Background German social legislation gives patients the right to obtain a second opinion before elective surgery and defines quality criteria for reimbursement by statutory health insurances. However, the effects of second opinions before elective surgery are largely unknown. The aim of this study was to evaluate the effects of a second opinion programme in patients recommended for knee arthroplasty. Methods The largest statutory health insurance funds in Bavaria offered patients who had been recommended to have knee arthroplasty the opportunity to partake in a second opinion programme which consisted of an in person presentation to an experienced knee surgeon. In this cohort study, consecutive patients from this second opinion programme who signed informed consent were included from 07/10/2016 to 14/02/2020. Data were collected before and after the second opinion visit. Results A total of 141 (66%) of 215 patients who presented for a second opinion participated in the evaluation study. The second opinion physician recommended knee arthroplasty to 40% of the patients, later knee arthroplasty if the conditions worsened to 40%, and no knee arthroplasty to 20%. After receiving the second opinion 28 of 56 (41%) undecided patients preferred knee arthroplasty, 14 no knee arthroplasty, 14 remained undecided. Four of 46 patients with a preference for “arthroplasty” changed their decision to “no arthroplasty”, five of 35 patients from “no arthroplasty” to “arthroplasty”. The patients were more confident in their decision according to the decision confidence scale (before: 5.4 ± 3.0; after: 7.8 ± 2.5; p < 0.001). They rated their satisfaction with the second opinion programme with a mean grade of 1.35 (± 0.60) (best:1; worst:6). Logistic regression analyses showed that the recommendation of the second opinion physician for joint arthroplasty was associated with the guideline criteria radiological severity of osteoarthritis (p = 0.001) and knee-joint-specific quality of life (p = 0.041). Conclusion The second opinion of an experienced knee surgeon frequently deviates from the initial recommendation for knee arthroplasty. The association of guideline criteria to the second recommendation suggests a high quality of the second opinion. From the patient perspective, the second opinion reduces uncertainties in their treatment decision.

IntroductionMobility limitations have a multitude of different negative consequences on elderly patients including decreasing opportunities for social participation, increasing the risk for morbidity and mortality. However, current healthcare has several shortcomings regarding mobility sustainment of older adults, namely a narrow focus on the underlying pathology, fragmentation of care across services and health professions and deficiencies in personalising care based on patients’ needs and experiences. A tailored healthcare strategy targeted at mobility of older adults is still missing.ObjectiveThe objective is to develop multiprofessional care pathways targeted at mobility sustainment and social participation in patients with vertigo/dizziness/balance disorders (VDB) and osteoarthritis (OA).MethodsData regarding quality of life, mobility limitation, pain, stiffness and physical function is collected in a longitudinal observational study between 2017 and 2019. General practitioners (GPs) recruit their patients with VDB or OA. Patients who visited their GP in the last quarter will be identified in the practice software based on VDB and OA-related International Classification of Diseases 10th Revision. Study material will be sent from the practice to patients by mail. Six months and 12 months after baseline, all patients will receive a mail directly from the study team containing the follow-up questionnaire. GPs fill out questionnaires regarding patient diagnostics, therapy and referrals.Ethics and disseminationThe study was approved by the ethical committee of the Ludwig-Maximilians-Universität München and of the Technische Universität Dresden. Results will be published in scientific, peer-reviewed journals and at national and international conferences. Results will be disseminated via newsletters, the project website and a regional conference for representatives of local and national authorities.

Background Due to reported barriers in the management of patients with vertigo, dizziness and balance problems (VDB), referral trajectories starting from primary care might be determined by other factors than medical necessity. The objective of this paper was to examine the impact of disease-related and other determinants on referral trajectories of older patients with VDB and to investigate, how these trajectories affect the patients’ functioning and health-related quality of life (HRQoL). Methods Data originate from the longitudinal multicenter study MobilE-TRA, conducted in two German federal states. Referrals to neurologists or ear-nose-throat (ENT) specialists were considered. Referral patterns were visualized using a state sequence analysis. Predictors of referral trajectories were examined using a multinomial logistic regression model. Linear mixed models were calculated to assess the impact of referral patterns on the patients’ HRQoL and functioning. Results We identified three patterns of referral trajectories: primary care physician (PCP) only, PCP and neurologist, and PCP and ENT. Chances of referral to a neurologist were higher for patients with a neurological comorbidity (OR = 3.22, 95%-CI [1.003; 10.327]) and lower for patients from Saxony (OR = 0.08, 95%-CI [0.013; 0.419]). Patients with a PCP and neurologist referral pattern had a lower HRQoL and lower functioning at baseline assessment. Patients with unspecific diagnoses also had lower functioning. Conclusion Referral trajectories were determined by present comorbidities and the regional healthcare characteristics. Referral trajectories affected patients’ HRQoL. Unspecific VDB diagnoses seem to increase the risk of ineffective management and consequently impaired functioning.

Background: German social legislation gives patients the right to obtain a second opinion before elective surgery and defines quality criteria for reimbursement by statutory health insurance. However, the effects of second opinions before elective surgery are largely unknown. The aim of this study was to evaluate the effects of a second opinion programme in patients recommended for knee arthroplasty.Methods: The largest statutory health insurance funds in Bavaria offered patients to whom knee arthroplasty was recommended participation in a second opinion programme with personal presentation to an experienced knee surgeon. In this cohort study, consecutive patients from this second opinion programme who signed informed consent were included from 07/10/2016 to 14/02/2020. Data were collected before and after the second opinion visit.Results: A total of 141 (66%) of 215 second opinion patients participated in the evaluation study. The second opinion physician recommended knee arthroplasty to 40% of the patients, later knee arthroplasty if the conditions worsened to 40%, and no knee arthroplasty to 20%. The frequency of undecided patients decreased from 41% to 12%. After the second opinion, the patients were more confident in their decision according to the decision confidence scale (before: 5.4 ± 3.0; after: 7.8 ± 2.5; p < 0.001). Logistic regression analyses showed that higher radiological severity of osteoarthritis on the Kellgren/Lawrence scale (p = 0.001) and lower knee-joint-specific quality of life on the KOOS questionnaire (p = 0.041) were associated with the recommendation for knee arthroplasty by the second opinion physician. The patients rated their satisfaction with the second opinion programme with a mean grade of 1.35 (± 0.60) on a scale from 1 to 5.Conclusion: The second opinion of an experienced knee surgeon frequently deviates from the initial recommendation for knee arthroplasty. The results of this study suggest that a second opinion may improve adherence to guidelines for indications of knee arthroplasty. From the patient perspective, the second opinion reduces uncertainties in their treatment decision.

Introduction: Anticholinergic and sedative medication is prescribed for various conditions in older patients. While the general association between anticholinergic and sedative medication and impaired functioning is well established, its specific role in older individuals with vertigo, dizziness, and balance disorders (VDB) is still incompletely understood. The objective of this study was to investigate, whether an exposure to anticholinergic and sedative medication is associated with lower generic and lower vertigo-specific functioning in older patients with VDB.Methods: Data originates from the longitudinal multicenter study MobilE-TRA with two follow-ups, conducted from 2017 to 2019 in two German federal states. Exposure to anticholinergic and sedative medication was quantified using the drug burden index (DBI). Generic functioning was assessed by the Health Assessment Questionnaire Disability Index, appraising the amount of difficulties in performing activities of daily living (ADL). Vertigo-specific functioning was measured using the Vestibular Activities and Participation (VAP) questionnaire, assessing patient-reported functioning regarding activities of daily living that are difficult to perform because of their propensity to provoke VDB (Scale 1) as well as immediate consequences of VDB on activities and participation related to mobility (Scale 2). Longitudinal linear mixed models were applied to assess the association of exposure to anticholinergic and sedative medication at baseline and the level of generic and vertigo-specific functioning status over time.Results: An overall of 19 (7 from Bavaria) primary care physicians (mean age = 54 years, 29% female) recruited 158 (59% from Bavaria) patients with VDB (median age = 78 years, 70% female). Anticholinergic and sedative medication at baseline was present in 56 (35%) patients. An exposure to anticholinergic and sedative medication at baseline was significantly associated with lower generic functioning [Beta = 0.40, 95%-CI (0.18; 0.61)] and lower vertigo-specific functioning [VAP Scale 1: Beta = 2.47, 95%-CI (0.92; 4.02)], and VAP Scale 2: Beta = 3.74, 95%-CI [2.23; 5.24]).Conclusion: Our results highlight the importance of a close monitoring of anticholinergic and sedative medication use in older patients with VDB. When feasible, anticholinergic and sedative medication should be replaced by equivalent alternative therapies in order to potentially reduce the burden of VDB.