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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trying to optimise the German version of the OPTION scale regarding the dyadic aspect of shared decision making

OBJECTIVES

The OPTION scale ("observing patient involvement in decision making") assesses the extent to which clinicians involve patients in decisions across a range of situations in clinical practice. It so far just covers physician behavior. We intended to modify the scoring of the OPTION scale to incorporate active patient behavior in consultations.

METHODS

Modification was done on scoring level, attempting a dyadic, relationship-centred approach in that high ratings can be evoked also by the behaviour of active patients. The German version of the OPTION scale was compared with a modified version by analysing video recordings of primary care consultations dealing with cardiovascular prevention. Fifteen general practitioners provided 40 videotaped consultations. Videos were analysed by two rater pairs and two experts in shared decision making (SDM).

RESULTS

Reliability measures of the modified version were lower than those of the original scale. Significant associations of the dichotomised scale with the expert SDM rating as well as with physicians' expertise in SDM were only found for the modified OPTION scale. Receiver Operating Characteristic (ROC) analyses confirmed a valid differentiation between the presence of SDM (yes/no) on total score level, even though the cut-off point was quite low. Standard deviations of the single items in the modified version were higher compared to the original OPTION scale, while the means of total scores were similar.

CONCLUSIONS

The original OPTION scale is physician-centered and neglects the activity and a possible self-involvement of the patient. Our modified instruction was able to capture the dyadic element partially. The development of a separate dyadic instrument might be more promising.

Impact of short evidence summaries in discharge letters on adherence of practitioners to discharge medication. A cluster-randomised controlled trial

BACKGROUND

International concern about quality of medical care has led to intensive study of interventions to ensure care is consistent with best evidence. Simple, inexpensive, feasible and effective interventions remain limited.

OBJECTIVE

We examined the impact of one-sentence evidence summaries appended to consultants' letters to primary care practitioners on adherence of the practitioners to recommendations made by the consultants regarding medication for patients with chronic medical problems.

DESIGN

Cluster-randomised trial.

SETTING

Secondary/primary care interface (urban district hospital/referral practices).

PARTICIPANTS

178 practices received one or more discharge letters with evidence summaries. The 66 practices in the intervention group provided feedback on 172 letters, and the 56 practices in the control group provided feedback on 96 letters.

RESULTS

Appending an evidence summary to discharge letters resulted in a decrease in non-adherence to discharge medication from 29.6% to 18.5% (difference adjusted for underlying medical condition 12.5%; p = 0.039). Among the five possible reasons for discontinuing discharge medication, the evidence summaries seemed to have the largest impact on budget-related reasons for discontinuation (2.6% in the intervention versus 10.7% in the control group (p = 0.052)). Most clinicians (72%) were enthusiastic about continuing receiving evidence summaries with discharge letters in routine care.

CONCLUSIONS

The one-sentence evidence summary is a simple, inexpensive, well-accepted intervention that may improve primary care practitioners' adherence to evidence-based consultant recommendations.

[Food-drug interactions: an underestimated risk]

With only few exceptions, administration of medicaments should, in principle, be independent of food intake (at least half an hour before or two hours after eating). This ensures uniform and assessable bioavailability. However, it also entails the risk that the patient is more likely to forget to take medication postponed to 2 hours after a meal, than when it is directly coupled to a meal. Certain foodstuffs or food constituents, such as, for example, grapefruit, Seville orange juice, red wine, alcoholic drinks in general, or large quantities of caffeine and garlic should be avoided during drug treatment. In addition, specific interactions with certain drugs must also be taken into account (e.g. MAO inhibitors and tyramine, curamine and vitamin K).

Clinical findings in patients presenting with sore throat. A study on inter-observer reliability

BACKGROUND

Several clinical prediction scores have been developed to help practitioners assess the probability of streptococcal throat infection. Prior to this study, it was not known how reliably doctors assess the signs that contribute to these decision aids.

OBJECTIVE

The aim of this study was to measure the inter-observer reliability of clinical findings related to sore throat.

METHODS

Consecutive patients presenting with sore throat in five primary care practices in Germany took part (n = 126). Each patient was assessed independently by two doctors with regard to lymph nodes, pharynx, soft palate and tonsils.

RESULTS

Agreement among practitioners was not satisfactory.

CONCLUSIONS

Results suggest that the performance of clinical scoring systems can be improved by training on how to elicit relevant clinical signs. Our findings cast some doubt on the effectiveness of under- and post-graduate training in this area.

[Perspectives in the treatment of hypertension in primary care]

Hypertension control by primary care practitioners has improved but is still not satisfactory. Four dilemmata seem to prevent further progress: pharmacological pseudo-innovations, discordance with regard to treatment objectives between patients and doctors, professional heteronomy and limited scope for behavioural change. With ample evidence from epidemiological and intervention studies being available, primary care practitioners are now in a position to counsel their patients more effectively. Models of shared decision-making and motivational interviewing will help to establish a new paradigm of care. However, high-risk approaches aiming at individual risk factor modification are not sufficient. Causes of high blood pressure and cardiovascular morbidity that operate at the population level and limit individual prevention have to be explored and modified.

Treatments for late life depression in primary care--a systematic review

BACKGROUND

Depression is common among older people. It is associated with increased mortality and use of health services. We could identify no prior systematic review of treatment for depression in either primary care attenders or population samples of older people.

OBJECTIVES

The aim of this study was to carry out a systematic review of trials of treatments for depression of patients over 60 years of age in primary care or population samples.

METHODS

We searched Medline, Embase, Cinahl, the Cochrane Library, Psyclit, BIDS--Social Science and BIDS--Science Citation Indices for trials of drug treatment, interpersonal psychotherapy, cognitive behavioural psychotherapy, counselling and social interventions for late life depression in English, French or German published between 1980 and June 1999.

RESULTS

Of the studies identified, only two were of patients over 60 years of age and met all inclusion criteria for content and quality. Three further studies that were not restricted to but included patients over the age of 60 years also fulfilled our criteria. We found no studies of psychological therapies for depression in older people. With few exceptions, studies were limited to older people who reached a diagnostic threshold and excluded those with 'subcase level depression'.

CONCLUSION

There is little evidence of effectiveness for a variety of treatment approaches for depression in older people in primary care, particularly in those with less severe depression. As older people take more medication, making contra-indications to the use of antidepressant drugs more likely, there is a pressing need for studies of the efficacy of non-pharmacological interventions in primary care settings.

Studies of symptoms in primary care

Publications on the frequency of defined symptoms in the practice setting, underlying conditions and prognosis have been rare in the past. Also, studies addressing these questions have suffered from several methodological problems. We therefore developed criteria to help investigators improve the quality of study design, implementation and publication. Studies evaluating symptoms in practice can make an important contribution to a more rational approach to diagnostic decision making especially in primary care.

[Combined vaccine against tetanus, diphtheria and polio. A randomized controlled study of immunogenicity and tolerance]

BACKGROUND, METHOD: Given the worldwide distribution of infection and the mobility of large parts of the population immunizations against tetanus, diphtheria and polio remain a challenge. This is especially true for adolescents and adults since antibodies tend to wane once immunized children enter adolescence and adulthood. A new combination vaccine against tetanus, diphtheria and polio (Td-IPV) for booster immunizations was subjected to a randomized, controlled and single-blind trial. Non-inferiority had to be demonstrated with regard to efficacy (immunogenicity) and safety in comparison to separate Td and IPV injections.

RESULTS

Almost 500 subjects from community practices and occupational/immunization clinics took part. Antibody titres were equivalent for all antigens. Local and systemic reactions were equal or even less marked in the intervention group.

CONCLUSION

From a public health perspective the new vaccine can make an important contribution to ensure adequate protection against tetanus, diphtheria and polio in adolescent and adult populations.

[Guidelines Clearing House Statement "Hypertension". Summary and recommendations for a rational hypertension guideline in Germany]

BACKGROUND

In order to promote quality of hypertension management in Germany, a national hypertension guidelines clearing project was initiated in 1999 by the German Guidelines Clearinghouse.

OBJECTIVES

To identify and review published German- and English language hypertension guidelines. To establish criteria for future guideline development and implementation. To familiarize stakeholders in Germany with state-of-the-art hypertension guidelines. To identify key topics for a future national evidence-based guideline.

METHODS

Search procedure, formal appraisal: Systematic search using literature databases and English-/German-language databases, published between 1990 and 1999. Abstract screening of the search results according to the inclusion criteria (n = 132 of a total of 548 hits). Systematic guideline evaluation using checklist with predefined criteria. APPRAISAL OF GUIDELINES' CONTENTS: Peer review of guidelines with the following inclusion criteria: hypertension--general, German and English language, published later than 1994, original or primary guideline or update, issued for nationwide use. Peer review was performed by a multidisciplinary focus group of EBM experts (primary and secondary care physicians, clinical pharmacologist, clinical epidemiologist). None of these was involved in hypertension guideline development during the review period. DOCUMENTATION OF CRITICAL APPRAISAL RESULTS: Systematic documentation of methodological appraisal and peer review results using a structured abstract form. The focus group wrote a final report (clearing report) including methodological abstracts for each guideline, essential topics for a future German hypertension guideline based on examples from the appraised guidelines, comments and recommendations for health care policy markers in Germany.

RESULTS

11 out of 132 guidelines were in accordance with the formal minimal standard with a wide range range within the following domains: "description of the development process", "declaration of authors' independence", "explicit link between recommendations and the supporting evidence", "management options", "tools for implementation". None of the guidelines identified all the key identified by the focus group, such as: (1) definition of hypertension--epidemiology--health care problems--intended guideline users/goals, (2) blood pressure measurement, (3) medical history and physical examination, (4) case-finding/screening, (5) indications for referral, (6) risk-stratification, (7) diagnostic procedures, (8) therapeutic goals/indications for therapy, (9) nonpharmacological measures, (10), pharmacotherapy, (11) follow-up/patient education/motivation/compliance, (12) comorbidity, hypertension in childhood/elderly, pregnancy, (13) primary prevention, (14) quality assurance/quality management, (15) dissemination/implementation, (16) open questions/challenges for the future.

SUMMARY POINTS

To improve the quality of hypertension management in Germany, the expert panel suggested to develop a national evidence-based guideline. This should follow internationally agreed criteria and procedures. The experts identified and reviewed 11 out of 132 hypertension, which might make useful contributions for a future German Hypertension guideline. The expert group identified 16 key topics for a national hypertension guideline.

Improving physician-delivered counseling in a primary care setting: lessons from a failed attempt

BACKGROUND

The high prevalence of behavioral risk factors for cardiovascular diseases demands innovative approaches to achieving behavior change. Primary care physicians are in an ideal position for offering such interventions.

PURPOSE

To evaluate whether training of primary care physicians in counseling skills based on the Transtheoretical Model (TTM) leads to motivational and behavioral changes in their patients.

METHOD

Seventy-four primary care physicians in Germany were randomly assigned to either an intervention condition (one day of training in TTM-based counseling plus brochures matched to their patients' "stages of change") or a control condition (usual care). Baseline and 12-month follow-up data were collected from 305 of their patients who signed up for a health check-up.

OUTCOME MEASURE

Patients' movements across the stages of change for smoking, diet, exercise and stress management.

RESULTS

After 12 months, patients of physicians in the intervention group did not show more movement through the stages of change for any of the behaviors than did patients of control physicians. Additionally, there were no differences between groups in counseling frequency, counseling intensity, or patient satisfaction with counseling.

CONCLUSIONS

A high dropout rate at follow-up and resulting "power" problems limit the possible conclusions. The high numbers of patients in early stages of change and the minimal improvement over time underline the need for improving motivational counseling skills of primary care physicians in Germany. In our study the dissemination of these strategies failed. We offer lessons we feel can be learned from this outcome. Further studies should focus on ways to enhance the process of educating physicians for implementing counseling strategies in primary care settings.

[Community emergency medical service. Epidemiology and quality of treatment in a rural district]

OBJECTIVES

Rapid aid provided by lay witnesses and emergency services can improve the outcome in medical emergencies arising in the community. We attempted to study the quality of first aid rendered by lay persons, paramedical personnel, and community medical practitioners attending out-of-hospital emergencies. We also evaluated the frequency of first aid provided before the arrival of specialised emergency physicians.

METHODS

Over a period of six months all emergencies in a rural district of Germany leading to the pre-hospital medical service being dispatched were studied. Specialised community emergency physicians arriving at the site of the event recorded demographic, clinical, and process data using a standardised instrument. They also assessed the performance of lay persons, paramedical personnel, and community physicians providing immediate care. Implicit and explicit criteria were used.

RESULTS

In 97% of cases analysed (n = 1150) members of the above mentioned groups were present before the arrival of the dedicated medical service. Lay persons were judged to provide inadequate care especially with regard to airway management and immobilisation of suspected fractures. For paramedical personnel, the administration of medication, venous lines and immobilisation turned out to be problematic areas. Medical practitioners fell below the defined standards especially in airway management, immobilisation and venous lines.

CONCLUSION

Our project has shown how important the evaluated groups are for community emergency care. Despite methodological problems in this area of study, the shortcomings demonstrated may be targeted by future training at different levels.

'Home hypertension': exploring the inverse white coat response

BACKGROUND

The classical 'white coat response' to blood pressure measurement has been studied thoroughly. However, little is known about patients showing a reverse pattern, i.e. who have lower blood pressure readings at the clinic than outside healthcare facilities.

AIM

To estimate the proportion of patients whose blood pressure levels as determined by self-measurements at home are higher than those taken at the clinic and to explore possible associations with demographic, clinical, and psychological variables.

METHOD

Patients consecutively attending (n = 214) an academic family medicine department in Toronto, Canada, were eligible. Subjects aged below 16 years and those on psychotropic or blood pressure-lowering agents were excluded. The clinic-home blood pressure difference (CHBPD) was calculated for each participating subject by subtracting home blood pressure from clinic blood pressure. Those who had negative values were compared with the rest of the sample.

RESULTS

A considerable proportion of patients had lower blood pressure at the clinic than at home (systolic, 34.6%; diastolic, 23.8%). These subjects did not differ from the rest of the sample with regard to age, sex, levels of education attained, immigration status, body mass index, experience of current symptoms, blood pressure levels, or psychological distress. However, in patients with a 'negative CHBPD', i.e. lower blood pressure at the clinic than at home, readings taken by an automatic, self-inflating device when still at the clinic were higher than in the rest of the sample.

CONCLUSION

The results point to measurement bias being at least partly responsible for higher blood pressure readings outside the clinic. Automatic measurement devices used for self/home blood pressure measurement seem to cause an alerting reaction analogous to the well-described 'white coat response'.

Family practitioners' remuneration and patterns of care--does social class matter?

The objective of the study is to examine whether medical care patterns and/or outcomes for patients under a prepaid system differ from those under fee-for-service according to social class. An effect of this kind was suggested by the investigators reporting on the RAND Health Insurance Experiment (RAND HIE). We performed a cross-sectional study in family practice in Germany (fee-for-service) and the UK (predominantly capitation i.e. prospective payment). 778 attending patients aged 18 and above were included. Indicators of care, relating mainly to cardiovascular prevention, were collected by patient interview and questionnaire, doctor's questionnaire, analysis of records, and blood pressure (BP) measurement. Multiple linear and logistic regression models with these indicators as dependent variables were calculated to examine possible interactions between social class and system of payment. Social class as a main effect was related to diastolic BP, BP measurement frequency, and the number of non-pharmacological interventions to lower BP. The data on the process and the outcome of primary care from British and German family practice do not show any significant interaction between system of family practitioners' remuneration and patients' social class. We were unable to reproduce the effect postulated by the RAND HIE investigators.

Low blood pressure associated with low mood: a red herring?

OBJECTIVE

Several reports have discussed a relationship between blood pressure (BP) and psychological well-being scales. Lower BP readings were associated with higher levels of psychological distress and fatigue. This study sought to replicate the association found by previous secondary analyses of epidemiological surveys.

DESIGN

Cross-sectional study.

SETTING

Academic Family Medicine Department in Toronto, Canada.

SUBJECTS

214 practice attenders. STUDY MEASURES: Extent of psychological abnormalities with the General Health Questionnaire (GHQ), self-reported fatigue, in-clinic and home BP measurements.

RESULTS

No significant relationship between blood pressure levels and GHQ-score or fatigue could be demonstrated. This applies to clinic and home measurements for systolic and diastolic pressure. Neither adjustment for age or sex nor for several confounders through multiple linear regression produced significant associations in the postulated direction. No nonlinear relationship could be shown either. The study had a power of 95% to detect a correlation of r = 0.22 (alpha = 0.05, one-sided).

CONCLUSION

The study specifically addressing the possible link between blood pressure and psychological dysfunction/fatigue, could not confirm the previously reported association. Problems related to type-I error in epidemiological research are discussed.

Is the 'clinic-home blood pressure difference' associated with psychological distress? A primary care-based study

OBJECTIVE

To determine whether there is an association between the 'clinic-home blood pressure difference' (CHBPD) and psychological distress in a sample not selected without regard to blood pressure and hypertension status.

DESIGN

A cross-sectional study.

SETTING

An academic family medicine department in Toronto, Canada.

PARTICIPANTS

Consecutive attenders (n = 214) of the primary care facility. Subjects aged less than 16 years and those being administered psychotropic or blood pressure-lowering agents were excluded.

MAIN OUTCOME MEASURES

The CHBPD was calculated from clinic blood pressure readings and self-measurements by subjects at home; psychological distress was measured by the 30-item version of the General Health Questionnaire (GHQ).

RESULTS

No significant association between the CHBPD and psychological distress could be shown for systolic and diastolic blood pressures. The same applied to GHQ subdomains and the CHBPD modelled on several independent variables by multiple linear regression analyses.

CONCLUSION

The results from this study, using a large sample drawn from a community, support the view that the CHBPD is not related to anxiety, depression and other forms of psychological distress, but rather is a reaction specific to the clinic setting itself.

Family practitioners' intervention against smoking in Germany and the UK: does remuneration affect preventive activity?

The effect of different systems of remuneration on preventive activity of family practitioners (FPs) were studied. Interventions against smoking were compared in FPs' practices in Germany and the UK. Almost 800 consecutively attending patients were included in a cross-sectional survey. Smoking prevalence was remarkably similar among German and British practice attenders. Slightly more than 50% of smokers in both countries remembered an intervention against their smoking by their FP or related staff. Multiple logistic regression analysis also showed that there was no significant difference for remembered interventions between the two countries (adjusted OR 1.15 [95%-Cl 0.6, 2.2]). The structure of interventions employed was similar in both countries. Most British and German ex-smokers denied that their FP had made an important contribution to their giving up smoking. There is evidence that, under capitation, FPs concentrate their activities on patients who are more at risk. Overall, however, the economic structure does not seem to influence the core of preventive behaviour of FPs to any great extent. Smoking cessation efforts in Family Practice need to be improved in both countries.

Hypotension--does it make sense in family practice?

In general practice many diagnostic labels are used that are related to cultural background rather than a scientific basis. To estimate the use of diagnoses like 'hypotension' and depression, a cross-sectional survey in German and British GPs' surgeries was performed. Prevalence of related symptoms, sociodemographic and medical data were recorded as well as actual and previous blood pressure levels. In German general practice, where 'hypotension' is an established entity, 17% of all patients attending were reported as hypotensive either by their doctor or by themselves. The proportion was twice as high among women than among men. It was more common among the young. One-quarter of these patients were on medication to raise their blood pressure. Actual and previous blood pressure levels failed to explain the occurrence of symptoms like tiredness, dizziness, headache etc. Demographic characteristics of patients diagnosed as depressed were similar in both countries. Presumably for economic reasons there is a tendency for German GPs to use more diagnostic labels of any kind. It was concluded that diagnostic labels attached to vague but frequently presented symptoms vary considerably between countries. They often lack a physiologic rationale. Nevertheless they often support the tendency to somatize common problems.