Neeltje van den Berg

GP-support by means of AGnES-practice assistants and the use of telecare devices in a sparsely populated region in Northern Germany – proof of concept

BackgroundIn many rural regions in Germany, the proportion of the elderly population increases rapidly. Simultaneously, about one-third of the presently active GPs will retire until 2010. Often it is difficult to find successors for vacant GP-practices. These regions require innovative concepts to avoid the imminent shortage in primary health care.The AGnES-concept comprises the delegation of GP-home visits to qualified AGnES-practice assistants (AGnES: GP-supporting, community-based, e-health-assisted, systemic intervention). Main objectives were the assessment of the acceptance of the AGnES-concept by the participating GPs, patients, and AGnES-practice assistants, the kind of delegated tasks, and the feasibility of home telecare in a GP-practice.MethodsIn this paper, we report first results of the implementation of this concept in regular GP-practices, conducted November 2005 – March 2007 on the Island of Rügen, Mecklenburg-Western Pomerania, Germany. This study was meant as a proof of concept.The GP delegated routine home-visits to qualified practice employees (here: registered nurses). Eligible patients were provided with telecare-devices to monitor disease-related physiological values.All delegated tasks, modules conducted and questionnaire responses were documented. The participating patients were asked for their acceptance based on standardized questionnaires. The GPs and AGnES-practice assistants were asked for their judgement about different project components, the quality of health care provision and the competences of the AGnES-practice assistants.Results550 home visits were conducted. 105 patients, two GPs and three AGnES-practice assistants (all registered nurses) participated in the project. 48 patients used telecare-devices to monitor health parameters. 87.4% of the patients accepted AGnES-care as comparable to common GP-care. In the course of the project, the GPs delegated an increasing number of both monitoring and interventional tasks to the AGnES-practice assistants. The GPs agreed that delegating tasks to a qualified practice assistant relieves them in their daily work.ConclusionA part of the GPs home visits can be delegated to AGnES-practice assistants to support GPs in regions with an imminent or already existing undersupply in primary care. The project triggered discussions among the institutions involved in the German healthcare system and supported a reconciliation of the respective competences of physicians and other medical professions.

Frequency and determinants of potential drug‐drug interactions in an elderly population receiving regular home visits by GPs ‐ results of the home medication review in the AGnES‐studies

There is limited knowledge about prevalence and determinants of potential drug‐drug‐interactions (pDDI) in the ambulatory health care setting. In this manuscript we analysed the prevalence and determinants of pDDI in the AGnES home visit population (GP‐supporting, community‐based, e‐health‐assisted, systemic intervention).

Development of a telemedical monitoring concept for the care of malnourished geriatric home-dwelling patients: a pilot study.

Elderly patients are at high risk of malnutrition and sarcopenia, promoting further morbidity which in turn decreases quality of life and increases the claiming of medical services and associated costs. Early and sustained administration of oral nutritional supplements has been shown to improve the nutritional status with robust clinical benefit. Many patients however, poorly adhere to prescribed supplements, so consistent monitoring is needed. Clinical monitoring usually ends with the discharge rendering the continuation of nutritional supplement therapy in the patients home problematic. We developed a telemedicine based health care concept for intensive home monitoring. In a first randomized controlled prospective study we analyzed the feasibility of this innovative approach. The intervention group received oral nutritional supplements and telemedical monitoring with daily assessment of body weight, number of taken oral energy supplements and state of health. The control group received usual care. 13 patients were included in each group, eight patients of the intervention group left the study prematurely, five patients were closely monitored and used the devices for a mean 67 ± 63.5 days. Follow up data of body weight and BMI showed no relevant differences between both groups. The results and experiences gained in this pilot study demonstrate that telemedical systems provide encouraging new options to enable an intensive monitoring of malnourished patients. A continuous intensive therapy monitoring of this patient group however, is a particular challenge. Albeit possibilities, limitations and useful parameters were identified, which will be used to improve the conception in an ongoing prospective randomized trial.

A curriculum for nurses in Germany undertaking medically-delegated tasks in primary care.

AIM This paper is a report of a study conducted to develop a qualification for nurses in primary care based on the delegation of medical tasks in order to relieve general practitioners and to supply the population in rural regions today and in the future. BACKGROUND Age-demographic changes will cause medical care supply problems, especially for older people, motivating a re-evaluation of the nursing role in ambulatory medical care. METHODS An intervention study was conducted in Germany between 1 January 2006 and 31 December 2007, comprising a theoretical and practical phase evaluated by participants, general practitioners and patients through questionnaires, reflection rounds and structured interviews during and after the practice phase. FINDINGS Participants and general practitioners rated the curriculum as relevant and useful. Nurses were motivated by the ability to be self-employed and the expansion of their scope of professional work general practitioners regarded medical duty delegation as workload relief. Patients positively evaluated nurse visits, comparing medical competence and conduct to that of a general practitioners. CONCLUSION The qualification is a promising approach to compensate for the imminent under-supply of primary care and allows maintenance a high standard of healthcare quality for rural areas of Germany and countries with similar structures. It supports doctors through task delegation, and offers an option for an advanced training for nurses.

Cognitive impairment in primary ambulatory health care: pharmacotherapy and the use of potentially inappropriate medicine.

Drug intake is associated with a risk of drug‐related problems, for example, the intake of potentially inappropriate medication (PIM), especially for cognitively impaired individuals. The proportion of PIM taken by immobile individuals, especially patients with suspicion of dementia in the AGnES studies (German: Arzt‐entlastende Gemeinde‐nahe E‐Health‐gestützte Systemische Intervention), and possible determinants were analyzed.

Delegation of GP-home visits to qualified practice assistants: assessment of economic effects in an ambulatory healthcare centre

BackgroundAgainst the background of a decreasing number of general practitioners (GPs) in rural regions in Germany, the AGnES-concept (AGnES = GP-supporting, community-based, e-health-assisted, systemic intervention) supports the delegation of regular GP-home visits to qualified practice assistants. The concept was implemented and evaluated in different model projects in Germany.To explore the economic effects of this concept, the development of the number of home visits in an ambulatory healthcare centre was analysed and compared with the number of home visits in the surrounding county.MethodsInformation about GP-home visits was derived from reimbursement data of the ambulatory healthcare centre and a statutory health insurance. Information about home visits conducted by AGnES-practice assistants was collected from the project documentation over a time period of 12 consecutive quarter years, four quarter years before the beginning of the project and 8 quarter years while the project was implemented, considering background temporal trends on the population level in the study region.ResultsWithin the ambulatory healthcare centre, the home visits by the GPs significantly decreased, especially the number of medically urgent home visits. However, the overall rate of home visits (conducted by the GPs and the AGnES-practice assistants together) did not change significantly after implementation of the AGnES-concept. In the surrounding county, the home visit rates of the GPs were continuous; the temporal patterns were approximately equal for both usual and urgent home visits.ConclusionThe results of the analyses show that the support by AGnES-practice assistants led to a decrease of GP-home visits rather than an induction of additional home visits by the AGnES-practice assistants. The most extended effect is related to the medically urgent home visits rather than to the usual home visits.

A mobile and asynchronous electronic data capture system for epidemiologic studies

A Central Data Management (CDM) system based on electronic data capture (EDC) software and study specific databases is an essential component for assessment and management of large data volumes in epidemiologic studies. Conventional CDM systems using web applications for data capture depend on permanent access to a network. However, in many study settings permanent network access cannot be guaranteed, e.g. when participants/patients are visited in their homes. In such cases a different concept for data capture is needed. The utilized EDC software must be able to ensure data capture as stand-alone instance and to synchronize captured data with the server at a later point in time. This article describes the design of the mobile information capture (MInCa) system an EDC software meeting these requirements. In particular, we focus on client and server design, data synchronization, and data privacy as well as data security measures. The MInCa software has already proven its efficiency in epidemiologic studies revealing strengths and weaknesses concerning both concept and practical application which will be addressed in this article.

A Telephone- and Text Message-Based Telemedicine Concept for Patients with Mental Health Disorders: Results of a Randomized Controlled Trial

Background: A telemedicine care concept based on telephone contacts and individualized text messages was developed for patients with mental disorders to continue treatment after therapy in a psychiatric day hospital. The primary objective of this study was to evaluate the effectiveness of the telemedicine interventions. Methods: The study had a 3-armed, randomized design with 2 intervention arms (intervention 1: telephone contacts; intervention 2: telephone contacts and short text messages; both took place over a period of 6 months and in addition to usual care), and a control group with usual care. Primary outcomes were 18-item Brief Symptom Inventory (BSI-18) scores for anxiety, depression and somatization. All participants were recruited from psychiatric day hospitals. The study was registered in the German Clinical Trials Register (DRKS00000662). Results: 113 participants were analyzed 6 months after starting the intervention. The average BSI-18 anxiety score after 6 months was -2.04 points lower in intervention group 2 than in the control group (p value: 0.042). The difference in BSI depression score between these two groups was marginally significant (p value: 0.1), with an average treatment effect of -1.73. In an exploratory sensitivity analysis restricted to the 75% of patients with the highest symptom scores at baseline, intervention group 1 yielded a significant effect for anxiety and depression compared to the control group (p = 0.036 and 0.046, respectively). Conclusions: Telemedicine provides a novel option in psychiatric ambulatory care with statistically significant effects on anxiety. A positive tendency was observed for depression, especially in cases with higher symptom load at baseline.

Outcomes and prognostic factors in gallbladder cancer: a single-centre experience

IntroductionGallbladder cancer is the most common malignant tumour of the biliary system with an extraordinarily poor prognosis. In this study, we retrospectively evaluated forty-two patients with histologically proven gallbladder cancer.Patients and methodsEstimated survival rates were calculated by the Kaplan–Meier method, and differences were assessed using the logrank test. The GKR (combined registry of cancer) and demographic data were used to gain information on community cancer statistics.ResultsIn this study, patients with metastases showed poorer survival rates. Furthermore, the survival was significantly better in patients with R0 resections, smaller tumour sizes and without lymph node infiltration. T stage, M stage and R stage were independent prognostic parameters. Sex and age had no significant effect on survival. Also, we found that patients with incidental gallbladder cancer and those with cholecystolithiasis showed significantly better survival rates. Demographic analyses of the study group confirmed a high coverage of our institution for incident cases in our catchment area and no significant regional deviations from the expected incidence of gallbladder cancer.ConclusionDespite differences in the incidence in different geographical areas, gallbladder cancer appears to be fairly normally distributed in Western Pomerania, a predominantly rural area of Northeastern Germany. Coverage of incident cases in our catchment area was high. T stage, M stage and R stage were independent prognostic factors in our study. We conclude that, whenever possible, an R0 resection should be the surgical goal in all patients staged resectable before surgery, but heroic resections in patients with highly advanced cancer disease or severe accompanying non-tumour diseases are not warranted.

Estimating future dental services' demand and supply: a model for Northern Germany.

OBJECTIVES To plan dental services, a spatial estimation of future demands and supply is required. We aimed at estimating demand and supply in 2030 in Northern Germany based on the expected local socio-demography and oral-health-related morbidity, and the predicted number of dentists and their working time. METHODS All analyses were performed on zip-code level. Register data were used to determine the number of retiring dentists and to construct regression models for estimating the number of dentists moving into each zip-code area until 2030. Demand was modelled using projected demography and morbidities. Demand-supply ratios were evaluated and spatial analyses applied. Sensitivity analyses were employed to assess robustness of our findings. RESULTS Compared with 2011, the population decreased (-7% to -11%) and aged (from mean 46 to 51 years) until 2030. Oral-health-related morbidity changed, leading to more periodontal and fewer prosthetic treatments needs, with the overall demand decreasing in all scenarios (-25% to -33%). In contrast, the overall number of dentists did only limitedly change, resulting in moderate decrease in the supplied service quantities (max. -22%). Thus, the demand-supply ratio increased in all but the worst case scenario, but was unequally distributed between spatial units, with several areas being over- and some being under- or none-serviced in 2030. CONCLUSIONS Within the limitations of the underlying data and the required assumptions, this study expects an increasingly polarized ratio of dental services demand and supply in Northern Germany. Our estimation allows to assess the impact of different influence factors on demand or supply and to specifically identify potential challenges for workforce planning and regulation in different spatial units.