Deprescribing of antidepressants: development of indicators of high-risk and overprescribing using the RAND/UCLA Appropriateness Method

BACKGROUND

Antidepressants are first-line medications for many psychiatric disorders. However, their widespread long-term use in some indications (e.g., mild depression and insomnia) is concerning. Particularly in older adults with comorbidities and polypharmacy, who are more susceptible to adverse drug reactions, the risks and benefits of treatment should be regularly reviewed. The aim of this consensus process was to identify explicit criteria of potentially inappropriate antidepressant use (indicators) in order to support primary care clinicians in identifying situations, where deprescribing of antidepressants should be considered.

METHODS

We used the RAND/UCLA Appropriateness Method to identify the indicators of high-risk and overprescribing of antidepressants. We combined a structured literature review with a 3-round expert panel, with results discussed in moderated meetings in between rounds. Each of the 282 candidate indicators was scored on a 9-point Likert scale representing the necessity of a critical review of antidepressant continuation (1-3 = not necessary; 4-6 = uncertain; 7-9 = clearly necessary). Experts rated the indicators for the necessity of review, since decisions to deprescribe require considerations of patient risk/benefit balance and preferences. Indicators with a median necessity rating of ≥ 7 without disagreement after 3 rating rounds were accepted.

RESULTS

The expert panel comprised 2 general practitioners, 2 clinical pharmacologists, 1 gerontopsychiatrist, 2 psychiatrists, and 3 internists/geriatricians (total N = 10). After 3 assessment rounds, there was consensus for 37 indicators of high-risk and 25 indicators of overprescribing, where critical reviews were felt to be necessary. High-risk prescribing indicators included settings posing risks of drug-drug, drug-disease, and drug-age interactions or the occurrence of adverse drug reactions. Indicators with the highest ratings included those suggesting the possibility of cardiovascular risks (QTc prolongation), delirium, gastrointestinal bleeding, and liver injury in specific patient subgroups with additional risk factors. Overprescribing indicators target patients with long treatment durations for depression, anxiety, and insomnia as well as high doses for pain and insomnia.

CONCLUSIONS

Explicit indicators of antidepressant high-risk and overprescribing may be used directly by patients and health care providers, and integrated within clinical decision support tools, in order to improve the overall risk/benefit balance of this commonly prescribed class of prescription drugs.

Correction: Siegel et al. PEN-13: A New Generic 13-Item Questionnaire for Measuring Patient Enablement (German Version). Int. J. Environ. Res. Public Health 2019, 16, 4867

In the original publication [...].

PEN-13: A New Generic 13-Item Questionnaire for Measuring Patient Enablement (German Version)

Background: The purpose of our study was to develop and psychometrically test a German-language survey instrument that measures patient enablement generically and in greater detail than previous instruments. Methods: A multidisciplinary team developed 13 items to capture individual aspects of patient enablement (PEN-13). A pre-test with 26 subjects was followed by a random sample survey of N = 1168 subjects. An exploratory factor analysis was conducted in a random split-half sample of the data to explore PEN-13's factor structure; a confirmatory factor analysis was conducted in the validation sample. The internal consistency of the factors was evaluated using Cronbach's alpha, PEN-13's construct validity was checked by means of additional hypothesis testing. Results: The two factors self-management and patient-practitioner interaction, detected in the exploratory analysis, were confirmed with a few modifications in the confirmatory factor analysis, with the comparative fit index (CFI) amounting to 0.903. The Cronbach's alpha values of those two factors amounted to α = 0.90 and α = 0.82, respectively. The correlations of the PEN-13 score with the 'general self-efficacy' and 'health literacy' (HLS-EU-Q16) scores further confirmed its construct validity; the respective correlation coefficients amounted to 0.57 and 0.60. Conclusion: The German version of the survey instrument Patient Enablement Scale-13 items (PEN-13) shows acceptable psychometric properties. Practical implications: PEN-13 seems particularly suitable for health services research purposes. We recommend checking the results in another sample as well as evaluating its responsiveness to enablement-enhancing interventions.

Local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro): study protocol of a randomised comparative effectiveness trial

Background

Multimorbid older adults suffering from a long-term health condition like depression, diabetes mellitus type 2, dementia or frailty are at high risk of losing their autonomy. Disability and multimorbidity in the older population are associated with social inequality and lead to soaring costs. Our local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro-Care) aims at improving outcomes for older multimorbid patients with chronic conditions whose social and medical care must be improved.

Methods

The study will evaluate the effects of LoChro-Care on functional health, depressive symptoms and satisfaction with care, resource utilisation as well as health costs in older persons with long-term conditions. The trial will compare the effectiveness of LoChro-Care and usual care in a cross-sectoral setting from hospital to community care. We will recruit 606 older adults (65+) admitted to local hospital inpatient or outpatient departments who are at risk of loss of independence. Half of them will be randomised to receive the LoChro-Care intervention, comprising seven to 16 contacts with chronic care managers (CCM) within 12 months. The hypothesis that LoChro-Care will result in better patient-centred outcomes will be tested through mixed-method process and outcome evaluation and valid measures completed at baseline and at 12 and 18 months. Cost-effectiveness analyses from the healthcare perspective will include incremental cost-effectiveness ratios.

Discussion

The trial will provide evidence about the effectiveness of local, collaborative, stepped and personalised care management for multimorbid patients with more than one functional impairment or chronic condition. Positive results will be a first step towards the implementation of a systematic cross-sectoral chronic care management to facilitate the appropriate use of available medical and nursing services and to enhance self-management of older people.

Trial registration

German Clinical Trials Register (DRKS): DRKS00013904; Trial registration date: 02. February 2018.

Well informed physician-patient communication in consultations on back pain - study protocol of the cluster randomized GAP trial

BACKGROUND

Back pain is one of the most frequent causes of health-related work absence. In Germany, more than 70% of adults suffer from at least one back pain episode per annum. It has strong impact on health care costs and patients' quality of life. Patients increasingly seek health information on the internet. However, judging its trustworthiness is difficult. In addition, physicians who are being confronted with this type of information often experience it to complicate the physician-patient interaction. The GAP trial aims to develop, implement and evaluate an evidence-based, easy-to-understand and trustworthy internet information portal on lower back pain to be used by general practitioners and patients during and after the consultation. Effectiveness of GAP portal use compared to routine consultation on improving communication and informedness of both physicians and patients will be assessed. In addition, effects on health care costs and patients' days of sick leave will be evaluated.

METHODS

We will conduct a prospective multi-centre, cluster-randomized parallel group trial including 1500 patients and 150 recruiting general practitioners. The intervention group will have access to the GAP portal. The portal will contain brief guides for patients and physicians on how to improve the consultation as well as information on epidemiology, aetiology, symptoms, benefits and harms of treatment options for acute, sub-acute and chronic lower back pain. The GAP portal will be designed to be user-friendly and present information on back pain tailored for either patients or physicians in form of brief fact sheets, educative videos, info-graphics, animations and glossaries. Physicians and patients will assess their informedness and the physician-patient communication in consultations at baseline and at two time points after the consultations under investigation. Days of sick leave and health care costs related to back pain will be compared between control and intervention group using routine data of company health insurance funds.

DISCUSSION

The GAP-trial intends to improve the communication between physicians and their patients and the informedness of both groups. If proven beneficial, the evidence-based and user-friendly portal will be made accessible for all patients and health professionals in back pain care. Inclusion of further indications might be implemented and evaluated in the long term.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00014279 (registered 27th of April 2018).

Cost-effectiveness analysis of collaborative treatment of late-life depression in primary care (GermanIMPACT)

BACKGROUND

Late-life depression is a highly prevalent disorder that causes a large economic burden. A stepped collaborative care program was set up in order to improve care for patients with late-life depression in primary care in Germany: GermanIMPACT is the adaption of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program that has already been established in primary care in the USA. The aim of this study was to determine the cost-effectiveness of GermanIMPACT compared with treatment as usual from a societal perspective.

METHODS

This study is part of a 12-month bi-centric cluster-randomized controlled trial aiming to assess the effectiveness of GermanIMPACT compared with treatment as usual among patients with late-life depression. A cost-effectiveness analysis using depression-free days (DFDs) was performed. Net-monetary benefit (NMB) regressions adjusted for baseline differences for different willingness-to-pay (WTP) thresholds were conducted and cost-effectiveness acceptability curves were constructed.

RESULTS

In total, n = 246 patients (intervention group: n = 139; control group: n = 107) with a mean age of 71 from 71 primary care practices were included in the analysis. After 12 months, adjusted mean differences in costs and DFDs between intervention group and control group were +€354 and +21.4, respectively. Only the difference in DFDs was significant (p = 0.022). According to the unadjusted incremental cost-effectiveness ratio, GermanIMPACT was dominant compared with treatment as usual. The probability of GermanIMPACT being cost-effective was 80%, 90% or 95% if societal WTP per DFD was ≥€70, ≥€110 or ≥€180, respectively.

CONCLUSION

Evidence for cost-effectiveness of GermanIMPACT relative to treatment as usual is not clear. Only if societal WTP was ≥€180 for an additional DFD, GermanIMPACT could be considered cost-effective with certainty.

Coordinated Treatment of Depression in Elderly People in Primary Care

BACKGROUND

Depression in the elderly is mainly treated by primary care physicians; the treatment is often suboptimal because of the limited resources available in pri- mary care. New models of care in which treatment by a primary care physician is supplemented by the provision of brief, low-threshold interventions mediated by care managers are showing themselves to be a promising approach.

METHODS

In this open, cluster-randomized, controlled study, we sought to determine the superiority of a model of this type over the usual form of treatment by a primary care physician. Patients in primary care aged 60 and above with moderate depres- sive manifestations (PHQ-9: 10-14 points) were included in the study. The primary endpoint was the percentage of patients in remission (score <5 on the Patient Health Questionnaire, PHQ-9) after the end of the intervention (12 months after baseline). The study was registered in the German Clinical Studies Registry (Deutsches Register für Klinische Studien) with the number DRKS00003589.

RESULTS

71 primary care physicians entered 248 patients in the study, of whom 109 were in the control group and 139 in the intervention group. In an intention-to-treat analysis, the remission rate at 12 months was 25.6% (95% confidence interval [18.3; 32.8]) in the intervention group and 10.9% [5.4; 16.5]) in the control group (p = 0.004).

CONCLUSION

This study demonstrates the superiority of the new care model in the primary care setting in Germany, as has been found in other countries.

Encouraging Self-Management in Cardiovascular Disease Prevention

BACKGROUND

Cardiovascular diseases are among the most common causes of death in industrialized countries. The goal of the DECADE study ("decision aid, action planning, and follow-up support for patients to reduce the 10-year risk of cardiovascular diseases") is to improve patient activation and health-related behavior by means of structured cardiovascular risk counseling and DECADE brochures. In this pilot study, the applicability of DECADE and the potential effects of the intervention on patients with cardiovascular risk factors were investigated.

METHODS

87 patients were included in the two-arm, randomized, controlled pilot study. All of them participated in four structured counseling sessions. The A+D group received DECADE brochures (intervention group), while the A group did not (control group). The change in patient activation four months later (PAM13-D) was the primary endpoint. Secondary endpoints included, among others, changes in health status and health-related behavior, goal achievement, and patient satisfaction. These changes were studied in an intention-to-treat analysis.

RESULTS

Endpoint data were available for 78 patients (38 in the A+D group and 40 in the A group) at four months. The use of DECADE brochures had a significant beneficial effect on PAM13-D scores (an increase of 3.30 points, p = 0.023), corresponding to a moderate effect size of 0.54. Positive trends were seen in most of the other endpoints. The improved patient activation was associated with an overall reduction of risk factors.

CONCLUSION

This pilot study shows that DECADE can support patient activation. The effects can be expected to be stronger in a larger study and in comparison to usual care. If this can be confirmed, DECADE should be embedded in routine patient care.

[Individual patient satisfaction in 'Gesundes Kinzigtal': Interim results of a trend study]

INTRODUCTION

The integrated health care pilot model "Gesundes Kinzigtal" (GK) is recognized as a reference model for integrated healthcare in Germany. The aim of GK is to improve the health of the insured persons and, at the same time, to decrease their healthcare costs compared to usual care. The evaluation of GK has so far shown that GK might reach this aim. However, there are still no evaluation studies on GK focusing on patient-reported outcomes. This gap needs to be closed by a trend study, which is the main topic of this paper: We present interim results of this study, focusing on patient satisfaction with GK, insured persons' self-reported change of health behavior, their knowledge on health maintenance, and health-related quality of life.

METHOD

The baseline survey of the trend study was conducted in 2013: 3,034 members of GK were invited to complete a standardized questionnaire (by mail). In the first follow-up survey in 2015, 3,471 members were invited. Health-related quality of life was measured by EQ-5D and EQ-VAS; the other above-mentioned indicators were developed by our work group. Conducting variance analysis and logistic regression analysis using SPSS, it was analyzed to what extent the above-mentioned indicators changed between the first and the second survey.

RESULTS

The response rate was 23.4 % and 24.9 %, respectively. Overall patient satisfaction with GK and the mean EQ-5D value remained stable; the remaining indicators improved more or less over the course of time. Among these, the proportion of participants who indicated that they "now lead an overall healthier life" than before their enrolment into GK significantly increased from 25.6 % to 30.7 % (p=0.020).

DISCUSSION AND CONCLUSION

The significant increase in the proportion of respondents who "now lead an overall healthier life" might be attributed to the fact that patient activation and empowerment was (and is) a top priority of the GK management strategy. Caution is advised, though, with this interpretation because of the limitations inherent to trend studies without an appropriate control group.

New paths in post-graduate medical training in general practice - 8 years of experience with the pilot project Verbundweiterbildungplus Baden-Württemberg

Background: In face of the looming shortage of general practitioners, primary healthcare providers and post-graduate training in general practice are increasingly becoming part of the political agenda in Germany. In 2009 the program "Verbundweiterbildung plus Baden-Württemberg" (VWB plus BW) was developed by the Competence Center for General Practice in Baden-Wuerttemberg to ensure primary healthcare in the future by enhancing the attractiveness of general medicine. This paper describes the experiences that have been gathered in developing a post-graduate training-program for physicians undergoing specialist training in general practice. Project description: The Competence Center for General Practice in Baden-Wuerttemberg supports the organization of regional networks dedicated to post-graduate medical education. First core element of the VWB plus BW program is a special seminar series for physicians pursuing post-graduate training. This seminar program is aligned with the German competency-based curriculum in general medicine and is meant to promote medical expertise and other related competencies, such as business and medical practice management and communication skills. Mentoring and advising the physicians regarding professional and personal planning form the second core element. The third core element is seen in the train-the-trainer seminars that address the competencies of the trainers. In order to focus the program's content closely on the needs of the target groups, scientifically based evaluations and research are carried out. Results: Since starting in 2009, 685 physicians have entered the program and 141 have passed the examination to become medical specialists (as of December 2016). In total, 31 networks, 60 hospitals and 211 general practices have participated. The seminar sessions have been rated on average with 1.43 on a six-point Likert scale by the physician trainees (1=extremely satisfied, 6=extremely dissatisfied). Alongside the medical training, these physicians viewed the exchange of information and experiences with other physicians as very positive and important. In 185 seminars lasting 90 minutes each, the seminar program has presently covered 250 out of 320 units in the competency-based curriculum for general medicine. A total of 281 trainers have been trained in 13 train-the-trainer courses and have rated this course on average with 1.36 on a six-point Likert scale. Above all, the trainers emphasized the exchange of information and experiences with other trainers as very positive. In 2013 the DEGAM concept for its Verbundweiterbildungplus program was developed based on that of the VWB plus BW. Since 2008 over 40 articles on the topic of post-graduate medical education have been published. Conclusion: The steadily increasing number of participants over the years demonstrates that the VWB plus BW is relevant for recent medical graduates and contributes to the attractiveness of general practice. The consistently excellent evaluations of the training program and the train-the-trainer course affirm the focus on the needs of the target groups. The post-graduate VWB plus BW program advances structured, competency-based and quality-oriented specialist training and fosters professional sharing between physicians - something that could also be relevant for other fields. The increasing numbers of participating physicians and specialists in general practice in Baden-Württemberg lead to the conclusion that the VWB plus BW program positively influences the number of general practitioners.

Three years of experience with a workshop for medical specialty examiners in South Baden: A project report and initial evaluation results

Introduction: An oral exam (30-60 minutes) is administered at the end of every post-graduate medical specialty program or is required to attain additional specialized qualifications. In both undergraduate and post-graduate medical education oral exams are not considered to be very objective or reliable. To improve the quality of exams in medical specialties, the Regional Medical Association for South Baden (Bezirksärztekammer Südbaden) decided in 2013 to offer a training program for head examiners and others responsible for administering exams in medical specialties. Project Description: Following a survey of examiners and examinees conducted from January through June, 2013, on the difficulty level of examination questions, satisfaction with the test, and the need for training in administering exams, the first workshop of its kind was designed. Since 2013, six workshops with a total of 93 participants have been held and evaluated. Results: The evaluations (response rate: 86%) showed a high level of acceptance for the concept behind the training. A large number of participants felt the need to define minimum standards for exams, to standardize the required level of difficulty and the assessment criteria in each subject, and to give examiners the appropriate tools needed to improve the validity and reliability of the exams. Conclusion: Offering a training program for those responsible for administering medical specialty exams appears to be both meaningful and necessary in order to meet the existing need for increased validity and reliability. In light of the initial experiences with this workshop and the differing percentages of failed exam attempts nationwide, the implementation of examiner training is to be recommended in other regions in Germany. In other European countries examiners conducting medical specialty exams undergo appropriate training before administering their first exam.

DECADE-pilot: decision aid, action planning, and follow-up support for patients to reduce the 10-year risk of cardiovascular diseases-a protocol of a randomized controlled pilot trial

Background

A healthy lifestyle can reduce cardiovascular risk (CVR) and prevent premature death. Usually most patients at increased CVR have difficulties implementing the necessary health behavior changes, such as smoking cessation, increasing of physical activity, healthy diet, stress reduction, etc. In this pilot study, a new intervention (DECADE) that includes a cardiovascular risk calculation, evidence-based decision aids, action planning, and follow-up support for patients to reduce their 10-year risk of cardiovascular diseases will be tested in primary care. The objectives of this trial are to test (1) the feasibility of the study design in preparation for the main trail including (2) the usability and acceptance of DECADE, and (3) initial data to ascertain that changes can be observed in these patients.

Methods

This randomized controlled pilot trial will generate initial data on the potential effects of DECADE on patients’ self-evaluated activity and behavior change as well as on clinical outcomes such as blood pressure, cholesterol, body mass index (BMI), HbA1C, and CVR score. In the qualitative part of the study, we will analyze data collected in semi-structured interviews with participating general practitioners (GP) and in patient questionnaires.

Discussion

The outcomes of this pilot study will indicate whether DECADE is a promising intervention in the domain of patient-centered prevention of cardiovascular diseases (CVD) and whether a larger multi-center randomized controlled trial is feasible.

Trial registration

German Clinical Trials Register (DRKS), DRKS00010584

Electronic supplementary material

The online version of this article (doi:10.1186/s40814-017-0172-5) contains supplementary material, which is available to authorized users.

Herbal medicinal products - Evidence and tradition from a historical perspective

BACKGROUND

Aside from the fully licensed herbal medicines there are products on the European pharmaceutical market which are registered by virtue of their longstanding traditional use. The normal registration procedure does not apply to them because presently they do not meet the legal requirements for a full license as set out in the relevant European Union Directive. One of these requirements, "proof of tradition", has so far been dealt with in different ways and fails to meet the criteria of good practice.

METHOD

This analysis is based on a selective literature search in PubMed and in databases of medical and pharmaceutical history, interviews with licensing experts, a consensus meeting attended by researchers with a background in general medicine, phytotherapy, medical and pharmaceutical history, biometry, ethnopharmacology, pharmacognosy and the pharmaceutical industry.

RESULTS AND DISCUSSION

The 2004 EU Directive, which governs the registration of Traditional Herbal Medicinal Products and demands proof of tradition, is a regulatory construct and, above all, the outcome of a political process that has ended in a pragmatic compromise. The concept of tradition applied in the Directive does not sufficiently reflect the semantic breadth of the term. The only condition defined is that a specific commercial preparation needs to have been on the market for 30 years (15 of them inside the EU). Such an approach does not make full scientific use of the evidence available because the information excerpted from historical sources, if adequately processed, may yield valuable insights. This applies to indications, modes of application, efficacy and product safety (innocuousness). Such criteria should enter in full into the benefit-risk-analysis of applied preparations, in the registration process as well as in the therapeutic practice.

CONCLUSION

When registering Traditional Herbal Medicinal Products the criterion of evidence-based medicine will only be met if all the facts available are assessed and evaluated, over and above the formally stipulated regulatory provisions (30 years, product reference). To this end, the scientific methods (from among the natural, life or cultural sciences), which are recognized as authoritative in each case, must be applied.

Declaration and Handling of Conflicts of Interest in Guidelines: A Study of S1 Guidelines From German Specialist Societies From 2010-2013

BACKGROUND

Authors' conflicts of interest may affect the content of medical guidelines. In April 2010, the Association of Scientific Medical Societies in Germany (AWMF) issued recommendations on how such conflicts of interest should be dealt with. Most AWMF guidelines are so-called S1 guidelines developed by informal consensus in a group of experts. We now present the first study to date on the management of conflicts of interest in S1 guidelines.

METHODS

On 2 December 2013, we selected the guidelines that had appeared from 1 November 2010 to 1 November 2013 among the 449 current S1 guidelines on the AWMF website. We extracted information about conflicts of interest from the guideline texts, reports, and/or conflict of interest statements and evaluated this information descriptively.

RESULTS

There were 234 S1 guidelines in this category, developed by a total of 2190 experts. For 7% (16/234) of the guidelines and 16% (354/2190) of the experts, no individual conflict of interest statement could be found. Where conflict of interest statements were available, conflicts of interest were often declared--in 98% (213/218) of the guidelines and by 85% (1565/1836) of the authors. The most common type of conflict of interest was membership in a specialist society or professional association (1571/1836, 86%). Half of the experts acknowledged a financial conflict of interest (911/1836, 50%). Conflicts of interest were more common among experts contributing to guidelines that mainly concerned treatment with drugs or other medical products than in guidelines that did not have an emphasis of this type (397/663, or 60%, versus 528/1173, or 45%). The conflicts of interest were assessed in 11% (25/234) of the guidelines, with practical consequences in a single case.

CONCLUSION

Conflicts of interest are often declared in the S1 guidelines of the AWMF, but they are only rarely assessed by external evaluators. Clear rules should be issued for how experts' declared conflicts of interest should be acted upon, whether they are of a financial nature or not.

Effects of culture-sensitive adaptation of patient information material on usefulness in migrants: a multicentre, blinded randomised controlled trial

OBJECTIVES

To evaluate the usefulness of culture-sensitive patient information material compared with standard translated material.

DESIGN

Multicentre, double-blind randomised controlled trial.

SETTING

37 primary care practices.

PARTICIPANTS

435 adult primary care patients with a migration background with unipolar depressive disorder or non-specific chronic low back pain were randomised. Patients who were unable to read in the language of their respective migration background were excluded. Sufficient data were obtained from 203 women and 106 men. The largest group was of Russian origin (202 patients), followed by those of Turkish (52), Polish (30) and Italian (25) origin.

INTERVENTIONS

Intervention group: provision of culture-sensitive adapted material.

CONTROL GROUP

provision of standard translated material.

MAIN OUTCOME MEASURES

Primary outcome: patient-rated usefulness (USE) assessed immediately after patients received the material.

SECONDARY OUTCOMES

patient-rated usefulness after 8 weeks and 6 months, symptoms of depression (PHQ-9), back pain (Back Pain Core Set) and quality of life (WHO-5) assessed at all time points.

RESULTS

Usefulness was found to be significantly higher (t=1.708, one-sided p=0.04) in the intervention group (USE-score=65.08, SE=1.43), compared with the control group (61.43, SE=1.63), immediately after patients received the material, in the intention-to-treat analysis, with a mean difference of 3.65 (one-sided 95% lower confidence limit=0.13). No significant differences were found for usefulness at follow-up (p=0.16, p=0.71). No significant effect was found for symptom severity in depression (p=0.95, p=0.66, p=0.58), back pain (p=0.40, p=0.45, p=0.32) or quality of life (p=0.76, p=0.86, p=0.21), either immediately after receiving the material, or at follow-up (8 weeks; 6 months). Patients with a lower level of dominant society immersion benefited substantially and significantly more from the intervention than patients with a high level of immersion (p=0.005).

CONCLUSION

Cultural adaptation of patient information material provides benefits over high quality translations. Clinicians are encouraged to use culture-sensitive material in their consultations, particularly with low-acculturated patients.

TRIAL REGISTRATION NUMBER

German Register for Clinical Trials: DRKS00004241, Universal Trial Number: U1111-1135-8043, Results.

[How do general practitioners evaluate collaborative care of elderly depressed patients? Results of a qualitative study]

BACKGROUND

Depression is a very common disease among the elderly. Various studies demonstrated the need to improve the care for elderly depressed patients. Within the GermanIMPACT trial specifically trained care managers were engaged to cooperate with general practitioners (GPs). This study investigates how GPs evaluate this cooperation and their attitude towards collaborative care.

METHODS

To explore the perspective of GPs a qualitative study design with semi-structured interviews was chosen. The guideline-based interviews were conducted with GPs from the intervention group, the control group and with GPs who had decided not to participate in the trial. The interviews were audio-taped, fully transcribed and analysed.

RESULTS

Eighteen GPs were interviewed. Almost all GPs from the intervention group appreciated the support by care managers. Advantages they mentioned included their own relief by the committed conversation between patient and care manager, the continuous monitoring of the patients as well as the regular feedback via protocols. GPs who refused to take part in the study expressed different attitudes towards collaborative care.

CONCLUSION

Due to the general overall positive valuation of care managers as well as their positive attitude towards collaborative care a continuation of the IMPACT program in Germany should be considered. More investigation needs to be done to answer the question how care managers can be integrated in everyday primary care.

Evaluation einer regionalen integrierten Vollversorgung mit GKV-Routinedaten – Probleme und Herausforderungen

Die Integrierte Versorgung Gesundes Kinzigtal (IVGK) ist eine regionale integrierte Vollversorgung und wird umfassend extern evaluiert. In einer kontrollierten Längsschnittstudie wird anhand von GKV-Routinedaten untersucht, wie sich die Versorgungsqualität in der Region Kinzigtal im Vergleich zu einer Kontrollgruppe aus dem restlichen Baden-Württemberg entwickelt. Hierfür wurden insgesamt 37 Kennziffern gebildet. An drei Beispielen zeigen wir, dass die Eignung einer Kennziffer als Qualitätsindikator und Endpunkt regional vergleichender Studien sehr voraussetzungsvoll ist.

Cancer survivorship in Germany: Education of GPS—Why and how?

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Background: General Practitioners (GP) play a pivotal role in caring for patients with malignant diseases in screening and detection, additional supporting care whilst treatment, and (long-term) follow-up. They often do not feel to be qualified enough for this task, and as well claim to lack support by specialists. This is a well-known problem, already addressed by the Institute of Medicine a few years ago. As an increasing number of patients will be diagnosed with cancer – and will survive for many years, following curatively intended treatment or with a chronic cancer disease, Cancer Survivorship was identified as the area of utmost importance. The relevance of this field was underlined by the disappointing results of the simple question we asked GPs: “When and how often should the tumor markers CEA, CA 15.3, and PSA be assessed during standardized follow-up of patients with early breast cancer, colorectal cancer or prostate cancer?”. Only one out of 30 answered it correctly. Together with the State Chamber of Medicine of Südbaden, we started an education program for GPs to improve this critical interface. Methods: During a full day training, we provided an educational program covering the most relevant topics in Cancer Survivorship: physical long-term sequelae and late complications after multimodal therapy strategies, their prevention and treatment; fatigue and self management, reasonable complementary and alternative medicine; management of chronic pain syndromes, recommendations for tertiary prevention, physical activities, nutrition and a guideline conform follow-up. Training was completed by a knowledge test and an overall evaluation. Results: All participants welcomed this newly implemented training program and considered it as very useful for their daily practice. Further support was urgently requested by the GPs, preferably in the format of (defined) Survivorship Care plans and follow-up schedules. Conclusions: GPs need more support and information in Cancer Survivorship. Widespread trainings programs should be developed and offered, in close collaboration with the respective State Chambers of Medicine and cancer specialists, and GPs, and further improve the outpatient care of cancer survivors.

Collaborative treatment of late-life depression in primary care (GermanIMPACT): study protocol of a cluster-randomized controlled trial

Background

Depression is not a normal side effect of aging, however it is one of the most prevalent mental health issues in later life, imposing a tremendous burden on patients, their families, and the healthcare system. We describe the experimental implementation of a collaborative, stepped-care model for the treatment of late-life depression (GermanIMPACT trial) in the German primary care context. GermanIMPACT was developed as an adaptation of a successful and widely used American model. The aim of the study is to evaluate the model’s applicability to the German primary care setting and its cost-effectiveness.

Methods/Design

The study will be conducted as a cluster-randomized controlled trial comparing the development of depressive symptoms in primary care patients who either receive treatment as usual (control arm) or treatment according to the GermanIMPACT model (intervention arm). In two German cities (Freiburg and Hamburg), a total of 60 general practice offices will be selected and randomized. Each general practice office will be asked to enroll five patients into the trial who are 60 years of age or older and who show moderate depressive symptoms in the scope of a diagnosed depressive episode, recurrent depressive disorder, or dysthymia. General practices in the control arm will provide treatment as usual; general practices in the intervention arm will work closely with a specially trained care manager and a supervising mental health specialist. Evidence-based elements of the treatment plan manual include patient education, identification and integration of positive activities into the daily routine, relapse prevention, and training of problem-solving techniques as needed. The intervention period per patient will be one year. Data will be collected at baseline, 6, and 12 months. Primary outcome is the patient-reported change of depressive symptoms (Patient Health Questionnaire, PHQ-9). Secondary outcomes include measures of quality of life, anxiety, depression-related behavior, problem-solving skills, resilience, and an overall economic evaluation of the program.

Discussion

The GermanIMPACT trial will provide evidence about the effectiveness, feasibility, and cost-effectiveness of collaborative stepped care in treating late-life depression in German primary care. Positive results will be a first step toward integrating specialized depression care managers into the primary care setting.

Trial registration

German Clinical Trials Register: DRKS00003589 (September 2012).

Shared decision-making in antihypertensive therapy: a cluster randomised controlled trial

Background

Hypertension is one of the key factors causing cardiovascular diseases. A substantial proportion of treated hypertensive patients do not reach recommended target blood pressure values. Shared decision making (SDM) is to enhance the active role of patients. As until now there exists little information on the effects of SDM training in antihypertensive therapy, we tested the effect of an SDM training programme for general practitioners (GPs). Our hypotheses are that this SDM training (1) enhances the participation of patients and (2) leads to an enhanced decrease in blood pressure (BP) values, compared to patients receiving usual care without prior SDM training for GPs.

Methods

The study was conducted as a cluster randomised controlled trial (cRCT) with GP practices in Southwest Germany. Each GP practice included patients with treated but uncontrolled hypertension and/or with relevant comorbidity. After baseline assessment (T0) GP practices were randomly allocated into an intervention and a control arm. GPs of the intervention group took part in the SDM training. GPs of the control group treated their patients as usual. The intervention was blinded to the patients. Primary endpoints on patient level were (1) change of patients’ perceived participation (SDM-Q-9) and (2) change of systolic BP (24h-mean). Secondary endpoints were changes of (1) diastolic BP (24h-mean), (2) patients’ knowledge about hypertension, (3) adherence (MARS-D), and (4) cardiovascular risk score (CVR).

Results

In total 1357 patients from 36 general practices were screened for blood pressure control by ambulatory blood pressure monitoring (ABPM). Thereof 1120 patients remained in the study because of uncontrolled (but treated) hypertension and/or a relevant comorbidity. At T0 the intervention group involved 17 GP practices with 552 patients and the control group 19 GP practices with 568 patients. The effectiveness analysis could not demonstrate a significant or relevant effect of the SDM training on any of the endpoints.

Conclusion

The study hypothesis that the SDM training enhanced patients’ perceived participation and lowered their BP could not be confirmed. Further research is needed to examine the impact of patient participation on the treatment of hypertension in primary care.

Trial registration

German Clinical Trials Register (DRKS): DRKS00000125

Does the pharmaceutical industry influence guidelines?: two examples from Germany

BACKGROUND

The recommendations in clinical guidelines are based on clinical trial findings and expert opinion. The influence of drug companies on these two factors is illustrated with two examples.

METHODS

A judicially ordered expert review revealed that the market authorization holder (MAH) of gabapentin manipulated study data. Gabapentin was, therefore, chosen as an example for this article to analyze whether manipulated data serve as a basis for recommendations in German clinical guidelines. A search was carried out for manipulated publications on gabapentin that found their way into guidelines published by the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). To analyze the possible effects of financial ties between guideline authors and drug companies, the S3 guideline on the treatment of psoriasis vulgaris with efalizumab was compared with guidelines whose authors had no conflicts of interest. One of the authors of this article had noted variable prescribing practices for psoriasis among dermatologists while carrying out an economic assessment for a German state Association of Statutory Health Insurance Physicians.

RESULTS

The data that had been manipulated by the MAH of gabapentin served as a basis for recommendations to prescribe gabapentin in guidelines that were published by the AWMF. Efalizumab was judged more favorably in the S3 guideline than in a guideline issued by the National Institute of Health and Care Excellence: for example, the evidence for it was judged as good, the use of efalizumab for induction and combination therapy in psoriasis vulgaris was recommended, and efalizumab was said to improve patients' health-related quality of life.

CONCLUSION

Public access to all trial data must be ensured so that independent evaluations are possible. We take the view that the responsibility for creating guidelines should be borne by authors and organizations that do not have any conflicts of interest.

Implementation of shared decision making by physician training to optimise hypertension treatment. Study protocol of a cluster-RCT

Background

Hypertension is one of the key factors causing cardiovascular diseases which make up the most frequent cause of death in industrialised nations. However about 60% of hypertensive patients in Germany treated with antihypertensives do not reach the recommended target blood pressure. The involvement of patients in medical decision making fulfils not only an ethical imperative but, furthermore, has the potential of higher treatment success. One concept to enhance the active role of patients is shared decision making. Until now there exists little information on the effects of shared decision making trainings for general practitioners on patient participation and on lowering blood pressure in hypertensive patients.

Methods/Design

In a cluster-randomised controlled trial 1800 patients receiving antihypertensives will be screened with 24 h ambulatory blood pressure monitoring in their general practitioners’ practices. Only patients who have not reached their blood pressure target (approximately 1200) will remain in the study (T1 – T3). General practitioners of the intervention group will take part in a shared decision making-training after baseline assessment (T0). General practitioners of the control group will treat their patients as usual. Primary endpoints are change of systolic blood pressure and change of patients’ perceived participation. Secondary endpoints are changes of diastolic blood pressure, knowledge, medical adherence and cardiovascular risk. Data analysis will be performed with mixed effects models.

Discussion

The hypothesis underlying this study is that shared decision making, realised by a shared decision making training for general practitioners, activates patients, facilitates patients’ empowerment and contributes to a better hypertension control. This study is the first one that tests this hypothesis with a (cluster-) randomised trial and a large sample size.

Trial registration

WHO International Clinical Trials: http://apps.who.int/trialsearch/Trial.aspx?TrialID=DRKS00000125

[Bringing evidence to practice: obstacles and barriers]

Translating clinical research findings into daily medical practice is a complex procedure and subject to multiple impacts. Studies sponsored by drug manufacturers produce positive results more frequently than would be expected by chance alone; positive studies have a better chance to be published than negative ones. There is a lack of effective implementation strategies for medical guidelines. The mismatch of study population and own patients renders the generalizability of study results difficult. Other confounding factors in head-to-head studies are drug comparisons that do not conform to the gold standard, non-equivalent dosages and study duration. To solve these problems clinical research must pick up questions and problems from daily medical care. Studies independent of drug companies should be funded with public money, and health care research needs public support. Access to study protocols and data must be open to the public.

[Evidence-based therapy of depression: S3 guidelines on unipolar depression]

Unipolar depressive disorders are among the most frequent reasons for utilizing the health care system. Although efficacious treatments are available and further advances have recently been made there is still a need for improving diagnostic and therapeutic procedures. Alignment of treatment on evidence-based treatment guidelines establishes an essential mainstay. The new S3 and National Health Care guidelines on unipolar depression, the compilation of which was coordinated by the German Society of Psychiatry, Psychotherapy and Neurology (DGPPN) and which were approved by 29 scientific and professional associations, is the ambitious effort to present state of the art evidence and clinical consensus for the treatment of depression. For pharmacotherapy of depression differentiated recommendations can be given, also separate from and in addition to psychotherapy.

Cluster-randomized controlled trial of dissemination strategies of an online quality improvement programme for alcohol-related disorders

AIMS

This project investigated different dissemination strategies of an online quality improvement programme for alcohol-related disorders into routine care in South Baden and South Württemberg in Germany.

METHODS

In a cluster-randomized controlled trial, 112 general practices were randomized into three groups. The first group (n = 43) received access to the online system and a training programme for the general practitioners (GPs). The second group (n = 42) additionally received education for the whole practice team. The third group (n = 27) acted as control and received only access to the online system.

RESULTS

Two thousand six hundred and forty-seven practitioners were asked to take part in the study, and it was possible to randomize 112 (4%) practices. There were no significant differences concerning the use of the system between the groups: 41.9% of the GPs in the first group, 42.9% in the second group and 44.4% in the control group used the system. In terms of only the system users, 55.6% of the GPs in the first group, 33.3% in the second group and 8.3% in the control group used the system six times or more (P = 0.019). Diagnostic assessments made by the GPs in the groups differed substantially: 72.2% of diagnoses in the first group were correct, while this figure lay at 69.7% in the second group and 36.4% in the control group (P = 0.034).

CONCLUSIONS

No effect of the additional training on the primary outcome (acceptance) was identified, but on two of the secondary outcomes. Further cost-effectiveness studies should investigate whether the effort involved in providing training additionally to the system is justifiable. The study is registered at ClinicalTrials.gov: NCT00314067. This article conforms to the guidelines in the Consolidated Standards of Reporting Trials (CONSORT) statement (Moher et al., 2001; Campbell et al., 2004).

The effects of a shared decision-making intervention in primary care of depression: a cluster-randomized controlled trial

OBJECTIVE

Patient-centred depression care approaches should better address barriers of insufficient patient information and involvement in the treatment decision process. Additional research is needed to test the effect of increased patient participation on outcomes. The aim of this study was to assess, if patient participation in decision-making via a shared decision-making intervention leads to improved treatment adherence, satisfaction, and clinical outcome without increasing consultation time.

METHODS

Cluster-randomized controlled intervention study based on physician training and patient-centered decision aid compared to usual care in primary care settings in Südbaden region of Germany. Twenty-three primary care physicians treating 405 patients with newly diagnosed depression were enrolled. Patient involvement was measured with the patient perceived involvement in care scale (PICS) and a patient participation scale (MSH-scale). Patient satisfaction was measured by the CSQ-8 questionnaire. Treatment adherence was evaluated by patient and provider self-report. Depression severity and remission outcomes were assessed with the Brief PHQ-D.

RESULTS

Physician facilitation of patient participation improved significantly and to a greater extent in the intervention compared to the control group. There was no intervention effect for depression severity reduction. Doctor facilitation of patient participation, patient-rated involvement, and physician assessment of adherence improved only in the intervention group. Patient satisfaction at post-intervention was higher in the intervention group compared to the control group. The consultation time did not differ between groups.

CONCLUSION

A shared decision-making intervention was better than usual care for improving patient participation in treatment decision-making, and patient satisfaction without increasing consultation time. Additional research is needed to model causal linkages in the decision-making process in regard to outcomes.

PRACTICE IMPLICATIONS

The study results encourage the implementation of patient participation in primary care of depression.

[Prescription of generic drugs in general practice. Results of a survey of general practitioners]

BACKGROUND AND PURPOSE

Switching brand-name drugs to generics is reasonable and desired for economic reasons. Few data exist about problems, if any, during the switching in general practice. In this survey, the view of general practitioners (GPs) should be ascertained.

METHODS

GPs in five counties in the German federal states Thüringen and Baden-Württemberg, who took part in a study on generic drug prescribing, were asked to complete a questionnaire about experiences and attitudes toward generic drug prescription.

RESULTS

A total of 195 (84%) of 233 GPs answered the questionnaire. Two thirds (127/195) stated, that brands and generics are pharmacologically equivalent. Many of these GPs estimated to prescribe generic drugs in > 50% of instances; fewer doctors did so, if they had doubts as to the equivalence of generics (65% vs. 46%; p < 0.05). Nearly 8% reported generics being less effective, and 10% observed new adverse effects after switching. Many GPs appointed the following barriers: cooperation with hospitals and colleagues (86%), GP's lack of time (68%), and communication problems with the patient (50%). GPs estimated that > 10% of patients strictly reject generic drugs.

CONCLUSION

An optimized cooperation between GPs and hospital physicians could facilitate the consumption of generic potential in pharmacotherapy. Reasons for the obvious contrast between the proven pharmacological equivalence of brand-name and generic drugs and the problems encountered after switching reported by GPs should be further studied.

[Ensuring safe medication in the physician's office]

The risk of adverse drug reactions can be appreciably reduced by limiting prescribing practice to a manageable number of medications, exercising restraint with regard to new drugs, and using a computerized system for the documentation of drug prescriptions. In order to further improve patient safety in this area appropriate efforts need to be made by medical self-administration, politicians and the computer industry to develop and apply computer-based prescription systems, with the additional requirement that their integration into existing doctor's office software should be simple and user-friendly, as well as free from "industrial contamination".

[The National Disease Management Guideline for Asthma--what's new from the point of view of general practice]

The National Disease Management Guideline for Asthma was developed through a consensus process that involved different medical societies, thus constituting a novelty in the improvement of the care for asthma patients in Germany. The German Association of General Practitioners (DEGAM) also participated in the development of the asthma guideline. The implementability of this new guideline in general practice will be discussed on the basis of the chapters that are most important to primary care physicians. The guideline offers many relevant aspects for the management of asthma in general practice. In future editions, the levels of evidence underlying the statements about diagnosis and therapy should be more elaborate, thus providing more concise decision aids for physicians in daily practice. In particular, the implementation aids on the guideline's website could be used to translate the content of the guidelines into practice. Continuous quality improvement and the further development of the implementation process would be most important in overcoming the cross-sectoral barriers of the German healthcare system and thus optimizing the quality of care.

[National Disease Management Guideline for Asthma: recommendations and evidence for "asthma prevention" issues]

The National Disease Management Program (NDM Program) represents the basic content of structured, cross-sectoral healthcare. In particular, the NDM Program is directed towards coordinating different disciplines and areas of healthcare. The recommendations are developed through interdisciplinary consensus of the scientific medical societies on the basis of the best available evidence. Within this scope the scientific medical societies concerned with the prevention, diagnosis, therapy and rehabilitation of asthma consented upon a National Disease Management Guideline for Asthma in 2005. Among other things, the following cornerstones of asthma prevention were agreed upon: Breastfeeding and non-smoking were suggested as primary prevention measures for (expectant) parents. With respect to secondary prevention, recommendations have been made for allergen avoidance, active/passive smoking and immunotherapy. Regarding tertiary prevention, position statements on vaccination and specific immunotherapy are developed. The present paper presents both the original texts of the recommendations and the evidence underlying them.

Improving quality of care for depression: the German Action Programme for the implementation of evidence-based guidelines

ISSUE

Depressive disorders are of great medical and political significance. The potential inherent in achieving better guideline orientation and a better collaboration between different types of care is clear. Throughout the 1990s, educational initiatives were started for implementing guidelines. Evidence-based guidelines on depression have been formulated in many countries.

PURPOSE

This article presents an action programme for structural, educational, and research-related measures to implement evidence-based care of depressive disorders in the German health system. The starting points of the programme are the 'Guidelines Critical Appraisal Reports' of the 'Guideline Clearing House' and measures from the 'Competence Network on Depression and Suicidality' (CNDS) funded by the Federal Ministry of Education and Research. The article gives an overview of the steps achieved as recommended by the Guidelines Critical Appraisal Reports and the ongoing transfer process into the German health care system.

RESULTS

The action programme shows that comprehensive interventions to develop and introduce evidence-based guidelines for depression can achieve benefits in the care of depression, e.g. in recognition, management, and clinical outcome.

CONCLUSION

It was possible to implement the German Action Programme in selected care settings, and initial evaluation results suggest some improvements. The action programme provides preliminary work, materials, and results for developing a future 'Disease Management Programme' (DMP) for depression.

[Naturopathic methods as part of the academic curriculum and the role of general practice]

BACKGROUND

With the implementation of the last 'Arztliche Approbationsordnung' in 2003, complementary medicine (CAM) became a required subject for all German medical schools. CAM will be taught together with rehabilitation and physical treatment in a compound as a cross sectional subject.

OBJECTIVES

As CAM has rarely been represented at German universities before,the question arose who would give the classes. Previously, CAM had often been taught within the curriculum of academic General Practice.

METHODS AND RESULTS

According to the replies from 27 departments of general practice at German universities, we show effects of the required additional curriculum on academic General Practice, which faculties are involved beyond General Practice, what kind of contents are taught and what type of examinations are considered. Descriptive statistical results will be given.

What do primary care patients think about generic drugs?

OBJECTIVE

To examine the attitude of patients towards generic drugs and prescriptions containing generic drugs as an alternative to brand-name products, with a special focus on information on patients attitude to generic drugs provided by their general practitioners (GPs).

METHODS

A total of 804 patients in 31 general practices were surveyed using a self-questionnaire. The influence of age, sex, education, disease, knowledge of generic drugs, experience with generic substitution and information provided by the GP on patient attitudes towards generic drugs and substitutions were examined.

RESULTS

Nearly two thirds of the patients (509/804) stated that they knew of the difference between brand-name drugs and generics; of these, one third were not satisfied with the information given by their GPs and 37% of patients expressed general skepticism towards generic drugs because of their lower price. This attitude was more frequent among those who felt that generic prescribing was "invented" to solve the financial crisis in the German health insurance system at their expense (odds ratio (OR): 6.2; 95% confidence interval: 4.0 - 9.8) and those who had not been confronted personally with a generic substitution (OR: 1.8; 1.3 3.0). Patients who had been skeptical when first confronted with a generic substitution were more frequently among those who considered inexpensive drugs to be inferior (OR: 4.5; 2.0 10.4) and they were frequently not satisfied with the information on substitution provided by their GP (OR: 2.7; 1.2 - 5.9).

CONCLUSION

GPs are in an ideal position to inform their patients adequately about the equivalence of brand-name and generic drugs. However, the patient view that inexpensive drugs must be inferior may be difficult to rectify in the short term.

Participation in a quality of care study and consequences for generalizability of general practice research

BACKGROUND

Non-participation of General Practitioners (GPs) hampers primary care research. Using existing network structures can improve participation, but may introduce sampling effects.

OBJECTIVES

To examine the role of network-based recruitment and other determinants of participation, and to estimate effects of sampling and non-participation on generalizability.

METHODS

For a study of quality of care assessment, we recruited GPs from a regionally defined population and a GP network. Effects of sampling and non-participation were analysed by comparing characteristics between participants, target samples, and reference data for all German GPs. Factors influencing study participation were assessed in multiple logistic regression.

RESULTS

Compared to the regional sample, network GPs were more likely to complete survey questionnaires (92% versus 69%) and to participate in the study (66% versus 23%). Compared to national reference data, study participants from both populations were younger, had a higher level of professional training, and included more men. These differences were already present in the network target sample, but were largely attributable to selective participation in the regional sample. Network membership remained the strongest determinant of participation in multiple logistic regression (odds ratio 5.01; 95% confidence interval 2.53-9.91). A younger age, higher professional training, and membership in the German Society of General Practice were also predictive of participation.

CONCLUSIONS

Although network-based recruitment of GPs increases participation rates, sample effects are similar in size and direction as effects of non-participation in the regionally defined population. Careful analysis of participants based on publicly available data is therefore crucial for the assessment of generalizability.

[Documentation of electronic patient records (EPRS) in German general practices: a telephone survey]

In Germany, use and contents of EPRs are largely unknown and expected to be highly variable, due to missing standards. We conducted a telephone survey to describe and compare computer documentation habits in general practices. Specifically, we were interested in: (1) the type of medical data recorded; and (2) which factors influence the extent to which doctors used the EPR while seeing their patients. The sampling frame consisted of family physicians participating in a general practice research project: 32% (145/452) of family physicians in the district of Göttingen, Lower Saxony, and 63% (52/83) of physicians from a quality assurance network of family practices in the district of Freiburg, Baden-Württemberg. With the exception of two practices in Göttingen, all practices (n = 165 of 167) took part in this survey. Diagnoses, digital codes for service fees, and prescriptions were computerized in nearly all practices, although doctors were significantly more involved in Freiburg than in Göttingen. Clinical symptoms and findings were recorded in 80% of Freiburg and 52% of Göttingen practices (p = 0.008). Overall, in 74% of Freiburg and 51% of Göttingen practices, the physicians opened the EPR while seeing patients (p = 0.022). Nearly half of the Göttingen practices (49%) and 24% of the Freiburg practices (p < 0.05) entered digital codes for service fees and diagnoses on paper before entering them electronically. In multivariate models adjusting for sex, target group and training specialty, internet access in the office was independently predictive of 'EPR-activity' (OR: 2.23; 95%-confidence interval: 1.12-4.43). There seems to be room for improvement in terms of degree and intensity of recording of clinically-relevant data. Technical interest, i.e., internet access in the office, seems to enhance electronic documentation activities.

Leitlinie „Kreuzschmerzen”

Chronic back pain is one of our society's most important health problems, causing long periods of sick leave and early retirements. Recently the German Society of General Practice and Family Medicine (DEGAM) published an evidence-based guideline for low back pain. It has been developed according to the 10-step concept of guideline development of the DEGAM, aiming for early detection of complicated clinical conditions, avoidance of unnecessary diagnostic tests and prevention of chronicity. Complicated, uncomplicated and radicular pain are defined by patient history and a short clinical examination. Imaging and further diagnostic tests are reserved for patients at risk. Basic therapy consists of structured advice. The aim of the guideline is to get patients back to their usual activity supported by effective pain relief. Psychosocial factors which are important for the prognosis should be evaluated already during the first consultation. Manual therapy might help in acute pain. Patients with persistent pain symptoms and long periods of sick leave should be transferred to multiprofessional management including pain treatment, behavioural therapy and physiotherapy. A randomised controlled trial has been set up to study the efficacy of guideline implementation.

Fr�h- und Basisintervention bei Patienten mit schizophrenen St�rungen

THEORETICAL BACKGROUND

Of all outpatients with a diagnosis of schizophrenia, 30-40% refuse a psychiatrist's care. For this group of patients the general practitioner holds a key position for such different tasks as detection of prodromal schizophrenia or early warning signs of relapse and identification of risk variables for deteriorating outcome, gatekeeping (referral to specialists or other services), integration, and counseling of key relatives. Fifty percent of GPs are interested in disease-specific medical education programs.

STUDY DESIGN AND METHODS

A control trial examined the changes that participating GPs intended to make in three main topics of the curriculum: (1) changing attitudes (pessimistic outcome expectation, low self-esteem), (2) enhancement of detection skills (prodromal schizophrenia, early warning signs of relapse, and risk factors for poor social and vocational integration), and (3) enhancement of management skills (dosing schemes, motivational interviewing).

RESULTS

In the assessment 2 weeks after the training session, we found significant changes in favor of the trained group in detection and management skills and also improved self-confidence of GPs.

CONCLUSIONS

Problem-oriented and case-based learning strategies should be preferred to lectures in training programs for psychiatric skills in primary care.

[Patient survey in general practice: development, validation and application of a survey instrument]

Patient surveys are one of the most important sources for quality management in ambulatory care. The quality assurance of the survey instrument itself is of outstanding importance, since only a high-quality instrument is able to supply high-quality data, which can serve as a reliable basis for improvement strategies. The present paper outlines the process of development and optimisation of a survey instrument for patients' rating in all sectors of general practice and primary care on the basis of one of the largest surveys of this kind that have so far been conducted in German-speaking countries. The technique presented here of building quality dimensions of care out of single items has been methodologically validated. On the one hand it allows rapid identification of critical areas at a glance, and on the other hand helps to focus--if necessary--on single aspects in order to define detailed improvement actions.

[Comprehensive ambulatory care quality management for patients with depressive disorders]

Depressive disorders are of great medical and political significance. Despite improvements in the treatment of depressive patients, the potential for guideline-oriented diagnosis and therapy as well as better co-operation between different levels of care is evident. This study is part of the German Research Network on Depression and Suicidality. The study is conducted in Southern Baden, North Rhine and Munich. The objective is to develop a quality management program for primary care physicians and psychiatrists. A comprehensive continuous medical education concept as well as quality management measures were developed, implemented and evaluated. A total of 66 physicians (43 primary care physicians and 23 psychiatrists) participated. They documented the diagnostic and treatment measures provided to depressive patients before and after the intervention that had been implemented in the intervention regions of Southern Baden and North Rhine. Effects regarding guideline orientation and implementation of stepped-care treatment are analysed with an intervention/control group design and prepost data measurement.

[Clinical practice guidelines for the diagnosis and therapy of depressive disorders in primary care]

The guidelines for diagnosis and treatment of depressive disorders are practice-oriented and evidence-based recommendations for primary care of depressive patients. They were developed in the context of subproject 3.1 "Comprehensive Quality Management in Outpatient Care" within the German Research Network on Depression and Suicidality. The guidelines were developed by research groups from study centres in Freiburg, Duesseldorf and Munich and an external expert group. In addition, a close co-operation was established with the Guideline Clearing Commission of the Agency for Quality in Medicine (AQuMed) and the Drug Commission of the German Medical Profession (AkdA) and are intended as an orientational aid in terms of a "pathway of care". The guidelines particularly address physicians in primary care. The development process followed the methodological recommendations of the Association of the Scientific Medical Societies in Germany (AWMF) and the requirements of evidence-based medicine. National and international guidelines for depressive disorders as well as Cochrane reviews (CR) and quality-assessed reviews (CRD) were taken into account. The present formulation of the treatment guidelines and the evidence was agreed upon in a consensus process that included all participants.