Tobias Freund

Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care–Sensitive Conditions

PURPOSE Hospitalizations for ambulatory care–sensitive conditions (ACSCs) are seen as potentially avoidable with optimal primary care. Little is known, however, about how primary care physicians rate these hospitalizations and whether and how they could be avoided. This study explores the complex causality of such hospitalizations from the perspective of primary care physicians. METHODS We conducted semistructured interviews with 12 primary care physicians from 10 primary care clinics in Germany regarding 104 hospitalizations of 81 patients with ACSCs at high risk of rehospitalization. RESULTS Participating physicians rated 43 (41%) of the 104 hospitalizations to be potentially avoidable. During the interviews the cause of hospitalization fell into 5 principal categories: system related (eg, unavailability of ambulatory services), physician related (eg, suboptimal monitoring), medical (eg, medication side effects), patient related (eg, delayed help-seeking), and social (eg, lack of social support). Subcategories frequently associated with physicians’ rating of hospitalizations for ACSCs as potentially avoidable were after-hours absence of the treating physician, failure to use ambulatory services, suboptimal monitoring, patients’ fearfulness, cultural background and insufficient language skills of patients, medication errors, medication nonadherence, and overprotective caregivers. Comorbidities and medical emergencies were frequent causes attributed to ACSC-based hospitalizations that were rated as being unavoidable. CONCLUSIONS Primary care physicians rated a significant proportion of hospitalizations for ACSCs to be potentially avoidable. Strategies to avoid these hospitalizations may target after-hours care, optimal use of ambulatory services, intensified monitoring of high-risk patients, and initiatives to improve patients’ willingness and ability to seek timely help, as well as patients’ medication adherence.

Validation of the German Version of the Patient Activation Measure 13 (PAM13-D) in an International Multicentre Study of Primary Care Patients

The patients’ active participation in their medical care is important for patients with chronic diseases. Measurements of patient activation are needed for studies and in clinical practice. This study aims to validate the Patient Activation Measure 13 (PAM13-D) in German-speaking primary care patients. This international cross-sectional multicentre study enrolled consecutively patients from primary care practices in three German-speaking countries: Germany, Austria, and Switzerland. Patients completed the PAM13-D questionnaire. General Self-Efficacy scale (GSE) was used to assess convergent validity. Furthermore Cronbach’s alpha was performed to assess internal consistency. Exploratory factor analysis was used to evaluate the underlying factor structure of the items. We included 508 patients from 16 primary care practices in the final analysis. Results were internally consistent, with a Cronbach’s alpha of 0.84. Factor analysis revealed one major underlying factor. The mean values of the PAM13-D correlated significantly (r = 0.43) with those of the GSE. The German PAM13 is a reliable and valid measure of patient activation. Thus, it may be useful in primary care clinical practice and research.

Patterns of Multimorbidity in Primary Care Patients at High Risk of Future Hospitalization

Care management is seen as a promising approach to address the complex care needs of patients with multimorbidity. Predictive modeling based on insurance claims data is an emerging concept to identify patients likely to benefit from care management interventions. We aimed to identify and explore patterns of multimorbidity in primary care patients with high predicted risk of future hospitalizations in order to develop a primary care-based care management intervention. We conducted a retrospective cohort study to assess insurance claims data of 6026 patients from 10 primary care practices in Germany. We stratified the population by the predicted likelihood of hospitalization (LOH) using a diagnostic cost group-based case-finding software. Co-occurrence of chronic conditions in multimorbid patients with an upper-quartile LOH score was explored by extraction of mutually exclusive patterns. Predictive modeling identified multimorbid elderly patients with a high number of co-occurring chronic conditions (mean number 7.8 [SD 3.1]). Assessing co-occurrence of highly prevalent chronic conditions in 1407 multimorbid patients with upper-quartile LOH revealed 471 mutually exclusive patterns with low single frequencies. The observed prevalence significantly exceeded expected prevalence for patterns with causal comorbidity. Additionally, chronic pain (related to osteoarthritis) or depression could be identified as discordant co-occurring conditions in 80% (12/15) of the most common multimorbidity patterns. High-risk primary care patients suffer from heterogeneous individual patterns of co-occurring chronic conditions. Care management interventions will have to account for discordant co-occurring conditions such as osteoarthritis and depression.

BCG priming of dendritic cells enhances T regulatory and Th1 function and suppresses allergen-induced Th2 function in vitro and in vivo.

Background: The inverse correlation of mycobacterial infection with asthma prevalence and the inhibitory effects of vaccination with Bacille Calmette-Guérin (BCG) on airway hyperreactivity in asthma models suggest modulation of dendritic cell (DC) and T cell functions by mycobacterial compounds. Methods: To delineate these immunological effects, the immunogenicity of BCG Copenhagen, BCG Chicago and BCG Pasteur was compared in a mouse model. Bone marrow-derived dendritic cells (BMDCs) from BALB/c mice were stimulated with ovalbumin (OVA) with or without BCG. BMDCs were phenotypically characterized by flow cytometry, and we used ELISA to measure the cytokine production of BMDCs as well as of co-cultivated allergen-specific T cells in response to OVA-pulsed. Immunomodulatory effects of BCG were studied in a model of allergic airway inflammation by adoptive transfer of allergen-pulsed BMDCs. Results: Immunomodulation with BCG induced production of IL-10 and IL-12 by BMDCs. Co-cultured allergen-specific T cells produced less IL-5, IL-13 and IFN-γ but more IL-10. Also the number of FoxP3+ regulatory T cells was enhanced. Strongest effects were seen with BCG Chicago and BCG Pasteur. In vivo, administration of BCG modulated OVA-pulsed BMDCs then reduced eosinophilic airway inflammation but enhanced infiltration with granulocytes. Airway hyperreactivity and mucus production were reduced and more FoxP3+ T cells were observed. Conclusion: BCG-induced suppression of Th2-type allergic airway inflammation was associated with enhancement of regulatory T cell function but also of Th1-associated neutrophilic airway inflammation. These findings raise concerns regarding the safety profile of BCG as a potential tool for prevention and therapy of allergic airway disease.

Determinants of heart failure self-care behaviour in community-based patients: a cross-sectional study

Background: Self-care behaviour in patients with heart failure (HF) represents a series of specific actions that patients should take, as an important treatment component. Aims: The aim of this study was to identify potential determinants of HF self-care in ambulatory patients with stable systolic HF. Methods: In a cross-sectional study of 318 patients with chronic systolic HF recruited in 48 German primary care practices, we evaluated the patient-reported European HF Self-care Behaviour scale (EHFScBs) assessments (range 12–60, where lower scores indicate better self-care). Potential determinants included socio-demographic (e.g. age, living status), clinical (e.g. NYHA class, LVEF, NT-proBNP levels, co-morbidities), behavioural (e.g. smoking and alcohol intake), psychosocial (SF-36 scales and KCCQ domains, e.g. quality of life and self-efficacy) and depression status (PHQ-D), plus previous health care utilisation. Mixed regression modelling was applied. Results: Patients had a mean (SD) age of 69.0 (10.4) years and were 71% male. They had a good overall EHFScBs score of 24.7 (7.8) (n=274). In the final regression model (n=271), six determinants were retained (β; descriptive p-value): self-efficacy (-0.24; <.001), age (-0.22; <.001), prosthetic heart valve (-0.14; .01), referrals to cardiologists (-0.14; .02), peripheral arterial disease (0.13; .03) and quality of life (0.16; .02). Conclusion: In this exploratory cross-sectional study, the potential non-modifiable and modifiable risk factors and resources involved in patients’ HF self-care were at the individual and organisational level. Self-efficacy and quality of life are potentially modifiable, so these could be targeted for improvement by enhancing patient motivation, HF education and further supporting a collaborative care approach.

Tailored Implementation for Chronic Diseases (TICD): a protocol for process evaluation in cluster randomized controlled trials in five European countries

BackgroundIn the ‘Tailored Implementation for Chronic Diseases (TICD)’ project, five tailored implementation programs to improve healthcare delivery in different chronic conditions have been developed. These programs will be evaluated in distinct cluster-randomized controlled trials. This protocol describes the process evaluation across these trials, which aims to identify determinants of change in chronic illness care, to examine the validity of the tailoring methods that were applied, and to analyze the association of implementation activities and the effectiveness of the program.MethodsA multilevel approach was used to develop five tailored implementation interventions. In order to guide the process evaluation in five distinct trials, the study protocols for the cluster randomized trials and the related process evaluations were developed simultaneously and iteratively.ResultsThe process evaluation comprises three main components: a structured survey with health professionals in the trials, semi-structured interviews with a purposeful sample of this study population, and standardized documentation of organizational practice characteristics. Norway will only conduct the qualitative part of the analysis because the survey and documentation of practice characteristics are considered to be not feasible. The evaluation is guided by ‘logic models’ of the implementation programs: frameworks that specify the linkages between the strategies used, the determinants addressed by tailoring, and the anticipated outcomes. Standardization of measures across trials is sought to facilitate analysis of aggregated data from the trials.ConclusionsThis process evaluation will need to find a balance between standardization of methods across trials and the tailoring of measures to the specificities of each trial.

The impact of perceived social support and sense of coherence on health-related quality of life in multimorbid primary care patients.

This study explores the impact of perceived social support and sense of coherence as positive resources for health-related quality of life in multimorbid primary care patients. We analysed cross-sectional survey data on health-related quality of life (EQ-5D), perceived social support (FSozU-K22), sense of coherence (SOC-L9), social demographics and self reported morbidity of 103 multimorbid patients from 10 general practices in Germany. A multiple linear regression model was used to determine the impact of social support and sense of coherence on the health-related quality of life while controlling for age, sex, educational level, marital status and number of chronic conditions. In the final regression model, higher sense of coherence scores were associated with higher health-related quality of life scores (standardized ß 0.34, p < 0.001) whereas a higher number of chronic conditions was associated with lower health-related quality of life scores (standardized ß −0.41, p < 0.001). In the bivariate model, higher perceived social support was associated with higher health-related quality of life scores (standardized ß 0.35, p < 0.001), whereas the model failed to show a significant association after controlling for sense of coherence which is a potential resource for improving health-related quality of life in multimorbid primary care patients. It emerged as a significant element contributing to the prediction of health-related quality of life. This issue may indicate the importance of internal resources for multimorbid patients.

Let’s talk about medication: concordance in rating medication adherence among multimorbid patients and their general practitioners

Background Medication adherence can be essential for improving health outcomes. Patients with multiple chronic conditions, often receiving multiple medications, are at higher risk for medication nonadherence. Previous research has focused on concordance between patients and providers about which medication should be taken. However, the question of whether patients and providers are concordant in rating actual medication intake has not been answered as yet. This study aimed to explore the extent and predictors of patient – provider concordance in rating medication adherence in patients with multiple chronic conditions. Methods Overall medication adherence was measured by self-report (Medication Adherence Report Scale, MARS-D) in a sample of 92 patients with multiple chronic conditions. Twelve treating primary care physicians were asked to rate medication adherence in these patients using a mirrored version of the MARS-D. Concordance between external rating and self-reported medication adherence was analyzed descriptively. Predictors of concordance in rating medication adherence were explored in a multilevel analysis. Results Patients rate their medication adherence markedly higher than their general practitioner. Accordingly, the percentage of concordance ranges between 40% (forgot to take medication) and 61% (deliberately omitted a dose). In multilevel analysis, concordance in rating medication adherence was positively associated with being the single primary care provider (β 2.24, P < 0.0001) and frequent questioning about medication use (β 0.66, P = 0.0031). At the patient level, “not [being] married” (β −0.81, P = 0.0064) and “number of prescribed medications” (β −0.10, P = 0.0203) were negative predictors of patient – provider concordance in rating medication adherence. Conclusion Concordance for rating medication adherence between general practitioners and their patients was low. Talking about medication on a regular basis and better continuity of care may enhance patient – provider concordance in rating medication adherence as a prerequisite for shared decisions concerning medication in patients with multiple chronic conditions.

Health-related quality of life and risk factor control: the importance of educational level in prevention of cardiovascular diseases

BACKGROUND This study aimed to describe and to analyse the importance of educational level for controlled risk factors and health-related quality of life (HRQoL). METHODS This observational study was conducted in nine European countries (5632 patients in 249 practices). We compared patients with a low level of education (up to 9 years) with patients with a high level of education (>9 years), with regard to controlled cardiovascular disease risk factors and HRQoL. A multilevel approach was used for statistical analysis. RESULTS Patients with a low level of education were older (P < 0.001), more often female (P < 0.001), more often single (P < 0.001) and had a higher number of other conditions (e.g. heart failure) (P < 0.001). Significant differences in terms of controlled risk factors were revealed for blood pressure (RR) ≤ 140/90 mmHg (P = 0.039) and the sum of controlled risk factors (P = 0.027). Higher age, lower education, female gender, living as single, patient group (coronary heart disease patients) and the number of other conditions were negatively associated with HRQoL. A higher sum of controlled risk factors were positively associated with higher HRQoL in the whole sample (r = 0.0086, P < 0.001) as well as in both educational-level groups (r = 0.0075, P = 0.038 in the low-level group and r = 0.0082, P = 0.001 in the high-level group). CONCLUSION Patients with a lower educational level were more often females, singles, had a higher number of other conditions, a higher number of uncontrolled risk factors and a lower HRQoL. However, the higher the control of risk factors was, the higher the HRQoL was overall as well as in both educational-level groups.

Targeting patients for multimorbid care management interventions: the case for equity in high-risk patient identification

Targeting patients for multimorbid care management interventions requires accurate and comprehensive assessment of patients’ need in order to direct resources to those who need and can benefit from them the most. Multimorbid patient selection is complicated due to the lack of clear criteria - unlike disease management programs for which patients with a specific condition are identified. This ambiguity can potentially result in inequitable selection, as biases in selection may differentially affect patients from disadvantaged population groups. Patient selection could in principal be performed in three ways: physician referral, patient screening surveys, or by statistical prediction algorithms. This paper discusses equity issues related to each method. We conclude that each method may result in inequitable selection and bias, such as physicians’ attentiveness or familiarity, or prediction models’ reliance on prior resource use, potentially affected by socio-cultural and economic barriers. These biases should be acknowledged and dealt with. We recommend combining patient selection approaches to achieve high care sensitivity, efficiency and equity.