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

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

Improving diagnostic accuracy of bacterial pharyngitis by near patient measurement of C-reactive protein (CRP)

BACKGROUND: Sore throat or pharyngitis is an extremely prevalent condition in primary care. There is a diagnostic dilemma in differentiating bacterial and non-bacterial infections for adequate use of antibiotics. Standard diagnostic procedures take too long for an immediate decision. AIM: To evaluate, if near patient C-reactive protein measurement in the general practice surgery improves diagnostic accuracy. METHOD: One hundred and seventy-nine consecutive patients with sore throat, from 15 general practitioners (GPs) in southern Germany (phase 1) and 161 consecutive patients from 14 GPs (phase 2), were examined physically and a throat-swab was taken and white blood-cell count (WBC) and CRP-measurement were performed. In phase 1, CRP was measured centrally to assess the method's diagnostic value and the adequate threshold. In the second phase, near patient CRP was measured and CRP values were used to make a diagnosis. RESULTS: Using relative operating characteristics (ROC) analysis, the diagnostic value of CRP measurement was much better than WBC count (area under curve = 0.85 versus 0.68). All diagnostic parameters improved when using the near patient CRP measurement. Sensitivity went up from 0.61 (95% confidence interval = 0.45-0.75) to 0.78 (0.61-0.90), specificity went up from 0.73 (0.65-0.81) to 0.82 (0.73-0.88). Positive and negative predictive value improved significantly as well. Diagnostic accuracy went up from 70.1% to 81.0%. Out of 1000 theoretical patients with sore throat, 109 more will be treated correctly when using CRP measurement as a diagnostic tool. CONCLUSIONS: Use of near patient CRP measurement can improve diagnostic accuracy in the differentiation of bacterial and non-bacterial pharyngitis in primary care, and potentially results in a more adequate use of antibiotics.

[The DEGAM guidelines "Dysuria" by the German Society of General Practice and Family Medicine (DEGAM)--possible consequences of the implementation in general practice]. / Die DEGAM-Leitlinie "Brennen beim Wasserlassen"--mögliche Konsequenzen der Umsetzung in der allgemeinärztlichen Praxis.

INTRODUCTION: In Germany, there are hardly any reliable data on patient care in the primary care setting which warrant the development and implementation of clinical guidelines. In this paper, data generated by a prospective observational study of patients with urinary tract symptoms are compared to the recommendations of an evidence-based clinical guideline. PATIENTS AND METHODOLOGY: Over a period of 6 months all patients consulting one of 6 General Practitioners in southern Germany with symptoms of dysuria have been documented on a standardised patient record. Data were compared to the recommendations of the guideline "Dysuria" by the German Society of General Practice and Family Medicine (DEGAM) to assess the relevance and feasibility of the guideline. In a scenario, compliance with the guideline is extrapolated to the realm of primary care. RESULTS: Basic demographic and epidemiological data agree with basic assumptions of the guideline. As far as diagnostic and therapeutic strategies are concerned there are significant discrepancies between the recommendations and the realm of primary care. Microbiologic cultures are ordered far less then recommended, second line drugs are prescribed far more often then recommended, macroscopic urinoscopy is performed widely but not covered by the guideline at all. If GPs complied completely with the guideline, many more diagnostic procedures would be performed and a different palette of antimicrobial drugs would be prescribed. CONCLUSION AND OUTLOOK: The "Dysuria-Guideline" of DEGAM was developed for a prevalent and relevant topic in primary care in Germany. There are significant discrepancies between the recommendations and the realm of primary care. Post-hoc-analysis is an informative and feasible tool to identify potential obstacles against implementation of guidelines.

[Second opinion as expert consultation--general practitioner as referral source]. / Zweitmeinung Expertensache--aber Hausarzt als Mittler.

The relationship between family doctor and patient is usually one of mutual trust developed over many years. This is why a patient with cancer most likely first raise the question of a second opinion with him, in particular in a "palliative situation". The family doctor, however, can properly deal with this task only if he is included as a link in the network of communication and cooperation between those engaged in the treatment and care of cancer patients. Only then can the family doctor, as the closest and most trusted medical carer who is well acquainted with the patient's overall situation, help the patient to obtain a well-founded second opinion. In so doing they can also additional benefit the patient by sparing him many a fruitless odyssey, dashed false hopes and great disappointments.

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

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

[Long-term ambulatory blood pressure monitoring in the practice of the established physician. Report of experience]. / Ambulante Blutdruck-Langzeitmessung (ABDM) in der Praxis des niedergelassenen Arztes. Ein Erfahrungsbericht.

Ambulatory 24-h blood pressure measurement (abpm) is a method for diagnosing hypertension and evaluation of antihypertensive therapy which is not yet often used in general practice. Six of 11 untreated patients with elevated office blood pressures were found to have normal blood pressures in abpm. In 39 treated patients abpm was performed for evaluation of therapy. In 21 of these patients drug treatment was revised after abpm. Thus, office pressure measurement is an unreliable parameter of real blood pressure in the individual patient; the most cited reason being the so-called white-coat hypertension. A special advantage of abpm is ability of blood pressure measurement during daily life activities and during sleep. abpm can be helpful in detecting patients with white-coat hypertension, and it allows the possibility of an effective treatment throughout the day. Because hypertension is usually diagnosed and treated by general practitioners, abpm is a useful and necessary technique even in general practice.

[Health diagnosis and health counseling. Traditional risk factors are not in the foreground!]. / Gesundheitsdiagnostik und Gesundheitsberatung. Herkömmliche Risikofaktoren stehen nicht im Vordergrund!

This article reviews the bio-psycho-social factors of health stabilization and health rehabilitation. It is our aim to improve psychology's and general medicine's cooperation in these fields of research and practice. We, therefore, firstly concentrate on the psychosocial factors which improve health diagnosing and health education; we illustrate health education by selectively reviewing illness-related health trainings. Secondly, we discuss health counseling. Again, we concentrate on the improvement of general practitioner's health counseling. On the one hand, this improvement seems possible on the basis of individual bio-psycho-social risk models. Individual bio-psycho-social risk models, on the other hand, only can serve as a basis for individual-centered interventions, but not for population-centered interventions. After reporting various case histories from different doctor-patient-interactions, we demonstrate the application of bio-psycho-social risk models in the individual case. These applications in the general practitioner's office promise to be useful. Nevertheless, general medicine as well as psychology seem to have only minor interest in intensifying their cooperation.

[The walking-counting test. A simple test for assessing the risk of falling]. / Der Geh-und-Zähl-Test. Ein einfacher Test zur Abschätzung des Sturzrisikos.

BACKGROUND AND OBJECTIVE: Falls and fractures caused by falls are common in the elderly. Interventions to prevent such falls and/or fractures are available. But there are no appropriate tests in general practice for the targeted use of preventative measures. This prospective study was undertaken to validate a simple "walking and counting" test for assessing the risk of falling. PATIENTS AND METHODS: 92 patients of a general practice, aged between 70 and 96 years (64 women, 28 men) were included in the study. All patients were given the "walking and counting" test in which they would walk as quickly as possible along a stretch of 4 m, repeated immediately in a 3-step sequence while counting backwards from 100. The walking speed without counting was measured initially (vo), as was the speed during distraction by counting (vD). The difference between the two values, delta v%, measured the percentage change under distraction. In 80 patients it was possible to record the number of falls over the entire subsequent period of 12 months. All data were assessed by relative operating characteristics (ROC) and Bayesian analysis. RESULTS: 40 patients had falls in the follow-up period of 12 months, falls being more frequent the higher the age and if there had been previous falls. While all patients were able to do the test, individual values differed considerably. There was a statistical correlation between the calculated change in walking speed and the risk of falling. Using a threshold value of 20% slowing of the walking speed, the test sensitivity was 95% (0.51-0.81: 95% confidence interval) and the specificity 0.85 (0.71-0.93), with a positive predictive value of 0.77 (0.59-0.84). CONCLUSION: The walking and counting test is a simple and informative test, more reliable than other parameters, to predict for an individual patient with danger of falling over a 12-months period. It provides the general practitioner with a tool for demanding appropriately targeted preventative measures.