Out of hours care in Germany - High utilization by adult patients with minor ailments?

BACKGROUND: Family practitioners (FPs) who work in Out-Of-Hours Care (OOHC) - especially in rural areas - complain about high workload related to low urgency and potentially unnecessary patient presentations with minor ailments. The aim of this study was to describe Reasons for Encounter (RFEs) in primary OOHC taken into account the doctor's perspective in the context of high workload without knowing patients' motives for visiting an OOHC-centre. METHODS: Within this descriptive study, OOHC data from 2012 were evaluated from a German statutory health insurance company in the federal state of Baden-Wuerttemberg. 1.53 Million of the 10.5 Million inhabitants of Baden-Wuerttemberg were covered. The frequency of the ICD-10 diagnoses was determined at the three- and four-digit-level. The rate of hospitalizations was used to estimate the severity of the evaluated cases. RESULTS: Taken as a whole, 163,711 reasons for encounter with 1,174 ICD-10 single diagnoses were documented, of these 62.2% were on weekends. Less than 5.0% of the examined patients were hospitalized. Low back pain-dorsalgia (M54) was the most common diagnosis in OOHC, with 10,843 cases. Injuries were found twelve times in the list of the 30 most frequent diagnoses. The most frequent infectious disease was acute upper respiratory infection of multiple and unspecified sites (J06). By analysing the ICD codes to four-digits and looking at the rate of hospitalizations, it can be assumed that many RFEs were of less urgency in terms of the prompt need for medical treatment. CONCLUSION: While it is acknowledged that it can be difficult to make an exact diagnosis in an OOHC setting, after analysing the ICD-10 diagnoses, the majority of reasons for encounter in OOHC were determined to be of low urgency, meaning that patients could have waited until regular consultation hours. In the OOHC setting, it is important to understand RFEs from both the patient perspective and the family practitioner perspective. Additionally, results like these can be used in staff education especially improving triage methods and medical recommendations and in developing specific guidelines for OOHC in Germany. Analysis of routine data, such as in this study, contributes to this understanding and contributes to resolving problems of coding.

[Assessment of ability to drive in patients with MCI and dementia]. / Beurteilung der Fahrtauglichkeit bei Patienten mit MCI und demenziellen Syndromen.

People with mild cognitive impairment and dementia are a frequent and continuously increasing patient group in practically all fields of medicine. The associated challenges involve nearly all areas of life in addition to the direct medical treatment. Assessment of the ability to drive in patients with cognitive deficits is becoming increasingly more important. What are the options available to physicians in order to make a valid assessment? Which legal aspects must be taken into consideration? Which rights and obligations arise from the framework conditions? These questions nowadays give rise to great uncertainty for many medical personnel; however, the increasing importance of these problems necessitates a clear procedure, which allows difficult decisions to be made with utmost sovereignty and legal certainty and to be able to give patients and relatives a plausible explanation. Because age is a substantial risk factor for the development of cognitive disorders, the question of the ability to drive is affected not only by neuropsychiatric diseases, such as mild cognitive disorders or dementia but also the frequently occurring somatic comorbidities. Estimation of the ability to drive is therefore a complex approach, which should be standardized in order to appreciate all relevant aspects. It would be desirable to have a practice-oriented algorithm, the formulation of which is the aim of this article. Additionally, we would like to make a contribution to road safety and make medical personnel fully aware of this topic.

[Health insurance discount contracts: problems and risks for the general practitioner in the medical care of patients with chronic illness]. / Krankenkassen-Rabattverträge: Probleme und Risiken für den Hausarzt bei der Betreuung chronisch kranker Patienten.

BACKGROUND AND OBJECTIVE: The German federal Health Insurance law to strengthen competition between the pharmaceutical companies commits pharmacies to hand out drugs from discount contract drug suppliers of a patient's health insurance company. Thus patients are confronted with constantly changing drug packets. This study aimed at exploring whether patients have been properly informed about the new discount contracts and if they have experienced changes and problems in their long- term medications. METHODS: Between May and June 2008 male and female patients older than 50 years who had a statutory health insurance and had been diagnosed with coronary heart disease for at least one year answered a standardized questionnaire filled in by doctors' assistants or general practitioners in the doctors' network "Weschnitztal". RESULTS: Of the 188 patients participated in this study 63,8% were informed about health insurance discount contracts. 31,3% of the patients reported that a positive effect due to the discount contracts was that they were discharged from paying the drug prescription fee, 22,2% mentioned that cost saving for the health insurance could also be positive. 120 patients (63,8%) knew that the names of their long-term drugs could change.101 of the questioned patients (53,7%) identified a change in their long-term drugs, 51,5% felt insecure about the permanent changes. 21,7% experienced adverse e effects due to the new drugs. 19% of the patients had serious problems regarding medication intake. CONCLUSION: This study demonstrates that the information which patients have on the new health insurance law is not adequate enough. Many of them felt insecure because of the changes of long-term medications. One fifth of the patients reported errors in their drug intake or their confusion about their drugs. There is a high risk that these circumstances may trigger further diseases or complications. The cost savings as intended by the health insurance companies may therefore not be achieved by discount contracts.

[Gender-specific differences in quality of life of patients with type 2 diabetes with or without participating in DMP]. / Geschlechtsspezifische Unterschiede in der Lebensqualität von Typ-2-Diabetikern mit und ohne DMP-Einschreibung.

OBJECTIVE: Disease management programmes (DMP) are supposed to improve the care of patients with type 2 diabetes or other chronic conditions. One stated aim is the improvement of the health-related quality of life. Within the ELSID study (controlled study for the evaluation of the DMP for patients with type 2 diabetes) there has been a survey of insurants of the general regional health funds (AOK) by means of the SF-36. The aim of this survey is a comparison of patients participating in the Diabetes DMP with those who are not participating in the program with regard to their quality of life. METHODS: A random sample of 3,546 patients with type 2 diabetes out of the total sample of the ELSID study (20,625) was asked to complete the SF-36. RESULTS: 1,532 questionnaires were returned (response rate 43.2%). 1,399 were analysed. Within all scales of the SF-36, men achieved higher scores than women. Differentiated in participants and non-participants in the DMP, in men there were lower scores for the participants than for the non-participants. In women this proportion was reversed. CONCLUSIONS: This cross-sectional-study provides first indications for gender-specific differences within the quality of life of patients with diabetes participating in the DMP compared to patients who are not participating. These differences should be considered more intensely within further research of DMP evaluation and the configuration of the programmes in the future.

Therapeutic drug monitoring of antidepressants--clinical aspects.

Therapeutic Drug Monitoring (TDM) is a tool to optimise antidepressant pharmacotherapy improving efficacy and avoiding side effects. The Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP)-TDM group has worked out consensus guidelines to make progress in the use of TDM which in spite of its obvious advantages, is far from optimal in everyday clinical practice. Research-based levels of recommendation were defined with regard to routine monitoring of plasma concentrations for dose titration. Main indications of TDM compromise control of compliance, lack of clinical response or adverse effects at recommended doses, drug interactions, pharmacovigilance programs, presence of a genetic predisposition particularity concerning the drug metabolism, children, adolescents and elderly patients. Therapeutic ranges of plasma concentrations that are considered to be optimal for treatment are proposed, implications on pharmacoeconomics aspects are discussed. The need to improve the implementation of TDM in routine patient care is emphasized.

Cost-benefit analysis of newer versus older antidepressants--pharmacoeconomic studies comparing SSRIs/SNRIs with tricyclic antidepressants.

Changes in the social and health services over the last years have forced doctors to concern themselves with cost benefit calculations and budget forecasting. Cost considerations are a (co-) determinant in the choice of antidepressants as well as neuroleptics and/or antipsychotics. In recent years, pharmacoeconomic studies have been performed to answer the question as to what extent treatment with new antidepressants, in particular SSRIs, is actually less expensive than treatment with (generic) tricyclic antidepressants due to better safety profiles and higher compliance in spite of the considerably higher retail price. Following descriptions of the methodological principles, the currently available studies are presented and discussed critically in this report. It can be stated that the economic value of different antidepressants can not be decided definitively at the present time. The available data do not allow the conclusion that SSRIs should be preferred over tricyclic antidepressants with the argument that the treatment as a whole is more cost effective in spite of the higher costs.

Assessment of sexual dysfunction in depressed patients and reporting attitudes in routine daily practice: Results of the postmarketing observational studies with moclobemide, a reversible MAO-A inhibitor.

OBJECT: The aim of this study was to assess the effect of moclobemide on sexual dysfunction in depressed patients treated under routine conditions in private practice and hospital settings. METHOD: sexual function was systematically assessed by a specific questionnaire and by recording spontaneously reported adverse events during large prospective postmarketing surveillance studies with moclobemide, carried out in Germany between 1992 and 1995. The data of 4333 patients were collected in two different settings: (a) specialized psychiatric and neurological private practices and (b) psychiatric hospitals. RESULTS: Up to 70% of depressed patients suffered from Some type of sexual dysfunction at baseline and in about two thirds the dysfunction was rated as moderate to severe. The severity and frequency of sexual dysfunction corresponded well to the severity of depressive syndrome. Sexual functions improved during treatment with moclobemide and the extent of improvement corresponded to the favourable outcome of antidepressant treatment. Deterioration of sexual functions under moclobemide treatment was infrequent and experienced by less than 3% of patients. The frequency of spontaneously reported sexual dysfunction, reported as adverse event, was lower than 0.1%. For a considerable proportion of patients included in the studies sexual function was not systematically recorded: up to 10-20% of data for variables related to sexual function were missing. Unreported sexual functioning varied in dependence of the type of function, age and gender of the patient and treatment settings. CONCLUSION: The results of the observational studies with moclobemide do not provide evidence that moclobemide induces or intensifies sexual dysfunction in depressed patients under routine daily treatment. The results also demonstrate that the assessment of sexual function in the practice is clearly influenced by the reporting attitudes of patients and physicians.

Assessment of cardiovascular autonomic function: age-related normal ranges and reproducibility of spectral analysis, vector analysis, and standard tests of heart rate variation and blood pressure responses.

To establish normal ranges for assessment of autonomic dysfunction, a battery of cardiovascular reflex tests was performed in 120 healthy subjects aged 15-67 years using a computer-based technique. Tests of heart rate variation (HRV) included 8 measures at rest: coefficient of variation (CV), root mean squared successive difference (RMSSD), spectral analysis of HRV in the low frequency, mid frequency, and high frequency bands in the supine and standing postures; 5 measures during deep breathing: CVb, RMSSDb, Expiration-Inspiration (E-I) difference, E/I ratio, and mean circular resultant of vector analysis; Valsalva ratio, and max/min 30:15 ratio. In addition, the change in systolic and diastolic blood pressure in response to standing and the diastolic blood pressure response to sustained handgrip were determined. The results of all measures, the blood pressure tests excepted, declined significantly with increasing age (r = -0.16 to -0.59; p less than 0.05). Moreover, RMSSD, RMSSDb, and E-I difference decreased considerably with increasing heart rate (r = -0.37 to -0.52; p less than 0.001). The longest and shortest R-R intervals in response to standing were distributed within beats 21-39 and 6-24, respectively. All tests were independent of sex. Log transformation was used to define the age-related lower limits of normal at the 2.3 centile for all tests of HRV, except for the E/I, Valsalva, and max/min 30:15 ratios. The results of these tests had to be analysed using a log(y-1) transformation. The intra-individual reproducibility determined on two consecutive days in 20 healthy subjects and 21 diabetic patients indicated that there were no major differences between the two groups regarding the day-to-day variation of test results, which was highest for the Valsalva ratio. We conclude that: (1) all indices of spectral and vector analyses of HRV are age-dependent and have the advantage of being independent of heart rate; (2) RMSSD, E-I difference, and the 30:15 ratio as it was used previously are not suitable for evaluation of autonomic dysfunction in diabetes; (3) log(y-1) transformation is required to determine age-dependent normal ranges and reproducibility for the three ratios.