Prevention of invasive ventilation (PRiVENT)-a prospective, mixed-methods interventional, multicentre study with a parallel comparison group: study protocol.

BACKGROUND: Invasive mechanical ventilation (IMV) is a standard therapy for intensive care patients with respiratory failure. With increasing population age and multimorbidity, the number of patients who cannot be weaned from IMV increases, resulting in impaired quality of life and high costs. In addition, human resources are tied up in the care of these patients. METHODS: The PRiVENT intervention is a prospective, mixed-methods interventional, multicentre study with a parallel comparison group selected from insurance claims data of the health insurer Allgemeine Ortskrankenkasse Baden-Württemberg (AOK-BW) conducted in Baden-Württemberg, Germany, over 24 months. Four weaning centres supervise 40 intensive care units (ICUs), that are responsible for patient recruitment. The primary outcome, successful weaning from IMV, will be evaluated using a mixed logistic regression model. Secondary outcomes will be evaluated using mixed regression models. DISCUSSION: The overall objective of the PRiVENT project is the evaluation of strategies to prevent long-term IMV. Additional objectives aim to improve weaning expertise in and cooperation with the adjacent Intensive Care Units. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov (NCT05260853).

GPs´ Personal Spirituality, Their Attitude and Spiritual Competence: A Cross-Sectional Study in German General Practices.

To understand if GPs' spiritual competence, their personal spirituality and attitude towards enquiring about spirituality in practice interrelate, we conducted a cross-sectional survey of 30 German GPs regarding issues of SC. We found correlations between GPs' personal spirituality, their spiritual competence and their attitudes towards SC. The ability to perceive spiritual needs of patients was the competence most strongly related to GPs' attitude towards SC. The competence with the strongest correlation to personal spirituality was Self-awareness and Proactive opening. No correlation was found between affiliation to a spiritual community and GPs' attitude towards SC. The results show that GPs' personal spirituality and spiritual competence are indeed related to addressing spirituality with their patients. To foster SC, training programmes should raise awareness for one's personal spirituality and encourage one to reflect on spiritual competence.

Evaluation of an intervention in general practices to strengthen social activities in older patients - A qualitative study of patients' experiences in the project HoPES3.

OBJECTIVE: In the research project HoPES3, the effectiveness of a multifaceted intervention, where one of the aims was to encourage social activities among older patients, was investigated in a cluster-randomised controlled trial. Patients were offered a conversation about their spirituality (spiritual history) which also included questions about their social relationships. The aim of this study was to examine patients' experiences regarding the acceptability, feasibility, conversational content and perceived benefits and harms of the interventions focusing on social relationships and activities. METHOD: Semi-structured interviews with 29 patients of the intervention group aged 70 years or older. RESULTS: Loneliness in old age is the result of a long history with underlying complex reasons. Activities proposed by the practice team were rarely carried out, but if they were, patients reported strong benefits. Patients reported their GPs' interest in their lives had resulted in a more trusting doctor-patient relationship. Almost all patients recommended to implement the intervention in general practices. CONCLUSION AND PRACTICE IMPLICATIONS: When raising the topic of loneliness, it is crucial to give patients the opportunity to explain the biographical developments which led to their situation. Therefore, embedding the conversation into a broader context such as a spiritual history might be helpful.

Experiences of German health care professionals with spiritual history taking in primary care: a mixed-methods process evaluation of the HoPES3 intervention.

BACKGROUND: Spiritual needs gain importance in old age but are often ignored in health care. Within the 'Holistic care program for elderly patients to integrate spiritual needs, social activity and self-care into disease management in primary care (HoPES3)' a complex intervention was evaluated in a cluster-randomized trial. The aim of this study was to explore the acceptability, feasibility, benefits, and harms of a spiritual history taken by general practitioners (GPs) as part of the complex intervention. METHODS: In this mixed-methods study telephone interviews with 11 German GPs and 12 medical assistants (MAs) of the HoPES3 intervention group were conducted and analysed using a content-analytical approach. Furthermore, GPs were asked to complete a questionnaire after each spiritual history. One hundred and forty-one questionnaires from 14 GPs were analysed descriptively. RESULTS: GPs considered the spiritual history very/quite helpful for the patient in 27% (n= 38) and very/quite stressful in 2% (n = 3) of the cases. Interviews indicated that GPs found discussing spiritual history easier than anticipated. GPs and MAs saw a difficulty in that many patients associated spirituality with religion or church and reacted with surprise or rejection. Benefits for patients were seen in the opportunity to talk about non-medical topics, and increased awareness of their own resources. Benefits for GPs mainly related to information gain and an intensified patient-physician relationship. CONCLUSIONS: A spiritual history in general practice has the potential to reveal important information about patients' lives and to improve the patient-physician relationship. Implementation barriers identified in this study have to be considered and addressed.

Risk Factors for Prolonged Mechanical Ventilation and Weaning Failure: A Systematic Review.

INTRODUCTION: Prolonged mechanical ventilation (PMV) and weaning failure are factors associated with prolonged hospital length of stay and increased morbidity and mortality. In addition to the burden these places on patients and their families, it also imposes high costs on the public health system. The aim of this systematic review was to identify risk factors for PMV and weaning failure. METHODS: The study was conducted according to PRISMA guidelines. After a comprehensive search of the COCHRANE Library, CINHAL, Web of Science, MEDLINE, and the LILACS Database a PubMed request was made on June 8, 2020. Studies that examined risk factors for PMV, defined as mechanical ventilation ≥96 h, weaning failure, and prolonged weaning in German and English were considered eligible; reviews, meta-analyses, and studies in very specific patient populations whose results are not necessarily applicable to the majority of ICU patients as well as pediatric studies were excluded from the analysis. This systematic review was registered in the PROSPERO register under the number CRD42021271038. RESULTS: Of 532 articles identified, 23 studies with a total of 23,418 patients met the inclusion criteria. Fourteen studies investigated risk factors of PMV including prolonged weaning, 9 studies analyzed risk factors of weaning failure. The concrete definitions of these outcomes varied considerably between studies. For PMV, a variety of risk factors were identified, including comorbidities, site of intubation, various laboratory or blood gas parameters, ventilator settings, functional parameters, and critical care scoring systems. The risk of weaning failure was mainly related to age, previous home mechanical ventilation (HMV), cause of ventilation, and preexisting underlying diseases. Elevated PaCO2 values during spontaneous breathing trials were indicative of prolonged weaning and weaning failure. CONCLUSION: A direct comparison of risk factors was not possible because of the heterogeneity of the studies. The large number of different definitions and relevant parameters reflects the heterogeneity of patients undergoing PMV and those discharged to HMV after unsuccessful weaning. Multidimensional scores are more likely to reflect the full spectrum of patients ventilated in different ICUs than single risk factors.

Evaluation of a Spiritual History with Elderly Multi-Morbid Patients in General Practice-A Mixed-Methods Study within the Project HoPES3.

BACKGROUND: The "Holistic Care Program for Elderly Patients to Integrate Spiritual Needs, Social Activity and Self-Care into Disease Management in Primary Care" (HoPES3) examines the implementation of a spiritual history (SH) as part of a multifaceted intervention in German general practices. While the effectiveness of the interventions was evaluated in a cluster-randomized trial, this article investigates the patients' views concerning the acceptability of the SH and its effects. METHODS: A mixed-methods study was conducted in which 133 patients of the intervention group filled in a standardized questionnaire after the intervention. Later, 29 of these patients took part in qualitative semi-standardized interviews. RESULTS: According to the survey, 63% (n = 77) of patients found the SH helpful. In the interviews, however, many indicated that they either kept the conversation brief or declined the offer to talk about spirituality. Contents of longer conversations referred to difficult life events, personal sources of strength, and experiences with religious institutions. Many patients who had a longer conversation about spirituality reported that their relationship with their general practitioner (GP) had improved. Almost all patients recommended integrating a personal conversation of this kind into primary care. CONCLUSIONS: The SH seems to be a possible 'door opener' for a trusting doctor-patient relationship, which can then be built upon.

Spirituality, Self-Care, and Social Activity in the Primary Medical Care of Elderly Patients.

BACKGROUND: Self-efficacy is decisive for the quality of life of elderly, multimorbid persons. It may be possible to strengthenpatients' self-efficacy can be strengthened by the targeted reinforcement of individual spirituality, social activity, and self-care.This hypothesis was tested with the aid of a complex intervention. METHODS: A non-blinded, exploratory, cluster-randomized, controlled trial was carried out, with primary care practices as therandomization unit (registration number DRKS00015696). The patients included were at least 70 years of age, had at least threechronic diseases, were taking at least three medications, and were participating in a disease management program. In theintervention group, primary care physicians took a spiritual history, and medical assistants advised the patients on the use ofhome remedies (e.g., tea, application of heat/cold) and on regionally available programs for the elderly. The primary endpoint-health-related self-efficacy, measured using the SES6G scale-and further, secondary endpoints were evaluated withmultistep regression analyses. RESULTS: Data from 297 patients treated in 24 primary care practices were evaluated. The analysis of the primary endpointindicated no effect (mean difference between study arms 0.30 points, 95% confidence interval [-0.21; 0.81], d = 0.14, p = 0.25).Subgroup analysis revealed the following situation for the secondary endpoint "mental well-being" (SF-12 subscale): patientswho had already been using home remedies before the trial began experienced a marked improvement (a difference of 7.3points on a scale from 0 to 100; d = 0.77, p < 0.001). This was also the case for patients who stated that spirituality played amajor role in their lives (a difference of 6.2 points on a scale from 0 to 100; d = 0.65; p = 0.002). CONCLUSION: The main hypothesis concerning health-related self-efficacy was not confirmed. The results of the analysis ofsecondary parameters indicate that some subgroups of patients can benefit from the interventional approach.

Self-Efficacy, Social Activity, and Spirituality in the Care of Elderly Patients with Polypharmacy in Germany-A Multicentric Cross-Sectional Study within the HoPES3 Trial.

About one third of Europe's elderly population takes ≥5 drugs. Polypharmacy increases their risk of adverse drug reactions. To ensure drug safety, innovative approaches are needed. The aim of this cross-sectional study was to explore the relationship between psychosocial factors and medication-related beliefs and behaviors. Medication lists of 297 patients were recorded according to the ATC classification. Correlations between the dependent variables, Medication Adherence (MARS) and Beliefs about Medicines (BMQ), and independent variables, General Self-Efficacy (GSE), self-efficacy for managing chronic diseases (SES6G), spiritual needs (SpNQ), patient activity (PAM), loneliness (DJG), and social networks (LSNS), were measured. Patients with higher self-efficacy (OR: 1.113; 95% CI [1.056-1.174]; p < 0.001) or self-confidence in managing their chronic condition (OR: 1.188; 95% CI [1.048-1.346]; p < 0.007) also showed higher adherence. Lonely patients (OR: 0.420; 95% CI [0.267-0.660]; p < 0.001) and those with a need for inner peace (OR: 0.613; 95% CI [0.444-0.846], p = 0.003) were more likely nonadherent. Stronger positive beliefs about medications' usefulness weakly correlated with higher scores on the SES6G (ρ = 0.178, p = 0.003) and GSES scale (ρ = 0.121, p = 0.042), patient activity (ρ = 0.155, p = 0.010) and functioning social networks scale (ρ = 0.159, p = 0.008). A weak positive correlation was found between loneliness and the belief that drugs were harmful (ρ = 0.194, p = 0.001). Furthermore, interesting correlations were detected regarding the number of medications and overuse beliefs. Psychosocial factors, such as self-efficacy, loneliness, and spiritual needs and medication-related beliefs and behaviors seem to interrelate. Addressing these factors may improve medication management and drug safety.