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BackgroundMost people affected by depression or anxiety disorders are treated solely by their primary care physician. Access to specialized mental health care is impeded by patients’ comorbidity and immobility in aging societies and long waiting times at the providers’ end. Video-based integrated care models may leverage limited resources more efficiently and provide timely specialized care in primary care settings. ObjectiveThe study aims to evaluate the feasibility of mental health specialist video consultations with primary care patients with depression or anxiety disorders. MethodsParticipants were recruited by their primary care physicians during regular practice visits. Patients who had experienced at least moderate symptoms of depression and/or anxiety disorders were considered eligible for the study. Patients were randomized into 2 groups receiving either treatment-as-usual as provided by their general practitioner or up to 5 video consultations conducted by a mental health specialist. Video consultations focused on systematic diagnosis and proactive monitoring using validated clinical rating scales, the establishment of an effective working alliance, and a stepped-care algorithm within integrated care adjusting treatments based on clinical outcomes. Feasibility outcomes were recruitment, rate of loss to follow-up, acceptability of treatment, and attendance at sessions. Effectiveness outcomes included depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), burden of specific somatic complaints (Somatic Symptom Disorder-B Criteria Scale-12), recovery (Recovery Assessment Scale-German [RAS-G]), and perception of chronic illness care (Patient Assessment of Chronic Illness Care), which were measured at baseline and 16 weeks postallocation by assessors blinded to the group allocation. ResultsA total of 50 patients with depression and/or anxiety disorders were randomized, 23 in the intervention group and 27 in the treatment-as-usual group. The recruitment yield (number randomized per number screened) and the consent rate (number randomized per number eligible) were 69% (50/73) and 86% (50/58), respectively. Regarding acceptability, 87% (20/23) of the participants in the intervention group completed the intervention. Of the 108 planned video consultations, 102 (94.4%) were delivered. Follow-up rates were 96% (22/23) and 85% (23/27) for the intervention and control groups, respectively. The change from baseline scores at postmeasurement for the No Domination by Symptoms domain of recovery (RAS-G) was somewhat higher in the intervention group than in the control group (Mann-Whitney U test: rank-biserial r=0.19; 95% CI −0.09 to 0.46; P=.18). We did not detect any notable differences between the intervention and control groups in terms of other effectiveness outcomes. We did not observe any serious adverse events related to the trial. ConclusionsThe intervention and study procedures were found to be feasible for patients, primary care practice staff, and mental health specialists. A sufficiently powered pragmatic trial on mental health specialist video consultations should be conducted to investigate their effectiveness in routine care. Trial RegistrationGerman Clinical Trials Register DRKS00015812; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015812.

BackgroundMany patients with mental disorders remain untreated. Video-based mental health care demonstrates comparable effectiveness to face-to-face treatments and is a promising mode for delivering specialized care within primary care. Nevertheless, professionals struggle with implementing video consultations in their daily practice. Specifically, little is known about mental health specialists’ acceptance of mental health video consultations in routine practice. The PROVIDE (ImPROving cross-sectoral collaboration between primary and psychosocial care: An implementation study on VIDEo consultations) project aims to improve cross-sectoral collaboration between primary and psychosocial care through implementing video consultations in primary care. To increase the uptake of video consultations, it is crucial to account for necessary prerequisites and to tailor interventions to the needs of the target group prior to implementation. ObjectiveThe aim of this study was to explore the acceptance of video consultations embedded in primary care from the perspectives of mental health specialists in Germany. MethodsWe conducted a qualitative, exploratory, preimplementation study in urban and rural counties. We conducted three semistructured focus groups with 11 mental health specialists. We used qualitative content analysis combining an inductive-deductive approach, applying the Tailored Implementation in Chronic Diseases (TICD) framework to the text material, which comprises individual health professional factors; patient factors; professional interactions; incentives and resources; capacity for organizational change; social, political, and legal factors; and guideline factors. ResultsAgainst the background of long waiting times and a shortage of mental health specialists, especially in rural areas, participants valued video consultations as a potential means to improve access to mental health care. With respect to the TICD framework domains, the participants most often discussed individual health professional factors, followed by patient factors. All participants highlighted the importance of a trusting relationship between the patient and the therapist and doubted whether such a relationship could be established through video consultations (11/11, 100%). However, participants considered mental health specialist video consultations to be particularly suited for patients in rural areas, those with impaired mobility, and those who may otherwise remain untreated (6/11, 55%). Most participants expected video consultations to help the aforementioned patient groups avoid tedious searching for an available therapist and save on travel time and, therefore, improve access to specialized care for patients (7/11, 64%). Moreover, the participants expected video consultations to improve collaboration with the family physician (6/11, 55%). Finally, participants identified organizational aspects, such as reliable scheduling, the duration of the individual consultation (9/11, 82%), and reimbursement conditions (7/11, 67%), as key drivers for the acceptance and adoption of the model. ConclusionsWhile mental health specialists expect video consultations to improve access to specialized care for some patients, they consistently wonder whether such consultations can establish a trusting patient-therapist relationship. When implementing video consultations, these concerns should be addressed by training providers in managing technology-based treatment settings, with extra consideration for fostering the patients’ and therapists’ engagement. Trial RegistrationGerman Clinical Trials Register DRKS00012487; https://tinyurl.com/uhg2one

[english] Objectives: A clinical practice guideline (CPG) contains specifically developed recommendations that can serve physicians as a decision aid in evidence-based practice. The implementation of heart failure (HF) CPGs represents a challenge in general practice. As part of the development of a tailored curriculum, aim of this study was to identify barriers of guideline adherence and needs for medical education (CME) in HF care.Methods: We conducted a modified focus group with elements of a workshop of three hours duration. Thirteen GPs collected and discussed together and parallel in smaller groups barriers of guideline implementation. Afterwards they performed a needs assessment for a tailored CME curriculum for chronic HF. The content of the discussions was analysed qualitatively according to Mayring and categorised thematically.Results: Barriers of guideline adherence were found in the following areas: doctor: procedural knowledge (knowledge gaps), communicative and organisational skills (e.g. time management) and attitude (dissatisfaction with time-money-relation). Patients: individual case-related problems (multimorbidity, psychiatric comorbidity, expectations and beliefs). Doctor and patient: Adherence and barriers of communication. Main measures for improvement of care concerned the areas of the identified barriers of guideline adherence with the focus on application-oriented training of the abovementioned procedural knowledge and skills, but also the supply of tools (like patient information leaflets) and patient education. Conclusion: For a CME-curriculum for HF tailored to the needs of GPs, a comprehensive educational approach seems necessary. It should be broad-based and include elements of knowledge and skills to be addressed and trained case-related. Additional elements should include support in the implementation of organisational processes in the practice and patient education.[german] Zielsetzung: Leitlinien zur Herzinsuffizienz (HI) enthalten systematisch entwickelte Empfehlungen, deren Umsetzung speziell in der hausärztlichen Praxis eine bekannte Herausforderung darstellt. Ziel der vorliegenden Studie war es, Barrieren bei der Umsetzung der Leitlinienempfehlungen zu identifizieren, Vorschläge zu Verbesserungsmaßnahmen der hausärztlichen Versorgung und für die Entwicklung einer bedarfsgerechten Fortbildung zu gewinnen.Methodik: Es wurde eine modifizierte Fokusgruppe mit Workshopcharakter durchgeführt. In drei parallelen Kleingruppen erarbeiteten 13 Hausärzte Barrieren bei der Leitlinienumsetzung zur HI. Darauf aufbauend wurde eine Bedarfsanalyse bzgl. der Lernziele und der spezifischen Verbesserungsmaßnahmen für eine hausärztliche Fortbildung zur HI durchgeführt. Die protokollierten Aussagen der Ärzte wurden mittels Inhaltsanalyse nach Mayring ausgewertet und anschließend thematisch kategorisiert.Ergebnisse: Als Barrieren der Umsetzung vorhandener Leitlinien nannten die teilnehmenden Ärzte arztseitige Defizite und Unterstützungsbedarf in den Dimensionen Wissen, kommunikativen und organisatorischen Fähigkeiten (z. B. Zeitmangel/-management) und der Haltung gegenüber Leitlinien (z.B. Faulheit). Den Patienten wurden individuelle, patientenbezogene Probleme (z.B. Komplexität des Einzelfalles bei Multimorbidität, psychische Komorbidität) sowie ablehnende Einstellungen (z.B. gegenüber „Schulmedizin“) zugeschrieben. Im Bereich der Arzt-Patient-Interaktion wurden u.a. mangelnde medikamentöse Adhärenz und Kommunikationsprobleme als Barrieren genannt. Vorschläge zu Verbesserungs- bzw. Schulungsmaßnahmen umfassten breit angelegte Schulungskonzepte (z.B. in interdisziplinären Qualitätszirkeln mit Fall-Audit), die neben der Vermittlung von Wissensaspekten aus einer (idealerweise einheitlichen) Leitlinie auch praktische Fertigkeiten hinsichtlich Arzt-Patienten-Kommunikation und Praxis-Organisation einschlossen. Die Bereitstellung praktikabler Arbeitsmaterialien und Patientenschulungen sollten aus Sicht der Teilnehmer die Arztschulungen ergänzen.Schlussfolgerung: Ein Fortbildungs-Curriculum für Hausärzte zur HI scheint einer umfassenden Leitlinienschulung zu bedürfen, in welchen insbesondere Handlungskompetenz und kommunikative Fertigkeiten anwendungsorientiert geübt werden sollten. Weitere Bestandteile sollten Hilfestellungen zur Implementierung von Organisationsabläufen und Patientenschulungen sein.

General practice-based research networks have become an integral tool to gain medical knowledge from primary care in many countries. For this purpose, a scalable IT-infrastructure is presented considering the limiting peculiarities in the German health system and enabling GPs to participate in clinical studies based on their patient population. The infrastructure consists of a central study management server and local clients for each practice. It adopts to the currently limited digital connectivity of GP practices, data protection regulations for clinical data and the needs of the medical staff to manage a clinical study. The infrastructure is in production at the four university hospitals in the state of Baden-Württemberg. Until now three clinical studies with over 70 GPs and 350 Participants are successfully conducted or have been finished. Further clinical studies are in the planning stages. [ABSTRACT FROM AUTHOR]

Introduction: A wide range of factors influence coordination and continuity of care. The aim of this study was to explore how management continuity of cardiovascularrelated ambulatory care is influenced by the following network characteristics: presence of a case coordinator, network reciprocity, network composition and team climate. Methods: This cross-sectional observational study included three written surveys. The primary outcome management continuity of cardiovascular care was measured with the team/cross-boundary scale in the Nijmegen Continuity Questionnaire. The final analysis comprised a multivariate linear multilevel model with the predictors: presence of a case coordinator, network reciprocity, network composition and team climate. Results: Eighteen general practices with 83 health workers and 340 patients participated. The linear multilevel regression analysis showed a positive influence of team climate on cross-boundary continuity of care (b-coefficient 0.44, 95% confidence interval 0.09-0.78, p = 0.02). No statistically significant influence was measured for the other predictors. Discussion: To improve integrated care, therefore, emphasis should also be placed on promoting the team climate within individual practices. Regarding network characteristics, further research is needed, especially in larger practices. Conclusion: This study showed that team climate had an independent, relevant and statistically significant association with cross-boundary continuity of cardiovascular ambulatory care. [ABSTRACT FROM AUTHOR]