Consequences of early thyroid ultrasound on subsequent tests, morbidity and costs: an explorative analysis of routine health data from German ambulatory care.

OBJECTIVES: This study aims to evaluate whether the use of thyroid ultrasound (US) early in the work-up of suspected thyroid disorders triggers cascade effects of medical procedures and to analyse effects on morbidity, healthcare usage and costs. STUDY DESIGN: Retrospective analysis of claims data from ambulatory care (2012-2017). SETTING: Primary care in Bavaria, Germany, 13 million inhabitants. PARTICIPANTS: Patients having received a thyroid stimulating hormone (TSH) test were allocated to (1) observation group: TSH test followed by an early US within 28 days or (2) control group: TSH test, but no early US. Propensity score matching was used adjusting for socio-demographic characteristics, morbidity and symptom diagnosis (N=41 065 per group after matching). PRIMARY AND SECONDARY OUTCOME MEASURES: Using cluster analysis, groups were identified regarding frequency of follow-up TSH tests and/or US and compared. RESULTS: Four subgroups were identified: cluster 1: 22.8% of patients, mean (M)=1.6 TSH tests; cluster 2: 16.6% of patients, M=4.7 TSH tests; cluster 3: 54.4% of patients, M=3.3 TSH tests, 1.8 US; cluster 4: 6.2% of patients, M=10.9 TSH tests, 3.9 US. Overall, reasons that explain the tests could rarely be found. An early US was mostly found in clusters 3 and 4 (83.2% and 76.1%, respectively, were part of the observation group). In cluster 4 there were more women, thyroid-specific morbidity and costs were higher and the early US was more likely to be performed by specialists in nuclear medicine or radiologists. CONCLUSION: Presumably unnecessary tests in the field of suspected thyroid diseases seem to be frequent, contributing to cascades effects. Neither German nor international guidelines provide clear recommendations for or against US screening. Therefore, guidelines on when to apply US and when not are urgently needed.

The quality of COPD care in German general practice-A cross-sectional study.

OBJECTIVES: Chronic Obstructive Pulmonary Disease (COPD) is a common health problem to be dealt with in primary care. Little is known about the quality of care provided for patients with COPD in Germany. Therefore, we wanted to assess the current quality of care delivered by a primary care network (PCN) for patients with COPD. METHODS: A cross-sectional study was conducted in collaboration with a primary care network (PCN). All patients of the PCN aged 40 years and older with a diagnosis of COPD were identified through electronic health records (EHR). A set of quality indicators (QIs) developed in accordance with current COPD-guidelines were appraised through numerical data retrieved from the EHR. RESULTS: In total, 2,568 patients with COPD were identified. Their mean age was 67 (SD±12) years, 49% were male. Thirty-five percent had a parallel diagnosis of asthma. There was no documentation of any spirometry for 54% of patients; 29% had a spirometry within the previous year. An influenza vaccination was documented for 37% within the preceding 12 months; 12% received a pneumococcal vaccination in the last 6 years. Smoking status was documented for 44% within the last year. CONCLUSION: The quality of care for patients with COPD in the PCN seemed suboptimal, despite the presence of a Disease Management Program (DMP). This finding is likely to apply widely to German general practice. Quality assessment through currently available EHR data was challenging due to non-standardized and insufficient documentation.

Is it really always only the others who are to blame? GP's view on medical overuse. A questionnaire study.

BACKGROUND: Medical overuse is a common problem in health care. Preventing unnecessary medicine is one of the main tasks of General Practice, so called quaternary prevention. We aimed to capture the current opinion of German General Practitioners (GPs) to medical overuse. METHODS: A quantitative online study was conducted. The questionnaire was developed based on a qualitative study and literature search. GPs were asked to estimate prevalence of medical overuse as well as to evaluate drivers and solutions of medical overuse. GPs in Bavaria were recruited via email (750 addresses). A descriptive data analysis was performed. Additionally the association between doctors' attitudes and (1) demographic variables and (2) interest in campaigns against medical overuse was assessed. RESULTS: Response rate was 18%. The mean age was 54 years, 79% were male and 68% have worked as GP longer than 15 years. Around 38% of medical services were considered as medical overuse and nearly half of the GPs (47%) judged medical overuse to be the more important problem than medical underuse. Main drivers were seen in "patients´ expectations" (76%), "lack of a primary care system" (61%) and "defensive medicine" (53%), whereas "disregard of evidence/guidelines" (15%) and "economic pressure on the side of the doctor" (13%) were not weighted as important causes. Demographic variables did not have an important impact on GPs´ response pattern. GPs interested in campaigns like "Choosing Wisely" showed a higher awareness for medical overuse, although these campaigns were only known by 50% of the respondents. DISCUSSION: Medical overuse is an important issue for GPs. Main drivers were searched and found outside their own sphere of responsibility. Campaigns as "Choosing Wisely" seem to have a positive effect on GPs attitude, but knowledge is still limited.

Do guidelines help us to deviate from their recommendations when appropriate for the individual patient? A systematic survey of clinical practice guidelines.

RATIONALE, AIMS, AND OBJECTIVES: Clinical practice guidelines (CPG) were introduced to summarize the best scientific evidence available. Thereby, CPG were meant to support evidence-based medicine (EBM). However, besides evidence, EBM also asks for patients' preferences and physicians' experiences to be considered when coming to therapeutic decisions. Thus, deviations from CPG recommendations are sometimes necessary when practicing EBM. We wanted to examine whether CPG support deviations from their recommendations when appropriate. For operationalization, we asked whether absolute effect sizes (AES) for benefit and/or harm of suggested therapies were provided along with the respective CPG recommendation. METHODS: This systematic survey comprised the most common CPG on chronic coronary heart disease (CCHD) and type 2 diabetes mellitus (T2DM) from English- and German-speaking countries. Only CPG recommendations on pharmacotherapy were evaluated. If AES of a recommended therapy were reported, we rated how easily findable they were within the CPG. Moreover, we assessed whether the CPG provided patient information material and whether this material supplied AES allowing patients to determine the effects to be expected. RESULTS: In the 13 CPG surveyed, 144 recommendations on pharmacotherapy were identified. For 108 recommendations (75%), no AES for benefit and/or harm were reported. Thirty-one recommendations (22%) were accompanied by one or more AES for either benefit or harm. Along with five recommendations (3%), one or more AES for both benefit and harm were given. AES were considered easy to find for three of these 36 recommendations (8%). Patient information material was provided in three of the 13 CPG (23%) accounting for AES in one occasion only. CONCLUSION: Current CPG on T2DM and CCHD do not sufficiently offer AES for benefits and harms of recommended therapies. Thus, they lack satisfactory information to support deviations from CPG recommendations. Consequently, CPG in their present form do not adequately facilitate EBM.

Referrals for uncomplicated lower back pain: a cluster parallel randomised trial of patient-centred communication to improve the management of acute back pain in primary care. A study protocol.

INTRODUCTION: Low back pain (LBP) is one of the most frequent encounters in General Practice. Investigation and referral remain common despite the self-limiting character of episodes that are not largely attributable to specific underlying injuries. Identifying patients' ideas, concerns and expectations (ICE) is a well-established element within consultation skills training and has been shown to improve prescribing. It can be a powerful communication tool setting the base for transferring and adjusting adequate clinical information. This study aims to evaluate whether ICE can decrease unnecessary medicine in the management of acute LBP in primary care. METHODS AND ANALYSIS: Research question: Does ICE training intervention have an effect on doctors' referrals of patients suffering from acute LBP? Population: Recruitment to this parallel cluster randomised trial will take place among general practitioners belonging to four independent practice networks in Northern Bavaria/Germany. Intervention: At baseline, 24 out of 48 doctors will be randomly assigned to take part in a 1-day training session covering theoretical background and clinical implementation of patient-centred communication by stimulating ICE. They will also be given access to a web-based supporting tool for reflective practice on their communication skills. Comparison: GPs in the control group will continue consultations as usual. Outcome: Outcome measures are referrals to diagnostic imaging, physiotherapy and specialists obtained from routine practice data, compared between intervention and control group. Time: Referrals of patients consulting their doctors for documented LBP will be monitored up to 3 months after the ICE training intervention. ETHICS AND DISSEMINATION: Ethical approval for the study was obtained by the Ethics Committee of the University Erlangen-Nuremberg (296_17B). Results will be disseminated by conference presentations and journal publications. TRIAL REGISTRATION NUMBER: The trial is registered in clinicaltrials.gov (NCT03711071).

[Evidence and practice: How do primary care physicians evaluate screening interventions? A questionnaire study]. / Zwischen Evidenz und Praxis: Wie bewerten Hausärzte Früherkennungsmaßnahmen? Eine Fragebogenstudie.

BACKGROUND: Patients receiving a screening intervention have to be informed about risks and benefits. On the part of the physician, it requires the understanding of statistical evidence and statistical literacy. OBJECTIVES: Do general practitioners (GPs) make different recommendations on screening interventions if they only rely on statistics compared to their decisions in everyday practice? Are the decisions relying on statistics and the decisions made in everyday practice consistent with official recommendations? Does the way of presenting the numbers (table versus pictogram) affect the decision? METHODS: Online survey among German GPs. The GPs were asked to make recommendations for three different screening scenarios which were based on statistical evidence of existing screening interventions. To avoid bias, statistics were not presented in relation to the actual diseases. The numbers were presented in either a table or a pictogram. Afterwards, the GPs were asked for their recommendations on the same screening interventions in everyday practice. RESULTS: Forty-three GPs were surveyed. Compared to everyday medical practice, participants were less likely to recommend a screening intervention when being confronted with the underlying statistical evidence (F (1, 3)=104.83, p=.002, ηpartial2=.97). Most of the decisions in everyday practice were consistent with official recommendations, while their decisions relying on statistics were more likely to deviate from them (everyday practice, M=1.79, SD=0.77; scenario, M=1.44, SD=0.80; t (42)=-2.29, p=.03). The way the numbers were presented did not affect the decision (t (127)=-1.83, p=.07). CONCLUSIONS: In everyday practice, GPs' screening recommendations do not seem to be based on statistical evidence. Presumably they would be more reluctant to recommend screening interventions if they knew the statistical evidence.

"What they see is what you get": Prescribing antibiotics for respiratory tract infections in primary care: Do high prescribers diagnose differently? An analysis of German routine data.

BACKGROUND: Characteristics of high and low prescribers of antibiotics in German primary care were analysed using population data. We aimed to evaluate differences in prescribing rates and factors being associated with high prescribing, and whether high prescribers made the diagnosis of perceived bacterial infections more often. METHODS: Routine data were provided by the Bavarian Association of Statutory Health Insurance Physicians. Routine data are delivered by primary care practices on a quarterly basis. We analysed data from 2011 and 2012. Patients older than 15 years with respiratory tract infections consulting a primary care physician were selected (6.647 primary care practices). Patient and physician characteristics associated with high prescribing were identified using stepwise logistic regression. RESULTS: Mean prescribing rate of antibiotics was 24.9%. Prescribing rate for high prescribers was 43.5% compared to 8.5% for low prescribers. High prescribers made the diagnosis of perceived bacterial infections more often (Mhigh = 64.5%, Mlow = 45.2%). In the adjusted regression model, perceived bacterial infections were strongly associated with high prescribing (OR = 13.9, 95% CI [10.2, 18.8]). Treating patients with comorbidities was associated with lower prescribing of antibiotics (OR = 0.6, 95% CI [0.4, 0.8]). High prescribers had a higher practice volume, a higher degree of prescribing dominance, and were situated more often in deprived areas and in rural settings. INTERPRETATION: Compared to findings of studies in other European countries, prescribing rates were low. There was a considerable difference between prescribing rates of high and low prescribers. Diagnostic labelling was the best predictor for high prescribing. Current guidelines recommend considering antibiotic treatment for patients with co-morbidities. In our study, treating a large number of high-risk patients was not associated with high prescribing.

Medical overuse and quaternary prevention in primary care - A qualitative study with general practitioners.

BACKGROUND: Medical overuse is a topic of growing interest in health care systems and especially in primary care. It comprises both over investigation and overtreatment. Quaternary prevention strategies aim at protecting patients from unnecessary or harmful medicine. The objective of this study was to gain a deeper understanding of relevant aspects of medical overuse in primary care from the perspective of German general practitioners (GPs). We focused on the scope, consequences and drivers of medical overuse and strategies to reduce it (=quaternary prevention). METHODS: We used the qualitative Grounded Theory approach. Theoretical sampling was carried out to recruit GPs in Bavaria, Germany. We accessed the field of research through GPs with academic affiliation, recommendations by interview partners and personal contacts. They differed in terms of primary care experience, gender, region, work experience abroad, academic affiliation, type of specialist training, practice organisation and position. Qualitative in-depth face-to-face interviews with a semi-structured interview guide were conducted (n = 13). The interviews were audiotaped and transcribed verbatim. Data analysis was carried out using open and axial coding. RESULTS: GPs defined medical overuse as unnecessary investigations and treatment that lack patient benefit or bear the potential to cause harm. They observed that medical overuse takes place in all three German reimbursement categories: statutory health insurance, private insurance and individual health services (direct payment). GPs criticised the poor acceptance of gate-keeping in German primary care. They referred to a low-threshold referral policy and direct patient access to outpatient secondary care, leading to specialist treatment without clear medical indication. The GPs described various direct drivers of medical overuse within their direct area of influence. They also emphasised indirect drivers related to system or societal processes. The proposed strategies for reducing medical overuse included a well-founded wait-and-see approach, medical education, a trustful doctor-patient relationship, the improvement of primary/health care structures and the involvement of patients and society. CONCLUSIONS: GPs are frequently located at the starting point of the diagnostic and treatment process. They have the potential to play a vital role in quaternary prevention. This requires a debate going beyond the medical profession and involving society as a whole.

Identifying the lowest effective dose of acetazolamide for the prophylaxis of acute mountain sickness: systematic review and meta-analysis.

OBJECTIVES: To assess the efficacy of three different daily doses of acetazolamide in the prevention of acute mountain sickness and to determine the lowest effective dose. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline and Embase along with a hand search of selected bibliographies. No language restrictions were applied. STUDY SELECTION: Randomised controlled trials assessing the use of acetazolamide at 250 mg, 500 mg, or 750 mg daily versus placebo in adults as a drug intervention for the prophylaxis of acute mountain sickness. Included studies were required to state the administered dose of acetazolamide and to randomise participants before ascent to either acetazolamide or placebo. Two reviewers independently carried out the selection process. DATA EXTRACTION: Two reviewers extracted data concerning study methods, pharmacological intervention with acetazolamide, method of assessment of acute mountain sickness, and event rates in both control and intervention groups, which were verified and analysed by the review team collaboratively. DATA SYNTHESIS: 11 studies (with 12 interventions arms) were included in the review. Acetazolamide at doses of 250 mg, 500 mg, and 750 mg were all effective in preventing acute mountain sickness above 3000 m, with a combined odds ratio of 0.36 (95% confidence interval 0.28 to 0.46). At a dose of 250 mg daily the number needed to treat for acetazolamide to prevent acute mountain sickness was 6 (95% confidence interval 5 to 11). Heterogeneity ranged from I(2)=0% (500 mg subgroup) to I(2)=44% (750 mg subgroup). CONCLUSIONS: Acetazolamide in doses of 250 mg, 500 mg, and 750 mg daily are all more effective than placebo for preventing acute mountain sickness. Acetazolamide 250 mg daily is the lowest effective dose to prevent acute mountain sickness for which evidence is available.

A review of human factors principles for the design and implementation of medication safety alerts in clinical information systems.

The objective of this review is to describe the implementation of human factors principles for the design of alerts in clinical information systems. First, we conduct a review of alarm systems to identify human factors principles that are employed in the design and implementation of alerts. Second, we review the medical informatics literature to provide examples of the implementation of human factors principles in current clinical information systems using alerts to provide medication decision support. Last, we suggest actionable recommendations for delivering effective clinical decision support using alerts. A review of studies from the medical informatics literature suggests that many basic human factors principles are not followed, possibly contributing to the lack of acceptance of alerts in clinical information systems. We evaluate the limitations of current alerting philosophies and provide recommendations for improving acceptance of alerts by incorporating human factors principles in their design.

Interventions to improve adherence to lipid lowering medication.

BACKGROUND: Lipid lowering drugs are still widely underused, despite compelling evidence about their effectiveness in the treatment and prevention of cardiovascular disease. Poor patient adherence to a medication regimen is a major factor in the lack of success in treating hyperlipidaemia. In this updated review we focus on interventions which encourage patients at risk of heart disease or stroke to take lipid lowering medication regularly. OBJECTIVES: To assess the effects of interventions aimed at improved adherence to lipid lowering drugs, focusing on measures of adherence and clinical outcomes. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE, EMBASE, PsycINFO and CINAHL (March 2008). No language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials of adherence-enhancing interventions for lipid lowering medication in adults for both primary and secondary prevention of cardiovascular disease in an ambulatory setting looking at adherence, serum lipid levels, adverse effects and health outcomes. Studies were selected independently by two review authors. DATA COLLECTION AND ANALYSIS: Data were extracted and assessed by two review authors following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS: Three additional studies were found in the update and, in total, 11 studies were included in this review. The studies included interventions that caused a change in adherence ranging from -3% to 25% (decrease in adherence by 3% to increase in adherence by 25%). Patient re-enforcement and reminding was the most promising category of interventions, investigated in six trials of which four showed improved adherent behaviour of statistical significance (absolute increase: 24%, 9%, 8% and 6%). Other interventions associated with increased adherence were simplification of the drug regimen (absolute increase 11%) and patient information and education (absolute increase 13%). The methodological and analytical quality of some studies was low and results have to be considered with caution. AUTHORS' CONCLUSIONS: At this stage, reminding patients seems the most promising intervention to increase adherence to lipid lowering drugs. The lack of a gold standard method of measuring adherence is one major barrier in adherence research. More reliable data might be achieved by newer methods of measurement, more consistency in adherence assessment and longer duration of follow up. More recent studies have started using more reliable methods for data collection but follow-up periods remain too short. Increased patient-centredness with emphasis on the patient's perspective and shared decision-making might lead to more conclusive answers when searching for tools to encourage patients to take lipid lowering medication.

What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior?

Alerts and prompts represent promising types of decision support in electronic prescribing to tackle inadequacies in prescribing. A systematic review was conducted to evaluate the efficacy of computerized drug alerts and prompts searching EMBASE, CINHAL, MEDLINE, and PsychINFO up to May 2007. Studies assessing the impact of electronic alerts and prompts on clinicians' prescribing behavior were selected and categorized by decision support type. Most alerts and prompts (23 out of 27) demonstrated benefit in improving prescribing behavior and/or reducing error rates. The impact appeared to vary based on the type of decision support. Some of these alerts (n = 5) reported a positive impact on clinical and health service management outcomes. For many categories of reminders, the number of studies was very small and few data were available from the outpatient setting. None of the studies evaluated features that might make alerts and prompts more effective. Details of an updated search run in Jan 2009 are included in the supplement section of this review.