Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home

Objectives

For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home.

Methods

Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting.

Results

A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study.

Conclusion

The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT.

Innovation

Adapting family conferences to primary care for frail patients with polypharmacy.

Die Erfahrung zeigt, dass man mit ganz Einfachem recht gut klar kommt

Ziel: Mit der Durchführung eines Praxistests der S3-Leitlinie zu Diagnostik und Therapie des Ulcus cruris venosum der DGP sollen Akzeptanz und Praktikabilität der Empfehlungen unter Bedingungen der phlebologischen Praxis untersucht und Erkenntnisse über mögliche Barrieren bei der Implementierung in die Regelversorgung erforscht werden.Methoden: Praxisanwendung bei vertragsärztlich tätigen Phlebologen. Qualitativer Ansatz mit Fokusgruppen und Telefoninterviews, die nach Protokollierung bzw. Transkribierung von zwei Forschern unabhängig inhaltsanalytisch unter der globalen Fragestellung des Projektes systematisch ausgewertet wurden. Ergebnisse: Die Phlebologen betrachten die Leitlinie als theoretischen Goldstandard in Abweichung zur eigenen praktischen Tätigkeit. Hemmende Faktoren bei der Umsetzung im Alltag sehen sie in unzureichenden Vergütungsstrukturen, den Patienten selbst sowie verschiedenen Rahmenbedingungen. Evidenzbasiertes Handeln scheint im Alltag nur eine untergeordnete Rolle zu spielen. Schlussfolgerung: Implementierungshindernisse sowie detaillierte Anregungen der Nutzer könnten für eine Überarbeitung der Leitlinie herangezogen werden.

[Ambulatory care of patients with asthma in Germany and disease management program for asthma from the view of statutory health insured patients. A postal survey of statutory health insured patients]

BACKGROUND

In spite of a decline in mortality due to asthma in Germany various studies point towards deficits in asthma care. Our investigation should collect data about ambulatory care from the view of statutory health insured patients (SHI), who participate in the disease management program asthma (DMP-P) or do not (NP). Primary question was, if there is a difference between asthma control. Secondary questions referred to process parameters.

METHODS

The postal inquiry was conducted in 2010 with 8000 randomly selected members of a SHI company with asthma (4000 DMP-P and 4000 NP). The descriptive evaluation of categorical items was performed with cross-tables. The absolute risk reduction (ARR) and 97.5 %-confidence interval (CI; multiple level 5 %) was used to evaluate the primary question. Secondary questions were analysed by ARR and 95 %-CI.

RESULTS

The response rate of the questionnaire accounted for 31.1 % (2565). 49.2 % of all respondents lived with an uncontrolled asthma with no differences between DMP-P and NP (ARR -2.7 %, 97.5 %-CI -7.9 -2.4 %). Results did not alter after adjustment for sex and age. The secondary questions revealed significant differences (DMP-P vs. NP) in participation in asthma trainings 50.6 vs. 32.3 %, use of a peak-flow-meter 49.3 vs. 25.3 % and asthma action plan within reach 21.7 vs. 11.0 %.

CONCLUSION

Half of all respondents lives selfreported - even in the DMP-group - with an uncontrolled asthma. Process parameters showed better results in the DMP-group. It can be considered, that the DMP has its desired effect on patient-centered care, but does not lead to a better therapeutic outcome. Explanations can only be assumed: insufficient impact of the process parameters on the outcome, patient behavior, that minimizes a possible effect, or selection effects, if patients, who were more sick and at the same time more motivated, were mainly included in the DMP. These aspects should be addressed in studies with a prospective design.

[Patients' needs and expectations concerning prevention and health advice in primary care. Results from the EUROPREVIEW survey]

BACKGROUND

The aim of the EUROPREVIEW study was to explore patients' beliefs about primary care prevention, to assess their needs to make changes in lifestyle and their willingness to receive support from GPs.

METHODS

A cross-sectional survey was undertaken in 22 European countries with 10 practices each that consecutively included 40 patients between 30 and 70 years. Validity of the structured questionnaire was evaluated by pilot testing after translation und back-translation for every country. This explorative analysis compared German data on lifestyle factors like smoking, body weight and physical activity to those from other European countries.

RESULTS

There were no differences in patients' needs for changes in unhealthy habits and the views of patients that GPs initiated a discussion on lifestyle factors. In Germany significantly less patients wish to receive advice by their GP [eating habits 41.1 (Germany %) vs. 66.6 (other countries %), physical activity 31.0 vs. 57.0, body weight 44.1 vs. 67.1, smoking 49.1 vs. 63.3, alcohol 43.5 vs. 55.9].

CONCLUSION

Further research should firstly adress the reasons for the low demand by German patients for health advice on lifestyle factors and, if necessary, secondly evaluate the opportunities for a better range of preventive services in primary care.

[Measurement of physical activity in older adults. Correlation between the PRISCUS-PAQ and accelerometry]

BACKGROUND

The German questionnaire PRISCUS-PAQ was developed to measure actual physical activity of older adults in a telephone interview. PRISCUS-PAQ consists of ten main questions to assess the time spend in domestic activities (e.g., housework, gardening), sporting activities (e.g., riding a bicycle), and inactivity (e.g., sedentary activity, sleeping during the day) during the prior week. By assessing the number of days for each activity and the mean duration of performing this activity, a total score can be calculated. The total score corresponds to the energy consumption for 1 week. The aim of this study is to estimate the correlation of the PRISCUS-PAQ total score and accelerometry as an objective measurement method for the assessment of physical activity.

MATERIAL AND METHODS

A total of 114 participants (58% women) with a mean age of 76 years participated in the study. PRISCUS-PAQ was initially analyzed descriptively. To assess the validity of PRISCUS-PAQ, the correlation (correlation coefficient of Spearman) was calculated between the total score of the questionnaire PRISCUS-PAQ and the 95% trimmed sum of an accelerometer with a measurement period of 1 week.

RESULTS

The correlation coefficient for the association of the PRISCUS-PAQ total score and the 95% trimmed sum of the acceleration values was r = 0.28 (95% confidence interval 0.10–0.44). Activities of daily life like cleaning and other domestic activities highly contributed to the weekly energy consumption of the participants.

CONCLUSION

The association between the PRISCUS-PAQ questionnaire and accelerometry measured physical activity is comparable to other validated and established international questionnaires. The PRISCUS-PAQ is the first German questionnaire that allows the measurement of physical activity of older adults in a telephone interview.

An exercise programme for community-dwelling, mobility-restricted and chronically ill older adults with structured support by the general practitioner's practice (HOMEfit). From feasibility to evaluation

Programmes containing health-enhancing physical exercise should be evaluated using standards that are just as rigorous as those required for drug development. In contrast to new medicines, exercise programmes are highly complex. This has to be taken into account when designing the research plan. In order to illustrate the development process of a "complex intervention", we use the example of an exercise programme for community-dwelling, mobility-restricted and chronically ill older adults. Based on a framework for evaluation of complex interventions (Medical Research Council [MRC], UK), a research plan was set up containing the phases: development, feasibility, evaluation, implementation. The development phase resulted in the design of a home-based exercise programme in which the target group is approached and supported via their general practitioner and an exercise therapist. A feasibility study was performed. Three quantitative criteria for feasibility (adoption, safety, continuing participation) were statistically confirmed which permitted the decision to proceed with the research plan. So far, the MRC framework has proved to be valuable for the development of the new programme.

[Reliability of the PRISCUS-PAQ. Questionnaire to assess physical activity of persons aged 70 years and older]

A questionnaire (Q) to measure physical activity (PA) of persons ≥70 years for epidemiological research is lacking. The aim was to develop the PRISCUS-PAQ and test the reliability in community-dwelling people (≥70 years). Validated PA questionnaires were translated and adapted to design the PRISCUS-PAQ. Its test-retest reliability for 91 randomly selected people (36% men) aged 70-98 (76±5) years ranged from 0.47 (walking) to 0.82 (riding a bicycle). The overall activity score was 0.59 as determined by the intraclass correlation coefficient (ICC). Recording of general activities, e.g., housework (ICC=0.59), was in general less reliable than athletic activities, e.g., gymnastics (ICC=0.76). The PRISCUS-PAQ, which is a short instrument with acceptable reliability to collect the physical activity of the elderly in a telephone interview, will be used to collect data in a large cohort of older people in the German research consortium PRISCUS.

The Prevalence of Fullness, Heartburn and Nausea among Persons with and without Diabetes Mellitus in Germany

BACKGROUND

Gastrointestinal symptoms are commonly reported among persons with diabetes mellitus and are attributed to gastropathy as an expression of autonomic neuropathy. These symptoms are also frequent in the general population. The goal of this study was to compare the prevalence of fullness, heartburn and nausea in the German population among persons with and without diabetes mellitus.

METHODS

A cross-sectional study was performed using the German Federal Health Surveys 1987, 1991 and 1998, and involving a representative random sample of German citizens (n = 18 411) aged 25 to 69 years. A comparison was made of the prevalence of self-reported symptoms among persons with and without self-reported diabetes mellitus.

RESULTS

Diabetes mellitus is significantly associated only with nausea in males (OR, 1.75) and in females (OR, 1.88). In both groups, persons with or without diabetes, the prevalence of fullness (28 vs. 21 %) and heartburn (23 vs. 18 %) are about the same, whereas nausea is much less common (12 vs. 6 %). Women suffered more often from nausea than men in people with diabetes and from fullness and nausea in non-diabetic patients. No correlation between age group and the percentage of persons (both sexes) suffering from a certain complaint can be found in persons with diabetes.

CONCLUSIONS

The prevalence of some gastrointestinal symptoms is higher in persons with diabetes. It is related to gender, but not to age. The association with diabetic gastropathy remains unclear.

[A comparison of different methods of performance assessment for the course in general medicine]

A novel Federal Regulation for Basic Medical Education was issued in Germany, which requires an end of course assessment. General Practice (GP) in Duesseldorf has introduced a written examination. An accompanying study was carried out to understand whether different methods of performance evaluation would show equivalent results intraindividually. Out of the GP class 21 students were randomised to undergo an oral examination on top of the regular written examination. Furthermore their teaching practitioners have appraised these students performance in small group teaching. Finally, the students have been rated following a practical term. At the end the students have been interviewed in a focus group to investigate their preferred method of assessment. The survey of the average grades showed comparable results for the written test, the oral examination and small group teaching while the appraisal at the end of the practical term happened to be significantly higher in grade. The comparison of the individual results, however, showed a statistical spreading in all directions. For example, a poor performance in the written test can come along with excellent results in the oral examination and vice versa. The intra-class correlation across all classes has been as low as 0.1. These results support the conclusion that apparently each method can appropriately evaluate only a very specific part of the complex contents of the GP education and of students' performance. In order to properly examine the performance of GP students a combination of different evaluation methods needs to be applied. As an alternative, different skills can be examined in different practical and theoretical test situations in an OSCE.

[Illness concepts and illness experience of patients and their family physicians in varicose ulcer]

Venous ulcers are common in ambulatory care, but there is not much known about the epidemiology or diagnostics and therapeutic strategies in the care for patients by German general practitioners (GPs). In a broader research context we study patients' and their GPs' concepts of disease and their influence on health outcomes. In a pilot study in 1999 a representative sample of all GPs in the State of Hesse (n = 319) are sent a questionnaire. Open problem-centred oral interviews are effected with an asystematic sample of 3 GPs and 2 ulcer patients (n = 6) of each GP to generate hypotheses. In the main study a representative sample of all GPs in the State of North-Rhine are included. They name all of their patients with a fresh venous ulcer during the following 18 months. Especially patients' pain is underestimated by the GPs. From their point of view difficulties in the therapeutic process are often due to 'non-compliant' behaviour of patients. Patients' perceptions of illness and their handling differ individually and are only partially known to the GPs. Concepts of disease and ideas of what is to blame for the development of disease vary considerably.

Ten statements on the motivation of medical teachers to teach

Not only high number of students, increasing disintegration of curricula, lack of resources or hindering state regulations and laws seem to be the crucial problem in medical education worldwide but in particular substantially reduced interest and poor commitment in educational matters. Ten statements on possible reasons for the teachers' lack of motivation to teach are given and proposals for promoting their commitment are made.