A randomized controlled trial to assess the effect of a medication plan containing drug administration recommendations on patients' drug knowledge after 2 months.

WHAT IS KNOWN AND OBJECTIVE: Patients' drug administration errors are often promoted by poor drug knowledge resulting from inadequate oral or written information. It has previously been shown that a medication plan enhanced with graphical and textual information on drug handling (enhanced medication plan) proved to immediately increase patients' drug knowledge. This study aimed to evaluate the effect of the enhanced medication plan on drug knowledge in outpatients after 2 months (intervention group) compared to patients with a simple medication plan with standard information (control group). METHODS: We recruited patients using ≥5 drugs in four family practices in Germany. After inclusion, patients' knowledge on handling of their drugs was assessed using three questions from a standardized catalog. Thereafter, patients were randomized to the intervention or control group. After 2 months, drug knowledge was reassessed with three different questions from the same standardized catalog. RESULTS AND DISCUSSION: Of 120 enrolled patients, 75% of participants in the control group (42/60 patients) and 78% of participants in the intervention group (46/60; P = 0·71) completed the study. Baseline drug knowledge was similar in both groups (43·7% vs. 40·6% correct answers). After 2 months, patients' drug knowledge showed an absolute increase of 23·2% in the intervention group (P < 0·01) and was unchanged in the control group (46·0%; P = 0·70). WHAT IS NEW AND CONCLUSION: The enhanced medication plan outperformed the effect of a simple medication plan and persistently increased the fraction of correct answers of polypharmacy patients. This demonstrates that the enhanced medication plan may be a useful tool in promoting drug knowledge.

Burden Experienced by Family Caregivers of Patients at the End of Life: What do General Practice Teams Offer?

The aim of the study: was to determine how far general practice teams are prepared to relieve family caregivers of palliative patients from their caregiving burden, the support they actually offer, and where they identify needs for improvement. Method: Focus groups and interviews on the issues of identification and support of family caregivers were conducted with practice teams (general practitioners, GPs, and medical assistants, MAs) and the results qualitatively analyzed. Results: 21 participants (14 GPs, 7 MAs) from 13 practices identified burdened family caregivers, thereupon offered support and provided contact details to local consultation services. They suggested to family caregivers that they should use their social network to create room for meeting their own needs. Conclusions: Practice teams use a multitude of individualized and unsystematic approaches to support family caregivers. In further studies within the framework of this project, systematic approaches will be identified and tried out.

[Symptom control and place of death in palliative cancer patients in primary care. Results of the controlled PAMINO evaluation study]. / Symptomkontrolle und Sterbeort hausärztlich versorgter Palliativpatienten. Ergebnisse der kontrollierten PAMINO-Evaluationsstudie.

BACKGROUND: The care of patients at the end of life focuses on preservation of the quality of life, symptom control and fulfillment of the preferred place of death. Only few care and outcome-related data for primary palliative care in Germany are available; therefore, the objective was to examine the quality of life, symptom control and place of death of patients with palliative treatment by general practitioners (GP). MATERIAL AND METHODS: The study is part of the PAMINO project, a non-randomized, controlled trial evaluating the effectiveness of continuing medical education for GPs (≥ 40 h) in palliative care (ISRCTN78021852). Cancer patients with an estimated life expectancy of less than 6 months were recruited by GPs with (PG) or without (CG) continuing education and documented the diagnosis, medication based on the hospice and palliative care collation ( Hospiz- und Palliativ-Erfassung, HOPE) core documentation and the preferred place of death. Patients rated their symptom burden and health-related quality of life using the quality of life questionnaire (QLQ-C15-PAL). Baseline (t0) data at enrollment and the last individual (t1) assessment were used for the analysis. RESULTS: Data of 68 patients (PG: n = 43, CG: n = 25, mean age 69.2 ± 12 years, average time since cancer diagnosis 14 months) were available at t0 and t1 (mean period 4.0 ± 2.1 months). Physical function decreased while emotional functioning remained stable. Patient-perceived pain did not increase; however, GPs intensified the pain therapy. The PGs prescribed non-opioid analgesics more frequently than CGs. During the observation period 59 patients died of which 40 out of 48 (83 %) as preferred at home. CONCLUSIONS: Stable emotional functioning, good symptom control in cancer patients at the end of life and the high rate of dying at home as preferred suggest that GPs with specific training can ensure high-quality general palliative care.

[Experiences and attitudes regarding practice-based clinical trials: results of a survey among German primary care physicians]. / Erfahrungen und Einstellungen zu Klinischen Studien in der Hausarztpraxis: Ergebnisse einer Befragung von deutschen Hausärzten.

OBJECTIVE: Clinical trials are regarded as complex due to the high demands on quality and patient safety and are still exceptional in German primary care. To optimise future trial planning, this study aimed at investigating the barriers and enablers experienced by primary care physicians (PCPs) for trial participation. METHODS: PCPs were surveyed on 11 regional primary care medical education (CME) events using a standardised questionnaire. Regression analyses were used to identify predictors for future trial participation. RESULTS: Of 804 invited PCPs, 408 (50.7%) participated in the survey (51 ± 9 years, female 35%). 69% of participants could imagine their participation in a clinical trial. Of 12 potential factors assessed, the final model retained the 2 predictors (OR; CI; P-value) "research questions relevant to practice" (2.25; 1.61-3.14;<0.001) and "new challenges/change from everyday life" (2.24; 1.67-2.97;<0.001). While 58% of participants were principally willing to participate in investigator training courses according to Good Clinical Practice (GCP), only 6% had participated in such training at the time of answering. Short events were preferred. Only 7% were willing to take over at least half of the costs of these courses. CONCLUSION: To enhance German PCPs motivation to participate in clinical trials, both trials and training courses should be tailored to the needs in the primary care setting.

[Prescriptions in outpatient physiotherapy for low back pain - descriptive analysis to relate indication key and everyday impairment]. / Heilmittelverordnungen in der ambulanten Physiotherapie bei Rückenbeschwerden - deskriptive Analyse zum Abgleich von Indikationsschlüssel und Alltagsbeeinträchtigung.

BACKGROUND: In Germany, in comparison to occupational therapy and speech therapy, physiotherapy is the most often prescribed treatment, with a prescription volume of 3 billion Euro in 2009. The catalogue of prescribable therapies (CPT; "Heilmittelkatalog") is a matter of controversial discussion. It represents the rationale which should support the physician in adhering to the efficiency principle. AIM: To describe the coded indications used by physicians to justify a physiotherapy prescription for patients with back pain, in order to verify its plausibility. Furthermore, we aimed to describe the manner in which patient subgroups differ regarding factors given in the CPT to allocate patients to various domains of indication. METHODS: A descriptive-exploratory secondary analysis of data from a prospective multicentre (84 private physiotherapy practices) observational trial was conducted. The Bother index of the Musculoskeletal Function Assessment Questionnaire (German, 16-Item version), the Work Ability Index and an 11-step box scale on pain intensity were measured as outcome. RESULTS: Coded indications related to dysfunction/pain due to joint-blockages dominated clearly (WS1a 30%, WS2a 35.3%). Patients who were allocated to the domains of indication WS1 and WS2 did not differ regarding botherment in daily life at the beginning of therapy (SES=0.05). CONCLUSION: It is hardly possible to identify clear prescription patterns. Results did not show any clear differences regarding major criteria for efficient prescription in line with the CPT. The weaknesses discussed should be targeted in future studies and should be considered during subsequent revisions of the CPT.

Determinants of heart failure self-care behaviour in community-based patients: a cross-sectional study.

BACKGROUND: Self-care behaviour in patients with heart failure (HF) represents a series of specific actions that patients should take, as an important treatment component. AIMS: The aim of this study was to identify potential determinants of HF self-care in ambulatory patients with stable systolic HF. METHODS: In a cross-sectional study of 318 patients with chronic systolic HF recruited in 48 German primary care practices, we evaluated the patient-reported European HF Self-care Behaviour scale (EHFScBs) assessments (range 12-60, where lower scores indicate better self-care). Potential determinants included socio-demographic (e.g. age, living status), clinical (e.g. NYHA class, LVEF, NT-proBNP levels, co-morbidities), behavioural (e.g. smoking and alcohol intake), psychosocial (SF-36 scales and KCCQ domains, e.g. quality of life and self-efficacy) and depression status (PHQ-D), plus previous health care utilisation. Mixed regression modelling was applied. RESULTS: Patients had a mean (SD) age of 69.0 (10.4) years and were 71% male. They had a good overall EHFScBs score of 24.7 (7.8) (n=274). In the final regression model (n=271), six determinants were retained (ß; descriptive p-value): self-efficacy (-0.24; <.001), age (-0.22; <.001), prosthetic heart valve (-0.14; .01), referrals to cardiologists (-0.14; .02), peripheral arterial disease (0.13; .03) and quality of life (0.16; .02). CONCLUSION: In this exploratory cross-sectional study, the potential non-modifiable and modifiable risk factors and resources involved in patients' HF self-care were at the individual and organisational level. Self-efficacy and quality of life are potentially modifiable, so these could be targeted for improvement by enhancing patient motivation, HF education and further supporting a collaborative care approach.

Guideline adherence for pharmacotherapy of chronic systolic heart failure in general practice: a closer look on evidence-based therapy.

BACKGROUND: There is robust evidence for effective pharmacotherapy of chronic (systolic) heart failure (CHF) which has led to the creation of guidelines, but many surveys evaluating CHF treatment show an under-utilisation of relevant drugs, while setting and patient population appear to be crucial for adequate appraisal of treatment patterns. AIMS: To evaluate the guideline adherence (GA) of general practitioners (GPs) in a well-defined patient population with CHF in primary care (PC). METHODS: A cross-sectional analysis was performed with the data of 167 patients enrolled in 37 GP practices (Germany) with documented left ventricular systolic dysfunction (LVEF: 33.3 +/- 6.9%). GA was assessed as usual (prescribing "yes" or "no"), through evaluation of target dosing, while adjusting for potential clinical contraindications, and through a modified Guideline Adherence Indicator-3 (mGAI-3), which assesses three relevant groups of substances according to New York Heart Association (NYHA) functional class: ACE-Inhibitors (ACE-I) or angiotensin receptor blockers (ARB), beta-blockers (BB) and aldosterone-antagonists (AA). RESULTS: Prescription rates for ACE-I/ARB, BB or both were 80%, 75% and 62%, respectively. The proportion of target doses reached for ACE-I was 16%, for BB only 8%. When adjusted for potential (mainly relative) contraindications (COPD, heart rate <60/min, hypotension, hyperkalaemia and renal dysfunction), the percentage of target doses reached increased to 49% for ACE-I/ARBs and 46% for BB. Application of the mGAI-3 showed moderate to perfect GA for usual assessment, proportion of target dose reached and adjusted in 83%, 16% and 55% of the patients, respectively. CONCLUSION: In the context of this patient and doctor setting, life-saving treatment was provided above average when assessed by usual criteria. The application of additional criteria showed further room for improvement. Future interventions aiming at optimisation should be tailored to the needs of doctors and patients likewise.