Medication Adherence and Healthcare Costs in Chronically Ill Patients Using German Claims Data.

BACKGROUND AND OBJECTIVE: Despite the importance of medication adherence for chronically ill patients and the vast literature on its relationship to costs, this field suffers from methodological limitations. These are caused, amongst others, by the lack of generalizability of data sources, varying definitions of adherence, costs, and model specification. We aim to address this with different modeling approaches and to contribute evidence on the research question. METHODS: We extracted large cohorts of nine chronic diseases (n = 6747-402,898) from German claims data of stationary health insurances between 2012 and 2015 (t0-t3). Defined as the proportion of days covered by medication, we examined the relationship of adherence using several multiple regression models at baseline year t0 with annual total healthcare costs and four sub-categories. Models with concurrent, and differently time-lagged measurements of adherence and costs were compared. Exploratively, we applied non-linear models. RESULTS: Overall, we found a positive association between the proportion of days covered by medication and total costs, a weak association with outpatient costs, positive with pharmacy costs, and frequently negative with inpatient costs. There were major differences by disease and its severity but little between years, provided adherence and costs were not measured concurrently. The fit of linear models was mainly not inferior to that of non-linear models. CONCLUSIONS: The estimated effect on total costs differed from most other studies, which highlights concerns about generalizability, although effect estimates in sub-categories were as expected. Comparison of time lags indicates the importance of avoiding concurrent measurement. A non-linear relationship should be considered. These methodological approaches are valuable in future research on adherence and its consequences.

Combining the GP's assessment and the PHQ-9 questionnaire leads to more reliable and clinically relevant diagnoses in primary care.

BACKGROUND: Screening questionnaires are not sufficient to improve diagnostic quality of depression in primary care. The additional consideration of the general practitioner's (GP's) assessment could improve the accuracy of depression diagnosis. The aim of this study was to examine whether the GP rating supports a reliable depression diagnosis indicated by the PHQ-9 over a period of three months. METHODS: We performed a secondary data analysis from a previous study. PHQ-9 scores of primary care patients were collected at the time of recruitment (t1) and during a follow-up 3 months later (t2). At t1 GPs independently made a subjective assessment whether they considered the patient depressive (yes/no). Two corresponding groups with concordant and discordant PHQ-9 and GP ratings at t1 were defined. Reliability of the PHQ-9 results at t1 and t2 was assessed within these groups and within the entire sample by Cohen's Kappa, Pearson's correlation coefficient and Bland-Altman plots. RESULTS: 364 consecutive patients from 12 practices in the region of Upper Bavaria/Germany participated in this longitudinal study. 279 patients (76.6%) sent back the questionnaire at t2. Concordance of GP rating and PHQ-9 at t1 led to higher replicability of PHQ-9 results between t1 and t2. The reliability of PHQ-9 was higher in the concordant subgroup (κ = 0.507) compared to the discordant subgroup (κ = 0.211) (p = 0.064). The Bland-Altman Plot showed that the deviation of PHQ-9 scores at t1 and t2 decreased by about 15% in the concordant subgroup. Pearson's correlation coefficient between PHQ-9 scores at t1 and t2 increased significantly if the GP rating was concordant with the PHQ-9 at t1 (r = 0.671) compared to the discordant subgroup (r = 0.462) (p = 0.044). CONCLUSIONS: The combination of PHQ-9 and GP rating might improve diagnostic decision making regarding depression in general practices. PHQ-9 positive results might be more reliable and accurate, when a concordant GP rating is considered.

COVID-19 assessment in family practice-A clinical decision rule based on self-rated symptoms and contact history.

The study aimed to evaluate the diagnostic accuracy of contact history and clinical symptoms and to develop decision rules for ruling-in and ruling-out SARS-CoV-2 infection in family practice. We performed a prospective diagnostic study. Consecutive inclusion of patients coming for COVID-PCR testing to 19 general practices. Contact history and self-reported symptoms served as index test. PCR testing of nasopharyngeal swabs served as reference standard. Complete data were available from 1141 patients, 605 (53.0%) female, average age 42.2 years, 182 (16.0%) COVID-PCR positive. Multivariable logistic regression showed highest odds ratios (ORs) for "contact with infected person" (OR 9.22, 95% CI 5.61-15.41), anosmia/ageusia (8.79, 4.89-15.95), fever (4.25, 2.56-7.09), and "sudden disease onset" (2.52, 1.55-4.14). Patients with "contact with infected person" or "anosmia/ageusia" with or without self-reported "fever" had a high probability of COVID infection up to 84.8%. Negative response to the four items "contact with infected person, anosmia/ageusia, fever, sudden disease onset" showed a negative predictive value (NPV) of 0.98 (95% CI 0.96-0.99). This was present in 446 (39.1%) patients. NPV of "completely asymptomatic," "no contact," "no risk area" was 1.0 (0.96-1.0). This was present in 84 (7.4%) patients. To conclude, the combination of four key items allowed exclusion of SARS-CoV-2 infection with high certainty. With the goal of 100% exclusion of SARS-CoV-2 infection to prevent the spread of SARS-CoV-2 to the population level, COVID-PCR testing could be saved only for patients with negative response in all items. The decision rule might also help for ruling-in SARS-CoV-2 infection in terms of rapid assessment of infection risk.

SARS-CoV-2 infection and cardiovascular or pulmonary complications in ambulatory care: A risk assessment based on routine data.

BACKGROUND: Risk factors of severe COVID-19 have mainly been investigated in the hospital setting. We investigated pre-defined risk factors for testing positive for SARS-CoV-2 infection and cardiovascular or pulmonary complications in the outpatient setting. METHODS: The present cohort study makes use of ambulatory claims data of statutory health insurance physicians in Bavaria, Germany, with polymerase chain reaction (PCR) test confirmed or excluded SARS-CoV-2 infection in first three quarters of 2020. Statistical modelling and machine learning were used for effect estimation and for hypothesis testing of risk factors, and for prognostic modelling of cardiovascular or pulmonary complications. RESULTS: A cohort of 99 811 participants with PCR test was identified. In a fully adjusted multivariable regression model, dementia (odds ratio (OR) = 1.36), type 2 diabetes (OR = 1.14) and obesity (OR = 1.08) were identified as significantly associated with a positive PCR test result. Significant risk factors for cardiovascular or pulmonary complications were coronary heart disease (CHD) (OR = 2.58), hypertension (OR = 1.65), tobacco consumption (OR = 1.56), chronic obstructive pulmonary disease (COPD) (OR = 1.53), previous pneumonia (OR = 1.53), chronic kidney disease (CKD) (OR = 1.25) and type 2 diabetes (OR = 1.23). Three simple decision rules derived from prognostic modelling based on age, hypertension, CKD, COPD and CHD were able to identify high risk patients with a sensitivity of 74.8% and a specificity of 80.0%. CONCLUSIONS: The decision rules achieved a high prognostic accuracy non-inferior to complex machine learning methods. They might help to identify patients at risk, who should receive special attention and intensified protection in ambulatory care.

Ambulatory specialist costs and morbidity of coordinated and uncoordinated patients before and after abolition of copayment: A cohort analysis.

To strengthen the coordinating function of general practitioners (GPs) in the German healthcare system, a copayment of €10 was introduced in 2004. Due to a perceived lack of efficacy and a high administrative burden, it was abolished in 2012. The present cohort study investigates characteristics and differences of GP-coordinated and uncoordinated patients in Bavaria, Germany, concerning morbidity and ambulatory specialist costs and whether these differences have changed after the abolition of the copayment. We performed a retrospective routine data analysis, using claims data of the Bavarian Association of the Statutory Health Insurance Physicians during the period 2011-2012 (with copayment) and 2013-2016 (without copayment), covering 24 quarters. Coordinated care was defined as specialist contact only with referral. Multinomial regression modelling, including inverse probability of treatment weighting, was used for the cohort analysis of 500 000 randomly selected patients. Longitudinal regression models were calculated for cost estimation. Coordination of care decreased substantially after the abolition of the copayment, accompanied by increasing proportions of patients with chronic and mental diseases in the uncoordinated group, and a corresponding decrease in the coordinated group. In the presence of the copayment, uncoordinated patients had €21.78 higher specialist costs than coordinated patients, increasing to €24.94 after its abolition. The results indicate that patients incur higher healthcare costs for specialist ambulatory care when their care is uncoordinated. This effect slightly increased after abolition of the copayment. Beyond that, the abolition of the copayment led to a substantial reduction in primary care coordination, particularly affecting vulnerable patients. Therefore, coordination of care in the ambulatory setting should be strengthened.

Systematic Assessment of Medical Diagnoses Preceding the First Diagnosis of Multiple Sclerosis.

OBJECTIVE: To explore the occurrence of diseases and symptoms in the five years prior to diagnosis in patients with multiple sclerosis (MS) in a case-control study. METHODS: Using ambulatory claims data we systematically assessed differences in the occurrence of diseases and symptoms in the five years prior to first diagnosis in patients with MS (n=10,262) as compared to patients with two other autoimmune diseases - Crohn's disease (n=15,502) and psoriasis (n=98,432) - and individuals without these diseases (n=73,430). RESULTS: Forty-three ICD-10 codes were recorded more frequently for patients with MS before diagnosis as compared to controls without autoimmune disease. Many of these findings were confirmed in a comparison to the other control groups. A high proportion of these ICD-10 codes represent symptoms suggestive of demyelinating events or other neurological diagnoses. In a sensitivity analysis excluding patients with such recordings prior to first diagnosis, no association remained significant. Seven ICD-10 codes were associated with lower odds ratios of MS, four of which represented upper respiratory tract infections. Here, the relations with MS were even more pronounced in the sensitivity analysis. CONCLUSIONS: Our analyses suggest that patients with MS are frequently not diagnosed at their first demyelinating event but often years later. Symptoms and physician encounters before MS diagnosis seem to be related to already ongoing disease rather than a prodrome. The observed association of upper respiratory tract infections with lower ORs of MS diagnosis suggests a link between protection from infection and MS that however needs to be validated and further investigated.

How European primary care practitioners think the timeliness of cancer diagnosis can be improved: a thematic analysis.

BACKGROUND: National European cancer survival rates vary widely. Prolonged diagnostic intervals are thought to be a key factor in explaining these variations. Primary care practitioners (PCPs) frequently play a crucial role during initial cancer diagnosis; their knowledge could be used to improve the planning of more effective approaches to earlier cancer diagnosis. OBJECTIVES: This study sought the views of PCPs from across Europe on how they thought the timeliness of cancer diagnosis could be improved. DESIGN: In an online survey, a final open-ended question asked PCPs how they thought the speed of diagnosis of cancer in primary care could be improved. Thematic analysis was used to analyse the data. SETTING: A primary care study, with participating centres in 20 European countries. PARTICIPANTS: A total of 1352 PCPs answered the final survey question, with a median of 48 per country. RESULTS: The main themes identified were: patient-related factors, including health education; care provider-related factors, including continuing medical education; improving communication and interprofessional partnership, particularly between primary and secondary care; factors relating to health system organisation and policies, including improving access to healthcare; easier primary care access to diagnostic tests; and use of information technology. Re-allocation of funding to support timely diagnosis was seen as an issue affecting all of these. CONCLUSIONS: To achieve more timely cancer diagnosis, health systems need to facilitate earlier patient presentation through education and better access to care, have well-educated clinicians with good access to investigations and better information technology, and adequate primary care cancer diagnostic pathway funding.

A Systematic Assessment of Prevalence, Incidence and Regional Distribution of Multiple Sclerosis in Bavaria From 2006 to 2015.

Introduction: Worldwide, incidence and prevalence of multiple sclerosis (MS) have increased over the last decades. We present a systematic epidemiological study with recent prevalence and incidence rates of MS in Bavaria. Methods: Incidence and prevalence of MS stratified by gender, age groups and region were analyzed by data records from 2006 to 2015 of more than 10 million people insured by the Bavarian Association of Statutory Health Insurance Physicians. Official statistics of the German Federal Ministry of Health provided the size of the general population. Future prevalence was estimated with a predictive model. Results: From 2006 to 2015 prevalence of MS in Bavaria increased from 171 per 100,000 to 277 per 100,000, while incidence rates remained relatively stable (range 16-18 per 100,000 inhabitants with a female to male ratio between 2.4:1 and 2:1). Incidence and prevalence were higher in urban than urbanized and rural areas. The prevalence is expected to increase to 374 per 100,000 in 2040 with the highest prevalence rates between 50 and 65 years. Conclusion: The prevalence of MS in Bavaria is among the highest worldwide and will further rise over the next two decades. This demonstrates a need to strengthen healthcare provision systems due to the increasing numbers of particularly older patients with MS in the future.

Identifying important health system factors that influence primary care practitioners' referrals for cancer suspicion: a European cross-sectional survey.

OBJECTIVES: Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners' (PCPs') referral decisions is lacking.This study analyses health system factors potentially influencing PCPs' referral decision-making when consulting with patients who may have cancer, and how these vary between European countries. DESIGN: Based on a content-validity consensus, a list of 45 items relating to a PCP's decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs' referral decision-making. SETTING: A primary care study; 25 participating centres in 20 European countries. PARTICIPANTS: 1830 PCPs completed the survey. The median response rate for participating centres was 20.7%. OUTCOME MEASURES: The factors derived from items related to PCPs' referral decision-making. Mean factor scores were produced for each country, allowing comparisons. RESULTS: Factor analysis identified five underlying factors: PCPs' ability to refer; degree of direct patient access to secondary care; PCPs' perceptions of being under pressure; expectations of PCPs' role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses. CONCLUSIONS: Five healthcare system factors influencing PCPs' referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.

Impact of regional socioeconomic variation on coordination and cost of ambulatory care: investigation of claims data from Bavaria, Germany.

OBJECTIVES: A considerable proportion of regional variation in healthcare use and health expenditures is to date still unexplained. The aim was to investigate regional differences in the gatekeeping role of general practitioners and to identify relevant explanatory variables at patient and district level in Bavaria, Germany. DESIGN: Retrospective routine data analysis using claims data held by the Bavarian Association of Statutory Health Insurance Physicians. PARTICIPANTS: All patients who consulted a specialist in ambulatory practice within the first quarter of 2011 (n=3 616 510). OUTCOMES MEASURES: Of primary interest is the effect of district-level measures of rurality, physician density and multiple deprivation on (1) the proportion of patients with general practitioner (GP) coordination of specialist care and (2) the mean amount in Euros claimed by specialist physicians. RESULTS: The proportion of patients whose use of specialist services was coordinated by a GP was significantly higher in rural areas and in highly deprived regions, as compared with urban and less deprived regions. The hierarchical models revealed that increasing age and the presence of chronic diseases are the strongest predictive factors for coordination by a GP. In contrast, the presence of mental illness, an increasing number of medical condition categories and living in a city are predictors for specialist use without GP coordination. The amount claimed per patient was €10 to €20 higher in urban districts and in regions with lower deprivation. Hierarchical models indicate that this amount is on average higher for patients living in towns and lower for patients in regions with high deprivation. CONCLUSION: The present study shows that regional deprivation is closely associated with the way in which patients access primary and specialist care. This has clear consequences, both with respect to the role of the general practitioner and the financial costs of care.

Costs of coordinated versus uncoordinated care in Germany: results of a routine data analysis in Bavaria.

OBJECTIVES: The efficiency of a gatekeeping system for a health system, as in Germany, remains unclear particularly as access to specialist ambulatory care is not restricted. The aim was to compare the costs of coordinated versus uncoordinated patients (UP) in ambulatory care; with additional subgroup analysis of patients with mental disorders. DESIGN: Retrospective routine data analysis of patients with statutory health insurance, using claims data held by the Bavarian Association of Statutory Health Insurance Physicians. A patient was defined as uncoordinated if he or she visited at least 1 specialist without a referral from a general practitioner within a quarter. Outcomes were compared with propensity score matching analysis. PARTICIPANTS: The study encompassed all statutorily insured patients in Bavaria contacting at least 1 ambulatory specialist in the first quarter of 2011 (n=3 616 510). PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was total costs of ambulatory care; secondary outcomes were financial claims of general physicians, specialists and for medication. RESULTS: The average age was 55.3 years for coordinated patients (CP, n=1 629 302), 48.3 years for UP (n=1 825 840). CP more frequently had chronic diseases (85.4%) as compared with UP (67.5%). The total unadjusted financial claim per patient was higher for UP (€234.52) than for CP (€224.41); the total adjusted difference was -€9.65 (95% CI -11.64 to -7.67), indicating lower costs for CP. The cost differences increased with increasing age. Total adjusted difference per patient with mental diseases as documented with an International Classification of Diseases (ICD)-10 F-diagnosis, was -€20.31 (95% CI -26.43 to -14.46). CONCLUSIONS: Coordination of care is associated with lower ambulatory healthcare expenditures and is of particular importance for patients who are more vulnerable to medical interventions, especially for elderly and patients with mental disorders. The role of general practitioners as coordinators should be strengthened to improve care for these patients as this could also help to frame a more efficient health system.

Quantity, topics, methods and findings of randomised controlled trials published by German university departments of general practice - systematic review.

BACKGROUND: Academic infrastructures and networks for clinical research in primary care receive little funding in Germany. We aimed to provide an overview of the quantity, topics, methods and findings of randomised controlled trials published by German university departments of general practice. METHODS: We searched Scopus (last search done in April 2015), publication lists of institutes and references of included articles. We included randomised trials published between January 2000 and December 2014 with a first or last author affiliated with a German university department of general practice or family medicine. Risk of bias was assessed with the Cochrane tool, and study findings were quantified using standardised mean differences (SMDs). RESULTS: Thirty-three trials met the inclusion criteria. Seventeen were cluster-randomised trials, with a majority investigating interventions aimed at improving processes compared with usual care. Sample sizes varied between 6 and 606 clusters and 168 and 7807 participants. The most frequent methodological problem was risk of selection bias due to recruitment of individuals after randomisation of clusters. Effects of interventions over usual care were mostly small (SMD <0.3). Sixteen trials randomising individual participants addressed a variety of treatment and educational interventions. Sample sizes varied between 20 and 1620 participants. The methodological quality of the trials was highly variable. Again, effects of experimental interventions over controls were mostly small. CONCLUSIONS: Despite limited funding, German university institutes of general practice or family medicine are increasingly performing randomised trials. Cluster-randomised trials on practice improvement are a focus, but problems with allocation concealment are frequent.

The effect of mental comorbidity on service delivery planning in primary care: an analysis with particular reference to patients who request referral without prior assessment.

BACKGROUND: In their everyday practice, primary-care physicians are often asked to refer patients to a specialist without a prior appointment in primary care. Such referrals are problematic, and one might suspect that patients who make such requests are more likely to have mental comorbidities predisposing them toward higher utilization of health-care services. METHODS: In a cross-sectional study, 307 patients of 13 primary-care practices who requested referral to a specialist without a prior appointment in primary care were given a Patient Health Questionnaire (PHQ) containing questions that related to depression, anxiety, panic disorder, and somatoform disorder (independent variables). Further information was obtained about these patients' primary-care contacts, referrals, and days taken off from work with a medical excuse over the course of one year (dependent variables). A regression model was used to compare these patients with 977 other primary-care patients. RESULTS: The groups of patients who did and did not request specialist referral without a primary-care appointment did not differ to any statistically significant extent with respect to mental comorbidity. In the overall group, somatoform disorder was found to be associated with a high rate of primary-care contacts (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.4-4.3). High rates of referral were strongly correlated (percentage of variance explained, R²) with depression (OR 2.1, 95% CI 1.1-4.0; R² = 35.3%), anxiety (OR 4.1, 95% CI 1.8-9.6; R² = 34.5%), panic disorder (OR 5.9, 95% CI 2.1-16.4; R² = 34.3%), and somatoform disorder (OR 2.2, 95% CI 1.2-4.0; R² = 34.6%). Taking a long time off from work with a medical excuse was correlated with depression (OR 2.5, 95% CI 1.2-4.8), anxiety (OR 4.2, 95% CI 1.7-10.5), and somatoform disorder (OR 2.2, 95% CI 1.2-4.2). CONCLUSION: Mental comorbidity contributes to the increased utilization of health-care services. This should be borne in mind whenever a patient requests many referrals to specialists (either with or without a prior appointment in primary care). It is important to identify "doctor-hopping" patients so that the causes of their behavior can be recognized, discussed, and properly treated.

Disease management programs for patients with asthma in Germany: a longitudinal population-based study.

BACKGROUND: The primary aim of the disease management program (DMP) for patients with asthma is to improve health outcomes and to reduce costs. Five years after its introduction in Germany, no consensus has yet been reached as to whether DMP has been effective in reaching these goals. OBJECTIVE: To evaluate the DMP for asthma in Bavaria using routinely collected subject medical records. METHODS: A longitudinal population-based study encompassing over 100,000 DMP participants between 2006 (when the program began) and 2010. RESULTS: The prescription rate of oral corticosteroids dropped from 15.7% in 2006 to 13.6% in 2007, and again from 7.5% in 2008 to 5.9% in 2010 (P < .001). The proportion of subjects with asthma self-management education increased from 4.4% to 23.4% (P < .001). Utilization of an individual asthma action plan increased from 40.3% to 69.3% (P < .001). Hospitalization decreased from 2.8% to 0.7% (P < .001). CONCLUSIONS: In the first 4 years of DMP there was an improvement in pharmacotherapy and patient self management. The proportion of subjects requiring hospitalization decreased. Our results suggest that the German DMP for asthma has been effective in enhancing the quality of care in regard to an improved symptom frequency, adherence to guidelines, pharmacotherapy, and hospitalization.

Diagnostic accuracy of clinical symptoms in obstructive airway diseases varied within different health care sectors.

OBJECTIVE: To determine the diagnostic accuracy and diagnostic patterns of clinical symptoms in patients suspected to suffer from obstructive airway diseases (OADs) within different health care sectors. STUDY DESIGN AND SETTING: Ten general practices (219 patients), one practice of pneumologists (259 patients) and one specialist hospital (300 patients). Sensitivities, specificities, positive (LR+), and negative (LR-) likelihood ratios of clinical symptoms were compared with lung function testing. RESULTS: Thirty-one percent had chronic obstructive pulmonary disease (COPD), 21% had asthma. Sensitivities increased and specificities decreased from outpatient to hospital setting. The multivariate model of adjusted likelihood ratios for COPD showed LR+=4.86 (95% confidence interval [CI]=2.09-11.29) and LR-=0.07 (95% CI=0.01-0.43) of the combination "wheezing," "dyspnea when going upstairs," "smoking" in general practice. In hospital, the combination "dyspnea when going upstairs," "dyspnea during minimal exercise," and "smoking" showed LR+=3.34 (95% CI=2.08-5.31) and LR-=0.02 (95% CI=0.01-0.12). The combination "no coughing," "dyspnea attacks," and "no smoking" showed LR+=4.08 (95% CI=1.67-10.4) and LR-=0.24 (95% CI=0.12-0.58) for asthma in general practice. The combination "dyspnea attacks" and "no dyspnea when walking" showed LR+=6.48 (95% CI=1.01-40.94) and LR-=0.28 (95% CI=0.11-0.75) for asthma in hospital. CONCLUSION: Clinical decision rules for OAD need to be derived from original studies in their respective settings or assessed on their transferability to other settings.

How do patients from eastern and western Germany compare with regard to their preferences for shared decision making?

BACKGROUND: Increasing emphasis is being placed on involving patients in decisions concerning their health. This shift towards more patient engagement by health professionals and towards more desire by patients for participation may be partly based on socio-political factors. METHODS: To compare the preferences for shared decision making of patients from eastern and western Germany we analysed five patient samples (n = 2318) (general practice patients and schizophrenia patients from eastern and western Germany). Patients' role preferences for shared decisions were measured using the decision-making subscale of the Autonomy Preference Index. RESULTS: Patients resident in eastern Germany expressed lower preferences for shared decision making than patients in western Germany. This was true after controlling for socio-demographic variables and for patient group. CONCLUSION: The cultural imprint (e.g. western vs. former communist society) seems to have a significant influence on patients' expectations and behaviour in the medical encounter. Health services providers need to be aware that health attitudes within the same health system might vary for historical and cultural reasons. The engagement of patients in medical decisions might not be susceptible to a 'one size fits all' approach; doctors should instead aim to accommodate the individual patient's desire for autonomy.

Prevention and management of chronic obstructive pulmonary disease (COPD) in primary care: position paper of the European Forum for Primary Care.

Chronic obstructive pulmonary disease (COPD) is a smoking-related, progressive lung disease that represents a substantial individual, societal and economic burden. Primary care professionals have an important role in healthcare provision for patients with COPD. In this position paper we summarise the current knowledge about, and management of patients with COPD. Next, we describe the role general practitioners and other primary care disciplines (should) have to prevent, diagnose and treat COPD. Finally, we explore differences in the way particular aspects of primary care COPD disease management are available or organised in a number of European countries, in order to identify barriers and provide examples of 'best practices' for optimal primary care management of patients with COPD.