Abstract Background Upper limb (UL) paresis is one of the most common stroke consequences and significantly restricts patients in everyday life. Instruments objectively measuring direct arm use in stroke patients are lacking, but might be helpful to understand patients’ impairment. Aiming to examine whether accelerometry is a suitable objective measure for everyday UL use in stroke patients, we conducted a systematic review on the association between accelerometer-derived measurements and clinical scales. Methods Articles were systematically searched in PubMed, Scopus, Cochrane Library, PeDro and LIVIVO through December 12 th , 2021, screened for inclusion by AH, and subsequently independently screened by CK and MK. Disagreements were discussed until consensus. We included English and German peer-reviewed articles dealing with the validity of accelerometers as a measurement of UL use in stroke patients and eligible systematic reviews. Studies exclusively using accelerometry as an outcome parameter, book contributions, conference abstracts and case studies were excluded. Data extraction was conducted by AH and confirmed by CK focussing on study type, objective, accelerometer device, sample size, stroke status, assessments conducted, measurement method, wearing time and key results. We analysed all eligible articles regarding the correlation between accelerometry and other clinical assessments and the validity in accordance with the type of accelerometer. Results Excluding duplicates, the initial search yielded 477 records. In the 34 eligible studies accelerometers was used with a predominance of tri-axial accelerometery ( n = 12) and only few with two-axial application ( n = 4). Regarding measures to examine association to accelerometer data different clinical scales were applied depending on the setting, the degree of impairment and/or the status of stroke. Cut-off values to determine correlations varied largely; most significant correlations are reported for the MAL [Range 0.31- 0.84] and the ARAT [Range 0.15–0.79]. Conclusions Accelerometers can provide reliable data about daily arm use frequency but do not supply information about the movements´ quality and restrictions on everyday activities of stroke patients. Depending on the context, it is advisable to use both, accelerometry and other clinical measures. According to the literature there is currently no accelerometer device most suitable to measure UL activity. High correlations indicate that multi-dimensional accelerometers should be preferred.
Abstract Background Perceived high chronic stress is twice as prevalent among German general practitioners (GPs) and non-physician medical staff compared to the general population. The reasons are multi-factorial and include patient, practice, healthcare system and societal factors, such as multi-morbidity, the diversity of populations and innovations in medical care. Also, practice-related factors, like stressful patient-staff interactions, poor process management of waiting times and lack of leadership, play a role. This publicly funded study evaluates the effectiveness of the newly developed participatory, interdisciplinary, and multimodal IMPROVE job intervention on improving job satisfaction among general practice personnel. The intervention aims at structural stress prevention with regard to working conditions and behavioural stress prevention for leaders and other practice personnel. Methods In this cluster-randomised controlled trial, a total of 56 general practices will be assigned to either (1) participation in the IMPROVE job intervention or (2) the waiting-list control group. The IMPROVE job intervention consists of the following elements: three workshops, a toolbox with supplemental material and an implementation period with regular contact to so-called IMPROVE job facilitators. The first workshop, addressing leadership issues, is designed for physicians with leadership responsibilities only. The two subsequent workshops target all GP and non-physician personnel; they address issues of communication (with patients and within the team), self-care and team-care and practice organisation. During the 9-month implementation period, practices will be contacted by IMPROVE job facilitators to enhance motivation. Additionally, the practices will have access to the toolbox materials online. All participants will complete questionnaires at baseline and follow up. The primary outcome is the change in job satisfaction as measured by the respective scale of the validated German version of the Copenhagen Psychosocial Questionnaire (COPSOQ, version 2018). Secondary outcomes obtained by questionnaires and - qualitatively - by facilitators comprise psychosocial working conditions including leadership aspects, expectations and experiences of the workshops, team and individual efforts and organisational changes. Discussion It is hypothesised that participation in the IMPROVE job intervention will improve job satisfaction and thus constitute a structural and behavioural prevention strategy for the promotion of psychological wellbeing of personnel in general practices and prospectively in other small and medium sized enterprises. Trial registration German Clinical Trials Register: DRKS00012677 . Registered on 16 October 2019. Retrospectively, https://www.drks.de/drks_web/navigate.do?navigationId=trial . HTML&TRIAL_ID = DRKS00012677.
In Germany, there are neither guidelines provided by the medical associations nor a public discussion about general practitioners (GPs) treating their family members. Only few studies on this topic from the primary care setting exist. The aim of this study is to describe GPs' treatment of family members and to generate empirical data on the most common reasons for this.In June 2018 we conducted a postal survey among GPs in the North Rhine region of Germany. The questionnaire was developed in a stepwise process including initial expert panels, interviews with GPs, item construction workshops, cognitive pre-tests and pilot testing with 40 questionnaires. The final questionnaire addressed: type and frequency of treatment, documentation and place of treatment, engagement as the official GP as well as reasons for and against the treatment. For data evaluation, descriptive and explorative statistical analyses were conducted.Overall, 393 questionnaires were returned (response rate 39.8%). 96.7% of the GPs had treated at least one family member during the last 12 months. Services that were provided frequently (more than three times in the last 12 months) included the prescription or dispensing of medication (partner 45%, children 37%, parents 43%, partner's parents 26%), physical examinations (partner 18%, children 24%, parents 25%, partner's parents 15%), and the arrangement or provision of laboratory tests (partner 14%, children 7%, parents 16%, partner's parents 9%). Less than one third of the study participants always treated their relatives in their office. Male GPs more often provided care to family members (except children) registered in their practice. Senior male GPs treated their relatives more often than junior female GPs. Family members were most commonly treated for practical reasons.The subject of GPs treating their relatives is of high everyday relevance, since nearly all GPs are involved in the treatment of their family members. Frequent at-home treatments and low documentation rates may indicate risks due to deviating from the professional routine.
BACKGROUND Longitudinal, patient-centered care represents a challenge for general practices. Decision support and reminder systems can offer targeted support. OBJECTIVE The objective of this study was to follow a user-oriented, stepwise approach to develop an add-on for German electronic health record (EHR) systems, which aims to support longitudinal care management of multimorbid seniors, using a flag system displaying patient-centered information relevant for comprehensive health care management. This study evaluated the prototype’s feasibility from both a technical and users’ perspective. METHODS The study was conducted with 18 general practitioners (GPs) and practice assistants (PAs) from 9 general practices using a mixed methods approach. In all practices, 1 GP and 1 PA tested the software each for 4 multimorbid seniors selected from the practice patient data. Technical feasibility was evaluated by documenting all technical problems. To evaluate the feasibility from the users’ perspective, participants’ responses during the software test were documented. In addition, they completed a self-administered questionnaire, including the validated System Usability Scale (SUS). Data were merged by transforming qualitative data into quantitative data. Analyses were performed using univariate statistics in IBM SPSS statistics. RESULTS From a technical perspective, the new software was easy to install and worked without problems. Difficulties during the installation occurred in practices lacking a 64-bit system or a current version of Microsoft .NET. As EHRs used in German practices do not provide an interface to extract the data needed, additional software was required. Incomplete flags for some laboratory data occurred, although this function was implemented in our software as shown in previous tests. From the users’ perspective, the new add-on provided a better overview of relevant patient information, reminded more comprehensively about upcoming examinations, and better supported guideline-based care when compared with their individual practice strategies. A total of 14 out of 18 participants (78%) were interested in using the software long-term. Furthermore, 8 of 9 GPs were willing to pay 5 to 25 Euros (mean 14.75, SD 5.93) monthly for its use. The usability was rated as 75% (43%-95%). CONCLUSIONS The new EHR add-on was well accepted and achieved a good usability rating measured by the validated SUS. In perspective, the legally consolidated, standardized interface to German EHRs will facilitate the technical integration. In view of the high feasibility, we plan to study the software’s effectiveness in everyday primary care. CLINICALTRIAL German Clinical Trials Register DRKS00008777; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00008777
The attention deficit hyperactivity disorder (ADHD) is associated with substantial impairment and psychiatric comorbidities. Thus, an optimized treatment is essential. In 2011, a new multidisciplinary treatment strategy (so-called Versorgungsvertrag) was contracted for the model region of Bremerhaven, Germany. This manuscript describes the results of the feasibility testing, focusing on the effects of the Versorgungsvertrag on patients' ADHD symptoms and on the treatment satisfaction of patients' kins.Patients with ADHD (4-17 years) were assessed at baseline and at 9 months follow-up. Kins documented the current symptomatology using the FBB-ADHS questionnaire on both occasions, and rated their satisfaction with the Versorgungsvertrag at follow-up. The FBB-ADHS gives information on the severity of the ADHD core symptoms (0=normal, 3=very noticeable).69 patients (77 kins) were included. At follow-up, data from 59 patients (67 kins) were available. FBB-ADHS data of both occasions was available for 44 patients. Improvements regarding the ADHD total score (1.27 at follow-up vs. 1.59 at baseline, p=0.003) and the subdomains inattention (1.42 vs. 1.81, p=0.001) and hyperactivity (0.96 vs. 1.22, p=0.032) were documented. In the subgroup of boys (n=34), inattention (p=0.001), impulsivity (p=0.019) and the ADHD total score (p=0.002) improved, while no changes were observed in the subgroup of girls (n=10). The majority of kins (52.4 to 68.4%) rated the treatment as helpful.Our study shows improvements for the ADHD core symptoms after 9 months and a high satisfaction of kins with the treatment strategy. Due to the lack of a control group from routine care, no certain statement about the additional benefit of the treatment strategy can be made. The null effect in the subgroup of girls might be explained by the underrepresentation of girls, but the gender distribution observed in our study is commonly observed in patients with ADHD.The positive effects during the observation period should be confirmed in further studies including a control group from routine care.
Longitudinal, patient-centered care represents a challenge for general practitioners (GPs), and in this context, reminder systems can offer targeted support. This study aimed to identify details of such reminders: (1) contents of care addressed, (2) their mode of display in the electronic health record (EHR), (3) their visual appearance, (4) personnel responsibilities for editing and applying reminders, and (5) use of reminders for patient recall. This mixed-methods study comprised (1) a cross-sectional survey among 185 GP practices from a German university network, and (2) structured observations of reminder utilization in six practices based on a clinical vignette describing a multimorbid senior with 26 care needs. Descriptive statistics were performed for survey data. The practice observations were analyzed by portraying different types of reminders. Seventy-three of 185 practices completed the survey (39.5%): 98.6% reported using reminders in the EHR. Frequent care contents addressed were allergies/adverse drug events (95.8%), preventive measures (93.1%), participation in disease management programs (87.5%), chronic diseases (75.0%), and upcoming vaccinations (68.1%). Practice observations showed a variety of mainly self-configured reminders. In a patients' EHR, information was displayed (1) compiled in a separate field, (2) scattered throughout the EHR, and/or (3) in a pop-up window. The visual appearance of electronic reminders varied: (1) colored fields with short text, (2) EHR entries and/or billing codes in pre-defined colors, (3) abbreviations within the treatment documentation, (4) symbols within the treatment documentation, (5) symbols linked to free text fields, and (6) traffic light schemes. Five practices self-designed reminders 'as needed'; one practice applied an EHR-embedded, pre-defined reminder system. Practices used reminders for a mean of 13.3 of the 26 aspects of care detailed in the clinical vignette (range: 9–21; standard deviation (SD): 4.3). Practices needed 20–35 min (mean: 27.5; SD: 6.1) to retrieve the information requested. Most GP practices use self-designed, visual reminders for some aspects of care, yet data-based, sophisticated solutions are needed to improve longitudinal care. German Clinical Trials Register, unique identifying number: DRKS00008777 (date of registration: 06/19/2015).
Abstract Background Longitudinal hypertension control prevents heart attacks, strokes, and other cardiovascular diseases. However, 49% of patients in German family medicine practices do not reach blood pressure (BP) targets (< 140/90 mmHg). Drawing on successful international approaches, the PIA study introduces the PIA information and communication technology system (PIA-ICT) for hypertension management in primary care. The PIA-ICT comprises the PIA-App for patients and the PIA practice management center for practices. Case management includes electronic communication with patients, recall, and stepwise medication adjustments following guidelines. The system supports a physician-supervised delegation model to practice assistants. General practitioners are qualified by eLearning. Patients learn how to obtain reliable BP readings, which they communicate to the practice using the PIA-App. Methods The effectiveness of the PIA-Intervention is evaluated in a cluster-randomized study with 60 practices, 120 practice assistants, and 1020 patients. Patients in the intervention group receive the PIA-Intervention; the control group receives usual care. The primary outcome is the BP control rate (BP < 140/90 mmHg) after 12 months. Using a mixed methods approach, secondary outcomes address the acceptance on behalf of physicians, practice assistants, and patients. This includes an evaluation of the delegation model. Discussion It is hypothesized that the PIA-Intervention will improve the quality of BP care. Perspectively, it may constitute an important health service model for primary care in Germany. Trial registration German Clinical Trials Register DRKS00012680. Registered on May 10, 2019
