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Background Patients with multiple long-term conditions often face a variety of challenges arising from the requirements of their health care. Knowledge of perceived treatment burden is crucial for optimizing treatment. In this study, we aimed to create a German version of the Multimorbidity Treatment Burden Questionnaire (MTBQ) and to evaluate its validity. Methods The steps to translate the MTBQ included forward/back translation, cognitive interviews ( n  = 6) and a pilot test ( n  = 7). Psychometric properties of the scale were assessed in a cross-sectional survey with primary care patients aged 65 and older with at least 3 long-term conditions ( n  = 344). We examined the distribution of responses, dimensionality, internal reliability and construct validity. Results Cognitive interviewing and piloting led to minor modifications and showed overall good face validity and acceptability. As expected, we observed a positively skewed response distribution for all items. Reliability was acceptable with McDonald’s omega = 0.71. Factor analysis suggested one common factor while model fit indices were inconclusive. Predefined hypotheses regarding the construct validity were supported by negative associations between treatment burden and health-related quality of life, self-rated health, social support, patient activation and medication adherence, and positive associations between treatment burden and number of comorbidities. Treatment burden was found to be higher in female participants ( Mdn 1  = 6.82, Mdn 2  = 4.55; U  = 11,729, p  = 0.001) and participants with mental health diagnoses ( Mdn 1  = 9.10, Mdn 2  = 4.55; U  = 3172, p  = 0.024). Conclusions The German MTBQ exhibited good psychometric properties and can be used to assess the perceived treatment burden of patients with multimorbidity.

Background Older adults with multimorbidity represent a growing segment of the population. Metrics to assess quality, safety and effectiveness of care can support policy makers and healthcare providers in addressing patient needs. However, there is a lack of valid measures of quality of care for this population. In the MULTIqual project, 24 general practitioner (GP)-reported and 14 patient-reported quality indicators for the healthcare of older adults with multimorbidity were developed in Germany in a systematic approach. This study aimed to select, validate and pilot core sets of these indicators. Methods In a cross-sectional observational study, we collected data in general practices ( n  = 35) and patients aged 65 years and older with three or more chronic conditions ( n  = 346). One-dimensional core sets for both perspectives were selected by stepwise backward selection based on corrected item-total correlations. We established structural validity, discriminative capacity, feasibility and patient-professional agreement for the selected indicators. Multilevel multivariable linear regression models adjusted for random effects at practice level were calculated to examine construct validity. Results Twelve GP-reported and seven patient-reported indicators were selected, with item-total correlations ranging from 0.332 to 0.576. Fulfilment rates ranged from 24.6 to 89.0%. Between 0 and 12.7% of the values were missing. Seventeen indicators had agreement rates between patients and professionals of 24.1% to 75.9% and one had 90.7% positive and 5.1% negative agreement. Patients who were born abroad (− 1.04, 95% CI =  − 2.00/ − 0.08, p  = 0.033) and had higher health-related quality of life (− 1.37, 95% CI =  − 2.39/ − 0.36, p  = 0.008), fewer contacts with their GP (0.14, 95% CI = 0.04/0.23, p  = 0.007) and lower willingness to use their GPs as coordinators of their care (0.13, 95% CI = 0.06/0.20, p  < 0.001) were more likely to have lower GP-reported healthcare quality scores. Patients who had fewer GP contacts (0.12, 95% CI = 0.04/0.20, p  = 0.002) and were less willing to use their GP to coordinate their care (0.16, 95% CI = 0.10/0.21, p  < 0.001) were more likely to have lower patient-reported healthcare quality scores. Conclusions The quality indicator core sets are the first brief measurement tools specifically designed to assess quality of care for patients with multimorbidity. The indicators can facilitate implementation of treatment standards and offer viable alternatives to the current practice of combining disease-related metrics with poor applicability to patients with multimorbidity.

The management of the long-term sequelae of coronavirus disease 2019 (COVID-19) infection, known as post-COVID-19 syndrome (PCS), continues to challenge the medical community, largely owing to a significant gap in the understanding of its aetiology, diagnosis and effective treatment. To examine general practitioners' (GPs) experiences of caring for patients with PCS and to identify unmet care needs and opportunities for improvement. This study follows a qualitative design, using in-depth semi-structured telephone interviews with GPs (  = 31) from across Germany. Interviews were audio-recorded, transcribed verbatim and analysed using qualitative content analysis. GPs reported that they were often the first point of contact for patients with persistent symptoms following SARS-CoV-2 infection, with symptoms typically resolving within weeks. While ongoing symptomatic COVID-19 is perceived to be more common, the relevance of PCS to GP practices is considerable given its severe impact on patients' functioning, social participation and the substantial time required for patient care. GPs coordinate diagnosis and treatment but face challenges because of the unclear definition of PCS and difficulties in attributing symptoms, resulting in a cautious approach to ICD-10 coding. Interviewees highlight lengthy diagnostic pathways and barriers to accessing specialist care. The findings confirm the high functional limitations and psychosocial burden of PCS on patients, and the central role of GPs in their care. The study suggests a need for further research and health policy measures to support GPs in navigating diagnostic uncertainty, interprofessional communication and the limited evidence on effective treatments.

BackgroundPrevalence of people with multimorbidity rises. Multimorbidity constitutes a challenge to the healthcare system, and treatment of patients with multimorbidity is prone to high-quality variations. Currently, no set of quality indicators (QIs) exists to assess quality of care, let alone incorporating the patient perspective. We therefore aim to identify aspects of quality of care relevant to the patients’ perspective and match them to a literature-based set of QIs.MethodsWe conducted eight focus groups with patients with multimorbidity and three focus groups with patients’ relatives using a semistructured guide. Data were analysed using Kuckartz’s qualitative content analysis. We derived deductive categories from the literature, added inductive categories (new quality aspects) and translated them into QI.ResultsWe created four new QIs based on the quality aspects relevant to patients/relatives. Two QIs (patient education/self-management, regular updates of medication plans) were consented by an expert panel, while two others were not (periodical check-ups, general practitioner-coordinated care). Half of the literature-based QIs, for example, assessment of biopsychosocial support needs, were supported by participants’ accounts, while more technical domains regarding assessment and treatment regimens were not addressed in the focus groups.ConclusionWe show that focus groups with patients and relatives adding relevant aspects in QI development should be incorporated by default in QI development processes and constitute a reasonable addition to traditional QI development. Our QI set constitutes a framework for assessing the quality of care in the German healthcare system. It will facilitate implementation of treatment standards and increase the use of existing guidelines, hereby helping to reduce overuse, underuse and misuse of healthcare resources in the treatment of patients with multimorbidity.Trial registration numberGerman clinical trials registry (DRKS00015718), Pre-Results.

ObjectivesThis study aimed to explore the association between patient activation and patients’ experience of care among an elderly multimorbid population in Germany.DesignCross-sectional study.SettingPrimary care practices in two German settings.Participants346 patients with 3 or more chronic conditions aged 65 years and over from 36 primary care practices.Outcome measuresPatient activation was measured with the patient activation measure (PAM). To assess patient experiences with primary care, a set of questions concerning domains of primary care were included. Multilevel regression analyses were performed to examine which domains of care were associated with patient activation.ResultsOut of 1243 invited patients, a total of 346 took part in the study (participation rate 27.8 %). Mean PAM score was 76.1. Across all patients, 3.8% achieved PAM level 1, 7.5% level 2, 27.2% level 3% and 60.7% level 4. PAM scores suggest a highly activated patient group. In the regression analysis, three out ten domains of patients’ experiences showed an association with patient activation. The domains ‘being involved in decision as much as desired’ (B=−8.56, p=0.012) and ‘receiving a self-management plan’ (B=6.51, p=0.051) were associated with higher patient activation scores. Patients with an up-to-date medication plan had lower patient activation scores (B=−12.01, p=0.041).ConclusionSpecific domains of primary care were found to be associated with patient activation. To enhance patient activation, primary care physicians may increase involvement of patients in decisions. Future research should examine the causality of these associations.Trial registration numberDRKS00015718.

Background Patients with advanced chronic non-malignant conditions often experience significant symptom burden. Therefore, overcoming barriers to interprofessional collaboration between general practitioners (GPs) and specialist palliative home care (SPHC) teams is essential to facilitate the timely integration of palliative care elements. The KOPAL trial aimed to examine the impact of case conferences between GPs and SPHC teams on symptom burden and pain in patients with advanced chronic heart failure, chronic obstructive pulmonary disease, and dementia. Methods The cluster-randomised controlled trial compared a structured palliative care nurse visit followed by an interprofessional case conference to usual care. Data were collected from GPs at baseline and 48 weeks, while standardised patient interviews were conducted at baseline, 6, 12, 24, and 48 weeks. Results We analysed 172 patients from 49 German GP practices. Both groups showed marginal improvement in symptom burden; however, no statistically significant between-group difference was found ( =-0.561, 95% CI: -3.201–2.079, p  = .68). Patients with dementia experienced a significant pain reduction ( =2.187, 95% CI: 0.563–3.812, p  = .009). Conversely, the intervention did not have a significant effect on pain severity ( =-0.711, 95% CI: -1.430 − 0.008, p =.053) or pain interference ( =-0.036, 95% CI:-0.797 − 0.725, p =.926) in other patient groups. Conclusions The intervention showed promise in the timely introduction of palliative care elements to address pain management in patients with dementia. Further studies are needed to identify and effectively address symptom burden and pain in other patient groups. Trial registration German Clinical Trials Register: https://www.drks.de/DRKS00017795 (Registration date: 9th January 2020).

Multimorbidity poses significant challenges for patients and healthcare systems, often exacerbated by fragmented care and insufficient collaboration across providers. Blended Collaborative Care (BCC) is a promising strategy to address care complexity by partnering care managers (CMs) with primary care providers (PCPs) and specialists. This study aimed to adapt and pilot a BCC intervention for patients aged 65+ with heart failure and physical–mental multimorbidity. Our objectives were to assess the feasibility of the study procedures, patient recruitment, participant satisfaction and acceptability, and to identify necessary adjustments for improving intervention delivery. We evaluated goal attainment and intervention fidelity through standardised electronic documentation by CMs, and patient acceptance and satisfaction through semi-structured interviews. A monocentric, one-arm pilot study involved nine patients with a mean of 6.7 contacts with their CM over three months. Patients’ health goals primarily focused on lifestyle changes and psychosocial support. The intervention was generally well-accepted, with no reported negative consequences. Difficulties in establishing working alliances with PCPs were a barrier to effective implementation. The analysis indicated the need for minor procedural adjustments. Next steps include launching the ESCAPE trial, a large randomised-controlled trial across different European healthcare systems and developing strategies to facilitate PCP involvement.

Multimorbidity, the simultaneous presence of multiple chronic conditions in one person, is becoming a growing concern for healthcare systems worldwide. This phenomenon leads to increased difficulty in managing and treating patients, ultimately resulting in higher healthcare costs and reduced health outcomes. To combat these challenges, healthcare providers and researchers must seek a better understanding of the specific experiences and needs of people with multimorbidity and use targeted interventions to improve care. The introduction of quality measures helps to identify areas for improvement, track progress over time and ensure accountability for the delivery of quality care. This thesis presents three studies that aim to gain insight into the quality of care and experiences of patients with multimorbidity through the development of measurement tools and frameworks. The first chapter explores the significance of multimorbidity and the impact of its growing prevalence on healthcare systems. It also examines methodological considerations for the generation of scientific evidence in this area and the applicability of existing measures for evaluating care in multimorbidity. The synopsis outlines the research questions that were derived from the current gaps in the literature and provides an overview of the methodology and results of the three individual studies. The overall findings are then discussed in relation to previous research, highlighting their strengths and limitations and drawing implications for research and clinical practice.

High-energy batteries for automotive applications require cells to endure well over a decade of constant use, making their long-term stability paramount. This is particularly challenging for emerging cell chemistries containing silicon, for which extended testing information is scarce. While much of the research on silicon anodes has focused on mitigating the consequences of volume changes during cycling, comparatively little is known about the time - dependent degradation of silicon-containing batteries. Here we discuss a series of studies on the reactivity of silicon that, collectively, paint a picture of how the chemistry of silicon exacerbates the calendar aging of lithium-ion cells. Assessing and mitigating this shortcoming should be the focus of future research to fully realize the benefits of this battery technology. Silicon-containing batteries are increasingly becoming a reality in the mass market, but their calendar aging behaviours have received comparatively little attention. Researchers from the Silicon Consortium Project discuss the issues surrounding the calendar lifetime of silicon anodes for lithium-ion batteries.

To evaluate the diagnostic performance of magnetic resonance imaging (MRI) alone in comparison to positron emission tomography/ magnetic resonance imaging (PET/MRI) in patients with meningiomas. 57 patients with a total of 112 meningiomas of the brain were included. PET/MRI, including a fully diagnostic contrast enhanced MRI and PET, were acquired. PET/MRI was used as reference standard. The size and location of meningiomas was recorded. Likelihood-ratio chi-square tests were used to calculate p-values within logistic regression in order to compare different models. A multi-level logistic regression was applied to comply the hierarchical data structure. Multi-level regression adjusts for clustering in data was performed. The majority (n = 103) of meningiomas could be identified based on standard MRI sequences compared to PET/MRI. MRI alone achieved a sensitivity of 95% (95% CI 0.78, 0.99) and specificity of 88% (95% CI 0.58, 0.98). Based on intensity of contrast medium uptake, 97 meningiomas could be diagnosed with intense uptake (93.75%). Sensitivity was lowest with 74% for meningiomas < 0.5 cm 3 , high with 95% for meningiomas > 2cm 3 and highest with 100% for meningiomas 0.5–1.0 cm 3 . Petroclival meningiomas showed lowest sensitivity with 88% compared to sphenoidal meningiomas with 94% and orbital meningiomas with 100%. Specificity of meningioma diagnostic with MRI was high with 100% for sphenoidal and hemispherical-dural meningiomas and meningiomas with 0.5–1.0 and 1.0–2.0 cm 3 . Overall MRI enables reliable detection of meningiomas compared to PET/MRI. PET/MRI imaging offers highest sensitivity and specificity for small or difficult located meningiomas.