RESUMEN
BACKGROUND: 11.5 % of girls and 17.8 % of boys are affected by a mental health problem (MHP). The most prevalent problem areas are behavioural problems (girls/boys in %: 11.9/17.9), emotional problems (9.7/8.6) and hyperactivity problems (4.8/10.8). Primary care paediatricians are the first in line to be contacted. Nevertheless, even for less severely affected patients, referral rates to specialised care are constantly high. Therefore, a major statutory health insurance fund introduced a Health Coaching (HC) programme, including a training concept for paediatricians, standardised guidelines for actions and additional payments to strengthen primary care consultation for MHP and to decrease referrals to specialised care. The aim of this study was to examine how the HC is perceived and implemented in daily practice to indicate potential strengths and challenges. METHODS: During a one-year period starting in November 2017, a series of guideline-based interviews were conducted by phone with HC-developers, HC-qualified paediatricians, parents and patients (≥14 years) treated according to the HC programme. Paediatricians were selected from a Bavarian practice network with a total of 577 HC qualified paediatricians. Parents of patients with the four most common MHP diagnoses were approached by their health insurance: [World Health Organization, 2013] developmental disorder of speech and language [Wille N, et al., 2008] head/abdominal pain (somatoform) [Holling H, et al., 2003-2006 and 2009-2012] conduct disorder [Plass-Christl A, et al., 2018] non-organic enuresis. 23 paediatricians, 314 parents and 10 adolescents consented to be interviewed. Potential participants were selected based on purposeful sampling, according to principles of maximum variance. All interviews were recorded and transcribed verbatim. Two researchers analysed the transcripts independently of each other. Structuring content analysis derived from Mayring was used for analysis. RESULTS: 11 paediatricians, 3 co-developers, 22 parents and 4 adolescents were included. Families were generally satisfied with paediatric care received in the programme's context. The HC supported paediatricians' essential role as consultants and improved their diagnostic skills. Lack of time, financial restrictions and patients' challenging family structures were reported as major barriers to success. CONCLUSION: The HC programme is perceived as a facilitator for more patient-centred care. However, structural barriers remain. Starting points for improvement are further options to strengthen families' resources and expanded interdisciplinary networking.
Asunto(s)
Salud Mental , Tutoría , Adolescente , Niño , Femenino , Humanos , Masculino , Pediatras , Atención Primaria de Salud , Investigación CualitativaRESUMEN
BACKGROUND: When patients die in a hospital their quality of life is lower than when they die at home or in a hospice. Despite efforts to improve palliative care supply structures, still about 60% of lung cancer patients die in a hospital. Studies have examined factors related to inhospital death in lung cancer patients, yet none used data of a representative German population, additionally including economic aspects. This study aimed to identify factors related to inhospital death in German lung cancer patients and analysed resulting costs. METHODS: We analysed a dataset of health insurance claims of 17,478 lung cancer patients (incident 2009) with 3 year individual follow-up. We grouped patients into inhospital death and death elsewhere. Studied factors were indicators of healthcare utilization, palliative care, comorbidities and disease spread. We used logistic regression models with LASSO selection method to identify relevant factors. We compared all-cause healthcare expenditures for the last 30 days of life between both groups using generalized linear models with gamma distribution. RESULTS: Twelve thousand four hundred fifty-seven patients died in the observation period, thereof 6965 (55.9%) in a hospital. The key factors for increased likelihood of inhospital death were receipt of inpatient palliative care (OR = 1.85), chemotherapeutic treatments in the last 30 days of life (OR = 1.61) and comorbid Congestive Heart Failure (OR = 1.21), and Renal Disease (OR = 1.19). In contrast, higher care level (OR = 0.16), nursing home residency (OR = 0.25) and receipt of outpatient palliative care (OR = 0.25) were associated with a reduced likelihood. All OR were significant (p-values< 0.05). Expenditures in the last 30 days of life were significantly higher for patients with inhospital death ( 6852 vs. 33,254, p-value< 0.0001). CONCLUSION: Findings suggest that factors associated with inhospital death often relate to previous contact with hospitals like prior hospitalizations, and treatment of the tumour or comorbidities. Additionally, factors associated with dying elsewhere relate to access to care settings which are more focused on palliation than hospitals. From these results, we can derive that implementing tools like palliative care into tumour-directed therapy might help patients make self-determined decisions about their place of death. This can possibly be achieved at reduced economic burden for SHIs.