Hausarztzentrierte Versorgung in Deutschland. Der Hausarzt als Lotse?

Work-Related Intervention Needs of Medical Assistants and How to Potentially Address Them according to Supervising General Practitioners: A Qualitative Study

Work stress is common among health care professionals and this observation also holds true for general practitioners (GPs) and their medical assistance staff in Germany. Therefore, prior studies have examined the work-related intervention needs of medical assistants (MAs). We sought to explore potential interventions that may help to address these needs according to GPs’ views. Between December 2018 and April 2019 GPs were recruited via physician networks and through personal visits in general practices. Information on the nature and prevalence of 20 work-related intervention needs of MAs was presented to GPs. GPs then participated in a qualitative interview to reflect on the MAs’ needs. Qualitative content analysis according to Mayring was carried out using MAXQDA. A total of 21 GPs participated and perceived many of the needs as justified. The least understanding was expressed for requests of MA related to occupational aspects that were already known prior to hiring. The responsibility to address needs was often assigned to the German health policy. GPs expressed though that they considered addressing the need for better leadership style as their own responsibility as supervisors. Furthermore, professional training was discussed as one opportunity to raise the recognition and remuneration of MAs. Measures to address the work-related intervention needs of MAs and to thereby improve the working conditions of MAs were discussed with GPs.

[Predictors of Admission to Nursing Home in Care-Dependent People - A Longitudinal Secondary Data Analysis]

OBJECTIVE

To determine predictors of admission to nursing home by means of secondary data analysis of German statutory health insurance claims data and care needs assessments.

MATERIALS AND METHODS

A retrospective longitudinal analysis was conducted covering the period 2006-2016 and using routine data. Health insurance data and care needs assessment data for people who became care dependent in 2006 and who lived in their own homes were merged. Cox regression analyses were conducted to identify predictors of admission to a nursing home.

RESULTS

The study population comprised 48,892 persons. Dementia, cancer of the brain, cognitive impairment, antipsychotics prescriptions, hospitalized fractures, hospital stays over ten days, and higher age had the highest hazard ratios among the predictors.

CONCLUSIONS

Knowledge about the predictors serves to sensitize health care professionals in the care of people in need of care. It facilitates identification of care needs in community-dwelling persons at an increased risk of admission to a nursing home.

Stigma and Knowledge as Determinants of Recommendation and Referral Behavior of General Practitioners and Internists

BACKGROUND

Despite reported effectiveness, weight loss surgery (WLS) still remains one of the least preferred options for outpatient providers, especially in Germany. The aim of this study was to examine the effect of stigma and knowledge on recommendation of WLS and referral to a surgeon by general practitioners (GPs) and internists.

METHOD

The sample consists of 201 GPs and internists from Germany. The questionnaire included questions on the perceived effectiveness of WLS, the frequency of recommendations of WLS, and the frequency of referral to WLS. Stigma, as well as knowledge was also assessed in this context. Linear and logistic regression models were conducted. A mediation analysis was carried out within post hoc analysis.

RESULTS

Knowledge (b = 0.258, p < 0.001) and stigma towards surgery (b = -0.129, p = 0.013) were related to the frequency of recommendation of WLS. Additionally, respondents, who were more likely to express negative attitudes towards WLS, were less likely to recommend WLS and thus refer patients to WLS (b = -0.107, p < 0.05). Furthermore, respondents with more expertise on WLS were more likely to recommend and thus refer patients to WLS (b = 0.026, p < 0.05).

CONCLUSION

This study showed that stigma plays a role when it comes to defining treatment pathways for patients with obesity. The question remains how this might influence the patients and their decision regarding their treatment selection. Interventions are required to make treatment decisions by physicians or patients independent of social pressure due to stigma.

Costs of coordinated versus uncoordinated care in Germany: results of a routine data analysis in Bavaria

OBJECTIVES

The efficiency of a gatekeeping system for a health system, as in Germany, remains unclear particularly as access to specialist ambulatory care is not restricted. The aim was to compare the costs of coordinated versus uncoordinated patients (UP) in ambulatory care; with additional subgroup analysis of patients with mental disorders.

DESIGN

Retrospective routine data analysis of patients with statutory health insurance, using claims data held by the Bavarian Association of Statutory Health Insurance Physicians. A patient was defined as uncoordinated if he or she visited at least 1 specialist without a referral from a general practitioner within a quarter. Outcomes were compared with propensity score matching analysis.

PARTICIPANTS

The study encompassed all statutorily insured patients in Bavaria contacting at least 1 ambulatory specialist in the first quarter of 2011 (n=3 616 510).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was total costs of ambulatory care; secondary outcomes were financial claims of general physicians, specialists and for medication.

RESULTS

The average age was 55.3 years for coordinated patients (CP, n=1 629 302), 48.3 years for UP (n=1 825 840). CP more frequently had chronic diseases (85.4%) as compared with UP (67.5%). The total unadjusted financial claim per patient was higher for UP (€234.52) than for CP (€224.41); the total adjusted difference was -€9.65 (95% CI -11.64 to -7.67), indicating lower costs for CP. The cost differences increased with increasing age. Total adjusted difference per patient with mental diseases as documented with an International Classification of Diseases (ICD)-10 F-diagnosis, was -€20.31 (95% CI -26.43 to -14.46).

CONCLUSIONS

Coordination of care is associated with lower ambulatory healthcare expenditures and is of particular importance for patients who are more vulnerable to medical interventions, especially for elderly and patients with mental disorders. The role of general practitioners as coordinators should be strengthened to improve care for these patients as this could also help to frame a more efficient health system.

How do patients with a Turkish background evaluate their medical care in Germany? An observational study in primary care

BACKGROUND

Patients' evaluation of medical care is an essential dimension of quality of care and an important aspect of the feedback cycle for health care providers. The aim of this study was to document how patients with a Turkish background evaluate primary care in Germany and determine which aspects of care are associated with language abilities.

METHODS

The study was based on an observational design. Patients with a Turkish background from German primary care practices completed the EUROPEP (European Project on Patient Evaluation of General Practice Care) questionnaire consisting of 23 items. Seventeen primary care practices were involved with either German (n=8) or Turkish (n=9) general practitioners (GPs).

RESULTS

A convenience sample of 472 patients with a Turkish background from 17 practices participated in the study (response rate 39.9%). Practices with a German GP had a lower response rate (19.6%) than those with a Turkish GP (57.5%). Items evaluated the highest were "keeping data confidential" (73.4%) and "quick services for urgent health problems" (69.9%). Subgroup analysis showed lower evaluation scores from patients with good or excellent German language abilities. Patients who consulted a Turkish GP had higher evaluation scores.

CONCLUSION

The evaluation from patients with a Turkish background living in Germany with either Turkish or German GPs showed lower scores than patients in other studies in Europe using EUROPEP. However, our results had higher evaluation scores than those of Turkish patients evaluating GPs in Turkey. Therefore, different explanation models for these findings should be explored in future studies.

[Do gatekeeping programs increase equality of health care in Germany? A comparison of the health care situation of participants and nonparticipants]

This article compares the health care situation of participants in programs of general practitioner-centered health care (gatekeeping) in Germany (participants) with that of statutory health insurance holders who are not participating in such programs (nonparticipants). Because a key objective of the general practitioner model is to reduce the number of visits to specialists, the article also examines factors influencing frequent utilization of specialists in both groups. The analysis draws on a survey conducted by the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, 2010) based on a sample representative of the German population. In this context, 5,232 holders of statutory health insurance aged between 18 and 79 years were interviewed on health care policy issues. The results show that regulating the utilization of specialists through the gatekeeping function of general practitioners succeeds in facilitating similar utilization rates across educational levels, between cities and towns, and between men and women. Thus, gatekeeping programs contribute to the reduction of health care inequalities.