How to strengthen basic competencies in self-care - a pre-post interventional study with postgraduate trainees in family medicine in Germany

Introduction: Self-care includes taking care of our psychosocial health. Many experts agree that self-care should be included in training for Family Medicine (FM) residents, though it is unclear to what extent and by what means. Objective: The aim of this study was to evaluate competencies of FM residents in self-care and changes in knowledge, skills and attitudes after an educational compact intervention.Methods: The authors performed a pre-post comparison on residents who were registered in the FM residency program KWBW VerbundweiterbildungPLUS© (n = 401). FM residents were offered participation in a self-care training (270 minutes featuring a broad spectrum of input and practical experience). The intervention group (IG) completed a questionnaire directly before the seminar (T1) and 10 weeks afterwards (T2). Non-attendees (=control group; CG) were asked to fill out a basic questionnaire once. Basic questionnaires for IG and CG covered previous experiences and skills while the follow-up questionnaire at T2 also focused on change of competencies and attitudes. All questionnaires contained free-text questions to capture qualitative impressions.Results: 287 FM residents (IG: n = 212; CG: n = 75) participated in the study. Generally, 86.4% of FM residents had worried that their profession might endanger their personal health (T1: n = 180, CG: n = 68). At T2, 59.5% of IG (n = 66/111) declared that they would not worry about their personal health anymore (T1:T2, p < .01). IG learned to facilitate time for recreation (T1:T2, p = .04) and to use relaxation techniques (T1:T2, p = .01). Gain in competence was described in awareness of stress, self-reward, activation of personal resources, and time management. A total of 85.6% of IG reflected their attitudes towards psychosocial health of physicians in general (n = 95/111) and 22.5% of IG changed the views on their own health (n = 25/111) in terms of improved risk-awareness, increased intention for self-care and change of behavior.Conclusion: A compact intervention in self-care strengthens competencies, increases awareness, and helps FM residents identify their psychosocial health risks. Further research is necessary to specify the effectiveness of similar compact interventions in self-care and their long-term results.

Job satisfaction and stressors for working in out-of-hours care - a pilot study with general practitioners in a rural area of Germany

BACKGROUND

Challenging work environment, high workload, and increasing physician shortages characterize current rural general practice in Germany and in most European Countries. These factors extend into Out-Of-Hours Care (OOHC). However, little research about potential stressors for general practitioners (GPs) in OOHC settings is available. This pilot study aimed to evaluate workload, different elements of job satisfaction and stressors for GPs in OOHC and to analyze whether these aspects are associated with overall job satisfaction.

METHODS

Cross-sectional survey with a sample of 320 GPs who are working in OOHC was used to measure workload in OOHC, job satisfaction (using the Warr-Cook-Wall scale) and stressors with the effort-reward imbalance questionnaire. In order to assess associations between workload, job satisfaction and stressors at work we performed descriptive analyses as well as multivariable regression analyses.

RESULTS

The response rate was 40.9%. Over 80% agreed that OOHC was perceived as a stressor and 79% agreed that less OOHC improved job satisfaction. Only 42% of our sample were satisfied with their overall job satisfaction. The regression analysis showed that the modification of current OOHC organization was significantly associated with overall job satisfaction.

CONCLUSIONS

Our results suggest that OOHC in the current form is a relevant stressor in daily work of rural GPs in Germany and one of the reasons for a decreasing overall job satisfaction. Strategic changes such as the implementation of structural reforms e.g. reducing frequency of OOHC duties for each GP and improving continuing professional development options related to OOHC are needed to address current workload challenges experienced by GPs providing OOHC in Germany.

Standardized Documentation of Drug Recommendations in Discharge Letters

Objectives: To analyze the necessity and potential usefulness of a computerized physician order entry (CPOE) system in supporting the writing of pharmacotherapeutic recommendations in discharge letters.

Methods: Systematic analysis of drug recommendations in discharge letters of a hospital providing tertiary care, structured interviews with in-hospital prescribers, and focus groups with general practitioners who admit patients to this hospital.

Results: We analyzed 1800 randomly selected discharge letters, 1205 of which contained pharmaco-therapeutic recommendations. The frequencies, structure, and quality of these recommendations varied considerably between departments. Nearly 16% of the recommendations contained both proprietary (brand) and non-proprietary names (active ingredient). Interviewed clinicians expressed interest in CPOE systems that check for contraindications and interactions between drugs, suggest cheaper products, and automatically insert active ingredients when omitted. The focus group sessions confirmed that the pharmacotherapeutic recommendations in current discharge letters do not effectively support daily clinical practice.

Conclusions: Documenting active ingredients as well as brand names in drug therapy recommendations is currently not part of clinical practice. Computerized decision support can help to optimise the structure and communication of therapeutic information across interfaces and can be a quality factor with considerable influence on process quality, outcome quality, and costs of cooperative patient care.

Prävalenz, lokale Komplikationen und Risikofaktoren der Beinvarikose in deutschen Hausarztpraxen

Einleitung: Angaben zur Prävalenz von Vari-zen der unteren Extremitäten variieren in epidemiologischen Studien als Folge unterschiedlicher Bewertungs- und Selektionskriterien stark. Ziel der vorliegenden Untersuchung war es, die Prävalenz des Krampfaderleidens, ihre Risikofaktoren und die Häufigkeit lokaler Komplikationen im Patienten-gut deutscher Hausarztpraxen zu untersuchen.

Patienten und Methoden: Die elektronischen Patientenakten von 87 548 Patienten aus 32 Hausarztpraxen der CONTENT Datenbank der Heidelberger Universitätsklinik wurden über einen Zeitraum von drei Jahren (1.7.2008– 30.6.2011) ausgewertet. Anhand der ICD-10 codes I83.0–I83.9 wurden aus der Datenbank 2 721 Patienten mit der Diagnose Varizen der unteren Extremitäten identifiziert. Ulzerationen und lokale Entzündungen wurden mit den ICD-10 codes I83.0, I83.1 und I83.2 ermittelt. Die Analyse der Risikofaktoren erfolgte durch binäre multivariable Regression.

Ergebnisse: Die Prävalenz der Varikose betrug durchschnittlich 3,1 % (Männer 0,86 %, Frau-en 2,25 %) und korrelierte mit dem Lebensalter. Bei etwa 10 % der Patienten mit Varikose waren Hautulzerationen oder Varikophlebitiden bzw. -thrombosen dokumentiert. Wichtigste Risikofaktoren waren hohes Lebensalter (OR 1,02 [95%CI 1,016–1,022]; p<0,001), weibliches Geschlecht (OR 1,76 [95%CI 1,60–1,92]; p<0,001) und kardiovaskuläre Erkrankungen (OR 2,02 [95%CI 1,84–2,11]; p<0,001).

Schlussfolgerungen: Krampfadern wurden vom Hausarzt bei 3,1% seiner Patienten in der Krankenakte kodiert und somit als medizinisches Problem wahrgenommen. Der Vergleich mit Daten anderer Studien auf der primären Versorgungsebene deutet auf eine „underestimation” der wahren Prävalenz. Lokale Komplikationen wie Varikophlebitis/-thrombose und Ulcus cruris traten bei etwa 10 % der Patienten auf und waren mit höherem Lebensalter und risikobehafteten chronischen Erkrankungen assoziiert.

A longitudinal communication approach in advanced lung cancer: A qualitative study of patients', relatives' and staff's perspectives

Communication and the care of patients with advanced cancer are a dynamic, interactive and challenging process, often characterised in every day practice by discontinuity and lack of coordination. The objective of this study was to explore the patients' and family-caregivers' needs and preferences regarding communication, quality of life and care over the trajectory of disease. The second aim was to assess health professionals' views on a longitudinally structured, forward-thinking communication approach based on defined milestones. A qualitative approach was chosen incorporating semi-structured interviews with nine patients with metastatic lung cancer and nine relatives, and focus groups with 15 healthcare providers from different professions involved in the care of these patients. Patients and relatives described a situation of shock and coping deficits with moments of insufficient communication and lack of continuity in care. Healthcare providers reported the strong need for improvement in communication within the team and between patients and professionals and welcomed the implementation of a longitudinal communication approach. Requirements for the implementation of a longitudinal communication approach include specific communication training with focus on the process that patients and relatives are involved in. Team-building measures and the necessary flexibility to respect individuality in life should be incorporated.

Process evaluation of five tailored programs to improve the implementation of evidence-based recommendations for chronic conditions in primary care

Background

Although there is evidence that tailored implementation strategies can be effective, there is little evidence on which methods of tailoring improve the effect. We designed and evaluated five tailored programs (TPs) each consisting of various strategies. The aim of this study was to examine (a) how determinants of practice prioritized in the design phase of the TPs were perceived by health care professionals who had been exposed to the TPs and whether they suggested other important determinants of practice and (b) how professionals used the offered strategies and whether they suggested other strategies that might have been more effective.

Methods

We conducted a mixed-method process evaluation linked to five cluster-randomized trials carried out in five European countries to implement recommendations for five chronic conditions in primary care settings. The five TPs used a total of 28 strategies which aimed to address 38 determinants of practice. Interviews of professionals in the intervention groups and a survey of professionals in the intervention and control groups were performed. Data collection was conducted by each research team in the respective national language. The interview data were first analyzed inductively by each research team, and subsequently, a meta-synthesis was conducted. The survey was analyzed descriptively.

Results

We conducted 71 interviews; 125 professionals completed the survey. The survey showed that 76 % (n = 29) of targeted determinants of practice were perceived as relevant and 95 % (n = 36) as being modified by the implementation interventions by 66 to 100 % of professionals. On average, 47 % of professionals reported using the strategies and 51 % considered them helpful, albeit with substantial variance between countries and strategies. In the interviews, 89 determinants of practice were identified, of which 70 % (n = 62) had been identified and 45 % (n = 40) had been prioritized in the design phase. The interviewees suggested 65 additional strategies, of which 54 % (n = 35) had been identified and 20 % (n = 13) had been prioritized, but not selected in the final programs.

Conclusions

This study largely confirmed the perceived relevance of the targeted determinants of practice. This contrasts with the fact that no impact of the trials on the implementation of the recommendations could be observed. The findings suggest that better methods for prioritization of determinants and strategies are needed.

Trial registration

Each of the five trials was registered separately in recognized trial registries. Details are given in the respective trial outcome papers.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0473-8) contains supplementary material, which is available to authorized users.

Structures and processes necessary for providing effective home treatment to severely mentally ill persons: a naturalistic study

BACKGROUND

Home treatment for severely mentally ill persons is becoming increasingly popular. This research aims to identify structures and processes in home treatment that impact on patient-related outcomes.

METHODS

We analysed 17 networks that provide home treatment to severely mentally ill persons using a naturalistic approach. The networks were similar with regard to central components of home treatment such as case management, 24 h crisis hotline and home visits, but differed in all other aspects such as the multidisciplinary teams, time spent with patients, etc. To determine treatment outcome, patients' psychosocial functioning was measured using the Health of the Nation Outcome Scales (HoNOS). Structures and processes were assessed using claims data and questionnaires answered by the different networks. Primary outcome was highlighted by the change in HoNOS scores from the start of home treatment compared with 6 months later. We sought to explain this outcome through patient and network characteristics using regression analysis. Data on 3,567 patients was available.

RESULTS

On average, psychosocial functioning improved by 0.84 across networks between t0 and t1. There were more similarities than differences between the networks with regard to the structures and processes that we tested. A univariate regression analysis found staff's prior experience in mental health care and the effort that they invested in their work correlated positively with patient outcome. This needs to be interpreted under considering that univariate analysis does not show causal relationship. A high case load per case manager, increased and longer patient contact and more family intervention were correlated with worse patient outcome, probably indicating that sicker patients receive more care and intervention.

CONCLUSION

Home treatment networks succeed in delivering care tailored to the needs of patients. In order to improve the quality of care in home treatment, this study suggests employing experienced staff who is ready to invest more effort in their patients. Further research needs to consider a longer follow-up time.

[Procedures Performed in General Practice - a Cross-sectional Study]

OBJECTIVE

General practice offers basic medical care to patients. Therefore, general practitioners (GPs) perform a variety of medical procedures. In order to estimate GPs array of services from the perspective of health services research, it is indispensable to know the procedures that are carried out by GPs and identify relevant influencing factors.

METHODS

Based on the results of a selective literature search, the Medical Association's regulations on specialty training and experiences gained so far in developing the competence-based curriculum for general practice, a questionnaire covering 89 procedures was developed and sent to 1 576 general practitioners all over Germany.

RESULTS

The response rate was 42%; 42 of 89 procedures were carried out by at least 50% of the participants. These procedures include the anatomical areas skin, eyes, ears, nose, gastrointestinal tract, urological tract and musculoskeletal system. Significant differences were shown in 25 of the most frequent procedures regarding practices in urban and rural areas, in 9 procedures with regard to the participant's length of occupation in general practice and in 19 procedures regarding male and female participants.

CONCLUSION

This is the first survey that shows which procedures are performed by German GPs and how often they are performed. Factors such as practice location in either rural or urban area, physician's gender and years practiced as GP have been identified as important influences on the spectrum of services provided.

Cross-sectoral cancer care: views from patients and health care professionals regarding a personal electronic health record

Cross-sectoral cancer care is complex and involves collaboration from health care professionals (HCPs) across multiple sectors. However, when health information exchange (HIE) is not adequate, it results in impeded coordination and continuity of care. A web-based personal electronic health record (PEPA) under patients' control, providing access to personal health data across sectors, is being developed. Aim of this study was to explore perceived benefits and concerns. Using a qualitative approach, 10 focus groups were performed collecting views of three prospective user groups: patients with colorectal cancer (n = 12), physicians (n = 17) and other HCPs (n = 16). Representatives from different health sectors across the Rhine-Neckar region (Germany) participated. Data were audio- and videotaped, transcribed verbatim and thematically analysed. Our study shows that patients and HCPs expected a PEPA to enhance cross-sectoral availability of information, cross-sectoral cooperation and facilitate data management. Quality of cancer care was expected to be improved. Concerns were expressed in terms of data protection and data security. Concepts like a PEPA offer the chance to support HIE and avoid gaps of information in cross-sectoral cancer care. This may lead to improvements in coordination and continuity of care. Issues concerning data security and protection have to be addressed.

[Voluntary and mandatory quality assurance in mental health care: European examples]

Since the turn of the century, quality assurance (QA) programs are increasingly being implemented; both generally in health systems and specifically for mental health services. These QA programs can be implemented on a mandatory basis as well as voluntarily. Benefits of mandatory QA programs are a reliable, country-wide dataflow, as well as their long-term sustainability and comparability. Shortcomings relate to the limitations imposed by legal requirements. Benefits of voluntary QA programs are their freedom and flexibility in terms of methods and data sources. Shortcomings relate to the impossibility of country-wide implementation and a lack of sustainability, as well as to the data quality. Examples for QA in mental health care from different European countries show that mandatory and voluntary QA initiatives could complement each other. Specialist medical societies play an important role in the development of voluntary QA and the promotion of high quality care. An example is the accreditation to mental health services offered by the Royal College of Psychiatrists in the United Kingdom.

[Prevention and Information for Patients Undergoing Periodontal Treatment: Potentials for Improvement from the Patients' Perspective]

2 334 patients from 29 dental practices took part in a written survey on their experiences with dental treatment in general as well as treatment of periodontal disease (response rate 80.8%). 72.6% of all participating patients fully agreed that they could recommend their dentist to their friends. 63.6% of patients undergoing treatment of periodontitis (N=328) rated this treatment as "excellent". However, for important aspects (prevention, patient information, treatment) potentials for improvement became obvious. 43.7% of patients treated for periodontitis were not completely satisfied with information on how this disease develops; 40.7% saw potentials for better information on preventive care (dental-hygiene, nutrition). An even higher percentage of patients actually not treated for periodontitis was interested in more information on prevention (51.4%). The results of the survey show that dentists should offer information and exercise on how to prevent periodontal desease more actively. There is a lack of research on the present state of affairs and potentials for improvement concerning treatment and prevention of periodontitis including the patients' perspective.

[Oversupplied? Undersupplied? - The Perspective of Local Governments of the Federal State of Baden-Württemberg: A Contribution to the Discussion of Close-to-Home Health Care]

BACKGROUND

The ageing of physicians working in ambulatory care make regional health planning a challenging task. This study examines the current supply of general practitioners (GP) within the communities from the perspective of mayors. The information gained on a community level can be used when discussing over- and undersupply as well as future health care planning.

METHODS

A questionnaire was sent to all 1101 mayors of the Federal state of Baden-Württemberg (BW) in May 2011. For the evaluation of the location of the communities, subjective ratings by the mayors were compared with official criteria, provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR).

RESULTS

The participation rate was 63% (n=698). According to the mayors about 70% (n=468) were located in a rural area, according to BBSR criteria were about 26% (n=177) of answers given by rural communities. Of the participating mayors about 54% (n=355) stated that their community is cared for merely by GPs. From this information there was a locally experienced undersupply of GPs calculated for 13.5% (n=86) of the communities. This affected rural as well as non-rural communities. In communities up to 20 000 inhabitants, the ratio between GPs and other specialists seems to be 60:40 whereas in bigger cities the proportion of other specialists appears to be much higher.

CONCLUSION

Half of the participating communities seem to not have a practicing specialised physician. An accumulation of specialised physicians in larger cities was reported. The GP shortage appears to mainly be experienced subjectively. Regarding the location (urban vs. rural) of the community, subjective views differ distinctly from the BBSR criteria. This discrepancy could influence a community's marketing strategy when competing for new physicians.

[Projection of General Practitioner Care Demand at the Community Level]

BACKGROUND

Within the next 8 years about 2 000 general practitioners (GPs) will be seeking a successor in the federal state of Baden-Württemberg, Germany. Both the small number of newly qualified GPs and the wish to work as an employee or in a group practice will lead to a situation in which about 500 practices will likely not find a successor. Using a single administrative district, the aim of this analysis was to develop a projection of the demand for GP health care at the community level.

METHODS

Using the administrative district of Rottweil with its 21 communities, a community-based demographic forecast on the basis of current birth and death probabilities was performed. From the projected population structure, the demand for GP care in the year 2023 was derived under the assumption of unchanged age- and gender-specific numbers of GP visits. The anticipated deficit or, respectively, overrun of GPs at the community level was calculated as the difference between expected demand and number of GPs not retiring for age-related reasons.

RESULTS

Until the year 2023 the demographic change will cause a shrinking population. However, with unchanged age- and gender-specific numbers of GP visits, a slightly higher demand of 0.6 GPs will occur as a result of population-aging. The expected age-related retirement of physicians will have a stronger impact on primary care demand than demography. Up to 32 (37%) GPs might need a successor. In addition to 4 communities today, this would result in another 5 communities not having a GP in 10 years.

CONCLUSION

Communities that are at higher risk of GP shortage based on demographic changes and age of practicing GPs, can be identified by the approach described and applied here in order to implement targeted comprehensive community models of care.

[Joint replacement quality index: the perspective of resident physicians]

BACKGROUND AND AIM

Joint replacement is an established therapy for arthrosis. The quality index for joint replacement (knee and hip) should include screening for quality of patient-centred care in hospitals providing replacements, on the basis of administrative data. The quality index summarizes 16 inpatient and posthospital complications (indicators). The aim of the study was to evaluate this quality index from the medical practitioner's viewpoint.

METHODS

Four semistructured focus groups with 11 family physicians and 8 orthopaedic/trauma surgeons were conducted. The discussions were recorded, transcribed and analysed qualitatively according to Mayring.

RESULTS

Infections and the revision of a total joint arthroplasty have been weighted as the most important indicators from the existing quality indicators. Between the participants some differences regarding the relevance of the indicators thrombosis and pulmonary embolism occurred. These indicators were weighted as more important by family physicians than orthopedic/trauma surgeons. For eight of the indicators, imprecision in words/meaning was criticized. In an open-ended second section, 20 new indicators within the areas complications, management and overall sector communication were identified.

CONCLUSION

Major amendments of the quality index for the joint replacement are necessary. The knowledge gained from this study may serve as a basis for this development.

[Characteristics of Health-Care Provision for Patients in Out-of-Hours Care and Regular Care]

BACKGROUND

Little is known of the primary care characteristics in out of hours care centres (OOHC) as compared to regular care in Germany. Obviously the provision of patients in OOHC exhibits special characteristics concerning supply requirements, occupation and physician services, that require a first approximation.

METHODS

The data retrieval is managed within the CONTENT (CONTinous morbidity registration Epidemiologic NeTwork) research network. The used software allows for classifying reasons for encounter (RFE), health-problems (diagnoses) and processes of care (prescriptions, referrals, hospitalisations) with the International Classification of Primary Care (ICPC). Furthermore the software allows for pseudonymised data export. One OOHC Centre in South Hessen is part of the network. Therefore, this allows the comparison of this OOHC centre with the regular care of the included 5 physicians in 4 practices of the same region.

RESULTS

A 3-year period (01 April 2010-31 March 2013) with 192,827 patient contacts of 13,394 patients (58.1% female) in regular care and 14,354 patient contacts with 9,208 patients (64.1% female) in OOHC was described. Medium age of the patients of the regular provision was 59.6 vs. 45.7 years in the OOHC centre based on the contacts (p<0.0001). The most frequent RFE in the OOHC centre were fever and pain predominantly caused by acute infections, injuries or acute pain of the musculoskeletal system. In regular care there could be documented predominantly chronic health issues and vaccinations. The prevalent prescriptions in OOHC were therefore antibiotics and analgesics in regular care blood pressure medication and antidiabetic drugs. The rate of referrals was obviously lower than in regular care (7.1 vs. 22.7; p<0.0001), whereas the rate of hospitalisations was obviously higher in OOHC than in regular care (5.6 vs. 1.1; p<0.0001).

CONCLUSION

With the help of the data, requirements, occupation, resulting diagnoses and care processes in regular and out of hours care can be compared and described in detail. We could document major differences between the provision in OOHC and regular care. The results encourage initiating further studies to ensure the supply of primary care in OOHC.

[Patients' perspectives beyond sectoral borders between inpatient and outpatient care - patients' experiences and preferences along cross-sectoral episodes of care]

AIM

Patient perspective is crucial concerning health care and quality improvement. During episodes of care, patients come into contact with multidisciplinary health-care providers in inpatient and outpatient settings and are in a unique position to describe processes throughout the entire chain of care. The aim of this study was to identify patients’ experiences and preferences with fragmented cross-sectoral care to develop a patient-centred cross-sectoral quality-assessment instrument.

METHOD

Patient perspective was analysed using qualitative focus-group methods. Patients were recruited from general practices if they had experienced cross-sectoral care. Focus group discussions were audiotaped, transcribed and analysed using ATLAS.ti software. Categories were extracted deductively according to a previously developed focus group guide and supplemented by inductive analyses.

RESULTS

Patients identified quality gaps mainly concerning communication and coordination of care mostly along the cross-sectoral interfaces. Referrals and hospitalisations were characterised by redundant examinations and deficits in forwarding clinical findings. Support and organisation of follow-up care was rated to be improvable mainly during inpatient care and discharge. Patients identified also quality deficits concerning inpatient hygiene factors and changes of medication. Lack of transparency and responsibility within the entire chain of care caused anxiety and unstableness of patients.

CONCLUSION

Patients' experiences provide important information to identify quality gaps along the entire chain of care. Study results can be used to develop a cross-sectoral patient-centred quality assessment instrument.

Specific collaborative group intervention for patients with medically unexplained symptoms in general practice: a cluster randomized controlled trial

BACKGROUND

Patients with medically unexplained symptoms (MUS) are frequent in primary care and substantially impaired in their quality of life (QoL). Specific training of general practitioners (GPs) alone did not demonstrate sustained improvement at later follow-up in current reviews. We evaluated a collaborative group intervention.

METHODS

We conducted a cluster randomized controlled trial. Thirty-five GPs recruited 304 MUS patients (intervention group: 170; control group: 134). All GPs were trained in diagnosis and management of MUS (control condition). Eighteen randomly selected intervention GPs participated in training for a specific collaborative group intervention. They conducted 10 weekly group sessions and 2 booster meetings in their practices, together with a psychosomatic specialist. Six and 12 months after baseline, QoL was assessed with the Short-Form 36. The primary outcome was the physical composite score (PCS), and the secondary outcome was the mental composite score (MCS).

RESULTS

At 12 months, intention-to-treat analyses showed a significant between-group effect for the MCS (p = 0.023) but not for the PCS (p = 0.674). This effect was preceded by a significant reduction of somatic symptom severity (15-item somatic symptom severity scale of the Patient Health Questionnaire, PHQ-15) at 6 months (p = 0.008) that lacked significance at 12 months (p = 0.078). As additional between-group effects at 12 months, per-protocol analyses showed less health anxiety (Whiteley-7; p = 0.038) and less psychosocial distress (PHQ; p = 0.024); GP visits were significantly (p = 0.042) reduced in the intervention group.

CONCLUSIONS

Compared to pure GP training, collaborative group intervention achieved a progressive, clinically meaningful improvement in mental but not physical QoL. It could bridge gaps between general practice and mental health care.

Eligibility of patients with peripheral arterial disease for participation in a community-based walking exercise program: a single-centre experience

AIM

Eligibility of patients with peripheral arterial disease (PAD) for exercise therapy is the most important requirement for predicting their training group adherence.

METHODS

In this prospective, exploratory study over a period of 1 year, a total of 462 PAD patients of an angiological outpatient routine care setting were consecutively recruited to the study. As non-eligibility criteria for exercise therapy were defined: resting pain or gangrene (Fontaine stage III and IV PAD), the inability to complete treadmill exercise, or premature treadmill discontinuation due to non-vascular walking pain. Also, PAD patients without subjective walking limitation (Fontaine stage I PAD) were assessed as unwilling, i.e. non-eligible for exercise training adherence. Criterion for patients eligibility was the occurrence of intermittent claudication on treadmill test (Fontaine stage II PAD).

RESULTS

A total of 346 patients (age median 71 years, males 58.5%) were candidates for conservative therapy. Of them, 166 subjects (48%) were assessed as eligible for participation in walking exercise program. 180 of the patients (52%) were deemed as non-eligible to perform walking exercise therapy. 115 patients (33%) were physically limited by critical limb ischemia (Fontaine stage III and IV PAD), severe comorbid cardiovascular disease or orthopaedic disorder. In 65 PAD patients (19%) the subjective walking capacity was not restricted. Social, logistical or other factors were found in 27 patients (8%) to be barriers for exercise training commencement.

CONCLUSION

In half of the PAD patients whose attendance in a community-based walking exercise program would be a therapeutically reasonable activity, a range of vascular and non-vascular factors are obstacles for participation. Further research is needed to investigate what measures might enhance the proportion of exercise therapy participants.

Low attendance of patients with intermittent claudication in a German community-based walking exercise program

AIM

Exercise therapy is an efficacious treatment for patients with peripheral arterial disease (PAD). The study aimed to determine the initiation and adherence of PAD patients with intermittent claudication in a supervised community-based walking exercise program.

METHODS

Over a period of one year, PAD patients with Fontaine stage II attending an angiological outpatient setting were consecutively recruited to the study. Willingness, commencement and adherence of patients in the training program were recorded.

RESULTS

Of 462 patients with intermittent claudication, only 166 (36%) subjects fulfilled the requirements for participation in physical exercise training. Of these eligible patients, 110 (66%) persons accepted the invitation to attend exercise therapy. However, despite the commitment, 58 (35%) subjects failed to initiate attendance in the training program. Fifty-two (24%) patients did start the program but 16 (8%) patients did not complete more than three initial training sessions. Over a three-month period, regular attendance was registered for 36 (16%) patients.

CONCLUSION

Although physical exercise improves symptoms and mobility of patients with intermittent claudication, only about one-third of them is commencing an exercise program. Through lacking initiation and discontinuation, only a small percentage of claudicants permanently engages in a walking exercise program.

[Challenges and potentials of primary care in a multicultural society]

The greatest proportion of basic health care for patients with a migrational background living in Germany is provided by general practitioners. There is evidence that patients with a migrational background see a general practitioner as a gate keeper in case of physical or mental complaints even more frequently than the native German population. In contrast, the impact of migration-specific tasks in general practice appears to be relatively low in the medical and public discourse. This article analyzes the current situation of medical care for migrant patients in general practice and shows its potential to offer low-threshold high quality health care services to migrant patients and the whole population. In addition, an overview on migration-specific issues in research, teaching, and continuous medical education of general practitioners is provided. Finally, the implications of these findings for future research questions on migration-sensitive interventions are discussed.

The impact of intrinsic and extrinsic factors on the job satisfaction of dentists

The Two-Factor Theory of job satisfaction distinguishes between intrinsic-motivation (i.e. recognition, responsibility) and extrinsic-hygiene (i.e. job security, salary, working conditions) factors. The presence of intrinsic-motivation facilitates higher satisfaction and performance, whereas the absences of extrinsic factors help mitigate against dissatisfaction. The consideration of these factors and their impact on dentists' job satisfaction is essential for the recruitment and retention of dentists.

OBJECTIVES

The objective of the study is to assess the level of job satisfaction of German dentists and the factors that are associated with it.

METHODS

This cross-sectional study was based on a job satisfaction survey. Data were collected from 147 dentists working in 106 dental practices. Job satisfaction was measured with the 10-item Warr-Cook-Wall job satisfaction scale. Organizational characteristics were measured with two items. Linear regression analyses were performed in which each of the nine items of the job satisfaction scale (excluding overall satisfaction) were handled as dependent variables. A stepwise linear regression analysis was performed with overall job satisfaction as the dependent outcome variable, the nine items of job satisfaction and the two items of organizational characteristics controlled for age and gender as predictors.

RESULTS

The response rate was 95.0%. Dentists were satisfied with 'freedom of working method' and mostly dissatisfied with their 'income'. Both variables are extrinsic factors. The regression analyses identified five items that were significantly associated with each item of the job satisfaction scale: 'age', 'mean weekly working time', 'period in the practice', 'number of dentist's assistant' and 'working atmosphere'. Within the stepwise linear regression analysis the intrinsic factor 'opportunity to use abilities' (β = 0.687) showed the highest score of explained variance (R(2) = 0.468) regarding overall job satisfaction.

CONCLUSIONS

With respect to the Two-Factor Theory of job satisfaction both components, intrinsic and extrinsic, are essential for dentists but the presence of intrinsic motivating factors like the opportunity to use abilities has most positive impact on job satisfaction. The findings of this study will be helpful for further activities to improve the working conditions of dentists and to ensure quality of care.

[Perceptions of the local government about the primary care physicians shortage - a survey among mayors in the Federal State of Baden-Wuerttemberg]

BACKGROUND

Local governments have a crucial role in dealing with the primary care physicians shortage (PS). The aim of this study is to evaluate the perspectives and experiences of the local mayors on this issue.

METHODS

In May 2011, all 1101 mayors in the Federal State of Baden-Wuerttemberg (BW) were invited to participate in the study by filling out a survey developed by the authors. Data were analysed descriptively.

RESULTS

Of the contacted mayors in BW, 63% (n=698) responded. More than 90% of the participants consider it their duty to ensure future primary care. 16% experienced local practice closures due to PS. The infrastructure provided by the communities seems to be at a high level, whereas emergency practices exist in only 15% of the communities at present. Supportive actions to attract new GPs are evaluated as appropriate by almost half of the participants.

CONCLUSIONS

The PS topic is of high relevance for communities in BW. In order to gain future physicians for their region, the majority of the communities are maintaining a high level of infrastructure and are willing to offer more actions. The young generation physicians need to be informed about these existing conditions. Innovative ideas should be implemented in individual communities as pilot projects.

[HeiCare®: a project aiming to improve medication communication across health care sectors]

BACKGROUND AND OBJECTIVE

Changes between health care sectors represent a critical phase in long-term pharmacotherapy. The aim of the Hei CARE(®) project was to close the communication gap at the interface between primary care physicians (PCP), hospital physicians and patients, and to improve quality and safety of pharmacotherapy.

METHODS

Physicians who enrolled patients with long-term pharmacotherapy were able to participate in the Hei CARE(®) project. After enrolment the patient's medication was entered in the internet-based medication knowledge data base AiD PRAXIS and checked for medication interactions and optimized if necessary. At hospitalisation medication was transferred electronically to the hospital (AiD KLINIK(®)) and on discharge integrated in the discharge letter and faxed to the primary care physician (PCP). The project was evaluated using quantitative and qualitative methods. Hei CARE(®) -cases, in which medication was transferred electronically as planned, were compared with the other cases. PCPs' experiences were collected in focus groups.

RESULTS

One thousand and three chronically ill patients of 56 primary care practices participated. 259 patients were hospitalized between October 2005 and March 2009 of which entrance and discharge medication were transferred both ways via the electronic prescribing platform in 67 cases. The number of changes in medication was reduced in comparison to the other cases. Participating PCPs reported positive changes through Hei CARE(®) as well as further potential for optimizing communication across health care sectors.

CONCLUSION

Use of a common internet-based medication knowledge data base (Hei CARE(®) ) in both health care sectors reduced the number of changes in pharmacotherapy. Seamless care in chronically ill patients was thereby improved. The project also demonstrated that improving communication across health care sectors is a slow process.

[Approaches to reduce shortage of general practitioners in rural areas--results of an online survey of trainee doctors]

BACKGROUND

In times of shortage of general practitioners (GPs), especially in rural areas, it is of particular interest to explore expectations and interests of GP trainees relating to their future work. The aim of this study was, to survey the willingness of trainee doctors to work in or open a general practice, as well as their expectations and plans concerning future work as a GP in a rural area.

METHODS

The survey was conducted online between April to October 2010 with trainee doctors. The questionaire contained 25 questions about the trainees' sociodemographic status, expectations and conception of their future work, factors influencing setting up a GP practice and their ideas about working in a rural area.

RESULTS

528 trainee doctors from across Germany responded. More than half of them were female, more than 40% older than 35 years. 89% could image themselves settling in a GP practice, 77% in a rural area. The three most important factors influencing working in a rural practice were family friendly surrounding, the rural village itself and cooperation with colleagues. Most trainees would accepted having to travel 30 minutes to work.

CONCLUSION

As the basic willingness to set up practice in rural areas is quite high, relevant influencing factors such as family friendly surroundings, out-of-hour services arrangements und working models offering the opportunity to work in group handed practices should be emphasized in recruitment.

[What factors aid in the recruitment of general practice as a career? An enquiry by interview of general practitioners]

OBJECTIVE

In some parts of Germany there is already a lack of general practitioners (GPs). The reasons for this lack are complex. On the one hand there is an increasing demand for GPs as a result to demographic changes and an increase in the number of chronic diseases. On the other hand fewer medical students decide to become a general practitioner. The aim of this study was to explore, from the perspective of GPs, factors influencing the choice of general practice as a career. Also analysed is the extent to which those factors influence medical students in their carrier choice.

METHODS

16 GPs were interviewed. Qualitative content analysis according to Mayring has been assisted by the Atlas.ti software program.

RESULTS

GPs thought that the occupational orientation of medical students would be strongly dependent on the attractiveness of their future profession. Factors affecting the day-to-day work of general practice and may deterring the carrier choice of students were: poor working and general conditions leading to an increasing dissatisfaction among GPs; decreasing prestige of GPs caused by changed personal and occupational values and attitudes within the society; as well as poor representation and image of general practice as a discipline within the medical curriculum.

CONCLUSION

Various approaches aimed at different target groups can be derived from these identified factors: the government providing general and occupational conditions that would relieve GPs of excessive bureaucracy; universities and medical associations meeting the challenge by improving undergraduate and postgraduate education in general practice; and GPs themselves giving a more self-confident presentation of general practice.