Discussion
SECONDARY
Using a prospective controlled, two-armed historical control group design, we were able to demonstrate that our novel telephone-based HAPA intervention targeting both patient and physician led to considerably improved adherence to recommended preventive measures in asplenic patients. Educating and motivating the patient was identified as the crucial factor of the intervention since even patients, whose physician did not receive the intervention, scored only marginally lower than those, whose physician had received some form of intervention.Integral part of all PSS prevention is the implementation of a vaccination plan. Due to different study designs and methodological approaches, investigators report a wide range of vaccine coverage in asplenic patients [Several attempts have been made to improve guideline adherence. One popular approach is to establish an outpatient service in order to follow up asplenic patients and provide them with the necessary education and, if needed, vaccinations [Secondly, our intervention is easily distributable, resource-saving when compared to face-to-face contacts and not confined to any specific setting in terms of both place and time. It can be understood as a telehealth preventive intervention, well applicable for example in underserved rural areas, and does not need dedicated structures but instead leverages existing ones, e. g. by involving the physician of the patient. By making our manual publicly available, we hope to open up a wide range of possibilities for implementation both in the inpatient and outpatient setting.Thirdly, our intervention sought to bridge the intersectorial divide by involving the physicians in the prevention process. Intensifying the collaboration between clinicians and physicians was shown to be essential in order to improve the quality of care for asplenic patients [Finally, a unique feature of our design lies in the important role it assigns to the health insurance provider. Our approach includes an easy to perform and inexpensive screening procedure that enables health insurance companies to actively take part in delivering preventive strategies in a focused and patient-specific way. Leveraging the existing infrastructure of the health insurance provider not only facilitated inclusion of patients but also may prove pivotal in further implementation and widespread roll-out of our intervention. Given its aptitude for printed distribution, part of the intervention could conceivably be automated and sent out to both patients and their physicians upon screening and identification via OPS codes.There are some limitations to our study. It is possible that our results are influenced by a responder bias, since first contact with patients was made via mail from the health insurance provider and we could only include those that responded to this letter. This might have led to an overrepresentation of patients, who were already motivated to obtain additional asplenia-related information. Our study was performed in cooperation with a singular health insurance provider. A potential barrier to widespread implementation could lie in the highly diverse landscape of the German health insurance system. While in theory all insurance companies should have access to the required data, the ability to implement the described intervention could conceivably vary depending on the type of insurance company (e.g., state funded vs. privately owned) and on the region in question. Additionally, due to the non-randomized design of our study, we cannot rule out confounding. Although we used a well-designed statistical model to account for this, unmeasured confounding might still be present. Due to the short follow-up time, we cannot speak to the long-term success of our intervention, yet we are currently performing a follow-up concerning primary and secondary outcomes three years after the intervention.In conclusion, asplenic patients who had received a HAPA-based, telephonic intervention exhibited a significantly higher adherence to guideline-based preventive measures compared to a historical control group. Widespread adoption of this pragmatic intervention could improve patient care and ultimately lead to reduced morbidity and mortality from PSS. Moreover, our strategy of health insurance provider-initiated identification of at-risk patients followed by a patient-focused intervention may serve as a blueprint for a wide range of other preventive efforts leading to patient empowerment and ultimately to better adherence to standards of care.