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1.  Weekly self-measurement of FEV1 and PEF and its impact on ACQ (asthma control questionnaire)-scores: 12-week observational study with 76 patients 
The “Asthma Control Questionnaire” (ACQ) is a very common questionnaire for assessing asthma control. This study compares different ACQ versions in a self-monitoring program over a 12-week period combining them with patients' self-measurements of peak expiratory flow (PEF) and forced expiratory volume in one second (FEV1). The objective was to test the feasibility of FEV1-self-measurements and to compare ACQ versions regarding possible additional information given by lung function. In this prospective multicenter observational study 100 adult asthma patients, recruited at six family practices and two pulmologists' private practices in Germany, completed the ACQ weekly, performing self-measurements of PEF and FEV1. Seventy-six patients were included into final analysis with only 3% missing values. Scores for all ACQ versions improved significantly (all P-values < 0.05) with reductions of 32% for ACQ5, 31% for ACQ6, 22% for ACQ7-FEV1, and 21% for ACQ7-PEF with high Pearson’s correlation coefficients of all scores (r between 0.96 and 0.99). ACQ7-FEV1 scores were significantly higher than others. Separated courses of lung function parameters showed nearly no change, but ACQ5 and ACQ6 as scores for symptoms and reliever medication improved constantly. ACQ5 and ACQ6 revealed higher percentages of patients classified as “controlled” than ACQ7-scores. In conclusion, with only a few missing data points, our results suggest feasibility of FEV1-self-measurements. Courses of symptom-related and lung function-related ACQ items differ clearly. Our results support the GINA recommendations to consider symptoms and lung function separately. FEV1-self-measurements for research purposes may be included with the ACQ, but in clinical practice seem to measure a different domain to symptomatic asthma control.
Asthma: self-measurement of lung function is feasible
Lung function tests taken by patients at home is doable, but yields different information than self-reports of disease control. Christoph Werner and colleagues from the Technical University of Munich, Germany, tested the feasibility of collecting lung function data from patients who measured forced expiratory volume in one second by themselves. These same patients also completed the Asthma Control Questionnaire (ACQ), which describes symptom severity and medication use. Looking at data from 76 participants, the researchers found that people did well measuring forced expiratory volume in one second, but they could not say whether this test was superior to another metric of lung function that considers peak expiratory flow. The results also showed that symptom scores and lung function assays seem to capture different aspects of the disease, meaning they’re worth considering separately rather than lumping together in a single test.
doi:10.1038/s41533-017-0064-4
PMCID: PMC5722863  PMID: 29222436
2.  Reasons for encounters and psychiatric comorbidity in an urban Bavarian primary care out-of-hour service - results of a cross sectional study 
Background
International studies have shown a contribution of psychiatric comorbidity to high utilization rates in out-of-hour primary care (OOHC). Up to now, the impact of psychiatric comorbidity in German OOHC remains unclear. Therefore, we aimed to investigate reasons for encounter (RFE), possible psychiatric comorbidity, utilization rates, and a possible association between utilization rate and psychiatric comorbidity among patients of an urban OOHC unit.
Methods
In a cross-sectional, prospective, naturalistic study five hundred self-referred patients completed a self-designed questionnaire addressing RFE, past office visits and personal information. Additionally, we employed three validated questionnaires (PHQ-9, PHQ-15 and GAD-7) to screen for mental disorders. We collected information about past visits through computerized patients’ charts. Diagnoses were classified according to the International Classification of Primary Care-2.
Results
The most frequent RFE were musculoskeletal complaints (36%), followed by respiratory diseases (13%), gastrointestinal problems (10%), skin conditions (8%) and urologic ailments (6%). Of the included patients 58% were working fulltime and 61% had greater than or equal to 10 years of education. The mean age was 37.3 in females and 40.5 years in males. Prevalence of psychiatric comorbidity was 27%. Only 3% visited the office more than twice over a 12 months period. We could not find an association between high utilization and psychiatric comorbidity.
Conclusion
In this study, musculoskeletal complaints were the most frequent RFE. Patients were predominantly young, employed and educated. The prevalence of psychiatric comorbidity was similar to the prevalence in common general practitioner offices and showed no significant relation to frequent attendance. This information might help to prepare physicians better for patient care in OOHC.
doi:10.1186/s12913-017-2749-3
PMCID: PMC5704587  PMID: 29183310
Out-of-hour primary care; Psychiatric comorbidity; Reason for encounter; General practitioner office; Utilization rate; Sociodemographic variables
3.  Impact of regional socioeconomic variation on coordination and cost of ambulatory care: investigation of claims data from Bavaria, Germany 
BMJ Open  2017;7(10):e016218.
Objectives
A considerable proportion of regional variation in healthcare use and health expenditures is to date still unexplained. The aim was to investigate regional differences in the gatekeeping role of general practitioners and to identify relevant explanatory variables at patient and district level in Bavaria, Germany.
Design
Retrospective routine data analysis using claims data held by the Bavarian Association of Statutory Health Insurance Physicians.
Participants
All patients who consulted a specialist in ambulatory practice within the first quarter of 2011 (n=3 616 510).
Outcomes measures
Of primary interest is the effect of district-level measures of rurality, physician density and multiple deprivation on (1) the proportion of patients with general practitioner (GP) coordination of specialist care and (2) the mean amount in Euros claimed by specialist physicians.
Results
The proportion of patients whose use of specialist services was coordinated by a GP was significantly higher in rural areas and in highly deprived regions, as compared with urban and less deprived regions. The hierarchical models revealed that increasing age and the presence of chronic diseases are the strongest predictive factors for coordination by a GP. In contrast, the presence of mental illness, an increasing number of medical condition categories and living in a city are predictors for specialist use without GP coordination. The amount claimed per patient was €10 to €20 higher in urban districts and in regions with lower deprivation. Hierarchical models indicate that this amount is on average higher for patients living in towns and lower for patients in regions with high deprivation.
Conclusion
The present study shows that regional deprivation is closely associated with the way in which patients access primary and specialist care. This has clear consequences, both with respect to the role of the general practitioner and the financial costs of care.
doi:10.1136/bmjopen-2017-016218
PMCID: PMC5665322  PMID: 29061608
healthcare research; regional variation; coordinated healthcare; gatekeeping; regional deprivation
4.  Self-help guidebook improved quality of life for patients with irritable bowel syndrome 
PLoS ONE  2017;12(7):e0181764.
Background
The primary aim of our study was to evaluate the impact of a comprehensive self-help guidebook on the disease related quality of life for patients with irritable bowel syndrome (IBS). The secondary aim was to evaluate whether the guidebook is less effective in IBS patients with depression, somatization disorder or panic disorder as a psychiatric comorbidity.
Methods
Prospective observational study. At baseline (t1), patients filled in the ´Functional Digestive Disorders Quality of Life´ (FDDQL) questionnaire and received the IBS guidebook together with an explanation of its content and use. Depression, anxiety and somatization were evaluated with the Patient Health Questionnaire (PHQ). Three (t2) and six months (t3) later, the questionnaire was sent by mail to the patients for follow-up evaluation. Data were analyzed with repeated measures ANOVA.
Results
71 patients participated (74.6% female). 53 (74.6%) completed the final assessment at t3 after 6 months. The global FDDQL score increased from 49.3 (SD 12.7) at t1 to 64.3 (SD 16.0) at t3 (p < 0.001). There was a significant between-subjects effect on the global FDDQL score related to depression (p = 0.001), anxiety (p = 0.001) and somatization (p = 0.011). Thus, the quality of life of patients with psychosomatic comorbidity was lower at baseline, but showed a similar increase within the following six months.
Conclusion
The self-help guidebook significantly improved measured quality of life for IBS patients. The use of screening questionnaires like PHQ might be valuable to identify patients with more complex problems. This might be helpful for them to intensify and adapt therapy. Further research has to evaluate if patients with psychological comorbidity are treated more effectively when they receive psychotherapy or specific medication in addition to the self-management guidebook.
doi:10.1371/journal.pone.0181764
PMCID: PMC5526555  PMID: 28742808
5.  World Congress Integrative Medicine & Health 2017: Part one 
Brinkhaus, Benno | Falkenberg, Torkel | Haramati, Aviad | Willich, Stefan N. | Briggs, Josephine P. | Willcox, Merlin | Linde, Klaus | Theorell, Töres | Wong, Lisa M. | Dusek, Jeffrey | Wu, Darong | Eisenberg, David | Haramati, Aviad | Berger, Bettina | Kemper, Kathi | Stock-Schröer, Beate | Sützl-Klein, Hedda | Ferreri, Rosaria | Kaplan, Gary | Matthes, Harald | Rotter, Gabriele | Schiff, Elad | Arnon, Zahi | Hahn, Eckhard | Luberto, Christina M. | Martin, David | Schwarz, Silke | Tauschel, Diethard | Flower, Andrew | Gramminger, Harsha | Gupta, Hedwig H. | Gupta, S. N. | Kerckhoff, Annette | Kessler, Christian S. | Michalsen, Andreas | Kessler, Christian S. | Kim, Eun S. | Jang, Eun H. | Kim, Rana | Jan, Sae B. | Mittwede, Martin | Mohme, Wiebke | Ben-Arye, Eran | Bonucci, Massimo | Saad, Bashar | Breitkreuz, Thomas | Rossi, Elio | Kebudi, Rejin | Daher, Michel | Razaq, Samaher | Gafer, Nahla | Nimri, Omar | Hablas, Mohamed | Kienle, Gunver Sophia | Samuels, Noah | Silbermann, Michael | Bandelin, Lena | Lang, Anna-Lena | Wartner, Eva | Holtermann, Christoph | Binstock, Maxwell | Riebau, Robert | Mujkanovic, Edin | Cramer, Holger | Lauche, Romy | Michalsen, Andres | Ward, Lesley | Cramer, Holger | Irnich, Dominik | Stör, Wolfram | Burnstock, Geoffrey | Schaible, Hans-Georg | Ots, Thomas | Langhorst, Jost | Lauche, Romy | Sundberg, Tobias | Falkenberg, Torkel | Amarell, Catherina | Amarell, Catherina | Anheyer, Melanie | Eckert, Marion | Eckert, Marion | Ogal, Mercedes | Eckert, Marion | Amarell, Catherina | Schönauer, Annette | Reisenberger, Birgit | Brand, Bernhard | Anheyer, Dennis | Dobos, Gustav | Kroez, Matthias | Martin, David | Matthes, Harald | Ammendola, Aldo | Mao, Jun J. | Witt, Claudia | Yang, Yufei | Dobos, Gustav | Oritz, Miriam | Horneber, Markus | Voiß, Petra | Reisenberger, Birgit | von Rosenstiel, Alexandra | Eckert, Marion | Ogal, Mercedes | Amarell, Catharina | Anheyer, Melanie | Schad, Friedemann | Schläppi, Marc | Kröz, Matthias | Büssing, Arndt | Bar-Sela, Gil | Matthes, Harald | Schiff, Elad | Ben-Arye, Eran | Arnon, Zahi | Avshalomov, David | Attias, Samuel | Schönauer, Annette | Haramati, Aviad | Witt, Claudia | Brinkhaus, Benno | Cotton, Sian | Jong, Miek | Jong, Mats | Scheffer, Christian | Haramati, Aviad | Tauschel, Diethard | Edelhäuser, Friedrich | AlBedah, Abdullah | Lee, Myeong Soo | Khalil, Mohamed | Ogawa, Keiko | Motoo, Yoshiharu | Arimitsu, Junsuke | Ogawa, Masao | Shimizu, Genki | Stange, Rainer | Kraft, Karin | Kuchta, Kenny | Watanabe, Kenji | Bonin, D | Büssing, Arndt | Gruber, Harald | Koch, Sabine | Gruber, Harald | Pohlmann, Urs | Caldwell, Christine | Krantz, Barbara | Kortum, Ria | Martin, Lily | Wieland, Lisa S. | Kligler, Ben | Gould-Fogerite, Susan | Zhang, Yuqing | Wieland, Lisa S. | Riva, John J. | Lumpkin, Michael | Ratner, Emily | Ping, Liu | Jian, Pei | Hamme, Gesa-Meyer | Mao, Xiaosong | Chouping, Han | Schröder, Sven | Hummelsberger, Josef | Wullinger, Michael | Brodzky, Marc | Zalpour, Christoff | Langley, Julia | Weber, Wendy | Mudd, Lanay M. | Wayne, Peter | Witt, Clauda | Weidenhammer, Wolfgang | Fønnebø, Vinjar | Boon, Heather | Steel, Amie | Bugarcic, Andrea | Rangitakatu, Melisa | Steel, Amie | Adams, Jon | Sibbritt, David | Wardle, Jon | Leach, Matthew | Schloss, Janet | Dieze, Helene | Boon, Heather | Ijaz, Nadine | Willcox, Merlin | Heinrich, Michael | Lewith, George | Flower, Andrew | Graz, Bertrand | Adam, Daniela | Grabenhenrich, Linus | Ortiz, Miriam | Binting, Sylvia | Reinhold, Thomas | Brinkhaus, Benno | Andermo, Susanne | Sundberg, Tobias | Falkenberg, Torkel | Nordberg, Johanna Hök | Arman, Maria | Bhasin, Manoj | Fan, Xueyi | Libermann, Towia | Fricchione, Gregory | Denninger, John | Benson, Herbert | Berger, Bettina | Stange, Rainer | Michalsen, Andreas | Martin, David D. | Boers, Inge | Vlieger, Arine | Jong, Miek | Brinkhaus, Benno | Teut, Michael | Ullmann, Alexander | Ortiz, Miriam | Rotter, Gabriele | Binting, Sylvia | Lotz, Fabian | Roll, Stephanie | Canella, Claudia | Mikolasek, Michael | Rostock, Matthias | Beyer, Jörg | Guckenberger, Matthias | Jenewein, Josef | Linka, Esther | Six, Claudia | Stoll, Sarah | Stupp, Roger | Witt, Claudia M. | Chuang, Elisabeth | Kligler, Ben | McKee, Melissa D. | Cramer, Holger | Lauche, Romy | Klose, Petra | Lange, Silke | Langhorst, Jost | Dobos, Gustav | Chung, Vincent C. H. | Wong, Hoi L. C. | Wu, Xin Y. | Wen, Grace Y. G. | Ho, Robin S. T. | Ching, Jessica Y. L. | Wu, Justin C. Y. | Coakley, Amanda | Flanagan, Jane | Annese, Christine | Empoliti, Joanne | Gao, Zishan | Liu, Xugang | Yu, Shuguang | Yan, Xianzhong | Liang, Fanrong | Hohmann, Christoph D. | Steckhan, Nico | Ostermann, Thomas | Paetow, Arion | Hoff, Evelyn | Michalsen, Andreas | Hu, Xiao-Yang | Wu, Ruo-Han | Logue, Martin | Blonde, Clara | Lai, Lily Y. | Stuart, Beth | Flower, Andrew | Fei, Yu-Tong | Moore, Michael | Liu, Jian-Ping | Lewith, George | Hu, Xiao-Yang | Wu, Ruo-Han | Logue, Martin | Blonde, Clara | Lai, Lily Y. | Stuart, Beth | Flower, Andrew | Fei, Yu-Tong | Moore, Michael | Liu, Jian-Ping | Lewith, George | Jeitler, Michael | Zillgen, Hannah | Högl, Manuel | Steckhan, Nico | Stöckigt, Barbara | Seifert, Georg | Michalsen, Andreas | Kessler, Christian | Khadivzadeh, Talat | Bashtian, Maryam Hassanzadeh | Aval, Shapour Badiee | Esmaily, Habibollah | Kim, Jihye | Kim, Keun H. | Klocke, Carina | Joos, Stefanie | Koshak, Abdulrahman | Wie, Li | Koshak, Emad | Wali, Siraj | Alamoudi, Omer | Demerdash, Abdulrahman | Qutub, Majdy | Pushparaj, Peter | Heinrich, Michael | Kruse, Sigrid | Fischer, Isabell | Tremel, Nadine | Rosenecker, Joseph | Leung, Brenda | Takeda, Wendy | Liang, Ning | Feng, Xue | Liu, Jian-ping | Cao, Hui-juan | Luberto, Christina M. | Shinday, Nina | Philpotts, Lisa | Park, Elyse | Fricchione, Gregory L. | Yeh, Gloria | Munk, Niki | Zakeresfahani, Arash | Foote, Trevor R. | Ralston, Rick | Boulanger, Karen | Özbe, Dominik | Gräßel, Elmar | Luttenberger, Katharina | Pendergrass, Anna | Pach, Daniel | Bellmann-Strobl, Judit | Chang, Yinhui | Pasura, Laura | Liu, Bin | Jäger, Sven F. | Loerch, Ronny | Jin, Li | Brinkhaus, Benno | Ortiz, Miriam | Reinhold, Thomas | Roll, Stephanie | Binting, Sylvia | Icke, Katja | Shi, Xuemin | Paul, Friedemann | Witt, Claudia M. | Rütz, Michaela | Lynen, Andreas | Schömitz, Meike | Vahle, Maik | Salomon, Nir | Lang, Alon | Lahat, Adi | Kopylov, Uri | Ben-Horin, Shomron | Har-Noi, Ofir | Avidan, Benjamin | Elyakim, Rami | Gamus, Dorit | NG, Siew | Chang, Jessica | Wu, Justin | Kaimiklotis, John | Schumann, Dania | Buttó, Ludovica | Langhorst, Jost | Dobos, Gustav | Haller, Dirk | Cramer, Holger | Smith, Caroline | de Lacey, Sheryl | Chapman, Michael | Ratcliffe, Julie | Johnson, Neil | Lyttleton, Jane | Boothroyd, Clare | Fahey, Paul | Tjaden, Bram | van Vliet, Marja | van Wietmarschen, Herman | Jong, Miek | Tröger, Wilfried | Vuolanto, Pia | Aarva, Paulina | Sorsa, Minna | Helin, Kaija | Wenzel, Claudia | Zoderer, Iris | Pammer, Patricia | Simon, Patrick | Tucek, Gerhard | Wode, Kathrin | Henriksson, Roger | Sharp, Lena | Stoltenberg, Anna | Nordberg, Johanna Hök | Xiao-ying, Yang | Wang, Li-qiong | Li, Jin-gen | Liang, Ning | Wang, Ying | Liu, Jian-ping | Balneaves, Lynda | Capler, Rielle | Bocci, Chiara | Guffi, Marta | Paolini, Marina | Meaglia, Ilaria | Porcu, Patrizia | Ivaldi, Giovanni B. | Dragan, Simona | Bucuras, Petru | Pah, Ana M. | Badalica-Petrescu, Marius | Buleu, Florina | Hogea-Stoichescu, Gheorghe | Christodorescu, Ruxandra | Kao, Lan | Cho, Yumin | Klafke, Nadja | Mahler, Cornelia | von Hagens, Cornelia | Uhlmann, Lorenz | Bentner, Martina | Schneeweiss, Andreas | Mueller, Andreas | Szecsenyi, Joachim | Joos, Stefanie | Neri, Isabella | Ortiz, Miriam | Schnabel, Katharina | Teut, Michael | Rotter, Gabriele | Binting, Sylvia | Cree, Margit | Lotz, Fabian | Suhr, Ralf | Brinkhaus, Benno | Rossi, Elio | Baccetti, Sonia | Firenzuoli, Fabio | Monechi, Maria V. | Di Stefano, Mariella | Amunni, Gianni | Wong, Wendy | Chen, Bingzhong | Wu, Justin | Amri, Hakima | Haramati, Aviad | Kotlyanskaya, Lucy | Anderson, Belinda | Evans, Roni | Kligler, Ben | Marantz, Paul | Bradley, Ryan | Booth-LaForce, Cathryn | Zwickey, Heather | Kligler, Benjamin | Brooks, Audrey | Kreitzer, Mary J. | Lebensohn, Patricia | Goldblatt, Elisabeth | Esmel-Esmel, Neus | Jiménez-Herrera, Maria | Ijaz, Nadine | Boon, Heather | Jocham, Alexandra | Stock-Schröer, Beate | Berberat, Pascal O. | Schneider, Antonius | Linde, Klaus | Masetti, Morgana | Murakozy, Henriette | Van Vliet, Marja | Jong, Mats | Jong, Miek | Agdal, Rita | Atarzadeh, Fatemeh | Jaladat, Amir M. | Hoseini, Leila | Amini, Fatemeh | Bai, Chen | Liu, Tiegang | Zheng, Zian | Wan, Yuxiang | Xu, Jingnan | Wang, Xuan | Yu, He | Gu, Xiaohong | Daneshfard, Babak | Nimrouzi, Majid | Tafazoli, Vahid | Alorizi, Seyed M. Emami | Saghebi, Seyed A. | Fattahi, Mohammad R. | Salehi, Alireza | Rezaeizadeh, Hossein | Zarshenas, Mohammad M. | Nimrouzi, Majid | Fox, Kealoha | Hughes, John | Kostanjsek, Nenad | Espinosa, Stéphane | Lewith, George | Fisher, Peter | Latif, Abdul | Lefeber, Donald | Paske, William | Öztürk, Ali Ö. | Öztürk, Gizemnur | Boers, Inge | Tissing, Wim | Naafs, Marianne | Busch, Martine | Jong, Miek | Daneshfard, Babak | Sanaye, Mohammad R. | Dräger, Kilian | Fisher, Peter | Kreitzer, Mary J. | Evans, Roni | Leininger, Brent | Shafto, Kate | Breen, Jenny | Sanaye, Mohammad R. | Daneshfard, Babak | Simões-Wüst, Ana P. | Moltó-Puigmartí, Carolina | van Dongen, Martien | Dagnelie, Pieter | Thijs, Carel | White, Shelley | Wiesener, Solveig | Salamonsen, Anita | Stub, Trine | Fønnebø, Vinjar | Abanades, Sergio | Blanco, Mar | Masllorens, Laia | Sala, Roser | Al-Ahnoumy, Shafekah | Han, Dongwoon | He, Luzhu | Kim, Ha Yun | In Choi, Da | Alræk, Terje | Stub, Trine | Kristoffersen, Agnete | von Sceidt, Christel | Michalsen, Andreas | Bruset, Stig | Musial, Frauke | Anheyer, Dennis | Cramer, Holger | Lauche, Romy | Saha, Felix J. | Dobos, Gustav | Anheyer, Dennis | Haller, Heidemarie | Lauche, Romy | Dobos, Gustav | Cramer, Holger | Azizi, Hoda | Khadem, Nayereh | Hassanzadeh, Malihe | Estiri, Nazanin | Azizi, Hamideh | Tavassoli, Fatemeh | Lotfalizadeh, Marzieh | Zabihi, Reza | Esmaily, Habibollah | Azizi, Hoda | Shabestari, Mahmoud Mohammadzadeh | Paeizi, Reza | Azari, Masoumeh Alvandi | Bahrami-Taghanaki, Hamidreza | Zabihi, Reza | Azizi, Hamideh | Esmaily, Habibollah | Baars, Erik | De Bruin, Anja | Ponstein, Anne | Baccetti, Sonia | Di Stefano, Mariella | Rossi, Elio | Firenzuoli, Fabio | Segantini, Sergio | Monechi, Maria Valeria | Voller, Fabio | Barth, Jürgen | Kern, Alexandra | Lüthi, Sebastian | Witt, Claudia | Barth, Jürgen | Zieger, Anja | Otto, Fabius | Witt, Claudia | Beccia, Ariel | Dunlap, Corina | Courneene, Brendan | Bedregal, Paula | Passi, Alvaro | Rodríguez, Alfredo | Chang, Mayling | Gutiérrez, Soledad | Beissner, Florian | Beissner, Florian | Preibisch, Christine | Schweizer-Arau, Annemarie | Popovici, Roxana | Meissner, Karin | Beljanski, Sylvie | Belland, Laura | Rivera-Reyes, Laura | Hwang, Ula | Berger, Bettina | Sethe, Dominik | Hilgard, Dörte | Heusser, Peter | Bishop, Felicity | Al-Abbadey, Miznah | Bradbury, Katherine | Carnes, Dawn | Dimitrov, Borislav | Fawkes, Carol | Foster, Jo | MacPherson, Hugh | Roberts, Lisa | Yardley, Lucy | Lewith, George | Bishop, Felicity | Al-Abbadey, Miznah | Bradbury, Katherine | Carnes, Dawn | Dimitrov, Borislav | Fawkes, Carol | Foster, Jo | MacPherson, Hugh | Roberts, Lisa | Yardley, Lucy | Lewith, George | Bishop, Felicity | Holmes, Michelle | Lewith, George | Yardley, Lucy | Little, Paul | Cooper, Cyrus | Bogani, Patrizia | Maggini, Valentina | Gallo, Eugenia | Miceli, Elisangela | Biffi, Sauro | Mengoni, Alessio | Fani, Renato | Firenzuoli, Fabio | Brands-Guendling, Nadine | Guendling, Peter W. | Bronfort, Gert | Evans, Roni | Haas, Mitch | Leininger, Brent | Schulz, Craig | Bu, Xiangwei | Wang, J. | Fang, T. | Shen, Z. | He, Y. | Zhang, X. | Zhang, Zhengju | Wang, Dali | Meng, Fengxian | Büssing, Arndt | Baumann, Klaus | Frick, Eckhard | Jacobs, Christoph | Büssing, Arndt | Grünther, Ralph-Achim | Lötzke, Désirée | Büssing, Arndt | Jung, Sonny | Lötzke, Désirée | Recchia, Daniela R. | Robens, Sibylle | Ostermann, Thomas | Berger, Bettina | Stankewitz, Josephin | Kröz, Matthias | Jeitler, Mika | Kessler, Christian | Michalsen, Andreas | Cheon, Chunhoo | Jang, Bo H. | Ko, Seong G. | Huang, Ching W. | Sasaki, Yui | Ko, Youme | Cheshire, Anna | Ridge, Damien | Hughes, John | Peters, David | Panagioti, Maria | Simon, Chantal | Lewith, George | Cho, Hyun J. | Han, Dongwoon | Choi, Soo J. | Jung, Young S. | Im, Hyea B | Cooley, Kieran | Tummon-Simmons, Laura | Cotton, Sian | Luberto, Christina M. | Wasson, Rachel | Kraemer, Kristen | Sears, Richard | Hueber, Carly | Derk, Gwendolyn | Lill, JR | An, Ruopeng | Steinberg, Lois | Rodriguez, Lourdes Diaz | la Fuente, Francisca García-de | De la Vega, Miguel | Vargas-Román, Keyla | Fernández-Ruiz, Jonatan | Cantarero-Villanueva, Irene | Rodriguez, Lourdes Diaz | García-De la Fuente, Francisca | Jiménez-Guerrero, Fanny | Vargas-Román, Keyla | Fernández-Ruiz, Jonatan | Galiano-Castillo, Noelia | Diaz-Saez, Gualberto | Torres-Jimenez, José I. | Garcia-Gomez, Olga | Hortal-Muñoz, Luis | Diaz-Diez, Camino | Dicen, Demijon | Diezel, Helene | Adams, Jon | Steel, Amie | Wardle, Jon | Diezel, Helene | Steel, Amie | Frawley, Jane | Wardle, Jon | Broom, Alex | Adams, Jon | Dong, Fei | Yu, He | Liu, Tiegang | Ma, Xueyan | Yan, Liyi | Wan, Yuxiang | Zheng, Zian | Gu, Xiaohong | Dong, Fei | Yu, He | Wu, Liqun | Liu, Tiegang | Ma, Xueyan | Ma, Jiaju | Yan, Liyi | Wan, Yuxiang | Zheng, Zian | Zhen, Jianhua | Gu, Xiaohong | Dubois, Julie | Rodondi, Pierre-Yves | Edelhäuser, Friedrich | Schwartze, Sophia | Trapp, Barbara | Cysarz, Dirk
doi:10.1186/s12906-017-1782-4
PMCID: PMC5498855
6.  Disease management programs for patients with type 2 diabetes mellitus in Germany: a longitudinal population-based descriptive study 
Background
The primary aim of the disease management program (DMP) for patients with diabetes mellitus type 2 is to improve the quality of health care and the treatment process. 12 years after its introduction in Germany, there is still no consensus as to whether DMP has been effective in reaching these goals.
Methods
A retrospective longitudinal population-based study between 2004 and 2015 were conducted to evaluate the DMP for type 2 diabetes in Bavaria using routinely collected patient medical records hold from the National Association of Statutory Health Insurance Physicians of Bavaria.
Results
During the first 12 years of DMP, the number of participants increased continually to reach 580,222 in 2015. The proportion of participants older than 70 years increased during the observation from 41.6 to 51.1%. The percentage of smokers increased slightly from 9 to 11%. Similarly, the distribution of body mass index remained constant with approximately 50% of patients having a body mass index >30 kg/m2. Control of HbA1c was without an appreciable change over the course, with between 8.3 and 9.4% of all patients with uncontrolled values higher than 8.5%. Prescription of metformin increased from 40.5% in 2004 to 54.1% in 2015. Among patients receiving insulin, the proportion receiving a combined therapy with metformin increased from 28.4% in 2004 to 50.8% in 2015. In contrast, the percentage with insulin monotherapy decreased from 55.4 to 33.7%. The proportion of patients with a diabetic education increased within the course from 12.8 to 29.3%.
Conclusion
Data from the German DMP for type 2 diabetes demonstrates an improvement in the quality of care with respect to pharmacotherapy and patient education and therefore to an improved adherence to guidelines. However, no appreciable improvement was observed with regard to smoking status, obesity or HbA1c control.
doi:10.1186/s13098-017-0236-y
PMCID: PMC5437566
Disease management program; Type 2 diabetes; Active patient participation; Self-management; Guideline care; General practice
7.  How do medical students engaging in elective courses on acupuncture and homeopathy differ from unselected students? A survey 
Background
We aimed to investigate whether students at German medical schools participating in elective courses on acupuncture and homeopathy differ from an unselected group of students regarding attitudes and personality traits.
Methods
Elective courses on acupuncture and homeopathy in the academic half-year 2013/14 all over Germany were identified and participants invited to fill in a questionnaire including nineteen questions on attitudes towards Complementary and Alternative Medicine (CAM), orientation towards science, care and status orientation, and a short validated instrument (Big-Five-Inventory-10) to measure personality traits (extraversion, neuroticism, openness, conscientiousness, and agreeableness). Participants of a mandatory family medicine course at one university served as unselected control group.
Results
Two hundred twenty and 113 students from elective courses on acupuncture and homeopathy, respectively, and 315 control students participated (response rate 93%). Students participating in elective courses had much more positive attitudes towards CAM, somewhat lower science and status orientation, and somewhat higher care orientation than control group students (all p-values for three-group comparisons < 0.001). There were no differences between the three groups regarding personality traits with the exception of lower values for agreeableness in controls (p = 0.009).
Conclusions
The findings of this study show that attitudes of students participating in elective courses on acupuncture or homeopathy at German medical schools differ to a considerable degree from the attitudes of unselected students.
Electronic supplementary material
The online version of this article (doi:10.1186/s12906-017-1653-z) contains supplementary material, which is available to authorized users.
doi:10.1186/s12906-017-1653-z
PMCID: PMC5343393  PMID: 28274213
Complementary and alternative medicine; Medical education; Attitudes; Personality traits
8.  Costs of coordinated versus uncoordinated care in Germany: results of a routine data analysis in Bavaria 
BMJ Open  2016;6(6):e011621.
Objectives
The efficiency of a gatekeeping system for a health system, as in Germany, remains unclear particularly as access to specialist ambulatory care is not restricted. The aim was to compare the costs of coordinated versus uncoordinated patients (UP) in ambulatory care; with additional subgroup analysis of patients with mental disorders.
Design
Retrospective routine data analysis of patients with statutory health insurance, using claims data held by the Bavarian Association of Statutory Health Insurance Physicians. A patient was defined as uncoordinated if he or she visited at least 1 specialist without a referral from a general practitioner within a quarter. Outcomes were compared with propensity score matching analysis.
Participants
The study encompassed all statutorily insured patients in Bavaria contacting at least 1 ambulatory specialist in the first quarter of 2011 (n=3 616 510).
Primary and secondary outcome measures
Primary outcome was total costs of ambulatory care; secondary outcomes were financial claims of general physicians, specialists and for medication.
Results
The average age was 55.3 years for coordinated patients (CP, n=1 629 302), 48.3 years for UP (n=1 825 840). CP more frequently had chronic diseases (85.4%) as compared with UP (67.5%). The total unadjusted financial claim per patient was higher for UP (€234.52) than for CP (€224.41); the total adjusted difference was −€9.65 (95% CI −11.64 to −7.67), indicating lower costs for CP. The cost differences increased with increasing age. Total adjusted difference per patient with mental diseases as documented with an International Classification of Diseases (ICD)-10 F-diagnosis, was −€20.31 (95% CI −26.43 to −14.46).
Conclusions
Coordination of care is associated with lower ambulatory healthcare expenditures and is of particular importance for patients who are more vulnerable to medical interventions, especially for elderly and patients with mental disorders. The role of general practitioners as coordinators should be strengthened to improve care for these patients as this could also help to frame a more efficient health system.
doi:10.1136/bmjopen-2016-011621
PMCID: PMC4908874  PMID: 27288386
access to care; health spending; PRIMARY CARE; organization and delivery of care
9.  Quantity, topics, methods and findings of randomised controlled trials published by German university departments of general practice – systematic review 
Trials  2016;17:211.
Background
Academic infrastructures and networks for clinical research in primary care receive little funding in Germany. We aimed to provide an overview of the quantity, topics, methods and findings of randomised controlled trials published by German university departments of general practice.
Methods
We searched Scopus (last search done in April 2015), publication lists of institutes and references of included articles. We included randomised trials published between January 2000 and December 2014 with a first or last author affiliated with a German university department of general practice or family medicine. Risk of bias was assessed with the Cochrane tool, and study findings were quantified using standardised mean differences (SMDs).
Results
Thirty-three trials met the inclusion criteria. Seventeen were cluster-randomised trials, with a majority investigating interventions aimed at improving processes compared with usual care. Sample sizes varied between 6 and 606 clusters and 168 and 7807 participants. The most frequent methodological problem was risk of selection bias due to recruitment of individuals after randomisation of clusters. Effects of interventions over usual care were mostly small (SMD <0.3). Sixteen trials randomising individual participants addressed a variety of treatment and educational interventions. Sample sizes varied between 20 and 1620 participants. The methodological quality of the trials was highly variable. Again, effects of experimental interventions over controls were mostly small.
Conclusions
Despite limited funding, German university institutes of general practice or family medicine are increasingly performing randomised trials. Cluster-randomised trials on practice improvement are a focus, but problems with allocation concealment are frequent.
Electronic supplementary material
The online version of this article (doi:10.1186/s13063-016-1328-y) contains supplementary material, which is available to authorized users.
doi:10.1186/s13063-016-1328-y
PMCID: PMC4842270  PMID: 27107809
Germany; Primary care; General practice; Randomised controlled trials; Academic performance
10.  Effects of a Web-Based Intervention for Stress Reduction in Primary Care: A Cluster Randomized Controlled Trial 
Background
Preliminary findings suggest that Web-based interventions may be effective in achieving significant stress reduction. To date, there are no findings available for primary care patients. This is the first study that investigates a Web-based intervention for stress reduction in primary care.
Objective
The aim was to examine the short-term effectiveness of a fully automated Web-based coaching program regarding stress reduction in a primary care setting.
Methods
The study was an unblinded cluster randomized trial with an observation period of 12 weeks. Individuals recruited by general practitioners randomized to the intervention group participated in a Web-based coaching program based on education, motivation, exercise guidance, daily text message reminders, and weekly feedback through the Internet. All components of the program were fully automated. Participants in the control group received usual care and advice from their practitioner without the Web-based coaching program. The main outcome was change in the Perceived Stress Questionnaire (PSQ) over 12 weeks.
Results
A total of 93 participants (40 in intervention group, 53 in control group) were recruited into the study. For 25 participants from the intervention group and 49 participants from the control group, PSQ scores at baseline and 12 weeks were available. In the intention-to-treat analysis, the PSQ score decreased by mean 8.2 (SD 12.7) in the intervention group and by mean 12.6 (SD 14.7) in the control group. There was no significant difference identified between the groups (mean difference –4.5, 95% CI –10.2 to 1.3, P=.13).
Conclusions
This trial could not show that the tested Web-based intervention was effective for reducing stress compared to usual care. The limited statistical power and the high dropout rate may have reduced the study’s ability to detect significant differences between the groups. Further randomized controlled trials are needed with larger populations to investigate the long-term outcome as well as the contents of usual primary care.
Trial Registration
German Clinical Trials Register DRKS00003067; http://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?=DRKS00003067 (Archived by WebCite at http://www.webcitation.org/6eXk0PXmO)
doi:10.2196/jmir.4246
PMCID: PMC4769360  PMID: 26872703
Web-based; randomized controlled trial; life stress; stress reduction
11.  Influence of the practice setting on diagnostic prediction rules using FENO measurement in combination with clinical signs and symptoms of asthma 
BMJ Open  2015;5(11):e009676.
Objectives
To evaluate the influence of the practice setting on diagnostic accuracy of fractional exhaled nitric oxide (FENO) for diagnosing asthma; and to develop prediction rules for diagnostic decision-making including clinical signs and symptoms (CSS).
Setting
Patients from 10 general practices and 1 private practice of 5 pneumologists in ambulatory care.
Participants
553 patients, 57.9% female. Consecutive inclusion of diagnostic-naive patients suspected of suffering from obstructive airway disease. Exclusion criteria were respiratory tract infections within the last 6 weeks.
Interventions
The index test was FENO measurement. Reference standard was the Tiffeneau ratio (forced expiratory volume in 1 s/vital capacity) or airway resistance as assessed by whole body plethysmography, with additional bronchoprovocation or bronchodilator testing.
Primary and secondary outcome measures
Asthma as determined by pneumologists, who were blind to FENO measurement results. Prediction rules were derived from multiple logistic regression analysis. A freely available calculator that allows computing all combinations was developed.
Results
The practice setting only had minor influence on sensitivities of FENO cut-off points. In the final model (n=472), allergic rhinitis, wheezing and previous medication were positively associated with asthma. Increasing age and recurrent respiratory tract infections were negatively associated. The area under the curve (AUC) of FENO (AUC=0.650; 95% CI 0.599 to 0.701) increased significantly (p<0.0001) when combined with CSS (AUC=0.753; 95% CI 0.707 to 0.798). Presence of wheezing and allergic rhinitis allowed ruling in asthma with FENO >30 ppb. Ruling out with FENO <16 ppb in patients <43 years was only possible without allergic symptoms when recurrent respiratory tract infections were present.
Conclusions
FENO results should be interpreted in the context of CSS to enhance their diagnostic value in primary care. The final diagnostic model appears as a sound algorithm fitting well to the established diagnostic rules related to CSS of asthma. FENO appears more effective for ruling in asthma than for ruling it out.
doi:10.1136/bmjopen-2015-009676
PMCID: PMC4663408  PMID: 26603255
PRIMARY CARE; sensitivity and specificity; diagnostic accuracy; nitric oxide
12.  Comparative effectiveness of psychological treatments for depressive disorders in primary care: network meta-analysis 
BMC Family Practice  2015;16:103.
Background
A variety of psychological interventions to treat depressive disorders have been developed and are used in primary care. In a systematic review, we compared the effectiveness of psychological treatments grouped by theoretical background, intensity of contact with the health care professional, and delivery mode for depressed patients in this setting.
Methods
Randomized trials comparing a psychological treatment with usual care, placebo, another psychological treatment, pharmacotherapy, or a combination treatment in adult depressed primary care patients were identified by database searches up to December 2013. We performed both conventional pairwise meta-analysis and network meta-analysis combining direct and indirect evidence. Outcome measures were response to treatment (primary outcome), remission of symptoms, post-treatment depression scores and study discontinuation.
Results
A total of 37 studies with 7,024 patients met the inclusion criteria. Among the psychological treatments investigated in at least 150 patients face-to-face cognitive behavioral therapy (CBT; OR 1.80; 95 % credible interval 1.35–2.39), face-to-face counselling and psychoeducation (1.65; 1.27–2.13), remote therapist lead CBT (1.87; 1.38–2.53), guided self-help CBT (1.68; 1.22–2.30) and no/minimal contact CBT (1.53; 1.07–2.17) were superior to usual care or placebo, but not face-to-face problem-solving therapy and face-to-face interpersonal therapy. There were no statistical differences between psychological treatments apart from face-to-face interpersonal psychotherapy being inferior to remote therapist-lead CBT (0.60; 0.37–0.95). Remote therapist-led (0.86; 0.21–3.67), guided self-help (0.93; 0.62–1.41) and no/minimal contact CBT (0.85; 0.54–1.36) had similar effects as face-to-face CBT.
Conclusions
The limited available evidence precludes a sufficiently reliable assessment of the comparative effectiveness of psychological treatments in depressed primary care patients. Findings suggest that psychological interventions with a cognitive behavioral approach are promising, and primarily indirect evidence indicates that it applies also when they are delivered with a reduced number of therapist contacts or remotely.
Systematic review registration: 01KG1012 at http://www.gesundheitsforschung-bmbf.de/de/2852.php
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0314-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0314-x
PMCID: PMC4545315  PMID: 26286590
13.  Effects of a Guided Web-Based Smoking Cessation Program With Telephone Counseling: A Cluster Randomized Controlled Trial 
Background
Preliminary findings suggest that Web-based interventions may be effective in achieving significant smoking cessation. To date, very few findings are available for primary care patients, and especially for the involvement of general practitioners.
Objective
Our goal was to examine the short-term effectiveness of a fully automated Web-based coaching program in combination with accompanied telephone counseling in smoking cessation in a primary care setting.
Methods
The study was an unblinded cluster-randomized trial with an observation period of 12 weeks. Individuals recruited by general practitioners randomized to the intervention group participated in a Web-based coaching program based on education, motivation, exercise guidance, daily short message service (SMS) reminding, weekly feedback through Internet, and active monitoring by general practitioners. All components of the program are fully automated. Participants in the control group received usual care and advice from their practitioner without the Web-based coaching program. The main outcome was the biochemically confirmed smoking status after 12 weeks.
Results
We recruited 168 participants (86 intervention group, 82 control group) into the study. For 51 participants from the intervention group and 70 participants from the control group, follow-up data were available both at baseline and 12 weeks. Very few patients (9.8%, 5/51) from the intervention group and from the control group (8.6%, 6/70) successfully managed smoking cessation (OR 0.86, 95% CI 0.25-3.0; P=.816). Similar results were found within the intent-to-treat analysis: 5.8% (5/86) of the intervention group and 7.3% (6/82) of the control group (OR 1.28, 95% CI 0.38-4.36; P=.694). The number of smoked cigarettes per day decreased on average by 9.3 in the intervention group and by 6.6 in the control group (2.7 mean difference; 95% CI -5.33 to -0.58; P=.045). After adjustment for the baseline value, age, gender, and height, this significance decreases (mean difference 2.2; 95% CI -4.7 to 0.3; P=.080).
Conclusions
This trial did not show that the tested Web-based intervention was effective for achieving smoking cessation compared to usual care. The limited statistical power and the high drop-out rate may have reduced the study’s ability to detect significant differences between the groups. Further randomized controlled trials are needed in larger populations and to investigate the long-term outcome.
Trial Registration
German Register for Clinical Trials, registration number DRKS00003067; http://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ ID=DRKS00003067 (Archived by WebCite at http://www.webcitation.org/6Sff1YZpx).
doi:10.2196/jmir.3536
PMCID: PMC4211026  PMID: 25253539
smoking cessation; Web-based; randomized controlled trial; primary care
14.  Communicating and Dealing with Uncertainty in General Practice: The Association with Neuroticism 
PLoS ONE  2014;9(7):e102780.
Background
Diagnostic reasoning in primary care setting where presented problems and patients are mostly unselected appears as a complex process. The aim was to develop a questionnaire to describe how general practitioners (GPs) deal with uncertainty to gain more insight into the decisional process. The association of personality traits with medical decision making was investigated additionally.
Methods
Raw items were identified by literature research and focus group. Items were improved by interviewing ten GPs with thinking-aloud-method. A personal case vignette related to a complex and uncertainty situation was introduced. The final questionnaire was administered to 228 GPs in Germany. Factorial validity was calculated with explorative and confirmatory factor analysis. The results of the Communicating and Dealing with Uncertainty (CoDU) – questionnaire were compared with the scales of the ‘Physician Reaction to Uncertainty’ (PRU) questionnaire and with the personality traits which were determined with the Big Five Inventory (BFI-K).
Results
The items could be assigned to four scales with varying internal consistency, namely ‘communicating uncertainty’ (Cronbach alpha 0.79), ‘diagnostic action’ (0.60), ‘intuition’ (0.39) and ‘extended social anamnesis’ (0.69). Neuroticism was positively associated with all PRU scales ‘anxiety due to uncertainty’ (Pearson correlation 0.487), ‘concerns about bad outcomes’ (0.488), ‘reluctance to disclose uncertainty to patients’ (0.287), ‘reluctance to disclose mistakes to physicians’ (0.212) and negatively associated with the CoDU scale ‘communicating uncertainty’ (−0.242) (p<0.01 for all). ‘Extraversion’ (0.146; p<0.05), ‘agreeableness’ (0.145, p<0.05), ‘conscientiousness’ (0.168, p<0.05) and ‘openness to experience’ (0.186, p<0.01) were significantly positively associated with ‘communicating uncertainty’. ‘Extraversion’ (0.162), ‘consciousness’ (0.158) and ‘openness to experience’ (0.155) were associated with ‘extended social anamnesis’ (p<0.05).
Conclusion
The questionnaire allowed describing the diagnostic decision making process of general practitioners in complex situations. Personality traits are associated with diagnostic reasoning and communication with patients, which might be important for medical education and quality improvement purposes.
doi:10.1371/journal.pone.0102780
PMCID: PMC4100927  PMID: 25029276
15.  The Use of Placebo and Non-Specific Therapies and Their Relation to Basic Professional Attitudes and the Use of Complementary Therapies among German Physicians – A Cross-Sectional Survey 
PLoS ONE  2014;9(4):e92938.
We aimed to investigate the use of placebos (e.g. saline injections) and non-specific treatments (e.g. vitamin supplements in individuals without a relevant deficiency) among physicians working in private practices in Germany, and how such use is associated with the belief in and the use of complementary and alternative treatments, and basic professional attitudes. A four-page questionnaire was sent to nationwide random samples of general practitioners (GP), internists and orthopaedists working in private practices. The response rate was 46% (935 of 2018). 24% of GPs, 44% of internists and 57% of orthopaedists had neither used pure placebos nor non-specific therapies in the previous 12 months. 11% percent of GPs, 12% of internists and 7% of orthopaedists had exclusively used pure placebos; 30%, 33% and 26%, respectively, had exclusively used non-specific therapies; 35%, 12% and 9% had used both. Age, sex and agreement to the statement that physicians should harness placebo effects were not significantly associated with any pattern of use. Exclusive use of pure placebos was associated with being a GP, being an internist, and having unorthodox professional views. In addition to these three factors, a lower use of CAM therapies and a wish for having more time was associated with the exclusive use of non-specific therapies. Among physicians using both pure placebo and non-specific therapies, heterodox views were also somewhat more pronounced. However, associations were particularly strong for being a GP (Odds ratio 11.6 (95%CI 6.41; 21.3)) and having orthodox views (Odds ratio 0.10 (95%CI 0.06; 0.18)) among this group. In conclusion, the use of placebos and non-specific treatments varies strongly between medical specialties and is associated with basic professional attitudes. The findings support the view that the use of placebos and, in particular, of non-specific therapies is primarily a coping behaviour for difficult and uncertain situations.
doi:10.1371/journal.pone.0092938
PMCID: PMC3973570  PMID: 24695272
16.  Can near-peer medical students effectively teach a new curriculum in physical examination? 
BMC Medical Education  2013;13:165.
Background
Students in German medical schools frequently complain that the subject ‘clinical examination’ is not taught in a satisfying manner due to time constraints and lack of personnel resources. While the effectiveness and efficiency of practice-oriented teaching in small groups using near-peer teaching has been shown, it is rarely used in German medical schools. We investigated whether adding a new near-peer teaching course developed with student input plus patient examination under supervision in small groups improves basic clinical examination skills in third year medical students compared to a traditional clinical examination course alone.
Methods
Third year medical students registered for the mandatory curricular clinical examination course at the medical faculty of the Technische Universität München were invited to participate in a randomised trial with blinded outcome assessment. Students were randomised to the control group participating in the established curricular physical examination course or to the intervention group, which received additional near-peer teaching for the same content. The learning success was verified by a voluntary objective structured clinical examination (OSCE).
Results
A total of 84 students were randomised and 53 (63%) participated in the final OSCE. Students in the control group scored a median of 57% (25th percentile 47%, 75th percentile 61%) of the maximum possible total points of the OSCE compared to 77% (73%, 80%; p < 0.001) for students in the intervention group. Only two students in the intervention group received a lower score than the best student in the control group.
Conclusion
Adding a near-peer teaching course to the routine course significantly improved the clinical examination skills of medical students in an efficient manner in the context of a resource-constrained setting.
doi:10.1186/1472-6920-13-165
PMCID: PMC3874636  PMID: 24325639
17.  Predictors of a positive attitude of medical students towards general practice – a survey of three Bavarian medical faculties 
Objective: Germany is witnessing an increasing shortage of general practitioners (GPs). The aim was to determine predictors of the job-related motivation of medical students of three medical faculties with different institutionalisation of general practice as an academic discipline.
Methods: Medical students were surveyed with a standardised questionnaire about their attitudes towards general practice and their motivation to work as a GP in different working conditions. Predictors for positive attitudes and motivation were calculated using logistic regression models.
Results: 940 (15.2%) out of 6182 medical students from three Bavarian medical faculties participated in an online survey. 585 (62.7%) were female, and the average age was 25.0 (standard deviation 3.7). The average grade of a university-entrance diploma was 1.6 (standard deviation 0.5). 718 (76.4%) could imagine working as a GP. However, they favoured being employed within another organisation and not having their own private practice (65.5% vs. 35.1%). “Presence of a professorship of general practice” was associated with a positive attitude towards general practice (OR 1.57; 95%CI 1.13-2.417). Motivation for working as a GP was associated with “being female” (OR 2.56; 95%CI 1.80-3.56) and “presence of a professorship of general practice” (OR 1.68; 95%CI 1.14-2.46). Having a lower grade for one’s university-entrance diploma was associated with a higher preference to work in one’s own practice (OR 1.39; 95%CI 1.02-1.90).
Conclusion: A high amount of medical students were open-minded towards general practice. However, they favoured employment within an organization over working in their own practice. Institutionalisation of general practice as an academic discipline might be of importance to gain positive attitudes towards general practice and motivate medical students to work as a GP.
PMCID: PMC3839073  PMID: 24282448
general practice; institutionalisation; medical students; medical profession; motivation
18.  Kidney function and clinical recommendations of drug dose adjustment in geriatric patients 
BMC Geriatrics  2013;13:92.
Background
In elderly patients chronic kidney disease often limits drug prescription. As several equations for quick assessment of kidney function by estimating glomerular filtration rate (eGFR) and several different clinical recommendations for drug dose adjustment in renal failure are published, choosing the correct approach for drug dosage is difficult for the practitioner. The aims of our study were to quantify the agreement between eGFR-equations grouped by creatinine-based or cystatin C-based and within the groups of creatinine and cystatin C-based equations and to investigate whether use of various literature and online references results in different recommendations for drug dose adjustment in renal disease in very elderly primary care patients.
Methods
We included 108 primary care patients aged 80 years and older from 11 family practices into a cross-sectional study. GFR was estimated using two serum creatinine-based equations (Cockroft-Gault, MDRD) and three serum cystatin C-based equations (Grubb, Hoek, Perkins). Concordance between different equations was quantified using intraclass correlation coefficients (ICCs). Essential changes in drug doses or discontinuation of medication were documented and compared in terms of estimated renal function as a consequence of the different eGFR-equations using five references commonly used in the US, Great Britain and Germany.
Results
In general, creatinine-based equations resulted in lower eGFR-estimation and in higher necessity of drug dose adjustment than cystatin C-based equations. Concordance was high between creatinine-based equations alone (ICCs 0.87) and between cystatin C-based equations alone (ICCs 0.90 to 0.96), and moderate between creatinine-based equations and cystatin C-based equations (ICCs 0.54 to 0.76). When comparing the five different references consulted to identify necessary drug dose adjustments we found that the numbers of drugs that necessitate dose adjustment in the case of renal impairment differed considerably. The mean number of recommended changes in drug dosage ranged between 1.9 and 2.5 per patient depending on the chosen literature reference.
Conclusions
Our data suggest that the choice of the literature source might have even greater impact on drug management than the choice of the equation used to estimate GFR alone. Efforts should be deployed to standardize methods for estimating kidney function in geriatric patients and literature recommendations on drug dose adjustment in renal failure.
doi:10.1186/1471-2318-13-92
PMCID: PMC3850264  PMID: 24020893
Estimated kidney function; Aged 80 years and older; Drug dose adjustment; Primary care; Literature references
19.  Effects of a general practice guided web-based weight reduction program - results of a cluster-randomized controlled trial 
BMC Family Practice  2013;14:76.
Background
Preliminary findings suggest that web-based interventions may be effective in achieving significant weight loss and weight loss maintenance. To date only few findings within primary care patients and especially the involvement of general practitioners are available. The aim of this trial was to examine the short-term effectiveness of a web-based coaching program in combination with an accompanied telephone counselling regarding weight reduction in a primary care setting.
Methods
The study was a cluster-randomized trial with an observation period of 12 weeks. Individuals recruited by general practitioners randomized to the intervention group participated in a web-based coaching program based on education, motivation, exercise guidance, daily SMS reminding, weekly feedback through internet and active monitoring by general practitioners. Participants in the control group received usual care and advice from their practitioner without the web-based coaching program. The main outcome was weight change between admission and after 12 weeks.
Results
186 participants (109 intervention group, 77 control group) were recruited into study. For 76 participants from the intervention group and 72 participants from the control group weight measurements were available both at baseline and 12 weeks. Weight decreased on average by 4.2 kg in the intervention group and 1.7 kg in the control group (mean group difference 2.5 kg; 95%CI 1,1; 3,8; p < 0.001). Reductions for waist circumference and BMI were also significantly larger within intervention.
Conclusion
Findings of the present trial suggest that the tested web-based coaching program for weight loss is effective in short-term. Further RCT’s are desirable in order to confirm present findings in larger populations and to investigate long-term outcomes.
Trial registration
German Register for Clinical Trials: DRKS00003067
doi:10.1186/1471-2296-14-76
PMCID: PMC3680299  PMID: 23981507
Overweight; Obesity; Weight loss; Web-based; Randomized controlled trial
20.  The development of general practice as an academic discipline in Germany - an analysis of research output between 2000 and 2010 
BMC Family Practice  2012;13:58.
Background
Governmental funding support is seen as a prerequisite for the growth of research in general practice. Several funding programs in the amount of € 13.2 Mio were introduced in Germany from 2002 to February 2012. We aim to provide an overview of publications reporting original data and systematic reviews from German academic family medicine published between 2000 and 2010.
Methods
Publications were identified by searching the database Scopus and screening publication lists of family medicine divisions or institutes. Papers had to report original primary research studies or systematic reviews; at least one of the authors had to be affiliated to a German academic family medicine division or institute.
Results
794 articles were included. The number of publications increased steadily starting from 107 in the period from 2000 to 2003, to 273 from 2004 to 2007, and finally to 414 from 2008 to 2010. Less than 25% were published in English in the first period. This proportion increased to 60.6% from 2008 to 2010. Articles published in a journal without impact factor decreased from 59.8% to 31.9%. Nevertheless, even in the most recent period only 31.6% of all articles were published in a journal with an impact factor above 2. The median impact factor increased from 0 in the first period to 1.2 in the last.
Conclusions
The output of original research publications from academic research divisions and institutes for general practice in Germany greatly increased during the last decade. However, professionalism of German primary care research still needs to be developed.
doi:10.1186/1471-2296-13-58
PMCID: PMC3489844  PMID: 22702476
Research articles; Germany; Primary care; General practice; Academic performance
21.  Treatment of depressive disorders in primary care - protocol of a multiple treatment systematic review of randomized controlled trials 
BMC Family Practice  2011;12:127.
Background
Several systematic reviews have summarized the evidence for specific treatments of primary care patients suffering from depression. However, it is not possible to answer the question how the available treatment options compare with each other as review methods differ. We aim to systematically review and compare the available evidence for the effectiveness of pharmacological, psychological, and combined treatments for patients with depressive disorders in primary care.
Methods/Design
To be included, studies have to be randomized trials comparing antidepressant medication (tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), hypericum extracts, other agents) and/or psychological therapies (e.g. interpersonal psychotherapy, cognitive therapy, behavioural therapy, short dynamically-oriented psychotherapy) with another active therapy, placebo or sham intervention, routine care or no treatment in primary care patients in the acute phase of a depressive episode. Main outcome measure is response after completion of acute phase treatment. Eligible studies will be identified from available systematic reviews, from searches in electronic databases (Medline, Embase and Central), trial registers, and citation tracking. Two reviewers will independently extract study data and assess the risk of bias using the Cochrane Collaboration's corresponding tool. Meta-analyses (random effects model, inverse variance weighting) will be performed for direct comparisons of single interventions and for groups of similar interventions (e.g. SSRIs vs. tricyclics) and defined time-windows (up to 3 months and above). If possible, a global analysis of the relative effectiveness of treatments will be estimated from all available direct and indirect evidence that is present in a network of treatments and comparisons.
Discussion
Practitioners do not only want to know whether there is evidence that a specific treatment is more effective than placebo, but also how the treatment options compare to each other. Therefore, we believe that a multiple treatment systematic review of primary-care based randomized controlled trials on the most important therapies against depression is timely.
doi:10.1186/1471-2296-12-127
PMCID: PMC3226438  PMID: 22085705
22.  Unlimited access to health care - impact of psychosomatic co-morbidity on utilisation in German general practices 
BMC Family Practice  2011;12:51.
Background
The effect of psychosomatic co-morbidity on resource use for systems with unlimited access remains unclear. The aim of this study was to evaluate the impact on practice visits, referrals and periods of disability in German general practices and to identify predictors of health care utilisation.
Methods
Cross sectional observational study in 13 practices in Upper Bavaria. Patients were included consecutively and filled in the Patients Health Questionnaire (PHQ). Numbers of practice visits, referrals and periods of disability within the last twelve months and permanent mental and somatic diagnoses were extracted manually by review of the computerised charts. Physicians in Germany are obliged to document repetitive reasons of encounter as permanent diagnoses in terms of ICD-10-codes. These ICD-10-codes are used for legitimisation of reimbursement in German general practices.
Results
1005 patients were included (58.6% female). On average, patients had 15.3 (sd 16.3) practice contacts, 3.8 (sd 4.2) referrals and 7.5 (sd 23.1) days of disability per year. The mean number of coded permanent diagnoses was 0.4 (sd 0.7) for mental and 4.0 (sd 4.0) for somatic diagnoses. Patients with mental diagnoses scored higher in depression, anxiety, panic and somatoform disorder scales of PHQ. Frequent practice visits were associated stronger with coded permanent mental diagnoses (OR 20.0; 95%CI 7.5-53.9) than with coded permanent somatic diagnoses (OR 14.4; 95%CI 5.9-35.4). Frequent referrals were associated stronger with somatic diagnoses (OR 4.9; 95%CI 2.0-11.9) than with mental diagnoses (OR 3.6; 95%CI 1.4-9.8). Periods of disability were predicted by mental diagnoses (OR 5.0; 95%CI 1.6-15.8) but not by somatic diagnoses (OR 2.5; 95%CI 0.7-8.1).
Conclusions
Psychosomatic co-morbidity has a stronger impact on health care utilisation in German general practices with respect to practice visits and periods of disability whereas somatic disorders play a stronger role for referrals. Time constraints in the practices might lead to frequent contacts as too little time is left for patients with mental problems. Therefore, structural changes in the health care reimbursement systems might be necessary. Mental diagnoses might be helpful to identify patients at risk for high health care utilisation. However, the use of routinely coded diagnoses for reimbursement might lead to distorted estimation of resource use.
doi:10.1186/1471-2296-12-51
PMCID: PMC3130659  PMID: 21682916
23.  An interdisciplinary intervention to prevent falls in community-dwelling elderly persons: protocol of a cluster-randomized trial [PreFalls] 
BMC Geriatrics  2011;11:7.
Background
Prevention of falls in the elderly is a public health target in many countries around the world. While a large number of trials have investigated the effectiveness of fall prevention programs, few focussed on interventions embedded in the general practice setting and its related network. In the Prevent Falls (PreFalls) trial we aim to investigate the effectiveness of a pre-tested multi-modal intervention compared to usual care in this setting.
Methods/Design
PreFalls is a controlled multicenter prospective study with cluster-randomized allocation of about 40 general practices to an experimental or a control group. We aim to include 382 community dwelling persons aged 65 and older with an increased risk of falling. All participating general practitioners are trained to systematically assess the risk of falls using a set of validated tests. Patients from intervention practices are invited to participate in a 16-weeks exercise program with focus on fall prevention delivered by specifically trained local physiotherapists. Patients from practices allocated to the control group receive usual care. Main outcome measure is the number of falls per individual in the first 12 months (analysis by negative binomial regression). Secondary outcomes include falls in the second year, the proportion of participants falling in the first and the second year, falls associated with injury, risk of falls, fear of falling, physical activity and quality of life.
Discussion
Reducing falls in the elderly remains a major challenge. We believe that with its strong focus on a both systematic and realistic fall prevention strategy adapted to primary care setting PreFalls will be a valuable addition to the scientific literature in the field.
Trial registration
NCT01032252
doi:10.1186/1471-2318-11-7
PMCID: PMC3050704  PMID: 21329525
24.  How large are the nonspecific effects of acupuncture? A meta-analysis of randomized controlled trials 
BMC Medicine  2010;8:75.
Background
While several recent large randomized trials found clinically relevant effects of acupuncture over no treatment or routine care, blinded trials comparing acupuncture to sham interventions often reported only minor or no differences. This raises the question whether (sham) acupuncture is associated with particularly potent nonspecific effects. We aimed to investigate the size of nonspecific effects associated with acupuncture interventions.
Methods
MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials and reference lists were searched up to April 2010 to identify randomized trials of acupuncture for any condition, including both sham and no acupuncture control groups. Data were extracted by one reviewer and verified by a second. Pooled standardized mean differences were calculated using a random effects model with the inverse variance method.
Results
Thirty-seven trials with a total of 5754 patients met the inclusion criteria. The included studies varied strongly regarding patients, interventions, outcome measures, methodological quality and effect sizes reported. Among the 32 trials reporting a continuous outcome measure, the random effects standardized mean difference between sham acupuncture and no acupuncture groups was -0.45 (95% confidence interval, -0.57, -0.34; I2 = 54%; Egger's test for funnel plot asymmetry, P = 0.25). Trials with larger effects of sham over no acupuncture reported smaller effects of acupuncture over sham intervention than trials with smaller nonspecific effects (β = -0.39, P = 0.029).
Conclusions
Sham acupuncture interventions are often associated with moderately large nonspecific effects which could make it difficult to detect small additional specific effects. Compared to inert placebo interventions, effects associated with sham acupuncture might be larger, which would have considerable implications for the design and interpretation of clinical trials.
doi:10.1186/1741-7015-8-75
PMCID: PMC3001416  PMID: 21092261
25.  Frequency and circumstances of placebo use in clinical practice - a systematic review of empirical studies 
BMC Medicine  2010;8:15.
Background
The use of placebo interventions outside clinical trials is ethically, professionally and legally controversial. Little is known about the frequency and circumstances of placebo use in clinical practice. Our aim was to summarize the available empirical studies addressing these issues.
Methods
We searched PubMed and EMBASE from inception to July 2009 in order to identify cross-sectional surveys, qualitative or longitudinal studies among health care professionals, students or patients which investigated at least one of the following issues - frequency of placebo use or attitudes to, or motivations for, the use of placebo interventions. At least two reviewers extracted information on the study methods, participants and findings. Descriptive summaries were prepared in an iterative process by at least two reviewers per study.
Results
Twenty-two studies from 12 different countries met the inclusion criteria. Most studies had relevant shortcomings. The proportion of respondents reporting that they had applied 'pure' placebos (for example, saline injection) during their professional life varied between 17% and 80% among physicians and between 51% and 100% among nurses, but it seems that the actual frequency of such use seems to be rare. The use of 'impure' or 'active' placebos (for example, antibiotics for viral infections) is likely to be much more frequent. However, it is impossible to make a reliable estimation because there is no agreement of what an impure placebo might be. Studies using qualitative methods or asking participants to judge case examples suggest that motivations and attitudes towards placebo use are complex and health care providers are often faced with a dilemma.
Conclusions
Although the available evidence is incomplete and confusing at times there can be little doubt that the prevalence of placebo use outside of clinical trials is not negligible and that views and attitudes on placebos use differ considerably among individuals, both health care professionals and patients. Further research is needed to clarify these issues.
doi:10.1186/1741-7015-8-15
PMCID: PMC2837612  PMID: 20178561

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