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Background: The birth experience plays a pivotal role in the mother´s mental well-being and has a crucial effect on the mother-child bond. Unanticipated medical interventions, including fundal pressure, episiotomy, assisted vaginal delivery (AVD), or unplanned cesarean section (CS) during labor, may adversely affect the birth experience. The objective of this study is to identify factors contributing to the diminished evaluation of the birth experience after assessing the prevalence of unplanned obstetrical interventions in Germany. Methods: For this cross-sectional analysis, 4000 mothers whose children were born 8 or 12 months before were asked about their birth experience via a paper-based questionnaire. Overall 1102 mothers participated in the study, representing a response rate of 27.6%. The revised Childbirth Experience Questionnaire (CEQ2) was used to measure the childbirth experience. In addition to descriptive and bivariate analyses using the Wilcoxon rank-sum test and Kruskal-Wallis-test, we calculated multivariate linear regression models for each dimension of the CEQ2. Results: In general, the participants evaluated their childbirth experience favorably, assigning an average rating of 3.09 on a scale ranging from 1 to 4. Women who experienced fundal pressure, an AVD, or an unplanned CS rated their birth experience significantly worse compared to women who gave birth without interventions. Unplanned CSs received the lowest ratings for "personal capability" and "perceived safety," and an AVD resulted in lower scores for "professional support" and "participation." However, the interventions we studied did not account for much of the variation in how the childbirth experience plays out for different individuals. Conclusion: Obstetric interventions have a significant effect on different dimensions of the birth experience. If a high level of birth satisfaction is to be achieved, it is important to know which dimension of satisfaction is affected by the intervention so that explicit measures, like fostering communication, participation or safety can be taken to promote improvement. German Clinical Trial Register: DRKS00029214, retrospectively registered (Registration Date 22.06.2023). [ABSTRACT FROM AUTHOR]

Background: Mild cognitive impairment (MCI) involves cognitive decline beyond typical age-related changes, but without significant daily activity disruption. It can encompass various cognitive domains as the causes of MCI are diverse. MCI as well as frequent comorbid neuropsychiatric conditions like depression and anxiety affect individuals' quality of life. Early interventions are essential, and computerized cognitive training (cCT) is an established treatment method. This paper presents the protocol for the NeuroNation MED Effectiveness Study, evaluating the self-administered mobile cCT intervention ("NeuroNation MED") in individuals with MCI to assess training effects on cognitive domains, health competence, neuropsychiatric symptoms, psychological well-being, and the general application usability. Methods: This study protocol presents a single-blinded multicenter randomized controlled trial that will be carried out in six study centers in Germany and Luxembourg. We included adults with MCI (existing F06.7 ICD-10-GM diagnosis and TICS ≥ 21 and ≤ 32). The intervention group will use a mobile, multi-domain cCT ("NeuroNation MED") for 12 weeks. Meanwhile, the wait list control group will receive standard medical care or no care. The eligibility of volunteers will be determined through a telephone screening. After completion of the baseline examination, patients will be randomly assigned to one of the experimental conditions in a 2:1 ratio. In total, 286 participants will be included in this study. The primary outcome is the change of cognitive performance measured by the index score of the screening module of the Neuropsychological Assessment Battery. Secondary outcomes are changes in the Cognitive Failures Questionnaire, Hospital Anxiety and Depression Scale, Health-49, Health Literacy Questionnaire, among others. All of the primary and secondary outcomes will be assessed at baseline and after the 12-week post-allocation period. Furthermore, the intervention group will undergo an assessment of the System Usability Scale, and the training data of the NeuroNation MED application will be analyzed. Discussion: This study aims to assess the effectiveness of a mobile self-administered cCT in enhancing cognitive abilities among individuals diagnosed with MCI. Should the findings confirm the effectiveness of the NeuroNation MED app, it may confer possible benefits for the care management of patients with MCI, owing to the accessibility, cost-effectiveness, and home-based setting it provides. Specifically, the cCT program could provide patients with personalized cognitive training, educational resources, and relaxation techniques, enabling participants to independently engage in cognitive training sessions at home without further supervision. Trial registration: German Clinical Trials Register DRKS00025133. Registered on November 5, 2021. [ABSTRACT FROM AUTHOR]

Background: Establishing successful lactation in mothers of very low birth weight (VLBW, <1500g) infants requires structured lactation support. Little is known about mothers' perspectives on lactation support in German neonatal intensive care units (NICUs). Methods: This paper features a convergent mixed-method approach that includes a retrospective, cross-sectional questionnaire and interview data to showcase mothers' perceptions of lactation support in NICUs. Content analysis of the interviews (n = 12) and a descriptive analysis of quantitative data (n = 533) were performed to illustrate the current status and need for lactation support in German NICUs. Results: The results show that lactation support in German NICUs is often inadequate and does not comply with recommendations based on the existing literature to encourage pumping and breastfeeding in mothers. The data imply that even if lactation is successfully initiated in most cases, it is often not maintained over time, which may be due to a lack of personal support and consistent information. Conclusion: The overall structures and institutional guidelines for lactation support should be encouraged to promote nutrition with mother´s own milk in German NICUs. [ABSTRACT FROM AUTHOR]

Background: Germany's medical specialist shortage is an acute challenge, especially in the rehabilitation segment. One countermeasure is to recruit foreign trained physicians (FTP), but the high turnover of FTP is a burden on the departments that train them and integrate them professionally. Preliminary research showed that currently one in three physician positions in German Pension Insurance (DRV) contract facilities is filled by FTP.This paper examines factors related to turnover intention of FTP in German rehabilitative departments. Methodology: In spring 2022, we surveyed FTP across all inpatient and outpatient rehabilitation departments under the German Pension Insurance, using a two-stage cross-sectional approach. We conducted an online survey of FTP and developed a specialized questionnaire that captured sociodemographic, occupation related and professional biographical data, turnover intention, satisfaction, difficulties with professional integration and departmental structural characteristics. To analyze retention within the rehabilitation field, we used a measure of turnover intention, taking into account the direction of potential turnover, residency requirements and considerations of returning to the rehabilitation field. The data was evaluated in a subgroup analysis comparing FTP with and without turnover intention using Fisher's exact tests. Results: The sample includes n = 145 FTP, 119 stating no turnover intention and 27 with turnover intention. More than half of FTP with turnover intention wished to move to an acute care hospital. FTP with turnover intention are comparatively younger and came to Germany and were employed in the rehabilitation departments more recently, indicating an earlier career stage. Besides, career-related and regional factors show the strongest relation to turnover intention. Discussion and conclusion: The results reveal a group of "established FTP" whose professional integration has been successfully completed. FTP with turnover intention are comparatively younger, career-oriented physicians for whom work in a rehabilitative facility is a career springboard to gain a foothold in acute care clinics. A limitation is that FTP with turnover intention are difficult to reach and may be underrepresented in our sample. [ABSTRACT FROM AUTHOR]

Background: Germany has the highest per capita health care spending among EU member states, but its hospitals face pressure to generate profits independently due to the government's withdrawal of investment cost coverage. The diagnosis related groups (DRG) payment system was implemented to address the cost issue, challenging hospital physicians to provide services within predefined prices and an economic target corridor to reduce costs. This study examines the extent of cost awareness among medical personnel in German hospitals and its influencing factors. Methods: We developed an online survey in which participants across all specialties in hospitals estimated the prices in euros of four common interventions and answered questions about their human capital and perceived stress on the workplace. As a measure of cost awareness, we used the probability of estimating the prices correctly within a reasonable margin. We employed logit logistic regression estimators to identify influencing factors in a sample of 86 participants. Results: The results revealed that most of the respondents were unaware of the costs of common interventions. General human capital, acquired through prior education, and job-specific human capital had no influence on cost awareness, whereas domain-specific human capital, that is, gaining economic knowledge based on self-interest, had a positive nonlinear effect on cost awareness. Furthermore, an increased stress level negatively influenced cost awareness. Conclusions: This paper is the first of its kind for the German health care sector that contributes responses to the question whether health care professionals in German hospitals have cost awareness and if not, what reasons lie behind this lack of knowledge. Our findings show that the cost awareness desired by the introduction of the DRG system has yet to be achieved by medical personnel. [ABSTRACT FROM AUTHOR]

Background: Germany has the highest per capita health care spending among EU member states, but its hospitals face pressure to generate profits independently due to the government's withdrawal of investment cost coverage. The diagnosis related groups (DRG) payment system was implemented to address the cost issue, challenging hospital physicians to provide services within predefined prices and an economic target corridor to reduce costs. This study examines the extent of cost awareness among medical personnel in German hospitals and its influencing factors. Methods: We developed an online survey in which participants across all specialties in hospitals estimated the prices in euros of four common interventions and answered questions about their human capital and perceived stress on the workplace. As a measure of cost awareness, we used the probability of estimating the prices correctly within a reasonable margin. We employed logit logistic regression estimators to identify influencing factors in a sample of 86 participants. Results: The results revealed that most of the respondents were unaware of the costs of common interventions. General human capital, acquired through prior education, and job-specific human capital had no influence on cost awareness, whereas domain-specific human capital, that is, gaining economic knowledge based on self-interest, had a positive nonlinear effect on cost awareness. Furthermore, an increased stress level negatively influenced cost awareness. Conclusions: This paper is the first of its kind for the German health care sector that contributes responses to the question whether health care professionals in German hospitals have cost awareness and if not, what reasons lie behind this lack of knowledge. Our findings show that the cost awareness desired by the introduction of the DRG system has yet to be achieved by medical personnel. [ABSTRACT FROM AUTHOR]

Background: Some of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments. However, for multi-center evaluations, standardized documentation is necessary. The AKTIN project ("National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany") has used the "German Emergency Department Medical Record" (GEDMR) published by the German Interdisciplinary Association of Intensive and Emergency Care as the documentation standard for its national data registry.Methods: Until March 2016 the documentation standard in ED was the pen-and-paper version of the GEDMR. In April 2016 we implemented the GEDMR in a timeline-based EDIS. Related to this, we compared the availability of structured treatment information of traumatological patients between pen-and-paper-based and electronic documentation, with special focus on the treatment time.Results: All 796 data fields of the 6 modules (basic data, severe trauma, patient surveillance, anesthesia, council, neurology) were adapted for use with the existing EDIS configuration by a physician working regularly in the ED. Electronic implementation increased availability of structured anamnesis and treatment information. However, treatment time was increased in electronic documentation both immediately (2:12 ± 0:04 h; n = 2907) and 6 months after implementation (2:18 ± 0:03 h; n = 4778) compared to the pen-and-paper group (1:43 ± 0:02 h; n = 2523; p < 0.001).Conclusions: We successfully implemented standardized documentation in an EDIS. The availability of structured treatment information was improved, but treatment time was also increased. Thus, further work is necessary to improve input time. [ABSTRACT FROM AUTHOR]

Background: The incidence of inflammatory bowel disease (IBD) in children is on the increase worldwide. Growth disorders are common in pediatric patients with inflammatory bowel disease. The aim of this paper is to investigate anthropometric indicators, including height and weight in children with inflammatory bowel disease in Saxony, one of the German federal states, and to evaluate growth trends in patients by comparing their height and weight with that of healthy children in Germany. Methods: In Saxony, all children and adolescents with IBD were registered in the Saxon Pediatric IBD Registry from 2000 to 2014. The data used are therefore based on a total area-wide survey over 15 years. For this study, 421 datasets of children and adolescents aged 0–14 years with Crohn's disease (CD) (n = 291) or ulcerative colitis (UC) (n = 130) were analyzed. Z-score and percentile calculations were used to compare differences between IBD patients and the general population. Results: The children with CD or UC (both sexes) had a significant lower weight at diagnosis (the mean weight z-score had negative values) versus the general population. The weight values lay mostly below P50 (the 50th percentile, median), more precisely, mostly between P10 and P50 of the body weight child growth curve for corresponding sexes (KiGGS 2003–2006). The height values of both sexes at diagnosis lay also mostly below P50 (the 50th percentile, median) of the child body growth curve for corresponding sexes (KiGGS 2003–2006), i.e. the mean height z-score was negative. But only the children with CD had a significant lower height, more precisely, mostly between P25 and P50 versus the general population (KIGGS). For children with UC the difference was not significant. Conclusion: In pediatric patients with IBD the possibility of growth disturbance, mainly in the form of weight retardation, is very probable. [ABSTRACT FROM AUTHOR]

Introduction: Various developments result in increasing workloads in general practices. New models of care and a restructuring of the division of tasks could provide relief. One approach is to extend the delegation of medical tasks from general practitioners (GPs) to medical practice assistants (MPAs). So far, there has been a lack of information about specific situations in which patients are willing to be treated exclusively by MPAs. Methods: In three German federal states, patients who visited a general practice were surveyed exploratively and cross-sectionally with a self-designed, paper-based questionnaire. The data were analysed descriptively and multivariate. A mixed binary logistic regression model was calculated to account for cluster effects at practice level (random intercept model). The dependent variable was patients' acceptance of task delegation. Results: A total of 1861 questionnaires from 61 general practices were included in the analysis. Regarding the current problem/request, a total of 30% of respondents could imagine being treated only by MPAs. Regarding theoretical reasons for consultation, more than half of the patients agreed to be treated by MPAs. According to the regression model, MPAs were preferred when patients were younger (10-year OR = 0.84, 95%-CI [0.75, 0.93]) or had a less complicated issue (OR = 0.44, 95%-CI [0.26, 0.8]). For four current problems/requests ("acute complaints" OR = 0.27, 95%-CI [0.17, 0.45], "routine health check" OR = 0.48, 95%-CI [0.3, 0.79], "new problem" OR = 0.13, 95%-CI [0.06, 0.28], "known problem" OR = 0.16, 95%-CI [0.1, 0.27]) patients prefer to be treated by GPs instead of MPAs. Discussion: For the first time, statements could be made on patients' acceptance of task delegation in relation to current and theoretical reasons for treatment in general practices in Germany. The discrepancy in response behaviour on a theoretical and individual level could be explained by different contexts of questions and differences at practice level. Overall, patients seem to be open to increased delegation of medical tasks, depending on the reason for treatment. Selection and response biases should be considered in the interpretation. Conclusion: The results are not completely opposed to an extension of task delegation. Further interventional studies could provide information on the possible effects of expansion of delegable tasks. [ABSTRACT FROM AUTHOR]

Background: The prevalence of mental health problems in childhood and adolescence has increased significantly, not least due to the COVID-19 pandemic in Germany and other countries worldwide. Although holistic school interventions to promote mental health and prevent mental health problems are considered promising, there is currently uncertainty about their effectiveness due to evaluation studies with heterogeneous methodological quality. This paper presents the study protocol for the evaluation of the primary school module of MindMatters. Methods: As part of a universal mental health intervention, the MindMatters primary school module 'Learning Together with Emotions' aims to promote social-emotional learning (SEL) in the classroom across five skill areas. In addition to classroom activities, the intervention includes a school development module to help primary schools create structures and processes to maintain and promote mental health. To evaluate the effectiveness of the intervention, a two-arm cluster-randomised controlled trial will be conducted, including schools implementing MindMatters over a 12-month period and a control group with no access to the intervention. Data will be collected before and 18 months after initiation of the intervention. Controlled for baseline conditions, multilevel regression analysis will be used to examine primary intervention outcomes at the pupil level (i.e. reductions in mental and behavioural problems). Further mediation and moderation analyses will examine whether proximal outcomes predict changes in mental health outcomes and whether school-level factors influence the effectiveness of the intervention. Discussion: This study will contribute to strengthen the evidence base for holistic school (mental) health promotion interventions using a study design with high internal validity. Based on an intervention model, the results will not only provide insights into the relationship between proximal and distal outcomes, but will also allow conclusions to be drawn about how the implementation of the intervention affects its effectiveness. Finally, the findings also address the question of whether improved mental health has a positive effect on primary school pupils' academic performance. Trial registration: German Clinical Trials Register DRKS00023762. Registered on 5 January 2021. [ABSTRACT FROM AUTHOR]

Background: Technology can support healthy aging and empower older adults to live independently. However, technology adoption by older adults, particularly assistive technology (AT), is limited and little is known about the types of AT used among older adults. This study explored the use of key information and communication technologies (ICT) and AT among community-dwelling adults aged ≥ 65. Methods: A cross-sectional study was conducted among community-dwelling adults aged ≥ 65 in southern Germany using a paper-based questionnaire. The questionnaire included questions on the three domains sociodemographic aspects, health status, and technology use. Technology use was considered separately for key ICT (smartphone, computer/laptop, and tablet) and a range of 31 different AT. Data were analyzed using descriptive statistics, univariate analyses, and Bernoulli Naïve Bayes modelling. Results: The questionnaire was answered by 616 participants (response rate: 24.64%). ICT were used by 497 (80.68%) participants and were associated with lower age, higher level of education, living together with someone, availability of internet connection, higher interest in technology, and better health status (p <.05). No association was found with sex and size of the hometown. The most frequently owned AT were a landline phone, a body scale, and a blood pressure monitor. Several AT related to functionality, (instrumental) activities of daily living- (IADL), and morbidity were used more frequently among non-ICT users compared to ICT-users: senior mobile phone (19.33% vs. 3.22%), in-house emergency call (13.45% vs. 1.01%), hearing aid (26.89% vs. 16.7%), personal lift (7.56% vs. 1.61%), electronic stand-up aid (4.2% vs. 0%). Those with higher interest in technology reported higher levels of benefit from technology use. Conclusions: Despite the benefits older adults can gain from technology, its use remains low, especially among those with multimorbidity. Particularly newer, more innovative and (I)ADL-related AT appear underutilized. Considering the potential challenges in providing adequate care in the future, it may be crucial to support the use of these specific AT among older and frailer populations. To focus scientific and societal work, AT with a high impact on autonomy ((I)ADL/disease-related) should be distinguished from devices with a low impact on autonomy (household-/ comfort-related). [ABSTRACT FROM AUTHOR]

Background: The World Health Organization (WHO)'s excess mortality estimates presented in May 2022 stirred controversy, due in part to the high estimate provided for Germany, which was later attributed to the spline model used. This paper aims to reproduce the problem using synthetic datasets, thus allowing the investigation of its sensitivity to parameters, both of the mortality curve and of the used method, thereby shedding light on the conditions that gave rise to this error and identifying possible remedies. Methods: A negative binomial model was used accounting for long-term change, seasonality, flu seasons, and heat waves. Simulated mortality curves from this model were then analysed using simple methods (mean, linear trend), the WHO method, and the method of Acosta and Irizarry. Results: The performance of the WHO's method with its original parametrization was indeed very poor, however it can be profoundly improved by a better choice of parameters. The Acosta–Irizarry method outperformed the WHO method despite being also based on splines, but it was also dependent on its parameters. Linear extrapolation could produce very good results, but was highly dependent on the choice of the starting year, while the average was the worst in almost all cases. Conclusions: Splines are not inherently unsuitable for predicting baseline mortality, but caution should be taken. In particular, the results suggest that the key issue is that the splines should not be too flexible to avoid overfitting. Even after having investigated a limited number of scenarios, the results suggest that there is not a single method that outperforms the others in all situations. As the WHO method on the German data illustrates, whatever method is chosen, it remains important to visualize the data, the fit, and the predictions before trusting any result. It will be interesting to see whether further research including other scenarios will come to similar conclusions. [ABSTRACT FROM AUTHOR]

Background: The international study PRICOV-19 aims to assess the impact of the COVID-19 pandemic on the organisation of primary health care. The German part focuses on German general practitioners during the second wave of the COVID-19 pandemic. This paper addresses the following research questions: (1) How were changes in tasks on primary care and patient treatment perceived by GPs?, (2) What was the role of GPs during the pandemic, and how was their wellbeing?, (3) How did GPs perceive health policy measures?, and, (4) What influenced the attitudes of GPs on health policy measures? Methods: This study pursues a multi-country cross-sectional design. Data collection took place throughout Germany from 01.02. to 28.02.2021 with a quantitative online questionnaire consisting of 53 items. The questionnaire was analysed through descriptive and inferential analyses using correlation and multiple regression models. Results: The response rate was 20.4% (n = 349). The respondents were mainly GPs (59.6%) in single practices (62.5%) with a mean work experience of 15 to 20 years. GPs experienced a change in their work and practice organisation (80.3%). They felt a high responsibility (70.6%) and found their work has become more meaningful to them (76%). They also saw a lack of political support (75.2%) and that the measures taken by the government overburdened the daily practice (66.4%). Not many GPs were at risk of being distressed (53.4%) but rated the health policies rather negatively (60%). The multiple regression showed, the more GPs were exposed to risk of distress, the worse they assessed the government's measures. Conclusion: GPs perceived their work as relevant and felt confident they could fulfil their tasks, but noticed that health policy initially hardly supported the outpatient sector. Health policies should increase their competence in relation to primary care, ensure its needs and consider an active inclusion of GPs in preparedness plans. [ABSTRACT FROM AUTHOR]

Background: Technology can support healthy aging and empower older adults to live independently. However, technology adoption by older adults, particularly assistive technology (AT), is limited and little is known about the types of AT used among older adults. This study explored the use of key information and communication technologies (ICT) and AT among community-dwelling adults aged ≥ 65. Methods: A cross-sectional study was conducted among community-dwelling adults aged ≥ 65 in southern Germany using a paper-based questionnaire. The questionnaire included questions on the three domains sociodemographic aspects, health status, and technology use. Technology use was considered separately for key ICT (smartphone, computer/laptop, and tablet) and a range of 31 different AT. Data were analyzed using descriptive statistics, univariate analyses, and Bernoulli Naïve Bayes modelling. Results: The questionnaire was answered by 616 participants (response rate: 24.64%). ICT were used by 497 (80.68%) participants and were associated with lower age, higher level of education, living together with someone, availability of internet connection, higher interest in technology, and better health status (p <.05). No association was found with sex and size of the hometown. The most frequently owned AT were a landline phone, a body scale, and a blood pressure monitor. Several AT related to functionality, (instrumental) activities of daily living- (IADL), and morbidity were used more frequently among non-ICT users compared to ICT-users: senior mobile phone (19.33% vs. 3.22%), in-house emergency call (13.45% vs. 1.01%), hearing aid (26.89% vs. 16.7%), personal lift (7.56% vs. 1.61%), electronic stand-up aid (4.2% vs. 0%). Those with higher interest in technology reported higher levels of benefit from technology use. Conclusions: Despite the benefits older adults can gain from technology, its use remains low, especially among those with multimorbidity. Particularly newer, more innovative and (I)ADL-related AT appear underutilized. Considering the potential challenges in providing adequate care in the future, it may be crucial to support the use of these specific AT among older and frailer populations. To focus scientific and societal work, AT with a high impact on autonomy ((I)ADL/disease-related) should be distinguished from devices with a low impact on autonomy (household-/ comfort-related). [ABSTRACT FROM AUTHOR]

Background: To prevent the transmission of blood-borne infections and reach the elimination of viral hepatitis by 2030, the World Health Organization (WHO) has set the goal to distribute 300 sterile needles and syringes each year per person who injects drugs (PWID). We aimed to assess drug paraphernalia distribution in Germany in 2021, including the WHO indicator, and to analyse changes to the distribution measured in 2018. Methods: We conducted a repeated cross-sectional study of low-threshold drug services in Germany. We assessed type and quantity of distributed drug paraphernalia and the number of supplied PWID in 2021 using an online and paper-based questionnaire. We conducted a descriptive statistical analysis of data from 2021, assessed fulfillment of the WHO indicator and changes in services that participated 2021 and in the previous study 2018. Results: Five hundred and eighty-nine of 1760 distributed questionnaires were returned in 2021. 204 drug services from 15 out of 16 federal states confirmed drug paraphernalia distribution, covering 20% of Germany's rural and 51% of urban counties. 108 services had also participated in 2018. The most frequently distributed paraphernalia for injecting drug use in 2021 were syringes (97% of services), needles (96%) and vitamin C (90%). Pre-cut aluminium foil (79% of services) and pipes (28%) for inhaling, and sniff tubes (43%) for nasal use were distributed less frequently. We found a median reduction in distributed syringes by 18% and by 12% for needles compared to 2018. Of 15 states, two reached the 2030 WHO-target for needles and one for syringes. Conclusions: The current national estimates and changes from 2018 to 2021 for drug paraphernalia distribution seem far from meeting the WHO target. Reasons could include a change in drug consumption behaviour towards less injecting use and more inhaling, and effects of the COVID-19 pandemic (supply difficulties, social distancing, lockdown, reduced opening hours of services). We observed pronounced regional differences in drug paraphernalia distribution. To close existing gaps, Germany should expand its drug paraphernalia distribution programmes and other harm reduction services, such as drug consumption rooms. Further investigation of determinants for adequate distribution is essential to reduce blood-borne infections in this key population. [ABSTRACT FROM AUTHOR]

Background: The current paper analyzed the effect of the pandemic-induced lockdown on maternal mental health during the first 12 postpartum weeks in Germany. Methods: In this cohort study, we compared the participants' anamnestic backgrounds and the results of psychological tests, measuring stress levels, depressive symptoms and attachment. The 327 participants were divided into two groups with one representing the "pre-COVID" sample and the other the "lockdown" sample. We performed multiple comparisons, investigating the distribution of diagnoses and the correlating risk profiles between the two cohorts. Results: Our analysis showed a significant difference between the two cohorts, with a 13.2% increase in the prevalence of adjustment disorders (AD), but not postpartum depression (PPD), in the first 12 weeks postpartum. However, during the pandemic, women with AD had fewer risk factors compared to their pre-pandemic counterparts. In the "lockdown" cohort, a tendency toward higher stress and lower mother-child attachment was observed in AD. Conclusions: In sum, we observed some negative impact of the pandemic on maternal mental health. The lockdown might have contributed to an increase in the number of cases involving AD in the postpartum period. The prevalence of PPD (ca. 6–10%), on the other hand, was not affected by the lockdown. Thus, the effect of COVID-19 on maternal mental health might not, after all, have been as severe as assumed at the beginning of the pandemic. [ABSTRACT FROM AUTHOR]

Background: Medical students often experience high levels of stress due to adverse study conditions, which may have adverse health consequences. Hair cortisol concentration (HCC) has been described as a physiological marker for chronic stress and might thus help to identify students under stress and examine the study conditions being responsible for long-term physiological stress responses. This study therefore investigated the association between study conditions and HCC in a sample of medical students. Methods: Fifty-five students from a medical school in Germany completed a paper-based questionnaire and had hair samples collected between May 2020 and July 2021. Study conditions were assessed with student versions of questionnaires based on the Job-Demand-Control-Support model (StrukStud, 25 items) and Effort-Reward Imbalance model (Student ERI, nine items). HCC of two centimeters closest to the scalp were determined by a cortisol luminescence immunoassay. Linear multiple regression analyses were performed to examine associations between study conditions and HCC. Results: Demands (B = 0.23, p = 0.002), effort (B = 0.12, p = 0.029) and the effort-reward-ratio (B = 0.28, p = 0.007) were positively associated with HCC in separate regression analyses, adjusted for age and sex. Only the association between demands and HCC remained significant when all components of the respective questionnaire were considered in the same model (B = 0.22, p = 0.003). Conclusion: The results suggest that adverse study conditions may be associated with activation of the hypothalamic-pituitary-adrenal axis stress response as reflected by increased HCC. Longitudinal research is needed to confirm these cross-sectional results and examine effects of more prolonged stress due to adverse study conditions. [ABSTRACT FROM AUTHOR]

Background: The communication processes between different stakeholders in outpatient palliative care face challenges when multiprofessional teams want to keep each other updated on patient information. Meanwhile, the software market offers different tools to connect these teams in real-time to improve communication. In the research project ADAPTIVE (Impact of Digital Technologies in Palliative Care), we investigated how information and communication technology affects collaboration and work in multiprofessional teams and what advantages and disadvantages the use of said software might entail. Methods: We conducted 26 semi-structured interviews between August and November 2020 with general practitioners (n = 8), palliative care nurses (n = 17), and a pharmacist (n = 1). They were conducted in a hybrid format, meaning that both face-to-face interviews and telephone interviews were carried out. Subsequently, we analyzed the interviews following the qualitative content analysis according to Kuckartz. Results: Information and communication software has the potential to enable faster communication and delegation of tasks and to simplify communication and task management between providers. Furthermore, it creates the opportunity to decrease unnecessary supervision of duties and responsibilities for physicians in multiprofessional teams. Therefore, it allows facilitating the collaboration between multiprofessional teams that work independently of each other but care for the same patients. All providers have the same knowledge about their patients without time-consuming coordination such as phone calls or search processes in paper documentation. On the other hand, mishandling, poor Internet connection, and unfamiliarity with various features can diminish these benefits. Conclusion: Even though the use of such software offers many advantages, these advantages only reveal themselves if the software is used as it was intended by the developers. Misuse and unawareness of the individual functions can lead to the full potential not being realized. The software developers frequently offer specialized training, and the multiprofessional teams should utilize that to improve team communication, facilitate tasks, and allow physicians to delegate tasks. Trial registration: The study is registered in the German Clinical Trials Register (DRKS): https://www.drks.de/drks%5fweb/navigate.do?navigationId=trial.HTML&TRIAL%5fID=DRKS00021603 (Registration number: DRKS00021603; date of first registration: 02/07/2020). [ABSTRACT FROM AUTHOR]

Background: An effective cross-cultural doctor-patient communication is vital for health literacy and patient compliance. Building a good relationship with medical staff is also relevant for the treatment decision-making process for cancer patients. Studies about the role of a specific migrant background regarding patient preferences and expectations are lacking. We therefore conducted a multicentre prospective survey to explore the needs and preferences of patients with a migrant background (PMB) suffering from gynecological malignancies and breast cancer to evaluate the quality of doctor-patient communication and cancer management compared to non-migrants (NM).Methods: This multicentre survey recruited patients with primary or recurrence of breast, ovarian, peritoneal, or fallopian tube cancer. The patients either filled out a paper form, participated via an online survey, or were interviewed by trained staff. A 58-item questionnaire was primarily developed in German and then translated into three different languages to reach non-German-speaking patients.Results: A total of 606 patients were included in the study: 54.1% (328) were interviewed directly, 9.1% (55) participated via an online survey, and 36.8% (223) used the paper print version. More than one quarter, 27.4% (166) of the participants, had a migrant background. The majority of migrants and NM were highly satisfied with the communication with their doctors. First-generation migrants (FGM) and patients with breast cancer were less often informed about participation in clinical trials (p < 0.05) and 24.5% of them suggested the help of an interpreter to improve the medical consultation. Second and third-generation migrants (SGM and TGM) experienced more fatigue and nausea than expected.Conclusions: Our results allow the hypothesis that training medical staff in intercultural competence and using disease-related patient information in different languages can improve best supportive care management and quality of life in cancer patients with migrant status. [ABSTRACT FROM AUTHOR]

Background: Given the nature of the spread of SARS-CoV-2, strong regional patterns in the fatal consequences of the COVID-19 pandemic related to local characteristics such as population and health care infrastructures were to be expected. In this paper we conduct a detailed examination of the spatial correlation of deaths in the first year of the pandemic in two neighbouring countries – Germany and Poland, which, among high income countries, seem particularly different in terms of the death toll associated with the COVID-19 pandemic. The analysis aims to yield evidence that spatial patterns of mortality can provide important clues as to the reasons behind significant differences in the consequences of the COVID-19 pandemic in these two countries. Methods: Based on official health and population statistics on the level of counties, we explore the spatial nature of mortality in 2020 in the two countries – which, as we show, reflects important contextual differences. We investigate three different measures of deaths: the officially recorded COVID-19 deaths, the total values of excessive deaths and the difference between the two. We link them to important pre-pandemic regional characteristics such as population, health care and economic conditions in multivariate spatial autoregressive models. From the point of view of pandemic related fatalities we stress the distinction between direct and indirect consequences of COVID-19, separating the latter further into two types, the spatial nature of which is likely to differ. Results: The COVID-19 pandemic led to much more excess deaths in Poland than in Germany. Detailed spatial analysis of deaths at the regional level shows a consistent pattern of deaths officially registered as related to COVID-19. For excess deaths, however, we find strong spatial correlation in Germany but little such evidence in Poland. Conclusions: In contrast to Germany, for Poland we do not observe the expected spatial pattern of total excess deaths and the excess deaths over and above the official COVID-19 deaths. This difference cannot be explained by pre-pandemic regional factors such as economic and population structures or by healthcare infrastructure. The findings point to the need for alternative explanations related to the Polish policy reaction to the pandemic and failures in the areas of healthcare and public health, which resulted in a massive loss of life. [ABSTRACT FROM AUTHOR]

Background: Conspiracy beliefs have become widespread throughout the COVID-19 pandemic. Previous studies have shown that endorsing conspiracy beliefs leads to lower protective guideline adherence (i.e., wearing face masks), posing a threat to public health measures. The current study expands this research across the lifespan, i.e., in a sample of adolescents with mental health problems. Here, we investigated the association between conspiracy beliefs and guideline adherence while also exploring the predictors of conspiracy beliefs. Methods: N = 93 adolescent psychiatric outpatients (57% female, mean age: 15.8) were assessed using anonymous paper–pencil questionnaires. Endorsement of generic and COVID-19 conspiracy beliefs was assessed, in addition to items measuring adherence to protective guidelines and mental health (stress, depressive symptoms, emotional/behavioral problems, and adverse childhood experiences). Multiple regressions and supervised machine learning (conditional random forests) were used for analyses. Results: Fourteen percent of our sample fully endorsed at least one COVID-19 conspiracy theory, while protective guidelines adherence was relatively high (M = 4.92, on a scale from 1 to 7). The endorsement of COVID-19 conspiracy beliefs—but not of generic conspiracy beliefs—was associated with lower guideline adherence (β = − 0.32, 95% CI − 0.53 to − 0.11, p <.001). Conditional random forests suggested that adverse childhood experiences and peer and conduct problems were relevant predictors of both conspiracy belief categories. Conclusion: While a significant proportion of our sample of adolescents in psychiatric treatment endorsed conspiracy beliefs, the majority did not. Furthermore, and to some degree, contrary to public perception, we found that adolescents show relatively good adherence to public health measures—even while experiencing a high degree of mental distress. The predictive value of adverse childhood experiences and peer/conduct problems for conspiracy beliefs might be explained by compensatory mechanisms to ensure the safety, structure, and inclusion that conspiracies provide. [ABSTRACT FROM AUTHOR]

Background: Research has shown that routinely assessed, patient-reported outcome measures (PROMs) have positive effects in patients with advanced oncologic diseases. However, the transferability of these results to specialist palliative care is uncertain because patients are more impaired and staff doubt the feasibility and benefits. The aim of this study is to evaluate the feasibility of patient self-assessment of PROMs, their use by staff and the benefits in palliative care wards. Method: A multicentre observational study was conducted in the context of the implementation of the Integrated Patient Outcome Scale (IPOS) in three specialist palliative care wards at university hospitals in Germany. All admitted patients who screened positive regarding their ability to complete questionnaires were asked to participate and complete the IPOS on paper weekly, with assistance if necessary. Feasibility of questionnaire completion (e.g. proportion of patients able to complete them), use (e.g. involvement of different professional groups) and benefit (e.g. unexpected information in IPOS as rated by treating physicians) were assessed. Staff members' opinion was obtained in a written, anonymous evaluation survey, patients' opinion in a short written evaluation. Results: A total of 557 patients were screened for eligibility, 235 were assessed as able to complete the IPOS (42.2%) and 137 participated in the study (24.6%). A majority needed support in completing the IPOS; 40 staff members and 73 patients completed the evaluation. Unexpected information was marked by physicians in 95 of the 137 patient questionnaires (69.3%). The staff differed in their opinions on the question of whether this also improved treatment. A majority of 32 staff members (80.0%) were in favour of continuing the use of IPOS (4 against continuation, 4 no answer); 43 (58.9%) patients rated their overall experience of IPOS use as 'positive', 29 (39.7%) as 'neutral' and 1 (1.4%) as 'negative'. Conclusions: While most staff wished to continue using IPOS, it was a challenge to integrate the effort to support the completion of IPOS into daily practice. Digital implementation was not successful, despite various attempts. To explore the effects on care and patient outcomes, multicentre cluster-randomised trials could be employed. Trial registration: German Clinical Trials Register DRKS-ID: DRKS00016681 (24/04/2019). [ABSTRACT FROM AUTHOR]

Background: In recent years, the topic of health-oriented leadership (HoL) has often been investigated with health-related outcomes like general health, strain, depression, and anxiety symptoms. In contrast, research which considers the gender of leaders and employees in connection to HoL as well as studies on relationships between HoL and job satisfaction, are scarce. The aim of this paper is to explore the relationships between HoL and health status assessed by employees and leaders, to analyse the relationships between HoL and job satisfaction as a non-health-related outcome for employees and leaders and to examine differences in the assessment of HoL between men and women in a representative dataset of the working population in Germany. Methods: Data were collected via an access panel as a cross-sectional survey. The quota sample included 643 German workers (managers and employees). We focused on staff-care as a core component of HoL. Statistical analyses were performed using Pearson correlations and regression analyses as well as t-tests and Mann-Whitney-U-Tests. Results: The results showed no significant differences between male and female employees or leaders in assessing HoL. Regarding HoL we found relationships between self-rated health status or job satisfaction, both for the self-rated assessment of leaders and employees. Conclusions: Our findings indicate relationships between HoL and well-being as well as job satisfaction at the workplace. For interventions of any kind, the lack of gender effects leaves a wide scope for the implementation of health-promoting measures. In particular, the findings on the relationship between HoL and job satisfaction through leaders' self-assessment could be used for salutogenic approaches to strengthen resources in leadership trainings. [ABSTRACT FROM AUTHOR]

Background: Internationally, intensive psychiatric home treatment has been increasingly implemented as a community-based alternative to inpatient admission. Since 2018, the so-called Inpatient Equivalent Home Treatment (IEHT; German: "Stationsäquivalente Behandlung", short: "StäB") has been introduced as a particularly intensive form of home treatment that provides at least one daily treatment contact in the service users' (SU) home environment. Prior research shows that this can be challenging in rural catchment areas. Our paper investigates to which extent the location of the SU home location within the catchment area as well as the distance between the home and the clinic influence the utilisation of inpatient treatment compared to IEHT. Method: Routine data of one psychiatric hospital in the federal state of Brandenburg in Germany were analysed for the observational period 07/2018–06/2021. Two comparison groups were formed: SU receiving inpatient treatment and SU receiving IEHT. The SU places of residence were respectively anonymised and converted into geo-coordinates. A geographic information system (GIS) was used to visualise the places of residence, and car travel distances as well as travel times to the clinic were determined. Spatial analyses were performed to show the differences between comparison groups. In a more in-depth analysis, the proximity of SU residences to each other was examined as an indicator of possible clustering. Results: During the observational period, the location of 687 inpatient and 140 IEHT unique SU were mapped using the GIS. SU receiving treatment resided predominantly within the catchment area, and this proportion was slightly higher for SU receiving IEHT than for those treated in inpatient setting (95.3% vs. 84.7%). In the catchment area, the geographical distribution of SU place of residence was similar in the two groups. There was a general higher service provision in the more densely populated communities close to Berlin. SU with residence in peripheral communities were mainly treated within the inpatient setting. The mean travel times and distances to the place of residence only differed minimally between the two groups of SU (p < 0.05). The places of residence of SU treated with IEHT were located in greater proximity to each other than those of SU treated in inpatient setting (p >; 0.1). Conclusion: In especially peripheral parts of the examined catchment area, it may be more difficult to have access to IEHT rather than to inpatient services. The results raise questions regarding health equity and the planning of health care services and have important implications for the further development of intensive home treatment. Telehealth interventions such as blended-care approaches and an increase of flexibility in treatment intensity, e.g. eliminating the daily visit requirement, could ease the implementation of intensive home treatment especially in rural areas. [ABSTRACT FROM AUTHOR]

Background: Internationally, intensive psychiatric home treatment has been increasingly implemented as a community-based alternative to inpatient admission. Since 2018, the so-called Inpatient Equivalent Home Treatment (IEHT; German: "Stationsäquivalente Behandlung", short: "StäB") has been introduced as a particularly intensive form of home treatment that provides at least one daily treatment contact in the service users' (SU) home environment. Prior research shows that this can be challenging in rural catchment areas. Our paper investigates to which extent the location of the SU home location within the catchment area as well as the distance between the home and the clinic influence the utilisation of inpatient treatment compared to IEHT. Method: Routine data of one psychiatric hospital in the federal state of Brandenburg in Germany were analysed for the observational period 07/2018–06/2021. Two comparison groups were formed: SU receiving inpatient treatment and SU receiving IEHT. The SU places of residence were respectively anonymised and converted into geo-coordinates. A geographic information system (GIS) was used to visualise the places of residence, and car travel distances as well as travel times to the clinic were determined. Spatial analyses were performed to show the differences between comparison groups. In a more in-depth analysis, the proximity of SU residences to each other was examined as an indicator of possible clustering. Results: During the observational period, the location of 687 inpatient and 140 IEHT unique SU were mapped using the GIS. SU receiving treatment resided predominantly within the catchment area, and this proportion was slightly higher for SU receiving IEHT than for those treated in inpatient setting (95.3% vs. 84.7%). In the catchment area, the geographical distribution of SU place of residence was similar in the two groups. There was a general higher service provision in the more densely populated communities close to Berlin. SU with residence in peripheral communities were mainly treated within the inpatient setting. The mean travel times and distances to the place of residence only differed minimally between the two groups of SU (p > 0.05). The places of residence of SU treated with IEHT were located in greater proximity to each other than those of SU treated in inpatient setting (p < 0.1). Conclusion: In especially peripheral parts of the examined catchment area, it may be more difficult to have access to IEHT rather than to inpatient services. The results raise questions regarding health equity and the planning of health care services and have important implications for the further development of intensive home treatment. Telehealth interventions such as blended-care approaches and an increase of flexibility in treatment intensity, e.g. eliminating the daily visit requirement, could ease the implementation of intensive home treatment especially in rural areas. [ABSTRACT FROM AUTHOR]

Background: The Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW) is a prevalent face-to-face interview method for measuring quality of life by integrating respondent-generated dimensions. To apply this method in clinical trials, a paper-administered alternative would be of interest. Therefore, our study aimed to analyze the agreement between the SEIQoL-DW and a paper questionnaire version (SEIQoL-PF/G).Methods: In a crossover design, both measures were completed in a random sequence. 104 patients at a heart surgery hospital in Germany were randomly assigned to receive either the SEIQoL-DW or the SEIQoL-PF/G as the first measurement in the sequence. Patients were approached on their earliest stable day after surgery. The average time between both measurements was 1 day (mean 1.3; SD 0.8). Agreement regarding the indices, ratings, and weightings of nominated life areas (cues) was explored using Bland-Altman plots with 95% limits of agreement (LoA). Agreement of the SEIQoL indices was defined as acceptable if the LoA did not exceed a threshold of 10 scale points. Data from n = 99 patients were included in the agreement analysis.Results: Both measures led to similarly nominated cues. The most frequently nominated cues were "physical health" and "family". In the Bland-Altman plot, the indices showed a mean of differences of 2 points (95% CI, - 1 to 6). The upper LoA showed a difference of 36 points (95% CI, 30 to 42), and the lower LoA showed a difference of - 31 points (95% CI, - 37 to - 26). Thus, the LoAs and confidence intervals exceeded the predefined threshold. The Bland-Altman plots for the cue levels and cue weights showed similar results. The SEIQoL-PF/G version showed a tendency for equal weighting of cues, while the weighting procedure of the SEIQoL-DW led to greater variability.Conclusions: For cardiac surgery patients, use of the current version of the SEIQoL-PF/G as a substitute for the SEIQoL-DW is not recommended. The current questionnaire weighting method seems to be unable to distinguish weighting for different cues. Therefore, the further design of a weighting method without interviewer support as a paper-administered measure of individual quality of life is desirable. [ABSTRACT FROM AUTHOR]

Background: In rural areas, epilepsy patients have limited access to specialist secondary care. Substantial travel and waiting times of several hours are common. Communication between general practitioners (GP) and specialist epileptologists regarding diagnosis and treatment is further complicated by the high workload on both sides and the different prioritisation of treatment goals. This study aims to investigate the feasibility of an interprofessional audiovisual patient-doctor teleconsultation, and its acceptance in clinical practice in patients with epilepsy in a rural region in Germany. Method: Ten patients participated in telemedicine consultations in their GP practice. The practice was located in a sparsely populated region of Mecklenburg-Western Pomerania, and was equipped with technical equipment specifically procured for the project. An explorative qualitative interview was conducted with all participants. We based this paper on the consolidated criteria for reporting qualitative research (COREQ). Results: Despite initial uncertainties on the patients' side regarding the consultation setting, all participants found the teleconsultation helpful. Some patients were initially intimidated and felt slightly overwhelmed by the attention provided and the technology used (multiple HD cameras, large high-resolution screens). However, during the consultation, they felt supported by their GP and were satisfied that their needs were addressed in an appropriate and timely manner. The hardware used was not felt to be a nuisance or to interfere with the conversation between doctor and patient. Patients also appreciated the time saved and the organisational convenience compared to a visit to a university outpatient clinic. Most consultations led to therapeutic consequences. Some patients seemed to benefit particularly, for example those who needed a medication change. Conclusion: This pilot study provides first evidence that teleconsultations between patients, specialists, and GPs are possible in rural areas. Interprofessional collaboration between GPs and epileptologists can improve the care of patients with epilepsy. Further research should investigate the effectiveness and efficiency of interprofessional telemedicine consultations for epilepsy and other conditions. [ABSTRACT FROM AUTHOR]

Background: The impact of technology and digitalization on health care systems will transform the nursing profession worldwide. Nurses need digital competencies to integrate new technology in their professional activities. Nurse educators play a crucial role in promoting the acquisition of digital competences and therefore need to be digitally competent themselves. Research on digital competencies of nursing educators is scarce but suggests lack of digital knowledge and skills and support needs. Although digitalization is to be seen as a global process, regional contexts need to be taken into account, such as pre-existing competencies, local conditions, and individual needs. Thus, it remains unclear which competencies nurse educators possess and which support needs they have. Aim of this study was to assess nurse educators' and clinical mentors' digital competencies and explore their needs and requirements concerning the digital aspects of their pedagogy and teaching activities in Germany. Methods: A descriptive exploratory study with a cross-sectional design was conducted. Participants were identified using a convenience sampling approach. Data were collected during July and September 2020 using a standardized self-reported questionnaire that was developed specifically for this study. The questionnaire was provided in a paper and online format and participants could decide which format to use. It contained open- and closed-ended questions. Data were analyzed using descriptive and content analysis. Additionally, explorative subgroup analyses based on job designation, age, and gender were performed. Reporting of this study adhered to the STROBE checklist. Results: A total of 169 educating nurses participated in the survey. The respondents considered themselves as digitally competent and showed a positive attitude towards the integration of digital technology in their teaching activities. Their perceived preparedness to integrate digital technology into teaching and training varied. Almost all respondents (98%) declared a need for further training and seemed motivated to participate in corresponding educational events. There were some indications for differences in competencies or needs between subgroups. Conclusions: Educating nurses appear to possess basic digital competencies but there is a need to support their professional development in terms of new technologies. Findings can be used as a basis for developing supportive interventions. Further qualitative investigations could inform the design and content of such interventions. [ABSTRACT FROM AUTHOR]

Background: Primary care is a relevant pillar in managing not only individual, but also societal medical crises. The COVID-19 pandemic has demanded a rapid response from primary care with interventions in the health care system. The aim of this paper was to explore the responses of primary care practitioners (PCP) during the early COVID-19 pandemic and to analyze these with a view on the resilience of the primary health care system from the PCPs perspective. Methods: Shortly after the first COVID-19 wave (July—October 2020) n = 39, semi-structured telephone interviews were conducted with PCP in practices and at Corona contact points (CCP) in Baden-Wuerttemberg (Germany). Qualitative content analysis was applied, and the evolved categories were related to in a framework for resilience. Results: Primary care had an overall strong ability to adapt and show resilience, albeit with wide variance in speed and scope of the responses. When coping with uncertainty, the reasons given by PCPs in favor of opening a CCP mainly involved intrinsic motivation and self-initiative; the reasons against doing so were i.e. the lack of personal protective equipment, problems with space, and worries about organizational burden. A strong association existed between the establishment of a CCP and the use of resources (i.e. existing networks, personal protective equipment, exercising an office of professional political function). Our study predominantly found adaptive aspects for measures taken at medical practices and transformative aspects for setting up outpatient infection centers. PCPs played an important role in the coordination process (i.e. actively transferring knowledge, integration in crisis management teams, inclusion in regional strategic efforts) reaching a high level in the dimensions knowledge and legitimacy. The dimension interdependence repeatedly came into focus (i.e. working with stakeholders to open CCP, interacting among different types of primary care facilities, intersectoral interfaces). A need for regional capacity planning was visible at the time of the interviews. Conclusions: The results can be used for practical and research-based institutional and capacity planning, for developing resilience in primary care and for augmentation by perspectives from other stakeholders in the primary health care system. [ABSTRACT FROM AUTHOR]

Background: Previous research has demonstrated the negative effects of study-related stressors on the mental health of medical students. It has been found that social resources such as social identity, dual identity and social support help buffer negative mental health outcomes. Notably, social status has been found to weaken the connection between stress and depressive symptoms. Based on these findings, the present study investigates how social resources (i.e., social identity, social support, dual identity and status) mitigate the impact of study-related stressors on the mental health of medical students who carry an inordinate stress burden. Methods: The data collection was based on a questionnaire (online and paper–pencil) which was distributed to medical students in North Rhine-Westphalia, Germany. The sample (224 participants) consisted of 77.2% female and 22.8% male medical students (36.2% human medicine students (HMS) and 63.8% dental medicine students (DMS)). The questionnaire included graphical scales and standardized questionnaires. We investigated demographic data, study-related stressors (i.e. academic performance, clinical practice, faculty relations) and depressive symptoms as outcomes, and social identity, social support, dual identity and status as moderators. The analyses were performed using SPSS 25 for Windows. Results: We found significant positive associations between study-related stressors and depressive symptoms. While dual identity as well as social support by fellow students emerged as buffers in these associations, the other social resources did not. As regards status, it was found to work as a buffer only in HMS, who typically enjoy a significantly higher status than dental medical students. Conclusion: It is only social resources such as support from fellow students and dual identity, but not other resource types, that can be effective buffers against depressive symptoms associated with study-related stressors. These findings can be used to promote students' identities in relation to both fellow students and the faculty, or the university as a whole, enabling students to better cope with stress and, thus, suffer less from depressive symptoms. Furthermore, the HMS, who ascribe a relatively high status to themselves, can use their status as a buffering factor in stressful situations, in which little can be done from the outside. [ABSTRACT FROM AUTHOR]

Background: Person-centred care (PCC) has been suggested as the preferred model of dementia care in all settings. The EPCentCare study showed that an adapted PCC approach was difficult to implement and had no effect on prescription of antipsychotics in nursing home residents in Germany. This paper reports the qualitative process evaluation to identify facilitators and barriers of the implementation of PCC in German nursing homes from the perspective of participating practice development champions. Methods: Five individual and 14 group interviews were conducted with 66 participants (staff and managers) from 18 nursing homes. The analysis was based on inductive coding to identify factors influencing the PCC implementation process. Identified factors were systematised and structured by mapping them to the four constructs (coherence, cognitive participation, collective action, reflexive monitoring) of the Normalization Process Theory (NPT) as a framework that explains implementation processes. Results: Facilitating implementation factors included among others broadening of the care perspective (coherence), tolerance development within the care team regarding challenging behaviour (cognitive participation), testing new approaches to solutions as a multi-professional team (collective action), and perception of effects of PCC measures (reflexive monitoring). Among the facilitating factors reported in all the NPT constructs, thus affecting the entire implementation process, were the involvement of relatives, multi-professional teamwork and effective collaboration with physicians. Barriers implied uncertainties about the implementation and expectation of a higher workload (coherence), concerns about the feasibility of PCC implementation in terms of human resources (cognitive participation), lack of a person-centred attitude by colleagues or the institution (collective action), and doubts about the effects of PCC (reflexive monitoring). Barriers influencing the entire implementation process comprised insufficient time resources, lack of support, lack of involvement of the multi-professional team, and difficulties regarding communication with the attending physicians. Conclusions: The findings provide a comprehensive and detailed overview of facilitators and barriers structured along the implementation process. Thus, our findings may assist both researchers and clinicians to develop and reflect more efficiently on PCC implementation processes in nursing homes. Trial registration: ClinicalTrials.gov identifier: NCT02295462; November 20, 2014. [ABSTRACT FROM AUTHOR]

In December 2019, the Digital Health Care Act ("Digitale-Versorgung-Gesetz") introduced a general entitlement to the provision and reimbursement of digital health applications (DiGA) for insured persons in the German statutory health insurance. As establishing a new digital service area within the solidarity-based insurance system implies several administrative and regulatory challenges, this paper aims to describe the legal framework for DiGA market access and pricing as well as the status quo of the DiGA market. Furthermore, we provide a basic approach to deriving value-based DiGA prices. To become eligible for reimbursement, the Federal Institute for Drugs and Medical Devices evaluates the compliance of a DiGA with general requirements (e.g., safety and data protection) and its positive healthcare effects (i.e., medical benefit or improvements of care structure and processes) in a fast-track process. Manufacturers may provide evidence for the benefits of their DiGA either directly with the application for the fast-track process or generate it during a trial phase that includes temporary reimbursement. After one year of \]reimbursement, the freely-set manufacturer price is replaced by a price negotiated between the National Association of Statutory Health Insurance Funds and the manufacturer. By February 2022, 30 DiGA had successfully completed the fast-track process. 73% make use of the trial phase and have not yet proven their benefit. Given this dynamic growth of the DiGA market and the low minimum evidence standards, fair pricing remains the central point of contention. The regulatory framework makes the patient-relevant benefits of a DiGA a pricing criterion to be considered in particular. Yet, it does not indicate how the benefits of a DiGA should be translated into a reasonable price. Our evidence-based approach to value-based DiGA pricing approximates the SHI's willingness to pay by the average cost-effectiveness of one or more established therapy in a field of indication and furthermore considers the positive healthcare effects of a DiGA. The proposed approach can be fitted into DiGA pricing processes under the given regulatory framework and can provide objective guidance for price negotiations. However, it is only one piece of the pricing puzzle, and numerous methodological and procedural issues related to DiGA pricing are still open. Thus, it remains to be seen to what extent DiGA prices will follow the premise of value-based pricing. [ABSTRACT FROM AUTHOR]

Background: Little is known about importance and implementation of end-of-life care (EOLC) in German intensive care units (ICU). This survey analyses preferences and differences in training between "medical" (internal medicine, neurology) and "surgical" (surgery, anaesthesiology) residents during intensive care rotation. Methods: This is a point-prevalence study, in which intensive care medicine course participants of one educational course were surveyed. Physicians from multiple ICU and university as well as non-university hospitals and all care levels were asked to participate. The questionnaire was composed of a paper and an electronic part. Demographic and structural data were prompted and EOLC data (48 questions) were grouped into six categories considering importance and implementation: category 1 (important, always implemented), 2 (important, sometimes implemented), 3 (important, never implemented) and 4–6 (unimportant, implementation always, sometimes, never). The trial is registered at the "Deutsches Register für klinische Studien (DRKS)", Study number DRKS00026619, registered on September 10th 2021, www.drks.de. Results: Overall, 194/ 220 (88%) participants responded. Mean age was 29.7 years, 55% were female and 60% had scant ICU working experience. There were 64% medical and 35% surgical residents. Level of care and size of ICU differed significantly between medical and surgical (both p < 0.001). Sufficient implementation was stated for 66% of EOLC questions, room for improvement (category 2 and 3) was seen in 25, and 8% were classified as irrelevant (category 6). Areas with the most potential for improvement included prognosis and outcome and patient autonomy. There were no significant differences between medical and surgical residents. Conclusions: Even though EOLC is predominantly regarded as sufficiently implemented in German ICU of all specialties, our survey unveiled still 25% room for improvement for medical as well as surgical ICU residents. This is important, as areas of improvement potential may be addressed with reasonable effort, like individualizing EOLC procedures or setting up EOLC teams. Health care providers as well as medical societies should emphasize EOLC training in their curricula. [ABSTRACT FROM AUTHOR]

Background: Access to healthcare is restricted for newly arriving asylum seekers and refugees (ASR) in many receiving countries, which may lead to inequalities in health. In Germany, regular access and full entitlement to healthcare (equivalent to statutory health insurance, SHI) is only granted after a waiting time of 18 months. During this time of restricted entitlements, local authorities implement different access models to regulate asylum seekers' access to healthcare: the electronic health card (EHC) or the healthcare voucher (HV). This paper examines inequalities in access to healthcare by comparing healthcare utilization by ASR under the terms of different local models (i.e., regular access equivalent to SHI, EHC, and HV). Methods: We used data from three population-based, cross-sectional surveys among newly arrived ASR (N=863) and analyzed six outcome measures: specialist and general practitioner (GP) utilization, unmet needs for specialist and GP services, emergency department use and avoidable hospitalization. Using logistic regression, we calculated odds ratios (OR) and 95% confidence intervals for all outcome measures, while considering need by adjusting for socio-demographic characteristics and health-related covariates. Results: Compared to ASR with regular access, ASR under the HV model showed lower needs-adjusted odds of specialist utilization (OR=0.41 [0.24-0.66]) while ASR under the EHC model did not differ from ASR with regular access in any of the outcomes. The comparison between EHC and HV model showed higher odds for specialist utilization under the EHC model as compared to the HV model (OR=2.39 [1.03-5.52]). GP and emergency department utilization, unmet needs and avoidable hospitalization did not show significant differences in any of the fully adjusted models. Conclusion: ASR using the HV are disadvantaged in their access to healthcare compared to ASR having either an EHC or regular access. Given equal need, they use specialist services less. The identified inequalities constitute inequities in access to healthcare that could be reduced by policy change from HV to the EHC model during the initial 18 months waiting time, or by granting ASR regular healthcare access upon arrival. Potential patterns of differences in GP utilization, unmet needs, emergency department use and avoidable hospitalization between the models deserve further exploration in future studies. [ABSTRACT FROM AUTHOR]

Background: During the first wave of the COVID-19 pandemic various ambulatory health care models (SARS-CoV-2 contact points: Subspecialised Primary Care Practices, Fever Clinics, and Special Places for Corona-Testing) were organised in a short period in Baden-Wuerttemberg, a region in Southern Germany. The aim of these SARS-CoV-2 contact points was to ensure medical treatment for patients with (suspected) and without SARS-CoV-2 infection. The present study aimed to assess the beliefs and practices of primary care physicians who either led a Subspecialised Primary Care Practice or a Primary Care Practice providing care as usual in Baden-Wuerttemberg during the first wave of the COVID-19 pandemic. Methods: This cross-sectional study was based on a paper-based questionnaire in primary care physicians during the first wave of the pandemic. Participants were identified via the web page of the Association of Statutory Health Insurance Physicians Baden-Wuerttemberg. The questionnaire was distributed in June and July 2020. It measured knowledge, practices, self-efficacy and fears towards SARS-CoV-2, using newly developed questions. Data was descriptively analysed. Results: One hundred fifty-five participants (92 leads of SARS-CoV-2 contact points/ 63 leads of primary care practices) completed the questionnaire. Out of 92 leads of SARS-CoV-2 contact points 74 stated to lead n Subspecialised Primary Care Practices. About half participants of both groups did not fear an own infection with the novel virus (between 50.8% and 62.2%), however about 75% feared financial loss. Knowledge was gained using various sources; main sources were the Association of Statutory Health Insurance Physicians (between 82.5% and 83.8%) and the German Society for Hygiene and Microbiology (RKI) (between 88.9% and 95.9%). Leads of Subspecialised Primary Care Practice felt more confident to perform anamnestic/diagnostic procedures (p < 0.001). The same was found for the confidence level regarding decision-making concerning the further treatment (p < 0.001). Several prevention measures to contain the spread of SARS-CoV-2 were adopted. Subspecialised Primary Care Practice had treated on average more patients with (suspected) COVID-19 (mean 408.12) than primary care practices (mean 83.8) (p < 0.001). Conclusion: The results of this study suggest that the Subspecialised Primary Care Practice that were implemented during the first wave of the SARS-CoV-2 pandemic contributed containment of the pandemic. Leads of Subspecialised Primary Care Practice indicated that physical separation of patients with potential SARS-CoV-2 infection was easier compared to those who continued working in their own practice. Additionally, leads of Subspecialised Primary Care Practice felt more confident in dealing with patients with SARS-CoV-2 infection. Trial registration: The study has been prospectively registered at the German Clinical Trial Register (DRKS00022224). [ABSTRACT FROM AUTHOR]

Background: There are different procedures for both, the diagnosis and the therapy of a periprosthetic joint infection (PJI), however, national or international guidelines for a standardised treatment regime are still lacking. The present paper evaluates the use of the predominant treatment protocols for PJI in certified total joint replacement centres (EPZ) in Germany based on an EndoCert questionnaire.Materials and Methods: The questionnaire was developed in cooperation with the EndoCert Certification Commission to survey the treatment protocols for septic revision arthroplasties in EPZ. Questions targeted the various treatment options including prosthesis preserving procedures (DAIR - Debridement, antibiotics, irrigation, and retention of the prosthesis), one-stage revision, two-stage revision, removal of the endoprosthesis and diagnostic sampling prior to re-implantation. All certified EPZ participated (n = 504) and the results from the current survey in 2020 were compared to data from a previous analysis in 2015.Results: The number of centres that performed DAIR up to a maximum of 4 weeks and more than 10 weeks after index surgery decreased since 2015, while the number of centres that provided a one-stage revision as a treatment option increased (hip: + 6.3%; knee: + 6.6%). The majority of the centres (73.2%) indicated a 4-8 week period as the preferred interval between prosthesis removal and re-implantation in two-stage revision in hip as well as knee revisions. Centres with a higher number of revision surgeries (> 200 revisions/year), opted even more often for the 4-8 week period (92.3%). In two-stage revision the use of metal-based spacers with/without reinforcement with antibiotic-containing cement as an interim placeholder was significantly reduced in 2020 compared to 2015. There was also a clear preference for cemented anchoring in two-stage revision arthroplasty in the knee in 2020, whereas the majority of hip replacements was cementless. Additionally, in 2020 the number of samples for microbiological testing during the removal of the infected endoprosthesis increased and 72% of the centres took five or more samples. Overall, the number of EPZ with a standardised protocol for the procedure expanded from 2015 to 2020.Conclusion: While there was a trend towards standardised therapeutic algorithms for PJI with more uniform choices among the centres in 2020 compared to 2015, the treatment often remains an individual decision. However, since a consistent treatment regime is of vital importance with an expected rise of total numbers of revision arthroplasties, uniform definitions with regard to comparability and standardisation are necessary for the further development of the EndoCert system. [ABSTRACT FROM AUTHOR]

Background: The shortage of qualified nurses is a problem of growing concern in many countries. Recruitment of internationally trained nurses has been used to address this shortage, but successful integration in the workplace is complex and resource intensive. For effective recruitment and retention, it is important to identify why nurses migrate and if their expectations are met to ensure their successful integration and promote a satisfying work climate for the entire nursing team. The aim of this study was to examine the perceptions of safety culture, work-life-balance, burnout and job demand of internationally trained nurses and associated host nurses in German hospitals. Methods: A multicentric, cross-sectional study was conducted with internationally trained nurses (n = 64) and host nurses (n = 103) employed at two university hospitals in the state of Baden-Wuerttemberg, Germany. An anonymous paper-based survey was conducted between August 2019 and April 2020. The questionnaire included sociodemographic questions, questions regarding factors related to migration, and the German version of the Assessment of your work setting Safety, Communication, Operational Reliability, and Engagement (SCORE) questionnaire. SCORE is divided into three sections: Safety Culture Domains (six subscales), Work-Life-Balance (one subscale), and Engagement Assessment Tool (four subscales). Results: Nurses who migrated to Germany were primarily seeking better working conditions, a higher standard of living, and professional development opportunities. Internationally trained nurses reported lower work-related burnout climate (Mean 55.4 (SD 22.5)) than host nurses (Mean 66.4 (SD 23.5)) but still at a moderately high degree (Safety Culture Domains). Host nurses indicated a higher workload (Mean 4.06 (SD 0.65)) (Engagement Assessment Tool) and a lower Work-Life-Balance (Mean 2.31 (SD 0.66)) (Work-Life-Balance) compared to nurses who trained abroad (Mean 3.67 (SD 0.81) and Mean 2.02 (SD 0.86), respectively). No differences were detected for the other subscales. The Safety Culture Domains and Engagement Assessment Tool showed room for improvement in both groups. Conclusion: The study suggest that the expectations migrant nurses had prior to migration may not be met and that in turn could have a negative impact on the integration process and their retention. With increasing recruitment of internationally trained nurses from within Europe but also overseas, it is crucial to identify factors that retain migrant nurses and assist integration. Trial registration: The study has been prospectively registered (27 June 2019) at the German Clinical Trial Register (DRKS00017465). [ABSTRACT FROM AUTHOR]

Background: During the first wave of the COVID-19 pandemic various ambulatory health care models (SARS-CoV-2 contact points: Subspecialised Primary Care Practices, Fever Clinics, and Special Places for Corona-Testing) were organised in a short period in Baden-Wuerttemberg, a region in Southern Germany. The aim of these SARS-CoV-2 contact points was to ensure medical treatment for patients with (suspected) and without SARS-CoV-2 infection. The present study aimed to assess the beliefs and practices of primary care physicians who either led a Subspecialised Primary Care Practice or a Primary Care Practice providing care as usual in Baden-Wuerttemberg during the first wave of the COVID-19 pandemic. Methods: This cross-sectional study was based on a paper-based questionnaire in primary care physicians during the first wave of the pandemic. Participants were identified via the web page of the Association of Statutory Health Insurance Physicians Baden-Wuerttemberg. The questionnaire was distributed in June and July 2020. It measured knowledge, practices, self-efficacy and fears towards SARS-CoV-2, using newly developed questions. Data was descriptively analysed. Results: One hundred fifty-five participants (92 leads of SARS-CoV-2 contact points/ 63 leads of primary care practices) completed the questionnaire. Out of 92 leads of SARS-CoV-2 contact points 74 stated to lead n Subspecialised Primary Care Practices. About half participants of both groups did not fear an own infection with the novel virus (between 50.8% and 62.2%), however about 75% feared financial loss. Knowledge was gained using various sources; main sources were the Association of Statutory Health Insurance Physicians (between 82.5% and 83.8%) and the German Society for Hygiene and Microbiology (RKI) (between 88.9% and 95.9%). Leads of Subspecialised Primary Care Practice felt more confident to perform anamnestic/diagnostic procedures (p < 0.001). The same was found for the confidence level regarding decision-making concerning the further treatment (p < 0.001). Several prevention measures to contain the spread of SARS-CoV-2 were adopted. Subspecialised Primary Care Practice had treated on average more patients with (suspected) COVID-19 (mean 408.12) than primary care practices (mean 83.8) (p < 0.001). Conclusion: The results of this study suggest that the Subspecialised Primary Care Practice that were implemented during the first wave of the SARS-CoV-2 pandemic contributed containment of the pandemic. Leads of Subspecialised Primary Care Practice indicated that physical separation of patients with potential SARS-CoV-2 infection was easier compared to those who continued working in their own practice. Additionally, leads of Subspecialised Primary Care Practice felt more confident in dealing with patients with SARS-CoV-2 infection. Trial registration: The study has been prospectively registered at the German Clinical Trial Register (DRKS00022224). [ABSTRACT FROM AUTHOR]

Background: The so-called sports consumption models are looking for the factors that influence the sports spending of households. This paper aims to examine the Hungarian, Polish and German households' sports expenditures which can be an important indicator of physical activity and sporty lifestyle.Methods: Surveying of households in three countries (Hungary, Poland and Germany) has been conducted with a self-designed questionnaire. We have used descriptive and bivariate non-parametric and parametric statistical methods: (1) χ2 test, Mann-Whitney test and Kruskal-Wallis test for checking the relationship between sociodemographic and physical activity variables and (2) independent sample t-test and ANOVA for checking the differences in sports expenditures.Results: Our research concluded that men, especially previous athletes, exercise more than women and those who have no history as registered athletes. The choice of sports venues is obviously different between the countries in the sample. Members of the study population spend the most on sports services while they spend the least on sports equipment. German households have the highest spending rates compared to the other two countries.Conclusions: Results are in line with our previous research findings and with other literatures. The difference in preferences of sports venues could have the reason of different supply of sports clubs or the different living standards too. It needs further researches to clear it. Material wealth, income level and sport socialisation can be a determining factor regarding the level of sports spending. [ABSTRACT FROM AUTHOR]

Background: In Germany, a mandatory policy on measles vaccination came into effect in March 2020. Physicians, as the main vaccine providers, have a crucial role in implementing it. Mandatory vaccination changes the preconditions under which patient-provider communication on vaccines occurs. Physicians might or might not favor vaccine mandates depending on, among other factors, their attitudes towards vaccines and capabilities as vaccine providers. The aim of this study was to investigate in different subgroups of physicians the association between various factors and their attitudes towards a mandatory policy.Methods: In total, 2229 physicians participated in a mixed-mode online/paper-pencil survey. Respondents were general practitioners, pediatricians, gynecologists, and internists. Primary determinants were the 5C psychological antecedents of vaccination, communication self-efficacy, patient clientele, projected consequences of the mandate and sociodemographic characteristics. Associations between outcomes and determinants were examined using linear regression analysis.Results: Approximately 86% of physicians were in favor of the measles vaccine mandate for children. Regarding the 5C model, physicians were more in favor of vaccine mandates when they scored higher on confidence and collective responsibility, and lower on complacency and calculation. They were more in favor of vaccine mandates when they had higher communication self-efficacy and a more vaccine-positive patient clientele. Pediatricians were less in favor of mandates for children (80.0%) than other physician subgroups (87.1%). They were also less convinced that a mandate would result in more children getting vaccinated (59.3%) than other physician subgroups (78.3%). When controlled for these expected consequences, being a pediatrician no longer lowered the attitude towards the mandate.Conclusions: Physicians in Germany are predominantly in favor of a measles vaccine mandate. Whether or not physicians believe the mandate to be effective in increasing vaccine coverage affects their attitude towards the mandate. In pediatricians, this belief explains their less positive attitude towards the mandate. In addition, physicians need adequate support to communicate well with patients, especially those who are hesitant, to booster their communication self-efficacy. To increase acceptance of vaccine mandates, the 5C model can be used, e.g., collective responsibility can be communicated, to avoid anger stemming from a negative attitude to mandates. [ABSTRACT FROM AUTHOR]

Background: Out-of-pocket payments have a diverse impact on the burden of those with a higher morbidity or the chronically ill. As the prevalence of chronic diseases increases with age, older adults are a vulnerable group. The paper aims to evaluate the impact of chronic diseases on the out-of-pocket payments burden of the 50+ populations in Belgium, the Czech Republic and Germany.Methods: Data from the sixth wave of the Survey of Health, Ageing and Retirement in Europe is used. A two-part model with a logit model in the first part and a generalised linear model in the second part is applied.Results: The diseases increasing the burden in the observed countries are heart attacks, high blood pressure, cancer, emotional disorders, rheumatoid arthritis and osteoarthritis. Reflecting country differences Parkinson's disease and its drug burden is relevant in Belgium, the drugs burden related to heart attack and outpatient care burden to chronic kidney disease in the Czech Republic and the outpatient care burden of cancer and chronic lung disease in Germany. In addition, we confirm the regressive character of out-of-pocket payments.Conclusions: We conclude that the burden is not equitably distributed among older adults with chronic diseases. Identification of chronic diseases with a high burden can serve as a supplementary protective feature. [ABSTRACT FROM AUTHOR]

Background: In the healthcare system in Germany, different institutions and actors play specific roles in the discharge and transition of patients from hospitals into primary care (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen, Wettbewerb an der Schnittstelle zwischen ambulanter und stationärer Gesundheitsversorgung, 2012). However, there are shortcomings in these intersectoral transitions. Especially in older people with cognitive impairment (PCI), discharge management often lacks coordination and cooperation between healthcare providers. This frequently results in higher rates of unscheduled readmission. The project intersec-CM is a randomised controlled trial (RCT) that aims to explore up to what extent an intersectoral care management (ICM) can improve this transition. This ICM is delivered by nurses with special training in care management. The objective of this paper is to describe a mixed-methods process evaluation of the intersectoral care management intervention and the factors that facilitate and inhibit its implementation.Methods: Different study designs for process evaluations from previous literature were collected and analysed according to the dimension implementation fidelity, satisfaction with the intervention, feasible transfer into routine care, optimum point of time, frequency and execution of the intervention, and context factors.Results: The actor-network theory was chosen as the theoretic framework for the process evaluation. Based on this theory, a mixed-methods design was developed to combine and integrate qualitative and quantitative evaluation methods. The qualitative part includes semi-structured interviews using topic guides (phase 1) and later in-depth interviews with narrative portions (phase 3), which will be analysed by using the qualitative content analysis according to Kuckartz. The quantitative survey (phase 2) is conducted with standardised questionnaires.Discussion: Challenges in data collection include the development of interview guidelines, which require different terminologies depending on every specific actor targeted in the intervention. Conducting the interviews, there is a risk of misunderstanding the older PCI by the interviewer and vice versa. However, the combination of qualitative and quantitative approaches as different techniques of process evaluation may help to capture, integrate and analyse data on different dimensions of the intervention.Conclusions: The results of our process evaluation may serve as an implementation guideline for intersectoral care management in the German healthcare system. Furthermore, the approach to evaluate the process of a complex intervention in health care for older PCI may serve as a stimulus to broaden the evidence base also of other complex intervention studies to improve health care for this vulnerable group. The study was ethically approved by the Ethics Committee of the Ernst-Moritz-Arndt University of Greifswald. The study has been registered at the U.S. National Library of Medicine.Trial Registration: ClinicalTrials.gov NCT03359408 . Registered on 2 December 2017. The approximate date when recruitment to the process evaluation of the study will be completed is 31 May 2021. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial resistance remains a global challenge. In Germany, the national health agenda supports measures that enhance the appropriate, guideline-oriented use of antibiotics. The study "Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3)" aimed at a sustainable reduction of antimicrobial resistance through converting patterns of prescribing practice and use of antibiotics and an increase in health literacy in primary care patients, practice teams, and in the general public. Embedded in a cluster-randomized trial of a multifaceted implementation program, a process evaluation focused on the uptake of program components to assess the fidelity of the implementation program in the CHANGE-3 study and to understand utilization of its educational components. Methods: A mix of qualitative and quantitative methods was used. Semi-structured telephone interviews were conducted with General Practitioners, Medical Assistants, patients treated for respiratory tract infection and outreach visitors who had carried out individual outreach visits. A two-wave written survey (T1: 5 months after start, T2: 16 months after start) was conducted in general practitioners and medical assistants. Qualitative data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze survey data. Results: Uptake of intervention components was heterogenous. Across all components, the uptake reported by General Practitioners varied from 20 to 88% at T1 and 31 to 63% at T2. Medical Assistants reported uptake from 22 to 70% at T1 and 6 to 69% at T2. Paper-based components could by and large be integrated in daily practice (64 to 90% in T1; 41 to 93% in T2), but uptake of digital components was low. A one-time outreach visit provided thematic information and feedback regarding actual prescribing, but due to time constraints were received with reluctance by practice teams. Patients were largely unaware of program components, but assumed that information and education could promote health literacy regarding antibiotics use. Conclusions: The process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics. Future research efforts need to identify the best mode of delivery to reach the targeted population. Trial registration: ISRCTN, ISRCTN15061174. Registered 13 July 2018 – Retrospectively registered [ABSTRACT FROM AUTHOR]

Background: Type 2 diabetes represents an increasingly critical challenge for health policy worldwide. It absorbs massive resources from both patients and national economies to sustain direct costs of the treatment of type 2 diabetes and its complications and indirect costs related to work loss and wages. More recently, there are innovations based on remote control and personalised programs that promise a more cost-effective diabetes management while reducing diabetes-related complications. In such a context, this work attempts to update cost analysis reviews on type 2 diabetes, focusing on France and Germany, in order to explore most significant cost drivers and cost-saving opportunities through innovations in diabetes care. Although both countries approach care delivery differently, France and Germany represent the primary European markets for diabetes technologies.Methods: A systematic review of the literature listed in MEDLINE, Embase and EconLit has been carried out. It covered interventional, observational and modelling studies on expenditures for type 2 diabetes management in France or Germany published since 2012. Included articles were analysed for annual direct, associated and indirect costs of type 2 diabetes patients. An appraisal of study quality was performed. Results were summarised narratively.Results: From 1260 records, the final sample was composed of 24 papers selected according to predefined inclusion/exclusion criteria. Both France and Germany revealed a predominant focus on direct costs. Comparability was limited due to different study populations and cost categories used. Indirect costs were only available in Germany. According to prior literature, reported cost drivers are hospitalisation, prescriptions, higher HbA1c and BMI, treatment with insulin and complications, all indicators of disease severity. The diversity of available data and included costs limits the results and may explain the differences found.Conclusions: Complication prevention and glycaemic control are widely recognized as the most effective ways to control diabetes treatment costs. The value propositions of self-based supports, such as hybrid closed-loop metabolic systems, already implemented in type 1 diabetes management, are the key points for further debates and policymaking, which should involve the perspectives of caregivers, patients and payers. [ABSTRACT FROM AUTHOR]

Background: Medical data from family doctors are of great importance to health care researchers but seem to be locked in German practices and, thus, are underused in research. The RADAR project (Routine Anonymized Data for Advanced Health Services Research) aims at designing, implementing and piloting a generic research architecture, technical software solutions as well as procedures and workflows to unlock data from family doctor's practices. A long-term medical data repository for research taking legal requirements into account is established. Thereby, RADAR helps closing the gap between the European countries and to contribute data from primary care in Germany.Methods: The RADAR project comprises three phases: (1) analysis phase, (2) design phase, and (3) pilot. First, interdisciplinary workshops were held to list prerequisites and requirements. Second, an architecture diagram with building blocks and functions, and an ordered list of process steps (workflow) for data capture and storage were designed. Third, technical components and workflows were piloted. The pilot was extended by a data integration workflow using patient-reported outcomes (paper-based questionnaires).Results: The analysis phase resulted in listing 17 essential prerequisites and guiding requirements for data management compliant with the General Data Protection Regulation (GDPR). Based on this list existing approaches to fulfil the RADAR tasks were evaluated-for example, re-using BDT interface for data exchange and Trusted Third Party-approach for consent management and record linkage. Consented data sets of 100 patients were successfully exported, separated into person-identifying and medical data, pseudonymised and saved. Record linkage and data integration workflows for patient-reported outcomes in the RADAR research database were successfully piloted for 63 responders.Conclusion: The RADAR project successfully developed a generic architecture together with a technical framework of tools, interfaces, and workflows for a complete infrastructure for practicable and secure processing of patient data from family doctors. All technical components and workflows can be reused for further research projects. Additionally, a Trusted Third Party-approach can be used as core element to implement data privacy protection in such heterogeneous family doctor's settings. Optimisations identified comprise a fully-electronic consent recording using tablet computers, which is part of the project's extension phase. [ABSTRACT FROM AUTHOR]

Background: General Practitioners (GPs) are increasingly affected by stress-related complaints and burnout. Although many studies have addressed this issue, little is known about the stress burden and burnout rates of postgraduate trainees specialising in General Practice (GP). This cross-sectional study was performed to explore the prevalence and risk of depression, stress and burnout in a large cohort of GP trainees. Methods: All GP trainees enrolled in the postgraduate training programme KWBW Verbundweiterbildungplus© in southwest Germany were invited to participate. A paper-based survey for the purpose of psychosocial screening was used: Prevalence of depression, perceived stress and burnout were measured with the depression module of the Patient Health Questionnaire (PHQ-9), Perceived Stress Questionnaire (PSQ-20) and Maslach Burnout Inventory (MBI). Additionally, linear regression models were used to analyse the association between sociodemographic characteristics and mental health scales. Results: N = 211 GP trainees participated in this study (response rate 95%). 75.3% (n = 159) of the participants were female and median age was 34 (IQR 32; 39). GP trainees had a mean PHQ-9 sum score of 5.4 (SD 3.4). Almost 11% (n = 23) reported symptoms of a moderate or moderately severe depression. PSQ-20 revealed moderate level of distress, whereas 20.8% (n = 42) showed a high level of perceived stress with a sum-score higher than.59. GP trainees showed moderate rates of burnout and only 2.5% (n = 5) scored high in all three dimensions of the MBI score. GP trainees showed increased levels of depression, perceived stress and burnout when compared with age-matched general population. Being a woman led to a higher PHQ-9 sum score (p <.05). Higher age was associated with less depersonalisation in the MBI (p <.05). Conclusions: The results of our study suggest that GP trainees considerably suffer from stress. Some GP trainees were even affected by depression or burnout. To detect and support colleagues at risk, trainees should be supported by early preventive measures such as anti-stress or resilience trainings and mentoring during their training. Prospective longitudinal studies are needed to understand the character and the course of the stress burden among GP trainees. [ABSTRACT FROM AUTHOR]

Background: Providing end of life care (EoLC) is an important aspect of primary care, which reduces the risk of hospital admission for most patients. However, general practitioners (GPs) seem to have low confidence in their ability to provide EoLC. Little is known about an adequate volume and kind of training in EoLC among GP trainees. Methods: We performed a before-after comparison in all post-graduate GP trainees who were registered in the vocational training program (KWBW VerbundweiterbildungPLUS). They were offered participation within a two-day seminar focussing on palliative care in 2017. Those who attended the seminar (intervention group I) completed a paper-based questionnaire directly before the intervention (T1) and 6 months after (T2). None-attendees (group C) were also asked to fill out the questionnaire once. The questionnaire covered previous experiences in palliative care, self-assessment of competencies in EoLC in the organisation of patient care as well as in control of symptoms, attitudes towards death and caring for dying patients and questions about GPs' role in EoLC. Results: In total, 294 GP trainees (I: n = 219; C: n = 75) participated in the study. Of those, more than 90% had previously gained experience in EoLC mainly during vocational training in the hospital rotation. Around a third had previously gained competencies in EoLC in medical school. Between groups I (T1) and C no significant differences were observed in socio-demographic characteristics, pre-existing experience or overall expertise. At T2, 75% of participants of group I declared they have extended their competencies in EoLC after the intervention and 70% classified the intervention as helpful or very helpful. Overall, they rated their competencies significantly higher than at T1 (p < 0.01). In detail, competencies in organisation of EoLC and competencies in handling of symptoms significantly improved (p < 0.01). Due to the intervention, 66% could reflect their attitudes towards dying, death and grief and 18% changed their attitudes. Group I highlighted palliative care as one of GPs tasks (Likert 4.47/5, SD 0.75). Conclusions: The intervention fostered personal competencies, understanding and self-confidence in EoLC among GP trainees. This is crucial for the aim to broadly provide EoLC. [ABSTRACT FROM AUTHOR]

Background: The identity management is a central component in medical research. Patients are recruited from various sites, which requires an error tolerant record linkage method, to ensure that patients are registered only once. In large research projects or institutions, the identity management has to deal with several thousands or millions of patients. In environments with large numbers of patients the register process could lead to high runtimes caused by record linkage. The Central Biomaterial Bank of the Charité (ZeBanC) searched for an identity management solution, which can handle millions of patients in large research projects with an acceptable performance. The goal of this paper was to simulate the registration of several million patients using the E-PIX service at Charité - Universitätsmedizin Berlin. The E-PIX service was evaluated in terms of needed runtimes, memory requirements, and processor utilization. A total of at least 20 million patients had to be registered. The runtimes to register patients into databases with various sizes should be examined, and the maximum number of patients, which the E-PIX service could handle, should be determined.Methods: Tools were set up or developed to measure the needed runtimes, the memory used and the processor usage to register patients into various sizes of databases. To generate runtimes close to reality, modified patient data based on transposed real patient data were used for the simulation. The transposed patient data were sent to E-PIX to measure the runtimes of the registration process. This measurement was repeated for various database sizes.Results: E-PIX is suitable to manage multi-million patients within a dataset. With the given hardware, it was possible to register a total of more than 30 million patients. It was possible to register more than 16 thousand patients per day into this database.Conclusions: The E-PIX tool fulfills the requirements of the Charité to be used for large research projects. The use of E-PIX is intended for the research context in the Charité. [ABSTRACT FROM AUTHOR]

Background: Existing physical activity guidelines predominantly focus on healthy age-stratified target groups. The objective of this study was to develop evidence-based recommendations for physical activity (PA) and PA promotion for German adults (18–65 years) with noncommunicable diseases (NCDs). Methods: The PA recommendations were developed based on existing PA recommendations. In phase 1, systematic literature searches were conducted for current PA recommendations for seven chronic conditions (osteoarthrosis of the hip and knee, chronic obstructive pulmonary disease, stable ischemic heart disease, stroke, clinical depression, and chronic non-specific back pain). In phase 2, the PA recommendations were evaluated on the basis of 28 quality criteria, and high-quality recommendations were analysed. In phase 3, PA recommendations for seven chronic conditions were deducted and then synthesised to generate generic German PA recommendations for adults with NCDs. In relation to the recommendations for PA promotion, a systematic literature review was conducted on papers that reviewed the efficacy/effectiveness of interventions for PA promotion in adults with NCDs. Results: The German recommendations for physical activity state that adults with NCDs should, over the course of a week, do at least 150 min of moderate-intensity aerobic PA, or 75 min of vigorous-intensity aerobic PA, or a combination of both. Furthermore, muscle-strengthening activities should be performed at least twice a week. The promotion of PA among adults with NCDs should be theory-based, specifically target PA behaviour, and be tailored to the respective target group. In this context, and as an intervention method, exercise referral schemes are one of the more promising methods of promoting PA in adults with NCDs. Conclusion: The development of evidence-based recommendations for PA and PA promotion is an important step in terms of the initiation and implementation of actions for PA-related health promotion in Germany. The German recommendations for PA and PA promotion inform adults affected by NCDs and health professionals on how much PA would be optimal for adults with NCDs. Additionally, the recommendations provide professionals entrusted in PA promotion the best strategies and interventions to raise low PA levels in adults with NCDs. The formulation of specific PA recommendations for adults with NCDs and their combination with recommendations on PA promotion is a unique characteristic of the German recommendations. [ABSTRACT FROM AUTHOR]

Background: Although psychosomatic medicine is not recognised as a medical specialisation globally, it has proven useful for treating many disorders in Germany. This paper reports on the impact of an educational workshop as a tool for raising awareness about psychosomatic medicine among international psychiatrists. Methods: Psychiatrists from eight different countries were educated on psychosomatic medicine and psychotherapy during a 90-min workshop using a video, a slide presentation and an innovative teaching format called 'speed coaching'. Learning outcomes were assessed by analysing questionnaires completed by the participants before and after the workshop. Results: Half of the participants who initially rejected the notion that psychosomatic medicine should be a specialisation on its own changed their minds in favour for it to be a separate discipline (p = 0.125). Awareness about which diseases and patients psychosomatic doctors deal with was increased. The intent for treatment of patients with eating disorders by a psychosomatic physician quadrupled among the participants (p = 0.004). Conclusions: A brief educational intervention can influence psychiatrists' decisions to opt for approaches by doctors specialized in psychosomatics for certain disorders. Further studies may explore why psychiatrists agree or disagree that psychosomatic medicine should be a separate specialisation on its own. [ABSTRACT FROM AUTHOR]