Assessing Reduction of Antibiotic Prescribing for Acute, Non-Complicated Infections in Primary Care in Germany: Multi-Step Outcome Evaluation in the Cluster-Randomized Trial ARena.

The three-armed cluster-randomized trial ARena (sustainable reduction of antibiotic-induced antimicrobial resistance) aimed to foster appropriate antibiotic use and reduce overprescribing in German ambulatory care to counter antibiotic resistance. Multi-faceted interventions targeted primary care physicians, teams and patients. This study examined the effectiveness of the implementation program. ARena was conducted in 14 primary care networks with 196 practices. All arms received data-based feedback on antibiotics prescribing and quality circles. Arms II and III received different add-on components each. Primary outcome examined is the prescribing rate for systemic antibiotics for cases with non-complicated acute infections (upper respiratory tract, bronchitis, sinusitis, tonsillitis, otitis media). Secondary outcomes refer to the prescribing of quinolones and guideline-recommended antibiotics. Based on pseudonymized quarterly claims data, mixed logistic regression models examined pre-post intervention antibiotic prescribing rate changes and compared to matched standard care. A significant rate reduction (arm I 11.7%; arm II 9.9%; arm III 12.7%) and significantly lower prescribing rates were observed for all arms (20.1%, 18.9% and 23.6%) compared to matched standard care (29.4%). Fluoroquinolone prescribing was reduced in all intervention arms and rates for recommended substances generally increased. No significant post-interventional difference between intervention arms was detected. Findings indicate implementation program impact compared to standard care.

Fostering Appropriate Antibiotic Use in a Complex Intervention: Mixed-Methods Process Evaluation Alongside the Cluster-Randomized Trial ARena.

The cluster randomized trial ARena (sustainable reduction of antibiotic-induced antimicrobial resistance, 2017-2020) promoted appropriate use of antibiotics for acute non-complicated infections in primary care networks (PCNs) in Germany. A process evaluation assessed determinants of practice and explored factors associated with antibiotic prescribing patterns. This work describes its findings on uptake and impacts of the complex intervention program and indicates potential implementation into routine care. In a nested mixed-methods approach, a three-wave study-specific survey for participating physicians and medical assistants assessed potential impacts and uptake of the complex intervention program. Stakeholders received a one-time online questionnaire to reflect on network-related aspects. Semi-structured, open-ended interviews, with a purposive sample of physicians, medical assistants and stakeholders, explored program component acceptance for daily practice and perceived sustainability of intervention component effects. Intervention components were perceived to be smoothly integrable into practice routines. The highest uptake was reported for educational components: feedback reports, background information, e-learning modules and disease-specific quality circles (QCs). Participation in PCNs was seen as the motivational factor for guideline-oriented patient care and adoption of new routines. Future approaches to fostering appropriate antibiotics use by targeting health literacy competencies and clinician's therapy decisions should combine evidence-based information sources, audit and feedback reports and QCs.

[Potentially inappropriate medication in a German practice network-who prescribes what to whom?] / Potenziell inadäquate Medikation in einem deutschen Praxisnetz ­ Wer verordnet was an wen?

BACKGROUND: Potentially inappropriate medication (PIM) carries the risk of increased drug side effects for older people. The prevalence data are known but no descriptive analyses of prescription behavior as a starting point for reducing PIM have yet been conducted. OBJECTIVE: The aim of the study was to analyze PIM prescription in the outpatient sector and to identify risk groups where increased awareness of the issue is needed. MATERIAL AND METHODS: The basis for the investigation was the data set of the AOK Bavaria health insurance, which contains anonymized prescription data of a practice network for patients aged 65 years and older from 2010 to 2014. The Priscus list was used to identify the PIM. RESULTS: There were 410,934 prescriptions during the investigation period. The prevalence of PIM was 5.60%. Family doctors prescribed 5.39% PIM and specialists for neurology, psychiatry and psychotherapy (NPP) prescribed 16.36% PIM. Regardless of the medical discipline, PIM from the drug groups psycholeptics, psychoanaleptics and antihypertensive drugs were most frequently prescribed. For men and women PIM accounted for 4.50% and 6.31%, respectively, of the prescriptions during the period. In terms of age groups older women received PIM most frequently. CONCLUSION: In the case of specialists for NPP a high prevalence of prescriptions for PIM could be established; however, in absolute terms family doctors prescribed significantly more PIM overall. This mainly affected women and especially those between 80 and 84 years old. In the future family doctors should be made more aware with respect to the prescription of psychopharmaceuticals and antihypertensive drugs to older women.

[Measuring, assessing, acting: A practice test of quality indicators for coronary heart disease]. / Messen, Bewerten, Handeln: Qualitätsindikatoren zur Koronaren Herzkrankheit im Praxistest.

BACKGROUND: There are only limited possibilities for doctors in outpatient services to establish quality management that is based on data-driven feedback regarding the quality of health care. However, transparency about one's own activities is a prerequisite for refining this quality. The aim of this project was to make the quality of care for patients with coronary heart disease (CHD) more transparent, use this as a basis to initiate improvement processes, and explore the framework conditions and factors promoting or inhibiting the intended improvement of health care quality. METHOD: 48 general practitioners (GPs) in 32 GP practices from a Bavarian doctors' network (Qualität und Effizienz, QuE) participated in the project. On the basis of claims data from the AOK-Bayern (a statutory health insurance in Bavaria), data from disease management programs (DMP) and medically documented data, 11 quality indicators for patients with CHD were calculated. The indicator scores were individually presented in feedback reports for each doctor's practice. These were the basis for two quality circles. The indicators were measured again after 12 months, and changes against the baseline measurement were registered. GPs from Bavaria formed the control group. Focus groups with the quality circle moderators and two participant surveys were used to identify promoting and inhibiting factors. RESULTS: The baseline values showed a good level of care. Potential for improvement became apparent for pharmacotherapy with beta blockers and statins. After conducting the quality circles four of the eleven indicators showed an increase as intended ("beta blockers for CHD and cardiac insufficiency", "beta blockers after myocardial infarction", "statins", "successful blood pressure control"). For three of these indicators the increase rates were higher than those in the Bavarian control group. One indicator ("statins") was striking because of the wide variation of practice values suggesting differences in care within the network. The majority of participating doctors regarded the database as valid. Quality circles were highly appreciated as an opportunity for professional exchange among colleagues. The data-based feedback reports helped to make deficits in health care transparent and to identify actions that need to be taken. Barriers to implementing quality improvement measures in clinical practice became apparent. DISCUSSION: Reflecting quality indicators in quality circles can effectively trigger quality improvement processes. Barriers would appear to exist, in particular, to the implementation of measures into daily practice routine. Additional organizational support offered by higher-level quality management structures, IT solutions for patient-related data processing as well as a system of financial compensation, which rewards professional concern for quality, may help to overcome the existing barriers.

Sustainable reduction of antibiotic-induced antimicrobial resistance (ARena) in German ambulatory care: study protocol of a cluster randomised trial.

BACKGROUND: Despite many initiatives to enhance the rational use of antibiotics, there remains substantial room for improvement. The overall aim of this study is to optimise the appropriate use of antibiotics in German ambulatory care in patients with acute non-complicated infections (respiratory tract infections, such as bronchitis, sinusitis, tonsillitis and otitis media), community-acquired pneumonia and non-complicated cystitis, in order to counter the advancing antimicrobial resistance development. METHODS: A three-armed cluster randomised trial will be conducted in 14 practice networks in two German federal states (Bavaria and North Rhine-Westphalia) and an added cohort that reflects standard care. The trial is accompanied by a process evaluation. Each arm will receive a different set of implementation strategies. Arm A receives a standard set, comprising of e-learning on communication with patients and quality circles with data-based feedback for physicians, information campaigns for the public, patient information material and performance-based additional reimbursement. Arm B receives this standard set plus e-learning on communication with patients and quality circles with data-based feedback tailored for non-physician health professionals of the practice team and information material for tablet computers (culture sensitive). Arm C receives the standard set as well as a computerised decision support system and quality circles in local multidisciplinary groups. The study aims to recruit 193 practices which will provide data on 23,934 patients each year (47,867 patients in total). The outcome evaluation is based on claims data and refers to established indicators of the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). Primary and secondary outcomes relate to prescribing of antibiotics, which will be analysed in multivariate regression models. The process evaluation is based on interviews with surveys among physicians, non-physician health professionals of the practice team and stakeholders. A patient survey is conducted in one of the study arms. Interview data will be qualitatively analysed using thematic framework analysis. Survey data of physicians, non-physician health professionals of the practice team and patients will use descriptive and exploratory statistics for analysis. DISCUSSION: The ARena trial will examine the effectiveness of large scale implementation strategies and explore their delivery in routine practice. TRIAL REGISTRATION: ISRCTN, ISRCTN58150046 . Registered 24 August 2017.

A cross-sectional study assessing the association between online ratings and structural and quality of care measures: results from two German physician rating websites.

BACKGROUND: Even though physician rating websites (PRWs) have been gaining in importance in both practice and research, little evidence is available on the association of patients' online ratings with the quality of care of physicians. It thus remains unclear whether patients should rely on these ratings when selecting a physician. The objective of this study was to measure the association between online ratings and structural and quality of care measures for 65 physician practices from the German Integrated Health Care Network "Quality and Efficiency" (QuE). METHODS: Online reviews from two German PRWs were included which covered a three-year period (2011 to 2013) and included 1179 and 991 ratings, respectively. Information for 65 QuE practices was obtained for the year 2012 and included 21 measures related to structural information (N = 6), process quality (N = 10), intermediate outcomes (N = 2), patient satisfaction (N = 1), and costs (N = 2). The Spearman rank coefficient of correlation was applied to measure the association between ratings and practice-related information. RESULTS: Patient satisfaction results from offline surveys and the patients per doctor ratio in a practice were shown to be significantly associated with online ratings on both PRWs. For one PRW, additional significant associations could be shown between online ratings and cost-related measures for medication, preventative examinations, and one diabetes type 2-related intermediate outcome measure. There again, results from the second PRW showed significant associations with the age of the physicians and the number of patients per practice, four process-related quality measures for diabetes type 2 and asthma, and one cost-related measure for medication. CONCLUSIONS: Several significant associations were found which varied between the PRWs. Patients interested in the satisfaction of other patients with a physician might select a physician on the basis of online ratings. Even though our results indicate associations with some diabetes and asthma measures, but not with coronary heart disease measures, there is still insufficient evidence to draw strong conclusions. The limited number of practices in our study may have weakened our findings.

[Health care networks in Germany: status quo and key success factors]. / Den Kinderschuhen entwachsen - Arztnetze in Deutschland leisten wertvollen Beitrag zur Optimierung der lokalen Versorgungssituation.

One third of all practicing physicians are currently working in one of the 400 German health care networks. These physicians' networks bring together GPs and specialists and cooperate with different partners, for example, nursing homes, hospitals, and self-help groups. To increase the quality and the efficiency of care and patient satisfaction by improving the collaboration and communication between physicians and other health care providers.The example of the accountable care organization "Gesundheitsnetz Qualität und Effizienz" (QuE; Health Quality and Efficiency Network) in Nuremberg is used to show that it is possible to achieve an increase in efficiency while providing above-average quality of care and achieving high patient satisfaction. Additionally, the article deals with the status quo, the core objectives, and the key activities of previous generations of health care networks. Quality indicators, satisfaction surveys, and economic parameters are the basis for measuring and representing the above-average performance of physicians' networks. Regional health care networks offer an entire range of patient care, from outpatients and inpatients to the complementary sector, and thereby have excellent prospects for playing an even more important role in the German health care system. The key success factors are: the consideration of specific regional characteristics, their proximity to the patient, and consistent patient orientation.