate use of antibiotics in urinary tract infection - a qualitative interview study]. / Hausärztliche Perspektiven auf eine multimodale Intervention zum adäquaten Einsatz von Antibiotika beim Harnwegsinfekt ­ eine qualitative Interviewstudie.

INTRODUCTION: Contrary to current guideline recommendations, second-line antibiotics are still frequently used in the ambulatory treatment of uncomplicated urinary tract infections (UTI), which are associated with a high risk of antibiotic resistance development. The REDARES project (REDuction of Antibiotic RESistance in uncomplicated urinary tract infections by treatment according to national guidelines in ambulatory care), funded by the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA)/Innovation Fund is developing a multimodal intervention for primary care physicians to support them in a guideline-based approach. The intervention consists of the following components: (1) provision of local resistance data of pathogens of uncomplicated UTI (Robert Koch Institute), (2) concise guideline content on the therapy of uncomplicated UTI for patients (paper and online), and (3) prescription feedback on practice level and benchmarking among the study participants (anonymized). In a participatory approach and as part of the process evaluation, representatives of the intended target group were interviewed in advance about the acceptance and feasibility of the intervention. METHODS: Using guided individual interviews, Thuringian GPs were interviewed before the start of the intervention phase. Following a description of the study concept and the planned components of the intervention, the interviewees were asked about their assessment regarding acceptance and feasibility. The individual interviews were recorded, transcribed verbatim and qualitatively analyzed according to Mayring. RESULTS: A total of ten interviews with an average duration of 29minutes were conducted and evaluated. 40 per cent of the interviewed GPs were female and, on average, 45 years old. The interviewees described the uncomplicated UTI as an easily manageable condition. The practical nature of the research question was described as a reason to potentially participate in the intervention phase; lack of time or human resources were cited as potential barriers. Regarding the intervention elements, the provision of local resistance data of UTI pathogens was considered beneficial to their own work. The extraction of their own antibiotic prescription data from the practice software was basically assessed as feasible. The interviewees differed in their assessment of whether they would take account of the feedback on their prescribing behavior in their daily work. DISCUSSION: The interviews generated a detailed picture of the different diagnostic and therapeutic pathways used by respondents for uncomplicated UTI. Overall, they predominantly regarded both the study concept and the intervention components as feasible. Although the study population is small and not representative, some of the results seem to be transferable to other regions in Germany. CONCLUSION: A research question relating to their daily routine can increase participation of primary care physicians in (intervention) studies. Starting the process evaluation before the intervention seems to be reasonable since the results will be integrated into the design of the intervention. The method of data extraction from practice software by practice teams seems to be promising.

[Palliative care at the end of life in Germany : Utilization and regional distribution]. / Palliativversorgung am Lebensende in Deutschland : Inanspruchnahme und regionale Verteilung.

BACKGROUND: Palliative care supply increased in Germany in recent years. But how many people use which forms of palliative care and how does this differ between regions? METHOD: Retrospective cohort study with claims data from insured persons who died in 2016: Based on services billed at least once in the last six months of life, we determined the use of primary palliative care (PPC), specialized palliative homecare (SPHC), as well as inpatient palliative and hospice care, using regional billing codes for PPC and SPHC services for the first time. RESULTS: Of the 95,962 deceased in the study population, 32.7% received palliative care nationwide, with variations from 26.4% in Bremen to 40.8% in Bavaria. PPC services were billed at 24.4% (16.9% in Brandenburg to 34.1% in Bavaria). SPHC services received 13.1% (6.3% in Rhineland-Palatinate to 18.9% in Brandenburg and 22.9% in Westphalia-Lippe with different SPHC practices). Inpatient palliative care was received by 8.1% (6.7% in Schleswig-Holstein/Hesse to 13.0% in Thuringia); 3.3% (1.6% in Bremen to 5.6% in Berlin) with hospice services. CONCLUSION: SPHC is used more frequently than previously reported, while PPC is declining. Utilization seems to be based less on objective needs than on region-specific framework conditions. Besides needs criteria, further development of palliative care should be oriented more towards outcomes and relevant framework conditions.

Study protocol for a multi-methods study: SAVOIR - evaluation of specialized outpatient palliative care (SAPV) in Germany: outcomes, interactions, regional differences.

BACKGROUND: Since 2007, the German statutory health insurance covers Specialized Outpatient Palliative Care (SAPV). SAPV offers team-based home care for patients with advanced and progressive disease, complex symptoms and life expectancy limited to days, weeks or months. The introduction of SAPV is ruled by a directive (SAPV directive). Within this regulation, SAPV delivery models can and do differ regarding team structures, financing models, cooperation with other care professionals and processes of care. The research project SAVOIR is funded by G-BA's German Innovations Fund to evaluate the implementation of the SAPV directive. METHODS: The processes, content and quality of SAPV will be evaluated from the perspectives of patients, SAPV teams, general practitioners and other care givers and payers. The influence of different contracts, team and network structures and regional and geographic settings on processes and results including patient-reported outcomes will be analyzed in five subprojects: [1] structural characteristics of SAPV and their impact on patient care, [2] quality of care from the perspective of patients, [3] quality of care from the perspective of SAPV teams, hospices, ambulatory nursing services, nursing homes and other care givers, content and extent of care from [4] the perspective of General Practitioners and [5] from the perspective of payers. The evaluation will be based on different types of data: team and organizational structures, treatment data based on routine documentation with electronic medical record systems, prospective assessment of patient-reported outcomes in a sample of SAPV teams, qualitative interviews with other stakeholders like nursing and hospice services, a survey in general practitioners and a retrospective analysis of claims data of all SAPV patients, covered by the health insurance fund BARMER in 2016. DISCUSSION: Data analysis will allow identification of variables, associated with quality of SAPV. Based on these findings, the SAVOIR study group will develop recommendations for the Federal Joint Committee for a revision of the SAPV directive. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00013949 (retrospectively registered, 14.03.2018), DRKS00014726 (14.05.2018), DRKS00014730 (30.05.2018). Subproject 3 is an interview study with professional caregivers and therefore not registered in DRKS as a clinical study.