Publications by authors named "Maria Flamm"

36 Publications

COVI-Prim survey: Challenges for Austrian and German general practitioners during initial phase of COVID-19.

PLoS One 2021 10;16(6):e0251736. Epub 2021 Jun 10.

Institute for General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University Salzburg, Salzburg, Austria.

Background: Coronavirus disease 2019 (COVID-19) represents a significant challenge to health care systems around the world. A well-functioning primary care system is crucial in epidemic situations as it plays an important role in the development of a system-wide response.

Methods: 2,187 Austrian and German GPs answered an internet survey on preparedness, testing, staff protection, perception of risk, self-confidence, a decrease in the number of patient contacts, and efforts to control the spread of the virus in the practice during the early phase of the COVID-pandemic (3rd to 30th April).

Results: The completion rate of the questionnaire was high (90.9%). GPs gave low ratings to their preparedness for a pandemic, testing of suspected cases and efforts to protect staff. The provision of information to GPs and the perception of risk were rated as moderate. On the other hand, the participants rated their self-confidence, a decrease in patient contacts and their efforts to control the spread of the disease highly.

Conclusion: Primary care is an important resource for dealing with a pandemic like COVID-19. The workforce is confident and willing to take an active role, but needs to be provided with the appropriate surrounding conditions. This will require that certain conditions are met.

Registration: Trial registration at the German Clinical Trials Register: DRKS00021231.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251736PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191874PMC
June 2021

A Choosing Wisely top-5 list to support general practitioners in Austria.

Wien Med Wochenschr 2021 May 10. Epub 2021 May 10.

Institute of General Practice and Evidence-Based Health Research, Medical University Graz, Graz, Austria.

From a pool of 147 reliable recommendations, ten experts from the Austrian Society of General Practice and Family Medicine selected 21 relevant recommendations as the basis for the Delphi process. In two Delphi rounds, eleven experts established a top‑5 list of recommendations designed for Austrian family practice to reduce medical overuse. Three of the chosen recommendations address the issue of antibiotic usage in patients with viral upper respiratory tract infections, in children with mild otitis media, and in patients with asymptomatic bacteriuria. The other two "do not do" recommendations concern imaging studies for nonspecific low back pain and routine screening to detect prostate cancer. A subsequent survey identified the reasons for selecting these top‑5 recommendations: the frequency of the issue, potential harms, costs, and patients' expectations. Experts hope the campaign will save time in educating patients and provide legal protection for omitting measures.
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http://dx.doi.org/10.1007/s10354-021-00846-6DOI Listing
May 2021

Home care nursing for persons with dementia from a family caregivers' point of view: Predictors of utilisation in a rural setting in Austria.

Health Soc Care Community 2021 May 7. Epub 2021 May 7.

Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria.

The service utilisation of persons with dementia (PwD) and their caregivers is subject to lively debate. The reasons for non-utilisation are manifold and heterogeneous. Conceptual models and explanatory frameworks may help identify predictors of the usage of health services. Literature examining the utilisation of home care services for PwD is scarce. This study explored predictors of home care nursing utilisation of PwD and their informal caregivers in a rural setting, according to the Andersen Behavioural Model of Health Care Use. A mixed-methods study was conducted in a rural area of Austria. In using non-random multistage sampling, anonymous questionnaires were distributed to collect data on family caregivers of PwD. Data were analysed using sequential binary logistic regression to characterise home care service users. To reflect the complexity of the Andersen model, a regression tree model was used. In total, 107 family caregivers completed the survey. Predisposing factors for home care nursing utilisation were higher age of the caregiver, female gender of PwD and kinship of the PwD and caregiver. Disruptive behaviour and independence in activities of daily living of PwD were associated with need factors for service use. According to the Andersen model, the predisposing and need factors contributed most to the explanation of home care nursing utilisation. The enabling factors employment, education and income tend to predict service use. Our findings indicate that higher age of the family caregiver and female gender of PwD are the main predictors for utilisation of home care nursing in a rural setting. To improve utilisation, the advantages of professional care services should be promoted, and the awareness about the variety of services available should be increased. To ensure a better understanding of the barriers to accessing home care, PwD should more often be included in healthcare service research.
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http://dx.doi.org/10.1111/hsc.13412DOI Listing
May 2021

Attitudes of medical students to general practice: a multinational cross-sectional survey.

Fam Pract 2021 Jun;38(3):265-271

Institute of General Practice and Evidence-Based Health Services Research, Medical University of Graz, Graz, Austria.

Background: A shortage of general practitioners (GPs) is common to many European countries. To counteract this, it is essential to understand the factors that encourage or discourage medical students from choosing to become a GP.

Objective: To evaluate medical students' attitudes towards general practice and to identify factors that discourage them from considering a career as a GP.

Methods: In this multinational cross-sectional online survey, 29 284 students from nine German, four Austrian and two Slovenian universities were invited to answer a questionnaire consisting of 146 closed and 13 open-ended items.

Results: Of the 4486 students that responded (response rate: 15.3%), 3.6% wanted to become a GP, 48.1% were undecided and 34.6% did not want to be a GP. Significant predictors for interest in becoming a GP were higher age [odds ratio (OR) = 1.06; 95% confidence interval (CI) = 1.02-1.10], positive evaluation of the content of a GP's work (OR = 4.44; 95% CI = 3.26-6.06), organizational aspects (OR = 1.42; 95% CI = 1.13-1.78), practical experience of general practice (OR = 1.66; 95% CI = 1.08-2.56) and the country of the survey [Slovenian versus German students (Reference): OR = 2.19; 95% CI = 1.10-4.38; Austrian versus German students (Reference): OR = 0.50; 95% CI = 0.32-0.79].

Conclusion: Strategies to convince undecided students to opt for a career as a GP should include a positive representation of a GP's work and early and repeated experience of working in a general practice during medical school.
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http://dx.doi.org/10.1093/fampra/cmaa126DOI Listing
June 2021

Improving medication appropriateness in nursing homes via structured interprofessional medication-review supported by health information technology: a non-randomized controlled study.

BMC Geriatr 2020 11 26;20(1):506. Epub 2020 Nov 26.

Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria.

Background: In nursing home residents (NHRs), polypharmacy is widespread, accompanied by elevated risks of medication related complications. Managing medication in NHRs is a priority, but prone to several challenges, including interprofessional cooperation. Against this background, we implemented and tested an interprofessional intervention aimed to improve medication appropriateness for NHRs.

Methods: A non-randomized controlled study (SiMbA; "Sicherheit der Medikamentherapie bei AltenheimbewohnerInnen", Safety of medication therapy in NHRs) was conducted in six nursing homes in Austria (2016-2018). Educational training, introduction of tailored health information technology (HIT) and a therapy check process were combined in an intervention aimed at healthcare professionals. Medication appropriateness was assessed using the Medication Appropriateness Index (MAI). Data was collected before (t0), during (t1, month 12) and after (t2, month 18) intervention via self-administered assessments and electronic health records.

Results: We included 6 NHs, 17 GPs (52.94% female) and 240 NHRs (68.75% female; mean age 85.0). Data of 159 NHRs could be included in the analysis. Mean MAI-change was - 3.35 (IG) vs. - 1.45 (CG). In the subgroup of NHRs with mean MAI ≥23, MAI-change was - 10.31 (IG) vs. -3.52 (CG). The intervention was a significant predictor of improvement in MAI when controlled for in a multivariable regression model.

Conclusions: Improvement of medication appropriateness was clearest in residents with inappropriate baseline MAI-scores. This improvement was independent of variances in certain covariates between the intervention and the control group. We conclude that our intervention is a feasible approach to improve NHRs' medication appropriateness.

Trial Registration: DRKS Data Management, ID: DRKS00012246 . Registered 16.05.2017 - Retrospectively registered.
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http://dx.doi.org/10.1186/s12877-020-01895-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690110PMC
November 2020

Use of an electronic decision support tool to reduce polypharmacy in elderly people with chronic diseases: cluster randomised controlled trial.

BMJ 2020 06 18;369:m1822. Epub 2020 Jun 18.

National Institute for Health Research School for Primary Care Research, School of Health Sciences, University of Manchester, UK.

Objective: To evaluate the effects of a computerised decision support tool for comprehensive drug review in elderly people with polypharmacy.

Design: Pragmatic, multicentre, cluster randomised controlled trial.

Setting: 359 general practices in Austria, Germany, Italy, and the United Kingdom.

Participants: 3904 adults aged 75 years and older using eight or more drugs on a regular basis, recruited by their general practitioner.

Intervention: A newly developed electronic decision support tool comprising a comprehensive drug review to support general practitioners in deprescribing potentially inappropriate and non-evidence based drugs. Doctors were randomly allocated to either the electronic decision support tool or to provide treatment as usual.

Main Outcome Measures: The primary outcome was the composite of unplanned hospital admission or death by 24 months. The key secondary outcome was reduction in the number of drugs.

Results: 3904 adults were enrolled between January and October 2015. 181 practices and 1953 participants were assigned to electronic decision support (intervention group) and 178 practices and 1951 participants to treatment as usual (control group). The primary outcome (composite of unplanned hospital admission or death by 24 months) occurred in 871 (44.6%) participants in the intervention group and 944 (48.4%) in the control group. In an intention-to-treat analysis the odds ratio of the composite outcome was 0.88 (95% confidence interval 0.73 to 1.07; P=0.19, 997 of 1953 1055 of 1951). In an analysis restricted to participants attending practice according to protocol, a difference was found favouring the intervention (odds ratio 0.82, 95% confidence interval 0.68 to 0.98; 774 of 1682 873 of 1712, P=0.03). By 24 months the number of prescribed drugs had decreased in the intervention group compared with control group (uncontrolled mean change -0.42 0.06: adjusted mean difference -0.45, 95% confidence interval -0.63 to -0.26; P<0.001).

Conclusions: In intention-to-treat analysis, a computerised decision support tool for comprehensive drug review of elderly people with polypharmacy showed no conclusive effects on the composite of unplanned hospital admission or death by 24 months. Nonetheless, a reduction in drugs was achieved without detriment to patient outcomes.

Trial Registration: Current Controlled Trials ISRCTN10137559.
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http://dx.doi.org/10.1136/bmj.m1822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301164PMC
June 2020

Comparison of high tone therapy and transcutaneous electrical nerve stimulation therapy in chemotherapy-induced polyneuropathy.

Medicine (Baltimore) 2020 May;99(19):e20149

Institute of Physical Medicine and Rehabilitation.

Introduction: Chemotherapy-induced peripheral neuropathy (CIPN) is a worldwide concern in patients receiving neurotoxic agents for cancer therapy. High tone external muscle stimulation is a promising therapeutic approach to alleviate symptoms of CIPN.

Methods: This pilot study aims to investigate whether the application of home-based high-tone external muscle stimulation therapy (HTEMS) improves symptoms of CIPN. The trial is planned as a therapist- and assessor-blinded, 1:1 randomized controlled study. A total of 50 patients with chemotherapy-induced peripheral polyneuropathy will be included. All patients will perform therapy at home. Study participants will be allocated randomly to the HTEMS therapy (intervention group) or to the transcutaneous electrical nerve stimulation (TENS, control group), respectively, following a standardized therapy schedule. Compliance of participants can be verified by reading out the tool box. Outcomes will be evaluated at baseline and after 8 weeks of home-based therapy. The primary outcome includes improvement of CIPN according to the patient-reported EORTC QLQ-CIPN 20 questionnaire. Secondary outcomes are the patient-reported change in health-related quality of life and clinician-reported changes of vibration sensibility, tendon reflexes, temperature sensibility, perception of touch, and strength of the lower leg muscles. Further a safety- and process evaluation will be performed.

Discussion: This pilot RCT aims to evaluate the impact of home-based HTEMS as compared to TENS in CIPN. There is a need for an effective treatment for CIPN and the results of this study are expected to possibly identify a novel and effective treatment strategy in the future.
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http://dx.doi.org/10.1097/MD.0000000000020149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7220357PMC
May 2020

Evaluation of baseline fracture risk in younger postmenopausal women with breast cancer using different risk assessment methods.

Skeletal Radiol 2020 Jun 24;49(6):1015-1019. Epub 2020 Jan 24.

University Clinic for Nuclear Medicine and Endocrinology, Salzburg, Austria.

Objective: Controversy exists about the impact of bone mineral density (BMD) and fracture risk in newly diagnosed patients with breast cancer (BC). It is presumed that there are differences in BMD between women with BC and healthy controls. BMD is therefore considered as a potential marker to predict BC risk. This study was conducted to investigate the association of BMD, trabecular bone score (TBS) and fracture risk in younger postmenopausal women with hormone responsive BC.

Methods: Overall, 343 women were examined. Women with BC were matched to a control group of the general population. Forty-nine women and fifty-nine controls were included in the final analysis. All subjects underwent dual energy x-ray absorptiometry (DXA) of the lumbar spine, femoral neck, and the total hip to evaluate bone mineral density. The 10-year fracture risk for a major osteoporotic fracture was assessed using the FRAX-score and the TBS-adjusted FRAX-Score, respectively.

Results: Lumbar and femoral neck BMD were similar in BC patients and controls. No difference was found for TBS of the spine (1.38 ± 0.1 vs.1.36 ± 0.09) in the BC and the control group, respectively (p = 0.19). The 10- year probability for a major osteoporotic fracture (MoF) or femoral neck (FN) fracture was 6.1 (± 2.6%) and 0.9 (± 1.2%) in the BC group vs. 6.7 (± 3.5%) (p = 0.33) and 0.9 (± 1.1%) (p = 0.73) in the control group.

Conclusion: Postmenopausal women younger than 60 years with breast cancer do not show any differences in baseline BMD, TBS, or TBS adjusted FRAX in comparison to controls.
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http://dx.doi.org/10.1007/s00256-020-03378-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7170974PMC
June 2020

The challenge to define a relevant change in medication appropriateness index score in older adults - An approach.

Br J Clin Pharmacol 2020 02 12;86(2):398-399. Epub 2020 Jan 12.

Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria.

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http://dx.doi.org/10.1111/bcp.14167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7015747PMC
February 2020

Comparing perspectives of family caregivers and healthcare professionals regarding caregiver burden in dementia care: results of a mixed methods study in a rural setting.

Age Ageing 2020 02;49(2):199-207

Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria.

Background: Persons with dementia (PwD) need support to remain in their own homes as long as possible. Family caregivers, homecare nurses and general practitioners (GPs) play an important role in providing this support, particularly in rural settings. Assessing caregiver burden is important to prevent adverse health effects among this population. This study analysed perceived burden and needs of family caregivers of PwD in rural areas from the perspectives of healthcare professionals and family caregivers.

Methods: This was a sequential explanatory mixed methods study that used both questionnaires and semi-structured interviews. Questionnaires measuring caregiver burden, quality of life and nursing needs were distributed to the caregivers; health professionals received questionnaires with adjusted items for each group. Additionally, in-depth qualitative interviews were carried out with eight family caregivers.

Results: The cross-sectional survey population included GPs (n = 50), homecare nurses (n = 140) and family caregivers (n = 113). Healthcare professionals similarly assessed the psychosocial burden and stress caused by behavioural disturbances as most relevant. Psychological stress, social burden and disruptive behaviour (in that order) were regarded as the most important factors from the caregivers' perspective. It was found that 31% of caregivers reported permanent or frequent caregiver overload. Eight themes related to caregiver burden emerged from the subsequent interviews with caregivers.

Conclusions: Professional support at home on an hourly basis was found to be highly relevant to prevent social isolation and compensate for lack of leisure among caregivers of PwD. Improvement of interprofessional dementia-related education is needed to ensure high-quality primary care.
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http://dx.doi.org/10.1093/ageing/afz165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7047818PMC
February 2020

Impact of training and structured medication review on medication appropriateness and patient-related outcomes in nursing homes: results from the interventional study InTherAKT.

BMC Geriatr 2019 09 18;19(1):257. Epub 2019 Sep 18.

Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria.

Background: Uncoordinated interprofessional communication in nursing homes increases the risk of polypharmacy and inappropriate medication use. This may lead to augmented frequency of adverse drug events, hospitalizations and mortality. The aims of this study were (1) to improve interprofessional communication and medication safety using a combined intervention and thus, (2) to improve medication appropriateness and health-related outcomes of the included residents.

Methods: The single-arm interventional study (2014-2017) was conducted in Muenster, Germany and involved healthcare professionals and residents of nursing homes. The intervention consisted of systematic education of participating healthcare professionals and of a structured interprofessional medication review which was performed via an online communication platform. The primary endpoint was assessed using the Medication Appropriateness Index MAI. Secondary endpoints were: cognitive performance, delirium, agitation, mobility, number of drugs, number of severe drug-drug interactions and appropriateness of analgesics. Outcomes were measured before, during and after the intervention. Data were analyzed using descriptive and inference-statistical methods.

Results: Fourteen general practitioners, 11 pharmacists, 9 nursing homes and 120 residents (n = 83 at all testing times) participated. Overall MAI sum-score decreased significantly over time (mean reduction: -7.1, CI -11.4 - - 2.8; median = - 3.0; d = 0.39), especially in cases with baseline sum-score ≥ 24 points (mean reduction: -17.4, CI -27.6 - - 7.2; median = - 15.0; d = 0.86). MAI sum-score of analgesics also decreased (d = 0.45). Mean number of severe drug-drug interactions rose slightly over time (d = 0.17). The proportion of residents showing agitated behavior diminished from 83.9 to 67.8%. Remaining secondary outcomes were without substantial change.

Conclusion: Medication appropriateness increased particularly in residents with high baseline MAI sum-scores. Cognitive decline of participating residents was seemingly decelerated when compared with epidemiologic studies. A controlled trial is required to confirm these effects. Interprofessional interaction was structured and performance of medication reviews was facilitated as the online communication platform provided unlimited and consistent access to all relevant and updated information.

Trial Registration: DRKS Data Management, ID: DRKS00007900 , date of registration: 2015-09-02 (retrospectively registered i.e. 6 weeks after commencement of the first data collection).
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http://dx.doi.org/10.1186/s12877-019-1263-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6749664PMC
September 2019

Multiprofessional COPD care in Austria-challenges and approaches : Results of a qualitative study.

Wien Klin Wochenschr 2018 Jun 28;130(11-12):371-381. Epub 2018 May 28.

Institute of General, Family and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria.

Background: Chronic obstructive pulmonary disease (COPD) is a frequent disease of the lungs. Its prevalence was estimated to be 26% in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) I and 11% for GOLD II-IV in Austria. Globally, it ranks third in mortality rate. The particular challenge is that care for these patients falls short due to the lack of structured integrated care. The aim was to assess the current status of multiprofessional COPD care in Austria and identify gaps and potentials.

Methods: We conducted guided focus group interviews between March and July 2016 addressing current COPD care and treatment gaps with the following professional and interest groups: general practitioners, nurses, patients, pharmacists, physiotherapists and pulmonologists. We interviewed 23 patients and 27 healthcare professionals. The interviews were transcribed verbatim and coded into 12 relevant categories.

Results: There needs to be a shift in thinking from treatment-based care to prevention. Patients, just like healthcare professionals, need periodic updates and comprehensive information on this disease. Creating internet platforms with useful information for COPD patients and solving the data privacy issues of the Austrian electronic medical record (ELGA) are also perceived as viable steps. There is a need and request for healthcare professionals to work as a team with clear COPD management guidelines in the outpatient sector, the establishment of outpatient rehabilitation centers as well as creating a new professional profile, the COPD nurse.

Conclusion: Current COPD care needs to be reorganized, particularly in the outpatient sector, to address the needs of patients and healthcare professionals.
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http://dx.doi.org/10.1007/s00508-018-1346-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6008351PMC
June 2018

The impact of a disease management programme for type 2 diabetes on health-related quality of life: multilevel analysis of a cluster-randomised controlled trial.

Diabetol Metab Syndr 2018 10;10:28. Epub 2018 Apr 10.

6Institute of General Practice and Family Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany.

Background: Type 2 diabetes is a chronic disease associated with poorer health outcomes and decreased health related quality of life (HRQoL). The aim of this analysis was to explore the impact of a disease management programme (DMP) in type 2 diabetes on HRQoL. A multilevel model was used to explain the variation in EQ-VAS.

Methods: A cluster-randomized controlled trial-analysis of the secondary endpoint HRQoL. Our study population were general practitioners and patients in the province of Salzburg. The DMP "Therapie-Aktiv" was implemented in the intervention group, and controls received usual care. Outcome measure was a change in EQ-VAS after 12 months. For comparison of rates, we used Fisher's Exact test; for continuous variables the independent T test or Welch test were used. In the multilevel modeling, we examined various models, continuously adding variables to explain the variation in the dependent variable, starting with an empty model, including only the random intercept. We analysed random effects parameters in order to disentangle variation of the final EQ-VAS.

Results: The EQ-VAS significantly increased within the intervention group (mean difference 2.19, p = 0.005). There was no significant difference in EQ-VAS between groups (mean difference 1.00, p = 0.339). In the intervention group the improvement was more distinct in women (2.46, p = 0.036) compared to men (1.92, p = 0.063). In multilevel modeling, sex, age, family and work circumstances, any macrovascular diabetic complication, duration of diabetes, baseline body mass index and baseline EQ-VAS significantly influence final EQ-VAS, while DMP does not. The final model explains 28.9% (EQ-VAS) of the total variance. Most of the unexplained variance was found on patient-level (95%) and less on GP-level (5%).

Conclusion: DMP "Therapie-Aktiv" has no significant impact on final EQ-VAS. The impact of DMPs in type 2 diabetes on HRQoL is still unclear and future programmes should focus on patient specific needs and predictors in order to improve HRQoL. Current Controlled trials Ltd., ISRCTN27414162.
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http://dx.doi.org/10.1186/s13098-018-0330-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5892002PMC
April 2018

Improving medication appropriateness in nursing home residents by enhancing interprofessional cooperation: A study protocol.

J Interprof Care 2018 Jul 9;32(4):517-520. Epub 2018 Mar 9.

b Institute of Nursing Science and Practice , Paracelsus Medical University, Salzburg , Austria.

Polypharmacy in elderly people is an increasing challenge for health professionals. Drug-Drug interactions, dosing or administration errors can cause preventable incidents and hospitalizations. Due to chronic illness and multi-morbidity, older people are considered as a particularly vulnerable group of patients. Furthermore, it is well known that communication between health professionals is often insufficient. The aim of this study is to improve the appropriateness of medication of nursing home residents by establishing a long-term structured medication review process and to enhance the interprofessional communication between general practitioners (GPs), nurses and pharmacists. GPs review and adapt medication of residents, nurses perform structured monitoring of residents for drug-related symptoms. Pharmacists check the appropriateness of prescribed therapy by performing a medication analysis. For this purpose, a special electronic platform (SiM-Pl) is developed to extend the original health documentation system with additional tools. SiM-Pl enables participants to gain access to relevant information regardless of time and place and shall facilitate health documentation and exchange of information. All involved health professionals receive a topic-related, specific education. The study is designed as a non-randomized, controlled trial. Health-related benefits and improved quality of life are expected for the participating residents.
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http://dx.doi.org/10.1080/13561820.2018.1448372DOI Listing
July 2018

Altitude and COPD prevalence: analysis of the PREPOCOL-PLATINO-BOLD-EPI-SCAN study.

Respir Res 2017 08 23;18(1):162. Epub 2017 Aug 23.

Department of Pulmonary Medicine, Kepler University Hospital, Krankenhausstrasse 9, A4021, Linz, Austria.

Background: COPD prevalence is highly variable and geographical altitude has been linked to it, yet with conflicting results. We aimed to investigate this association, considering well known risk factors.

Methods: A pooled analysis of individual data from the PREPOCOL-PLATINO-BOLD-EPI-SCAN studies was used to disentangle the population effect of geographical altitude on COPD prevalence. Post-bronchodilator FEV1/FVC below the lower limit of normal defined airflow limitation consistent with COPD. High altitude was defined as >1500 m above sea level. Undiagnosed COPD was considered when participants had airflow limitation but did not report a prior diagnosis of COPD.

Results: Among 30,874 participants aged 56.1 ± 11.3 years from 44 sites worldwide, 55.8% were women, 49.6% never-smokers, and 12.9% (3978 subjects) were residing above 1500 m. COPD prevalence was significantly lower in participants living at high altitude with a prevalence of 8.5% compared to 9.9%, respectively (p < 0.005). However, known risk factors were significantly less frequent at high altitude. Hence, in the adjusted multivariate analysis, altitude itself had no significant influence on COPD prevalence. Living at high altitude, however, was associated with a significantly increased risk of undiagnosed COPD. Furthermore, subjects with airflow limitation living at high altitude reported significantly less respiratory symptoms compared to subjects residing at lower altitude.

Conclusion: Living at high altitude is not associated with a difference in COPD prevalence after accounting for individual risk factors. However, high altitude itself was associated with an increased risk of undiagnosed COPD.
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http://dx.doi.org/10.1186/s12931-017-0643-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569455PMC
August 2017

Effect of training and structured medication review on medication appropriateness in nursing home residents and on cooperation between health care professionals: the InTherAKT study protocol.

BMC Geriatr 2017 01 18;17(1):24. Epub 2017 Jan 18.

Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria.

Background: Pharmacotherapy in residents of nursing homes is critical due to the special vulnerability of this population. Medical care and interprofessional communication in nursing homes are often uncoordinated. As a consequence, polypharmacy and inappropriate medication use are common and may lead to hospitalizations and health hazards. The aim of this study is to optimize communication between the involved professional groups by specific training and by establishing a structured medication review process, and to improve medication appropriateness and patient-relevant health outcomes for residents of nursing homes.

Methods/design: The trial is designed as single-arm study. It involves 300 nursing home residents aged ≥ 65 years and the members of the different professional groups practising in nursing home care (15-20 general practitioners, nurses, pharmacists). The intervention consists of interprofessional education on safe medication use in geriatric patients, and a systematic interprofessional therapy check (recording, reviewing and adapting the medication of the participating residents by means of a specific online platform). The intervention period is divided into two phases; total project period is 3 years. Primary outcome measure is the change in medication appropriateness according to the Medication Appropriateness Index. Secondary outcomes are cognitive performance, occurrence of delirium, agitation, tendency of falls, total number of drugs, number of potentially dangerous drug-drug interactions and appropriateness of recorded analgesic therapy regimens according to the Medication Appropriateness Index. Data are collected at t (before the start of the intervention), t (after the first intervention period) and t (after the second intervention period). Cooperation and communication between the professional groups are investigated twice by qualitative interviews.

Discussion: The project aims to establish a structured system for monitoring of drug therapy in nursing home residents. The newly developed online platform is designed to systematize and to improve the communication between the professional groups and, thus, to enhance quality and safety of drug therapy. Limitations of the study are the lack of a control group and the non-randomly recruited study sample.

Trial Registration: DRKS Data Management, DRKS-ID: DRKS00007900.
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http://dx.doi.org/10.1186/s12877-017-0418-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5241939PMC
January 2017

Interventions to reduce inappropriate polypharmacy: Implications for research and practice.

Maturitas 2017 03 26;97:66-68. Epub 2016 Dec 26.

Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria.

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http://dx.doi.org/10.1016/j.maturitas.2016.12.007DOI Listing
March 2017

Reply to 'Endpoints in strategies to reduce polypharmacy'.

Br J Clin Pharmacol 2017 02 4;83(2):434. Epub 2016 Oct 4.

Institute of General Practice and Family Medicine, University of Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.

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http://dx.doi.org/10.1111/bcp.13125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5237688PMC
February 2017

Impact of strategies to reduce polypharmacy on clinically relevant endpoints: a systematic review and meta-analysis.

Br J Clin Pharmacol 2016 08 7;82(2):532-48. Epub 2016 May 7.

Institute of General Practice and Family Medicine, University of Witten/Herdecke, 58448, Witten, Germany.

Aim: The aim of the present study was to explore the impact of strategies to reduce polypharmacy on mortality, hospitalization and change in number of drugs.

Methods: Systematic review and meta-analysis: a systematic literature search targeting patients ≥65 years with polypharmacy (≥4 drugs), focusing on patient-relevant outcome measures, was conducted. We included controlled studies aiming to reduce polypharmacy. Two reviewers independently assessed studies for eligibility, extracted data and evaluated study quality.

Results: Twenty-five studies, including 10 980 participants, were included, comprising 21 randomized controlled trials and four nonrandomized controlled trials. The majority of the included studies aimed at improving quality or the appropriateness of prescribing by eliminating inappropriate and non-evidence-based drugs. These strategies to reduce polypharmacy had no effect on all-cause mortality (odds ratio 1.02; 95% confidence interval 0.84, 1.23). Only single studies found improvements, in terms of reducing the number of hospital admissions, in favour of the intervention group. At baseline, patients were taking, on average, 7.4 drugs in both the intervention and the control groups. At follow-up, the weighted mean number of drugs was reduced (-0.2) in the intervention group but increased (+0.2) in controls.

Conclusions: There is no convincing evidence that the strategies assessed in the present review are effective in reducing polypharmacy or have an impact on clinically relevant endpoints. Interventions are complex; it is still unclear how best to organize and implement them to achieve a reduction in inappropriate polypharmacy. There is therefore a need to develop more effective strategies to reduce inappropriate polypharmacy and to test them in large, pragmatic randomized controlled trials on effectiveness and feasibility.
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http://dx.doi.org/10.1111/bcp.12959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4972170PMC
August 2016

Polypharmacy in chronic diseases-Reduction of Inappropriate Medication and Adverse drug events in older populations by electronic Decision Support (PRIMA-eDS): study protocol for a randomized controlled trial.

Trials 2016 Jan 29;17:57. Epub 2016 Jan 29.

Duodecim Medical Publications, Helsinki, Finland.

Background: Multimorbidity is increasing in aging populations with a corresponding increase in polypharmacy as well as inappropriate prescribing. Depending on definitions, 25-50 % of patients aged 75 years or older are exposed to at least five drugs. Evidence is increasing that polypharmacy, even when guidelines advise the prescribing of each drug individually, can potentially cause more harm than benefit to older patients, due to factors such as drug-drug and drug-disease interactions. Several approaches reducing polypharmacy and inappropriate prescribing have been proposed, but evidence showing a benefit of these measures regarding clinically relevant endpoints is scarce. There is an urgent need to implement more effective strategies. We therefore set out to develop an evidence-based electronic decision support (eDS) tool to aid physicians in reducing inappropriate prescribing and test its effectiveness in a large-scale cluster-randomized controlled trial.

Methods: The "Polypharmacy in chronic diseases-Reduction of Inappropriate Medication and Adverse drug events in older populations" (PRIMA)-eDS tool is a tool comprising an indication check and recommendations for the reduction of polypharmacy and inappropriate prescribing based on systematic reviews and guidelines, the European list of inappropriate medications for older people, the SFINX-database of interactions, the PHARAO-database on adverse effects, and the RENBASE-database on renal dosing. The tool will be evaluated in a cluster-randomized controlled trial involving 325 general practitioners (GPs) and around 3500 patients across five study centres in the United Kingdom, Germany, Austria and Italy. GP practices will be asked to recruit 11 patients aged 75 years or older who are taking at least eight medications and will be cluster-randomized after completion of patient recruitment. Intervention GPs will have access to the PRIMA-eDS tool, while control GPs will treat their patients according to current guidelines (usual care) without access to the PRIMA-eDS tool. After an observation time of 2 years, intervention and control groups will be compared regarding the primary composite endpoint of first non-elective hospitalization or death.

Discussion: The principal hypothesis is that reduction of polypharmacy and inappropriate prescribing can improve the clinical composite outcome of hospitalization or death. A positive result of the trial will contribute substantially to the improvement of care in multimorbidity. The trial is necessary to investigate not only whether the reduction of polypharmacy improves outcome, but also whether GPs and patients are willing to follow the recommendations of the PRIMA-eDS tool.

Trial Registration: This trial has been registered with Current Controlled Trials Ltd. on 31 July 2014 (ISRCTN10137559).
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http://dx.doi.org/10.1186/s13063-016-1177-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5526277PMC
January 2016

The impact of preoperative testing for blood glucose concentration and haemoglobin A1c on mortality, changes in management and complications in noncardiac elective surgery: a systematic review.

Eur J Anaesthesiol 2015 Mar;32(3):152-9

From the Department of Anaesthesiology, Bolzano Central Hospital, Bolzano, Italy (MB), Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria (MB, GF), Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria (TJ, MF, BH, EM), and Institute of General Practice and Family Medicine, University of Witten/Herdecke, Witten, Germany (AS) *Matthias Bock and Tim Johansson contributed equally to this work.

Background: The risks associated with surgery are elevated in patients with diabetes mellitus. For this reason, preoperative diagnostics frequently include the measurement of blood glucose and haemoglobin A1c (HbA1c), but it is unclear whether these tests contribute to improved perioperative or postoperative outcomes.

Objectives: This systematic review aimed to evaluate the evidence that preoperative testing for blood glucose and HbA1c might influence the following outcome parameters: changes in clinical management; mortality; and the incidence of perioperative and postoperative complications in patients undergoing elective, noncardiac surgery.

Design: We performed a systematic search of the literature from January 2001 to March 2013, thus updating a review carried out by the National Institute for Health and Clinical Excellence (NICE) up to the year 2001.

Eligibility Criteria: Controlled studies including cohort and case-control studies with a population of at least 60 patients were eligible.

Results: The search retrieved 1346 records (including hand-search). Twenty-two studies met all inclusion criteria and were included in the review. Fifteen cohort and two case-control studies evaluated the effectiveness of preoperative blood glucose testing and nine studies the effectiveness of testing HbA1c. Four of the included studies evaluated both tests. There were no data derived from high-quality studies supporting routine preoperative testing for blood glucose or HbA1c in otherwise healthy adult patients undergoing elective noncardiac surgery. Only in vascular and orthopaedic surgery may screening identify patients at an increased risk.

Conclusion: Preoperative blood glucose testing and testing for HbA1c is not required in nondiabetic patients unless there are clinical sings arousing suspicion. Patients scheduled for vascular and orthopaedic surgery carry an elevated risk justifying preoperative testing for blood glucose or HbA1c as a screening tool.
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http://dx.doi.org/10.1097/EJA.0000000000000117DOI Listing
March 2015

Is the Cochrane collaboration prepared for the era of patient-centred outcomes research?

Cochrane Database Syst Rev 2013 Mar 28(3):ED000054. Epub 2013 Mar 28.

Austrian Branch of the German Cochrane Centre, Department for Evidence-based Medicine and Clinical Epidemiology, Danube University Krems, Austria.

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http://dx.doi.org/10.1002/14651858.ED000054DOI Listing
March 2013

Quality improvement in preoperative assessment by implementation of an electronic decision support tool.

J Am Med Inform Assoc 2013 Jun 18;20(e1):e91-6. Epub 2013 Apr 18.

Institute of General Practice, Family Medicine and Preventive Medicine; Paracelsus Medical University, Salzburg, Austria.

Objectives: To evaluate the impact of the electronic decision support (eDS) tool 'PReOPerative evaluation' (PROP) on guideline adherence in preoperative assessment in statutory health care in Salzburg, Austria.

Materials And Methods: The evaluation was designed as a non-randomized controlled trial with a historical control group (CG). In 2007, we consecutively recruited 1363 patients admitted for elective surgery, and evaluated the preoperative assessment. In 2008, PROP was implemented and available online. In 2009 we recruited 1148 patients preoperatively assessed using PROP (294 outpatients, 854 hospital sector). Our analysis includes full blood count, liver function tests, coagulation parameters, electrolytes, ECG, and chest x-ray.

Results: The number of tests/patient without indication was 3.39 in the CG vs 0.60 in the intervention group (IG) (p<0.001). 97.8% (CG) vs 31.5% (IG) received at least one unnecessary test. However, we also observed an increase in recommended tests not performed/patient (0.05±0.27 (CG) vs 0.55±1.00 (IG), p<0.001). 4.2% (CG) vs 30.1% (IG) missed at least one necessary test. The guideline adherence (correctly tested/not tested) improved distinctively for all tests (1.6% (CG) vs 49.3% (IG), p<0.001).

Discussion: PROP reduced the number of unnecessary tests/patient by 2.79 which implied a reduction of patients' burden, and a relevant cut in unnecessary costs. However, the advantage in specificity caused an increase in the number of patients incorrectly not tested. Further research is required regarding the impact of PROP on perioperative outcomes.
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http://dx.doi.org/10.1136/amiajnl-2012-001178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715339PMC
June 2013

Patient and physician related factors of adherence to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: a cross sectional study.

BMC Fam Pract 2013 Apr 4;14:47. Epub 2013 Apr 4.

Institute of General Practice and Family Medicine, University of Witten/Herdecke, Witten, Germany.

Background: Patients do not always receive guideline-adherent therapy, yet little is known about the underlying causes on the patients' side. We quantified non-guideline-adherent treatment of chronic diseases (diabetes mellitus, hypertension, cardiovascular disease, heart failure, atrial fibrillation) in primary care and analysed the causes from the physician's as well as the patient's view.

Methods: With the intention to analyze the frequency and causes of non-guideline-adherent treatment of patients with chronic diseases, we drew a random sample of 124 general practitioners (GP) in Salzburg, Austria, of which 58 (46.8%) participated. In the participating GP surgeries, we consecutively recruited 501 patients with at least one of the target-diseases and checked the guideline conformity of treatment using 9 quality indicators. We then interviewed the patients as well as the general practitioners regarding factors affecting deviation from guideline recommendations.

Results: Of the 501 patients, a total of 1224 quality indicators could be analysed. Non-adherence to guideline recommendations were present in 16.8% (n = 205, 95% CI 14.7 to 18.8%) of all quality indicators. In 61.5% of these cases (n = 126, 95% CI 53.0 to 70.0%) the treatment was wrongly judged as not recommended by the physicians. In 10.2% (n = 21, 95% CI 0 to 23.2%) physicians attributed non-adherence to patient's non-compliance, and in 10.7% (n = 22, 95% CI 0 to 23.7%) to an adverse drug event, whereas only 5.4% (n = 11, 95% CI 0 to 18.7%) of non-adherence was related to an adverse drug event reported by the patients. Patients were unaware regarding the reason for non-adherent therapy in 64.4% (n = 132, 95% CI 56.2 to 72.6%) of the quality indicators. In 20.0% (n = 41, 95% CI 7.8 to 32.2%) patients regarded a drug as not needed.

Conclusions: Guideline adherence in chronic care was relatively good in our study sample, but still leaving room for improvement. Physicians' lack of knowledge and patients' lack of awareness account for about 70% of non-adherence, indicating the necessity to improve physician education, and patient involvement. In about 30% of the quality indicators not fulfilled, non-adherence is due to other reasons like adverse drug events or patients not willing to take a recommended drug.
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http://dx.doi.org/10.1186/1471-2296-14-47DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3623850PMC
April 2013

Is Europe putting theory into practice? A qualitative study of the level of self-management support in chronic care management approaches.

BMC Health Serv Res 2013 Mar 26;13:117. Epub 2013 Mar 26.

Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Duboisdomein 30, PO Box 616, 6200 MD, Maastricht, The Netherlands.

Background: Self-management support is a key component of effective chronic care management, yet in practice appears to be the least implemented and most challenging. This study explores whether and how self-management support is integrated into chronic care approaches in 13 European countries. In addition, it investigates the level of and barriers to implementation of support strategies in health care practice.

Methods: We conducted a review among the 13 participating countries, based on a common data template informed by the Chronic Care Model. Key informants presented a sample of representative chronic care approaches and related self-management support strategies. The cross-country review was complemented by a Dutch case study of health professionals' views on the implementation of self-management support in practice.

Results: Self-management support for chronically ill patients remains relatively underdeveloped in Europe. Similarities between countries exist mostly in involved providers (nurses) and settings (primary care). Differences prevail in mode and format of support, and materials used. Support activities focus primarily on patients' medical and behavioral management, and less on emotional management. According to Dutch providers, self-management support is not (yet) an integral part of daily practice; implementation is hampered by barriers related to, among others, funding, IT and medical culture.

Conclusions: Although collaborative care for chronic conditions is becoming more important in European health systems, adequate self-management support for patients with chronic disease is far from accomplished in most countries. There is a need for better understanding of how we can encourage both patients and health care providers to engage in productive interactions in daily chronic care practice, which can improve health and social outcomes.
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http://dx.doi.org/10.1186/1472-6963-13-117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3621080PMC
March 2013

Reported barriers to evaluation in chronic care: experiences in six European countries.

Health Policy 2013 May 27;110(2-3):220-8. Epub 2013 Feb 27.

London School of Hygiene & Tropical Medicine, Faculty of Public Health and Policy, 15-17 Tavistock Place, London WC1H9SH, United Kingdom. Electronic address:

Introduction: The growing movement of innovative approaches to chronic disease management in Europe has not been matched by a corresponding effort to evaluate them. This paper discusses challenges to evaluation of chronic disease management as reported by experts in six European countries.

Methods: We conducted 42 semi-structured interviews with key informants from Austria, Denmark, France, Germany, The Netherlands and Spain involved in decision-making and implementation of chronic disease management approaches. Interviews were complemented by a survey on approaches to chronic disease management in each country. Finally two project teams (France and the Netherlands) conducted in-depth case studies on various aspects of chronic care evaluation.

Results: We identified three common challenges to evaluation of chronic disease management approaches: (1) a lack of evaluation culture and related shortage of capacity; (2) reluctance of payers or providers to engage in evaluation and (3) practical challenges around data and the heterogeity of IT infrastructure. The ability to evaluate chronic disease management interventions is influenced by contextual and cultural factors.

Conclusions: This study contributes to our understanding of some of the most common underlying barriers to chronic care evaluation by highlighting the views and experiences of stakeholders and experts in six European countries. Overcoming the cultural, political and structural barriers to evaluation should be driven by payers and providers, for example by building in incentives such as feedback on performance, aligning financial incentives with programme objectives, collectively participating in designing an appropriate framework for evaluation, and making data use and accessibility consistent with data protection policies.
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http://dx.doi.org/10.1016/j.healthpol.2013.01.019DOI Listing
May 2013

Frequency of medication errors in primary care patients with polypharmacy.

Fam Pract 2013 Jun 6;30(3):313-9. Epub 2012 Nov 6.

Paracelsus Medical University, Salzburg, Austria.

Background: Chronic diseases affect more than half of the population ≥75 years of age in developed countries. Prescription medication use increases with age. Depending on definition, 25-80% of elderly are exposed to polypharmacy. Polypharmacy increases the risk of hospitalization, interactions and adverse drug reactions.

Objective: To examine the frequency of medication errors in patients with polypharmacy treated in general practice.

Methods: The medications of 169 patients with polypharmacy treated in 22 GP surgeries in Austria were analysed. The analysis identified (i) medication errors, including non-evidence-based medications, dosing errors and potentially dangerous interactions in all patients and (ii) potentially inappropriate medications (PIMs) in the subgroup of elderly patients (≥65 years).

Results: The patients took on average 9.1±3.0 medications per day. The maximum, in one patient, was 20 medications per day. Some 93.5% had at least one non-evidence-based medication. On average, 2.7±1.66 medications per patient were found to be not indicated. At least one dosing error was found in 56.2% of all patients. One potential interaction of the most severe degree (category X interaction) was detected in 1.8% (n = 3) and two such interactions in 0.6% (n = 1). These combinations should have been avoided. Of the 169 patients, 158 were elderly (≥65 years). Of these seniors, 37.3% (n = 59) had at least one PIM according to the PRISCUS list for the elderly.

Conclusion: The frequency of medication errors is high in patients with polypharmacy in primary care. Development of strategies (e.g. external medication review) is required to counteract medication errors.
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http://dx.doi.org/10.1093/fampra/cms070DOI Listing
June 2013

Effectiveness of the Austrian disease management programme "Therapie Aktiv" for type 2 diabetes regarding the improvement of metabolic control, risk profile and guideline adherence: 2 years of follow up.

Wien Klin Wochenschr 2012 Sep 8;124(17-18):639-46. Epub 2012 Aug 8.

Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria.

Background: We evaluated the disease management programme (DMP) "Therapie Aktiv" for diabetes mellitus type 2 during the first year of implementation in a cluster-randomised controlled trial (RCT), which revealed an improvement of process quality, but only insignificant effects on HbA1c. To further analyse the effects of the DMP we followed up participants of the RCT for another year.

Methods: After completion of the RCT, the study was continued as an open observational trial. By patient's choice, three groups were formed. Group 1 (DMP/DMP): interventions of the RCT (DMP), who remained in the DMP; group 2 (Control/DMP): controls of the RCT (usual care), who participated in the DMP during the second year; group 3 (Control/Control): controls of the RCT (usual care), who remained as controls.

Primary Outcome Measure: HbA1c.

Secondary Outcome Measures: BMI, lipids, blood pressure and measures of process quality.

Results: Only 801 of 1,489 RCT participants completed the study (53.8 %). Group 1: n = 355; group 2: n = 335; group 3: n = 111. After 2 years, pre-post-analysis revealed a significant reduction of HbA1c (0.37 %, p < 0.001) in both DMP groups, and a reduction of only 0.03 % (p = 0.975) in the control group. However, the difference between the groups was not significant (p = 0.065). There was a significant improvement of process quality in the DMP groups compared with controls.

Conclusion: The DMP clearly enhances process quality. Furthermore, the DMP yields a reduction of HbA1c within groups after 2 years, but significance is lost in between-group analysis. We conclude that the DMP has only a minor effect on metabolic control.
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http://dx.doi.org/10.1007/s00508-012-0226-xDOI Listing
September 2012

Overcoming fragmentation in health care: chronic care in Austria, Germany and The Netherlands.

Health Econ Policy Law 2012 Jan;7(1):125-46

Health and Healthcare Research programme, Westbrook Centre, RAND Europe, Cambridge, UK.

The growing recognition of care fragmentation is causing many countries to explore new approaches to healthcare delivery that can bridge the boundaries between professions, providers and institutions and so better support the rising number of people with chronic health problems. This paper examines the role of the regulatory, funding and organisational context for the development and implementation of approaches to chronic care, using examples from Austria, Germany and the Netherlands. We find that the three countries have implemented a range of policies and approaches to achieve better coordination within and across the primary and secondary care interface and so better meet the needs of patients with chronic conditions. This has involved changes to the regulatory framework to support more coordinated approaches to care (Austria, Germany), coupled with financial incentives (Austria, Germany) or changes in payment systems (the Netherlands). What is common to the three countries is the comparative 'novelty' of policies and approaches aimed at fostering coordinated care; however, the evidence of their impact remains unclear.
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http://dx.doi.org/10.1017/S1744133111000338DOI Listing
January 2012