[Reasons of changes in drug therapy after hospital discharge - a qualitative study of perception by general practitioners and patients]. / Gründe von Änderungen der medikamentösen Therapie nach Krankenhausentlassung - eine qualitative Studie aus Sichtweise von Hausärzten und Patienten.

BACKGROUND: After discharge from hospital there is often change of medication regimen. Usually, the main results of the inpatient stay and the subsequent treatment recommendations are summarised in a "discharge letter". Based on this, the general practitioner decides on how to proceed taking the individual aspects of his/her patient into consideration. The aim of the study is to trace changes of medication and suggested therapy in the discharge letter, from the GP through to the patient and the reasons/influencing factors for any changes in medication undertaken or retained. METHODS: A prospective qualitative study with successively selected patients, who were put on a new long-term medication, at discharge after a stay in a hospital internal medicine unit was undertaken. Semi-structured interviews were conducted with the patients 4-6 weeks after hospital discharge. Subsequently, interviews were conducted with the patient's GP on details of current medication. The interviews were recorded electronically, based on the consensus method and evaluated with respect to changes in medication and influencing factors. In order to detect discrepancies in drug therapy, discharge letters were included in the analysis. RESULTS: A total of 34 patients and their GPs were interviewed. Few changes of medication changes were registered; however, these were more frequent in the weeks after hospital discharge. Drug therapy recommendations were modified by GPs for different medical or non-medical reasons. Non-medical reasons identified included economic, health policy constraints, personal conviction or non-adhrence of the patient. Reasons for a change in medication by the patient included, questioning of the need for taking the drug, incompatibility, fears and a lack of knowledge about the medication. CONCLUSION: The data demonstrate that the transition from inpatient to outpatient care is a sensitive interface. The data do not allow quantitative estimation of the magnitude of this phenomenon. In this study, the reasons for the modification of the drug demonstrated that these findings could be the basis for further studies or the development of interventions for preventing unwanted medication changes.

[Influence of package inserts on adherence to medication in primary care patients]. / Der Einfluss des Beipackzettels auf die medikamentöse Adhärenz bei hausärztlichen Patienten.

BACKGROUND: German legislation requires a package insert (PI) to be attached to any drug that informs patients about the use, indications, dosage and possible side effects. This PI is often blamed for deliberate deviations from the patient's prescribed medication regimen. It is unknown to what extent patients use the opportunity to inform themselves by the PI and potential consequences for medication adherence. METHODS: In semi-structured interviews patients were asked about their use of package inserts, their opinion about PI and potential consequences of PI. Patients with newly prescribed drugs were included in the study. Data analysis was carried according to the qualitative content analysis by Mayring. RESULTS: 71 interviews were analyzed. PIs are used in very different ways and intensity. PIs are predominantly associated with negative connotations. Reading of PI seems to have hardly any immediate impact on medication adherence. Patients expressed that they feel confidence in the pharmaceutical industry and especially rely on the expertise of theirs general practitioner. CONCLUSION: These results point out that the use of PIs may have less impact than often assumed. Reading the package insert in these patients did hardly affect medication adherence.

[GP (general practitioners)-centered care - international data and recent development in Germany with focus on Baden-Württember]. / Hausarztzentrierte Versorgung - internationale Daten und aktuelle Entwicklungen in Deutschland mit Fokus auf Baden-Württemberg.

BACKGROUND: Since the health-care reform in 1993, there are ambitious efforts of introducing gatekeeping in Germanys' primary health-care system. Gatekeeping is said to reduce costs and improve health-care quality. The aim of this article is to summarise the actual literature and the newest progression of gatekeeping for the example of Baden-Württemberg. METHODS: By means of a selective literature search, national and international data on gatekeeping are summarised. RESULTS: Most available data on gatekeeping are from US-American studies whereas data from Germany are rare so far. The effects of gatekeeping are defined by means of various outcome measures (e.g., physician-patient relationship, health-care quality, visits, referrals, costs, prescribing behaviour). The observed effects in terms of these outcome measures are not uniform and are contradictory to a great extent. Newest data from GP (general practitioners)-centred care model regions in Germany indicate a high satisfaction among these patients. Furthermore, an increase of consultations at specialists with referrals from the gatekeepers could be observed whilst the overall number of referrals to specialists remained equal so far. Baden-Württemberg's first generation contracts for GP-centred care were based on different legal paragraphs resulting in partially considerable differences in terms of the conditions for physicians and patients. DISCUSSION: On the basis of the available data, the effects of gatekeeping cannot conclusively be determined. In Germany, scientific evaluation of the different gatekeeping models and publication of their results are absolutely necessary to assess the expected cost saving and quality improving effects of gatekeeping.

Indications for total hip replacement: comparison of assessments of orthopaedic surgeons and referring physicians.

OBJECTIVES: To analyse differences of opinions on indications for primary total hip replacements (THRs) within and between groups of orthopaedic surgeons and the physicians who refer patients to them. METHODS: 22 orthopaedic centres in 12 European countries took part, resulting in a postal survey of 304 orthopaedic surgeons and 314 referring physicians. Each participant was asked to state what importance different domains (pain, functional impairment, physical examination and radiographs) have on their decision to recommend THR and to select the most appropriate level of severity of each symptom or sign for recommending THR. In addition, the participants were asked to prioritise other personal or environmental factors that affect their decision to undertake a THR. RESULTS: Rest pain, pain with activity and functional limitations were the most important criteria for THR, although range of motion and radiographic changes were of least importance. Both similarities and differences were observed within and between groups of surgeons and referring physicians in the overall approach to indications and the most appropriate level of severity of disease for recommending THR. Most surgeons agreed on severity levels in only 4 of 11 items and most referring physicians in only one. Between the groups, major differences occurred with regard to the importance of activities of daily living and the appropriate level of symptoms for THR. In general, compared with surgeons, referring physicians reported that the disease needed to be more advanced to warrant surgery. CONCLUSION: Currently, no consensus exists on objective indication criteria for THR. The observed differences between the gatekeepers (referring physicians) and surgeons can lead to variations and perhaps inequities in the provision of care.

Differences in the views of orthopaedic surgeons and referring practitioners on the determinants of outcome after total hip replacement.

In order to assess current opinions on the long-term outcome after primary total hip replacement, we performed a multicentre, cross-sectional survey in 22 centres from 12 European countries. Different patient characteristics were categorised into 'decreases chances', 'does not affect chances', and 'increases chances' of a favourable long-term outcome, by 304 orthopaedic surgeons and 314 referring practitioners. The latter were less likely to associate age older than 80 years and obesity with a favourable outcome than orthopaedic surgeons (p < 0.001 and p = 0.006, respectively) and more likely to associate age younger than 50 years with a favourable outcome (p = 0.006). Comorbidity, rheumatoid arthritis, and poor bone quality were thought to be associated with a decreased chance of a favourable outcome. We found important differences in the opinions regarding long-term outcome after total hip replacement within and between referring practitioners and orthopaedic surgeons. These are likely to affect access to and the provision of total hip replacement.