[Improving Postgraduate Medical Training In Germany: A Proposal]

Postgraduate (vocational, residency) training in Germany is regulated by the Physicians' Chamber in each federal state. Although training requirements are specified in detail by regulatory documents, young doctors are left on their own to find training posts and suitable learning experiences. There are no programmes in place to support trainees nor to identify the need of the health care system regarding the composition of its medical workforce. Hospitals and practices pay salaries to physicians in training from funding obtained for services they provide. We propose a systematic and continuing process of identifying gaps in the workforce. Disciplines with a lack of qualified doctors will be supported by additional funds directed to practices and hospitals. Regional rotation schemes will coordinate and improve the quality of training. Apart from an administrative overhead, this system of regulation will not need additional resources because a limited part of current budgets will be explicitly channelled into salaries for trainees in specialties for which there is a higher need than into others.

Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure

BACKGROUND

The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study.

METHODS

General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis.

RESULTS

Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees.

CONCLUSIONS

Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.

A volunteer-supported walking programme to improve physical function in older people with restricted mobility (the POWER Study): a randomised controlled trial

BACKGROUND

Regular physical activity has multiple health benefits, especially in older people. Therefore, the World Health Organization recommends at least 2.5 h of moderate physical activity per week. The aim of the POWER Study was to investigate whether volunteer-assisted walking improves the physical performance and health of older people.

METHODS

We approached people aged 65 years and older with restricted mobility due to physical limitations and asked them to participate in this multicentre randomised controlled trial. The recruitment took place in nursing homes and the community setting. Participants randomly assigned to the intervention group were accompanied by volunteer companions for a 30-50 min walk up to three times a week for 6 months. Participants in the control group received two lectures that included health-related topics. The primary endpoint was physical function as measured with the Short Physical Performance Battery (SPPB) at baseline and 6 and 12 months. The secondary and safety endpoints were quality of life (EQ-5D-5L), fear of falling (Falls Efficacy Scale), cognitive executive function (the Clock Drawing Test), falls, hospitalisations and death.

RESULTS

The sample comprised 224 participants (79% female). We failed to show superiority of the intervention with regard to physical function (SPPB) or other health outcomes in the intention-to-treat analyses. However, additional exploratory analyses suggest benefits in those who undertook regular walks. The intervention appears to be safe regarding falls.

CONCLUSIONS

Regular physical activity is essential to preserve function and to improve health and quality of life. Against the background of a smaller-than-planned sample size, resulting in low power, and the interference of the COVID-19 pandemic, we suggest that community based low-threshold interventions deserve further exploration.

TRIAL REGISTRATION

The trial was registered with the German Clinical Trials Register ( www.germanctr.de ), with number DRKS00015188 on 31/08/2018.

Efficacy of a computer based discontinuation strategy to reduce PPI prescriptions: a multicenter cluster-randomized controlled trial

Deprescribing of inappropriate long-term proton pump inhibitors (PPI) is challenging and there is a lack of useful methods for general practitioners to tackle this. The objective of this randomized controlled trial was to evaluate the effectiveness of the electronic decision aid tool arriba-PPI on reduction of long-term PPI intake. Participants (64.5 ± 12.9 years; 54.4% women) with a PPI intake of at least 6 months were randomized to receive either consultation with arriba-PPI from their general practitioner (n = 1256) or treatment as usual (n = 1131). PPI prescriptions were monitored 6 months before, 6 and 12 months after study initiation. In 49.2% of the consultations with arriba-PPI, the general practitioners and their patients made the decision to reduce or discontinue PPI intake. At 6 months, there was a significant reduction by 22.3% (95% CI 18.55 to 25.98; p < 0.0001) of defined daily doses (DDD) of PPI. A reduction of 3.3% (95% CI - 7.18 to + 0.62) was observed in the control group. At 12 months, the reduction of DDD-PPI remained stable in intervention patients (+ 3.5%, 95% CI - 0.99 to + 8.03), whereas control patients showed a reduction of DDD-PPI (- 10.2%, 95% CI - 6.01 to - 14.33). Consultation with arriba-PPI led to reduced prescription rates of PPI in primary care practices. Arriba-PPI can be a helpful tool for general practitioners to start a conversation with their patients about risks of long-term PPI intake, reduction or deprescribing unnecessary PPI medication.

Physicians' assessment of the Bavarian drug-expenditure control system: a qualitative study

BACKGROUND

In 2014 a new system for drug expenditures, the Wirkstoffvereinbarung (WSV, English: Active substance agreement) was implemented in Bavaria. In pre-defined indication groups, economic prescription of medications shall be enabled based on the selection, quantity, and proportion of an individual drug. Ambulatory care physicians receive quarterly trend reports on their prescribing behavior. This study examines physicians' perceptions of the WSV.

METHODS

Qualitative interviews (n = 20) and seven focus groups (n = 36) were conducted with ambulatory care physicians (e.g. general practitioners, cardiologists, pulmonologists). The methodology followed Qualitative Content Analysis.

RESULTS

Physicians generally accepted the necessity of prescribing economically. The majority of them rated the WSV positively and better than the previous system. As an improvement, they especially named timely feedback in form of easily understandable trend reports, encouraging self-reflection as well as allowing early control options. Problems perceived were drug discount contracts that were strongly criticized as leading to patients mixing up medications. Some perceived constraints of therapeutic freedom.

CONCLUSIONS

The implementation of the WSV is mostly viewed positively by physicians. The restrictions of therapeutic freedom partially perceived might be met by improved information on the reasons why some drugs are rated as less economical than others.

TRIAL REGISTRATION NUMBER

Main ID: DRKS00019820 (German Register of Clinical Studies and World Health Organization).

Experiences of participants of a volunteer-supported walking intervention to improve physical function of nursing home residents - a mixed methods sub-study of the POWER-project

BACKGROUND

Regular physical activity improves physical health and mental well-being and reduces the risk of falling in older adults. The randomized controlled "Prevention by lay-assisted Outdoor-Walking in the Elderly at Risk" POWER-study investigates whether volunteer-supported outdoor-walking improves physical function and quality of life in older people living independently or in nursing homes. This sub-study explores the experiences of older participants and volunteers in relation to their physical and psychosocial well-being as well as the challenges faced by both groups. A further aim was to explore volunteers' experience with people living in nursing homes during the first pandemic lockdown (spring 2020).

METHODS

The sub-study was designed as mixed-methods approach consisting of 11 individual semi-structured guide-based interviews (nursing home residents), two focus group interviews (volunteers), and a cross-sectional questionnaire survey (volunteers). The interviews were audiotaped, transcribed verbatim, and analyzed by content analysis as described by Kuckartz. Topics addressed in the interviews were triangulated by means of a questionnaire. The quantitative data were analyzed using descriptive statistics.

RESULTS

Participants' evaluation of the intervention was generally positive. Nursing home residents appreciated the social interaction associated with the assisted walking, which motivated them to take part regularly, provided a sense of safety, and caused pleasure on both sides. The impact on physical health status of the nursing home residents of this sub-study varied to a large degree as reported in interviews: in some cases, an improvement in physical performance, a decrease in physical complaints, and an improvement in gait or independence was reported. If not, reference was made to previous or sudden illnesses and the advanced age of the participants. Despite the COVID-19-lockdown and the associated restrictions, about 60% of contacts were still possible and participants planned to continue the assisted walks after the lockdown.

CONCLUSION

Volunteers have a positive effect on the quality of life, mobility, and general health of nursing home residents. Even more than the improvement of physical performance, social interaction was seen as helpful. Despite their advanced age, the nursing home residents were curious and open to new contacts. When removing the identified barriers, it might be possible to integrate this program into the long-term everyday life of nursing homes.

TRIAL REGISTRATION

DRKS-ID: DRKS00015188, date of registration: 31.08.2018.

Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds

BACKGROUND

Chest pain is a frequent consultation issue in primary care, with coronary artery disease (CAD) being a serious potential cause. Primary care physicians (PCPs) assess the probability for CAD and refer patients to secondary care if necessary. Our aim was to explore PCPs' referral decisions, and to investigate determinants which influenced those decisions.

METHODS

PCPs working in Hesse, Germany, were interviewed in a qualitative study. We used 'stimulated recall' with participants to discuss patients with suspected CAD. With a sample size of 26 cases from nine practices we reached inductive thematic saturation. Interviews were audio-recorded, transcribed verbatim and analyzed by inductive-deductive thematic content analysis. For the final interpretation of the material, we used the concept of decision thresholds proposed by Pauker and Kassirer.

RESULTS

PCPs reflected on their decisions for or against a referral. Aside from patient characteristics determining disease probability, we identified general factors which can be understood as influencing the referral threshold. These factors relate to the practice environment, to PCPs themselves and to non-diagnostic patient characteristics. Proximity of specialist practice, relationship with specialist colleagues, and trust played a role. PCPs sometimes felt that invasive procedures were performed too easily. They tried to steer their patients through the system with the intent to avoid over-treatment. Most PCPs were unaware of guidelines but relied on informal local consensus, largely influenced by specialists. As a result, PCPs gatekeeping role was limited.

CONCLUSIONS

We could identify a large number of factors that impact referral for suspected CAD. Several of these factors offer possibilities to improve care at the clinical and system level. The threshold model proposed by Pauker and Kassirer was a useful framework for this kind of data analysis.

Diffusion of a new drug among ambulatory physicians-The impact of patient pathways

When drugs enter the market, physicians' prescribing behavior plays a crucial role in the diffusion process. Although regulations to foster economically efficient prescribing exist, physicians have some degree of freedom in choosing medication and are subject to various influencing factors. The aim of the present analysis is to investigate how interaction among patients and physicians affects the diffusion. We look at two different ways that patient pathways might influence physicians and examine these effects for Sacubitril/Valsartan (S/V), a new drug for patients with heart failure. Using administrative data from Germany, we identify physicians who prescribed S/V in the first 2 years of its availability. We apply survival models to estimate the impact of the patient-physician interaction on the physicians' adoption time. To this end, we determine whether individual physicians treated patients that had been prescribed S/V, and how many other physicians already prescribing S/V were connected in patient-sharing networks. Our main findings are that patients with a previous prescription seem to induce adoption by demanding repeat prescriptions. Moreover, patients establish connections between physicians that may lead to prescriptions for new patients. Our results therefore suggest that patient pathways play a significant role in the diffusion of a new drug.

Influence of a guideline or an additional rapid strep test on antibiotic prescriptions for sore throat: the cluster randomized controlled trial of HALS (Hals und Antibiotika Leitlinien Strategien)

BACKGROUND

Pharyngitis due to Group A beta-hemolytic streptococci (GAS) is seen as the main indication for antibiotics for sore throat. In primary care settings prescription rates are much higher than the prevalence of GAS. Recommendations in international guidelines differ considerably. A German guideline suggested to consider antibiotics for patients with Centor or McIsaac scores ≥ 3, first choice being penicillin V for 7 days, and recommended analgesics for all. We investigated, if the implementation of this guideline lowers the antibiotic prescription rate, and if a rapid antigen detection strep-test (RADT) in patients with scores ≥ 3 lowers the rate further.

METHODS

HALS was an open pragmatic parallel group three-arm cluster-randomized controlled trial. Primary care practices in Northern Germany were randomized into three groups: Guideline (GL-group), modified guideline with a RADT for scores ≥ 3 (GL-RADT-group) or usual care (UC-group). All practices were visited and instructed by the study team (outreach visits) and supplied with material according to their group. The practices were asked to recruit 11 consecutive patients ≥ 2 years with an acute sore throat and being at least moderately impaired. A study throat swab for GAS was taken in every patient. The antibiotic prescription rate at the first consultation was the primary outcome.

RESULTS

From October 2010 to March 2012, 68 general practitioners in 61 practices recruited 520 patients, 516 could be analyzed for the primary endpoint. Antibiotic prescription rates did not differ between groups (p = 0.162) and were about three times higher than the GAS rate: GL-group 97/187 patients (52%; GAS = 16%), GL-RADT-group 74/172 (43%; GAS = 16%) and UC-group 68/157 (43%; GAS = 14%). In the GL-RADT-group 55% of patients had scores ≥ 3 compared to 35% in GL-group (p < 0.001). After adjustment, in the GL-RADT-group the OR was 0.23 for getting an antibiotic compared to the GL-group (p = 0.010), even though 35 of 90 patients with a negative Strep-test got an antibiotic in the GL-RADT-group. The prescription rates per practice covered the full range from 0 to 100% in all groups.

CONCLUSION

The scores proposed in the implemented guideline seem inappropriate to lower antibiotic prescriptions for sore throat, but better adherence of practitioners to negative RADTs should lead to fewer prescriptions.

TRIAL REGISTRATION

DRKS00013018, retrospectively registered 28.11.2017.

Mapping the methodological diversity of published drug discontinuation studies-a scoping review of study topics, objectives, and designs

BACKGROUND

Trials evaluating drug discontinuation (drug discontinuation trials, DDTs) show a broad methodological spectrum. There are several specific methodological aspects in drug discontinuation trials (e.g., determination of research question; configuration of intervention; definition of outcomes). To verify this specifies, we did a scoping review about the study designs of drug discontinuation trials.

METHODS

A systematic literature search in Medline (PubMed), The Cochrane Library, EMBASE, CINAHL, Web of Science, and PsycINFO was performed. In a two-step selection process, we identified DDTs, which evaluate the discontinuation of one or more long-term medication as the investigated intervention, by two independent reviewers. Besides bibliographic data, we extracted several parameters to describe the used study design of the included DDTs: motivation for DDT, initially treatment aim of the discontinued medication, study design, methods of discontinuation, follow-up times, number of study participants, and outcome parameter.

RESULTS

Out of 12,132 records, we included 581 DDTs. The most common motivation for doing a DDT were expected side effects (48.8%), the motivation of proving the efficacy of medication (21.6%), or doubts on the expected benefit of the used medication (13.8%). The majority of the discontinued medication was initially prescribed to improve the prognosis of a chronic disease (60.4%) or to relieve symptoms (31%). The study designs of the trials showed a broad methodological spectrum. The minority of the drug discontinuation trials were randomized controlled trials (34%).

CONCLUSION

The results of this scoping review illustrates the need for an evidence-based methodological standard for planning and conducting drug discontinuation trials.

Anticholinergic burden measures, symptoms, and fall-associated risk in older adults with polypharmacy: Development and validation of a prognostic model

BACKGROUND

Anticholinergic burden has been associated with adverse outcomes such as falls. To date, no gold standard measure has been identified to assess anticholinergic burden, and no conclusion has been drawn on which of the different measure algorithms best predicts falls in older patients from general practice. This study compared the ability of five measures of anticholinergic burden to predict falls. To account for patients' individual susceptibility to medications, the added predictive value of typical anticholinergic symptoms was further quantified in this context.

METHODS AND FINDINGS

To predict falls, models were developed and validated based on logistic regression models created using data from two German cluster-randomized controlled trials. The outcome was defined as "≥ 1 fall" vs. "no fall" within a 6-month follow-up period. Data from the RIME study (n = 1,197) were used in model development, and from PRIMUM (n = 502) for external validation. The models were developed step-wise in order to quantify the predictive ability of anticholinergic burden measures, and anticholinergic symptoms. In the development set, 1,015 patients had complete data and 188 (18.5%) experienced ≥ 1 fall within the 6-month follow-up period. The overall predictive value of the five anticholinergic measures was limited, with neither the employed anticholinergic variable (binary / count / burden), nor dose-dependent or dose-independent measures differing significantly in their ability to predict falls. The highest c-statistic was obtained using the German Anticholinergic Burden Score (0.73), whereby the optimism-corrected c-statistic was 0.71 after interval validation using bootstrapping and 0.63 in the external validation. Previous falls and dizziness / vertigo had the strongest prognostic value in all models.

CONCLUSIONS

The ability of anticholinergic burden measures to predict falls does not appear to differ significantly, and the added value they contribute to risk classification in fall-prediction models is limited. Previous falls and dizziness / vertigo contributed most to model performance.

Educating physicians on strong opioids by descriptive versus simulated-experience formats: a randomized controlled trial

BACKGROUND

Long-term prescriptions of strong opioids for chronic noncancer pain-which are not supported by scientific evidence-suggest miscalibrated risk perceptions among those who prescribe, dispense, and take opioids. Because risk perceptions and behaviors can differ depending on whether people learn about risks through description or experience, we investigated the effects of descriptive versus simulated-experience educative formats on physicians' risk perceptions of strong opioids and their prescription behavior for managing chronic noncancer pain.

METHODS

Three hundred general practitioners and 300 pain specialists in Germany-enrolled separately in two independent exploratory randomized controlled online trials-were randomly assigned to either a descriptive format (fact box) or a simulated-experience format (interactive simulation).

PRIMARY ENDPOINTS

Objective risk perception (numerical estimates of opioids' benefits and harms), actual prescriptions of seven therapy options for managing chronic pain.

SECONDARY ENDPOINT

Implementation of intended prescriptions of seven therapy options for managing chronic pain.

RESULTS

Both formats improved the proportion of correct numerical estimates of strong opioids' benefits and harms immediately after intervention, with no notable differences between formats. Compared to description, simulated experience led to significantly lower reported actual prescription rates for strong and/or weak opioids, and was more effective at increasing prescription rates for non-drug-based therapies (e.g., means of opioid reduction) from baseline to follow-up for both general practitioners and pain specialists. Simulated experience also resulted in a higher implementation of intended behavior for some drug-based and non-drug-based therapies.

CONCLUSIONS

The two formats, which recruit different cognitive processes, may serve different risk-communication goals: If the goal is to improve exact risk perception, descriptive and simulated-experience formats are likely to be equally suitable. If, however, the goal is to boost less risky prescription habits, simulated experience may be the better choice.

TRIAL REGISTRATION

DRKS00020358 (German Clinical Trials Register, first registration: 07/01/2020).

MediQuit – an electronic deprescribing tool: a pilot study in German primary care; GPs’ and patients’ perspectives

Background

General practitioners (GPs) are the central coordinators for patients with multimorbidity and polypharmacy in most health care systems. They are entrusted with the challenging task of deprescribing when inappropriate polypharmacy is present.

MediQuit (MQu) is a newly developed electronic tool that guides through a deprescribing consultation. It facilitates the identification of a medicine to be discontinued (stage 1), a shared decision-making process weighing the pros and cons (stage 2), and equips patients with take-home instructions on how to discontinue the drug and monitor its impact (stage 3). We here aim to evaluate utility and acceptance of MQu from GPs’ and patients’ perspectives.

Methods

Uncontrolled feasibility study, in which 16 GPs from two regions in Germany were invited to use MQu in consultations with their multimorbid patients. We collected quantitative data on demography, utility and acceptance of MQu and performed descriptive statistical analyses.

Results

Ten GPs performed 41 consultations using MQu. Identification (step 1) and implementation elements (Step 3) were perceived most helpful by GPs. Whereas, shared-decision making elements (step 2) revealed room for improvement. Patients appreciated the use of MQu. They were broadly satisfied with the deprescribing consultation (85%) and with their decision made regarding their medication (90%).

Conclusions

Implementation of MQu in general practice generally seems possible. Patients welcome consultations targeting medication optimization. GPs were satisfied with the support of MQu and likewise gave important hints for future development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01852-2.

Identifying and Investigating Ambulatory Care Sequences Before Invasive Coronary Angiography

BACKGROUND

The concept of care pathways is widely used to provide efficient, timely, and evidence-based medical care. Recently, the investigation of actual empirical patient pathways has gained attention. We demonstrate the usability of State Sequence Analysis (SSA), a data mining approach based on sequence clustering techniques, on comprehensive insurance claims data from Germany to identify empirical ambulatory care sequences. We investigate patients with coronary artery disease before invasive coronary angiography (CA) and compare identified patterns with guideline recommendations. This patient group is of particular interest due to high and regionally varying CA rates.

METHODS

Events relevant for the care of coronary artery disease patients, namely physician consultations and medication prescriptions, are identified based on medical guidelines and combined to define states. State sequences are determined for 1.5 years before CA. Sequence similarity is defined for clustering, using optimal matching with theory-informed substitution costs. We visualize clusters, present descriptive statistics, and apply logistic regression to investigate the association of cluster membership with subsequent undesired care events.

RESULTS

Five clusters are identified, the included patients differing with respect to morbidity, urbanity of residential area, and health care utilization. Clusters exhibit significant differences in the timing, structure, and extent of care before CA. When compared with guideline recommendations, 3 clusters show signs of care deficits.

CONCLUSIONS

Our analyses demonstrate the potential of SSA for exploratory health care research. We show how SSA can be used on insurance claims data to identify, visualize, and investigate care patterns and their deviations from guideline recommendations.

[Prescribing behavior of Bavarian general practitioners at the inpatient-outpatient interface within the context of the Bavarian active substance agreement-qualitative results of the WirtMed Study]

Hintergrund und Ziel

Zur transparenten Steuerung der Arzneimittelausgaben im Rahmen des Wirtschaftlichkeitsgebots (§ 12 Fünftes Buch Sozialgesetzbuch (SGB V)) hat die Kassenärztliche Vereinigung Bayerns im Jahr 2014 die Wirkstoffvereinbarung (WSV) eingeführt. Diese hat die Richtgrößensystematik abgelöst. Mit Bezug auf die Rolle der WSV werden im Artikel die Gründe der Hausärzt*innen (HÄ) für oder gegen eine Weiterverordnung von Arzneimitteln aus dem Krankenhaus beschrieben.

Material und Methode

In einem qualitativen Studiendesign wurden im Zeitraum 11/2019 bis 03/2020 mit bayerischen HÄ Einzelinterviews (n = 18) und 2 Fokusgruppen (n = 10) durchgeführt und nach der qualitativen Inhaltsanalyse ausgewertet.

Ergebnisse

Mit der Einführung der WSV nahmen die Regresssorgen der HÄ insgesamt ab. Große Bedeutung bei Verordnungen haben – vor der Wirtschaftlichkeit – die patient*innenorientierte Versorgung und fachliche Richtigkeit von Therapieentscheidungen. Mit der Entlassmedikation ergeben sich wirtschaftliche Herausforderungen, besonders mit dem Leitsubstanzziel der oralen Antikoagulation, den Generikazielen bei Antidiabetika und bei Therapeutika für das Herz-Kreislauf-System. Allgemein kritisiert werden Rabattverträge, die oft zu Umstellungen von Arzneimitteln führen. Vereinzelt wird von einer „Vormachtstellung“ der Klinikärzt*innen berichtet, die dem hausärztlichen wirtschaftlichen Handeln entgegenstehen. Es fehlt laut HÄ eine sektorenübergreifende Kostenverantwortung.

Diskussion

Ein reibungsloser Schnittstellenübergang ist aus Sicht der HÄ trotz des Rahmenvertrags Entlassmanagement und der neuen Steuerungssystematik der WSV im ambulanten Sektor noch nicht vorhanden. Für eine wirtschaftliche Arzneimittelversorgung bedarf es weiterhin einer sektorenübergreifenden, aber auch bundesländerübergreifenden politischen Diskussion.

Zusatzmaterial online

Im Onlinematerial sind vertiefende Informationen zu der Methodik (Onlinematerial 1: Interview- und Fokusgruppenleitfaden) sowie zur Auswertung (Onlinematerial 2: Kategoriensystem) dieser Studie (10.1007/s00103-022-03563-6) verfügbar.

Validation of Cardiovascular Risk Prediction by the Arriba Instrument

BACKGROUND

It is recommended in cardiovascular prevention guidelines that treatment should be based on overall cardiovascular risk. The arriba instrument has been widely used for this purpose in Germany. The aim of this study is to validate risk prediction by arriba with the aid of morbidity and mortality data from the population- based Study of Health in Pomerania.

METHODS

In a longitudinal analysis, the arriba instrument was used to calculate the 10-year overall cardiovascular risk at baseline for subjects who had not sustained any prior cardiovascular event. Cardiovascular event rates were determined from follow-up data, and discrimination and calibration measures for the risk determination algorithm were calculated.

RESULTS

Data from 1973 subjects (mean age 51 ± 13 years, 48% men) were included in the analysis. After a median follow-up of 10.9 years, cardiovascular events had occurred in 196 subjects, or 9.8%. The ratio of predicted to observed event rate was 0.8 (95% confidence interval: [0.5; 1.1]), 1.3 [1.0; 1.8], and 1.1 [0.8; 1.4] for subjects at low, intermediate, and high cardiovascular risk, respectively. Arriba underestimated cardiovascular event rates in women and overestimated them in persons aged 30-44 and 45-59. The area under curve was 0.84 [95% CI 0.81; 0.86].

CONCLUSION

The discrimination scores of the arriba instrument resemble those of SCORE-Germany and PROCAM, but a better adjustment to the target population would be desirable. The results support the recommendation of the German Guideline for Cardiovascular Risk Counseling in General Practice for the use of the arriba instrument. An unresolved problem is the failure to consider intervention effects, resulting in an overall mild overestimation of risk.

Moving towards patient-centered care and shared decision-making in Germany

The main focus of this paper is to describe the development and current state of policy, research and implementation of patient-centered care (PCC) and shared decision-making (SDM) in Germany. What is the current state in health policy? Since 2013, the Law on Patients' Rights has standardized all rights and responsibilities regarding medical care for patients in Germany. This comprises the right to informed decisions, comprehensive and comprehensible information, and decisions based on a clinician-patient partnership. In addition, reports and action plans such as the German Ethics Council's report on patient well-being, the National Health Literacy Action Plan, or the National Cancer Plan emphasize and foster PCC and SDM on a policy level. There are a number of public organizations in Germany that support PCC and SDM. How are patients and the public involved in health policy and research? Publishers and funding agencies increasingly demand patient and public involvement. Numerous initiatives and organizations are involved in publicizing ways to engage patients and the public. Also, an increasing number of public and research institutions have established patient advisory boards. How is PCC and SDM taught? Great progress has been made in introducing SDM into the curricula of medical schools and other health care providers' (HCPs) schools (e.g., nursing, physical therapy). What is the German research agenda? The German government and other public institutions have constantly funded research programs in which PCC and SDM are important topics. This yielded several large-scale funding initiatives and helped to develop SDM training programs for HCPs in different fields of health care and information materials. Recently, two implementation studies on SDM have been conducted. What is the current uptake of PCC and SDM in routine care, and what implementation efforts are underway? Compared to the last country report from 2017, PCC and SDM efforts in policy, research and education have been intensified. However, many steps are still needed to reliably implement SDM in routine care in Germany. Specifically, the further development and uptake of decision tools and countrywide SDM trainings for HCPs require further efforts. Nevertheless, an increasing number of decision support tools - primarily with support from health insurance funds and other public agencies - are to be implemented in routine care. Also, recent implementation efforts are promising. For example, reimbursement by health insurance companies of hospital-wide SDM implementation is being piloted. A necessary next step is to nationally coordinate the gathering and provision of the many PCC and SDM resources available.

Inductive foraging: patients taking the lead in diagnosis, a mixed-methods study

BACKGROUND

Patient involvement in treatment decisions is widely accepted. Making a diagnosis, however, is still seen as a technical task mainly driven by physicians. Patients in this respect are perceived as passive providers of data. But, recent patient-centred concepts highlight the value of an active patient involvement in diagnosis.

OBJECTIVE

We aim to reach a deeper understanding of how patients themselves contribute to the diagnostic process.

METHODS

This is an observational study of patient consultations with their General Practitioner (GP) in 12 German practices. We performed a mixed-method qualitative and quantitative analysis of 134 primary care consultations.

RESULTS

At the beginning of most consultations lies a phase where patients were invited to freely unfold their reason for encounter: This was named "inductive foraging" (IF). While patients actively present their complaints, GPs mainly listen and follow the presentation. This episode was found with every GP participating in this study. Ninety-one percent of consultations with diagnostic episodes were opened by IF. IF had a major contribution to the number of cues (diagnostic information) yielded in the diagnostic process. We illustrate a variety of tactics GPs make use of to invite, support, and terminate their patients in IF.

CONCLUSION

IF was found to be a highly relevant strategy in the diagnostic process. Patient involvement through IF offered a major contribution of diagnostic cues. We hypothesize that a patient-centred approach improves diagnosis.

Regional variation in coronary angiography rates: the association with supply factors and the role of indication: a spatial analysis

Background

Coronary angiographies (CAs) are among the most common diagnostic procedures carried out in German hospitals, and substantial regional differences in their frequency of use have been documented. Given the heterogeneity with regard to the expected benefits and the varying scope for discretion depending on the indication for the procedure, we hypothesized that the observed variation and the association of need and supply factors differs by indication for CA.

Methods

We investigated the correlation between supply factors and the regional rates of CAs in Germany while controlling for need using spatial‐autoregressive error models (SARE) and spatial cross-regressive models with autoregressive errors (SCRARE). The overall rates of CAs and the rates in specific patient subgroups, namely, patients with and without myocardial infarction (MI), were calculated based on a comprehensive set of nationwide routine data from three statutory health insurances at the district level.

Results

Although little variation was found in cases with MI, considerable variation was seen in the overall cases and cases without MI. The SARE models revealed a positive association between the number of hospitals with a cardiac catheterization laboratory per 10,000 population and the rates of overall cases and cases without MI, whereas no such relationship existed in cases with MI. Additionally, an association between regional deprivation and the rates of CAs was found in cases with MI, but no such association was seen in cases without MI.

Conclusions

The results supported the hypothesis that the relative association of need and supply factors differed by the indication for CA. Although the regional differences in the frequency of use of CAs can only be explained in part by the factors examined in our study, it offers insight into patient access to and the provision of CA services and can provide a platform for further local research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02513-z.

Decision aid and cost compensation influence uptake of PSA-based early detection without affecting decisional conflict: a cluster randomised trial

International guidelines recommend to inform men about the benefits and harms of prostate specific antigen (PSA) based early detection of prostate cancer. This study investigates the influence of a transactional decision aid (DA) or cost compensation (CC) for a PSA test on the decisional behaviour of men. Prospective, cluster-randomised trial to compare two interventions in a 2 × 2 factorial design: DA versus counselling as usual, and CC versus noCC for PSA-testing. 90 cluster-randomised physicians in the administrative district of Muenster, Germany recruited 962 participants aged 55-69 yrs. in 2018. Primary endpoint: the influence of the DA and CC on the decisional conflict. Secondary endpoints: factors which altered the involvement of the men regarding their decision to take a PSA-test. The primary endpoint was analysed by a multivariate regression model. The choice to take the PSA test was increased by CC and reduced by the DA, the latter also reduced PSA uptake in men who were offered CC. The DA led to an increase of the median knowledge about early detection, changed willingness to perform a PSA test without increasing the level of shared decision, giving participants a stronger feeling of having made the decision by themselves. The DA did not alter the decisional conflict, as it was very low in all study groups. DA reduced and CC increased the PSA uptake. The DA seemed to have a greater impact on the participants than CC, as it led to fewer PSA tests even if CC was granted.Trial registration: German Clinical Trial Register (Deutsches Register Klinischer Studien DRKS00007687). Registered: 06/05/2015. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00007687 .

Patients' self-reported physical and psychological effects of opioid use in chronic noncancer pain-A retrospective cross-sectional analysis

BACKGROUND

Strong opioids can have unintended effects. Clinical studies of strong opioids mainly report physical side effects, psychiatric or opioid use disorders. To date, too little attention has been paid to the psychological effects of opioids to treat patients with chronic noncancer pain (CNCP). This study aims to identify and measure (i) the nature and frequency of physical and psychological effects and (ii) the degree of physician counseling of patients with CNCP taking strong opioids.

METHODS

Within a cross-sectional survey-conducted as part of a randomised controlled online intervention trial (ERONA [Experiencing the risk of overusing opioids among patients with chronic non-cancer pain in ambulatory care])-300 German CNCP patients were surveyed via patient-reported outcome measures regarding on both the side effects from their use of strong opioids as well as their counselling experience.

RESULTS

Among the patients' reported effects, the psychological outcomes of the opioids in CNCP were: feeling relaxed (84%), fatigue (76%), dizziness (57%), listlessness (37%), difficulty with mental activities (23%), dulled emotions (17%) and poor memory (17%). Ninety-two per cent of the patients reported having received information about opioid effects, and 46% had discussed cessation of the opioid medication with their physicians before commencing the prescription.

CONCLUSIONS

In addition to the well-known physical side effects, patients with CNCP taking strong opioids experience significant psychological effects. In view of these effects, discontinuation of opioid therapy should be discussed early to ensure their benefits do not outweigh their harm.

SIGNIFICANCE

In this study, patients with non-cancer pain notice that opioids they have taken do not only cause physical side effects but also may have an impact on their psyche and their emotions and, thus, may also affect quality of life substantially. Clinical trial number: DRKS00020358.

Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences

Background Health professionals are encouraged to learn from their errors. Determining how primary care physicians (PCPs) react to a case, in which their original diagnosis differed from the final outcome, could provide new insights on how they learn from experiences. We explored how PCPs altered their diagnostic evaluation of future patients after cases where the originally assumed diagnosis turned out to be wrong. Methods We asked German PCPs to complete an online survey where they described how the patient concerned originally presented, the subsequent course of events and whether they would change their diagnostic work-up of future patients. Qualitative methods were used to analyze narrative text obtained by this survey. Results A total of 29 PCPs submitted cases, most of which were ultimately found to be more severe than originally assumed. PCPs (n = 27) reflected on changes to their subsequent clinical decisions in the form of general maxims (n = 20) or more specific rules (n = 11). Most changes would have resulted in a lower threshold for investigations, referral and/or a more extensive collection of diagnostic information. PCPs decided not only to listen more often to their intuition (gut feelings), but to also practice more analytical reasoning. Participants felt the need for change of practice even if no clinical standards had been violated in the diagnosis of that case. Some decided to resort to defensive strategies in the future. Conclusions We describe mechanisms by which physicians calibrate their decision thresholds, as well as their cognitive mode (intuitive vs. analytical). PCPs reported the need for change in clinical practice despite the absence of error in some cases.

Fatigue as the Chief Complaint – Epidemiology, Causes, Diagnosis, and Treatment

BACKGROUND

Fatigue is a main or secondary reason for 10-20% of all consultations with a primary care physician.

METHODS

This review is based on pertinent publications retrieved by a comprehensive, selective literature search on the epidemiology, etiology, and diagnostic evaluation of fatigue as a leading symptom of disease, as well as on the treatment of its common causes. Information was also included from the literature search we conducted for the German clinical practice guideline on fatigue that was issued by the German College of General Practitioners and Family Physicians (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, DEGAM).

RESULTS

Fatigue can be due to any of a broad spectrum of diseases, including decompensation of already known conditions. Sleep disorders and sleep-related disorders of breathing, depression (18.5%), and excessive psychosocial stress are the most common causes of persistent fatigue. Previously undiagnosed cancer is a rare cause, accounting for only 0.6% of cases (95% confidence interval [0.3; 1.3]). Anemia and other organic causes are rare as well (4.3% [2.7; 6.7]). Investigations beyond the history, physical examination, and simple laboratory tests are needed only in the presence of additional symptoms or findings. If the diagnosis remains unclear, watchful waiting and regularly scheduled follow-up help prevent an excessive focus on somatic causes, leading to overdiagnosis. Irrespective of specific causes, psychoeducative and psychotherapeutic approaches should be discussed with the patient, as well as an individually adapted exercise program.

CONCLUSION

The work-up of fatigue as a chief complaint should be guided by investigating common and/or potentially dangerous disorders. Since the latter are rare, an exclusively somatic focus should be avoided in order to prevent overdiagnosis.

Prevalence, aetiologies and prognosis of the symptom cough in primary care: a systematic review and meta-analysis

Background

Cough is a relevant reason for encounter in primary care. For evidence-based decision making, general practitioners need setting-specific knowledge about prevalences, pre-test probabilities, and prognosis. Accordingly, we performed a systematic review of symptom-evaluating studies evaluating cough as reason for encounter in primary care.

Methods

We conducted a search in MEDLINE and EMBASE. Eligibility criteria and methodological quality were assessed independently by two reviewers. We extracted data on prevalence, aetiologies and prognosis, and estimated the variation across studies. If justifiable in terms of heterogeneity, we performed a meta-analysis.

Results

We identified 21 eligible studies on prevalence, 12 on aetiology, and four on prognosis. Prevalence/incidence estimates were 3.8–4.2%/12.5% (Western primary care) and 10.3–13.8%/6.3–6.5% in Africa, Asia and South America. In Western countries the underlying diagnoses for acute cough or cough of all durations were respiratory tract infections (73–91.9%), influenza (6–15.2%), asthma (3.2–15%), laryngitis/tracheitis (3.6–9%), pneumonia (4.0–4.2%), COPD (0.5–3.3%), heart failure (0.3%), and suspected malignancy (0.2–1.8%). Median time for recovery was 9 to 11 days. Complete recovery was reported by 40.2- 67% of patients after two weeks, and by 79% after four weeks. About 21.1–35% of patients re-consulted; 0–1.3% of acute cough patients were hospitalized, none died. Evidence is missing concerning subacute and chronic cough.

Conclusion

Prevalences and incidences of cough are high and show regional variation. Acute cough, mainly caused by respiratory tract infections, is usually self-limiting (supporting a “wait-and-see” strategy). We have no setting-specific evidence to support current guideline recommendations concerning subacute or chronic cough in Western primary care. Our study presents epidemiological data under non non-pandemic conditions. It will be interesting to compare these data to future research results of the post-pandemic era.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01501-0.

MediQuit, an Electronic Deprescribing Tool for Patients on Polypharmacy: Results of a Feasibility Study in German General Practice

BACKGROUND

Deprescribing is an important task for general practitioners (GPs) in the face of risky polypharmacy. The electronic tool "MediQuit" was developed to guide GPs and patients through a deprescribing consultation that entails a drug-selection phase, shared decision making, and advice on safe implementation.

OBJECTIVES

A pilot study was conducted to determine the target group of patients that is selected for consultation and to assess the impact, patient involvement, and feasibility of the tool.

METHODS

This was an uncontrolled pilot study. GPs from two German regions were invited to use MediQuit in consultations with a view to deprescribing one drug, if appropriate. They selected patients on the basis of broad inclusion criteria. Collected data entailed participants' characteristics, patients' medication lists, deprescribed drugs, and feasibility assessments. Patients were contacted shortly after the consultation and again after 4 weeks.

RESULTS

In total, 16 GPs agreed to participate, of whom ten actually performed deprescribing consultations. They selected 41 predominately older patients on excessive polypharmacy. Deprescribing was achieved in 70% of consultations in agreement with patients. Drugs deprescribed were symptom-lowering and preventive drugs (mainly anatomical therapeutic chemical classes A and C). GPs found MediQuit useful in initiating communication on this issue and enhancing deliberations for a deprescribing decision. The median consultation length was 15 min (interquartile range 10-20). At follow-up, GPs and patients infrequently disagreed on which drug(s) was discontinued, and GPs rated patient involvement higher than did patients themselves.

DISCUSSION

MediQuit assists in identifying concrete deprescribing opportunities, patient involvement, and shared decision making. The three-step deprescribing procedure is well-accepted once initial organizational efforts are overcome. After revision, further studies are needed to enhance the quality of evidence on acceptance and effectiveness.

Coughing children in family practice and primary care: a systematic review of prevalence, aetiology and prognosis

BACKGROUND

For evidence-based decision making, primary care physicians need to have specific and reliable information on the pre-test probabilities of underlying diseases and a symptom's course. We performed a systematic review of symptom-evaluating studies in primary care, following three research questions: (1) What is the prevalence of the symptom cough in children consulting primary care physicians? (2) What are the underlying aetiologies of cough and the respective frequencies? (3) What is the prognosis of children with cough?

METHODS

Following a pre-defined algorithm and independent double reviewer ratings we searched MEDLINE and EMBASE. All quantitative original research articles in English, French or German were included if they focused on unselected study populations of children consulting a primary care physician for cough. We used the random effects model for meta-analysis in subgroups, if justifiable in terms of heterogeneity.

RESULTS

We identified 14 eligible studies on prevalence, five on aetiology and one on prognosis. Prevalence estimates varied between 4.7 and 23.3% of all reasons for an encounter, or up to estimates of 60% when related to patients or consultations. Cough in children is more frequent than in adults, with lowest prevalences in adolescents and in summer. Acute cough is mostly caused by upper respiratory tract infections (62.4%) and bronchitis (33.3%); subacute or chronic cough by recurrent respiratory tract infection (27.7%), asthma (up to 50.4% in cough persisting more than 3 weeks), and pertussis (37.2%). Potentially serious diseases like croup, pneumonia or tuberculosis are scarce. In children with subacute and chronic cough the total duration of cough ranged from 24 to 192 days. About 62.3% of children suffering from prolonged cough are still coughing two months after the beginning of symptoms.

CONCLUSION

Cough is one of the most frequent reasons for an encounter in primary care. Our findings fit in with current guideline recommendations supporting a thoughtful wait-and-see approach in acute cough and a special awareness in chronic cough of the possibility of asthma and pertussis. Further evidence of aetiological pre-test probabilities is needed to assess the diagnostic gain based on patient history and clinical signs for differential diagnoses of cough in children.

Are Anticholinergic Symptoms a Risk Factor for Falls in Older General Practice Patients With Polypharmacy? Study Protocol for the Development and Validation of a Prognostic Model

Background: Cumulative anticholinergic exposure, also known as anticholinergic burden, is associated with a variety of adverse outcomes. However, studies show that anticholinergic effects tend to be underestimated by prescribers, and anticholinergics are the most frequently prescribed potentially inappropriate medication in older patients. The grading systems and drugs included in existing scales to quantify anticholinergic burden differ considerably and do not adequately account for patients’ susceptibility to medications. Furthermore, their ability to link anticholinergic burden with adverse outcomes such as falls is unclear. This study aims to develop a prognostic model that predicts falls in older general practice patients, to assess the performance of several anticholinergic burden scales, and to quantify the added predictive value of anticholinergic symptoms in this context.

Methods: Data from two cluster-randomized controlled trials investigating medication optimization in older general practice patients in Germany will be used. One trial (RIME, n = 1,197) will be used for the model development and the other trial (PRIMUM, n = 502) will be used to externally validate the model. A priori, candidate predictors will be selected based on a literature search, predictor availability, and clinical reasoning. Candidate predictors will include socio-demographics (e.g. age, sex), morbidity (e.g. single conditions), medication (e.g. polypharmacy, anticholinergic burden as defined by scales), and well-being (e.g. quality of life, physical function). A prognostic model including sociodemographic and lifestyle-related factors, as well as variables on morbidity, medication, health status, and well-being, will be developed, whereby the prognostic value of extending the model to include additional patient-reported symptoms will be also assessed. Logistic regression will be used for the binary outcome, which will be defined as “no falls” vs. “≥1 fall” within six months of baseline, as reported in patient interviews.

Discussion: As the ability of different anticholinergic burden scales to predict falls in older patients is unclear, this study may provide insights into their relative importance as well as into the overall contribution of anticholinergic symptoms and other patient characteristics. The results may support general practitioners in their clinical decision-making and in prescribing fewer medications with anticholinergic properties.

A volunteer-supported walking programme to improve physical function in older people (the POWER Study): study protocol for a randomised controlled trial

BACKGROUND

Currently 21% of the German population is older than 65 years. Above this age, the risk of suffering from chronic disease and mental disorders increases rapidly. Therefore, physical inactivity is one of the most important public health concerns among older people. To address this issue, we have conceptualised and evaluated a simple and low-threshold intervention, which requires only minimal demand on the participants, targeting older people with inadequate activity levels. The aim of the POWER Study is to investigate whether volunteer-supported outdoor-walking improves physical function and quality of life in older people.

METHODS/DESIGN

In a randomised, controlled interventional superiority-trial, individuals older than 65 years of age living in the community or nursing homes will be randomised into two groups. The study will be conducted in two study centres with assessments at baseline, 6 and 12 months. The intervention group will participate in a supported physical activity intervention for 6 months. An assigned volunteer will visit them three times a week for an outdoor walk between 30 and 50 min, or equivalent indoor activity. Persons in the control group will be invited to two lectures covering topics related to health. Primary endpoint is the physical function measured by the Short Physical Performance Battery (SPPB) at baseline, after 6 and 12 months. Secondary and safety endpoints will be quality of life (EQ. 5D), fear of falling (Falls Efficacy Scale), physical activity (activity diary), cognitive executive function (clock drawing test), falls requiring medical attention, hospitalisation and death. Primary analysis will be carried out by intention to treat.

DISCUSSION

We expect the intervention to improve the overall health status of the participants in a wide range of health-related outcomes. If effectiveness can be shown, the intervention will close an important gap in current services for older people. We will disseminate our experiences and results in the form of informational documents (training manual) to allow municipalities and health care organisations to implement a similar intervention.

TRIAL REGISTRATION

The trial was registered on 31 Aug 2018; German Clinical Trials Register (www.germanctr.de), Deutsches Register Klinischer Studien: DRKS00015188 .

Enhancing Specific Health Literacy with a Digital Evidence-Based Patient Decision Aid for Hypertension: A Randomized Controlled Trial

INTRODUCTION

Health literacy is an important competency to make informed, shared decisions in line with patient's preferences. On the other hand, lower health literacy is associated with poorer health outcomes. Evidence-based patient decision aids (EbPDA) are validated instruments to support informed medical decisions and empower patients for relevant involvement in their care. This study aimed to investigate the effect of a digital EbPDA for hypertension on health literacy.

METHODS

In a randomized controlled trial, 124 participants were presented with a web-based scenario related to a newly diagnosed condition of arterial hypertension. The intervention group was provided with an online decision aid, while the control group was prompted to search for related information without support. Specific health literacy for hypertension was operationalized based on the European survey for health literacy (HLS-EU-Q47).

RESULTS

The intervention group showed a statistically significant increase in subjectively perceived overall specific health literacy regarding hypertension (p=0.02, Cohen's d=0.44). The effect was also statistically significant for the subcategories understanding, appraising, and applying health-related information (all p<0.05). At least equal results could be shown for participants with a lower level of education compared to participants with a high level.

CONCLUSION

The findings suggest that digital EbPDAs can be an effective and easily scalable instrument to improve populations' specific health literacy. A possible advantage of the measure could be that patients are addressed concerning important and pressing personal decisions, fostering awareness of the individual's need for health literacy to reflect one's options and preferences. EbPDAs may also be a promising approach to target vulnerable populations, as the investigated EbPDA seems to perform equally in less versus more educated individuals. For future research, it may be interesting to investigate whether EbPDAs have effects on general health literacy that go beyond the disease specifically addressed.

Use of guideline-recommended drug therapy in patients undergoing percutaneous coronary intervention for stable coronary heart disease in Germany: a multilevel analysis of nationwide routine data

OBJECTIVES

To determine the prescription of guideline recommended drug therapy in patients with stable coronary heart disease (sCHD) prior to percutaneous coronary intervention (PCI) in Germany and to examine the role of patient characteristics and features of regional healthcare supply in a multilevel model.

DESIGN

Secondary data analysis of factors associated with the prescription of guideline recommended drug therapy using a multilevel model to analyse regional-level effects, over and above the effects of patient-level demographic and health status.

SETTING

Office-based prescriptions in the year prior to the invasive procedure.

PARTICIPANTS

A linked nationwide dataset from Germany's three largest statutory health insurance funds of all patients receiving PCI in the year 2016.

MAIN OUTCOME MEASURES

Patients' odds of receiving optimal medical therapy and symptom-oriented therapy within 1 year prior to PCI.

RESULTS

68.6% of patients received at least one lipid-lowering drug and one symptom-oriented therapy prior to PCI. 43.6% received at least two agents to control their symptoms. Patients who received treatment in accordance with the recommendations had a greater number of diagnosed risk factors, a more severe history of cardiac disease and used a higher volume of ambulatory office-based physician services. The prescriptions prevalence for the symptom-oriented therapies differed significantly between eastern and western Germany, with a higher prevalence in the eastern districts.

CONCLUSIONS

Guidelines can only provide decision-making corridors, and the applicability of recommendations must always be assessed on a case by case basis. Nevertheless, our analysis indicates that the prevalence of prescriptions in routine practice is subject to substantial variation and that conservative therapy options are not fully exhausted prior to PCI. This suggests that there might be room for improvement in the care of patients with sCHD.

Experiencing the risk of overutilising opioids among patients with chronic non-cancer pain in ambulatory care (ERONA): the protocol of an exploratory, randomised controlled trial

INTRODUCTION

The US opioid crisis and increasing prescription rates in Europe suggest inappropriate risk perceptions and behaviours of people who prescribe, take or advise on opioids: physicians, patients and pharmacists. Findings from cognitive and decision science in areas other than drug safety suggest that people's risk perception and behaviour can differ depending on whether they learnt about a risk through personal experience or description. Experiencing the risk of overutilising opioids among patients with chronic non-cancer pain in ambulatory care (ERONA) is the first-ever conducted trial that aims at investigating the effects of these two modes of learning on individuals' risk perception and behaviour in the long-term administration of WHO-III opioids in chronic non-cancer pain.

METHODS AND ANALYSIS

ERONA-an exploratory, randomised controlled online survey intervention trial with two parallel arms-will examine the opioid-associated risk perception and behaviour of four groups involved in the long-term administration of WHO-III opioids: (1) family physicians, (2) physicians specialised in pain therapy, (3) patients with chronic (≥3 months) non-cancer pain and (4) pharmacists who regularly dispense narcotic substances. Participants will be randomly assigned to one of two online risk education interventions, description based or experiencebased. Both interventions will present the best medical evidence available. Participants will be queried at baseline and after intervention on their risk perception of opioids' benefit-harm ratio, their medical risk literacy and their current/intended risk behaviour (in terms of prescribing, taking or counselling, depending on study group). A follow-up will occur after 9 months, when participants will be queried on their actual risk behaviour. The study was developed by the authors and will be conducted by the market research institution IPSOS Health.

ETHICS AND DISSEMINATION

The study was approved by the Institutional Review Board of the Max Planck Institute for Human Development. Results will be disseminated through peer-reviewed journals, conference presentations and social media.

TRIAL REGISTRATION NUMBER

DRKS00020358.

Professional roles of general practitioners, community pharmacists and specialist providers in collaborative medication deprescribing - a qualitative study

Background

Collaborative care approaches between general practitioners (GPs) and pharmacists have received international recognition for medication optimization and deprescribing efforts. Although specialist providers have been shown to influence deprescribing, their profession so far remains omitted from collaborative care approaches for medication optimization. Similarly, while explorative studies on role perception and collaboration between GPs and pharmacists grow, interaction with specialists for medication optimization is neglected. Our qualitative study therefore aims to explore GPs’, community pharmacists’ and specialist providers’ role perceptions of deprescribing, and to identify interpersonal as well as structural factors that may influence collaborative medication optimization approaches.

Method

Seven focus-group discussions with GPs, community pharmacists and community specialists were conducted in Hesse and Lower Saxony, Germany. The topic guide focused on views and experiences with deprescribing with special attention to inter-professional collaboration. We conducted conventional content analysis and conceptualized emerging themes using the Theoretical Domains Framework.

Results

Twenty-six GPs, four community pharmacists and three community specialists took part in the study. The main themes corresponded to the four domains ‘Social/professional role and identity’ (1), ‘Social influences’ (2), ‘Reinforcement’ (3) and ´Environmental context and resources’ (4) which were further described by beliefs statements, that is inductively developed key messages. For (1), GPs emerged as central medication managers while pharmacists and specialists were assigned confined or subordinated tasks in deprescribing. Social influences (2) encompassed patients’ trust in GPs as a support, while specialists and pharmacists were believed to threaten GPs’ role and deprescribing attempts. Reinforcements (3) negatively affected GPs’ and pharmacists’ effort in medication optimization by social reprimand and lacking reward. Environmental context (4) impeded deprescribing efforts by deficient reimbursement and resources as well as fragmentation of care, while informational and gate-keeping resources remained underutilized.

Conclusion

Understanding stakeholders’ role perceptions on collaborative deprescribing is a prerequisite for joint approaches to medication management. We found that clear definition and dissemination of roles and responsibilities are premise for avoiding intergroup conflicts. Role performance and collaboration must further be supported by structural factors like adequate reimbursement, resources and a transparent continuity of care.

[Narratives help disseminate medical technologies: the case of coronary interventions]

Medical technologies are often disseminated and used although evidence demonstrating their effectiveness and safety is missing. Percutaneous intervention (PCI) in stable coronary artery disease (CAD) is an example. This raises the question of how these technologies get disseminated and on which basis they are accepted by clinicians, patients, and the wider public.Studies investigating the communication between clinicians and patients show that simple narratives play a decisive role here. In this paper I discuss how narratives contribute to the dissemination of medical technologies. Communication within the profession, which includes medical education, also relies on narratives to a large degree. They have the following characteristics in common: 1) extreme simplification, 2) reduction to biological processes, 3) deterministic logic, and 4) strong moral message. These narratives are always biased; narratives dealing with interventions paint an overoptimistic picture of their effectiveness and safety. Although they represent "modern" technologies, their logic and purpose are akin to archaic myths.Presumably education and persuasion cannot eschew narratives completely. But health professionals, patients and the public should be aware of the inevitable bias that comes with narratives and their potential for manipulation.

Generic instruments for drug discontinuation in primary care: A systematic review

Aims

The aim of this systematic review was to identify generic instruments for drug discontinuation in patients with polypharmacy in the primary care setting.

Methods

We systematically searched PubMed and EMBASE, 8 guideline databases (AWMF, NICE, NGC, SIGN, NHMRC, CPG, KCE), the Cochrane Library and grey literature (Google) in 2016 and 2017. Two independent researchers screened and analysed data. The drug discontinuation instruments of the included publications were described and classified.

Results

We identified 16 relevant publications. Here we found complex algorithms as well as instruments composed of distinct sequential steps. Two guidelines are constructed as electronic web‐applications. Instruments revealed diverging emphases on the stages of deprescribing, i.e. preparation, drug evaluation, decision‐making and implementation. Accordingly, 3 types of instruments emerged: general frameworks, detailed drug assessment tools and comprehensive discontinuation guidelines.

Conclusion

Diverse generic instruments exist for different areas of applications in regard to drug discontinuation. However, there is still a need for practical and user‐friendly tools that support physicians in communicational aspects, visualise trade‐offs and also enhance patient involvement.

Regret among primary care physicians: a survey of diagnostic decisions

BACKGROUND

Experienced and anticipated regret influence physicians' decision-making. In medicine, diagnostic decisions and diagnostic errors can have a severe impact on both patients and physicians. Little empirical research exists on regret experienced by physicians when they make diagnostic decisions in primary care that later prove inappropriate or incorrect. The aim of this study was to explore the experience of regret following diagnostic decisions in primary care.

METHODS

In this qualitative study, we used an online questionnaire on a sample of German primary care physicians. We asked participants to report on cases in which the final diagnosis differed from their original opinion, and in which treatment was at the very least delayed, possibly resulting in harm to the patient. We asked about original and final diagnoses, illness trajectories, and the reactions of other physicians, patients and relatives. We used thematic analysis to assess the data, supported by MAXQDA 11 and Microsoft Excel 2016.

RESULTS

29 GPs described one case each (14 female/15 male patients, aged 1.5-80 years, response rate < 1%). In 26 of 29 cases, the final diagnosis was more serious than the original diagnosis. In two cases, the diagnoses were equally serious, and in one case less serious. Clinical trajectories and the reactions of patients and relatives differed widely. Although only one third of cases involved preventable harm to patients, the vast majority (27 of 29) of physicians expressed deep feelings of regret.

CONCLUSION

Even if harm to patients is unavoidable, regret following diagnostic decisions can be devastating for clinicians, making them 'second victims'. Procedures and tools are needed to analyse cases involving undesirable diagnostic events, so that 'true' diagnostic errors, in which harm could have been prevented, can be distinguished from others. Further studies should also explore how physicians can be supported in dealing with such events in order to prevent them from practicing defensive medicine.

[Between precision medicine and symbolic mastery: What doctors want]

INTRODUCTION

Caring for patients is inevitably fraught with uncertainties. These may result from clinicians not having or not using the available knowledge, from the incompleteness of the medical science base as a whole, or from the inevitable randomness of biological, psychological and social phenomena. Advances in science promise to reduce uncertainty by making ever more precise diagnosis and treatment possible.

METHODS

Here, we discuss two typical examples of scientific progress and on how they impact on clinical uncertainty: first, the stratification of chemotherapy for early breast cancer by a 70-gene signature, and second, the interpretation of knee MRI regarding meniscal damage.

RESULTS

According to a large randomized trial, the 70-gene -signature successfully differentiates between strata for invasive treatments. The quantitative results and related trade-offs, however, pose considerable difficulties for patient information and shared decision-making, thus increasing uncertainty. Knee complaints are only weakly associated with MRI findings. Pathological findings are highly prevalent in symptom-free individuals.

CONCLUSION

Recent advances in diagnostic methods increase the cognitive demands on clinicians and thus their uncertainty. By uncritically using advanced technologies in their practice, physicians exploit their archetypical healing powers. In a paradoxical way, modern technologies reduce uncertainties felt by doctors and their patients in an archaic fashion.

Development and Prospective Randomized Evaluation of a Decision Aid for Prostate-specific Antigen-based Early Detection of Prostate Cancer in Men Aged Between 55 and 69Yr: The PSAInForm Trial

For men interested in early detection of prostate cancer, the potential impact on decisional conflict of a decision aid with or without cost compensation for the prostate-specific antigen test will be investigated.

Planning and Analysis of Trials Using a Stepped Wedge Design

BACKGROUND

The stepped-wedge design (SWD) of clinical trials has become very popular in recent years, particularly in health services research. Typically, study participants are randomly allotted in clusters to the different treatment options.

METHODS

The basic principles of the stepped wedge design and related statistical techniques are described here on the basis of pertinent publications retrieved by a selective search in PubMed and in the CIS statistical literature database.

RESULTS

In a typical SWD trial, the intervention is begun at a time point that varies from cluster to cluster. Until this time point is reached, all participants in the cluster belong to the control arm of the trial. Once the intervention is begun, it is continued with- out change until the end of the trial period. The starting time for the intervention in each cluster is determined by randomization. At the first time point of measurement, no intervention has yet begun in any cluster; at the last one, the intervention is in prog- ress in all clusters. The treatment effect can be optimally assessed under the assumption of an identical correlation at all time points. A method is available to calculate the power and the number of clusters that would be necessary in order to achieve statistical significance by the appropriate type of significance test. All of the statistical techniques presented here are based on the assumptions of a normal distribution of cluster means and of a constant intervention effect across all time points of measure- ment.

CONCLUSION

The necessary statistical tools for the planning and evaluation of SWD trials now stand at our disposal. Such trials nevertheless are subject to major risks, as valid results can be obtained only if the far-reaching assumptions of the model are, in fact, justified.

Diagnostic strategies in general practice and the emergency department: a comparative qualitative analysis

OBJECTIVE

We sought to explore differences and commonalities between diagnostic strategies used by clinicians in general practice and the emergency department.

DESIGN

Qualitative study.

SETTINGS

We videotaped 282 consultations of 12 general practitioners (GPs) in Germany, irrespective of presenting complaint or final diagnosis. Reflective interviews were performed after each consultation. In addition, 171 consultations of 16 emergency physicians (EPs) based at two tertiary care hospitals in the Midwest of the USA were observed, and their conversations recorded. Recordings of consultations and GP interviews were transcribed verbatim and analysed using a coding system that was based on published literature and systematically checked for reliability.

RESULTS

EPs more often considered acute and severe conditions, even if pretest probabilities were low. In contrast, GPs more often involved their patients in the decision-making process and provided assurance concerning their complaints. To focus their workup, EPs used a more directive style of interviewing including a high proportion of routine questions and rarely used open questions or active listening.

CONCLUSIONS

Strategies used by physicians in both settings seem to be well adapted to their respective environments. Whereas the physician-led diagnostic process in the emergency department is well suited to rule out life-threating disease, diagnosis and appropriate treatment of everyday problems may require a more patient-centred style.

Development of practical recommendations for diagnostic accuracy studies in low-prevalence situations

OBJECTIVE

Low disease prevalence poses challenges for diagnostic accuracy studies because of the large sample sizes that are required to obtain sufficient precision. The aim is to collate and discuss designs of diagnostic accuracy studies suited for use in low-prevalence situations.

STUDY DESIGN AND SETTING

We conducted a literature search including backward citation tracking and expert consultation. Two reviewers independently selected studies on designs for estimating diagnostic accuracy in a low-prevalence situation. During a 1-day expert meeting, all designs were discussed and recommendations were formulated.

RESULTS

We identified six designs for diagnostic accuracy studies that are suitable in low-prevalence situations because they reduced the total sample size or the number of patients undergoing the index test or reference standard depending on which poses the highest burden. We described the advantages and limitations of these designs and evaluated efficiencies in sample sizes, risk of bias, and alignment with the clinical pathway for applicability in routine care.

CONCLUSION

Choosing a study design for diagnostic accuracy studies in low-prevalence situations should depend on whether the aim is to limit the number of patients undergoing the index test or reference standard, and the risk of bias associated with a particular design type.

Prescribing practice of pregabalin/gabapentin in pain therapy: an evaluation of German claim data

OBJECTIVES

To analyse the prevalence and incidence of pregabalin and gabapentin (P/G) prescriptions, typical therapeutic uses of P/G with special attention to pain-related diagnoses and discontinuation rates.

DESIGN

Secondary data analysis.

SETTING

Primary and secondary care in Germany.

PARTICIPANTS

Four million patients in the years 2009-2015 (anonymous health insurance data).

INTERVENTION

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

P/G prescribing rates, P/G prescribing rates associated with pain therapy, analysis of pain-related diagnoses leading to new P/G prescriptions and the discontinuation rate of P/G.

RESULTS

In 2015, 1.6% of insured persons received P/G prescriptions. Among the patients with pain first treated with P/G, as few as 25.7% were diagnosed with a typical neuropathic pain disorder. The remaining 74.3% had either not received a diagnosis of neuropathic pain or showed a neuropathic component that was pathophysiologically conceivable but did not support the prescription of P/G. High discontinuation rates were observed (85%). Among the patients who had discontinued the drug, 61.1% did not receive follow-up prescriptions within 2 years.

CONCLUSION

The results show that P/G is widely prescribed in cases of chronic pain irrespective of neuropathic pain diagnoses. The high discontinuation rate indicates a lack of therapeutic benefits and/or the occurrence of adverse effects.

[Which Proportion of Prescriptions in Germany is Evidence Based?]

BACKGROUND

The provision of healthcare has to take into consideration evidence-based results from valid and relevant studies; this principle is included in German social laws. The prescribing assessment scheme (PAS) of the German National Association of Statutory Health Insurance Physicians contains a systematic appraisal of the benefit of drugs on the basis of their clinical evidence, their safety, and indications for their prescription.

METHODS

We analysed nationwide prescription data of physicians that have contractual relationships with statutory health insurance funds in 2014. The drugs have been classified on the basis of their clinical evidence as "standard", "reserve" or "third level" medication. We report proportions of prescriptions in the first and third priority levels of the PAS in primary care, cardiology, and neurology/psychiatry as their prescriptions have a high correspondence with the PAS.

RESULTS

The proportion in the first priority in primary care was more than two-thirds of the total prescriptions. The highest proportion in this category was observed in Bremen; the lowest proportions were found in the new federal states. In cardiology, the first priority was chosen in 54%, in neurology/psychiatry in about 41% of prescriptions (DDDs). The proportion of the third priority is with one-fifth highest in cardiology, with 16%, lowest in primary care; neurology/psychiatry takes a middle position with 17.7%.

CONCLUSIONS

Prescriptions predominantly conformed with the first priority of the PAS. There were variations across disciplines and regions (federal states). The PAS offers an opportunity to connect quality and indication in the prescription process.

The Optimizing-Risk-Communication (OptRisk) randomized trial - impact of decision-aid-based consultation on adherence and perception of cardiovascular risk

BACKGROUND

Shared decision-making is a well-established approach to increasing patient participation in medical decisions. Increasingly, using lifetime-risk or time-to-event (TTE) formats has been suggested, as these might have advantages in comparison with a 10-year risk prognosis, particularly for younger patients, whose lifetime risk for some events may be considerably greater than their 10-year risk. In this study, a randomized trial, the most popular 10-year risk illustration in the decision-aid software Arriba (emoticons), is compared with a newly developed TTE illustration, which is based on a Markov model. The study compares the effect of these two methods of presenting cardiovascular risk to patients on their subsequent adherence to intervention.

METHODS

A total of 294 patients were interviewed 3 months after they had had a consultation with their GP on cardiovascular risk prevention. Adherence to behavioral change or medication intervention was measured as the primary outcome. The latter was expressed as a generated score. Furthermore, different secondary outcomes were measured, ie, patient perception of risk and self-rated importance of avoiding a cardiovascular event, as well as patient numeracy, which was used as a proxy for patient health literacy.

RESULTS

Overall, no significant difference in patient adherence was found depending on risk representation. In the emoticon group, the number of interventions had a significant impact on the adherence score (P=0.025). Perception of risk was significantly higher in patients counseled with the TTE risk display, whereas the importance of avoiding a cardiovascular event was rated equally highly in both groups and actually increased over time.

CONCLUSION

The TTE format is an appropriate means for counseling patients. Adherence is a very complex construct, which cannot be fully explained by our findings. The study results support our call for considering TTE illustrations as a valuable alternative to current decision-support tools covering cardiovascular prevention. Nevertheless, further research is needed to shed light on patient motivation and adherence with regard to cardiovascular risk prevention.

TRIAL REGISTRATION

The study was registered at the German Clinical Trials Register and at the WHO International Clinical Trials Register Platform (ICTRP, ID DRKS00004933); registered February 2, 2016 (retrospectively registered).

Detecting and Visualizing Outliers in Provider Profiling Using Funnel Plots and Mixed Effects Models-An Example from Prescription Claims Data

When prescribing a drug for a patient, a physician also has to consider economic aspects. We were interested in the feasibility and validity of profiling based on funnel plots and mixed effect models for the surveillance of German ambulatory care physicians’ prescribing. We analyzed prescriptions issued to patients with a health insurance card attending neurologists’ and psychiatrists’ ambulatory practices in the German federal state of Saarland. The German National Association of Statutory Health Insurance Physicians developed a prescribing assessment scheme (PAS) which contains a systematic appraisal of the benefit of drugs for so far 12 different indications. The drugs have been classified on the basis of their clinical evidence as “standard”, “reserve” or “third level” medication. We had 152.583 prescriptions in 56 practices available for analysis. A total of 38.796 patients received these prescriptions. The funnel plot approach with additive correction for overdispersion was almost equivalent to a mixed effects model which directly took the multilevel structure of the data into account. In the first case three practices were labeled as outliers, the mixed effects model resulted in two outliers. We suggest that both techniques should be routinely applied within a surveillance system of prescription claims data.

[Use of the S3 guidelines for early detection of prostate cancer in urological practices]

OBJECTIVES

The German S3 guideline on prostate cancer gives recommendations on early detection of prostate cancer. In this study we analyzed the adherence of urologists in private practice from the administrative district of Münster, Germany to this guideline.

METHODS

Data were collected through a semistructured survey of 22 urologists based on the COREQ checklist (Consolidated criteria for reporting qualitative research) in four focus groups consisting of five or six urologists in private practice. We developed 23 questions relating to 12 recommendations of the paragraphs of the S3 guidelines dealing with early detection of prostate cancer and prostate biopsy. The recommendations of the guideline are subdivided in nine "strong", one "optional recommendation" and two "statements". The adherence to the guideline was investigated by using frequency and qualitative content analysis (Mayring) based on a mixed methods design.

RESULTS

The urologists follow six of the nine "strong recommendations" of the guideline and deviate from three. Reasons for deviations from "strong recommendations" are the following: information about advantages and disadvantages of early detection for prostate cancer, recommendation of a prostate biopsy in case of PSA level ≥4 ng/ml, and indication for repeat biopsy.

CONCLUSION

Most of the "strong recommendations" are followed by the interviewed urologists of the administrative district of Münster. Contextually relevant deviations from "strong recommendations" are justified, e. g., the only limited transferability of the PSA threshold of 4 ng/ml derived from population-based studies of asymptomatic men to men presenting in a urologist's office.

Solving the Diagnostic Challenge: A Patient-Centered Approach

Arriving at an agreed-on and valid explanation for a clinical problem is important to patients as well as to clinicians. Current theories of how clinicians arrive at diagnoses, such as the threshold approach and the hypothetico-deductive model, do not accurately describe the diagnostic process in general practice. The problem space in general practice is so large and the prior probability of each disease being present is so small that it is not realistic to limit the diagnostic process to testing specific diagnoses on the clinician's list of possibilities. Here, new evidence is discussed about how patients and clinicians collaborate in specific ways, in particular, via a process that can be termed inductive foraging, which may lead to information that triggers a diagnostic routine. Navigating the diagnostic challenge and using patient-centered consulting are not separate tasks but rather synergistic.

The effect of a new lifetime-cardiovascular-risk display on patients' motivation to participate in shared decision-making

BACKGROUND

This study investigated the effects of three different risk displays used in a cardiovascular risk calculator on patients' motivation for shared decision-making (SDM). We compared a newly developed time-to-event (TTE) display with two established absolute risk displays (i.e. emoticons and bar charts). The accessibility, that is, how understandable, helpful, and trustworthy patients found each display, was also investigated.

METHODS

We analysed a sample of 353 patients recruited in general practices. After giving consent, patients were introduced to one of three fictional vignettes with low, medium or high cardiovascular risk. All three risk displays were shown in a randomized order. Patients were asked to rate each display with regard to motivation for SDM and accessibility. Two-factorial repeated measures analyses of variance were conducted to compare the displays and investigate possible interactions with age.

RESULTS

Regarding motivation for SDM, the TTE elicited the highest motivation, followed by the emoticons and bar chart (p < .001). The displays had no differential influence on the age groups (p = .445). While the TTE was generally rated more accessible than the emoticons and bar chart (p < .001), the emoticons were only superior to the bar chart in the younger subsample. However, this was only to a small effect (interaction between display and age, p < .01, η 2  = 0.018).

CONCLUSIONS

Using fictional case vignettes, the novel TTE display was superior regarding motivation for SDM and accessibility when compared to established displays using emoticons and a bar chart. If future research can replicate these results in real-life consultations, the TTE display will be a valuable addition to current risk calculators and decision aids by improving patients' participation.

Beyond accuracy: hidden motives in diagnostic testing

BACKGROUND

Diagnostic decision-making is usually disease-focussed and intended to examine the patient's medical condition accurately. But diagnostic interventions may serve further purposes that are not yet fully understood.

OBJECTIVE

To explore GPs' diagnostic behaviour not related to confirming or refuting a specific disease.

METHODS

We recorded 295 primary care consultations in 12 practices. One hundred thirty-four consultations comprised at least one diagnostic episode. GPs were asked to reflect on their own diagnostic thinking in interviews for every single case. Qualitative and quantitative analyses were applied with focus on the GPs' cognitive processes during diagnostic decision-making.

RESULTS

Primary care physicians clearly stated that they requested some tests for other reasons than diagnosing disease. A feeling of uncertainty stimulated diagnostic procedures aiming to regulate the anticipation of regret. We identified patients' reassurance, patients' requests and strategic issues as further motives for diagnostic actions.

CONCLUSION

Besides focussing on disease in the diagnostic process, emotional and strategic goals are hidden motives that play a critical role in clinical decision-making. They might even represent an initial factor in a cascade of interventions leading to overdiagnosis. How GPs might control these influences provides an important aspect for further research, practice and teaching.

Factors associated with prescribing costs: analysis of a nationwide administrative database

Objective

All health care systems in the world struggle with rising costs for drugs. We sought to explore factors impacting on prescribing costs in a nationwide database of ambulatory care in Germany. Factors identified by this research can be used for adjustment in future profiling efforts.

Methods

We analysed nationwide prescription data of physicians having contractual relationships with statutory health insurance funds in 2014. Predictor and outcome variables were aggregated at the practice level. We performed analyses separately for primary care and specialties of cardiology, gastroenterology, neurology and psychiatry, pulmology as well as oncology and haematology. Bivariate robust regressions and Spearman rank correlations were computed in order to find meaningful predictors for our outcome variable prescription costs per patient.

Results

Median age of patients and proportion of DDD issued were substantial predictors for prescription costs per patient in Primary Care, Cardiology, and Pulmology with explained variances between 41 and 61%. In Neurology and Psychiatry only proportion of patients with polypharmacy ≥ 2 quarters was a significant predictor for prescription costs per patient, explaining 20% of the variance. For gastroenterologists, oncologists and haematologists no stable models could be established.

Conclusions

Any analysis of prescribing behaviour must take the degree into account to which an individual physician or practice is responsible for prescribing patients' medication. Proportion of prescriptions/DDDs is an essential confounder for future studies of drug prescribing.