Zeitschrift fur Evidenz Fortbildung und Qualitaet im Gesundheitswesen最新文献

Background: Cancer is a major global health burden, and lung cancer stands out due to its severe lethality. To enhance efforts to improve cancer care, this study analyzes the relationship between regional disparities and survival among patients with non-small cell lung cancer (NSCLC) in Lower Saxony, Germany, and discusses the findings in the context of worldwide evidence.

Methods: Patient data from the Clinical Cancer Registry of Lower Saxony were used to perform a small-scale survival analysis at the municipality level. Diagnoses from 2019 to 2022 were included, resulting in a cohort of 11,692 patients. These data were supplemented with publicly available datasets on regional residential types and socioeconomic deprivation. Survival outcomes were analyzed using Kaplan-Meier curves and Cox proportional hazards regression models.

Results: The overall median survival for the entire cohort was 334 days (95 % CI: 322-346 days). For patients residing in very central areas, the median survival was 353 days (95 % CI: 331-392 days), while for those living in very peripheral areas, it was 275 days (95 % CI: 242-333 days). Stratified by socioeconomic deprivation, the findings on median survival were ambiguous. Cox regression models show a significant higher hazard ratio for patients living peripheral (HR = 1.06, 95 % CI: 0.99-1.13) and very peripheral (HR = 1.20, 95 % CI: 1.06-1.36). Regarding socioeconomic deprivation, the findings on hazard ratios were ambiguous, too.

Conclusions: Results show disadvantages in survival for NSCLC patients living in peripheral areas of Lower Saxony. The effect of socioeconomic deprivation on survival remains challenging. Policymakers should carefully consider regional disparities when designing interventions for cancer care.

Background: Routine documentation in inpatient palliative care units takes up a significant amount of caregivers' workload, but at the same time offers many opportunities for data use, e.g. for quality assurance. The S3 guideline on palliative medicine formulates eleven quality indicators (QIs). It is currently unknown how or to what extent QIs are documented on palliative care units.

Method: Semi-structured planning interviews were conducted at seven palliative care units in the catchment area of the Comprehensive Cancer Center of Lower Saxony to determine the extent to which routine documentation contains data sources for measuring ten of the eleven QIs. The documentation systems, data sources and assessments used were recorded and compared with regard to the individual QIs of the S3 guideline on palliative medicine, at the same time identifying challenges in documentation.

Results: There is no explicit documentation of all QIs across palliative care units, and the fulfilment of QIs can only be determined secondarily from routine documentation. For all seven palliative care units, the data sources are the baseline palliative care assessment, assessments such as MIDOS, IPOS or individual instruments, the progress documentation in text form and the letter from the attending physician. Challenges regarding documentation include duplicate documentation of content, technical difficulties, and inconsistent documentation procedures of different caregivers.

Discussion: Routine documentation in palliative care units is heterogeneous. To determine compliance with the ten QIs, different data sources must be used for each palliative care unit, which makes comparisons between palliative care units difficult. The challenges mentioned above influence the use of data for scientific purposes. In research projects, sufficient time should be allowed for the use of pseudonymised secondary data, in particular to enable data protection coordination.

Conclusion: Documentation in palliative care units provides important data sources for measuring QIs, and at the same time, scientific analysis is subject to many limitations. Further research is needed to identify which aspects can motivate the implementation and systematic documentation of QIs.

Background: The "Registry for Recurrent Stone Diseases of the Upper Urinary Tract" (RECUR) was developed as a prospective long-term study. The aim was to link clinical data from hospital information systems (HIS) with self-report data from patients. The aim was to sustainably minimize resource requirements through digital and automated processes. However, numerous formal, legal, and logistical factors led to considerable delays in the implementation of the necessary digital infrastructure. This caused a significant delay in the start of recruitment. In addition, recruitment itself fell far short of the projected figures so that the registry had to be closed, partly because further funding could no longer be guaranteed. This paper describes the obstacles, supporting measures and reasons for the inability to achieve the targets, in particular the inadequate recruitment.

Methods: To evaluate the recruitment process, seven guided expert interviews were conducted in the autumn of 2024 at the Freiburg site with healthcare professionals recruiting for RECUR (doctors and a ward secretary). Interview transcripts served as the basis for the qualitative summarizing content analysis according to Mayring. This involved sorting and summarizing the data material on the basis of case- and topic-related summaries.

Results: The following reasons for insufficient recruitment of participants were identified: (1) Physicians faced increasing workloads, particularly due to administrative tasks, making even minor additional duties a low priority. (2) There was no intrinsic benefit perceived by those responsible for recruitment. (3) On the patient side, challenges included language and cognitive barriers, lack of technical affinity and equipment, as well as information overload. Opportunities for optimization include centralizing responsibilities, providing additional staffing resources, automating and digitalizing processes, and implementing incentive systems for staff.

Discussion: Everyday hospital life is characterized by a high level of organizational and administrative effort combined with limited personnel and time resources. Such conditions considerably limit the implementation of care research studies. In the RECUR use case, recruitment was hampered by limited cognitive, technological, and linguistic competences as well as little recognizable intrinsic benefit for both staff and patients. Future research projects should incorporate these findings to improve design and recruitment.

Background: Patient-centered therapy, with shared decision making (SDM) as a fundamental principle, is recommended in clinical guidelines for the care of individuals with type 2 diabetes mellitus but is often not implemented in practice. "arriba Diabetes" was developed as a decision aid to support shared decision-making (SDM) regarding therapy intensity. The underlying linear model requires four inputs: (1) age, (2) comorbidities, (3) preference preferences regarding treatment efforts, and (4) preferences regarding the avoidance of organ damage. Based on these inputs, the program calculates an appropriate therapy intensity. This study aimed to examine how GPs perceive "arriba Diabetes".

Methods: This qualitative interview study aimed to explore general practitioners' (GPs') perceptions of "arriba Diabetes", specifically (1) whether the therapy intensity suggested by the model was considered appropriate, (2) whether the tool was perceived as comprehensible, and (3) whether it was regarded as complete. Interviews were conducted at two time points-before and after the application of the tool. The interview performed before the application followed the cognitive pretest approach. Data were analyzed thematically according to Braun and Clarke.

Results: We conducted five interviews before and 18 interviews after the application of "arriba Diabetes". GPs generally perceived the recommended therapy intensity as appropriate. In some cases, it was initially regarded as not strict enough but, upon reflection, was considered comprehensible and even educational in terms of supporting de-escalation. The four input parameters (age, comorbidities, preference regarding treatment efforts, and preference regarding the avoidance of complications) were largely viewed as meaningful and complete, although the assessment of comorbidities and treatment efforts was sometimes described as challenging. Overall, GPs considered "arriba Diabetes" to be a practical and comprehensible tool for supporting SDM.

Conclusions: "arriba Diabetes" has the potential to support shared decision-making on therapy intensity for individuals with type 2 diabetes mellitus.

Introduction: In Switzerland, there is no obligation to record outpatient diagnoses. PraxisGruppe Schweiz (PraxiS), a network of about 30 GP and specialist practices in predominantly rural German-speaking regions in Switzerland, assign diagnosis codes per patient and consultation using the ICD-10 classification system. We compare these diagnoses with approximate ones, the so-called Pharmaceutical Cost Groups (PCGs), based on claims data from SWICA health insurance. We suspected that the distributions of diagnoses differed significantly between the two samples.

Methods: The PraxiS database was used to identify patients with at least one consultation between 2020 and 2022 who were insured with SWICA. Claims data identified patients who had at least one consultation with a PraxiS network clinician in the same period. Diagnoses (ICD-10) were analyzed, and the ten most frequent diagnoses per age group were reported. The number of consultations per patient and age group were calculated. PCG information was derived from claims data following the official Swiss risk equalization definition, based on defined daily doses in the last observation year. Differences in diagnosis distributions between the two samples were tested using a Pearson χ² test.

Results: High cholesterol, hypertension, diabetes, and depression are amongst the most frequently recorded diagnoses in both data sources. Furthermore, acute events (e.g., infections of the upper respiratory tract) and non-specific symptoms or problems that cannot be clearly assigned to a certain diagnosis occur frequently in primary care, while thyroid diseases, asthma/COPD and glaucoma are more commonly recorded in the claims data, since they are associated with regular medication intake. For 6 of the 32 PCG diagnoses, we rejected the null hypothesis of identical distributions, i.e., the diagnosis prevalences differ significantly between the two samples.

Discussion and conclusion: While the GPs' diagnoses reflect the most frequent reasons for consultations, claims data also include prescriptions from outside primary care. Both data sources must be used in a complementary manner. Claims data should be used to analyze morbidity and medication use in a population. To gain a deeper understanding of the care situation, the data generated by GPs should be used. Particularly in times of GP shortages, when it is necessary to think about alternative or advanced forms of primary care, a detailed analysis of the care needs and care situations of the affected patient groups is necessary. Efforts in this direction should be supported.

Background: With the beginning of a vocational training, nursing students are challenged with a new professional role and required to develop a professional identity. It is not clear which challenges nursing students perceive in this process and to what extent the professional identity is developed over the course of the training. These findings are needed to support nursing students in these development processes with suitable informal and formal learning and educational opportunities.

Method: A three-year qualitative panel study with guideline-based, episodic interviews was conducted. A total of 26 nursing students from nursing training courses took part and were interviewed three times, namely at the end of each training year. The data material was analyzed using a reconstructive-hermeneutical method, and development types were formed.

Results: Finding a role in organizations and the associated development of a professional identity was identified as a major challenge for nursing students in vocational training. Most students finally succeed in finding a balance between individuation and adaptation when taking on their new professional role and develop an appropriate tolerance for ambiguity. For some nursing students, though, the ongoing tension between their own expectations and the role expectations of others leads to a pronounced intolerance of ambiguity and a persistent experience of stress.

Discussion: Especially at the beginning of the training, trainees' role actions are strongly guided by their own or other people's expectations, and they often find themselves in conflict situations, which also means that learning opportunities are missed. The persons responsible for nursing training are required to support trainees in recognizing their learning needs and opportunities. In addition, the development of ambiguity tolerance should be specifically promoted in order to create the appropriate conditions for achieving training success and maintaining the trainees' health.

Conclusion: The development of a professional identity should be understood as a dimension of professional competence and supported accordingly by formal learning and educational offers. Further research is needed to determine future development needs and to accordingly review existing offers.

Background: The active involvement of patients is considered a key factor in improving patient safety. With the model project Mehr Patientensicherheit, Germany has, for the first time, implemented a Critical Incident Reporting System (CIRS) specifically for patients and their relatives, enabling the anonymous reporting of patient safety events. This study aimed to analyze the demographic characteristics of reporters, assess their evaluations of information status, severity, and recurrence risk of incidents, test hypotheses regarding potential influencing factors, and derive implications for the further development of the platform.

Methods: A cross-sectional observational study analyzed 1,390 reports submitted via the online platform www.mehr-patientensicherheit.de between January and October 2024. Data were collected anonymously using a structured questionnaire containing open-ended and closed-ended items. Descriptive analyses, chi-square tests, and Mann-Whitney U tests were applied.

Results: Of all reports, 73 % originated directly from patients, while 24.4 % were submitted by relatives reporting on behalf of patients. The majority of reports concerned female patients (62.2 %). Age distribution was as follows: >80 years (9.9 %), 70-79 years (12.4 %), 50-69 years (32.1 %), 30-49 years (29.1 %), 15-29 years (10.8 %), and <15 years (4.2 %). The majority of the incidents were reported from ambulatory and in-patient care settings. Overall, 71 % of reports indicated insufficient information regarding patient safety measures.

Discussion: The findings demonstrate that patients can actively contribute to patient safety. The reports submitted provide novel insights into subjectively perceived risks, thereby complementing existing reporting systems with a previously underrepresented perspective. At the same time, the results highlight structural deficiencies, particularly in communication and feedback processes following serious incidents.

Conclusion: The patient-centered CIRS has the potential to foster cross-sector learning and advance the development of patient safety culture. The systematic inclusion of the patient perspective and the institutionalization of the system should be actively encouraged.

Background: Hospital referrals from office-based physicians represent an important pathway to emergency departments (EDs), but in only about one-third of cases they result in inpatient admissions. Ambulatory care sensitive conditions (ACSCs) are considered an indicator of potentially avoidable hospitalizations and thus a measure of the quality of outpatient care. The aim of this study was to systematically analyze referral forms, determine the proportion of ACSCs, and examine patients' subsequent care pathways.

Methods: A retrospective analysis was conducted of all patients that were referred to the ED of a university tertiary care center by office-based physicians over a one-month period in June 2022 and subsequently triaged to the specialties of General Medicine or Internal Medicine within the ED. Recorded variables included referral diagnoses, additional information provided on the referral form, and the subsequent care pathway. ACSCs were identified on the basis of a consensus-based list of diagnostic groups. Data were analyzed descriptively and using the Chi-squared test.

Results: Of 1,038 patients assigned to the two specialties in the ED during the study period, 171 (16.5 %) had been referred by office-based physicians. A diagnosis was documented on 97 % of referral forms; in 27 % of cases, this corresponded to ACSCs, predominantly cardiovascular or respiratory conditions. Of all referred patients, 32 % were admitted. Neither the designation of the referral as an emergency nor the presence of an ACSC was significantly associated with the likelihood of admission.

Conclusion: These findings reveal a marked discrepancy between physician referrals and the actual need for inpatient treatment. The observed proportion of ambulatory care-sensitive conditions and the partially incomplete documentation on referral forms point to potential challenges at the interface between outpatient and inpatient care. These should be further investigated in the context of complex clinical decision-making processes, limited outpatient resources, and possible shortcomings in cross-sectoral coordination.

Introduction: To reduce the impact of boundaries between inpatient (hospital) and outpatient (ambulatory) care sectors in Germany, both outpatient hospital treatments (AOP) and the newly introduced site-neutral payment (Hybrid Diagnosis Related Groups [DRGs]) are being further expanded. This study examines whether ambulatory care sensitive conditions (ACSCs), i.e., hospitalizations assumed to be avoidable by adequate outpatient treatment, can also be used to identify additional treatments for AOP and Hybrid DRGs.

Methods: Identification of ACSC cases among all inpatient cases in Germany 2018-2023 by main diagnosis. Exclusion of cases requiring inpatient treatment (according to, e.g., procedures, diagnoses) and cases already eligible for outpatient reimbursement. Analysis of the remaining ones by case (e.g., length of stay - LOS, age, admission time, and reason) and DRG characteristics (e.g., Patient Clinical Complexity Level - PCCL, cost weight).

Results: The identified 1.4 to 2.0 million cases per year (9-11 % of all inpatient cases) were predominantly non-invasively treated (97 %) with short LOS (≤1 day: 30 %) and low clinical (PCCL < 2: 71-98 %) and economic effort (cost weights: 0.19-0.68). Case numbers declined above-average in 2020/21 (by -30 %). Elevated ACSC rates were seen in rural districts. Of the top 30 DRGs in 2023 (88 % of cases), 13 seem to be suitable for deriving Hybrid DRGs (n = 202,000 with LOS ≤ 1), and 10 (n = 164,000) mostly cover patients with an acute need for diagnostic evaluation which might be reimbursed via Hybrid DRGs where outpatient treatment is sufficient. Additionally, possible procedures for expanding hospital outpatient treatments were identified.

Conclusions: The findings suggest a low need for inpatient treatment among the identified cases and provide a basis for expanding outpatient hospital care and site-neutral payment.