[Changes in Prescription Patterns of Oral Anticoagulants in Family Practices after Marketing Approval of Direct Oral Anticoagulants]. / Änderungen bei der Verordnung oraler Antikoagulation in Hausarztpraxen nach Einführung der direkten oralen Antikoagulanzien.

AIM OF THE STUDY: Since 2011, non-vitamin-K-dependent oral anticoagulants (NOAC) have extended the spectrum of anticoagulation therapy. Initially, the approval of NOAC was limited to the prophylaxis of postoperative thrombosis, but in the course of time the spectrum was extended to the therapy of thrombosis and embolism as well as anticoagulation in non-valvular atrial fibrillation. The study was designed to examine how the approval of NOAC had affected the prescribing behaviour of general practitioners in the first years of their approval. METHODS: In a retrospective longitudinal study, the prescriptions of anticoagulants between 2012 and 2017 were analysed in 3 general practitioners' practices in the Bonn area. The study included all patients for whom at least one prescription from a NOAC or a vitamin K antagonist (VKA) was documented in the administrative system of the practices during this period. RESULTS: A total of n=579 patient files were evaluated (47% female; median age 75 years). Of these, 47% received a VKA, and 40% a NOAC (59% rivaroxaban, 29% apixaban, 9% dabigatran and 3% edoxaban). During the period under examination, the share of VKA prescriptions decreased from 45% to 14% and the share of NOAC increased from 28% to 87%. Anti-coagulation was changed in 12%. The most frequent change was from a VKA to a NOAC (70%). CONCLUSION: After marketing approval, the use of NOAC in the initial prescriptions increased steadily. This trend can also be seen in other European studies. VKA are mainly prescribed to patients with stable oral anticoagulation. As recommended in the guidelines, anticoagulation is changed mainly when problems occur during therapy. If the trend in the prescription of anticoagulants continues, in the medium term, VKA will only be prescribed for patients who have been stable for many years and for patients with artificial heart valves.

[Views on Retirement by General Practitioners]. / Renteneintrittswünsche und mögliche Determinanten bei Hausärztinnen und Hausärzten.

EINLEITUNG: In Hinblick auf den immer größer werdenden Ärztemangel und gleichzeitig steigenden Versorgungsbedarf in der Allgemeinbevölkerung war das Ziel der vorliegenden Untersuchung, ein detailliertes Bild über Renteneintrittswünsche der aktiven Hausärztinnen und Hausärzte (N=143) zu erfassen. METHODE: Die Daten wurden im Rahmen einer Baseline-Befragung einer Langzeitstudie erhoben (repräsentative Ärztebefragung). Es wurde untersucht, inwiefern soziodemographische als auch berufsbezogene Variablen mit einem vorzeitigen bzw. späteren Renteneintritt in Zusammenhang gebracht werden können und welche Gründe für eine ärztliche Tätigkeit über das Rentenalter hinaus sprechen. ERGEBNISSE: Die Ergebnisse zeigen, dass die Hälfte der Befragten zwischen 29 und 66 Jahren vorzeitig in den Ruhestand gehen möchte und diese Entscheidung vor allem von Familienstand, aber auch von Arbeitszufriedenheit und Arbeitsbelastung abhängig ist. Zu den Gründen, die für einen späteren Eintritt sprechen, zählen "Freude an der Arbeit", "sich nützlich und gebraucht fühlen" und ein allgemein "berufliches Interesse". SCHLUSSFOLGERUNG: Renteneintrittswünsche sollten bei der zukünftigen Planung der Versorgung berücksichtigt werden, um Maßnahmen zu ergreifen, die einem ungewollten oder vorzeitigen Ausstieg der Mediziner aus der Versorgung entgegenwirken. BACKGROUND: There is a steadily increasing shortage of doctors and simultaneously an increasing need for health care of the general population. The aim of the present survey was to investigate retirement planning by family doctors (n=143). METHOD: Data was collected as part of a baseline survey (longitudinal design, representative sample of physicians). Possible association between socio-demographic and occupation-related variables with early or later retirement was investigated and also why some physicians may consider continuing in their profession beyond retirement age. RESULTS: The results showed that half of the respondents between 29 and 66 of age would like to retire early and that this decision depended primarily on marital status, but also on job satisfaction and workload. Reasons for late retirement were "enjoying work", "feeling useful and needed" and general "professional interest". CONCLUSION: The results indicate that retirement wishes of GPs must be taken into account in the future planning of health care and that measures should be taken to counteract their early retirement from professional activity.

Walking a mile in Grandma's shoes - medical students' evaluation of a very simple online aging game to enhance their understanding of older patients.

BACKGROUND: Aging simulation games are established educational interventions to make older patients' perspectives noticeable, raise awareness about their needs, and positively influence attitudes toward older adults. Due to the COVID-19 pandemic restrictions imposed on education, we replaced a classroom-based aging simulation course with a simple online equivalent. This consisted of short introductory screencasts, four downloadable Portable Document Format (PDF) files containing issue-specific audio and video links, quizzes, case studies, and prompts for reflection. We explored how well our self-directed simple online simulation succeeded in providing students with relevant insights and experiences, raising awareness about age-related difficulties, and enhancing understanding of older patients. METHODS: In this cross-sectional study, an anonymous post hoc online survey was conducted among 277 5th-year medical students eligible for the course at the Leipzig University in May 2020. The questionnaire addressed overall course evaluations, assessments of the individual PDF components (working enjoyment, personal insights, professional learning gain, enhanced understanding, increased interest in working with older patients), and students' main insights from the course (free text). Descriptive statistical and qualitative content analyses were performed. RESULTS: The response rate was 92.4% (n = 256, mean age 25.7 ± 3.4 years, 59.8% women). Nearly all respondents reported that the course was well structured, easily understandable, and that processing was intuitive. The majority (82.8%) perceived the course as practice-oriented, 88.3% enjoyed processing, 60.3% reported having gained new professional knowledge, and 75.4% had new personal insights. While only 14.8% agreed that the online course could generally replace the real-world simulation, 71.1% stated that it enabled them to change their perspective and 91.7% reported enhanced understanding of older patients. PDF components containing audio and video links directly imitating conditions (visual or hearing impairment) were rated highest. Qualitative data revealed manifold insights on the part of the students, most frequently referring to aspects of professional doctor-patient interaction, knowledge about conditions and diseases, role reversal, and enhanced empathy. CONCLUSION: Simple online aging simulations may be suitable to provide students with relevant insights and enhance their understanding of older patients. Such simulations could be alternatively implemented in health professionals' education where resources are limited.

General practitioners' willingness to participate in research networks in Germany.

OBJECTIVES: To investigate general practitioners' (GPs') willingness to participate in long-term medical research and in research networks (RNs). DESIGN AND SETTING: Cross-sectional survey among German GPs around Halle-Wittenberg and Leipzig in 2020. SUBJECTS: Random sample of 905 GPs. MAIN OUTCOME MEASURES AND RESULTS: Response rate 37%, 69% female. Overall, 57% were interested in participating in medical research, 34% in an active role in a RN. Interest in RN participation was positively associated with male sex, younger age, previous experiences in medical research, being involved in teaching undergraduates, and having qualification in a further specialty. Main motivators were improving patient care, giving a more realistic picture of GP care, and carrying out research on topics within their own interest areas and a reliable contact person at the leading institution. Most GPs were not afraid of reduced earnings; however, time investment was the main barrier for participation. GPs were willing to dedicate twice as much time to research when remuneration was offered. High rated topics were polypharmacy, chronic diseases, drug safety and adverse drug reactions. CONCLUSION: GPs are interested to participate in practice-based research. The study results providing useful and generalizable insights in barriers and motivators should be considered when building and running GP-RNs.KEY POINTSThere is a difference between general practitioners' (GPs') overall interest in clinical research and their job and socio-demographic related readiness to participate in research networks (RNs).GPs are interested in RNs when it is a resource of and leading to enhanced patient-oriented care.GPs are willing to dedicate twice as much time to research when remunerated.GPs need a reliable counterpart within the leading institution.

Workshop with medical students on physicians' earning opportunities, workload and job satisfaction increases the attractiveness of working self-employed and working in general practice.

BACKGROUND: Among the various factors identified as relevant for primary care career choice, financial considerations have been consistently shown to have an impact. In Germany, reliable and easily understandable information on physicians' earning opportunities in self-employed settings is difficult to obtain for medical students, leading to substantial misperceptions that may negatively affect respective career considerations. This study investigated medical students' evaluation of a 45-min evidence-based workshop on earning opportunities, workload and job satisfaction in different specialties and settings to examine its effect on the perceived attractiveness of working self-employed and working in general practice. METHODS: The workshop was implemented as part of a mandatory general practice clerkship in the fourth study year (of six). Post-hoc evaluations of all participants between October 2017 and September 2018 (one cohort) were analysed cross-sectionally including descriptive statistics, subgroup comparisons and qualitative analysis of free-text answers regarding students' main insights. RESULTS: Response rate was 98.1% (307/313). Participants were on average 25.0 years old, and 68.3% were women. Based on a ten-point scale ranging from 1 = 'no influence' to 10 = 'very big influence', 91.9% confirmed at least some (> = 2) and 57.3% a rather high (> = 5) influence of earning expectations on their career choice process. Regarding the workshop, 86.1% were overall satisfied, and 89.5% indicated they had gained new insights, primarily regarding earning opportunities in different specialties and work settings, and frequently regarding job satisfaction, workload and the structure of revenues and expenditures in a doctor's office (according to qualitative analysis). In the opinion of 89.8% of students, the provided learning content should be part of the undergraduate curriculum. More than half of participants reported an increase regarding the attractiveness of working self-employed and working as a general practitioner, most frequently regarding earning opportunities, but also in general and in respect to job satisfaction, cost-benefit ratio and workload. This increase was significantly higher among students favouring or at least considering a general practice career. CONCLUSIONS: The workshop and its content were appreciated by the students and showed clear potential to usefully complement undergraduate curricula aiming at increasing or reinforcing students' interest in working self-employed and working in general practice.

General practitioners' deprescribing decisions in older adults with polypharmacy: a case vignette study in 31 countries.

BACKGROUND: General practitioners (GPs) should regularly review patients' medications and, if necessary, deprescribe, as inappropriate polypharmacy may harm patients' health. However, deprescribing can be challenging for physicians. This study investigates GPs' deprescribing decisions in 31 countries. METHODS: In this case vignette study, GPs were invited to participate in an online survey containing three clinical cases of oldest-old multimorbid patients with potentially inappropriate polypharmacy. Patients differed in terms of dependency in activities of daily living (ADL) and were presented with and without history of cardiovascular disease (CVD). For each case, we asked GPs if they would deprescribe in their usual practice. We calculated proportions of GPs who reported they would deprescribe and performed a multilevel logistic regression to examine the association between history of CVD and level of dependency on GPs' deprescribing decisions. RESULTS: Of 3,175 invited GPs, 54% responded (N = 1,706). The mean age was 50 years and 60% of respondents were female. Despite differences across GP characteristics, such as age (with older GPs being more likely to take deprescribing decisions), and across countries, overall more than 80% of GPs reported they would deprescribe the dosage of at least one medication in oldest-old patients (> 80 years) with polypharmacy irrespective of history of CVD. The odds of deprescribing was higher in patients with a higher level of dependency in ADL (OR =1.5, 95%CI 1.25 to 1.80) and absence of CVD (OR =3.04, 95%CI 2.58 to 3.57). INTERPRETATION: The majority of GPs in this study were willing to deprescribe one or more medications in oldest-old multimorbid patients with polypharmacy. Willingness was higher in patients with increased dependency in ADL and lower in patients with CVD.

Osteopathy in Germany: attitudes, beliefs and handling among general practitioners - results of a nationwide cross-sectional questionnaire survey.

BACKGROUND: Osteopathy is a type of complementary medicine based on specific manual techniques. In many countries, including Germany, the profession is not officially regulated, and evidence for the effectiveness of osteopathy is insufficient for most diseases. Nevertheless, many health insurances in Germany offer reimbursement for therapy costs, if osteopathy is recommended by a physician. This cross-sectional survey of German general practitioners (GPs) explored beliefs and attitudes towards osteopathic medicine and described their daily interactions with it. METHODS: A random sample of 1000 GPs from all federal states was surveyed by mail using a self-designed questionnaire. We collected data on sociodemographics, personal experiences with osteopathy, and attitudes and expectations towards osteopathy. In particular, participants were asked about indications for osteopathic treatment and their beliefs about its effectiveness for different patient groups and diagnoses. A self-designed score was used to estimate general attitudes towards osteopathy and identify factors correlated with greater openness. Additionally, we performed logistic regression to reveal factors associated with the frequency of recommending osteopathy to patients. RESULTS: Response rate was 34.4%. 46.5% of participants were women, and the median age was 56.0 years. 91.3% of GPs had referred patients to an osteopath, and 88.0% had recommended osteopathy to their patients. However, 57.5% acknowledged having little or no knowledge about osteopathy. Most frequent reasons for a recommendation were spinal column disorders (46.2%), other complaints of the musculoskeletal system (18.2%) and headaches (9.8%). GPs estimated the highest benefit for chronically ill and middle-aged adults. Female gender (OR 2.09; 95%CI 1.29-3.38) and personal treatment experiences (OR 5.14; 95%CI 2.72-9.72) were independently positively associated with more frequent treatment recommendation. CONCLUSION: GPs in Germany have frequent contact with osteopathy, and the vast majority have recommended osteopathic treatment to some extent in their practice, with foci and opinions comparable to other Western countries. The discrepancy between GPs making frequent referrals for osteopathic treatment while self-assessing to have little knowledge about it demonstrates need for intensified research on the collaboration with osteopaths and how to best integrate osteopathic treatments. Our results may help to focus future effectiveness studies on most relevant clinical conditions in general practice.

Risk factors for a positive SARS-CoV-2 PCR in patients with common cold symptoms in a primary care setting - a retrospective analysis based on a joint documentation standard.

BACKGROUND: Combating the COVID-19 pandemic is a major challenge for health systems, citizens and policy makers worldwide. Early detection of affected patients within the large and heterogeneous group of patients with common cold symptoms is an important element of this effort, but often hindered by limited testing resources, false-negative test results and the lack of pathognomonic symptoms in COVID-19. Therefore, we aimed to identify anamnestic items with an increased/decreased odds ratio for a positive SARS-CoV-2 PCR (CovPCR) result in a primary care setting. METHODS: We performed a multi-center cross-sectional cohort study on predictive clinical characteristics for a positive CovPCR over a period of 4 weeks in primary care patients in Germany. RESULTS: In total, 374 patients in 14 primary care centers received CovPCR and were included in this analysis. The median age was 44.0 (IQR: 31.0-59.0) and a fraction of 10.7% (n = 40) tested positive for COVID-19. Patients who reported anosmia had a higher odds ratio (OR: 4.54; 95%-CI: 1.51-13.67) for a positive test result while patients with a sore throat had a lower OR (OR: 0.33; 95%-CI: 0.11-0.97). Furthermore, patients who had a first grade contact with an infected persons and showed symptoms themselves also had an increased OR for positive testing (OR: 5.16; 95% CI: 1.72-15.51). This correlation was also present when they themselves were still asymptomatic (OR: 12.55; 95% CI: 3.97-39.67). CONCLUSIONS: Several anamnestic criteria may be helpful to assess pre-test probability of COVID-19 in patients with common cold symptoms.

[Urgent Visits to Nursing Homes: A General Practitioner's Perspective]. / Dringende Hausbesuche in Altenheimen ­ ein Status Quo aus hausärztlicher Sicht.

AIM OF THE STUDY: Due to demographic changes, home visits to nursing care facilities are increasing. Urgent home visits represent a challenge for general practitioners. There are no recommendations for the implementation of urgent home visits. Therefore, in this study, we investigated how GP practices deal with urgent home visits and what improvements can be made to the medical emergency care. METHODS: A total of 15 teaching doctors of the Department of Family Medicine at the University of Bonn were interviewed using semi-structured interviews on the subject. We evaluated the interviews with the qualitative content analysis according to Mayring. RESULTS: Urgent house visits were requested by telephone or fax. The home visits were carried out usually after the consultation hours during the lunch break of the doctors. General practitioners consider forwarding the request for a house visit to the rescue service as an absolute exception. At the nursing home, there were waiting times until the responsible nursing staff could do a joint emergency visit. In addition, there were clear differences in the qualifications of nurses and in dealing with emergencies. The physicians therefore saw improvements in their ability to provide further training to the nursing staff, to preventive house visits, and to assess the urgency of home visits. CONCLUSION: To improve emergency care in elderly homes, the suggestions for improvement proposed by the family doctors should be tested in controlled studies. In addition, the cooperation between general practitioners and nursing homes could be strengthened by joint training in geriatric emergency care.

[Outpatient Emergency Care for Nursing Home Residents: A Status Quo From a Nursing Perspective]. / Ambulante Notfallversorgung von Pflegeheimbewohner: Ein Status Quo aus pflegerischer Sicht.

AIM OF THE STUDY: At present about 2 million people need care in Germany, about one third of them live in old people's homes or nursing homes. Outpatient emergency care of nursing home residents is ensured by primary care physicians, the medical emergency service and the emergency services. Emergency care has rarely been examined from the perspective of nurses. Therefore, in our study, we investigated how the nurses perceive medical care in medical emergencies and what suggestions for improvements they have. METHODS: In 2015/16, guided interviews with a total of 13 females and one male elderly care nurses in northern Rhineland-Palatinate were conducted. The interviews were digitally recorded and literally transcribed. Evaluation was performed using the qualitative content analysis Mayring with MAXQDA® 12. RESULTS: In the case of an acute deterioration in the general condition of a resident, the family doctor in charge was first called in. It was difficult for the nursing staff to contact the physician in charge during consultation hours. The quality of the emergency care was dependent on the respective practice structure. Outside the opening hours of the surgery, the emergency medical service took over care of the patients. These doctors did not know the patients, which, from the point of view of the nursing care, was a burden for the residents since they had to face new doctors. Emergency physicians have long access routes, which led to delays, even in emergencies. Some nurses wanted the "old system" back, where the home care physicians were also available over the weekend by telephone. Overall, the request was a better care of residents. CONCLUSION: GPs are the main contact persons for medical emergencies for the nursing staff. However, most physicians are only available during office hours. From the point of view of care, it would make sense to create incentives for the general practitioners to be available for emergencies even outside their consulting hours.

[Advance Directives in Family Practices: Results of a Survey of GP Patients on their Care Situation]. / Patientenverfügungen in Hausarztpraxen ­ Ergebnisse einer Befragung von Hausarztpatienten zur ihrer Versorgungssituation.

BACKGROUND: Advance directives (AD) are an important tool for documentation of patients' wishes and are therefore recommended to the elderly as well as patients with chronic diseases. However, there is no standardized procedure in Germany and no guideline for counseling patients who wish to write an AD with or without health care proxy. The aim of this study was to evaluate the care situation concerning the ADs and the role of the primary care physician in drafting the document METHOD: We conducted semi-structured interviews with patients in primary care in North Rhine-Westphalia using a cross-sectional study design. RESULT: Most of the 154 patients who were interviewed (average age: 58 years; 52% female) suffered from chronic diseases (79%), and about one-third (32%) already had an AD. Fear of "loss of autonomy" was the main reason for preparing an AD. Patients without AD were generally not opposed to the concept and named procrastination (43%) as the main reason for not having prepared one. The chance for preparing an AD increased by the factor 1.08 per life-year (Odds ratio (OR): 1.08; CI: 1.04-1.11). Patients with AD mostly got advice via the internet (22%), their primary care physicians (12%) and relatives (12%). Most patients were satisfied with their AD. CONCLUSION: The majority of primary care patients do not make use of ADs. The primary care physicians play an important role in counseling and should motivate patients to complete ADs. Here, the establishment of quality standards would be desirable in the future.

[The postmortem examination and death certificate by the general practitioner: problems with certification on site]. / Leichenschau und Todesbescheinigung durch den Hausarzt: Probleme beim Bescheinigen vor Ort.

Family doctors are the most competent persons for the postmortem examination due to their knowledge of the patient, previous history, and the circumstances of death. The postmortem examination is a medical activity with specific requirements for the physician that require special training. The situation on site enables the physician to gather important information about the circumstances of death. However, a local postmortem examination is also carried out under difficult conditions, without personal or professional support and in an environment that knows neither the meaning nor the procedure of a postmortem examination. Differences in the understanding of the terms unnatural or unclarified death type lead to conflicts between physicians and the surrounding field of the deceased.

Risk of opioid misuse in chronic non-cancer pain in primary care patients - a cross sectional study.

BACKGROUND: Efforts to improve treatment of pain using opioids have to adequately take into account their therapeutic shortcomings which involve addictiveness. While there are no signs of an "opioid epidemic" in Germany similar to that in the US, there is little data on the prevalence of prescription opioid misuse and addiction. Therefore, our objective was to screen primary care patients on long-term opioid therapy for signs of misuse of prescription opioids. METHODS: We recruited 15 GPs practices and asked all patients on long-term opioid therapy (> 6 months) to fill out a questionnaire including the "Current Opioid Misuse Measure" (COMM®), a self-report questionnaire. Patients with a malignant disease were excluded. RESULTS: N = 91 patients participated in the study (response rate: 75.2%). A third (31.5%) showed a positive COMM® - Score which represents a high risk of aberrant drug behaviour. A positive COMM® - Score showed a statistically significant correlation with a lifetime diagnosis of depression and neck pain. CONCLUSIONS: While Germany does not face an "opioid eoidemic", addictiveness of opioids should be considered when using them in chronic non-tumor pain. In our study population, almost every third patient was at risk and should therefore be followed up closely. Co-prevalence of depression is a significant issue and should always be screened for in patients with chronic pain, especially thus with aberrant drug behaviour.

[Prevention of Infections of the Upper Respiratory Tract]. / Prävention von Infekten der oberen Atemwege.

Because of its high prevalence acute respiratory diseases have a significant impact on the population. The focus of this review was the current state of knowledge for the prophylactic efficacy of: zinc, vitamin C, Echinacea preparations, garlic and carrying out physical measures. Furthermore, the benefits of pneumococcal and influenza vaccine were elicited. In the synopsis, the physical measures proved to be the most effective, cost-effective method to prevent infections. The intake of zinc, Echinacea preparations (for example: E. purpurea), vitamin C and garlic showed moderate success in the prevention of infection and must be elicited individually. Pneumococcal and annual influenza vaccines in family practice should be given furthermore accordingly topical STIKO-recommendation. Nevertheless, the prophylactic effect from influenza vaccines on usual cold illnesses is unsettled.

[Prevention of nosocomial infections and antibiotic resistance in nursing homes]. / Prävention von nosokomialen Infektionen und Antibiotikaresistenzen in Altenpflegeheimen.

BACKGROUND: Nosocomial infections and multidrug-resistant organisms are an increasing problem in nursing homes worldwide; therefore, new approaches for infection control need to be developed. OBJECTIVES: This article gives an overview of infections in nursing homes, their medical treatment and previous measures for infection prevention. MATERIALS AND METHODS: The article is based on a selective literature search including the literature database PubMed. In particular, scientific studies on the prevalence of nosocomial infections in German nursing homes, publications for medical care in long-term care facilities in Europe and international studies for infection prevention were evaluated. RESULTS: The basis for an effective reduction of infections is the establishment of a surveillance system. All participating medical professionals provide feedback about local infections and resistance situations and the presence of risk factors, such as urinary catheters or chronic wounds. Only then can targeted antibiotic strategies be adapted and the effectiveness of preventive measures, such as hand disinfection is continuously reviewed. So far, in particular multimodal, multidisciplinary prevention projects were successful. These included frequent staff training, reduction of urinary catheters and a rational use of antibiotics. CONCLUSIONS: Most prevention models have been previously tested in hospitals. A possible applicability of the results to the infection prevention in long-term care facilities has so far hardly been studied. Accordingly, further studies on infection control in nursing homes are absolutely necessary.

[Urgency of GP Emergency Visits to Nursing Homes]. / Dringlichkeit von hausärztlichen Notfallbesuchen in Altenheimen.

Until now there are no uniform criteria or standards for classification of emergency home visits. Due to demographic changes, especially urgent visits to patients in nursing homes will increase. In the URGENT study, physicians and nurses rated the urgency of emergency visits to nursing home patients before and after the visit. This should help to see how many emergency house calls had been classified as less urgent and how often the assessment of physicians and nurses were in agreement with each other. In a prospective observational study, home visits were analyzed, which were classified as urgent at request by the physicians. After performing home visits, the physicians and the responsible nurse classified again the urgency of the home visit from 0 (not urgent) to 10 (highly urgent). In addition, the times of the home visit requests and the time for carrying out the visits, as well the reasons for the home visits were documented. A total of 75 urgent home visits were documented. The patients were on average 82 years old (65% female). The home visits were done on average 2.5 h after request. In retrospect, the physicians evaluated emergency home visits on average less urgent (5.7±2.7) than the nurses (7.2±2.2). In 20% of emergency home visits (15 cases), physicians and nurses agreed as to their being less urgent (0-5). Our data show that in the absence of a standardized urgent assessment scheme, a significant proportion of home visits is misclassified. In further studies it has to be investigated if a uniform score for urgent assessment could reduce the proportion of incorrect medical response operations so that the efficiency of emergency care for nursing home patients can be improved.

Misuse of Substitution Drugs in the Substitution-Based Therapy.

BACKGROUND: The reasons for, and the extent of, misuse of prescribed substitution medication as well as parallel consumption of other drugs during substitution-based therapy have still not been adequately researched in Germany. METHODS: This study examines the use of substitution medication in German substitution clinics utilizing a nationwide survey with anonymised questionnaires. RESULTS: The analysis of the 605 questionnaires showed a 30-day consumption prevalence of 8.8% with regard to misuse of substitution substances. The lack of available heroin (38%) and the lack of open spots in treatment programs (21%) were quoted as being the main reasons for the misuse of substitution medication. CONCLUSION: Although the misuse of substitution medications is considered an important problem, our study showed that the current misuse was prevalent only among a minority of the patients. German regulations focused on the avoidance of misuse might be partially contributing to the problem.

Written survey on recently deceased patients in germany and switzerland: how do general practitioners see their role?

BACKGROUND: General practitioners (GPs) play an important role in end-of-life care due to their proximity to the patient's dwelling-place and their contact to relatives and other care providers. METHODS: In order to get a better understanding of the role which the GP sees him- or herself as playing in end-of-life care and which care their dying patients get, we conducted this written survey. It asked questions about the most recently deceased patient of each physician. The questionnaire was sent to 1,201 GPs in southern North Rhine-Westphalia (Germany) and the Canton of Bern (Switzerland). RESULTS: Response rate was 27.5% (n = 330). The average age of responding physicians was 54.5 years (range: 34-76; standard derivation: 7.4), 68 % of them were male and 45% worked alone in their practice. Primary outcome measures of this observational study are the characteristics of recently deceased patients as well as their care and the involvement of other professional caregivers. Almost half of the most recently deceased patients had cancer. Only 3 to 16% of all deceased suffered from severe levels of pain, nausea, dyspnea or emesis. More than 80% of the doctors considered themselves to be an indispensable part of their patient's end-of-life care. Almost 90% of the doctors were in contact with the patient's family and 50% with the responsible nursing service. The majority of the GPs had taken over the coordination of care and cooperation with other attending physicians. CONCLUSION: The study confirms the relevance of caring for dying patients in GPs work and provides an important insight into their perception of their own role.

Individualized versus standardized risk assessment in patients at high risk for adverse drug reactions (IDrug) - study protocol for a pragmatic randomized controlled trial.

BACKGROUND: Elderly patients are particularly vulnerable to adverse drug reactions, especially if they are affected by additional risk factors such as multimorbidity, polypharmacy, impaired renal function and intake of drugs with high risk potential. Apart from these clinical parameters, drug safety and efficacy can be influenced by pharmacogenetic factors. Evidence-based recommendations concerning drug-gene-combinations have been issued by international consortia and in drug labels. However, clinical benefit of providing information on individual patient factors in a comprehensive risk assessment aiming to reduce the occurrence and severity of adverse drug reactions is not evident. Purpose of this randomized controlled trial is to compare the effect of a concise individual risk information leaflet with standard information on risk factors for side effects. METHODS/DESIGN: The trial was designed as a prospective, two-arm, randomized, controlled, multicenter, pragmatic study. 960 elderly, multimorbid outpatients in general medicine are included if they take at least one high risk and one other long-term drug (polymedication). As high risk "index drugs" oral anticoagulants and antiplatelets were chosen because of their specific, objectively assessable side effects. Following randomization, test group patients receive an individualized risk assessment leaflet evaluating their personal data concerning bleeding- and thromboembolic-risk-scores, potential drug-drug-interactions, age, renal function and pharmacogenetic factors. Control group patients obtain a standardized leaflet only containing general information on these criteria. Follow-up period is 9 months for each patient. Primary endpoint is the occurrence of a thromboembolic/bleeding event or death. Secondary endpoints are other adverse drug reactions, hospital admissions, specialist referrals and medication changes due to adverse drug reactions, the patients' adherence to medication regimen as well as health related quality of life, mortality and resulting costs. DISCUSSION: Despite extensive evidence of risk factors for adverse drug reactions, there are few prospective trial data about an individualized risk assessment including pharmacogenetic information to increase patient safety. By conducting a health economic analysis, we will evaluate if the application of an individualized drug therapy in daily routine is cost-effective. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00006256 , date of registration 09/01/15.