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Michel C, Seipp H, Kuss K, Hach M, Kussin A, Riera-Knorrenschild J, Bösner S. Key aspects of psychosocial needs in palliative care - a qualitative analysis within the setting of a palliative care unit in comparison with specialised palliative home care. BMC Palliat Care 2023; 22:100. [PMID: 37480117 PMCID: PMC10360287 DOI: 10.1186/s12904-023-01227-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND The number of palliative care patients with complex needs is increasing in developed countries. In addition to physical aspects and symptom control, psychosocial aspects are of great importance for palliative care patients. The aim of this study was to understand which psychosocial aspects are important to patients, relatives and health professionals within the setting of a palliative care unit in comparison with specialised palliative home-care (SPHC). METHODS We used a qualitative design based on semistructured interviews, which were coded via qualitative content analysis. The study took place in the state of Hesse, Germany, and data collection was conducted in 2017 (interviews from the ELSAH study, which was conducted in a SPHC) and 2018 (supplementary interviews conducted in a palliative care unit). The results from both settings were compared. RESULTS In the palliative care unit, 10 health professionals, 11 patients and 8 relatives were interviewed. In the outpatient setting, we interviewed 30 health professionals, 14 patients and 14 relatives. We identified four key psychosocial issues related to palliative care that were relevant in both the inpatient and outpatient settings: care planning, patient-centred care, a protected environment with feelings of safety, and psychological well-being. In addition, immediate availability of medical staff, greater relief of the relatives and better accessibility of psychological care were more important in the inpatient setting than in the specialised palliative home care setting. CONCLUSIONS Knowledge and application of the identified key issues may improve patient-centred palliative care. Accessibility of psychological care and immediate availability of medical staff may be important factors for enhancing psychological well-being in the inpatient palliative care setting. Consideration of the identified key issues may help to develop more collaborative transitions between the palliative care unit and the SPHC and may help to provide palliative care patients and their families with care that is appropriate and feasible for them. TRIAL REGISTRATION The underlying comparative study of the outpatient setting of specialised palliative home-care (ELSAH) was registered within the German Clinical Trials Register DRKS-ID: DRKS00012421, ( https://drks.de/search/de/trial/DRKS00012421 ) on 19th May 2017.
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Affiliation(s)
- Cathrin Michel
- Department of General Practice and Family Medicine, Philipps- University Marburg, Karl-von-Frisch-Straße 4, 35032, Marburg, Germany.
| | - Hannah Seipp
- Department of General Practice and Family Medicine, Philipps- University Marburg, Karl-von-Frisch-Straße 4, 35032, Marburg, Germany
| | - Katrin Kuss
- Department of General Practice and Family Medicine, Philipps- University Marburg, Karl-von-Frisch-Straße 4, 35032, Marburg, Germany
| | - Michaela Hach
- Professional Association of Specialised Palliative Homecare in Hesse, Wiesbaden, Germany
| | - Andrea Kussin
- Department of Anaesthesia and Intensive Care Therapy, Philipps-University of Marburg, Marburg, Germany
| | | | - Stefan Bösner
- Department of General Practice and Family Medicine, Philipps- University Marburg, Karl-von-Frisch-Straße 4, 35032, Marburg, Germany
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Fülbert H, Schäfer LN, Gerspacher LM, Bösner S, Schut C, Krolewski R, Knipper M. Elective course "Climate-sensitive health counselling" - prevention as an opportunity for people and planet? An interactive, student-led project focusing on prevention and agency in physician's climate communication. GMS J Med Educ 2023; 40:Doc34. [PMID: 37377566 PMCID: PMC10291343 DOI: 10.3205/zma001616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 12/15/2022] [Accepted: 02/06/2023] [Indexed: 06/29/2023]
Abstract
Objective According to the WHO, anthropogenic climate change poses the greatest threat to human health in the 21st century. However, the link between climate change and human health is not an integral part of medical education in Germany. Within a student-led project, an elective clinical course was designed and successfully implemented, which has been made accessible to undergraduate medical students at the Universities of Giessen and Marburg. The implementation and didactic concept are explained in this article. Methodology In a participatory format, knowledge is imparted using an action-based, transformative approach. Topics discussed are, amongst others, interactions of climate change and health, transformative action, and health behavior, as well as "green hospital" and the simulation of a "climate-sensitive health counselling". Lecturers from different disciplines within and beyond medicine are invited as speakers. Results Overall, the elective was evaluated positively by the participants. The fact that there is a high demand among students for participation in the elective, as well as for the transfer of concepts underlines the need for including this topic into medical education. The implementation and further development of the concept at two universities with different study regulations demonstrates its adaptability. Conclusion Medical education can raise awareness of the multiple health consequences of the climate crisis, can have a sensitizing and transformative effect on various levels, and can promote climate-sensitive action ability in patient care. In the long term, however, these positive consequences can only be guaranteed by including mandatory education on climate change and health in medical curricula.
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Affiliation(s)
- Hannah Fülbert
- Justus Liebig University Giessen, Medical Faculty, Giessen, Germany
- Health for Future Giessen, Giessen, Germany
| | - Louis N. Schäfer
- Philipps University Marburg, Medical Faculty, Marburg, Germany
- Health for Future Marburg, Marburg, Germany
| | - Laura M. Gerspacher
- Justus Liebig University Giessen, Medical Faculty, Giessen, Germany
- Health for Future Giessen, Giessen, Germany
| | - Stefan Bösner
- Philipps University Marburg, Department of General Practice/Family Medicine, Marburg, Germany
| | - Christina Schut
- Justus Liebig University Giessen, Institute of Medical Psychology, Giessen, Germany
| | - Ralph Krolewski
- Academic teaching practice of the University of Cologne, Gummersbach, Germany
| | - Michael Knipper
- Justus Liebig University Giessen, Institute for History of Medicine, Giessen, Germany
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Seipp H, Haasenritter J, Hach M, Becker D, Schütze D, Engler J, Bösner S, Kuss K. State-wide implementation of patient-reported outcome measures (PROMs) in specialized outpatient palliative care teams (ELSAH): A mixed-methods evaluation and implications for their sustainable use. BMC Palliat Care 2022; 21:216. [PMID: 36461081 PMCID: PMC9716659 DOI: 10.1186/s12904-022-01109-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/18/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Such patient-reported outcome measures (PROMs) and patient-centered outcome measures as the Integrated Palliative Care Outcome Scale (IPOS), Phase of Illness, and IPOS Views on Care (IPOS VoC), facilitate patient-centered care and help improve quality. To ensure sustainability, implementation and usage should be adapted according to setting. When settings involve several distinct teams that differ in terms of views and working practices, it is more difficult to integrate outcome measures into daily care. The ELSAH study aimed to learn how health professionals working in specialized outpatient palliative care (SOPC) viewed the use of these outcome measures in daily care, and what they express is needed for successful sustainable, state-wide application. METHODS We used a parallel mixed-methods design involving three focus groups (n = 14) and an online-survey based on normalization process theory (n = 76). Most participants were nurses and physicians from 19 SOPC-teams in Hesse, Germany. We used a triangulation protocol including convergence coding matrices to triangulate findings. RESULTS The majority of health professionals were able to integrate the outcome measures into their working lives and said that it had become a normal part of their day-to-day work. To ensure their sustainable integration into daily care, the motivation and concerns of health professionals should be taken into consideration. Health professionals must clearly recognize how the measures help improve daily care and quality evaluation. CONCLUSIONS To implement the outcome measures in a number of teams, it will be necessary to take individual team characteristics into account, because they influence motivation and concerncs. Further, it will be necessary to offer opportunities for them to engage in peer support and share information with other teams. The sustainable use of outcome measures in SOPC will require continuous support within each team as well as across teams. When several distinct teams are working in the same setting, a cross-team coordination unit can help to coordinate their work efficiently. TRIAL REGISTRATION German Clinical Trials Register DRKS-ID: DRKS00012421; www.germanctr.de/DRKS00012421.
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Affiliation(s)
- Hannah Seipp
- grid.10253.350000 0004 1936 9756Department of General Practice and Family Medicine, Philipps-University of Marburg, Karl-Von-Frisch-Straße 4, 35032 Marburg, Germany
| | - Jörg Haasenritter
- grid.10253.350000 0004 1936 9756Department of General Practice and Family Medicine, Philipps-University of Marburg, Karl-Von-Frisch-Straße 4, 35032 Marburg, Germany
| | - Michaela Hach
- Professional Association of Specialized, Palliative Homecare in Hesse, Weihergasse 15, 65203 Wiesbaden, Germany
| | - Dorothée Becker
- Professional Association of Specialized, Palliative Homecare in Hesse, Weihergasse 15, 65203 Wiesbaden, Germany
| | - Dania Schütze
- grid.7839.50000 0004 1936 9721Institute of General Practice, Goethe-University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jennifer Engler
- grid.7839.50000 0004 1936 9721Institute of General Practice, Goethe-University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Stefan Bösner
- grid.10253.350000 0004 1936 9756Department of General Practice and Family Medicine, Philipps-University of Marburg, Karl-Von-Frisch-Straße 4, 35032 Marburg, Germany
| | - Katrin Kuss
- grid.10253.350000 0004 1936 9756Department of General Practice and Family Medicine, Philipps-University of Marburg, Karl-Von-Frisch-Straße 4, 35032 Marburg, Germany
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Abstract
BACKGROUND Patient involvement in treatment decisions is widely accepted. Making a diagnosis, however, is still seen as a technical task mainly driven by physicians. Patients in this respect are perceived as passive providers of data. But, recent patient-centred concepts highlight the value of an active patient involvement in diagnosis. OBJECTIVE We aim to reach a deeper understanding of how patients themselves contribute to the diagnostic process. METHODS This is an observational study of patient consultations with their General Practitioner (GP) in 12 German practices. We performed a mixed-method qualitative and quantitative analysis of 134 primary care consultations. RESULTS At the beginning of most consultations lies a phase where patients were invited to freely unfold their reason for encounter: This was named "inductive foraging" (IF). While patients actively present their complaints, GPs mainly listen and follow the presentation. This episode was found with every GP participating in this study. Ninety-one percent of consultations with diagnostic episodes were opened by IF. IF had a major contribution to the number of cues (diagnostic information) yielded in the diagnostic process. We illustrate a variety of tactics GPs make use of to invite, support, and terminate their patients in IF. CONCLUSION IF was found to be a highly relevant strategy in the diagnostic process. Patient involvement through IF offered a major contribution of diagnostic cues. We hypothesize that a patient-centred approach improves diagnosis.
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Affiliation(s)
- Matthias Michiels-Corsten
- Department of General Practice, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Anna M Weyand
- Department of General Practice, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany.,Department of Neurology, University Hospital Marburg UKGM, Marburg, Germany
| | - Judith Gold
- Department of General Practice, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Stefan Bösner
- Department of General Practice, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice, Faculty of Medicine, Philipps-University of Marburg, Marburg, Germany
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Seipp H, Haasenritter J, Hach M, Becker D, Schütze D, Engler J, Ploeger C, Bösner S, Kuss K. Integrating patient- and caregiver-reported outcome measures into the daily care routines of specialised outpatient palliative care: a qualitative study (ELSAH) on feasibility, acceptability and appropriateness. BMC Palliat Care 2022; 21:60. [PMID: 35501844 PMCID: PMC9063228 DOI: 10.1186/s12904-022-00944-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/12/2022] [Indexed: 12/15/2022] Open
Abstract
Abstract
Background
The use of patient-reported outcome measures (PROM) and caregiver-reported outcome measures can raise the patient centeredness of treatment and improve the quality of palliative care. Nevertheless, the everyday implementation of self-report in patients and caregivers is complex, and should be adapted for use in specific settings. We aimed to implement a set of outcome measures that included patient and caregiver self- and proxy-reported outcome measures in specialised outpatient palliative care (SOPC). In this study, we explore how the Integrated Palliative Outcome Scale (IPOS), IPOS Views on Care (IPOS VoC) and the Short-form Zarit Caregiver Burden Interview (ZBI-7) can be feasibly, acceptably and appropriately implemented in the daily care routines of SOPC.
Methods
Five SOPC teams were trained, and used the outcome measures in daily practice. Team members were mainly nurses and physicians. To investigate their feedback, we used a multi-method qualitative design consisting of focus groups with SOPC-team members (n = 14), field notes of meetings and conversations with the SOPC teams. In an iterative process, we analysed the findings using qualitative content analysis and refined use of the outcome measures.
Results
We found that integrating patient and caregiver outcome measures into daily care routines in SOPC is feasible. To improve feasibility, acceptability and appropriateness, the resulting burden on patients and relatives should be kept to a minimum, the usefulness of the measures must be understood, they should be used considerately, and administration must be manageable. We removed ZBI-7 from the set of measures as a result of feedback on its content and wording.
Conclusions
SOPC-team members have reservations about the implementation of PROM in SOPC, but with appropriate adjustments, its application in daily care is feasible, accepted and perceived as appropriate. Previous to use, SOPC-team members should be trained in how to apply the measures, in the design of manageable processes that include integration into electronic documentation systems, and in ongoing evaluation and support. They should also be taught how useful the measures can be.
Trial registration
May 19th, 2017, German Clinical Trials Register DRKS-ID: DRKS00012421.
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Schuetze D, Ploeger C, Hach M, Seipp H, Kuss K, Bösner S, Gerlach FM, van den Akker M, Erler A, Engler J. Care practices of specialized outpatient pediatric palliative care teams in collaboration with parents: Results of participatory observations. Palliat Med 2022; 36:386-394. [PMID: 34927494 PMCID: PMC8894953 DOI: 10.1177/02692163211065294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Collaboration between parents and professional care providers is an essential part of pediatric palliative care. As children are embedded in family systems and many of the patients are not able to communicate verbally, their parents are the primary interaction partners for palliative care providers. International standards for pediatric palliative care in Europe state that parents should be supported, acknowledged as the primary carers and involved as partners in all care and decisions. AIM To find out through which care practices pediatric palliative care teams shape collaboration with parents in everyday care. DESIGN Ethnographic method of participatory observations. Field notes were analyzed using thematic analysis. SETTING/PARTICIPANTS Researchers accompanied three pediatric palliative care teams on home visits to eight different families caring for a child with life-limiting conditions. RESULTS Care practices of palliative care teams were characterized by familiarity, a resource-oriented attitude, empowerment of parents, shared decision-making and support for parents. Palliative care teams not only provided palliative medical treatment for the children, but also developed a trusting care partnership with parents. The teams employed a sensitive and multifaceted communication style in their collaboration with parents. CONCLUSIONS Care practices in pediatric palliative care require time, communication skills, and a high level of psychosocial competence, to develop a trusting, collaborative relationship with parents. This should be taken into consideration when establishing pediatric palliative care structures, preparing guidelines, training staff, and deciding upon appropriate remuneration.
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Affiliation(s)
- Dania Schuetze
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Cornelia Ploeger
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Michaela Hach
- Professional Association of Specialized Outpatient Palliative Care in Hesse, Wiesbaden, Germany
| | - Hannah Seipp
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Katrin Kuss
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Stefan Bösner
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Marjan van den Akker
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany.,Department of Family medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Antje Erler
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Jennifer Engler
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
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Seipp H, Haasenritter J, Hach M, Becker D, Ulrich LR, Schütze D, Engler J, Michel C, Bösner S, Kuss K. How can we ensure the success of specialised palliative home-care? A qualitative study (ELSAH) identifying key issues from the perspective of patients, relatives and health professionals. Palliat Med 2021; 35:1844-1855. [PMID: 34169767 DOI: 10.1177/02692163211026516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Specialised palliative home-care supports patients with life-limiting diseases in their familiar surroundings. The number of palliative care teams and patients being cared for is increasing worldwide. To assess and improve quality, it is needed to understand, how specialised palliative home-care can be provided successfully. For this purpose we examined the views of all involved stakeholders. AIM To identify the issues that patients, their relatives and involved health professionals view as important in ensuring the success of specialised palliative home-care. DESIGN We used a qualitative design based on participant observations, interviews and focus groups following the principles of a Grounded Theory approach. SETTING/PARTICIPANTS All specialised palliative home-care teams (n = 22) caring for adults in Hesse, Germany, participated. We conducted participant observations (n = 5), and interviewed patients (n = 14), relatives (n = 14) and health professionals working in or collaborating with specialised palliative home-care (n = 30). We also conducted focus groups (n = 4) with health professionals including a member check. RESULTS Successful specialised palliative home-care needs to treat complex symptoms, and provide comprehensive care including organisation of care, involving relatives and addressing issues of death and dying. Sense of security for patients and relatives is key to enable care at home. Care delivery preferences include a focus on the quality of relationships, respect for individuality and the facilitation of self-determination. CONCLUSIONS Consideration of the identified key issues can help to ensure successful specialised palliative home-care. Knowledge of these should also be considered when researching and assessing quality of care. TRIAL REGISTRATION German Clinical Trials Register DRKS-ID: DRKS00012421; http://www.germanctr.de.
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Affiliation(s)
- Hannah Seipp
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Hessen, Germany
| | - Jörg Haasenritter
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Hessen, Germany
| | - Michaela Hach
- Professional Association of Specialised Palliative Homecare in Hesse, Wiesbaden, Germany
| | - Dorothée Becker
- Professional Association of Specialised Palliative Homecare in Hesse, Wiesbaden, Germany
| | - Lisa-R Ulrich
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany.,German Federal Rehabilitation Council (BAR e.V.), Frankfurt am Main, Germany
| | - Dania Schütze
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Jennifer Engler
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Cathrin Michel
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Hessen, Germany
| | - Stefan Bösner
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Hessen, Germany
| | - Katrin Kuss
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Hessen, Germany
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Bergmann M, Haasenritter J, Beidatsch D, Schwarm S, Hörner K, Bösner S, Grevenrath P, Schmidt L, Viniol A, Donner-Banzhoff N, Becker A. Prevalence, aetiologies and prognosis of the symptom cough in primary care: a systematic review and meta-analysis. BMC Fam Pract 2021; 22:151. [PMID: 34253179 PMCID: PMC8274469 DOI: 10.1186/s12875-021-01501-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 06/28/2021] [Indexed: 11/10/2022]
Abstract
Background Cough is a relevant reason for encounter in primary care. For evidence-based decision making, general practitioners need setting-specific knowledge about prevalences, pre-test probabilities, and prognosis. Accordingly, we performed a systematic review of symptom-evaluating studies evaluating cough as reason for encounter in primary care. Methods We conducted a search in MEDLINE and EMBASE. Eligibility criteria and methodological quality were assessed independently by two reviewers. We extracted data on prevalence, aetiologies and prognosis, and estimated the variation across studies. If justifiable in terms of heterogeneity, we performed a meta-analysis. Results We identified 21 eligible studies on prevalence, 12 on aetiology, and four on prognosis. Prevalence/incidence estimates were 3.8–4.2%/12.5% (Western primary care) and 10.3–13.8%/6.3–6.5% in Africa, Asia and South America. In Western countries the underlying diagnoses for acute cough or cough of all durations were respiratory tract infections (73–91.9%), influenza (6–15.2%), asthma (3.2–15%), laryngitis/tracheitis (3.6–9%), pneumonia (4.0–4.2%), COPD (0.5–3.3%), heart failure (0.3%), and suspected malignancy (0.2–1.8%). Median time for recovery was 9 to 11 days. Complete recovery was reported by 40.2- 67% of patients after two weeks, and by 79% after four weeks. About 21.1–35% of patients re-consulted; 0–1.3% of acute cough patients were hospitalized, none died. Evidence is missing concerning subacute and chronic cough. Conclusion Prevalences and incidences of cough are high and show regional variation. Acute cough, mainly caused by respiratory tract infections, is usually self-limiting (supporting a “wait-and-see” strategy). We have no setting-specific evidence to support current guideline recommendations concerning subacute or chronic cough in Western primary care. Our study presents epidemiological data under non non-pandemic conditions. It will be interesting to compare these data to future research results of the post-pandemic era. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01501-0.
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Affiliation(s)
- Milena Bergmann
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Jörg Haasenritter
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Dominik Beidatsch
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Sonja Schwarm
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Kaja Hörner
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Stefan Bösner
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Paula Grevenrath
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Laura Schmidt
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Annika Viniol
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Annette Becker
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
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Bergmann M, Haasenritter J, Beidatsch D, Schwarm S, Hörner K, Bösner S, Grevenrath P, Schmidt L, Viniol A, Donner-Banzhoff N, Becker A. Coughing children in family practice and primary care: a systematic review of prevalence, aetiology and prognosis. BMC Pediatr 2021; 21:260. [PMID: 34088294 PMCID: PMC8176681 DOI: 10.1186/s12887-021-02739-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND For evidence-based decision making, primary care physicians need to have specific and reliable information on the pre-test probabilities of underlying diseases and a symptom's course. We performed a systematic review of symptom-evaluating studies in primary care, following three research questions: (1) What is the prevalence of the symptom cough in children consulting primary care physicians? (2) What are the underlying aetiologies of cough and the respective frequencies? (3) What is the prognosis of children with cough? METHODS Following a pre-defined algorithm and independent double reviewer ratings we searched MEDLINE and EMBASE. All quantitative original research articles in English, French or German were included if they focused on unselected study populations of children consulting a primary care physician for cough. We used the random effects model for meta-analysis in subgroups, if justifiable in terms of heterogeneity. RESULTS We identified 14 eligible studies on prevalence, five on aetiology and one on prognosis. Prevalence estimates varied between 4.7 and 23.3% of all reasons for an encounter, or up to estimates of 60% when related to patients or consultations. Cough in children is more frequent than in adults, with lowest prevalences in adolescents and in summer. Acute cough is mostly caused by upper respiratory tract infections (62.4%) and bronchitis (33.3%); subacute or chronic cough by recurrent respiratory tract infection (27.7%), asthma (up to 50.4% in cough persisting more than 3 weeks), and pertussis (37.2%). Potentially serious diseases like croup, pneumonia or tuberculosis are scarce. In children with subacute and chronic cough the total duration of cough ranged from 24 to 192 days. About 62.3% of children suffering from prolonged cough are still coughing two months after the beginning of symptoms. CONCLUSION Cough is one of the most frequent reasons for an encounter in primary care. Our findings fit in with current guideline recommendations supporting a thoughtful wait-and-see approach in acute cough and a special awareness in chronic cough of the possibility of asthma and pertussis. Further evidence of aetiological pre-test probabilities is needed to assess the diagnostic gain based on patient history and clinical signs for differential diagnoses of cough in children.
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Affiliation(s)
- Milena Bergmann
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Jörg Haasenritter
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Dominik Beidatsch
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Sonja Schwarm
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Kaja Hörner
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Stefan Bösner
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Paula Grevenrath
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Laura Schmidt
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Annika Viniol
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Annette Becker
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
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10
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Schütze D, Engler F, Ploeger C, Ulrich LR, Hach M, Seipp H, Kuss K, Bösner S, Gerlach FM, van den Akker M, Erler A, Engler J. Specialised outpatient paediatric palliative care team-parent collaboration: narrative interviews with parents. BMJ Support Palliat Care 2021; 12:e664-e670. [PMID: 33402383 DOI: 10.1136/bmjspcare-2020-002576] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/14/2020] [Accepted: 12/12/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE In Germany, children with life-limiting conditions and complex symptoms are eligible for specialised outpatient palliative care (SOPC). In the federal state of Hesse, SOPC for children (SOPPC) is delivered by teams with paediatric expertise. While burdened by the life-limiting condition of their child, parents must also fulfill their roles as main care providers and decision makers. Collaboration between parents and SOPPC teams is important, as the intermittent care and uncertainty it entails often lasts for several months or years. We explored parents' experiences and their demands of collaboration with SOPPC teams. METHODS We conducted nine narrative interviews with 13 parents of children and adolescents with life-limiting conditions and used a grounded theory approach to analyse interview data. RESULTS Parents stressed the importance of paediatric expertise, honesty, psychosocial support, an individualised approach, experience of self-efficacy and the need to be recognised as experts for their children. The narrative interviews showed that collaboration between parents and SOPPC teams was characterised by parents' need for specialised professional assistance and their simultaneous empowerment by SOPPC teams. CONCLUSIONS Parents' perceptions of what good collaboration with SOPPC teams entails are manifold. To meet these complex needs, SOPPC requires time and specialised expertise.
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Affiliation(s)
- Dania Schütze
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Fabian Engler
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Cornelia Ploeger
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Lisa-R Ulrich
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany.,German Federal Rehabilitation Council (BAR e. V.), Frankfurt am Main, Germany
| | - Michaela Hach
- Professional Association of Specialized Outpatient Palliative Care in Hesse, Wiesbaden, Germany
| | - Hannah Seipp
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Katrin Kuss
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Stefan Bösner
- Department of General Practice and Family Medicine, Philipps-University of Marburg, Marburg, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Marjan van den Akker
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany.,Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Antje Erler
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Jennifer Engler
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
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11
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Abstract
BACKGROUND In the professional public there is agreement that healthcare professionals worldwide should already be prepared for safety in patient care during their education. OBJECTIVE How can the topic of patient safety be successfully integrated into the curricula of healthcare professions? MATERIAL AND METHODS Overview of the Marburg curriculum on patient safety during the practical year as well as of other approaches to teaching patient safety described in the literature. RESULTS In recent years teaching initiatives on patient safety have significantly increased; however, they are still not comprehensively distributed in German-speaking countries or throughout Europe. In the context of implementation, the multiprofessional edition of the World Health Organization (WHO) patient safety curriculum guide may be used as guideline. A current, very promising development in connection with acquiring and examining the competences that are necessary for safe patient care is the establishment of interprofessional training wards. CONCLUSION In the meantime, there are clearly defined strategies for the integration of the topic of patient safety into the curricula of healthcare professionals. On the way towards a successful restructuring of the curricula including the necessary competences and behavioral changes of the students, however, relevant support by the management of faculties and teaching hospitals is essential.
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Affiliation(s)
- E Opitz
- Dekanat des Fachbereichs Medizin, Philipps-Universität Marburg, Baldingerstraße, 35032, Marburg, Deutschland.
| | - S Bösner
- Abteilung für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Philipps-Universität Marburg, Marburg, Deutschland
| | - S Heinis
- Kaufmännische Geschäftsführung Standort Marburg, Universitätsklinikum Gießen und Marburg GmbH, Marburg, Deutschland
| | - E C Stibane
- Dr. Reinfried Pohl-Zentrum für medizinische Lehre, Studiendekanat des Fachbereichs Medizin, Philipps-Universität Marburg, Marburg, Deutschland
| | - A Jerrentrup
- Zentrum für Notfallmedizin, Universitätsklinikum Gießen und Marburg GmbH, Marburg, Deutschland
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12
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Abstract
OBJECTIVE We sought to explore differences and commonalities between diagnostic strategies used by clinicians in general practice and the emergency department. DESIGN Qualitative study. SETTINGS We videotaped 282 consultations of 12 general practitioners (GPs) in Germany, irrespective of presenting complaint or final diagnosis. Reflective interviews were performed after each consultation. In addition, 171 consultations of 16 emergency physicians (EPs) based at two tertiary care hospitals in the Midwest of the USA were observed, and their conversations recorded. Recordings of consultations and GP interviews were transcribed verbatim and analysed using a coding system that was based on published literature and systematically checked for reliability. RESULTS EPs more often considered acute and severe conditions, even if pretest probabilities were low. In contrast, GPs more often involved their patients in the decision-making process and provided assurance concerning their complaints. To focus their workup, EPs used a more directive style of interviewing including a high proportion of routine questions and rarely used open questions or active listening. CONCLUSIONS Strategies used by physicians in both settings seem to be well adapted to their respective environments. Whereas the physician-led diagnostic process in the emergency department is well suited to rule out life-threating disease, diagnosis and appropriate treatment of everyday problems may require a more patient-centred style.
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Affiliation(s)
- Stefan Bösner
- Department of General Practice/Family Medicine, Philipps University of Marburg, Marburg, Germany
| | - Jamal Abushi
- Department of General Practice/Family Medicine, Philipps University of Marburg, Marburg, Germany
| | - Markus Feufel
- Department of Psychology and Ergonomics, Division of Ergonomics, Technische Universitat Berlin, Berlin, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice/Family Medicine, Philipps University of Marburg, Marburg, Germany
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13
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Kuss K, Seipp H, Becker D, Bösner S, Erler A, Gruber D, Hach M, Ulrich LR, Haasenritter J. Study protocol: evaluation of specialized outpatient palliative care in the German state of Hesse (ELSAH study) - work package I: assessing the quality of care. BMC Palliat Care 2018; 17:111. [PMID: 30285709 PMCID: PMC6169025 DOI: 10.1186/s12904-018-0363-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Germany, patients suffering from life-limiting conditions are eligible for specialized outpatient palliative care (SOPC). Evaluation of the quality of this service lacks currently integration of patient-relevant outcomes. There is also no scientific consensus how to prove quality of care in the special context of SOPC adequately. Existing quality reports are primarily based on descriptive structural data which do not allow for estimation of process quality or result quality. The ELSAH study ('Evaluation of Specialized Outpatient Palliative Care in the German state of Hesse') aims to choose - or, if necessary, to adopt - to evaluate and to implement a suit of measures to assess, evaluate and monitor the quality of specialized, home-based palliative care. METHODS All 22 SOPC teams providing their services in the state of Hesse, Germany, participate in the ELSAH study. The study is divided in two phases: a preparation phase and a main study phase. Based on the findings of the preparation phase we have chosen a preliminary set of instruments including the Integrated Palliative Outcome Scale, Views on Care, Zarit Burden Interview, Phase of Illness, Goal Attainment Scaling, Eastern Cooperative Oncology Group Performance Status, Consumer Quality Indices Palliative Care and Sense of Security in Care. During the main study phase, we will use a mixed-methods approach to evaluate the instruments' psychometric properties (reliability, validity, feasibility and practicability), to identify barriers, facilitators and limitations of their routine use and to explore how their use affects the care within the SOPC setting. DISCUSSION At the end of this study, an outcome- and patient-centered, validated measurement approach should be provided, adapted for standardized evaluations in SOPC across patient groups, palliative care services and regions nationwide. The standardized application of instruments should allow for making valid statements and comparisons of health care quality in SOPC based on process- and outcome-evaluation rather than relying on structural data only. Moreover, the instruments might directly influence the care of patients in palliative situations. TRIAL REGISTRATION German Clinical Trials Register (DRKS-ID: DRKS00012421 ).
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Affiliation(s)
- Katrin Kuss
- Department of General Practice/ Family Medicine, Philipps-University Marburg, Karl-von-Frisch-Strasse 4, 35032 Marburg, Germany
| | - Hannah Seipp
- Department of General Practice/ Family Medicine, Philipps-University Marburg, Karl-von-Frisch-Strasse 4, 35032 Marburg, Germany
| | - Dorothée Becker
- Professional Association of Specialized Outpatient Palliative Care in Hesse, Wiesbaden, Germany
| | - Stefan Bösner
- Department of General Practice/ Family Medicine, Philipps-University Marburg, Karl-von-Frisch-Strasse 4, 35032 Marburg, Germany
| | - Antje Erler
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt, Germany
| | - Dania Gruber
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt, Germany
| | - Michaela Hach
- Professional Association of Specialized Outpatient Palliative Care in Hesse, Wiesbaden, Germany
| | - Lisa R Ulrich
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt, Germany
| | - Jörg Haasenritter
- Department of General Practice/ Family Medicine, Philipps-University Marburg, Karl-von-Frisch-Strasse 4, 35032 Marburg, Germany
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14
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Havemann M, Bösner S. Global Health as "umbrella term" - a qualitative study among Global Health teachers in German medical education. Global Health 2018; 14:32. [PMID: 29587856 PMCID: PMC5870065 DOI: 10.1186/s12992-018-0352-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 03/13/2018] [Indexed: 11/22/2022] Open
Abstract
Background The increasing impact of globalisation on healthcare demands new knowledge, skills and attitudes from healthcare professionals. One consequence of this is the rise of Global Health (GH) programs in health education all over the world. In Germany no consensus exists on what GH is and how it should be taught. This study used a grounded theory approach. We conducted eleven in-depth interviews with GH teachers in German medical education to ask them about their views on Global Health and the approaches they took in teaching these topics. Data collection and Analysis informed each other and followed an inductive approach. Results Our research identified three major questions: (1) What is GH? (2) What belongs to GH? (3) How can GH be taught? A central finding of our study is the understanding of GH as an umbrella term. We show how this understanding helps clarify the relation between GH and Public Health, International Health and Tropical medicine. At the core of GH we see the supraterritorial determinants of health. Surrounding the core, we describe a wide variety of topics that are a facultative, but not necessarily a compulsory part GH. One of the key characteristics of GH within all its aspects is its multidisciplinary nature. Based on this understanding we present models about the content of GH, how it can be taught and how GH teaching improves and strengthens overall medical education. Conclusions This is to our knowledge the first study that conducts in-depth interviews with GH teachers to explore the practical understanding of GH in medical education. While the generalisability of our results needs to be subject of further research, the models presented can help shape the future discourse around GH and its integration into medical education. Electronic supplementary material The online version of this article (10.1186/s12992-018-0352-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthias Havemann
- Department of Family Medicine, Philipps-University Marburg, Karl-von-Fritsch-Straße 4, D-35043, Marburg, Germany. .,London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Stefan Bösner
- Department of Family Medicine, Philipps-University Marburg, Karl-von-Fritsch-Straße 4, D-35043, Marburg, Germany
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15
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Bösner S, Schwarm S, Grevenrath P, Schmidt L, Hörner K, Beidatsch D, Bergmann M, Viniol A, Becker A, Haasenritter J. Prevalence, aetiologies and prognosis of the symptom dizziness in primary care - a systematic review. BMC Fam Pract 2018; 19:33. [PMID: 29458336 PMCID: PMC5819275 DOI: 10.1186/s12875-017-0695-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 12/12/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Dizziness is a common reason for consulting a general practitioner and there is a broad range of possible underlying aetiologies. There are few evidence-based data about prevalence, aetiology and prognosis in primary care. We aimed to conduct a systematic review of symptom-evaluating studies on prevalence, aetiology or prognosis of dizziness in primary care. METHODS We systematically searched MEDLINE and EMBASE. Two independent researchers screened titles and abstracts according to predefined criteria. We included all studies evaluating the symptoms 'dizziness' or 'vertigo' as a reason for consultation in primary care. We extracted data about study population and methodology and prevalence, aetiology and prognosis. Two raters independently judged study quality and risk of bias. We investigated the variation across studies using forest plots, I2 and prediction intervals. Since we anticipated a great amount of clinical and unexplained statistical heterogeneity, we provided qualitative syntheses instead of pooled estimates. RESULTS We identified 31 studies (22 on prevalence, 14 on aetiology and 8 on prognosis). Consultation prevalence differs between 1,0 and 15,5%. The most common aetiologies are vestibular/peripheral (5,4-42,1%), benign peripheral positional vertigo (4,3-39,5%), vestibular neuritis (0,6-24,0%), Menière's disease (1,4-2,7%), cardiovascular disease (3,8-56,8%), neurological disease (1,4-11,4%), psychogenic (1,8-21,6%), no clear diagnosis (0,0-80,2%). While studies based on subjective patient assessment reported improvement rates from 37 to 77%, these findings could not be confirmed when applying instruments that measure symptom severity or quality of life. CONCLUSION There is a broad variety of possible underlying diseases for the symptom dizziness. There exist only few methodologically sound studies concerning aetiology and prognosis of dizziness.
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Affiliation(s)
- Stefan Bösner
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str, 435043 Marburg, Germany
| | - Sonja Schwarm
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str, 435043 Marburg, Germany
| | - Paula Grevenrath
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str, 435043 Marburg, Germany
| | - Laura Schmidt
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str, 435043 Marburg, Germany
| | - Kaja Hörner
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str, 435043 Marburg, Germany
| | - Dominik Beidatsch
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str, 435043 Marburg, Germany
| | - Milena Bergmann
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str, 435043 Marburg, Germany
| | - Annika Viniol
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str, 435043 Marburg, Germany
| | - Annette Becker
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str, 435043 Marburg, Germany
| | - Jörg Haasenritter
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str, 435043 Marburg, Germany
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16
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Mews C, Schuster S, Vajda C, Lindtner-Rudolph H, Schmidt LE, Bösner S, Güzelsoy L, Kressing F, Hallal H, Peters T, Gestmann M, Hempel L, Grützmann T, Sievers E, Knipper M. Cultural Competence and Global Health: Perspectives for Medical Education - Position paper of the GMA Committee on Cultural Competence and Global Health. GMS J Med Educ 2018; 35:Doc28. [PMID: 30186938 PMCID: PMC6120152 DOI: 10.3205/zma001174] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 06/01/2018] [Accepted: 06/11/2018] [Indexed: 05/11/2023]
Abstract
Introduction: Routine medical care in Germany, Austria and Switzerland is being increasingly impacted by the cultural and linguistic diversity of an ever more complex world. Both at home and as part of international student exchanges, medical students are confronted with different ways of thinking and acting in relation to health and disease. Despite an increasing number of courses on cultural competence and global health at German-speaking medical schools, systematic approaches are lacking on how to integrate this topic into medical curricula. Methodological approach: This paper is based on a structured consensus-building process by a multidisciplinary committee composed of faculty and students. In a first step, a qualitative online survey was carried out in order to establish an inventory of definitions and concepts. After the second step, in which a literature search was conducted and definitions of global health and transcultural and intercultural competence were clarified, recommendations were formulated regarding content, teaching and institutional infrastructure. Based on small-group work and large-group discussions, different perspectives and critical issues were compiled using multiple feedback loops that served to ensure quality. Results: An inventory on the national and international level showed that great heterogeneity exists in regard to definitions, teaching strategies, teaching formats and faculty qualification. Definitions and central aspects considered essential to medical education were thus established for the use of the terms "cultural competence" and "global health". Recommendations are given for implementation, ranging from practical realization to qualification of teaching staff and education research. Outlook: High-quality healthcare as a goal calls for the systematic internationalization of undergraduate medical education. In addition to offering specific courses on cultural competence and global health, synergies would be created through the integration of cultural competence and global health content into the curricula of already existing subject areas. The NKLM (the national competence-based catalogue of learning objectives for undergraduate medical education) would serve as a basis for this.
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Affiliation(s)
- Claudia Mews
- University Medical Center Hamburg-Eppendor,f Department of General Practice/Primary Care , Hamburg, Germany
- *To whom correspondence should be addressed: Claudia Mews, University Medical Center Hamburg-Eppendor,f Department of General Practice/Primary Care , Martinistr. 52, D-20246 Hamburg, Germany, Phone: +49 (0)40/7410-56854, Fax: +49 (0)40/7410-53681, E-mail:
| | - Sylvie Schuster
- University Hospital Basel, Head of Program on Diversity Management, Basel, Switzerland
| | - Christian Vajda
- Medical University of Graz, Department of Medical Psychology and Psychotherapy, Graz, Austria
| | - Heide Lindtner-Rudolph
- University Medical Center Hamburg-Eppendorf, Center for Psychosocial Medicine, Institute and Outpatients Clinic Medical Psychology, Research Group on Migration and Psychosocial Health (MiPH), Hamburg, Germany
| | - Luise E. Schmidt
- University of Greifswald, Department of Psychiatry and Psychotherapy, Greifswald, Germany
- Helios Hanseklinikum Stralsund, Department of Psychiatry and Psychotherapy, Stralsund, Germany
| | - Stefan Bösner
- University of Marburg, Department of General Practice/Family Medicine, Marburg, Germany
| | - Leyla Güzelsoy
- Paracelsus Medical Private University, Nuremberg Hospital, Department of Psychosomatic Medicine and Psychotherapy, Psychosomatic Consultation and Liaison Service, Nuremberg, Germany
| | - Frank Kressing
- Ulm University, Institute of the History, Philosophy and Ethics of Medicine, Ulm, Germany
| | - Houda Hallal
- University of Cologne, Faculty of Medicine, Cologne, Germany
| | - Tim Peters
- Ruhr-University Bochum, Medical Faculty, Center for Medical Education, Bochum, Germany
| | - Margarita Gestmann
- University of Duisburg-Essen, Medical Faculty, Dean's office for student affairs, Essen, Germany
| | - Linn Hempel
- University of Dusseldorf, Medical Faculty, Psychosomatic and Psychotherapy, Dusseldorf, Germany
| | - Tatjana Grützmann
- RWTH Aachen University, Dean's office for student affairs, Aachen, Germany
| | - Erika Sievers
- Academy of Public Health Services, Düsseldorf, Germany
| | - Michael Knipper
- Justus Liebig University Giessen, Institute for the History of Medicine, Giessen, Germany
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17
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Kalda R, Silina V, Bayen-Krohn S, Deruytter N, Streit S, Verschoor M, Rodondi Bonfim Daiana N, Burman RA, Canan T, Collins C, Gerasimovska Biljana K, Gintere S, Bravo Gómez R, Hoffmann K, Biyiklioglu T, Kolesnyk P, Mechili EA, Harris M, Schonmann Y, Bleich O, Matalon A, Yeshua H, Vinker S, Prus J, Comaneshter DS, Cohen AD, Lahad A, Terjajeva L, Silina V, Skurule I, Le Reste JY, Le Mer R, Derriennic J, odorico M, le Goff D, Lalande S, Nabbe P, Le Floch B, Billot Grasset A, Baptiste Nousbaum J, Collins C, O’Shea M, Wrigley M, Ryan J, Osborne B, Thakore J, Hanlon DO, Finegan P, Skuja E, Kristina Zackrisson E, Skuja I, Biyiklioglu T, Kolesnyk P, Mechili EA, Harris M, Bösner S, Abushi J, Donner-Banzhoff N, Stolper E, Van Royen P, van de Wiel M, van Bokhoven L, Jan Dinant G, Schmalstieg K, Himmel W, Hummers E, Pautrat M, Laporte C, Pierre Lebeau J, Ivanova J, Silina V, Muñoz MA, Vaillant-Roussel H, Lingner H, Demurtas J, Neves AL, Torsza P, Asenova R, Klemenc-Ketis Z, Glynn L, Kulbay H, Verdú JM, Tabenkin H, Nothnagle M, Borkan J, Schlöszler K, Splittgerber R, Kühlwind A, Donner-Banzhoff N, Saxvik A, Franz A, Hagqvist I, Rödjer S, Bondjers G, Saxvik A, Petek Šter M, Selič P, Hauswaldt J, Heinemann S, Verhoeven A, Leuridan E, Peremans L, Remmen R, Mada L, Tilea R. European General Practice Research Network (EGPRN) Abstracts from the EGPRN conference in Riga, Latvia, 11?14 May 2017. Theme: 'Reducing the risk of chronic diseases in general practice/family medicine'. Eur J Gen Pract 2017; 23:227-240. [PMID: 29022405 PMCID: PMC5965853 DOI: 10.1080/13814788.2017.1357694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ruth Kalda
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Vija Silina
- Department of Family Medicine, Riga Stradins University, Riga, Latvia
| | | | | | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Schweiz
| | | | | | - Robert A. Burman
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Schweiz
| | - Tuz Canan
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Schweiz
| | - Claire Collins
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Schweiz
| | | | - Sandra Gintere
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Schweiz
| | - Raquel Bravo Gómez
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Schweiz
| | - Kath Hoffmann
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Schweiz
| | | | | | | | | | - Yochai Schonmann
- Clalit Health Services and Department of Family Medicine, Rabin Medical Center, Tel Aviv, Israel
| | - O. Bleich
- Clalit Health Services and Department of Family Medicine, Rabin Medical Center, Tel Aviv, Israel
| | - Andre Matalon
- Clalit Health Services and Department of Family Medicine, Rabin Medical Center, Tel Aviv, Israel
| | - Hanny Yeshua
- Clalit Health Services and Department of Family Medicine, Rabin Medical Center, Tel Aviv, Israel
| | - Shlomo Vinker
- Family Medicine, Tel Aviv University, Ashdod, Israel
| | - Judit Prus
- Family Medicine, Tel Aviv University, Ashdod, Israel
| | | | | | - Amnon Lahad
- Family Medicine, Tel Aviv University, Ashdod, Israel
| | | | - Vija Silina
- Family Medicine, Riga Stradins University, Salaspils, Latvia
| | - Iveta Skurule
- Family Medicine, Riga Stradins University, Salaspils, Latvia
| | | | - Ronan Le Mer
- General Practice, Université de Bretagne Occidentale, Brest, France
| | | | - Michele odorico
- General Practice, Université de Bretagne Occidentale, Brest, France
| | - Delphine le Goff
- General Practice, Université de Bretagne Occidentale, Brest, France
| | - Sophie Lalande
- General Practice, Université de Bretagne Occidentale, Brest, France
| | - Patrice Nabbe
- General Practice, Université de Bretagne Occidentale, Brest, France
| | - Bernard Le Floch
- General Practice, Université de Bretagne Occidentale, Brest, France
| | | | | | | | | | | | | | | | | | | | | | - Elina Skuja
- Family Medicine, Riga Stradins University, Riga, Latvija
| | | | - Ilze Skuja
- Family Medicine, Riga Stradins University, Riga, Latvija
| | | | | | | | | | | | | | | | - Erik Stolper
- General Practice, CAPHRI, Maastricht, The Netherlands
| | | | | | | | | | - Katharina Schmalstieg
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
| | - Wolfgang Himmel
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
| | - Eva Hummers
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
| | - Maxime Pautrat
- Département universitaire de médecine générale, Faculté de médecine, Tours, France
| | - Catherine Laporte
- Département universitaire de médecine générale, Faculté de médecine, Tours, France
| | - Jean Pierre Lebeau
- Département universitaire de médecine générale, Faculté de médecine, Tours, France
| | | | - Vija Silina
- Continuing education faculty, Riga Stradins University, Riga, Latvia
| | - Miguel-Angel Muñoz
- Unitat de Suport a la Recerca, Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Helene Vaillant-Roussel
- Unitat de Suport a la Recerca, Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Heidrun Lingner
- Unitat de Suport a la Recerca, Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Jacopo Demurtas
- Unitat de Suport a la Recerca, Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Ana-Luisa Neves
- Unitat de Suport a la Recerca, Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Peter Torsza
- Unitat de Suport a la Recerca, Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Radost Asenova
- Unitat de Suport a la Recerca, Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Zalika Klemenc-Ketis
- Unitat de Suport a la Recerca, Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Liam Glynn
- Unitat de Suport a la Recerca, Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Hayriye Kulbay
- Unitat de Suport a la Recerca, Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - José-Maria Verdú
- Unitat de Suport a la Recerca, Primary Healthcare University Research Institute IDIAP-Jordi Gol, Barcelona, Spain
| | - Hava Tabenkin
- Family Medicine, Ben Gurion University, Ein Harod M, Israel
| | | | - Jeffrey Borkan
- Family Medicine, Ben Gurion University, Ein Harod M, Israel
| | | | | | - Anne Kühlwind
- Family Medicine, Philipps-University Marburg, Marburg, Germany
| | | | - Ausra Saxvik
- Family Physician Center Närhälsan Öckerö, PLUS program, Hönö, Sweden
| | - Anna Franz
- Family Physician Center Närhälsan Öckerö, PLUS program, Hönö, Sweden
| | - Inger Hagqvist
- Family Physician Center Närhälsan Öckerö, PLUS program, Hönö, Sweden
| | - Stig Rödjer
- Family Physician Center Närhälsan Öckerö, PLUS program, Hönö, Sweden
| | - Göran Bondjers
- Family Physician Center Närhälsan Öckerö, PLUS program, Hönö, Sweden
| | - Ausra Saxvik
- Family Physician Center Närhälsan Öckerö, PLUS program, Hönö, Sweden
| | - Marija Petek Šter
- Department for Family medicine, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Polona Selič
- Department for Family medicine, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Johannes Hauswaldt
- University Medicine Göttingen, Institute of General Practice and Family Medicine, Göttingen, Germany
| | - Stephanie Heinemann
- University Medicine Göttingen, Institute of General Practice and Family Medicine, Göttingen, Germany
| | - Ann Verhoeven
- Centre for general practice-department Eliza, University of Antwerp, Antwerpen, Belgium
| | - Elke Leuridan
- Centre for general practice-department Eliza, University of Antwerp, Antwerpen, Belgium
| | - Lieve Peremans
- Centre for general practice-department Eliza, University of Antwerp, Antwerpen, Belgium
| | - Roy Remmen
- Centre for general practice-department Eliza, University of Antwerp, Antwerpen, Belgium
| | - Leonard Mada
- Department of Research, Syonic SRL, Timisoara, Romania
| | - Roxana Tilea
- Department of Research, Syonic SRL, Timisoara, Romania
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Stadje R, Dornieden K, Baum E, Becker A, Biroga T, Bösner S, Haasenritter J, Keunecke C, Viniol A, Donner-Banzhoff N. The differential diagnosis of tiredness: a systematic review. BMC Fam Pract 2016; 17:147. [PMID: 27765009 PMCID: PMC5072300 DOI: 10.1186/s12875-016-0545-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 10/18/2016] [Indexed: 02/03/2023]
Abstract
Background Tiredness is one of the most frequent complaints in primary care. Although often self-limiting and frequently associated with psychosocial stress, patients but also their physicians are often uncertain regarding a serious cause and appropriate diagnostic work-up. We conducted a systematic review and meta-analysis of studies reporting on differential diagnosis of fatigue in primary care. Methods MEDLINE, EMBASE and conference abstracts were searched for primary care based studies of patients presenting with tiredness. Twenty-six studies were included. We report on anaemia, malignancy, serious organic disease, depression and the chronic fatigue syndrome (CFS) as causes of tiredness as presenting complaint. Results We found considerable heterogeneity of estimates which was reduced by limiting our analysis to high quality studies. Prevalences were as follows-anaemia: 2.8 % (CI (confidence interval) 1.6–4.8 %); malignancy: 0.6 % (CI 0.3–1.3 %); serious somatic disease: 4.3 % (CI 2.7–6.7 %); depression 18.5 % (CI 16.2–21.0 %). Pooling was not appropriate for CFS. In studies with control groups of patients without the symptom of tiredness, prevalence of somatic disease was identical to those complaining of tiredness. Depression, however, was more frequent among those with tiredness. Conclusions Serious somatic disease is rare in patients complaining of tiredness. Since prevalence is similar in patients without tiredness, the association may not be causal. Extensive investigations are only warranted in case of specific findings from the history or clinical examination. Instead, attention should focus on depression and psychosocial problems. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0545-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rebekka Stadje
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Katharina Dornieden
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Erika Baum
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Annette Becker
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Tobias Biroga
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Stefan Bösner
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Jörg Haasenritter
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Christian Keunecke
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Annika Viniol
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice/Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany
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Aerts M, Minalu G, Bösner S, Buntinx F, Burnand B, Haasenritter J, Herzig L, Knottnerus JA, Nilsson S, Renier W, Sox C, Sox H, Donner-Banzhoff N. Pooled individual patient data from five countries were used to derive a clinical prediction rule for coronary artery disease in primary care. J Clin Epidemiol 2016; 81:120-128. [PMID: 27773828 DOI: 10.1016/j.jclinepi.2016.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 08/09/2016] [Accepted: 09/01/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To construct a clinical prediction rule for coronary artery disease (CAD) presenting with chest pain in primary care. STUDY DESIGN AND SETTING Meta-Analysis using 3,099 patients from five studies. To identify candidate predictors, we used random forest trees, multiple imputation of missing values, and logistic regression within individual studies. To generate a prediction rule on the pooled data, we applied a regression model that took account of the differing standard data sets collected by the five studies. RESULTS The most parsimonious rule included six equally weighted predictors: age ≥55 (males) or ≥65 (females) (+1); attending physician suspected a serious diagnosis (+1); history of CAD (+1); pain brought on by exertion (+1); pain feels like "pressure" (+1); pain reproducible by palpation (-1). CAD was considered absent if the prediction score is <2. The area under the ROC curve was 0.84. We applied this rule to a study setting with a CAD prevalence of 13.2% using a prediction score cutoff of <2 (i.e., -1, 0, or +1). When the score was <2, the probability of CAD was 2.1% (95% CI: 1.1-3.9%); when the score was ≥ 2, it was 43.0% (95% CI: 35.8-50.4%). CONCLUSIONS Clinical prediction rules are a key strategy for individualizing care. Large data sets based on electronic health records from diverse sites create opportunities for improving their internal and external validity. Our patient-level meta-analysis from five primary care sites should improve external validity. Our strategy for addressing site-to-site systematic variation in missing data should improve internal validity. Using principles derived from decision theory, we also discuss the problem of setting the cutoff prediction score for taking action.
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Affiliation(s)
| | - Marc Aerts
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Hasselt University, I-BioStat, Agoralaan, Building D, Diepenbeek B-3590, Belgium.
| | - Girma Minalu
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Hasselt University, I-BioStat, Agoralaan, Building D, Diepenbeek B-3590, Belgium
| | - Stefan Bösner
- Department of General Practice and Family Medicine, Philipps University Marburg, Karl-von-Str. 4, Marburg 35037, Germany
| | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, Blok J, PB 7001, Leuven 3000, Belgium; Department of General Practice, Maastricht University, Peter Debyeplein 1, P.O. Box 616, Maastricht 6200 MD, The Netherlands
| | - Bernard Burnand
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Route de la Corniche 10, Lausanne 1010, Switzerland
| | - Jörg Haasenritter
- Department of General Practice and Family Medicine, Philipps University Marburg, Karl-von-Str. 4, Marburg 35037, Germany
| | - Lilli Herzig
- Institute of Family Medicine, University of Lausanne, 44 rue du Bugnon, Lausanne CH-1011, Switzerland
| | - J André Knottnerus
- Department of General Practice, Maastricht University, Peter Debyeplein 1, P.O. Box 616, Maastricht 6200 MD, The Netherlands
| | - Staffan Nilsson
- Division of Community Medicine, Department of Medicine and Health Sciences, Linköping University, Linköping SE-581 83, Sweden
| | - Walter Renier
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, Blok J, PB 7001, Leuven 3000, Belgium
| | - Carol Sox
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH 03755-1404, USA
| | - Harold Sox
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH 03755-1404, USA; Patient-Centered Outcomes Research Institute, 1828 L Street, NW, Suite 900, Washington, DC 20036, USA
| | - Norbert Donner-Banzhoff
- Department of General Practice and Family Medicine, Philipps University Marburg, Karl-von-Str. 4, Marburg 35037, Germany
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Stibane T, Sitter H, Neuhof D, Wiechens H, Schönbauer A, Bösner S, Baum E. Feedback promotes learning success! Which kind of feedback for the faculty is given by an interdisciplinary OSCE with focus on decision-making? GMS J Med Educ 2016; 33:Doc53. [PMID: 27579353 PMCID: PMC5003130 DOI: 10.3205/zma001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 05/31/2016] [Accepted: 05/31/2016] [Indexed: 06/06/2023]
Abstract
Clinical skills such as history taking, diagnostic reasoning, therapy planning, and giving advice are even more complex than practical skills like lung auscultation and have to be applied in complex clinical situations. We judged this competence in an interdisciplinary formative OSCE conducted with students of Marburg University. Results of 218 students passing 643 OSCE stations composed of 37 different scenarios were analyzed. As a competence based examination that reflects the practical skills gained during clinical training, the here presented analysis serves also as a feedback instrument for clinical teachers, their respective disciplines and the medical faculty as a whole.
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Affiliation(s)
- Tina Stibane
- Universität Marburg, Fachbereich Medizin, Dr. Reinfried Pohl-Zentrum für medizinische Lehre (RPZ), Marburg, Germany
| | - Helmut Sitter
- Universität Marburg, Dekanat Medizin, Marburg, Germany
| | | | - Helena Wiechens
- ehem. Universität Marburg, Fachbereich Medizin, Dr. Reinfried Pohl-Zentrum für medizinische Lehre (RPZ), Marburg, Germany
| | - Andrea Schönbauer
- Universität Marburg, Fachbereich Medizin, Dr. Reinfried Pohl-Zentrum für medizinische Lehre (RPZ), Marburg, Germany
| | - Stefan Bösner
- Universität Marburg, Abteilung für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Marburg, Germany
| | - Erika Baum
- Universität Marburg, Abteilung für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Marburg, Germany
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21
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Donner-Banzhoff N, Seidel J, Sikeler AM, Bösner S, Vogelmeier M, Westram A, Feufel M, Gaissmaier W, Wegwarth O, Gigerenzer G. The Phenomenology of the Diagnostic Process. Med Decis Making 2016; 37:27-34. [DOI: 10.1177/0272989x16653401] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 05/13/2016] [Indexed: 11/17/2022]
Abstract
Background. While dichotomous tasks and related cognitive strategies have been extensively researched in cognitive psychology, little is known about how primary care practitioners (general practitioners [GPs]) approach ill-defined or polychotomous tasks and how valid or useful their strategies are. Objective. To investigate cognitive strategies used by GPs for making a diagnosis. Methods. In a cross-sectional study, we videotaped 282 consultations, irrespective of presenting complaint or final diagnosis. Reflective interviews were performed with GPs after each consultation. Recordings of consultations and GP interviews were transcribed verbatim and analyzed using a coding system that was based on published literature and systematically checked for reliability. Results. In total, 134 consultations included 163 diagnostic episodes. Inductive foraging (i.e., the initial, patient-guided search) could be identified in 91% of consultations. It contributed an average 31% of cues obtained by the GP in 1 consultation. Triggered routines and descriptive questions occurred in 38% and 84% of consultations, respectively. GPs resorted to hypothesis testing, the hallmark of the hypothetico-deductive method, in only 39% of consultations. Limitations. Video recordings and interviews presumably interfered with GPs’ behavior and accounts. GPs might have pursued more hypotheses and collected more information than usual. Conclusions. The testing of specific disease hypotheses seems to play a lesser role than previously thought. Our data from real consultations suggest that GPs organize their search for information in a skillfully adapted way. Inductive foraging, triggered routines, descriptive questions, and hypotheses testing are essential building blocks to make a diagnosis in the generalist setting.
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Affiliation(s)
- Norbert Donner-Banzhoff
- Department of Primary Care, Philipps University of Marburg, Marburg, Germany (ND-B, JS, AMS, SB, MV)
- Harding Center for Risk Literacy, Max-Planck-Institute for Human Development, Berlin, Germany (AW, MF, OW, GG)
- Department of Psychology, University of Konstanz, Konstanz, Germany (WG)
| | - Judith Seidel
- Department of Primary Care, Philipps University of Marburg, Marburg, Germany (ND-B, JS, AMS, SB, MV)
- Harding Center for Risk Literacy, Max-Planck-Institute for Human Development, Berlin, Germany (AW, MF, OW, GG)
- Department of Psychology, University of Konstanz, Konstanz, Germany (WG)
| | - Anna Maria Sikeler
- Department of Primary Care, Philipps University of Marburg, Marburg, Germany (ND-B, JS, AMS, SB, MV)
- Harding Center for Risk Literacy, Max-Planck-Institute for Human Development, Berlin, Germany (AW, MF, OW, GG)
- Department of Psychology, University of Konstanz, Konstanz, Germany (WG)
| | - Stefan Bösner
- Department of Primary Care, Philipps University of Marburg, Marburg, Germany (ND-B, JS, AMS, SB, MV)
- Harding Center for Risk Literacy, Max-Planck-Institute for Human Development, Berlin, Germany (AW, MF, OW, GG)
- Department of Psychology, University of Konstanz, Konstanz, Germany (WG)
| | - Maria Vogelmeier
- Department of Primary Care, Philipps University of Marburg, Marburg, Germany (ND-B, JS, AMS, SB, MV)
- Harding Center for Risk Literacy, Max-Planck-Institute for Human Development, Berlin, Germany (AW, MF, OW, GG)
- Department of Psychology, University of Konstanz, Konstanz, Germany (WG)
| | - Anja Westram
- Department of Primary Care, Philipps University of Marburg, Marburg, Germany (ND-B, JS, AMS, SB, MV)
- Harding Center for Risk Literacy, Max-Planck-Institute for Human Development, Berlin, Germany (AW, MF, OW, GG)
- Department of Psychology, University of Konstanz, Konstanz, Germany (WG)
| | - Markus Feufel
- Department of Primary Care, Philipps University of Marburg, Marburg, Germany (ND-B, JS, AMS, SB, MV)
- Harding Center for Risk Literacy, Max-Planck-Institute for Human Development, Berlin, Germany (AW, MF, OW, GG)
- Department of Psychology, University of Konstanz, Konstanz, Germany (WG)
| | - Wolfgang Gaissmaier
- Department of Primary Care, Philipps University of Marburg, Marburg, Germany (ND-B, JS, AMS, SB, MV)
- Harding Center for Risk Literacy, Max-Planck-Institute for Human Development, Berlin, Germany (AW, MF, OW, GG)
- Department of Psychology, University of Konstanz, Konstanz, Germany (WG)
| | - Odette Wegwarth
- Department of Primary Care, Philipps University of Marburg, Marburg, Germany (ND-B, JS, AMS, SB, MV)
- Harding Center for Risk Literacy, Max-Planck-Institute for Human Development, Berlin, Germany (AW, MF, OW, GG)
- Department of Psychology, University of Konstanz, Konstanz, Germany (WG)
| | - Gerd Gigerenzer
- Department of Primary Care, Philipps University of Marburg, Marburg, Germany (ND-B, JS, AMS, SB, MV)
- Harding Center for Risk Literacy, Max-Planck-Institute for Human Development, Berlin, Germany (AW, MF, OW, GG)
- Department of Psychology, University of Konstanz, Konstanz, Germany (WG)
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Bösner S, Roth LM, Duncan GF, Donner-Banzhoff N. Verification and feedback for medical students: an observational study during general practice rotations. Postgrad Med J 2016; 93:3-7. [DOI: 10.1136/postgradmedj-2015-133420] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/11/2016] [Accepted: 05/13/2016] [Indexed: 11/03/2022]
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23
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Haasenritter J, Biroga T, Keunecke C, Becker A, Donner-Banzhoff N, Dornieden K, Stadje R, Viniol A, Bösner S. Causes of chest pain in primary care--a systematic review and meta-analysis. Croat Med J 2016; 56:422-30. [PMID: 26526879 PMCID: PMC4655927 DOI: 10.3325/cmj.2015.56.422] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim To investigate the frequencies of different and relevant underlying etiologies of chest pain in general practice. Methods We systematically searched PubMed and EMBASE. Two reviewers independently rated the eligibility of publications and assessed the risk of bias of included studies. We extracted data to calculate the relative frequencies of different underlying conditions and investigated the variation across studies using forest plots, I2, tau2, and prediction intervals. With respect to unexplained heterogeneity, we provided qualitative syntheses instead of pooled estimates. Results We identified 11 eligible studies comprising about 6500 patients. The overall risk of bias was rated as low in 6 studies comprising about 3900 patients. The relative frequencies of different conditions as the underlying etiologies of chest pain reported by these studies ranged from 24.5 to 49.8% (chest wall syndrome), 13.8 to 16.1% (cardiovascular diseases), 6.6 to 11.2% (stable coronary heart disease), 1.5 to 3.6% (acute coronary syndrome/myocardial infarction), 10.3 to 18.2% (respiratory diseases), 9.5 to 18.2% (psychogenic etiologies), 5.6 to 9.7% (gastrointestinal disorders), and 6.0 to 7.1% (esophageal disorders). Conclusion This information may be of practical value for general practitioners as it provides the pre-test probabilities for a range of underlying diseases and may be suitable to guide the diagnostic process.
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Affiliation(s)
- Jörg Haasenritter
- Jörg Haasenritter, Philipps University of Marburg, Department of General Practice/Family Medicine, Karl-von-Frisch-Str. 4, 35043 Marburg, Germany,
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Viniol A, Beidatsch D, Frese T, Bergmann M, Grevenrath P, Schmidt L, Schwarm S, Haasenritter J, Bösner S, Becker A. Studies of the symptom dyspnoea: a systematic review. BMC Fam Pract 2015; 16:152. [PMID: 26498502 PMCID: PMC4619993 DOI: 10.1186/s12875-015-0373-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 10/15/2015] [Indexed: 12/15/2022]
Abstract
Background To deal with patients suffering from dyspnoea, it is crucial for general practitioners to know the prevalences of different diseases causing dyspnoea in the respective area and season, the likelihood of avoidable life-threatening conditions and of worsening or recovery from disease. Aim Aim of our project was to conduct a systematic review of symptom-evaluating studies on the prevalence, aetiology, and prognosis of dyspnoea as presented to GPs in a primary care setting. Methods We did a systematic review of symptom-evaluating studies on dyspnoea in primary care. For this we included all studies investigating the complaint “dyspnoea” as a primary or secondary consulting reason in general practice. Apart from qualitative studies, all kind of study designs independent from type of data assessment, outcome measurement or study quality were included. Symptom-evaluating studies from other settings than primary care and studies which exclusively included children (age <18 years) were excluded from the review. Studies selecting patients prior to recruitment, e.g. because of an increased probability for a particular diagnosis, were also excluded. Results This systematic review identified 6 symptom evaluating studies on dyspnoea in the primary care setting. The prevalence of dyspnoea as reason for consultation ranges from 0.87 to 2.59 % in general practice. Among all dyspnoea patients 2.7 % (CI 2.2–3.3) suffer from pneumonia. Further specification of underlying aetiologies seems difficult due to the studies’ heterogeneity showing a great variety of probabilities. Conclusion There is a great lack of empirical evidence on the prevalence, aetiology and prognosis of dyspnoea in general practice. This might yield uncertainty in diagnosis and evaluation of dyspnoea in primary care.
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Affiliation(s)
- Annika Viniol
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Dominik Beidatsch
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Thomas Frese
- Department of General Practice / Family Medicine, University of Leipzig, Ph.-Rosenthal-Str. 55, 04103, Leipzig, Germany.
| | - Milena Bergmann
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Paula Grevenrath
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Laura Schmidt
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Sonja Schwarm
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Jörg Haasenritter
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Stefan Bösner
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Annette Becker
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Germany.
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Abstract
BACKGROUND Skin diseases are a common reason for consulting a GP. This regular occurrence happens despite most GPs' lack of knowledge and training in skin disease. OBJECTIVES We aimed to explore different diagnostic approaches of GPs in patients presenting with a dermatological problem. In addition, we aimed to identify strategies used by GPs to handle diagnostic uncertainty in these patients. METHODS We conducted interviews (20-40 minutes) with 14 GPs using a semi-structured guideline. Recalling encounters with patients with skin disease, GPs described their individual diagnostic strategies. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters using a deductive-inductive approach. RESULTS We identified several aspects of a complex decision-making process in GPs' diagnostic management of patients with dermatological problems. In the general diagnostic workup, GPs used a broad spectrum of different strategies such as spot diagnosis, stepwise refinement, pattern recognition trigger or test of treatment. GPs reduced diagnostic uncertainty through the identification of red flags, the application of the test of time, therapeutic trials and asking for further advice, including patient referral. CONCLUSIONS GPs encounter a broad range of dermatological problems in their daily work using a variety of strategies in the workup of these patients. However, in a significant number of patients, there remains diagnostic uncertainty that is mainly reduced by specialist referral. Regular training in the diagnosis and treatment of common dermatological diseases should be offered to all GPs.
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Affiliation(s)
- Marie-Luise Rübsam
- Department of Family Medicine, Philipps University of Marburg, Marburg, Germany
| | - Maximilian Esch
- Department of Family Medicine, Philipps University of Marburg, Marburg, Germany
| | - Erika Baum
- Department of Family Medicine, Philipps University of Marburg, Marburg, Germany
| | - Stefan Bösner
- Department of Family Medicine, Philipps University of Marburg, Marburg, Germany
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Bösner S, Pickert J, Stibane T. Teaching differential diagnosis in primary care using an inverted classroom approach: student satisfaction and gain in skills and knowledge. BMC Med Educ 2015; 15:63. [PMID: 25879809 PMCID: PMC4404043 DOI: 10.1186/s12909-015-0346-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 03/16/2015] [Indexed: 05/07/2023]
Abstract
BACKGROUND Differential diagnosis is a crucial skill for primary care physicians. General practice plays an increasing important role in undergraduate medical education. Via general practice, students may be presented with an overview of the whole spectrum of differential diagnosis in regard to common symptoms encountered in primary care. This project evaluated the impact of a blended learning program (using the inverted classroom approach) on student satisfaction and development of skills and knowledge. METHODS An elective seminar in differential diagnosis in primary care, which utilized an inverted classroom design, was offered to students. Evaluation followed a mixed methods design: participants completed a pre- and post-test, a questionnaire, and a focus group discussion. Interviews were transcribed verbatim and answers were grouped according to different themes. Test results were analysed using the Wilcoxon matched-pairs signed-ranks test. RESULTS Participants (n = 17) rated the course concept very positively. Especially the inverted classroom approach was appreciated by all students, as it allowed for more time during the seminar to concentrate on interactive and practice based learning. Students (n = 16) showed a post-test significant overall gain in skills and knowledge of 33%. CONCLUSIONS This study showed a positive effect of the inverted classroom approach on students' satisfaction and skills and knowledge. Further research is necessary in order to explore the potentials of this approach, especially the impact on development of clinical skills.
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Affiliation(s)
- Stefan Bösner
- Department of Family Medicine, University of Marburg, Karl-von-Frisch-Strasse 4, 35043, Marburg, Germany.
| | - Julia Pickert
- Marburg Interactive Skills Lab (MARIS), Faculty of Medicine, University of Marburg, Marburg, Germany.
| | - Tina Stibane
- Marburg Interactive Skills Lab (MARIS), Faculty of Medicine, University of Marburg, Marburg, Germany.
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Viniol A, Keunecke C, Biroga T, Stadje R, Dornieden K, Bösner S, Donner-Banzhoff N, Haasenritter J, Becker A. Studies of the symptom abdominal pain--a systematic review and meta-analysis. Fam Pract 2014; 31:517-29. [PMID: 24987023 DOI: 10.1093/fampra/cmu036] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Diagnostic reasoning in primary care patients with abdominal pain is a complex challenge for GPs. To ensure evidence-based decision making for this symptom, GPs need setting-specific knowledge about the prevalence, potential risks for diseases and chance of recovery or risk of undesirable courses of disease. AIM We conducted a systematic review of symptom-evaluating studies on prevalence, aetiology or prognosis of abdominal pain. METHODS We included all studies evaluating the symptom 'abdominal pain' as a reason for consultation in primary care. We included all types of study designs except for qualitative studies. Studies focussed solely on children or settings other than primary care were also excluded. RESULTS We identified 14 studies. Mean consultation prevalence is 2.8% for abdominal pain. In about one-third of patients the underlying cause of abdominal pain cannot be specified. The most common aetiologies are gastroenteritis (7.2-18.7%), irritable bowel disease (2.6-13.2%), urological cause (5.3%) and gastritis (5.2%). About 1 in 10 abdominal pain patients suffers from an acute disease like appendicitis (1.9%), diverticulitis (3.0%), biliary/pancreatic (4.0%) or neoplastic (1.0%) diseases needing immediate therapy. CONCLUSION There is a high prevalence of patients consulting GPs for abdominal pain. The review identified a comparably high rate of acute underlying diseases in need of further investigation or therapy. At the same time, the underlying cause of the complaints often remains unexplained. Further symptom-evaluating studies are necessary, ideally using standardized methodology in order to gain sufficient evidence for developing much-needed guidelines and decision support tools.
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Affiliation(s)
- Annika Viniol
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany.
| | - Christian Keunecke
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Tobias Biroga
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Rebekka Stadje
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Katharina Dornieden
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Stefan Bösner
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | | | - Jörg Haasenritter
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Annette Becker
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
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Abstract
BACKGROUND The symptom leg oedema represents a broad range of possible underlying aetiologies. The background of leg oedema is multifactorial and usually the GP is the first contact point for patients presenting with this symptom. GPs rely on patient history and physical examination as their main diagnostic tools. OBJECTIVE To identify GPs' diagnostic approaches and heuristics in patients presenting with leg oedema. METHODS Interviews with 15 GPs (20-30 min) using a semi-structured interview-guideline were conducted. GPs described their individual diagnostic strategies concerning all patients presenting with leg oedema they had prospectively identified during the previous four weeks. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters. RESULTS GPs applied a variety of diagnostic approaches, which can be grouped in active and passive strategies. Active strategies comprised the use of decision rules and guidelines, Bayesian arguing, problem dichotomisation and discrepancy heuristics. Passive approaches included test of time, therapy as diagnosis, and taking patient assumptions into account. CONCLUSION When dealing with leg oedema, GPs use prior information of individual patients in a specific way. There is a broad variety of diagnostic approaches that can be grouped in 'active' and 'passive' behaviour. Approaches mostly match with established diagnostic strategies in primary care.
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Donner-Banzhoff N, Haasenritter J, Hüllermeier E, Viniol A, Bösner S, Becker A. Response to van den Bruel and Perera: the comprehensive diagnostic study: a new solution to old problems? J Clin Epidemiol 2014; 67:135-6. [DOI: 10.1016/j.jclinepi.2013.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 09/13/2013] [Indexed: 10/26/2022]
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Donner-Banzhoff N, Haasenritter J, Hüllermeier E, Viniol A, Bösner S, Becker A. The comprehensive diagnostic study is suggested as a design to model the diagnostic process. J Clin Epidemiol 2014; 67:124-32. [DOI: 10.1016/j.jclinepi.2013.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 05/01/2013] [Accepted: 05/07/2013] [Indexed: 11/24/2022]
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Haasenritter J, Viniol A, Becker A, Bösner S, Hüllermeier E, Senge R, Donner-Banzhoff N. [Diagnosis in context - broadening the perspective]. Z Evid Fortbild Qual Gesundhwes 2013; 107:585-91. [PMID: 24315328 DOI: 10.1016/j.zefq.2013.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 10/22/2013] [Accepted: 10/22/2013] [Indexed: 10/26/2022]
Abstract
In a primary care setting the diagnostic process typically starts with a symptom or sign reported by the patient. Primary care physicians face the challenge to consider a broad spectrum of possible aetiologies or differential diagnoses when choosing appropriate diagnostic tests. The classical diagnostic cross-sectional study investigates the accuracy of a diagnostic test or a combination of several tests in regard to just one target disease. The complexity facing the clinician remains unconsidered or is being split and presented in several parts which the clinician has to combine. In this paper we suggest a design for diagnostic studies that considers the requirements of diagnosis in primary care more comprehensively: the comprehensive diagnostic study. The essential characteristic of the design is the simultaneous consideration of the whole spectrum of relevant aetiologies when evaluating several diagnostic tests. We present single characteristics and specific features of this design in regard to research question, study sampling, index test, reference standard and analysis, and illustrate them using the example of a study investigating chest pain in primary care.
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Affiliation(s)
- Jörg Haasenritter
- Abteilung für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Philipps Universität, Marburg.
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Bösner S, Bönisch K, Haasenritter J, Schlegel P, Hüllermeier E, Donner-Banzhoff N. Chest pain in primary care: is the localization of pain diagnostically helpful in the critical evaluation of patients?--A cross sectional study. BMC Fam Pract 2013; 14:154. [PMID: 24138299 PMCID: PMC3853238 DOI: 10.1186/1471-2296-14-154] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 09/25/2013] [Indexed: 11/12/2022]
Abstract
Background Chest pain is a common complaint and reason for consultation in primary care. Traditional textbooks still assign pain localization a certain discriminative role in the differential diagnosis of chest pain. The aim of our study was to synthesize pain drawings from a large sample of chest pain patients and to examine whether pain localizations differ for different underlying etiologies. Methods We conducted a cross-sectional study including 1212 consecutive patients with chest pain recruited in 74 primary care offices in Germany. Primary care providers (PCPs) marked pain localization and radiation of each patient on a pictogram. After 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient, deciding on the etiology of chest pain at the time of patient recruitment. PCP drawings were entered in a specially designed computer program to produce merged pain charts for different etiologies. Dissimilarities between individual pain localizations and differences on the level of diagnostic groups were analyzed using the Hausdorff distance and the C-index. Results Pain location in patients with coronary heart disease (CHD) did not differ from the combined group of all other patients, including patients with chest wall syndrome (CWS), gastro-esophageal reflux disease (GERD) or psychogenic chest pain. There was also no difference in chest pain location between male and female CHD patients. Conclusions Pain localization is not helpful in discriminating CHD from other common chest pain etiologies.
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Affiliation(s)
- Stefan Bösner
- Department of General Practice/Family Medicine, Philipps University Marburg, Marburg, Germany.
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Abstract
Background Thyroid hormones are among the most prescribed drugs in Germany. Although iodine supply has been improving in the last decade, annual prescriptions for thyroid hormones are rising. The aim of this study was to provide prevalence of thyroid hormone prescribing and to explore reasons for thyroid hormone prescription in primary care settings. Study design A cross-sectional study. Methods Data collection took place in six general practitioner (GP) practices in Hesse, Germany. We used the records of six GP practices to estimate prevalence of thyroid hormone prescribing. All patients who received a prescription of the active ingredient levotyroxine during the preceding 3 months were mailed a study invitation. A proportion of the identified patients were interviewed. In addition, demographical data and all medical findings related to thyroid disease were recorded. Results On average, 9.2% (SD 4.6) of all patients from participating practices were taking thyroid hormones. The majority were female (82.5%). In 47.7% of the study participants, the GP’s diagnosis, according to their records, was nonexistent. In 13.6% of cases, the documentation of the diagnostic information was incomplete. While 25% of interviewed patients with high educational background initiated further diagnostic investigation, only 4.4% of the patients with lower education did so. Conclusion In the majority of patients treated with thyroid hormones, doctors had not documented the precise indication for prescription.
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Affiliation(s)
- Annika Viniol
- Department of General Practice/Family Medicine, Philipps University of Marburg, Marburg, Germany
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Haasenritter J, Aerts M, Bösner S, Buntinx F, Burnand B, Herzig L, Knottnerus JA, Minalu G, Nilsson S, Renier W, Sox C, Sox H, Donner-Banzhoff N. Coronary heart disease in primary care: accuracy of medical history and physical findings in patients with chest pain--a study protocol for a systematic review with individual patient data. BMC Fam Pract 2012; 13:81. [PMID: 22877212 PMCID: PMC3545850 DOI: 10.1186/1471-2296-13-81] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 07/27/2012] [Indexed: 11/23/2022]
Abstract
Background Chest pain is a common complaint in primary care, with coronary heart disease (CHD) being the most concerning of many potential causes. Systematic reviews on the sensitivity and specificity of symptoms and signs summarize the evidence about which of them are most useful in making a diagnosis. Previous meta-analyses are dominated by studies of patients referred to specialists. Moreover, as the analysis is typically based on study-level data, the statistical analyses in these reviews are limited while meta-analyses based on individual patient data can provide additional information. Our patient-level meta-analysis has three unique aims. First, we strive to determine the diagnostic accuracy of symptoms and signs for myocardial ischemia in primary care. Second, we investigate associations between study- or patient-level characteristics and measures of diagnostic accuracy. Third, we aim to validate existing clinical prediction rules for diagnosing myocardial ischemia in primary care. This article describes the methods of our study and six prospective studies of primary care patients with chest pain. Later articles will describe the main results. Methods/Design We will conduct a systematic review and IPD meta-analysis of studies evaluating the diagnostic accuracy of symptoms and signs for diagnosing coronary heart disease in primary care. We will perform bivariate analyses to determine the sensitivity, specificity and likelihood ratios of individual symptoms and signs and multivariate analyses to explore the diagnostic value of an optimal combination of all symptoms and signs based on all data of all studies. We will validate existing clinical prediction rules from each of the included studies by calculating measures of diagnostic accuracy separately by study. Discussion Our study will face several methodological challenges. First, the number of studies will be limited. Second, the investigators of original studies defined some outcomes and predictors differently. Third, the studies did not collect the same standard clinical data set. Fourth, missing data, varying from partly missing to fully missing, will have to be dealt with. Despite these limitations, we aim to summarize the available evidence regarding the diagnostic accuracy of symptoms and signs for diagnosing CHD in patients presenting with chest pain in primary care. Review registration Centre for Reviews and Dissemination (University of York): CRD42011001170
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Affiliation(s)
- Jörg Haasenritter
- Department of General Practice/ Family Medicine, University of Marburg, Marburg, D-35032, Germany.
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Hirsch O, Träger S, Bösner S, Ilhan M, Becker A, Baum E, Donner-Banzhoff N. Referral from primary to secondary care in Germany: Developing a taxonomy based on cluster analysis. Scand J Public Health 2012; 40:571-8. [DOI: 10.1177/1403494812455113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims: Referrals from primary to secondary care may differ regarding motivation and initiative. Previous research on the frequency and variation of referrals has mostly treated referrals as homogeneous. We intended to develop a taxonomy regarding referrals from primary to secondary care in Germany that could support decision making on a macro level. Methods: We analyzed 3,988 referrals by 29 German general practitioners (GPs). GPs were asked to document all referrals during one week; in subsequent audits they stated the reasons and initiative for any referral. We postulated the following five referral types: clinical problem, shared care, administrative, patient initiated and shared cost. The data were analyzed with k-means cluster analysis. Results: We identified three of our five postulated referral types with cluster analytic techniques: shared care, clinical problem, and patient initiated. This solution accounted for 11.7% of total variance. The majority of referrals in German primary care practices were initiated by the GP, or they were part of a shared decision with patients. Conclusions: We suggest a taxonomy of referrals that might offer insights regarding the allocation of resources within the German health system. Referrals might be reduced by improved training of primary care physicians and by giving them more competencies in routine care of chronic patients.
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Affiliation(s)
- Oliver Hirsch
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Susanne Träger
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Stefan Bösner
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Muazzez Ilhan
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Annette Becker
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
| | - Erika Baum
- Department of General Practice/Family Medicine, University of Marburg, Marburg, Germany
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Ronga A, Vaucher P, Haasenritter J, Donner-Banzhoff N, Bösner S, Verdon F, Bischoff T, Burnand B, Favrat B, Herzig L. Development and validation of a clinical prediction rule for chest wall syndrome in primary care. BMC Fam Pract 2012; 13:74. [PMID: 22866824 PMCID: PMC3444903 DOI: 10.1186/1471-2296-13-74] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 07/16/2012] [Indexed: 11/10/2022]
Abstract
Background Chest wall syndrome (CWS), the main cause of chest pain in primary care practice,
is most often an exclusion diagnosis. We developed and evaluated a clinical
prediction rule for CWS. Methods Data from a multicenter clinical cohort of consecutive primary care patients with
chest pain were used (59 general practitioners, 672 patients). A final diagnosis
was determined after 12 months of follow-up. We used the literature and bivariate
analyses to identify candidate predictors, and multivariate logistic regression
was used to develop a clinical prediction rule for CWS. We used data from a German
cohort (n = 1212) for external validation. Results From bivariate analyses, we identified six variables characterizing CWS: thoracic
pain (neither retrosternal nor oppressive), stabbing, well localized pain, no
history of coronary heart disease, absence of general practitioner’s
concern, and pain reproducible by palpation. This last variable accounted for 2
points in the clinical prediction rule, the others for 1 point each; the total
score ranged from 0 to 7 points. The area under the receiver operating
characteristic (ROC) curve was 0.80 (95% confidence interval 0.76-0.83) in the
derivation cohort (specificity: 89%; sensitivity: 45%; cut-off set at 6 points).
Among all patients presenting CWS (n = 284), 71% (n = 201)
had a pain reproducible by palpation and 45% (n = 127) were correctly
diagnosed. For a subset (n = 43) of these correctly classified CWS
patients, 65 additional investigations (30 electrocardiograms, 16 thoracic
radiographies, 10 laboratory tests, eight specialist referrals, one thoracic
computed tomography) had been performed to achieve diagnosis. False positives
(n = 41) included three patients with stable angina (1.8% of all
positives). External validation revealed the ROC curve to be 0.76 (95% confidence
interval 0.73-0.79) with a sensitivity of 22% and a specificity of 93%. Conclusions This CWS score offers a useful complement to the usual CWS exclusion diagnosing
process. Indeed, for the 127 patients presenting CWS and correctly classified by
our clinical prediction rule, 65 additional tests and exams could have been
avoided. However, the reproduction of chest pain by palpation, the most important
characteristic to diagnose CWS, is not pathognomonic.
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Affiliation(s)
- Alexandre Ronga
- Institute of General Medicine, University of Lausanne, Lausanne, Switzerland.
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Bösner S, Keller H, Wöhner A, Wöhner C, Sönnichsen A, Baum E, Donner-Banzhoff N. Prevention of falls by outdoor-walking in elderly persons at risk (“power”) – a pilot study. Eur Geriatr Med 2012. [DOI: 10.1016/j.eurger.2011.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hirsch O, Bösner S, Hüllermeier E, Senge R, Dembczynski K, Donner-Banzhoff N. Multivariate modeling to identify patterns in clinical data: the example of chest pain. BMC Med Res Methodol 2011; 11:155. [PMID: 22108386 PMCID: PMC3228697 DOI: 10.1186/1471-2288-11-155] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 11/22/2011] [Indexed: 11/16/2022] Open
Abstract
Background In chest pain, physicians are confronted with numerous interrelationships between symptoms and with evidence for or against classifying a patient into different diagnostic categories. The aim of our study was to find natural groups of patients on the basis of risk factors, history and clinical examination data which should then be validated with patients' final diagnoses. Methods We conducted a cross-sectional diagnostic study in 74 primary care practices to establish the validity of symptoms and findings for the diagnosis of coronary heart disease. A total of 1199 patients above age 35 presenting with chest pain were included in the study. General practitioners took a standardized history and performed a physical examination. They also recorded their preliminary diagnoses, investigations and management related to the patient's chest pain. We used multiple correspondence analysis (MCA) to examine associations on variable level, and multidimensional scaling (MDS), k-means and fuzzy cluster analyses to search for subgroups on patient level. We further used heatmaps to graphically illustrate the results. Results A multiple correspondence analysis supported our data collection strategy on variable level. Six factors emerged from this analysis: „chest wall syndrome“, „vital threat“, „stomach and bowel pain“, „angina pectoris“, „chest infection syndrome“, and „ self-limiting chest pain“. MDS, k-means and fuzzy cluster analysis on patient level were not able to find distinct groups. The resulting cluster solutions were not interpretable and had insufficient statistical quality criteria. Conclusions Chest pain is a heterogeneous clinical category with no coherent associations between signs and symptoms on patient level.
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Affiliation(s)
- Oliver Hirsch
- Department of General Practice/Family Medicine, Philipps University Marburg, Germany.
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Kramer L, Rabanizada N, Haasenritter J, Bösner S, Baum E, Donner-Banzhoff N. Do guidelines on first impression make sense? Implementation of a chest pain guideline in primary care: a systematic evaluation of acceptance and feasibility. BMC Fam Pract 2011; 12:128. [PMID: 22103603 PMCID: PMC3267789 DOI: 10.1186/1471-2296-12-128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 11/21/2011] [Indexed: 12/05/2022]
Abstract
BACKGROUND Most guidelines concentrate on investigations, treatment, and monitoring instead of patient history and clinical examination. We developed a guideline that dealt with the different aetiologies of chest pain by emphasizing the patient's history and physical signs. The objective of this study was to evaluate the guideline's acceptance and feasibility in the context of a practice test. METHODS The evaluation study was nested in a diagnostic cross-sectional study with 56 General Practitioners (GPs) and 862 consecutively recruited patients with chest pain. The evaluation of the guideline was conducted in a mixed method design on a sub-sample of 17 GPs and 282 patients. Physicians' evaluation of the guideline was assessed via standardized questionnaires and case record forms. Additionally, practice nursing staff and selected patients were asked for their evaluation of specific guideline modules. Quantitative data was analyzed descriptively for frequencies, means, and standard deviations. In addition, two focus groups with a total of 10 GPs were held to gain further insights in the guideline implementation process. The data analysis and interpretation followed the standards of the qualitative content analysis. RESULTS The overall evaluation of the GPs participating in the evaluation study regarding the recommendations made in the chest pain guideline was positive. A total of 14 GPs were convinced that there was a need for this kind of guideline and perceived the guideline recommendations as useful. While the long version was partially criticized for a perceived lack of clarity, the short version of the chest pain guideline and the heart score were especially appreciated by the GPs. However, change of clinical behaviour as consequence of the guideline was inconsistent. While on a concrete patient related level, GPs indicated to have behaved as the guideline recommended, the feedback on a more general level was heterogeneous. Several suggestions to improve guideline implementation were made by participating physicians. Due to the small number of practice nursing staff evaluating the flowchart and patients remembering the patient leaflet, no valid results regarding the flowchart and patient leaflet modules could be reported. CONCLUSIONS Overall, the participating GPs perceived the guideline recommendations as useful to increase awareness and to reflect on diagnostic issues. Although behaviour change in consequence of the guideline was not reported on a general level, guidelines on history taking and the clinical examination may serve an important conservative and practical function in a technology driven environment. Further research to increase the implementation success of the guideline should be undertaken.
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Affiliation(s)
- Lena Kramer
- Department of General Practice, Philipps University of Marburg, Germany
| | - Nagela Rabanizada
- Department of General Practice, Philipps University of Marburg, Germany
| | - Jörg Haasenritter
- Department of General Practice, Philipps University of Marburg, Germany
| | - Stefan Bösner
- Department of General Practice, Philipps University of Marburg, Germany
| | - Erika Baum
- Department of General Practice, Philipps University of Marburg, Germany
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Bösner S, Haasenritter J, Donner-Banzhoff N. [Rational clinical decision making in general practice: chest pain]. MMW Fortschr Med 2011; 153:30-31. [PMID: 21939143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Stefan Bösner
- Abt. für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Philipps-Universität Marburg.
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Bösner S, Celemin-Heinrich S, Mühlbauer S, Stibane T, Schönbauer A, Baum E. Differential diagnosis in primary care: conception and implementation of a new elective seminar - An experience report. GMS Z Med Ausbild 2011; 28:Doc40. [PMID: 21866242 PMCID: PMC3159204 DOI: 10.3205/zma000752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 04/29/2011] [Accepted: 05/25/2011] [Indexed: 11/30/2022]
Abstract
Primary care is in a unique position to teach the broad spectrum of differential diagnoses. We developed and piloted a new elective seminar 'Differential Diagnosis in Primary Care'. With the help of simulation patients, training models, interactive small group work, and short lectures we addressed common complaints presented in the daily routine of primary care like vertigo, dyspnoea, chest or abdominal pain. We put a special focus on the diagnostic accuracy of history and physical examination. The final examination was conducted as an objective structured clinical examination.
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Affiliation(s)
- Stefan Bösner
- Universität Marburg, Abteilung für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Marburg, Deutschland,*To whom correspondence should be addressed: Stefan Bösner, Universität Marburg, Abteilung für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Karl-von-Frisch-Straße 4, 35043 Marburg, Deutschland, Tel.: +49 (0)6421/2865-122, E-mail:
| | - Salome Celemin-Heinrich
- Universität Marburg, Abteilung für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Marburg, Deutschland
| | - Stephanie Mühlbauer
- Charité - Universitätsmedizin Berlin, Studiengang Medizin- und Pflegepädagogik, Berlin, Deutschland
| | - Tina Stibane
- Philipps Universität Marburg, Marburger Interdisziplinäres Skills Lab (MARIS), Marburg, Deutschland
| | - Andrea Schönbauer
- Philipps Universität Marburg, Marburger Interdisziplinäres Skills Lab (MARIS), Marburg, Deutschland
| | - Erika Baum
- Universität Marburg, Abteilung für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Marburg, Deutschland
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Bösner S. [Not Available]. MMW Fortschr Med 2011; 153:30-32. [PMID: 27370770 DOI: 10.1007/bf03368670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Stefan Bösner
- Philipps-Universität Marburg, Karl-von-Frisch-Str. 4, D-35043, Marburg, Deutschland.
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Bösner S, Haasenritter J, Keller H, Abu Hani M, Sönnichsen AC, Baum E, Donner-Banzhoff N. The diagnosis of coronary heart disease in a low-prevalence setting: follow-up data from patients whose CHD was misdiagnosed by their family doctors. Dtsch Arztebl Int 2011; 108:445-51. [PMID: 21776318 DOI: 10.3238/arztebl.2011.0445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 03/17/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND The diagnosis of coronary heart disease (CHD) is a challenge for primary care physicians (PCPs). We studied the further course of 57 patients who presented to their PCPs with chest pain and were initially misdiagnosed as not having CHD as the cause of chest pain. METHODS The 57 misdiagnosed patients were among 1,249 consecutive patients aged 35 and above who presented with chest pain to 74 different PCPs (35% of the 209 PCPs initially invited to participate in the study). For each patient, the PCPs recorded the initial history and physical findings and the course over the ensuing six months. An independent interdisciplinary reference panel reviewed all of the data and retrospectively determined each patient's most likely cause of chest pain at the time of inclusion in the study. RESULTS For 405 patients (32.4%), the PCPs rated the probability that CHD was the cause of chest pain at 0 to 5%. The reference panel retrospectively diagnosed CHD as the cause of chest pain in 180 patients. The PCPs correctly diagnosed CHD as the cause of chest pain in 123 (68.3%) of these patients and failed to diagnose CHD as the cause of chest pain in 57 of them (31.7%). 26 (45.6%) of the 57 misdiagnosed patients had a history of CHD. Even when the diagnosis of CHD as the cause of chest pain was missed, the PCPs often ordered an ECG (42 of 57 patients, or 73.7%) or referred the patient to a cardiologist or internist (20 of 57 patients, or 35.1%). CONCLUSION Primary care physicians diagnose CHD with moderate sensitivity. Even when they initially fail to make the diagnosis, they often order further tests and consultations that ultimately lead to a correct diagnosis of CHD.
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Affiliation(s)
- Stefan Bösner
- Abteilung für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Universität Marburg, Germany.
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Bösner S, Haasenritter J, Hani MA, Keller H, Sönnichsen AC, Karatolios K, Schaefer JR, Baum E, Donner-Banzhoff N. Gender bias revisited: new insights on the differential management of chest pain. BMC Fam Pract 2011; 12:45. [PMID: 21645336 PMCID: PMC3125218 DOI: 10.1186/1471-2296-12-45] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 06/06/2011] [Indexed: 11/17/2022]
Abstract
Background Chest pain is a common complaint and reason for consultation in primary care. Few data exist from a primary care setting whether male patients are treated differently than female patients. We examined whether there are gender differences in general physicians' (GPs) initial assessment and subsequent management of patients with chest pain, and how these differences can be explained Methods We conducted a prospective study with 1212 consecutive chest pain patients. The study was conducted in 74 primary care offices in Germany from October 2005 to July 2006. After a follow up period of 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient and decided about the etiology of chest pain at the time of patient recruitment (delayed type-reference standard). We adjusted gender differences of six process indicators for different models. Results GPs tended to assume that CHD is the cause of chest pain more often in male patients and referred more men for an exercise test (women 4.1%, men 7.3%, p = 0.02) and to the hospital (women 2.9%, men 6.6%, p < 0.01). These differences remained when adjusting for age and cardiac risk factors but ceased to exist after adjusting for the typicality of chest pain. Conclusions While observed gender differences can not be explained by differences in age, CHD prevalence, and underlying risk factors, the less typical symptom presentation in women might be an underlying factor. However this does not seem to result in suboptimal management in women but rather in overuse of services for men. We consider our conclusions rather hypothesis generating and larger studies will be necessary to prove our proposed model.
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Affiliation(s)
- Stefan Bösner
- Department of General Practice/Family Medicine, University of Marburg, 35032 Marburg, Germany.
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Bösner S, Haasenritter J, Abu Hani M, Keller H, Sönnichsen AC, Karatolios K, Schaefer JR, Baum E, Donner-Banzhoff N. Accuracy of general practitioners' assessment of chest pain patients for coronary heart disease in primary care: cross-sectional study with follow-up. Croat Med J 2010. [PMID: 20564768 DOI: 10.3325//cmj.2010.51.243] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM To estimate how accurately general practitioners' (GP) assessed the probability of coronary heart disease in patients presenting with chest pain and analyze the patient management decisions taken as a result. METHODS During 2005 and 2006, the cross-sectional diagnostic study with a delayed-type reference standard included 74 GPs in the German state of Hesse, who enrolled 1249 consecutive patients presenting with chest pain. GPs recorded symptoms and findings for each patient on a report form. Patients and GPs were contacted 6 weeks and 6 months after the patients' visit to the GP. Data on chest complaints, investigations, hospitalization, and medication were reviewed by an independent panel, with coronary heart disease being the reference condition. Diagnostic properties (sensitivity, specificity, and predictive values) of the GPs' diagnoses were calculated. RESULTS GPs diagnosed coronary heart disease with the sensitivity of 69% (95% confidence interval [CI], 62-75) and specificity of 89% (95% CI, 87-91), and acute coronary syndrome with the sensitivity of 50% (95% CI, 36-64) and specificity of 98% (95% CI, 97-99). They assumed coronary heart disease in 245 patients, 41 (17%) of whom were referred to the hospital, 77 (31%) to a cardiologist, and 162 (66%) to electrocardiogram testing. CONCLUSIONS GPs' evaluation of chest pain patients, based on symptoms and signs alone, was not sufficiently accurate for diagnosing or excluding coronary heart disease or acute coronary syndrome.
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Affiliation(s)
- Stefan Bösner
- Department of General Practice/Family Medicine, University of Marburg, D-35043 Marburg, Germany.
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Bösner S, Becker A, Hani MA, Keller H, Sönnichsen AC, Karatolios K, Schaefer JR, Haasenritter J, Baum E, Donner-Banzhoff N. Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis. Fam Pract 2010; 27:363-9. [PMID: 20406787 DOI: 10.1093/fampra/cmq024] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Chest wall syndrome (CWS) is the most frequent aetiology of chest pain in a primary care setting. OBJECTIVE The aims of the study are to describe the epidemiology, clinical characteristics and prognosis of CWS and to provide a simple decision rule for diagnosis. METHODS We included 1212 consecutive patients with chest pain aged 35 years and older attending 74 GPs. GPs recorded symptoms and findings of each patient and provided follow-up information. An independent interdisciplinary reference panel reviewed clinical data of every patient and decided about the aetiology of chest pain at the time of patient recruitment. Multivariable regression analysis was performed to identify clinical predictors that help to rule in or out the diagnosis of CWS. RESULTS GPs diagnosed pain originating from the chest wall in 46.6% of all patients. In most patients, pain was localized retrosternal (52.0%) and/or on the left side (69.2%). In total, 28.0% of CWS patients showed persistent pain and most patients reported no temporal association of pain (72.3%). In total, 55.4% of patients still had chest pain after 6 months. A simple score containing four determinants (localized muscle tension, stinging pain, pain reproducible by palpation and absence of cough) shows an area under the receiver operating characteristic curve of 0.78 (95% confidence interval: 0.75-0.81). CONCLUSIONS This study broadens the knowledge about pain characteristics and the diagnostic accuracy of selected signs and symptoms for CWS. A simple four-point score can help the GP in the diagnostic workup of chest pain patients.
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Affiliation(s)
- Stefan Bösner
- Department of General Practice/Family Medicine, University of Marburg, D-35043 Marburg, Germany.
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Bösner S, Haasenritter J, Becker A, Karatolios K, Vaucher P, Gencer B, Herzig L, Heinzel-Gutenbrunner M, Schaefer JR, Abu Hani M, Keller H, Sönnichsen AC, Baum E, Donner-Banzhoff N. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ 2010; 182:1295-300. [PMID: 20603345 DOI: 10.1503/cmaj.100212] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Chest pain can be caused by various conditions, with life-threatening cardiac disease being of greatest concern. Prediction scores to rule out coronary artery disease have been developed for use in emergency settings. We developed and validated a simple prediction rule for use in primary care. METHODS We conducted a cross-sectional diagnostic study in 74 primary care practices in Germany. Primary care physicians recruited all consecutive patients who presented with chest pain (n = 1249) and recorded symptoms and findings for each patient (derivation cohort). An independent expert panel reviewed follow-up data obtained at six weeks and six months on symptoms, investigations, hospital admissions and medications to determine the presence or absence of coronary artery disease. Adjusted odds ratios of relevant variables were used to develop a prediction rule. We calculated measures of diagnostic accuracy for different cut-off values for the prediction scores using data derived from another prospective primary care study (validation cohort). RESULTS The prediction rule contained five determinants (age/sex, known vascular disease, patient assumes pain is of cardiac origin, pain is worse during exercise, and pain is not reproducible by palpation), with the score ranging from 0 to 5 points. The area under the curve (receiver operating characteristic curve) was 0.87 (95% confidence interval [CI] 0.83-0.91) for the derivation cohort and 0.90 (95% CI 0.87-0.93) for the validation cohort. The best overall discrimination was with a cut-off value of 3 (positive result 3-5 points; negative result <or= 2 points), which had a sensitivity of 87.1% (95% CI 79.9%-94.2%) and a specificity of 80.8% (77.6%-83.9%). INTERPRETATION The prediction rule for coronary artery disease in primary care proved to be robust in the validation cohort. It can help to rule out coronary artery disease in patients presenting with chest pain in primary care.
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Affiliation(s)
- Stefan Bösner
- Department of General Practice and Family Medicine, University of Marburg, D-35032 Marburg, Germany.
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Bösner S, Haasenritter J, Abu Hani M, Keller H, Sönnichsen AC, Karatolios K, Schaefer JR, Baum E, Donner-Banzhoff N. Accuracy of general practitioners' assessment of chest pain patients for coronary heart disease in primary care: cross-sectional study with follow-up. Croat Med J 2010; 51:243-9. [PMID: 20564768 PMCID: PMC2897083 DOI: 10.3325/cmj.2010.51.243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 04/30/2010] [Indexed: 05/29/2023] Open
Abstract
AIM To estimate how accurately general practitioners' (GP) assessed the probability of coronary heart disease in patients presenting with chest pain and analyze the patient management decisions taken as a result. METHODS During 2005 and 2006, the cross-sectional diagnostic study with a delayed-type reference standard included 74 GPs in the German state of Hesse, who enrolled 1249 consecutive patients presenting with chest pain. GPs recorded symptoms and findings for each patient on a report form. Patients and GPs were contacted 6 weeks and 6 months after the patients' visit to the GP. Data on chest complaints, investigations, hospitalization, and medication were reviewed by an independent panel, with coronary heart disease being the reference condition. Diagnostic properties (sensitivity, specificity, and predictive values) of the GPs' diagnoses were calculated. RESULTS GPs diagnosed coronary heart disease with the sensitivity of 69% (95% confidence interval [CI], 62-75) and specificity of 89% (95% CI, 87-91), and acute coronary syndrome with the sensitivity of 50% (95% CI, 36-64) and specificity of 98% (95% CI, 97-99). They assumed coronary heart disease in 245 patients, 41 (17%) of whom were referred to the hospital, 77 (31%) to a cardiologist, and 162 (66%) to electrocardiogram testing. CONCLUSIONS GPs' evaluation of chest pain patients, based on symptoms and signs alone, was not sufficiently accurate for diagnosing or excluding coronary heart disease or acute coronary syndrome.
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Affiliation(s)
- Stefan Bösner
- Department of General Practice/Family Medicine, University of Marburg, D-35043 Marburg, Germany.
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Affiliation(s)
- Julia Anna Glombiewski
- Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Germany.
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Gencer B, Vaucher P, Herzig L, Verdon F, Ruffieux C, Bösner S, Burnand B, Bischoff T, Donner-Banzhoff N, Favrat B. Ruling out coronary heart disease in primary care patients with chest pain: a clinical prediction score. BMC Med 2010; 8:9. [PMID: 20092615 PMCID: PMC2832616 DOI: 10.1186/1741-7015-8-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2009] [Accepted: 01/21/2010] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Chest pain raises concern for the possibility of coronary heart disease. Scoring methods have been developed to identify coronary heart disease in emergency settings, but not in primary care. METHODS Data were collected from a multicenter Swiss clinical cohort study including 672 consecutive patients with chest pain, who had visited one of 59 family practitioners' offices. Using delayed diagnosis we derived a prediction rule to rule out coronary heart disease by means of a logistic regression model. Known cardiovascular risk factors, pain characteristics, and physical signs associated with coronary heart disease were explored to develop a clinical score. Patients diagnosed with angina or acute myocardial infarction within the year following their initial visit comprised the coronary heart disease group. RESULTS The coronary heart disease score was derived from eight variables: age, gender, duration of chest pain from 1 to 60 minutes, substernal chest pain location, pain increasing with exertion, absence of tenderness point at palpation, cardiovascular risks factors, and personal history of cardiovascular disease. Area under the receiver operating characteristics curve was of 0.95 with a 95% confidence interval of 0.92; 0.97. From this score, 413 patients were considered as low risk for values of percentile 5 of the coronary heart disease patients. Internal validity was confirmed by bootstrapping. External validation using data from a German cohort (Marburg, n = 774) revealed a receiver operating characteristics curve of 0.75 (95% confidence interval, 0.72; 0.81) with a sensitivity of 85.6% and a specificity of 47.2%. CONCLUSIONS This score, based only on history and physical examination, is a complementary tool for ruling out coronary heart disease in primary care patients complaining of chest pain.
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Affiliation(s)
- Baris Gencer
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland.
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