COVID-19 Continues to Burden General Practitioners: Impact on Workload, Provision of Care, and Intention to Leave.

General practitioners (GPs), already in a profession with a high workload, have been at the frontline of providing COVID-19-related healthcare in addition to routine care. Our study examined the impact of pandemic-related consultations and changes in practice organization on GPs' current workload and provision of healthcare in summer 2021 (May 2021-July 2021) and early 2022 (January 2022-February 2022). In total, 143 German GPs participated in an online survey in the summer of 2021. Of these, 51 GPs participated in the follow-up survey in 2022. Most GPs perceived an increase in consultation frequency, consultation times, and workload since the pandemic outbreak. Increased consultation times were related to the reduced provision of medical care to other patients with chronic diseases. More SARS-CoV-2 vaccination consultations were associated with reduced home visits, acute consultation times, and cancer screenings. A quarter of GPs considered leaving their job. Pandemic-related bureaucracy, restricted access to therapy and rehabilitation services specialized on COVID-19, unreliable vaccine deliveries, mandatory telematics-infrastructure implementation, and frequent changes in official regulations were the main reasons reported for dissatisfaction. Our results provide insights into how the pandemic continues to burden GPs' work routines and how better working conditions in times of high demand could be achieved in future pandemics.

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.

Telemedical Diabetic Retinopathy Screening in a Primary Care Setting: Quality of Retinal Photographs and Accuracy of Automated Image Analysis.

BACKGROUND: Screening for diabetic eye disease (DED) and general diabetes care is often separate, which leads to delays and low adherence to DED screening recommendations. Thus, we assessed the feasibility, achieved image quality, and possible barriers of telemedical DED screening in a point-of-care general practice setting and the accuracy of an automated algorithm for detection of DED. METHODS: Patients with diabetes were recruited at general practices. Retinal images were acquired using a non-mydriatic camera (CenterVue, Italy) by medical assistants. Images were quality assessed and double graded by two graders. All images were also graded automatically using a commercially available artificial intelligence (AI) algorithm (EyeArt version 2.1.0, Eyenuk Inc.). RESULTS: A total of 75 patients (147 eyes; mean age 69 years, 96% type 2 diabetes) were included. Most of the patients (51; 68%) preferred DED screening at the general practice, but only twenty-four (32%) were willing to pay for this service. Images of 63 patients (84%) were determined to be evaluable, and DED was diagnosed in 6 patients (8.0%). The algorithm's positive/negative predictive values (95% confidence interval) were 0.80 (0.28-0.99)/1.00 (0.92-1.00) and 0.75 (0.19-0.99)/0.98 (0.88-1.00) for detection of any DED and referral-warranted DED, respectively.Overall, the number of referrals was 18 (24%) for manual telemedical assessment and 31 (41%) for the artificial intelligence (AI) algorithm, resulting in a relative increase of referrals by 72% when using AI. CONCLUSIONS: Our study shows that achieved overall image quality in a telemedical GP-based DED screening was sufficient and that it would be accepted by medical assistants and patients in most cases. However, good image quality and integration into existing workflow remain challenging. Based on these findings, a larger-scale implementation study is warranted.

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.

[Back Pain: When do I Have to Commit?] / Rückenschmerzen: Wann muss man einweisen?

In the case of acute back pain, the indication for inpatient diagnosis and therapy is rarely given. The indication is provided if a potentially dangerous disease situation is suspected and if the pain is immobilizing or cannot be controlled on an outpatient basis. The high treatment numbers in German hospitals indicate that there is overuse in the treatment of back pain. Back pain, especially acute low back pain, is a frequent consultative activity of general practitioners. Serious diseases of the spine occur in only about 1 % of cases in GP practices. Identifying potentially dangerous disease outcomes requires a detailed history and thorough physical examination of the unclothed patient. "Red flags", together with the overall clinical impression of the patient, provide decisive warnings for urgently needed back pain. Common non-specific low back pain can be treated on an outpatient basis by prescribing painkillers and instructions for exercise by GPs.

Opioid use disorder in chronic non-cancer pain in Germany: a cross sectional study.

OBJECTIVES: The DSM-5 diagnosis 'opioid use disorder' (OUD) was established to better describe and detect significant impairment or distress related to opioid use. There is no data on rates of OUD in chronic non-cancer pain (CNCP) in European countries. Therefore, our objective was to screen patients in specialised pain centres for signs of OUD. DESIGN: Cross-sectional questionnaire study. SETTING: Four outpatient pain clinics in the area of Bonn, Germany. PARTICIPANTS: n=204 patients participated in the study (response rate: 87.9%). All adult patients with opioid pain therapy >6 months for CNCP were included. Excluded were patients with malignant disease, patients who could not collect their prescription themselves due to age or multimorbidity and patients on opioid-maintenance therapy. PRIMARY AND SECONDARY OUTCOME MEASURE: Primary outcome measure was the proportion of patients with mild to severe OUD. RESULTS: One-fourth (26.5%) of participants were diagnosed with OUD. Moderate to severe disorder was found in 9.3. Young age was the only connected risk factor (OR 0.96 [95% CI 0.94 to 0.99], p: 0.003). CONCLUSIONS: OUD is a relevant diagnosis in patients on long-term opioid therapy for CNCP in the Bonn area. Careful follow-up by the attending physicians is advisable, especially in patients with moderate or severe disorder.

[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.

[Survey of physicians on dealing with the topic "Tobacco consumption in patients with lung cancer"]. / Befragung von Ärzten zum Umgang mit dem Thema "Tabakkonsum bei Patienten mit Lungenkrebs".

INTRODUCTION: About 40 % of the patients are active smokers when diagnosed lung cancer. Half of these patients is the nicotine consumption continues despite the existence of cancer. The overall mortality in these patients is a factor of 3 higher. In addition, the quality of life increases and symptoms such as cough and dyspnoea are reduced. QUESTION: How do the treating physicians deal with the tobacco consumption of their patients with lung carcinoma? METHODS: A total of 14 physicians from the Bonn University Hospital were interviewed from the departments of pneumology, oncology and thoracic surgery involved in the treatment of the lung carcinoma. The interviews were transcribed and analysed according to the qualitative content analysis Mayring with MAXQDA® 12. RESULTS: The doctors handled the nicotine consumption of their patients very individually. In doing so, the doctors were primarily oriented on the possible life expectancy of the patients. In a curative treatment approach, the doctors presumed a smoking stop in their patients for successful treatment. In the context of a palliative treatment, many doctors no longer wanted the burden of smoking cessation to their patients. Came the desire for a cessation therapy in patients were referred generally to colleagues who were trained in smoking cessation. Obstacles to the independent execution of a smoking cessation were in particular lack of knowledge and short treatment times or high number of patients, especially during the consultation hours. DISCUSSION: The doctors were quite convinced of the benefit of a smoking stop in the treatment of the lung carcinoma. Lung cancer patients would benefit if smoking cessation would be even more integrated into the overall therapy. For that one could rely on already established cessation programs and concepts for clinics.

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.

Potential Drug-Drug Interactions in a Cohort of Elderly, Polymedicated Primary Care Patients on Antithrombotic Treatment.

INTRODUCTION: Drug-drug interactions (DDIs) are an important risk factor for adverse drug reactions. Older, polymedicated patients are particularly affected. Although antithrombotics have been detected as high-risk drugs for DDIs, data on older patients exposed to them are scarce. METHODS: Baseline data of 365 IDrug study outpatients (≥ 60 years, use of an antithrombotic and one or more additional long-term drug) were analyzed regarding potential drug-drug interactions (pDDIs) with a clinical decision support system. Data included prescription and self-medication drugs. RESULTS: The prevalence of having one or more pDDI was 85.2%. The median number of alerts per patient was three (range 0-17). For 58.4% of the patients, potential severe/contraindicated interactions were detected. Antiplatelets and non-steroidal anti-inflammatory drugs (NSAIDs) showed the highest number of average pDDI alert involvements per use (2.9 and 2.2, respectively). For NSAIDs, also the highest average number of severe/contraindicated alert involvements per use (1.2) was observed. 91.8% of all pDDI involvements concerned the 25 most frequently used drug classes. 97.5% of the severe/contraindicated pDDIs were attributed to only nine different potential clinical manifestations. The most common management recommendation for severe/contraindicated pDDIs was to intensify monitoring. Number of drugs was the only detected factor significantly associated with increased number of pDDIs (p < 0.001). CONCLUSION: The findings indicate a high risk for pDDIs in older, polymedicated patients on antithrombotics. As a consequence of patients' frequently similar drug regimens, the variety of potential clinical manifestations was small. Awareness of these pDDI symptoms and the triggering drugs as well as patients' self-medication use may contribute to increased patient safety.

Dependence on Prescription Opioids.

BACKGROUND: The incidence of initial prescriptions of opioids for chronic non-cancer pain rose by 37% in Germany from 2000 to 2010. Prescribing practice does not always conform with the recommendations of current guidelines. In the USA, 8-12% of patients with chronic non-cancer pain are opioid-dependent. METHODS: This review is based on publications retrieved by a selective PubMed search and on the German S3 guideline on the long-term use of opioids in non-cancer pain. RESULTS: Patients must be informed and counseled about the effects and risks of opioids before these drugs are prescribed. All opioid prescriptions for patients with chronic non-cancer pain should be regularly reviewed. The risk of abuse is high in young adults (odds ratio [OR] = 6.74) and in those with a history of substance abuse (OR = 2.34). Any unusual medication-related behavior, e.g., loss of prescriptions or increasing the dose without prior discussion with the physician, calls for further assessment by the physician in conversation with the patient. Urine testing for drugs and their metabolites is helpful as well. The goal of treatment of opioid abuse is opioid abstinence by gradual reduction of the dose. If this is not possible on an outpatient basis, hospitalization for drug withdrawal or substitution-based addiction therapy can be offered. CONCLUSION: Physicians who know the indications and risks of opioid therapy and the typical behavior of drug-dependent patients will be better able to identify patients at risk and to prevent dependence. Studies on the prevalence of opioid abuse and dependence in German patients with chronic pain can help provide better estimates of the current extent and implications of this problem in Germany.

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.

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.

Chronic recurrent multifocal osteomyelitis manifested as painful clavicular swelling: a case report.

BACKGROUND: Chronic recurrent multifocal osteomyelitis is a form of non-bacterial osteomyelitis which occurs primarily in childhood. In some cases painful bone swelling occurs. After a malignancy has been ruled out, antibiotic therapy is often started to treat the osteomyelitis. The course of this benign disease is self-limiting and is not positively affected by the antibiotic therapy. CASE PRESENTATION: A 14-year-old German girl from South Africa came to the surgery with painful swelling in the right clavicle. The condition had first appeared two months earlier. The patient was unable to identify a trigger. In addition, the patient exhibited painless swelling in the area of the 5th metatarsal of the left foot. Chronic recurrent multifocal osteomyelitis was diagnosed based on characteristic clinical symptoms and imaging. Treatment with ibuprofen had caused the symptoms to regress rapidly. CONCLUSION: The case demonstrates to general practitioners and other clinicians that a prolonged administration of antibiotics can be prevented by means of a comprehensive diagnostic procedure for possible bacterial osteomyelitis.