[Which patients are (not) included in the DMP diabetes programme?]. / Welche Patienten werden (nicht) in das DMP Diabetes eingeschlossen?

AIM: The disease management programme for diabetes mellitus type 2 (DMP) is joined by many General Practitioners. Aim of the study is to compare patients included in this programme with patients not included and to explore reasons for the selection. METHODS: 10 GPs in Hamburg participated. From each patient list 10 participants in the DMP and the same number of non-participants were randomly selected. HbA1c before start of the programme, presence of insulin therapy, comorbidity and language skills were documented. GPs reported their estimation of the compliance and their reasoning in the selection process. The hypothesis for the primary endpoint was: Diabetics not included have a worse HbA1c value than those included in the DMP. RESULTS: The hypothesis was not confirmed. In both groups similarly good HbA1c values were observed (7.0 in DMP participants, 7.3 in non-participants). The included participants differed from those not included with respect to age (statistically significantly younger) and a better compliance. In the subgroup of patients younger than 70 years the patients included have a better HbA1c and get insulin more frequently (both n. s.). CONCLUSIONS: One part of the patients seems to be not included into the DMP for good reasons. Two questions should be further evaluated: To what extent are patients included although they already have a good metabolic situation? And to what extent are patients with a poor compliance not included, although they might benefit from participation?

[Comparison of two different educational concepts in general practice]. / Vergleich zweier didaktischer Varianten in der Kursweiterbildung Allgemeinmedizin.

In a postgraduate training course in general practice in Hamburg two different educational concepts were used and compared with each other. One was oriented more towards problem-based learning, the other more towards lectures. The participants were asked to fill in a written questionnaire after each day (n = 970) and at the end of the course (n = 26). Both courses achieved good results. On a five point scale the median of the general satisfaction was 4. The problem oriented course, however, was judged better than the other in many respects.

[Problem-based learning in graduate general practice education: the why and how]. / Problemorientiertes Lernen in der Kursweiterbildung Allgemeinmedizin: Das Warum und das Wie.

This paper describes the experiences with different concepts of problem oriented learning in a postgraduate training course in general practice in Hamburg. It is argued that for postgraduate training of general practitioners a four-step-model is more adequate than the "classical" seven-step-model.

[Disease Management Program for diabetes mellitus type 2: cooperation or resistance of the general practitioner]. / DMP Diabetes mellitus Typ 2: kooperation oder widerstand der hausärzte?

AIM: of the study was to seize the attitudes of General Practitioners (GPs) towards the disease management program (DMP) for type 2 diabetes implemented in summer 2003 in Germany. Moreover we were interested in the way GPs realise the program in daily practice, e. g. how many patients and which patients they include. METHOD: A postal questionnaire was sent twice to all GPs in the region of Hamburg (n = 1.230), in November 2003 and in December 2004. Response rate without reminder was 20 respective 16 percent. RESULTS: In 2004 81 percent of the GPs taking part in the survey participate in the DMP. These doctors include a third of their patients with type 2 diabetes into the program. 65 percent of the GPs nevertheless do not believe, that the patients will benefit from the program. 47 percent of the participating GPs object to DMP in general. Only 66 percent say they follow the DMP guidelines for pharmacotherapy. Half of the doctors state they actively canvass patients for the program, while one fifth says they advice patients against participation. The GPs participate in first line to supply the demand of the patients and because of the public pressure less because they think the DMP is good in respect of content. In 2003 critics and pessimism regarding benefit for patients were even stronger than in 2004. CONCLUSIONS: GPs participate in the DMP diabetes half-heartedly and with doubts. The results suggest selections in the inclusion of patients. Further research should find out whether patients being likely to profit from the DMP are systematically not included.

[Need for and benefit of medical rehabilitation measures from a general practitioner's perspective]. / Bedarf an und Nutzen von medizinischen Rehabilitationsmassnahmen aus hausärztlicher Sicht.

With different methodological approaches (postal survey, case analyses and focus group discussions) we investigated the attitudes of general practitioners (GPs) regarding the need, demand and effectiveness of medical rehabilitative measures. General Practitioners have a rather positive attitude towards rehabilitation in general. Male GPs have a tendency to be more sceptical than female GPs. With regard to the different measures within the German system, GPs show a differentiated opinion. They see a high number of patients who have a good benefit, though their definition of benefit differs from the statutory criteria for needs and outcomes. Patients and GPs mostly agree in their estimation of the outcome. Recent political ideas on improvement of the rehabilitative system are discussed on the basis of the results.

[Who should decide on applications for medical rehabilitation? A critical reappraisal of the proposals of the Advisory Board on Concerted Action in Health Care]. / Wer sollte über Anträge zur medizinischen Rehabilitation entscheiden? Eine kritische Betrachtung der Vorschläge des Sachverständigenrates.

Summary. In Germany the allocation of rehabilitation services depends on a decision of one of the social insurance funds. This decision is taken on the basis of an assessment of the application file by a physician of the fund. The general practitioner who may be the best informed professional as to the patients' disability, has no decision power in this allocation process. In 2001, however, the prestigious Advisory Board to the Ministry of Health proposed to leave the allocation to the general practitioner or another physician in office practice, thus restricting the role of the fund to verifying the appropriateness of the decision of the GP. This proposal is reviewed on the basis of the results of a survey among all general practitioners in the four Länder of Hamburg, Schleswig-Holstein, Mecklenburg-Vorpommern and Sachsen-Anhalt (n = 2110; response rate of 46%) done between 1999 and 2001. Furthermore, several steps and measures are proposed in view of increasing the involvement of the GP in the allocation process and of improving the communication between the funds and the general practitioners.

[Utilization of general (monitoring) practices based on environmental medicine problems]. / Inanspruchnahme von hausärztlichen (Beobachtungs-)Praxen aufgrund umweltmedizinischer Probleme.

How often do general practitioners have to deal with environmental problems? To answer this question 23 GPs recorded all relevant consultations during one year in Hamburg. On an average, each of these GPs reported one contact once a month. The spectrum of both patient complaints and environmental sources was broad. The GP is less often convinced of a causal connection between both than the patient. In most cases a referral was not necessary. This study supports the assumption that the frequency of environmental problems in General Practice is--at least in the larger cities--lower than estimated from former studies and the self-image of general practice in Germany.

[The opinion of general practitioners in East and west Germany on rehabilitation]. / Was denken Hausärzte aus den neuen und alten Bundesländern über Rehabilitation?

GPs in the former German Democratic Republic (now called 'New Federal States') and in West-Germany (the 'Old Federal States') differ more than ten years after reunification in several respects. This survey shows that they have different attitudes to medical rehabilitation programmes as well. Written questionnaires were sent to all GPs in Hamburg and Schleswig-Holstein (representing the Old Federal States) and in Sachsen-Anhalt and Mecklenburg-Vorpommern (representing the New Federal States). GPs in the New Federal States value medical rehabilitation in general and single programmes more than those in the old ones. They see a higher number of patients who have a good benefit from rehabilitation and estimate the degree of overuse as smaller. They observe more often patients who do not take part in a rehabilitative programme because they are afraid of losing their job. The higher proportion of female GPs in the New Federal States does not explain these differences.

[Need for rehabilitation from the viewpoint of the general practitioner]. / Der Bedarf an Rehamassnahmen aus allgemeinärztlicher Sicht.

In Germany, the general practitioner plays an important role in the allocation process of rehabilitative measures. A survey concerning the questions of need, demand and effectiveness of medical rehabilitation measures as seen from the general practitioner's perspective in Hamburg, Schleswig-Holstein und Halle/Saale (n = 956) in 1999 shows that general practitioners have a rather positive attitude towards rehabilitation in general. With regard to the different measures within the rehabilitation system they show a differentiated opinion. As they see a large percentage of over- and underuse of rehabilitation they would appreciate that their information on the patient would be more intensively taken into account in the allocation process.

[SF-36 Health Survey in Rehabilitation Research. Findings from the North German Network for Rehabilitation Research, NVRF, within the rehabilitation research funding program]. / Der SF-36 in der rehabilitationswissenschaftlichen Forschung--Ergebnisse aus dem Norddeutschen Verbund für Rehabilitationsforschung (NVRF) im Förderschwerpunkt Rehabilitationswissenschaften.

The SF-36 Health Survey and its 12-item abridged form is an instrument for the assessment of health related quality of life that can be used with healthy persons and patient populations. Its use has been recommended within a large German multicentre rehabilitation research programme. The paper examines missing data across all five study projects of the North German Network for Rehabilitation Research (NVRF) as well as psychometric properties of the instrument. In addition, data were compared to representative norm data using the SF-36 (SF-12) in the German National Health Survey. Results showed that there were few missing data in the SF-36. Examining the impact of age, gender and health status yielded effects of higher age and female gender on missing data. Psychometric analyses showed good to excellent results of the instrument in terms of scale fit and reliability. In terms of convergent validity, medium to high correlation of the SF-36 subscales with comparable instruments (e. g. SCL-90-R) could be found. Summarizing, the SF-36/SF-12 can be recommended for use in rehabilitation research. Analyses regarding sensitivity should be conducted in future studies.