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Background: Sex differences exist not only in the efficacy but also in adverse event rates of many vaccines. Here we compared the safety of BNT162b2 vaccine administered off-label in female and male children younger than 5 years in Germany., Methods: This is a retrospective cohort study, in which we performed a post-hoc analysis of a dataset collected through an authentication-based survey of individuals having registered children aged 0-<5 years for vaccination against SARS-CoV-2 in six private practices and/or two lay person-initiated vaccination campaigns. We analyzed the safety profiles of the first 3 doses of 3-10 µg BNT162b2. Primary outcome was comparison in frequencies of 4 common post-vaccination symptom categories such as local, general, musculoskeletal symptoms and fever. Data were analyzed according to sex in bivariate analyses and regression models adjusting for age, weight, and dosage. Interaction between sex and BNT162b2 dosage was assessed. An active-comparator analysis was applied to compare post-vaccination symptoms after BNT162b2 versus non-SARS-CoV-2 vaccines., Results: The dataset for the present analysis consisted of 7801 participants including 3842 females (49%) and 3977 males (51%) with an age of 3 years (median, interquartile: 2 years). Among individuals receiving 3 µg BNT162b2, no sex differences were noted, but after a first dose of 5-10 µg BNT162b2, local injection-site symptoms were more prevalent in girls compared to boys. In logistic regression, female sex was associated with higher odds of local symptoms, odds ratio (OR) of 1.33 (95% confidence interval [CI]: 1.15-1.55, p < 0.05) and general symptoms with OR 1.21 (95% CI: 1.01-1.44, p < 0.05). Following non-BNT162b2 childhood vaccinations, female sex was associated with a lower odds of post-vaccination musculoskeletal symptoms (OR: 0.29, 95% CI: 0.11-0.82, p < 0.05). An active comparator analysis between BNT162b2 and non-SARS-CoV-2 vaccinations revealed that female sex positively influenced the association between BNT162b2 vaccine type and musculoskeletal symptoms., Conclusions: Sex differences exist in post-vaccination symptoms after BNT162b2 administration even in young children. These are of importance for the conception of approval studies, for post-vaccination monitoring and for future vaccination strategies (German Clinical Trials Register ID: DRKS00028759)., (© 2024. The Author(s).)

Patient empowerment calls for an intensified participation of (informed) patients with more treatment opportunities to choose from. A growing body of literature argues that confronting consumers with too many opportunities can lead to a choice overload (CO) resulting in uncertainty that the selected alternative dominates all other options in the choice set. We examine whether there is a CO effect in the demand for ambulatory health care in Germany by analyzing the association of medical specialists supply on so-called patients' health uncertainty. Further, we investigate if the CO effect is smaller in areas with a higher density of general practitioners (GPs). We find that patients who live in an area with a large supply of specialists are subject to a CO effect that is expressed by an increased health uncertainty. The coordinating role of GPs seems to be effective to reduce the CO effect, while preserving free consumer choice., (© 2024. The Author(s).)

Background: Digital transformation offers new opportunities to improve the exchange of information between different health care providers, including inpatient, outpatient and care facilities. As information is especially at risk of being lost when a patient is discharged from a hospital, digital transformation offers great opportunities to improve intersectoral discharge management. However, most strategies for improvement have focused on structures within the hospital., Objective: This study aims to evaluate the implementation of a digitalized discharge management system, the project "Optimizing instersectoral discharge management" (SEKMA, derived from the German Sektorübergreifende Optimierung des Entlassmanagements), and its impact on the readmission rate., Methods: A mixed methods design was used to evaluate the implementation of a digitalized discharge management system and its impact on the readmission rate. After the implementation, the congruence between the planned (logic model) and the actual intervention was evaluated using a fidelity analysis. Finally, bivariate and multivariate analyses were used to evaluate the effectiveness of the implementation on the readmission rate. For this purpose, a difference-in-difference approach was adopted based on routine data of hospital admissions between April 2019 and August 2019 and between April 2022 and August 2022. The department of vascular surgery served as the intervention group, in which the optimized discharge management was implemented in April 2022. The departments of internal medicine and cardiology formed the control group., Results: Overall, 26 interviews were conducted, and we explored 21 determinants, which can be categorized into 3 groups: "optimization potential," "barriers," and "enablers." On the basis of these results, 19 strategies were developed to address the determinants, including a lack of networking among health care providers, digital information transmission, and user-unfriendliness. On the basis of these strategies, which were prioritized by 11 hospital physicians, a logic model was formulated. Of the 19 strategies, 7 (37%; eg, electronic discharge letter, providing mobile devices to the hospital's social service, and generating individual medication plans in the format of the national medication plan) have been implemented in SEKMA. A survey on the fidelity of the application of the implemented strategies showed that 3 of these strategies were not yet widely applied. No significant effect of SEKMA on readmissions was observed in the routine data of 14,854 hospital admissions (P=.20)., Conclusions: This study demonstrates the potential of optimizing intersectoral collaboration for patient care. Although a significant effect of SEKMA on readmissions has not yet been observed, creating a digital ecosystem that connects different health care providers seems to be a promising approach to ensure secure and fast networking of the sectors. The described intersectoral optimization of discharge management provides a structured template for the implementation of a similar local digital care networking infrastructure in other care regions in Germany and other countries with a similarly fragmented health care system., (©Christoph Strumann, Lisa Pfau, Laila Wahle, Raphael Schreiber, Jost Steinhäuser. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.03.2024.)

Background: Hypertension is a leading cause of morbidity and mortality if not properly managed. Primary care has a major impact on these outcomes if its strengths, such as continuity of care, are deployed wisely. The analysis aimed to evaluate the quality of care for newly diagnosed hypertension in routine primary care data., Methods: In the retrospective cohort study, routine data (from 2016 to 2022) from eight primary care practices in Germany were exported in anonymized form directly from the electronic health record (EHR) systems and processed for this analysis. The analysis focused on five established quality indicators for the care of patients who have been recently diagnosed with hypertension., Results: A total of 30,691 patients were treated in the participating practices, 2,507 of whom have recently been diagnosed with hypertension. Prior to the pandemic outbreak, 19% of hypertensive patients had blood pressure above 140/90 mmHg and 68% received drug therapy (n = 1,372). After the pandemic outbreak, the proportion of patients with measured blood pressure increased from 63 to 87%, while the other four indicators remained relatively stable. Up to 80% of the total variation of the quality indicators could be explained by individual practices., Conclusion: For the majority of patients, diagnostic procedures are not used to the extent recommended by guidelines. The analysis showed that quality indicators for outpatient care could be mapped onto the basis of routine data. The results could easily be reported to the practices in order to optimize the quality of care., (© 2024. The Author(s).)

Introduction: Since the patient-doctor relationship (PDR) plays a crucial role in patient primary health care and management, the evaluation of the PDR from both, the patients' and primary care physicians', perspectives is an important approach to improve the quality of primary care. However, although there are a variety of questionnaires surveying the patients' view of the PDR, only few consider the physicians' perspective. The purpose of this study was to develop a questionnaire that adds the physicians' perspective to an existing PDR instrument and thus enables a mutual assessment of the relationship., Methods: This study was embedded in a German project aiming at enhancing the adherence in patients with hypertension. Patients and primary care physicians were asked to complete a questionnaire concerning their PDR. The Patient-Doctor Relationship Questionnaire (PDRQ-9) was used to assess the patients' perspective. For the physicians, the PDRQ-9 items were adapted to the physicians' perspective resulting in the GP-Patient Relationship Questionnaire (GPPR). The Helping Alliance Questionnaire (HAQ) was used for external validation., Results: A total of 60 physician questionnaires and 50 matched pairs of questionnaires from physicians and patients were included in the analyses. Within the analysis, notable deviations were found for one item, nevertheless the calculated Cronbach's α of 0.89 showed a high internal consistency of the 9-item questionnaire. External validation showed a high correlation of the GPPR with the HAQ, confirming the good psychometric properties demonstrated for the overall instrument., Discussion: Overall, this initial validation study revealed good psychometric properties of the GPPR. A retest will be performed in the course of the overall project to confirm the reliability of the newly developed questionnaire., Conclusion: A new questionnaire to assess the physicians' perspectives on the PDR was successfully developed to improve adherence-dependent processes of quality improving in primary care., (Copyright © 2023. Published by Elsevier GmbH.)

Background: There is an increasing number of patients that do not make a rapid or full recovery from a SARS-CoV-2 infection, the Coronavirus Disease 2019 (COVID-19) and suffer from the so-called "long-COVID" or post-acute sequelae of COVID-19 (PASC). The long-term implications for health services are expected to be substantial. The objective of this analysis was to estimate the utilization of outpatient services from primary and secondary care. Further, we evaluated the multidisciplinary ambulatory care management of PASC patients in Germany., Methods: All members of the Physician network "MEDI Baden-Württemberg e.V.", i.e., 1,263 primary care physicians (PCPs) and 1,772 specialists working in secondary care were invited to participate in a questionnaire surveying routine data regarding the general care situation at the physician practice level of patients suffering from PASC. Bivariate analyses were applied to consider potential differences between primary and secondary care., Results: In total, 194 physicians participated in this survey (response rates of 9.6% (primary care) and 4.1% (secondary care). On average, each physician treated 31.9 PASC patients. Most PASC patients (61.2%) had three or more long-COVID symptoms. On average, 10.6 PASC patients visited a physicians' practice per quarter. The additional consulting effort for treating PASC patients was 34.1 min (median: 20 min) and higher in primary care. Most PCPs (71.1%) integrated secondary care in the treatment of their PASC patients. Less than half of the PASC patients (42.0%) sought secondary care with a referral from primary care. 5.7 patients visited the physicians' practices per week, who were concerned about suffering from PASC without any following medical confirmation. This caused an average additional effort for the physicians of 17.5 min per visit. There were no differences between rural and urban areas., Conclusion: Our results reveal that there is a substantial additional consulting effort for treating PASC patients that is especially high in primary care. The additional consulting effort results from the consultation of a particular high number of patients that are concerned about suffering from PACS without a following medical confirmation. To guarantee a high quality and adequate provision of care for a potentially further increasing number of concerned patients, the ambulatory health services should be strengthened and adequately compensated., (© 2023. The Author(s).)

Studying can be very stressful leading to a decreased academic efficacy. In this exploratory longitudinal study, we analysed a wide range of students' leisure activities and their effects on students' academic efficacy. Further, we identified the personality types of students who choose specific leisure activities as a strategy to stress reduction and determined how the use of leisure behaviours affects academic performance among students with different personality types. Students were asked about their personality (Neo-FFI), leisure time behaviour (self-generated items), and academic efficacy (MBI-SS) at three measurement points. Multivariate regression analyses were applied to estimate the moderation effects. In total, 331 students were included in the study. Social activities were found to have a direct effect on academic efficacy. The students' personality moderated the effects of leisure behaviour on efficacy, suggesting a negative effect on academic efficacy for some personality traits. Since our results suggest that the effectiveness of stress management through the use of leisure behaviour depends on the students' personality, universities offering stress management services should pay attention to precise targeting to attract the specific students who might benefit the most from the offered services., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Köslich-Strumann et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Routinely collected health data from ambulatory care providers offer a wide range of research opportunities. However, the access is often (e.g., technically) hindered, particularly in Germany. In the following, we describe the development of an infrastructure for the analysis of pseudonymized routine data extracted from primary care practices in Germany. Further, we analyze the impact of the outbreak of SARS-CoV-2 on the utilization of primary care services for patients with type 2 diabetes mellitus (DM type 2)., Methods: In this retrospective cohort study, routine data were extracted from nine private primary care practices before and since the outbreak of SARS-CoV-2 in Germany. The sample consisted of patients who were treated between 2016 and 2022 in one of the participating practices. The effects of the outbreak on the frequency of practice visits and the disease course of DM type 2 patients were analyzed by means of bivariate and multivariate analyses., Results: The developed infrastructure offers an analysis of routine data from outpatient care within 24 h. In total, routine data of 30,734 patients could be processed for the analyses with 4182 (13.6%) patients having a diagnosed DM type 2 and 59.0% of these patients were enrolled in a disease management program (DMP). In the multivariate analysis, there was a significant negative effect of the SARS-CoV-2 outbreak on utilization of outpatient services of patients with DM type 2 disease. This decrease was less pronounced among DMP patients. The glycated haemoglobin level (HbA1c) has not changed significantly., Conclusions: The study showed that the analysis of routine data from outpatient care in Germany is possible in a timely manner using a special developed electronic health record system and corresponding software. The significantly negative effect of the SARS-CoV-2 outbreak on utilization of outpatient services of patients with DM type 2 disease was less pronounced among DMP patients. Two years after the start of the Covid pandemic a significantly worsened course of illness cannot be observed. However, it must be taken into account that the observation period for clinically relevant outcomes is still relatively short., (© 2022. The Author(s).)

Importance: SARS-CoV-2 vaccines are authorized for use in most age groups. The safety of SARS-CoV-2 vaccines is unknown in children younger than 5 years., Objective: To retrospectively evaluate the safety of the BNT162b2 vaccine used off-label in children younger than 5 years compared with the safety of non-SARS-CoV-2 vaccines in the same sample., Design, Setting, and Participants: This investigator-initiated retrospective cohort study included parents or caregivers who registered children for SARS-CoV-2 vaccination in outpatient care facilities in Germany. The study was performed as an authenticated online survey. A total of 19 000 email addresses were contacted from vaccination registration databases between April 14 and May 9, 2022. Inclusion criteria were child age younger than 5 years at the first BNT162b2 vaccination and use of a correct authentication code to prove invitation., Exposures: Off-label BNT162b2 vaccination and on-label non-SARS-CoV-2 vaccinations., Main Outcomes and Measures: Reported short-term safety data of 1 to 3 doses of 3 to 10 μg BNT162b2 in children from birth to younger than 60 months are presented. Coprimary outcomes were the frequencies of 11 categories of symptoms after vaccination with bivariate analyses and regression models adjusting for age, sex, weight, and height., Results: The study included 7806 children (median age, 3 years [IQR, 2-4 years]; 3824 [49.0%] female) who were followed up of for a mean (SD) of 91.4 (38.8) days since first BNT162b2 vaccination (survey response rate, 41.1%). A 10-μg dosage was more frequently associated with local injection-site symptoms compared with lower dosages. In the active-comparator analysis, the probability of any symptoms (odds ratio [OR], 1.62; 95% CI, 1.43-1.84), local symptoms (OR, 1.68; 95% CI, 1.38-2.05), musculoskeletal symptoms (OR, 2.55; 95% CI, 1.32-4.94), dermatologic symptoms (OR, 2.18; 95% CI, 10.7-4.45), or otolaryngologic symptoms (OR, 6.37; 95% CI, 1.50-27.09) were modestly elevated after BNT162b2 compared with non-SARS-CoV-2 vaccines, whereas the probabilities of general symptoms (OR, 0.77; 95% CI, 0.63-0.95) and fever (OR, 0.42; 95% CI, 0.32-0.55) were lower after BNT162b2. Symptoms requiring hospitalization (n = 10) were reported only at BNT162b2 dosages above 3 μg., Conclusions and Relevance: In this cohort study, the symptoms reported after BNT162b2 administration were comparable overall to those for on-label non-SARS-CoV-2 vaccines in this cohort of children younger than 5 years. The present data may be used together with prospective licensure studies of BNT162b2 efficacy and safety and could help guide expert recommendations about BNT162b2 vaccinations in this age group.

Background: The GERDA ("Protected e-prescription service for pharmacies") project of the Chamber of Pharmacists (LAK) and Pharmacists Association (LAV) of the federal state of Baden-Wuerttemberg provided the opportunity to prescribe medications within the telemedical portal "docdirekt" that is operated by the Association of Statutory Health Insurance Physicians of Baden-Wuerttemberg. Against this background, the aim of the study was to explore and prioritize barriers and enablers among pharmacists to participate in a medical supply system that includes electronic prescriptions (e-prescriptions). Based on these determinants, recommendations for optimizing the successful implementation of similar care offers were derived., Method: A mixed methods design was chosen to explore and prioritize the determinants. In the first step, determinants for participation in an electronic prescribing system were explored by means of individual interviews of docdirekt tele-physicians, primary care physicians and pharmacists. In a second step, these determinants were prioritized through a quantitative survey of pharmacists., Results: Out of the 523 pharmacists that answered the questionnaire, more than half were willing to participate in an e-prescription system, while 8.5% excluded future participation. A total of 18 determinants for the e-prescription system participation could be explored. The protection of the free pharmacy choice for the patients was identified as the most important determinant, followed by the option of a correction function for e-prescriptions (e. g. to avoid retaxing or medication errors), the integration of the e-prescription into the existing pharmacy IT system and the statutory exclusion of direct contracts with online pharmacies. Time savings and possibly higher remunerations were rated as less relevant., Conclusion: More than half of the pharmacies surveyed stated that they wanted to participate in an e-prescription system. Widespread introduction of e-prescriptions in planned for January 2022. Successful implementation of this move will be facilitated if the identified determinants are taken into consideration by politics, software developers and associations., Competing Interests: Die Autoren geben keinen Interessenkonflikt an. Die Studie wurde finanziell durch die Landesapothekerkammer Baden-Württemberg und das Ministerium für Soziales und Integration Baden-Württemberg unterstützt. Die Studie erfolgte weisungsunabhängig., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Public reporting on the quality of care is intended to guide patients to the provider with the highest quality and to stimulate a fair competition on quality. We apply a difference-in-differences design to test whether hospital quality has improved more in markets that are more competitive after the first public release of performance data in Germany in 2008. Panel data from 947 hospitals from 2006 to 2010 are used. Due to the high complexity of the treatment of stroke patients, we approximate general hospital quality by the 30-day risk-adjusted mortality rate for stroke treatment. Market structure is measured (comparatively) by the Herfindahl-Hirschman index (HHI) and by the number of hospitals in the relevant market. Predicted market shares based on exogenous variables only are used to compute the HHI to allow a causal interpretation of the reform effect. A homogenous positive effect of competition on quality of care is found. This effect is mainly driven by the response of non-profit hospitals that have a narrow range of services and private for-profit hospitals with a medium range of services. The results highlight the relevance of outcome transparency to enhance hospital quality competition., (© 2022. The Author(s).)

Background: The increase of centralization developments in primary and secondary care practices may cause the organizational needs to increase as well, as the practices grow in size. This continuous change is observed in different stages in various countries since, from the perspective of a physician, it is reinforced by the benefits it adds to flexible work configuration, professional exchange and specialization. However, in order to benefit from the joint practice system, the proper managerial skills of practice managers are required, as doctors are not naturally prepared to fulfill such tasks. This study thus aims to gain insight into physicians' views in group practices and acquire a greater understanding of expectations towards practice management and the emerging role of practice managers (PM)., Methods: A cross-sectional study design was employed which utilized an anonymous online questionnaire. In total, 3,456 physicians were invited to participate in the study between February 8 th and March 17 th 2021 by the Association of Statutory Health Insurance Physicians of Baden-Württemberg, Germany. Bivariate and multivariate analyses were applied to characterize the expectations of physicians towards practice management., Results: The survey yielded 329 replies (9,5%). 50% of the participating practices already had a PM employed. In general, these practices were larger than practices without a PM. Most physicians (85%) considered a medical background to be essential for the task of a PM. While practices without a PM considered it important for PMs to have medical qualifications, practices with a PM favored qualifications in business administration. 77.2% of physicians preferred to educate and recruit PMs out of their current practice staff. Competence in organizational tasks, such as coordination of tasks and quality management, was considered to be an essential skill of a PM and had the highest agreement levels among those surveyed, followed by staff management of non-physicians, billing, bookkeeping, staff management of physicians and recruiting. Based on multivariate regression analysis, larger practices valued the role of a PM more and were more likely to employ a PM. Notably, the effect that size had on these items was more substantial for generalists than specialists., Conclusions: The benefits and importance of PMs as well as the potential for delegation are recognized, in particular, by larger practices. The positive feelings that physicians who already employ PMs have towards their contribution to ambulatory care are even more significant. Pre-existing medical support staff has been identified to be the most desirable candidates for taking on the role of PM., (© 2022. The Author(s).)

Key Points: In our clinical cross-sectional study, we identified 107 of 347 patients who were tested positive for antibodies of novel Coronavirus 2019 (SARS-CoV-2). Main symptoms were exhaustion and cough, exposition to other COVID-19-patients appeared frequently., Background: There is urgent need for information on predictive parameters on immunity and infectivity in Coronavirus disease-2019 (COVID-19) pandemic. Our aim was to investigate distribution of novel Coronavirus 2019 (SARS-CoV-2) infections in a German General Practice and to learn about possible predictive parameters regarding infection and pathways of transmission., Methods: In our cross-sectional study, we tested 347 patients of our General Practice using 2019-nCoV-2-IgG/IgM antibody test [2019-nCoV2 IgG/IgM Rapid Test Cassette (Ref.: INCP-402/INCP-402B; ACRO, BIOTECH, INC.)]. We asked for 13 specific symptoms and 4 questions to investigate patients' surroundings., Results: A total of 107 of 347 patients were tested positive for antibodies (Immunoglobulin M-positive and/or Immunoglobulin G-positive). In antibody-positive group, body aches and rhinorrhea were seen more often and there were significantly less asymptomatic patients. Stay in area of risk was significantly more frequent in antibody-positive group as well as contact to infected persons. Distribution of other symptoms was not significantly different between both groups. Most adults or children with SARS-CoV-2 infection presented with mild flu-like symptoms., Conclusion: A total of 30% of patients had antibodies. It was not possible to identify one solid predictive symptom. Serological testing may be helpful for the diagnosis of suspected patients with negative RT-PCR results and for the identification of asymptomatic infections., (© 2021. Royal Academy of Medicine in Ireland.)

Background: In Germany, family physicians care for about 85% of the patients infected with SARS-CoV-2. The geographic distribution of the first wave in 2020 was heterogeneous, and each federal state experienced different percentages of patients that died from COVID-19. Each of the 16 federal states implemented its own regulation about medical care for SARS-CoV-2 infected patients. Against this background, the objective of this analysis was to gather experiences made by primary care physicians managing SARS-CoV-2 infected patients during the first wave in March 2020 and to clinically characterize these patients., Methods: In total, 5,632 physicians were invited to participate in an online questionnaire surveying routine data regarding the general care situation at the physician practice level and the care for patients infected with SARS-CoV-2. Bivariate and multivariate analyses were applied to characterize treatment experiences and to identify patient characteristics predicting the course of disease., Results: 132 family physicians from all German federal states (except from Berlin) participated in this analysis (response rate 2.3%) and provided routine care data for 1,085 patients. Information from 373 of these patients were provided in greater detail. On average, each physician treated 8.5 patients infected with SARS-CoV-2. About 15% of the physicians used video consultations to communicate with their infected patients. More than 82% made positive experiences with the exceptional regulation to provide a certificate of incapacity to work by telephone. Half of the physicians faced equipment insufficiencies due to a lack of protective gear, and in 10% of the practices, the staff themselves acquired SARS-CoV-2 infection. Greater numbers of SARS-CoV-2 cases treated in a practice translated into higher odds for members of the practice to get infected (odds ratio (OR) 1.03, 95% CI [1.01;1.06]). Older persons, males and patients in rural areas had higher odds of a severe course of disease., Conclusions: Our results show that a large percentage of primary care physicians additionally managed their COVID-19 patients remotely by telephone or video during the outbreak, while also being at a higher risk for SARS-CoV-2 infection. Further, the increased severity in rural areas underlines the importance of strong primary health care in order to enable hospitals to concentrate on critically ill patients., (Copyright © 2021. Published by Elsevier GmbH.)

Objective: Current telemedical services, such as the "docdirekt" project in Baden-Württemberg (BW), are evaluated for optimizing their implementation. Based on the results of this evaluation, strategies for adapting these services for exclusive remote treatment are identified that enable their integration in regular medical care., Methods: In the first part of the study, citizens from BW were individually interviewed on their expectations regarding such a project, and the advantages and barriers in the use of services for exclusive remote treatment. Determinants were explored by means of Mayring's qualitative content analysis. In the second part of the study, these determinants were prioritized by using a quantitative survey of randomly selected citizens from BW., Results: A total of 27 subjects (mean age 51 years, min: 23 years, max: 86 years) participated in the interviews. Most importantly, they found the direct accessibility of healthcare professionals a great advantage. A "24/7" hotline was found to be beneficial, as well as the possibility to get electronic prescriptions or medical sickness certificates. Privacy and a missing physical examination were perceived as barriers. In the questionnaire, the participants (n=217, return 10.9%, mean age: 53 years, min: 19 years, max: 88 years) rated a "direct medical contact" as the most important, followed by the "possibility to get a specialist" and to receive "a first therapy suggestion". In total, n=71 (34.6%) rejected the future use of such a service. The willingness to use the service decreased with increasing age and decreasing digital skills., Conclusion: The study shows that there is an interest in the use of services for exclusive remote treatment. People who intend to use telemedical service prioritize the fast-initial medical assessment and the comfort aspects and, among other things, consider the inclusion of additional services as beneficial. The next step is to incorporate these determinants into the existing telemedical service., Competing Interests: Die Autoren geben keinen Interessenkonflikt an. Die Studie wurde finanziell durch die Kassenärztliche Vereinigung Baden-Württemberg und das Ministerium für Soziales und Integration Baden-Württemberg unterstützt. Die Studie erfolgte weisungsunabhängig., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: The treatment of upper respiratory tract infections (URTIs) accounts for the majority of antibiotic prescriptions in primary care, although an antibiotic therapy is rarely indicated. Non-clinical factors, such as time pressure and the perceived patient expectations are considered to be reasons for prescribing antibiotics in cases where they are not indicated. The improper use of antibiotics, however, can promote resistance and cause serious side effects. The aim of the study was to clarify whether the antibiotic prescription rate for infections of the upper respiratory tract can be lowered by means of a short (2 x 2.25h) communication training based on the MAAS-Global-D for primary care physicians., Methods: In total, 1554 primary care physicians were invited to participate in the study. The control group was formed from observational data. To estimate intervention effects we applied a combination of difference-in-difference (DiD) and statistical matching based on entropy balancing. We estimated a corresponding multi-level logistic regression model for the antibiotic prescribing decision of German primary care physicians for URTIs., Results: Univariate estimates detected an 11-percentage-point reduction of prescriptions for the intervention group after the training. For the control group, a reduction of 4.7% was detected. The difference between both groups in the difference between the periods was -6.5% and statistically significant. The estimated effects were nearly identical to the effects estimated for the multi-level logistic regression model with applied matching. Furthermore, for the treatment of young women, the impact of the training on the reduction of antibiotic prescription was significantly stronger., Conclusions: Our results suggest that communication skills, implemented through a short communication training with the MAAS-Global-D-training, lead to a more prudent prescribing behavior of antibiotics for URTIs. Thereby, the MAAS-Global-D-training could not only avoid unnecessary side effects but could also help reducing the emergence of drug resistant bacteria. As a consequence of our study we suggest that communication training based on the MAAS-Global-D should be applied in the postgraduate training scheme of primary care physicians., Competing Interests: CS, KG, TE and JS: the authors declare that they have no competing interests. I have read the journal's policy and the author AS of this manuscript have the following competing interests: AS is an editor of the German version of EbMG. The online access is provided free of charge to the study PCPs by Verlagshaus der Aerzte, Vienna. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Objective: In many places in Germany, the need for primary care physicians has been steadily increasing for several years, especially in rural areas. It is hypothesized that physicians are more likely to practice in rural areas if they have received a broad education and vocational training. Differences between general practitioners (GPs) and physicians in general internal medicine (GIM) in the breadth of their vocational training are created by the underlying distinct training schemes. The aim of the analysis was to test whether GPs and GIM physicians differ in their distribution between urban and rural regions of Schleswig-Holstein and whether there are differences in the rate and frequency of performing home visits., Methods: Based on invoicing data of the Association of Statutory Health Insurance Physicians in the federal state of Schleswig-Holstein (Northern Germany) covering the years 2015 up to the third quarter (Q3) of 2018, we analysed differences between GPs and GIM physicians in their regional distribution. Furthermore, we looked at differences between both specialties regarding the application rate and the number of home visits performed and unforeseen physician visits. In addition to bivariate approaches, we also used multivariate regression analysis., Results: Between 2017 (Q4) and 2018 (Q3), 1,378 GPs and 585 GIM physicians provided medical services in Schleswig-Holstein. While 27.5 % of the GPs had practices in rural areas, the share of GIM physicians was 14.5 % (p < 0.001). Home visits were performed by 97.8 % of the GPs and 93.2 % of the GIM physicians (p < 0.001). This difference was even more pronounced in rural areas (99.5 % vs. 94.1 % (p = 0.002)). Significant differences have also been found in the number of billed home visits. GPs made 36 % more home visits than GIM physicians. In rural areas, the difference was 60 %., Conclusion: The analysis revealed significant differences between GPs and GIM physicians regarding the type of region where they work, the application rate and the number of performed home visits. The findings could foster a discussion about how GIM physicians can be better prepared to provide primary care, especially in rural areas., (Copyright © 2020. Published by Elsevier GmbH.)

We specify a Bayesian, geoadditive Stochastic Frontier Analysis (SFA) model to assess hospital performance along the dimensions of resources and quality of stroke care in German hospitals. With 1,100 annual observations and data from 2006 to 2013 and risk-adjusted patient volume as output, we introduce a production function that captures quality, resource inputs, hospital inefficiency determinants and spatial patterns of inefficiencies. With high relevance for hospital management and health system regulators, we identify performance improvement mechanisms by considering marginal effects for the average hospital. Specialization and certification can substantially reduce mortality. Regional and hospital-level concentration can improve quality and resource efficiency. Finally, our results demonstrate a trade-off between quality improvement and resource reduction and substantial regional variation in efficiency., Competing Interests: The authors have declared that no competing interests exist.

The introduction of prospective hospital reimbursement based on diagnosis-related groups (DRG) has been a conspicuous attempt to decelerate the steady increase of hospital expenditures in the German health sector. In this work, the effect of the financial reform on hospital efficiency is subjected to empirical testing by means of two complementary testing approaches. On the one hand, we apply a two-stage procedure based on non-parametric efficiency measurement. On the other hand, a stochastic frontier model is employed that allows a one-step estimation of both production frontier parameters and inefficiency effects. To identify efficiency gains as a consequence of changes in the hospital incentive structure, we account for technological progress, spatial dependence and hospital heterogeneity. The results of both approaches do not reveal any increase in overall efficiency after the DRG reform. In contrast, a significant decline in overall hospital efficiency over time is observed.

The introduction of prospective hospital reimbursement based on diagnosis related groups (DRG) in 2004 has been a conspicuous attempt to increase hospital efficiency in the German health sector. As a consequence of the reform a rise of competition for (low cost) patients could be expected. In this paper the competition between hospitals, quantified as spatial spillover estimates of hospital efficiency, is analyzed for periods before and after the reform. We implement a two-stage efficiency model that allows for spatial interdependence among hospitals. Hospital efficiency is determined by means of non-parametric and parametric econometric frontier models. We diagnose a significant increase of negative spatial spillovers characterizing hospital performance in Germany, and thus, confirm the expected rise of competition.