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1.  Implementation of shared decision making by physician training to optimise hypertension treatment. Study protocol of a cluster-RCT 
Background
Hypertension is one of the key factors causing cardiovascular diseases which make up the most frequent cause of death in industrialised nations. However about 60% of hypertensive patients in Germany treated with antihypertensives do not reach the recommended target blood pressure. The involvement of patients in medical decision making fulfils not only an ethical imperative but, furthermore, has the potential of higher treatment success. One concept to enhance the active role of patients is shared decision making. Until now there exists little information on the effects of shared decision making trainings for general practitioners on patient participation and on lowering blood pressure in hypertensive patients.
Methods/Design
In a cluster-randomised controlled trial 1800 patients receiving antihypertensives will be screened with 24 h ambulatory blood pressure monitoring in their general practitioners’ practices. Only patients who have not reached their blood pressure target (approximately 1200) will remain in the study (T1 – T3). General practitioners of the intervention group will take part in a shared decision making-training after baseline assessment (T0). General practitioners of the control group will treat their patients as usual. Primary endpoints are change of systolic blood pressure and change of patients’ perceived participation. Secondary endpoints are changes of diastolic blood pressure, knowledge, medical adherence and cardiovascular risk. Data analysis will be performed with mixed effects models.
Discussion
The hypothesis underlying this study is that shared decision making, realised by a shared decision making training for general practitioners, activates patients, facilitates patients’ empowerment and contributes to a better hypertension control. This study is the first one that tests this hypothesis with a (cluster-) randomised trial and a large sample size.
Trial registration
WHO International Clinical Trials: http://apps.who.int/trialsearch/Trial.aspx?TrialID=DRKS00000125
doi:10.1186/1471-2261-12-73
PMCID: PMC3467178  PMID: 22966894
Arterial hypertension; Cardiovascular diseases; Cardiovascular risk; Shared decision making; Educational training; Blood pressure control; Ambulatory blood pressure monitoring; Adherence; Primary care; Family medicine
2.  Becoming a general practitioner - Which factors have most impact on career choice of medical students? 
BMC Family Practice  2011;12:25.
Background
In Germany, there is a shortage of young physicians in several specialties, the situation of general practitioners (GP) being especially precarious. The factors influencing the career choice of German medical students are poorly understood. This study aims to identify factors influencing medical students' specialty choice laying a special focus on general practice.
Methods
The study was designed as a cross-sectional survey. In 2010, students at the five medical schools in the federal state of Baden-Wuerttemberg (Germany) filled out an online-questionnaire. On 27 items with 5-point Likert scales, the students rated the importance of specified individual and occupational aspects. Furthermore, students were asked to assign their intended medical specialty.
Results
1,299 students participated in the survey. Thereof, 1,114 students stated a current choice for a specialty, with 708 students choosing a career in one of the following 6 specialties: internal medicine, surgery, gynaecology and obstetrics, paediatrics, anaesthetics and general practice. Overall, individual aspects ('Personal ambition', 'Future perspective', 'Work-life balance') were rated as more important than occupational aspects (i.e. 'Variety in job', 'Job-related ambition') for career choice. For students favouring a career as a GP individual aspects and the factor 'Patient orientation' among the occupational aspects were significantly more important and 'Job-related ambition' less important compared to students with other specialty choices.
Conclusions
This study confirms that future GPs differ from students intending to choose other specialties particularly in terms of patient-orientation and individual aspects such as personal ambition, future perspective and work-life balance. Improving job-conditions in terms of family compatibility and work-life balance could help to increase the attractiveness of general practice. Due to the shortage of GPs those factors should be made explicit at an early stage at medical school to increase the number of aspirants for general practice.
doi:10.1186/1471-2296-12-25
PMCID: PMC3112095  PMID: 21549017
3.  Confirmatory factor analysis and recommendations for improvement of the Autonomy‐Preference‐Index (API) 
Abstract
Objective  Validation of the German version of the Autonomy‐Preference‐Index (API), a measure of patients’ preferences for decision making and information seeking.
Methods  Stepwise confirmatory factor analysis was conducted on a sample of patients (n = 1592) treated in primary care for depression (n = 186), surgical and internal medicine inpatients (n = 811) and patients with minor trauma treated in an emergency department (n = 595). An initial test of the model was done on calculation and validation halves of the sample. Both local and global indexes‐of‐fit suggested modifications to the scale. The scale was modified and re‐tested in the calculation sample and confirmed in the validation sample. Subgroup analyses for age, gender and type of treatment setting were also performed.
Results  The confirmatory analysis led to a modified version of the API with better local and global indexes‐of‐fit for samples of German‐speaking patients. Two items of the sub‐scale, ‘preference for decision‐making’, and one item of the sub‐scale, ‘preference for information seeking’, showed very low reliability scores and were deleted. Thus, several global indexes‐of‐fit clearly improved significantly. The modified scale was confirmed on the validation sample with acceptable to good indices of fit. Results of subgroup analyses indicated that no adaptations were necessary.
Discussion and conclusions  This first confirmatory analysis for a German‐speaking population showed that the API was improved by the removal of several items. There were theoretically plausible explanations for this improvement suggesting that the modifications might also be appropriate in English and other language versions.
doi:10.1111/j.1369-7625.2009.00584.x
PMCID: PMC5060541  PMID: 20579122
confirmatory factor analysis; measurement; patient preferences; validation study
4.  Participation preferences of patients with acute and chronic conditions 
Abstract
Background  There is little knowledge as to whether the chronicity of a disease affects patients’ desire for participation.
Aim  To study whether participation preferences vary according to the type of disease.
Design, participants and methods  Data of 1393 patients from six trials with different medical conditions (hypertension, depression, breast cancer, schizophrenia, multiple sclerosis, minor traumas) were pooled and analysed, using multiple regression analysis controlling for socio‐demographic variables.
Results  Younger age, better education as well as female gender accounted for a small but statistically significantly greater desire to participate. Patients suffering from multiple sclerosis (MS) exhibited significantly higher participation preferences than the other diagnostic groups. There were no major differences between the other diagnostic groups. Age, gender, education and diagnosis explained only 14% of the variance.
Conclusions  We found no clear differences between chronic and acute conditions. However, patients suffering from MS, a chronic condition, were clearly different from all other diagnostic groups. The reasons for this difference remain unclear. The predictive value of socio‐demography and type of illness is low.
doi:10.1111/j.1369-7625.2007.00458.x
PMCID: PMC5060420  PMID: 17986072
patient autonomy; patient participation; shared decision‐making
5.  Depressed patients’ perceptions of depression treatment decision‐making 
Abstract
Objective  Little is known about the feasibility and effects of patient‐clinician shared decision‐making (SDM) for depression treatment. Within a goal of informing the design of a SDM intervention, the objective of this study was to investigate depressed patients’ perceptions of the treatment decision‐making process with general practitioners (GPs).
Setting and participants  Data were gathered from a convenience sample of 40 depressed patients to understand key aspects of treatment decision‐making from the patient perspective. The sample varied in depression severity and type of setting in which treatment was sought.
Main variables studied  Semi‐structured interview questions focused on patients’ prior experiences with depression and treatment, perceptions of the treatment decision‐making process, and needs and expectations about treatment. Current depression severity was also assessed.
Results  Patient lack of insight regarding depression severity substantially delayed patient engagement in treatment seeking and decision‐making. Patients expected their GPs to be a first and main source of objective information and discussion about depression and treatment and to provide emotional support for decision‐making. Patients also identified needs for additional information about depression and its treatment, as well as concerns about certain aspects of treatment.
Conclusions  The depression treatment context has some aspects that differ from treatment decision‐making for other types of health conditions. SDM approaches for depression treatment should be adapted based on depression severity and patient‐identified needs.
doi:10.1111/j.1369-7625.2006.00424.x
PMCID: PMC5060378  PMID: 17324195
barriers; depression; shared decision‐making

Results 1-5 (5)