[Practice of early detection of prostate cancer : Descriptive survey in preparation for the PSAInForm study]. / Praxis der Früherkennung des Prostatakarzinoms : Deskriptive Erhebung im Vorfeld der PSAInForm-Studie.

BACKGROUND: The randomized controlled PSAInForm study aims to investigate the effects of a computer-based decision aid which informs men in the age group 55-69 years about advantages and disadvantages of PSA testing. In preparation for the study, the current PSA testing practice in the Münster district was assessed. MATERIALS AND METHODS: The frequencies of early detection examinations, medically indicated PSA tests, and prostate biopsies in the Münster district were determined, using aggregated data from the regional association of Statutory Health Insurance (SHI) Physicians in Westfalen-Lippe. With anonymized laboratory data, the frequency of PSA tests in general and urological practices, and their distribution among the accounting categories SHI, individual health services, and invoices for privately insured patients were investigated. RESULTS: In about half of more than 50,000 PSA tests, the accounting category could be determined; the rest could only be assigned to SHI or non-SHI services. The percentage of PSA tests that were performed due to reasons other than medically necessary SHI-reimbursed services was > 50% in each age group; it was highest in men younger than 55 years, and declined markedly with advanced age. More than half of the PSA tests that were likely due to opportunistic screening were performed outside the age group 55-69 years. CONCLUSIONS: The percentage of PSA tests that were not carried out as SHI services was > 80% in general practices, and 60% in urological practices. These percentages decreased markedly with advancing age. Most of the PSA tests were performed outside the age group which can be considered as the target group for an effective PSA screening according to the results of the European Randomized study of Screening for Prostate Cancer (ERSPC).

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

OBJECTIVE: All health care systems in the world struggle with rising costs for drugs. We sought to explore factors impacting on prescribing costs in a nationwide database of ambulatory care in Germany. Factors identified by this research can be used for adjustment in future profiling efforts. METHODS: We analysed nationwide prescription data of physicians having contractual relationships with statutory health insurance funds in 2014. Predictor and outcome variables were aggregated at the practice level. We performed analyses separately for primary care and specialties of cardiology, gastroenterology, neurology and psychiatry, pulmology as well as oncology and haematology. Bivariate robust regressions and Spearman rank correlations were computed in order to find meaningful predictors for our outcome variable prescription costs per patient. RESULTS: Median age of patients and proportion of DDD issued were substantial predictors for prescription costs per patient in Primary Care, Cardiology, and Pulmology with explained variances between 41 and 61%. In Neurology and Psychiatry only proportion of patients with polypharmacy ≥ 2 quarters was a significant predictor for prescription costs per patient, explaining 20% of the variance. For gastroenterologists, oncologists and haematologists no stable models could be established. CONCLUSIONS: Any analysis of prescribing behaviour must take the degree into account to which an individual physician or practice is responsible for prescribing patients' medication. Proportion of prescriptions/DDDs is an essential confounder for future studies of drug prescribing.

[Use of the S3 guidelines for early detection of prostate cancer in urological practices]. / Anwendung der S3-Leitlinie zur Prostatakrebsfrüherkennung in urologischen Praxen.

OBJECTIVES: The German S3 guideline on prostate cancer gives recommendations on early detection of prostate cancer. In this study we analyzed the adherence of urologists in private practice from the administrative district of Münster, Germany to this guideline. METHODS: Data were collected through a semistructured survey of 22 urologists based on the COREQ checklist (Consolidated criteria for reporting qualitative research) in four focus groups consisting of five or six urologists in private practice. We developed 23 questions relating to 12 recommendations of the paragraphs of the S3 guidelines dealing with early detection of prostate cancer and prostate biopsy. The recommendations of the guideline are subdivided in nine "strong", one "optional recommendation" and two "statements". The adherence to the guideline was investigated by using frequency and qualitative content analysis (Mayring) based on a mixed methods design. RESULTS: The urologists follow six of the nine "strong recommendations" of the guideline and deviate from three. Reasons for deviations from "strong recommendations" are the following: information about advantages and disadvantages of early detection for prostate cancer, recommendation of a prostate biopsy in case of PSA level ≥4 ng/ml, and indication for repeat biopsy. CONCLUSION: Most of the "strong recommendations" are followed by the interviewed urologists of the administrative district of Münster. Contextually relevant deviations from "strong recommendations" are justified, e. g., the only limited transferability of the PSA threshold of 4 ng/ml derived from population-based studies of asymptomatic men to men presenting in a urologist's office.

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

OBJECTIVES: The OPTION scale ("observing patient involvement in decision making") assesses the extent to which clinicians involve patients in decisions across a range of situations in clinical practice. It so far just covers physician behavior. We intended to modify the scoring of the OPTION scale to incorporate active patient behavior in consultations. METHODS: Modification was done on scoring level, attempting a dyadic, relationship-centred approach in that high ratings can be evoked also by the behaviour of active patients. The German version of the OPTION scale was compared with a modified version by analysing video recordings of primary care consultations dealing with cardiovascular prevention. Fifteen general practitioners provided 40 videotaped consultations. Videos were analysed by two rater pairs and two experts in shared decision making (SDM). RESULTS: Reliability measures of the modified version were lower than those of the original scale. Significant associations of the dichotomised scale with the expert SDM rating as well as with physicians' expertise in SDM were only found for the modified OPTION scale. Receiver Operating Characteristic (ROC) analyses confirmed a valid differentiation between the presence of SDM (yes/no) on total score level, even though the cut-off point was quite low. Standard deviations of the single items in the modified version were higher compared to the original OPTION scale, while the means of total scores were similar. CONCLUSIONS: The original OPTION scale is physician-centered and neglects the activity and a possible self-involvement of the patient. Our modified instruction was able to capture the dyadic element partially. The development of a separate dyadic instrument might be more promising.

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

BACKGROUND: International concern about quality of medical care has led to intensive study of interventions to ensure care is consistent with best evidence. Simple, inexpensive, feasible and effective interventions remain limited. OBJECTIVE: We examined the impact of one-sentence evidence summaries appended to consultants' letters to primary care practitioners on adherence of the practitioners to recommendations made by the consultants regarding medication for patients with chronic medical problems. DESIGN: Cluster-randomised trial. SETTING: Secondary/primary care interface (urban district hospital/referral practices). PARTICIPANTS: 178 practices received one or more discharge letters with evidence summaries. The 66 practices in the intervention group provided feedback on 172 letters, and the 56 practices in the control group provided feedback on 96 letters. RESULTS: Appending an evidence summary to discharge letters resulted in a decrease in non-adherence to discharge medication from 29.6% to 18.5% (difference adjusted for underlying medical condition 12.5%; p = 0.039). Among the five possible reasons for discontinuing discharge medication, the evidence summaries seemed to have the largest impact on budget-related reasons for discontinuation (2.6% in the intervention versus 10.7% in the control group (p = 0.052)). Most clinicians (72%) were enthusiastic about continuing receiving evidence summaries with discharge letters in routine care. CONCLUSIONS: The one-sentence evidence summary is a simple, inexpensive, well-accepted intervention that may improve primary care practitioners' adherence to evidence-based consultant recommendations.

[Food-drug interactions: an underestimated risk]. / Interaktionen zwischen Medikamenten und Ernährung. Verkannte Ursache von Nebenwirkungen und Therapieversagen.

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

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

BACKGROUND: Several clinical prediction scores have been developed to help practitioners assess the probability of streptococcal throat infection. Prior to this study, it was not known how reliably doctors assess the signs that contribute to these decision aids. OBJECTIVE: The aim of this study was to measure the inter-observer reliability of clinical findings related to sore throat. METHODS: Consecutive patients presenting with sore throat in five primary care practices in Germany took part (n = 126). Each patient was assessed independently by two doctors with regard to lymph nodes, pharynx, soft palate and tonsils. RESULTS: Agreement among practitioners was not satisfactory. CONCLUSIONS: Results suggest that the performance of clinical scoring systems can be improved by training on how to elicit relevant clinical signs. Our findings cast some doubt on the effectiveness of under- and post-graduate training in this area.

[Perspectives in the treatment of hypertension in primary care]. / Perspektiven der Hypertoniebehandlung in der hausärztlichen Praxis.

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

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

BACKGROUND: Depression is common among older people. It is associated with increased mortality and use of health services. We could identify no prior systematic review of treatment for depression in either primary care attenders or population samples of older people. OBJECTIVES: The aim of this study was to carry out a systematic review of trials of treatments for depression of patients over 60 years of age in primary care or population samples. METHODS: We searched Medline, Embase, Cinahl, the Cochrane Library, Psyclit, BIDS--Social Science and BIDS--Science Citation Indices for trials of drug treatment, interpersonal psychotherapy, cognitive behavioural psychotherapy, counselling and social interventions for late life depression in English, French or German published between 1980 and June 1999. RESULTS: Of the studies identified, only two were of patients over 60 years of age and met all inclusion criteria for content and quality. Three further studies that were not restricted to but included patients over the age of 60 years also fulfilled our criteria. We found no studies of psychological therapies for depression in older people. With few exceptions, studies were limited to older people who reached a diagnostic threshold and excluded those with 'subcase level depression'. CONCLUSION: There is little evidence of effectiveness for a variety of treatment approaches for depression in older people in primary care, particularly in those with less severe depression. As older people take more medication, making contra-indications to the use of antidepressant drugs more likely, there is a pressing need for studies of the efficacy of non-pharmacological interventions in primary care settings.

[Combined vaccine against tetanus, diphtheria and polio. A randomized controlled study of immunogenicity and tolerance]. / Kombinationsimpfstoff gegen Tetanus, Diphtherie und Polio. Eine randomisierte kontrollierte Studie zu Immunogenität und Verträglichkeit.

UNLABELLED: BACKGROUND, METHOD: Given the worldwide distribution of infection and the mobility of large parts of the population immunizations against tetanus, diphtheria and polio remain a challenge. This is especially true for adolescents and adults since antibodies tend to wane once immunized children enter adolescence and adulthood. A new combination vaccine against tetanus, diphtheria and polio (Td-IPV) for booster immunizations was subjected to a randomized, controlled and single-blind trial. Non-inferiority had to be demonstrated with regard to efficacy (immunogenicity) and safety in comparison to separate Td and IPV injections. RESULTS: Almost 500 subjects from community practices and occupational/immunization clinics took part. Antibody titres were equivalent for all antigens. Local and systemic reactions were equal or even less marked in the intervention group. CONCLUSION: From a public health perspective the new vaccine can make an important contribution to ensure adequate protection against tetanus, diphtheria and polio in adolescent and adult populations.

Studies of symptoms in primary care.

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

[Guidelines Clearing House Statement "Hypertension". Summary and recommendations for a rational hypertension guideline in Germany]. / Leitlinien-Clearing-Bericht "Hypertonie". Zusammenfassung und Empfehlungen für eine nationale Hypertonie-Leitlinie in Deutschland.

BACKGROUND: In order to promote quality of hypertension management in Germany, a national hypertension guidelines clearing project was initiated in 1999 by the German Guidelines Clearinghouse. OBJECTIVES: To identify and review published German- and English language hypertension guidelines. To establish criteria for future guideline development and implementation. To familiarize stakeholders in Germany with state-of-the-art hypertension guidelines. To identify key topics for a future national evidence-based guideline. METHODS: Search procedure, formal appraisal: Systematic search using literature databases and English-/German-language databases, published between 1990 and 1999. Abstract screening of the search results according to the inclusion criteria (n = 132 of a total of 548 hits). Systematic guideline evaluation using checklist with predefined criteria. APPRAISAL OF GUIDELINES' CONTENTS: Peer review of guidelines with the following inclusion criteria: hypertension--general, German and English language, published later than 1994, original or primary guideline or update, issued for nationwide use. Peer review was performed by a multidisciplinary focus group of EBM experts (primary and secondary care physicians, clinical pharmacologist, clinical epidemiologist). None of these was involved in hypertension guideline development during the review period. DOCUMENTATION OF CRITICAL APPRAISAL RESULTS: Systematic documentation of methodological appraisal and peer review results using a structured abstract form. The focus group wrote a final report (clearing report) including methodological abstracts for each guideline, essential topics for a future German hypertension guideline based on examples from the appraised guidelines, comments and recommendations for health care policy markers in Germany. RESULTS: 11 out of 132 guidelines were in accordance with the formal minimal standard with a wide range range within the following domains: "description of the development process", "declaration of authors' independence", "explicit link between recommendations and the supporting evidence", "management options", "tools for implementation". None of the guidelines identified all the key identified by the focus group, such as: (1) definition of hypertension--epidemiology--health care problems--intended guideline users/goals, (2) blood pressure measurement, (3) medical history and physical examination, (4) case-finding/screening, (5) indications for referral, (6) risk-stratification, (7) diagnostic procedures, (8) therapeutic goals/indications for therapy, (9) nonpharmacological measures, (10), pharmacotherapy, (11) follow-up/patient education/motivation/compliance, (12) comorbidity, hypertension in childhood/elderly, pregnancy, (13) primary prevention, (14) quality assurance/quality management, (15) dissemination/implementation, (16) open questions/challenges for the future. SUMMARY POINTS: To improve the quality of hypertension management in Germany, the expert panel suggested to develop a national evidence-based guideline. This should follow internationally agreed criteria and procedures. The experts identified and reviewed 11 out of 132 hypertension, which might make useful contributions for a future German Hypertension guideline. The expert group identified 16 key topics for a national hypertension guideline.

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

BACKGROUND: The high prevalence of behavioral risk factors for cardiovascular diseases demands innovative approaches to achieving behavior change. Primary care physicians are in an ideal position for offering such interventions. PURPOSE: To evaluate whether training of primary care physicians in counseling skills based on the Transtheoretical Model (TTM) leads to motivational and behavioral changes in their patients. METHOD: Seventy-four primary care physicians in Germany were randomly assigned to either an intervention condition (one day of training in TTM-based counseling plus brochures matched to their patients' "stages of change") or a control condition (usual care). Baseline and 12-month follow-up data were collected from 305 of their patients who signed up for a health check-up. OUTCOME MEASURE: Patients' movements across the stages of change for smoking, diet, exercise and stress management. RESULTS: After 12 months, patients of physicians in the intervention group did not show more movement through the stages of change for any of the behaviors than did patients of control physicians. Additionally, there were no differences between groups in counseling frequency, counseling intensity, or patient satisfaction with counseling. CONCLUSIONS: A high dropout rate at follow-up and resulting "power" problems limit the possible conclusions. The high numbers of patients in early stages of change and the minimal improvement over time underline the need for improving motivational counseling skills of primary care physicians in Germany. In our study the dissemination of these strategies failed. We offer lessons we feel can be learned from this outcome. Further studies should focus on ways to enhance the process of educating physicians for implementing counseling strategies in primary care settings.

[Community emergency medical service. Epidemiology and quality of treatment in a rural district]. / Notfallversorgung durch Ersthelfer. Epidemiologie und Versorgungs-Qualität in einer ländlichen Region.

OBJECTIVES: Rapid aid provided by lay witnesses and emergency services can improve the outcome in medical emergencies arising in the community. We attempted to study the quality of first aid rendered by lay persons, paramedical personnel, and community medical practitioners attending out-of-hospital emergencies. We also evaluated the frequency of first aid provided before the arrival of specialised emergency physicians. METHODS: Over a period of six months all emergencies in a rural district of Germany leading to the pre-hospital medical service being dispatched were studied. Specialised community emergency physicians arriving at the site of the event recorded demographic, clinical, and process data using a standardised instrument. They also assessed the performance of lay persons, paramedical personnel, and community physicians providing immediate care. Implicit and explicit criteria were used. RESULTS: In 97% of cases analysed (n = 1150) members of the above mentioned groups were present before the arrival of the dedicated medical service. Lay persons were judged to provide inadequate care especially with regard to airway management and immobilisation of suspected fractures. For paramedical personnel, the administration of medication, venous lines and immobilisation turned out to be problematic areas. Medical practitioners fell below the defined standards especially in airway management, immobilisation and venous lines. CONCLUSION: Our project has shown how important the evaluated groups are for community emergency care. Despite methodological problems in this area of study, the shortcomings demonstrated may be targeted by future training at different levels.