Mild Cognitive Impairment (MCI) and Mild Behavioral Impairment (MBI) are important constructs in the context of cognitive decline. MBI can be assessed with the Mild Behavioral Impairment Checklist (MBI-C). However, the instrument has deficits in psychometrics and content, thus indicating a need for improvement. The aim of this study was to develop a complementary short instrument, the Mild Behavioral Impairment Scale (MBI-S), designed to measure MBI as a short-term modifiable state criterion, and to validate it in a non-clinical sample of people 18 years of age or older. Most of the items on the MBI-S stem from the MBI-C and were chosen to represent the dimensions of the Neuropsychiatric Inventory Questionnaire. The MBI-S was validated on self-reported data from 175 individuals. In an item analysis, the discriminatory power and item difficulties were examined. Cronbach’s alpha was calculated to assess the internal consistency, and a principal component analysis was conducted to determine the structure of the instrument. Construct validity was established by testing four hypotheses about relationships between the MBI-S and other instruments by calculating correlation coefficients. After the item analysis, two items were removed from the final version of the scale on the basis of insufficient discriminatory power and the finding that the internal consistency of the total score increased when the items were deleted. The principal component analysis yielded a single-component structure for the MBI-S. Two more items were excluded from the scale due to insufficiently low loadings on the extracted component. Cronbach’s alpha for the final eight-item scale was 0.79. The final MBI-S score was strongly related to that of the MBI-C and a loneliness score as well as moderately related to maladaptive coping. There was no association with respondents’ level of education. The MBI-S is a valid short instrument for the assessment of MBI. It has high test economy and measures current neuropsychiatric symptoms and their intensity as a state criterion. Therefore, the MBI-S can be used for the longitudinal measurement of MBI.

Vaccinations against COVID-19 are of the utmost importance in long-term care facilities. During the pandemic, mental health issues increased significantly. This cross-sectional analysis aimed to assess the associations of depression and anxiety with health literacy in people in need of care and the association of depression and burnout with vaccination readiness against COVID-19 in health care workers (HCWs). Within our cross-sectional study, people in need of care were assessed for symptoms of depression (PHQ-9), anxiety (GAD-7), and health literacy (HLS-EU-Q16). Among HCWs, we assessed symptoms of depression (PHQ-9) and burnout (MBI-HSS), as well as psychological antecedents of vaccination (5C) to measure vaccination readiness against COVID-19. A multivariate regression analysis was performed. Symptoms of a major depression were significantly associated with reduced health literacy (p = 0.010) in people in need of care. Among HCWs, symptoms of depression and burnout reduced vaccination readiness against COVID-19 significantly. In particular, collective responsibility was reduced in HCWs suffering from burnout symptoms (p = 0.001). People in need of care and their HCWs could benefit from intensified target group-specific vaccination counseling. Additionally, more attention should be paid to the protection of mental health in long-term care facilities.

Introduction: Vaccinations are important for informal caregivers and their care recipients. Mental health problems are common among care givers. The aim of this study was to investigate vaccination readiness in informal caregivers and associations with mental health issues. Associations between vaccination readiness in informal caregivers and the vaccination status of their aged care recipients were examined. Methods: Within the multicenter prospective registry study 'Bavarian ambulatory Covid-19 Monitor (BaCoM) ', informal caregivers were asked for symptoms of depression (PHQ-9), burden of caretaking (BSFC-s), psychological antecedents of vaccination readiness (5C model) and previous Covid-19 infections of their care recipients. The vaccination status against Covid-19, seasonal influenza and pneumococcal disease was determined via vaccination certificates. Data analysis was performed using ordinal regressions and Mann-Whitney-U U tests. Results: Data of n = 91 informal caregivers, associated with n = 84 care recipients were collected. Symptoms of depression were associated with reduced vaccination readiness (Calculation: p = 0.026, OR = 1.18), as well as the perceived burden of caretaking (Confidence: p = 0.006, OR = 0.88). A previous Covid-19 infection of the care recipients was associated with decreased vaccination readiness of informal caregivers (Median (Q1-Q3) Confidence: 5.0 (4.5-6.0) vs. 4.0 (3.0-5.0); Calculation: 5.0 (3.0-6.0) vs. 4.0 (1.0-5.0)). The vaccination status of the care recipients interrelated significantly with vaccination readiness of their informal caregivers (Confidence: p < 0.001; Complacency: p <0.01; Constraints p < 0.05). No significant interrelations between vaccination readiness and the vaccination status against seasonal influenza or pneumococcal disease occurred. Conclusion: Mental health issues of informal caregivers seem to be associated with the actual vaccination status against Covid-19 in their care recipients. Target group specific counselling as well as an active involvement of informal caregivers in shared decision-making processes can be of relevance, but even more attention should be paid to the protection of mental health for informal caregivers.

Many practicing physicians struggle to properly evaluate clinical research studies – they either simply do not know them, regard the reported findings as ‘truth’ since they were reported in a ‘reputable’ journal and blindly implement these interventions, or they disregard them as having little pragmatic impact or relevance to their daily clinical work. Three aspects for the latter are highlighted: study populations rarely reflect their practice population, the absolute average benefits on specific outcomes in most controlled studies, while statistically significant, are so small that they are pragmatically irrelevant, and overall mortality between the intervention and control groups are unaffected. These observations underscore the need to rethink our research approaches in the clinical context – moving from the predominant reductionist to an eco-systemic research approach will lead to knowledge better suited to clinical decision-making for an individual patient as it takes into account the complex interplay of multi-level variables that impact health outcomes in the real-world setting.

Objectives Medical overuse exposes patients to unnecessary risks of harm. It is an open question whether and how patients perceive the concept of medical overuse, its causes and negative consequences.Design A qualitative study design, using elements of the Grounded Theory Approach by Strauss and Corbin.Setting Between May 2017 and January 2020, we recruited participants and conducted face-to-face interviews in the participants’ homes. Data collection took place in Bavaria, Germany.Participants We recruited 16 participants (female=8, male=8) with various characteristics for the study. We used different strategies such as flyers in supermarkets, pharmacies, participants spreading information about the study or local multipliers (snowball sampling).Results The participants mostly defined medical overuse as too much being done but understood the concept superficially. During the interviews, most participants could describe examples of medical overuse. They named a variety of direct and indirect drivers with economic factors suspected to be the main driver. As a consequence of medical overuse, participants named the physical and emotional harm (eg, side effects of medication). They found it difficult to formulate concrete solutions. In general, they saw themselves more in a passive role than being responsible for bringing about change and solutions themselves. Medical overuse is a ‘problem of the others’. The participants emphasised that health education is important in reducing medical overuse.Conclusions Medical overuse was little discussed among participants, although many participants reported experiences of too much medicine. Health education and strengthening the patients’ self-responsibility can play a vital role in reducing medical overuse.

Background Medical overuse is defined as health care services that exceed the individual needs of patients and when the potential harms of medical interventions exceed their benefits. It has impacts on patients as well as on health care resources. To address medical overuse, it is important to understand the knowledge and experiences of overuse on the side of patients. Research questions What is the citizens’ understanding of overuse? How do they assess its relevance, causes, consequences and potential solutions? Methods A quantitative online survey was conducted. The participants were asked to state what they understand by medical overuse. Statements on causes, consequences and possible solutions were evaluated. Recruitment was carried out via a panel of a market research institute (Schlesinger Group). Results The survey was completed by 406 participants. In terms of age and gender, the sample corresponded to the distribution in the German population. The majority had never heard of medical overuse (58%). About 60% assumed that medical overuse means "too much medicine including overtreatment and overtesting”. Medical overuse was mainly suspected for services not covered by the public health insurance system (56%), surgical interventions (45%) and medication prescriptions (37%). Reasons for medical overuse were seen in uncoordinated care and financial incentives, but also in the expectations of patients. The main problem with medical overuse was seen in rising health care costs, while harmful physical and mental consequences for patients were mentioned less often. In order to reduce medical overuse, little importance was attributed to a primary care based system or higher financial contribution of patients. Instead, stricter cost control on the side of physicians and better coordination between care providers were suggested as solutions. Differences in socio-demographic characteristics hardly showed any differences in response behavior. Conclusion More than half of the respondents had never heard of medical overuse. Overuse was mainly associated with financial causes and consequences. It was not seen that overuse can be harmful for patients directly. The limited awareness of the problem of overuse probably is a barrier to tackling it effectively. Communicating the topic to the public might therefore be an effective start to mitigate medical overuse. Take home message Many citizens seem not to be familiar with the concept of medical overuse, especially not with the fact that it may directly cause harm to patients. Informing citizens about the harms of medical overuse might be helpful in mitigating it.

Zusammenfassung In diesem Artikel wird der aktuelle Stand der DVO-Leitlinienempfehlungen zur Basistherapie vorgestellt. Die Basistherapie ist die Grundlage jeder Osteoporosebehandlung und ist auch für die Primärprävention von entscheidender Bedeutung, noch bevor die Knochenmineraldichte niedrig ist oder Frakturen auftreten. Auf der Grundlage einer aktualisierten Literaturrecherche umfasst das Kapitel Empfehlungen zu Kalzium, Vitamin D, Vitamin K und anderen Ernährungsaspekten sowie zu körperlicher Aktivität. Frühere Empfehlungen wurden überprüft und auf der Grundlage der neuen Literatur ergänzt. Die Empfehlungen für die Einnahme von Kalzium und Vitamin D, situationsabhängig entweder über die Ernährung oder über Supplemente, bleiben unverändert. Vitamin K wird nur zum Ausgleich eines Mangels empfohlen, da die Datenlage für eine Empfehlung in anderen Bereichen wie der allgemeinen Frakturprävention zu inkonsistent ist. Körperliche Aktivität hat einen positiven Effekt auf das Frakturrisiko und die Knochendichte und ist daher auch weiterhin eine wichtige Empfehlung, idealerweise im Rahmen eines angepassten, supervidierten Trainingsprogramms.

Based on a systematic literature search, the S3 guideline on "Prophylaxis, Diagnosis and Therapy of Osteoporosis" (AWMF register number 183-001) was completely revised. This literature search was based on predefined PICO (Patient Intervention-Comparison-Outcome) questions. Structured consensus was reached in the interdisciplinary, German-speaking expert group from Germany, Austria, and Switzerland, representing the member societies of the DVO, and in the presence of a patient representative of the Bundesselbsthilfeverband fur Osteoporose e.V. (German Self-Help Association for Osteoporosis). In this article, the most important aspects of the chapter "General Fracture and Osteoporosis Prophylaxis" with the focus on "Falls" are presented.

BackgroundThe international collaboration study PRICOV-19 -Primary Health Care in times of COVID-19 aims to assess the impact of the COVID-19 pandemic on the organisation of primary health care. The German part focuses on the subjective perceptions of general practitioners on primary health care and the impact of political measures during the second wave of the COVID-19 pandemic. Within this survey, the "open text field" of the questionnaire was utilised remarkably frequently and extensively by the respondents. It became clear that the content that was named needed to be analysed in an exploratory manner. Accordingly, this paper addresses the following question: What preoccupies general practitioners in Germany during COVID-19 that we have not yet asked them enough? MethodsThe data collection took place throughout Germany from 01.02.2021 to 28.02.2021with a quantitative online questionnaire consisting of 53 items arranged across six topics as well as an "open text field" for further comments. The questionnaire's open text field was analysed following the premises of the qualitative content analysis. ResultsThe topics discussed by the respondents were: insufficient support from health policies, not being prioritised and involved in the vaccination strategy, feeling insufficient prepared, that infrastructural changes and financial concerns threatened the practice, and perceiving the own role as important, as well as that health policies affected the wellbeing of the respondents. One of the main points was the way general practitioners were not sufficiently acknowledged for their contribution to ensuring high-quality care during the pandemic. DiscussionGerman general practitioners perceived their work and role as highly relevant during the COVID-19 pandemic. In controversy with their perception, they described political conditions in which they were the ones who contributed significantly to the fight against the pandemic but were not given enough recognition.

Introduction People in need of care or support are severely affected by the COVID-19 pandemic. We lack valid data of long-term assessments. We present a register study to detect the physical and psychosocial impact of the COVID-19 pandemic on people in need of care or support in Bavaria, Germany. To describe the persons’ life conditions comprehensively, we assess the perspectives and needs of the respective care teams too. Results will serve as evidence-based source to manage the pandemic and long-term prevention strategies.Methods and analysis The ‘Bavarian ambulatory COVID-19 Monitor’ is a multicentre registry including a purposive sample of up to 1000 patient–participants across three study sites in Bavaria. The study group consists of 600 people in need of care with a positive SARS-CoV-2 PCR test. Control group 1 comprises 200 people in need of care with a negative SARS-CoV-2 PCR test, while control group 2 comprises 200 people with a positive SARS-CoV-2 PCR test but are not in need of care. We assess the clinical course of infection, psychosocial aspects and care needs using validated measures. Follow-up is every 6 months for up to 3 years. Additionally, we assess up to 400 people linked to these patient–participants (caregivers, general practitioners (GPs)) for their health and needs. Main analyses are stratified by level of care I–V (I=minor/V=most severe impairment of independence), inpatient/outpatient care setting, sex and age. We use descriptive and inferential statistics to analyse cross-sectional data and changes over time. In qualitative interviews with 60 stakeholders (people in need of care, caregivers, GPs, politicians), we explore interface problems of different functional logics, of everyday and professional perspectives.Ethics and dissemination The Institutional Review Board of the University Hospital LMU Munich (#20-860) and the study sites (Universities of Wurzburg and Erlangen) approved the protocol. We disseminate the results by peer-reviewed publications, international conferences, governmental reports, etc.

Background and Objectives The first wave of the COVID-19 pandemic (Mar-Apr 2020) posed significant challenges for primary care. The goal of this study was to analyse the burden of the crisis situation as experienced by the general practitioners (GPs) at its beginning and over the course of the pandemic and to identify factors predictive of the sense of being overburdened.Methods In this cross-sectional study, a total of 6300 randomly selected GPs in four federal states of Germany were contacted per post in order to survey changes in health care they provided and their psychological burden in the context of the pandemic between August and October 2020.Results The response rate was 23%; 46% of the participants were female. At the beginning of the pandemic, 40% of the participants experienced a high or a very high level of being overburdened; later on, it was only 10%. With increasing numbers of COVID patients, the sense of being overburdened increased, as also their perceived capability to care for COVID patients. Predictors of a sense of being overburdened were, among others, a high level of psychological stress, excessive organising efforts, poor capability to care for COVID patients, and scarce supply of protective equipment.Conclusion Despite a sense of being overburdened initially, GPs felt increasingly capable of caring for COVID patients. To help GPs in future crisis situations like this pandemic, organization of care should be simplified to the extent possible so that they can focus on patient care.

Tackling overdiagnosis will create more sustainable healthcare for people and the planet

INTRODUCTION:General practitioners often criticise clinical trials for their poor applicability in primary care, which may at least partially explain why their engagement in primary care research remains limited. In order to enhance primary care research, the German government has funded six regional practice based research networks (PBRNs). Within the Bavarian PBRN (BayFoNet), two cluster-randomised pilot trials will be conducted. This paper presents the protocol of the process evaluation accompanying both trials, which aims to explore relevance, feasibility, acceptability and credibility of clinical research in primary care from the perspectives of BayFoNet researchers, general practitioners, and patients.METHODS AND ANALYSIS:The BayFoNet will be established by recruiting general practices (GPs) as prospective research collaborators in two cluster randomised pilot trials. Research teams will provide training in good clinical practice, and support practices in patient recruitment, data collection and documentation. Our process evaluation explores barriers and facilitators in the set up of the BayFoNet PBRN and both cluster randomised pilot trials, under the application of the consolidated framework for implementation research and the theoretical domains framework. In a mixed-methods concept, we will use qualitative and quantitative approaches to evaluate both pilot cluster-randomised trials as well as the BayFoNet itself: focus groups with researchers, semi-structured interviews with general practitioners and questionnaires for patients participating in the pilot cluster-randomised trials at three different time points.ETHICS AND DISSEMINATION:Research ethical approval for this study was granted by the Ethics Committee of the Medical Department, Ludwig-Maximilians-University Munich (AZ 21-1135). Results will be published in international peer-reviewed journals and summaries will be provided to the funders of the study as well as other PBRNs, GP teams and patients.TRIAL REGISTRATION NUMBERS:DRKS00028805, NCT05667207.

Zusammenfassung Basierend auf einer systematischen Literaturrecherche erfolgte die komplette Überarbeitung der S3 Leitlinie zur „Prophylaxe, Diagnostik und Therapie der Osteoporose“ (AWMF Registernummer 183–001). Dieser Literaturrecherche lagen prädefinierte PICO (Patienten-Intervention-Comparison-Outcome) Fragen zugrunde. Die strukturierte Konsensfindung erfolgte in der interdisziplinären, deutschsprachigen Expertengruppe aus Deutschland, Österreich und der Schweiz, die die Mitgliedgesellschaften des DVO repräsentieren, und in Anwesenheit einer Patient*innenvertreterin des Bundesselbsthilfeverbandes für Osteoporose e. V. In diesem Artikel werden die wichtigsten Aspekte des Kapitels „Generelle Fraktur-und Osteoporoseprophylaxe“ mit dem Fokus „Sturz“ dargestellt.

This article presents the current status of the DVO guideline recommendations on basic therapy. Basic therapy is the foundation of any osteoporosis management and is also vital to its primary prevention; even before bone mineral density is low, or fractures occur. Based on an updated literature review, the chapter covers recommendations on calcium, vitamin D, vitamin K and other nutritional aspects as well as physical activity. Previous recommendations were reviewed and amended based on the new literature. Recommendations on calcium and vitamin D intake, through diet or supplements, remain unchanged. Vitamin K is recommended only to compensate for a deficiency, since data are too inconsistent for a recommendation in other settings such as fracture prevention. Physical activity has a positive effect on fracture risk and bone mineral density and therefore continues to be an important recommendation, also recommended, ideally in an appropriate supervised training program.

ObjectivesThis study aims to evaluate whether the use of thyroid ultrasound (US) early in the work-up of suspected thyroid disorders triggers cascade effects of medical procedures and to analyse effects on morbidity, healthcare usage and costs.Study designRetrospective analysis of claims data from ambulatory care (2012–2017).SettingPrimary care in Bavaria, Germany, 13 million inhabitants.ParticipantsPatients having received a thyroid stimulating hormone (TSH) test were allocated to (1) observation group: TSH test followed by an early US within 28 days or (2) control group: TSH test, but no early US. Propensity score matching was used adjusting for socio-demographic characteristics, morbidity and symptom diagnosis (N=41 065 per group after matching).Primary and secondary outcome measuresUsing cluster analysis, groups were identified regarding frequency of follow-up TSH tests and/or US and compared.ResultsFour subgroups were identified: cluster 1: 22.8% of patients,mean (M)=1.6 TSH tests; cluster 2: 16.6% of patients,M=4.7 TSH tests; cluster 3: 54.4% of patients,M=3.3 TSH tests, 1.8 US; cluster 4: 6.2% of patients,M=10.9 TSH tests, 3.9 US. Overall, reasons that explain the tests could rarely be found. An early US was mostly found in clusters 3 and 4 (83.2% and 76.1%, respectively, were part of the observation group). In cluster 4 there were more women, thyroid-specific morbidity and costs were higher and the early US was more likely to be performed by specialists in nuclear medicine or radiologists.ConclusionPresumably unnecessary tests in the field of suspected thyroid diseases seem to be frequent, contributing to cascades effects. Neither German nor international guidelines provide clear recommendations for or against US screening. Therefore, guidelines on when to apply US and when not are urgently needed.

Objectives Functioning of older adults needs to be adequately described before it can become the focus of care. The International Classification of Functioning, Disability and Health (ICF) provides a basis for describing functioning. As the ICF is too extensive for daily practice in primary care, there is a need for a reduced number of categories. The aim is to develop an ICF-subset for community-dwelling older adults aged 75 and above in primary care. Design The scientific basis for decision-making in our consensus study was laid by four preparatory studies, identifying potentially relevant ICF categories from four perspectives (research, patients’, experts’ and clinical perspective). The results of the preparatory phase were discussed by an international expert panel in a consensus study following the Nominal Group Technique (NGT). Setting An international 1-day online consensus conference. Participants International experts (n=7) participated in the consensus conference, meeting the following criteria: extensive expertise in the field of the ICF and/or caring for older adults, and being fluent in English. Results Each preparatory study yielded a different number of categories with some overlaps but also differences. The expert panel decided to: (1) restrict the subset to second-level categories and reduce the number of categories from the preparatory phase, (2) limit the subset to the component activities and participation and (3) weight the patients’ perspective as the most relevant one. Conclusions By using consensus techniques and the NGT, the process led to 51 second-level ICF categories to describe the functioning of community-dwelling older adults. The decisions made in the consensus conference emphasised the importance of considering the individual life situation from a more holistic perspective and addressing functioning as a focus of care. Next, the 51 categories will contribute to the development of an ICF-based questionnaire.

Introduction: Starting in 2013, a five-year, competence-based postgraduate programme, the “Seminartage Weiterbildung Allgemeinmedizin” (SemiWAM®) for continuing education in general practice, was developed and offered in Bavaria. This evaluation reports on the experiences of SemiWAM® after a first cycle. Material and methods: Process reflection based on the cycle of Kern: In addition to qualitative findings, results of the evaluation forms (mean values with standard deviation) are presented. The evaluation form contained questions on organisational issues, content of presentation, didactic preparation of the supervisor, transfer to real life practice as well as demographic variables. All questions were voted on a six-point Likert scale from “1=very satisfied” to “6=very dissatisfied”. Results: The reflection showed three crucial entry points: Choosing “reason for encounter” as a content precondition to ensure target audience needs, the close didactic supervision of supervisor, and the continuous growth of supervisor team with newly qualified GP. The evaluation results for the overall assessment (MW 1.11-1.60), the didactic concept (MW 1.30-1.87), as well as the transfer into daily life practice (MW 1.48-2.35) reflect the high quality of the SemiWAM®. Discussion: The SemiWAM® curriculum presented can be easily transferred to comparable structures in Germany that accompany specialty training, such as the competence centres for residency training in general practice. The process evaluation based on the core cycle also provides important support for the agile implementation of these or similar programmes.

Background and teaching situation:The SARS-CoV-2 pandemic had a substantial didactic impact on medical teaching. In Erlangen, the lecture "General Practice" was offered asynchronously and digitally in an inverted-classroom concept. Contents were available via a learning platform. The lecture was presented using annotated videos, consolidation materials and control questions. A forum encouraged for discussions and feedback and collected in-depth aspects for a case-based video consultation. The aim of this work is to evaluate and critically examine the digital teaching concept during the SARS-CoV-2 pandemic.Methodology:Two semester cohorts evaluated the lecture. Overall impression of the lecture, didactic elements, suitability and the desired future lecture format were surveyed quantitatively. Free text answers were evaluated by means of qualitative content synthesis.Results:In terms of overall impression, the students (N=199) rated the lecture on average as "very good" (M=1.41, SD=.57). Digital methods were perceived as suitable for supporting self-study, and digital usage was rated as unproblematically (M=1.18, SD=.50). Desired future teaching formats were blended learning concepts (79.4%). Organisation, structure and content presentation were highly appreciated. The time for completing the course was perceived critically. The students urged for more practical and consolidating lecture work.Discussion and implications:The results illustrate high acceptance of digital teaching and underline the demand for future blended learning concepts. It is particularly important to better consider the students' time investment and practical relevance of digital self-learning mechanisms.