Development of indicators to assess quality and patient pathways in interdisciplinary care for patients with 14 ambulatory-care-sensitive conditions in Germany.

BACKGROUND: In settings like the ambulatory care sector in Germany, where data on the outcomes of interdisciplinary health services provided by multiple office-based physicians are not always readily available, our study aims to develop a set of indicators of health care quality and utilization for 14 groups of ambulatory-care-sensitive conditions based on routine data. These may improve the provision of health care by informing discussions in quality circles and other meetings of networks of physicians who share the same patients. METHODS: Our set of indicators was developed as part of the larger Accountable Care in Deutschland (ACD) project using a pragmatic consensus approach. The six stages of the approach drew upon a review of the literature; the expertise of physicians, health services researchers, and representatives of physician associations and statutory health insurers; and the results of a pilot study with six informal network meetings of office-based physicians who share the same patients. RESULTS: The process resulted in a set of 248 general and disease specific indicators for 14 disease groups. The set provides information on the quality of care provided and on patient pathways, covering patient characteristics, physician visits, ambulatory care processes, pharmaceutical prescriptions and outcome indicators. The disease groups with the most indicators were ischemic heart diseases, diabetes and heart failure. CONCLUSION: Our set of indicators provides useful information on patients' health care use, health care processes and health outcomes for 14 commonly treated groups of ambulatory-care-sensitive conditions. This information can inform discussions in interdisciplinary quality circles in the ambulatory sector and foster patient-centered care.

Using social network analysis methods to identify networks of physicians responsible for the care of specific patient populations.

BACKGROUND: Coordinating health care within and among sectors is crucial to improving quality of care and avoiding undesirable negative health outcomes, such as avoidable hospitalizations. Quality circles are one approach to strengthening collaboration among health care providers and improving the continuity of care. However, identifying and including the right health professionals in such meetings is challenging, especially in settings with no predefined patient pathways. Based on the Accountable Care in Germany (ACD) project, our study presents a framework for and investigates the feasibility of applying social network analysis (SNA) to routine data in order to identify networks of ambulatory physicians who can be considered responsible for the care of specific patients. METHODS: The ACD study objectives predefined the characteristics of the networks. SNA provides a methodology to identify physicians who have patients in common and ensure that they are involved in health care provision. An expert panel consisting of physicians, health services researchers, and data specialists examined the concept of network construction through informed decisions. The procedure was structured by five steps and was applied to routine data from three German states. RESULTS: In total, 510 networks of ambulatory physicians met our predefined inclusion criteria. The networks had between 20 and 120 physicians, and 72% included at least ten different medical specialties. Overall, general practitioners accounted for the largest proportion of physicians in the networks (45%), followed by gynecologists (10%), orthopedists, and ophthalmologists (5%). The specialties were distributed similarly across the majority of networks. The number of patients this study allocated to the networks varied between 95 and 45,268 depending on the number and specialization of physicians per network. CONCLUSIONS: The networks were constructed according to the predefined characteristics following the ACD study objectives, e.g., size of and specialization composition in the networks. This study shows that it is feasible to apply SNA to routine data in order to identify groups of ambulatory physicians who are involved in the treatment of a specific patient population. Whether these doctors are also mainly responsible for care and if their active collaboration can improve the quality of care still needs to be examined.

Improving the continuity and coordination of ambulatory care through feedback and facilitated dialogue-a study protocol for a cluster-randomised trial to evaluate the ACD study (Accountable Care in Germany).

BACKGROUND: Patients in Germany are free to seek care from any office-based physician and can always ask for multiple opinions on a diagnosis or treatment. The high density of physicians and the freedom to choose among them without referrals have led to a need for better coordination between the multiple health professionals treating any given patient. The objectives of this study are to (1) identify informal networks of physicians who treat the same patient population, (2) provide these physicians with feedback on their network and patients, using routine data and (3) give the physicians the opportunity to meet one another in facilitated network meetings. METHODS: The Accountable Care Deutschland (ACD) study is a prospective, non-blinded, cluster-randomised trial comprising a process and economic evaluation of informal networks among 12,525 GPs and office-based specialists and their 1.9 million patients. The units of allocation are the informal networks, which will be randomised either to the intervention (feedback and facilitated meetings) or control group (usual care). The informal networks will be generated by identifying connections between office-based physicians using complete datasets from the Regional Associations of Statutory Health Insurance (SHI) Physicians in Hamburg, Schleswig Holstein, North Rhine and Westphalia Lip, as well as data from three large statutory health insurers in Germany. The physicians will (a) receive feedback on selected indicators of their own treatment activity and that of the colleagues in their network and (b) will be invited to voluntary, facilitated network meetings by their Regional Association of SHI physicians. The primary outcome will be ambulatory-care-sensitive hospitalisations at baseline, at the end of the 2-year intervention period, and at six months and at 12 months after the end of the intervention period. Data will be analysed using the intention-to-treat principle. A pilot study preceded the ACD study. DISCUSSION: Cochrane reviews show that feedback can improve everyday medical practice by shedding light on previously unknown relationships. Providing physicians with information on how they are connected with their colleagues and what the outcomes are of care delivered within their informal networks can help them make these improvements, as well as strengthen their awareness of possible discontinuities in the care they provide. TRIAL REGISTRATION: German Clinical Trials Register DRKS00020884 . Registered on 25 March 2020-retrospectively registered.

Study protocol for a mixed methods exploratory investigation of aftercare services for gestational diabetes in women to develop a new patient-centred model in Germany: the GestDiNa_basic study.

INTRODUCTION: Women with gestational diabetes mellitus (GDM) have a higher risk of developing type 2 diabetes mellitus compared with women who never had GDM. Consequently, the question of structured aftercare for GDM has emerged. In all probability, many women do not receive care according to the guidelines. In particular, the process and interaction between obstetrical, diabetic, gynaecological, paediatric and general practitioner care lacks clear definitions. Thus, our first goal is to analyse the current aftercare situation for women with GDM in Germany, for example, the participation rate in aftercare diabetes screening, as well as reasons and attitudes stated by healthcare providers to offer these services and by patients to participate (or not). Second, we want to develop an appropriate, effective and patient-centred care model. METHODS AND ANALYSIS: This is a population-based mixed methods study using both quantitative and qualitative research approaches. In various working packages, we evaluate data of the GestDiab register, of the Association of Statutory Health Insurance Physicians of North Rhine and the participating insurance companies (AOK Rheinland/Hamburg, BARMER, DAK Gesundheit, IKK classic, pronova BKK). In addition, quantitative (postal surveys) and qualitative (interviews) surveys will be conducted with randomly selected healthcare providers (diabetologists, gynaecologists, paediatricians and midwives) and affected women, to be subsequently analysed. All results will then be jointly examined and evaluated. ETHICS AND DISSEMINATION: The study was approved by the ethics committee of the Faculty of Medicine, Heinrich-Heine-University Düsseldorf (Ethics Committee No.: 2019-738). Participants of the postal surveys and interviews will be informed in detail about the study and the use of data as well as the underlying data protection regulations before voluntarily participating. The study results will be disseminated through peer-reviewed journals, conferences and public information. TRIAL REGISTRATION NUMBER: DRKS00020283.

Quit attempts and tobacco abstinence in primary care patients: follow-up of a pragmatic, two-arm cluster randomised controlled trial on brief stop-smoking advice - ABC versus 5As.

We developed a 3.5-h training for general practitioners (GPs) in delivering brief stop-smoking advice according to different methods (ABC, 5As). In a pragmatic, cluster randomised controlled trial our training proved effective in increasing GP-delivered rates of such advice (from 13% to 33%). In this follow-up analysis we examined the effect of the training and compared ABC versus 5As on patient-reported quit attempts and point prevalence abstinence at weeks 4, 12 and 26 following GP consultation. Follow-up data were collected in 1937 smoking patients - independently of the receipt of GP advice - recruited before or after the training of 69 GPs. At week 26, ∼70% of the patients were lost to follow-up. All 1937 patients were included in an intention-to-treat analysis; missing outcome data were imputed. Quit attempts and abstinence rates did not differ significantly from pre- to post-training or between patients from the ABC versus the 5As group. However, ancillary analyses showed that patients who received GP advice compared to those who did not had two times higher odds of reporting a quit attempt at all follow-ups and abstinence at week 26. We reported that our training increases GP-delivered rates of stop-smoking advice, and the present analysis confirms that advice is associated with increased quit attempts and abstinence rates in patients. However, our training did not further improve these rates, which might be related to patients' loss to follow-up or to contextual factors, e.g. access to free evidence-based cessation treatment, which can hamper the transfer of GPs' advice into patients' behaviour change.

Training general practitioners in the ABC versus 5As method of delivering stop-smoking advice: a pragmatic, two-arm cluster randomised controlled trial.

This study assessed the effectiveness of a 3.5-h training session for general practitioners (GPs) in providing brief stop-smoking advice and compared two methods of giving advice - ABC versus 5As - on the rates of delivery of such advice and of recommendations of evidence-based smoking cessation treatment during routine consultations. A pragmatic, two-arm cluster randomised controlled trial was carried out including a pre-/post-design for the analyses of the primary outcome in 52 GP practices in Germany. Practices were randomised (1:1) to receive a 3.5-h training session (ABC or 5As). In total, 1937 tobacco-smoking patients, who consulted trained GPs in these practices in the 6 weeks prior to or following the training, were included. The primary outcome was patient-reported rates of GP-delivered stop-smoking advice prior to and following the training, irrespective of the training method. Secondary outcomes were patient-reported receipt of recommendation/prescription of behavioural therapy, pharmacotherapy or combination therapy for smoking cessation, and the effectiveness of ABC versus 5As regarding all outcomes. GP-delivered stop-smoking advice increased from 13.1% (n=136 out of 1039) to 33.1% (n=297 out of 898) following the training (adjusted odds ratio (aOR) 3.25, 95% CI 2.34-4.51). Recommendation/prescription rates of evidence-based treatments were low (<2%) pre-training, but had all increased after training (e.g. behavioural support: aOR 7.15, 95% CI 4.02-12.74). Delivery of stop-smoking advice increased non-significantly (p=0.08) stronger in the ABC versus 5As group (aOR 1.71, 95% CI 0.94-3.12). A single training session in stop-smoking advice was associated with a three-fold increase in rates of advice giving and a seven-fold increase in offer of support. The ABC method may lead to higher rates of GP-delivered advice during routine consultations.

GPs' awareness of car driving among oldest patients: exploratory results from a primary care cohort.

BACKGROUND: Increasingly more very old people are active drivers. Sensory, motor and cognitive limitations, and medication can increase safety risks. Timely attention to driving safety in the patient-doctor relationship can promote patient-centred solutions. AIM: To explore the following questions: do GPs know which patients drive a car? Is fitness to drive addressed with patients? DESIGN & SETTING: Cross-sectional data from patient interviews and GP survey in the ninth follow-up phase of a prospective primary care cohort (the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe) and the Study on Needs, Health Service Use, Costs and Health-Related Quality of Life in a large sample of 'oldest-old' primary care patients (≥85 years; AgeQualiDe)) . METHOD: The sample consisted of patients in the age group ≥85 years and their GPs. Independent reports were gathered on driving activity from the GP and the patient, and information was gained from GPs on whether driving ability was discussed with the patient. Statistical analyses included validity parameters and bivariate characterisation of subgroups (non-parametric significance tests, effect size). RESULTS: Self-reports of 553 patients were available (69.5% female; mean age 90.5 years; 15.9% drive a car). For 427 patients, GP data were also available: GPs recognised 67.1% correctly as drivers and 94.9% as non-drivers. GPs said that they had discussed fitness to drive with 32.1% of potentially driving patients. Among drivers who were not recognised and with whom driving had not been discussed, there were more patients with a low educational level. CONCLUSION: The GP's assessment of driving activity among very old patients showed moderate sensitivity and good specificity. Driving ability was seldom discussed. Asking an appropriate question during assessment could increase GPs' awareness of older patients' automobility.

Driving status and health-related quality of life among the oldest old: a population-based examination using data from the AgeCoDe-AgeQualiDe prospective cohort study.

BACKGROUND: It is almost unknown whether the driving status is associated with HRQOL among individuals in highest age. AIMS: Based on a multicenter prospective cohort study, the objective of this study was to examine whether the driving status is associated with health-related quality of life (HRQOL) among the oldest old in Germany. METHODS: Cross-sectional data from follow-up wave 9 (n = 544) were derived from the "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe). Average age was 90.3 years (± 2.7; 86 to 101 years). The current driver status (no; yes) was used in our analysis. The EuroQoL EQ-5D questionnaire was used to assess HRQOL in this study. RESULTS: Regression analysis showed that being a current driver was associated with the absence of problems in 'self-care' [OR 0.41 (95%-CI 0.17 to 0.98)], and 'usual activities' [OR 0.48 (0.26 to 0.90)], whereas it was not significantly associated with problems in 'pain/discomfort' [OR  0.82 (0.47 to 1.45)] and 'anxiety/depression' [OR  0.71 (0.36 to 1.39)]. Being a current driver was marginally significantly associated with the absence of problems in 'mobility' [OR 0.60 (0.34 to 1.06)]. While being a current driver was not associated with the EQ-VAS in the main model, it was positively associated with the driving status (ß = 5.00, p < .05) when functional impairment was removed from the main model. DISCUSSION: Our findings provide first evidence for an association between driving status and HRQOL among the oldest old. CONCLUSIONS: Future longitudinal studies are required to evaluate a possible causal relationship between driving status and HRQOL in very old individuals.

Study protocol of a systematic review and qualitative evidence synthesis using two different approaches: Healthcare related needs and desires of older people with post-stroke aphasia.

INTRODUCTION: Stroke is a frequent disease in the older population of Western Europe with aphasia as a common consequence. Aphasia is known to impede targeting treatment to individual patients' needs and therefore may reduce treatment success. In Germany, the postacute care of patients who had stroke is provided by different healthcare institutions of different sectors (rehabilitation, nursing and primary care) with substantial difficulties to coordinate services. We will conduct two qualitative evidence syntheses (QESs) aiming at exploring distinct healthcare needs and desires of older people living with poststroke aphasia. We thereby hope to support the development of integrated care models based on needs of patients who are very restricted to communicate them. Since various methods of QESs exist, the aim of the study embedding the two QESs was to determine if findings differ according to the approach used. METHODS AND ANALYSIS: We will conduct two QESs by using metaethnography (ME) and thematic synthesis (ThS) independently to synthesise the findings of primary qualitative studies. The main differences between these two methods are the underlying epistemologies (idealism (ME) vs realism (ThS)) and the type of research question (emerging (ME) vs fixed (ThS)).We will search seven bibliographical databases. Inclusion criteria comprise: patients with poststroke aphasia, aged 65 years and older, studies in German/English, all types of qualitative studies concerning needs and desires related to healthcare or the healthcare system. The protocol was registered in the International Prospective Register of Systematic Reviews, follows Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines and includes three items from the Enhancing Transparency in Reporting the synthesis of Qualitative Research checklist. ETHICS AND DISSEMINATION: Ethical approval is not required. Findings will be published in a peer-reviewed journal and presented on national conferences.

Barriers and facilitators to integrate oral health care for older adults in general (basic) care in East Netherlands. Part 1: Normative integration.

OBJECTIVE: to synthesise a framework of barriers and facilitators in the normative integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels. BACKGROUND: Identification of these barriers and facilitators is expected to promote better and more appropriate care. METHODS: For this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home-dwelling, and nursing home patients) in East Netherlands were interviewed. Transcripts of the in-depth, topic-guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined. RESULTS: Two main themes were identified: (1) a compartmentalised care culture in which OHC and general health care are seen as two separate realms, and (2) prioritisation, awareness and attitude regarding OHC integration. Subthemes such as low political attention (macro level); unclear responsibilities, hierarchical relations and the lack of vision of organisations (meso level); and poor awareness and low prioritisation by care providers and patients (micro level) were identified as potential barriers. Subthemes such as leadership (meso level), and the supportive personality of individual caregivers and ownership of patients (micro level) were identified as facilitators. CONCLUSION: Barriers and facilitators in normative OHC integration in The Netherlands are interrelated and apparent at macro-, meso- and micro levels. They are mainly related to (a) a compartmentalised care culture, and (b) related low prioritisation, and poor awareness of and attitude towards (integration of) oral health (care).

Effectiveness of training general practitioners to improve the implementation of brief stop-smoking advice in German primary care: study protocol of a pragmatic, 2-arm cluster randomised controlled trial (the ABCII trial).

BACKGROUND: The German clinical guideline on tobacco addiction recommends that general practitioners (GPs) provide brief stop-smoking advice to their patients according to the "5A" or the much briefer "ABC" method, but its implementation is insufficient. A lack of training is one barrier for GPs to provide such advice. Moreover, the respective effectiveness of a 5A or ABC training regarding subsequent delivery of stop-smoking advice has not been investigated. We developed a training for GPs according to both methods, and conducted a pilot study with process evaluation to optimize the trainings according to the needs of GPs. This study aims at evaluating the effectiveness of both trainings. METHODS: A pragmatic 2-arm cluster randomised controlled trial with a pre-post data collection will be conducted in 48 GP practices in North Rhine-Westphalia (Germany). GPs will be randomised to receive a 3.5-h-training in delivering either 5A or ABC, including peer coaching and intensive role plays with professional actors. The patient-reported primary outcome (receipt of GP advice to quit: yes/no) and secondary outcomes (recommendation rates of smoking cessation treatments, group comparison (5A versus ABC): receipt of GP advice to quit) will be collected in smoking patients routinely consulting their GP within 4 weeks prior, and 4 weeks following the training. Additional secondary outcomes will be collected at 4, 12 and 26 weeks following the consultation: use of cessation treatments during the last quit attempt (if so) since the GP consultation, and point-prevalence abstinence rates. The primary data analysis will be conducted using a mixed-effects logistic regression model with random effects for the cluster variable. DISCUSSION: If the training increases the rates of delivery of stop-smoking advice, it would offer a low-threshold strategy for the guideline implementation in German primary care. Should one method prove superior, a more specific guideline recommendation can be proposed. TRIAL REGISTRATION: German Clinical Trials Register (DRKS00012786); registered on 22th August 2017, prior to the first patient in.

Prevalence and determinants of driving habits in the oldest old: Results of the multicenter prospective AgeCoDe-AgeQualiDe study.

AIM: To present data on the prevalence of driving habits and to identify the determinants of driving habits among the oldest old in Germany. METHODS: Cross-sectional data were used from the "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe), including primary care patients aged 85 years and above (n = 549 at FU 9, mean age was 90.3 years; 86-101 years). Driving habits were measured (driving a car; frequency of driving a car and driving duration). Correlates were quantified using widely established scales (e.g., Geriatric Depression Scale, Instrumental Activities of Daily Living Scale). Multiple regression models were used to identify the determinants of driving habits. RESULTS: Sixteen percent (87 out of 549) drove a car. Among the car-drivers, about 80% drove at least several times a week and about two-thirds drove longer distances (>15 min). Multiple logistic regressions showed that among the oldest old being a male was more likely to be a current driver compared to being a female. Other significant factors were subjective memory impairment, severe visual impairment, functional and cognitive impairment. Correlates of frequency of driving a car and driving duration were further identified. CONCLUSION: About one in six very old Germans is still a regular car driver. Several determinants of driving habits among the oldest old were identified. Future longitudinal studies are required to clarify the factors leading to changes in driving habits.

[Driving and dementia : An issue for general practice?!] / Autofahren und Demenz : Ein Thema für die Hausarztpraxis?!

BACKGROUND: With most forms of dementia, the risk of road traffic accidents increases with disease progression. Addressing the issue of fitness to drive at an early stage can help to reduce driving-related risks and simultaneously preserve mobility. General practitioners (GPs) are central contact persons for dementia patients and their relatives in medical and psychosocial matters, and also play a key role in addressing the issue of driving safety. OBJECTIVE: Identification of relevant aspects of managing fitness to drive in dementia, as well as of support requirements for German general practice. MATERIALS AND METHODS: Seven focus groups with dementia patients, family caregivers and GPs were conducted in order to define the different requirements for counselling in the general practice setting. The transcribed discussions were analysed by a multiprofessional research team using content analysis. RESULTS: For people with dementia, declining mobility and driving cessation is related to a loss of autonomy. Addressing fitness to drive in dementia is thus a subject of conflict and uncertainty for both family caregivers and GPs. The difficulties include the assessment of fitness to drive in the general practice setting, concerns about compromising the patient-physician relationship by raising the issue of driving fitness, as well as uncertainties about the GP's own role. GPs consider the involvement of caregivers to be important to successfully address the topic of driving safety and organise alternative transport. Support is required in the form of criteria defining the time point at which fitness to drive should be assessed, information on compensation possibilities and mobility alternatives. CONCLUSION: Resource-oriented and patient-centred development of management strategies for limited mobility is needed in general practice. Finding the correct balance between documentation, adequately informing the patient and establishing patient-centred strategies represents a challenge.

Putting dementia awareness into general practice : The CADIF approach.

BACKGROUND: International studies show that dementia is often recognized at later stages in general practice. Pure knowledge-sharing interventions could not change this in a sustainable manner. Concepts for changing attitudes of general practitioners (GPs) are required. OBJECTIVES: What barriers affect GPs' recognition of and diagnostic approach to dementia? What recommendations for a GP-specific diagnostic procedure can be derived from this? METHODS: Metasynthesis of qualitative studies with GPs on barriers to dementia recognition, explication of the "frailty" concept and the diagnostic approach described therein and the development of an approach in cases of suspected cognitive decline in a multiprofessional team. RESULTS: A metasynthesis of qualitative studies revealed a lack of a general practice framework in the diagnostic approach of GPs, characterized by poor patient-centeredness and confusion of early detection, diagnostics and disclosure. The embedding of cognitive decline into the geriatric triad is intended to promote the focus on everyday function and quality of life, i.e. on caring instead of curing. The proposed concept for a transfer into practice emphasizes increased awareness for cognitive warning signs among practice personnel, a geriatric and personal approach to the patient, as well as follow-up assessment and monitoring. CONCLUSION: In contrast to early recognition, awareness initially does not imply an active search for cognitive deficits with questions and tests but a vigilance for red flags. The described scheme is a component of a complex intervention for attitude change among GPs towards dementia.

Subjective memory impairment in general practice : Short overview and design of a mixed methods study.

BACKGROUND: Public awareness for dementia is rising and patients with concerns about forgetfulness are not uncommon in general practice. For the general practitioner (GP) subjectively perceived memory impairment (SMI) also offers a chance to broach the issue of cognitive function with the patient. This may support GPs' patient-centered care in terms of a broader frailty concept. OBJECTIVE: What is SMI (definition, operationalization, prevalence and burden)? Which conceptions and approaches do GPs have regarding SMI? METHODS: Narrative overview of recent SMI criteria and results, selective utilization of results from a systematic literature search on GP dementia care, non-systematic search regarding SMI in general practice, deduction of a study design from the overview and development according to international standards. RESULTS: Studies revealed that approximately 60% of GP patients aged >74 reported a declining memory, every sixth person had concerns about this aspect and only relatively few seek medical advice. Concerns about SMI are considered a risk factor for future dementia. Specific general practice conceptions about SMI could not be identified in the literature. Using guidelines for mixed methods research, the design of an exploratory sequential mixed methods study is presented, which should reveal different attitudes of GPs towards SMI. CONCLUSION: Subjective memory impairment (SMI) is a common feature and troubles a considerable proportion of patients. Neuropsychiatric research is progressing, but for the transfer of the SMI concept into routine practice, involvement of GP research is necessary. A new study aims to make a contribution to this.

[Fitness to drive in dementia - theoretical framing and design of a recommendation for German general practice]. / Fahrtauglichkeit bei Demenz - Theoretische Rahmung und Konzept einer Vorgehensempfehlung für die Hausarztpraxis.

BACKGROUND: General practitioners (GPs) are among the first to be contacted by persons with dementia and their relatives. Fitness to drive in dementia is a subject of uncertainty and conflict for GPs. OBJECTIVE: Development of recommendations for German general practice on managing fitness to drive in dementia. METHODS: Specification of problem areas by using relevant parts of a metasynthesis of international qualitative dementia research with GPs; literature review on evidence regarding the pre-defined problem areas; deduction of a preliminary design for a recommendation in a multi-professional team. RESULTS: The difficulties include the assessment of fitness to drive in the office setting, concerns about damaging the patient-physician relationship by raising the issue of driving fitness, and uncertainties about the GP's own legal role. A diagnosis of dementia does not per se preclude driving. The majority of elderly people would accept discussing fitness to drive with their GP. In Germany, GPs are not obliged to assess fitness to drive, or to report unsafe drivers to the Licensing Agency, but under certain conditions they do have the right to report. Addressing the issue of driving and dementia early with the patient seems to be a prerequisite for a resource-oriented and patient-centred management. DISCUSSION: The distinction between medical, ethical-communicative, and legal aspects enabled us to break down this complex problem and thus provide the informative basis to draft tailored recommendations. In an ongoing project, this framework will be further developed and informed by the expertise of patients, family caregivers, and professionals from various fields.

[Is it quality of life that patients really want? Assessment from a general practitioner's perspective]. / Ist Lebensqualität das, was Patienten wirklich wollen? Einschätzungen aus einer hausärztlichen Perspektive.

The multidimensional, complex construct of 'quality of life' as a patient-reported outcome is used in medicine as a measurable indicator of health and illness. But do we know what we do when we measure 'quality of life'? Can we grasp how the patient with his individual concept of disease really feels when we use instruments that were designed, administered and analysed by professionals? Do we know the meaning of what we have measured? Is it not shortsighted to focus on health-related quality of life? And is it really quality of life that patients actually want? From a general practitioner's perspective, these questions will be asked of three patients.

[The role of non-pharmaceutical and non-technical therapeutic interventions in patient care]. / Stellenwert nicht-medikamentöser und nicht-technischer Behandlungsverfahren in der Versorgung.

A clear definition of the broad field of non-pharmaceutical and non-technical therapeutic interventions in patient care does not exist, making the discussion more difficult. Here, the relationship between patient and professional, contextual factors, and the influence of the patient play a more prominent role than with drug therapy and technical interventions. The vast majority of non-pharmaceutical and non-technical procedures consist of complex and nearly always communication-based interventions. It is difficult to describe their role, since reliable data on criteria like frequency, time required, costs, quality, number of professionals involved and the importance for the patient are sparse. These therapeutic interventions may well form the core and biggest part of therapy in patient care. (As supplied by publisher).