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Hintergrund
Die chronische Nierenkrankheit (CKD) ist eine häufige Erkrankung, insbesondere im höheren Alter. Um der Progression der Erkrankung und deren Komplikationen vorzubeugen, ist eine leitliniengerechte ambulante Versorgung von Patient:innen mit CKD anzustreben. Zur Messung und Bewertung der Versorgungsqualität können Qualitätsindikatoren (QI) genutzt werden. In Deutschland existieren bisher keine QI für CKD. Ziel der Arbeit war die Entwicklung von QI für die Qualitätsüberprüfung der ambulanten Versorgung von Patient:innen über 70 Jahren mit nichtdialysepflichtiger CKD.
Material und Methoden
Auf Grundlage der nationalen S3-Leitlinie CKD und eines Reviews internationaler QI wurde eine Liste von QI erstellt. Die ausgewählten QI wurden in 2 Sets eingeteilt: basierend auf Routinedaten (z. B. Abrechnungsdaten der Krankenkassen) und auf Datenerhebung in der Praxis (Chart-Review). Expert:innen verschiedener Fachrichtungen sowie ein Patient:innenvertreter bewerteten diese in einem Delphi-Verfahren mit 2‑stufiger Onlinebefragung im Oktober 2021 und Januar 2022 und abschließender Konsensuskonferenz im März 2022. Zusätzlich wurden Ranglisten der wichtigsten QI von jedem Set erstellt.
Ergebnisse
Ein Inzidenz- und ein Prävalenzindikator wurden a priori festgelegt und standen nicht zur Abstimmung. Weitere 21 QI standen zur Abstimmung durch die Expert:innen. Für jedes QI-Set wurden die 7 wichtigsten Indikatoren ausgewählt. Nur 1 QI wurde von dem Expert:innenpanel für den zusätzlichen Einsatz bei Erwachsenen unter 70 Jahren als nicht geeignet eingestuft.
Diskussion
Die QI sollen es ermöglichen, die Qualität der ambulanten Versorgung von Patient:innen mit CKD zu untersuchen, mit dem Ziel, die leitlinienkonforme ambulante Versorgung zu optimieren.
Background
Multimedia multi-device measurement platforms may make the assessment of prevention-related medical variables with a focus on cardiovascular outcomes more attractive and time-efficient. The aim of the studies was to evaluate the reliability (Study 1) and the measurement agreement with a cohort study (Study 2) of selected measures of such a device, the Preventiometer.
Methods
In Study 1 (N = 75), we conducted repeated measurements in two Preventiometers for four examinations (blood pressure measurement, pulse oximetry, body fat measurement, and spirometry) to analyze their agreement and derive (retest-)reliability estimates. In Study 2 (N = 150), we compared somatometry, blood pressure, pulse oximetry, body fat, and spirometry measurements in the Preventiometer with corresponding measurements used in the population-based Study of Health in Pomerania (SHIP) to evaluate measurement agreement.
Results
Intraclass correlations coefficients (ICCs) ranged from .84 to .99 for all examinations in Study 1. Whereas bias was not an issue for most examinations in Study 2, limits of agreement for most examinations were very large compared to results of similar method comparison studies.
Conclusion
We observed a high retest-reliability of the assessed clinical examinations in the Preventiometer. Some disagreements between Preventiometer and SHIP examinations can be attributed to procedural differences in the examinations. Methodological and technical improvements are recommended before using the Preventiometer in population-based research.
Background: Fatigue, dyspnea, and lack of energy and concentration are commonly interpreted as indicative of symptomatic anemia and may thus play a role in diagnostic and therapeutic decisions. Objective: To investigate the association between symptoms commonly attributed to anemia and the actual presence of anemia. Methods: Data from two independent cohorts of the Study of Health in Pomerania (SHIP) were analyzed. Interview data, laboratory data, and physical examination were individually linked with claims data from the Association of Statutory Health Insurance Physicians. A complete case analysis using logistic regression models was performed to evaluate the association of anemia with symptoms commonly attributed to anemia. The models were adjusted for confounders such as depression, medication, insomnia, and other medical conditions. Results: A total of 5979 participants (53% female, median age 55) were included in the analysis. Of those, 30% reported fatigue, 16% reported lack of energy, 16% reported lack of concentration, and 29% reported dyspnea and/or weakness. Anemia was prevalent in about 6% (379). The symptoms were more prevalent in participants with anemia. However, participants with anemia were older and had a poorer health status. There was no association in multivariate logistic regression models between the symptoms fatigue, lack of concentration, dyspnea, and/or weakness and anemia. Anemia was associated (OR: 1.45; 95% CI: 1.13–1.86) with lack of energy in the multivariate analysis. Other factors such as depression, insomnia, and medication were more strongly associated with the symptoms. Conclusion: The clinical symptoms commonly attributed to anemia are unspecific and highly prevalent both in non-anemic and anemic persons. Even in the presence of anemia, other diagnoses should be considered as causes such as depression, heart failure, asthma, and COPD, which are more closely associated with the symptoms. Further diagnostic research is warranted to explore the association of symptoms in different subgroups and settings in order to help clinical decision making.
Background
Although chronic kidney disease (CKD) is highly prevalent in the general population, little research has been conducted on CKD management in ambulatory care.
Objective was to assess management and quality of care by evaluating CKD coding in ambulatory care, patient diagnosis awareness, frequency of monitoring and whether appropriate patients are referred to nephrology.
Methods
Clinical data from the population-based cohort Study of Health in Pomerania (SHIP-START) were matched with claims data of the Association of Statutory Health Insurance Physicians. Quality of care was evaluated according international and German recommendations.
Results
Data from 1778 participants (56% female, mean age 59 years) were analysed. 10% had eGFR < 60 ml/min/1.73m2 (mean age 74 years), 15% had albuminuria. 21% had CKD as defined by KDIGO. 20% of these were coded and 7% self-reported having CKD. Coding increased with GFR stage (G3a 20%, G3b 61%, G4 75%, G5 100%). Serum creatinine and urinary dip stick testing were billed in the majority of all participants regardless of renal function. Testing frequency partially surpassed recommendations. Nephrology consultation was billed in few cases with stage G3b-G4.
Conclusion
CKD coding increased with stage and was performed reliably in stages ≥ G4, while CKD awareness was low. Adherence to monitoring and referral criteria varied, depending on the applicability of monitoring criteria. For assessing quality of care, consent on monitoring, patient education, referral criteria and coordination of care needs to be established, accounting for patient related factors, including age and comorbidity.
Trial registration
This study was prospectively registered as DRKS00009812 in the German Clinical Trials Register (DRKS).
Background
Clinical practice guidelines recommend specialist referral according to different criteria. The aim was to assess recommended and observed referral rate and health care expenditure according to recommendations from:
• Kidney Disease Improving Global Outcomes (KDIGO,2012)
• National Institute for Health and Care Excellence (NICE,2014)
• German Society of Nephrology/German Society of Internal Medicine (DGfN/DGIM,2015)
• German College of General Practitioners and Family Physicians (DEGAM,2019)
• Kidney failure risk equation (NICE,2021)
Methods
Data of the population-based cohort Study of Health in Pomerania were matched with claims data. Proportion of subjects meeting referral criteria and corresponding health care expenditures were calculated and projected to the population of Mecklenburg-Vorpommern.
Results
Data from 1927 subjects were analysed. Overall proportion of subjects meeting referral criteria ranged from 4.9% (DEGAM) to 8.3% (DGfN/DGIM). The majority of patients eligible for referral were ≥ 60 years. In subjects older than 60 years, differences were even more pronounced, and rates ranged from 9.7% (DEGAM) to 16.5% (DGfN/DGIM). Estimated population level costs varied between €1,432,440 (DEGAM) and €2,386,186 (DGfN/DGIM). From 190 patients with eGFR < 60 ml/min, 15 had a risk of end stage renal disease > 5% within the next 5 years.
Conclusions
Applying different referral criteria results in different referral rates and costs. Referral rates exceed actually observed consultation rates. Criteria need to be evaluated in terms of available workforce, resources and regarding over- and underutilization of nephrology services.
The structure and content of the training phase following completion of medical school, referred to in most countries as postgraduate medical training, varies between countries. The purpose of this article is to give national and international readers an overview of the organisation and structure of postgraduate medical training in Germany.
The content and duration of postgraduate training in Germany are stipulated by state medical boards, officially termed associations (Landesärztekammer). In a periodically updated decree, the federal German medical association (Bundesärztekammer) provides a template for postgraduate medical training structure (Musterweiterbildungsordnung), which is adapted by the state medical associations. Admission to postgraduate medical training in Germany takes place by way of open, free-market selection. Based on the traditional assumption that junior doctors acquire all necessary clinical skills “on the job”, formal education in the form of seminars, lectures, or preorganised, detailed rotation plans through various specialties or wards is largely absent. Requirements for postgraduate medical training focus on the fulfilment of broad categories of rotations rather than specific content or gaining competencies. With few exceptions, no structured educational programs with curricular learning objectives exist. Limited funding impedes program development and expansion. Junior doctors bear the primary organisational responsibility in their training, which often results in extended training times and dissatisfaction. Structured training programs which prioritise skill-building and formal education are needed to support junior doctors and ensure their competence in primary and specialty care.
(1) Background: Predicting chronic low back pain (LBP) is of clinical and economic interest as LBP leads to disabilities and health service utilization. This study aims to build a competitive and interpretable prediction model; (2) Methods: We used clinical and claims data of 3837 participants of a population-based cohort study to predict future LBP consultations (ICD-10: M40.XX-M54.XX). Best subset selection (BSS) was applied in repeated random samples of training data (75% of data); scoring rules were used to identify the best subset of predictors. The rediction accuracy of BSS was compared to randomforest and support vector machines (SVM) in the validation data (25% of data); (3) Results: The best subset comprised 16 out of 32 predictors. Previous occurrence of LBP increased the odds for future LBP consultations (odds ratio (OR) 6.91 [5.05; 9.45]), while concomitant diseases reduced the odds (1 vs. 0, OR: 0.74 [0.57; 0.98], >1 vs. 0: 0.37 [0.21; 0.67]). The area-under-curve (AUC) of BSS was acceptable (0.78 [0.74; 0.82]) and comparable with SVM (0.78 [0.74; 0.82]) and randomforest (0.79 [0.75; 0.83]); (4) Conclusions: Regarding prediction accuracy, BSS has been considered competitive with established machine-learning approaches. Nonetheless, considerable misclassification is inherent and further refinements are required to improve predictions.
Effectiveness of Varenicline as an Aid to Smoking Cessation in Primary Care: An Observational Study
(2012)
Aims: Although varenicline is commonly prescribed in primary care, information on smoking-related comorbidities and the effectiveness of varenicline in this context in Germany is scarce. This study assessed the efficacy and safety of varenicline in a large sample of patients seeking smoking cessation treatment through their general practitioners. The frequency of comorbidities was also evaluated. Methods: This was a 12-week, prospective, observational, non-comparative phase IV trial conducted in Germany. Abstinence rates at week 12 were evaluated by verbal reporting using the nicotine use inventory. Results: Overall, 1,391 subjects were enrolled; 1,177 received study medication and were evaluated for effectiveness and safety. At the end of the study, 71.1% (95% confidence interval 68.5–73.7) of subjects were abstinent. There were a total of 205 all-causality adverse events; 2.2% were classified as serious or severe. There were no fatal adverse events. At inclusion, 66.7% of participants had at least 1 concurrent comorbidity, with chronic obstructive pulmonary disease (35.5%), hypertension (29.6%) and depression (10.4%) being the most commonly reported. Conclusion: These real-world data indicate that varenicline is an effective and well-tolerated smoking cessation treatment when used in the primary care setting including patients with smoking-related comorbidities.