[Physician Numbers and Employment in Bavaria: Trends in statistics of the Bavarian Medical Association and the Association of Statutory Health Insurance Physicians of Bavaria]. / Entwicklung der Ärzt*innenzahlen und Beschäftigungsverhältnisse in Bayern ­ Trends in den Ärzt*innenstatistiken der Bayerischen Landesärztekammer und der Kassenärztlichen Vereinigung Bayerns.

BACKGROUND: Although the number of places at medical schools and physicians in Germany has increased continuously over the past 25 years, there is a threat of a shortage of physicians. Based on data from the Bavarian Medical Association (BLÄK) and the Association of Statutory Health Insurance Physicians of Bavaria (KVB), an analysis of the number of physicians in Bavaria over a longer period of time was carried out in order to understand current developments and possible starting points for the future organization of medical care. The figures were analyzed with regard to the distribution of physicians by outpatient and inpatient sector as well as with regard to the development of the number of employees, the scope of employment and the gender distribution in the outpatient sector. METHODS: Data were taken from the annually published and systematically compiled numbers of physicians from the BLÄK (2000 to 2022) as well as the outpatient billing data of practicing and employed physicians in Bavaria (2010 to 2022), processed by the KVB. Descriptive analyses were performed. RESULTS: Since 2000, the number of physicians in Bavaria has risen by 83% in the inpatient setting and by 35% in the outpatient setting. As a result, more physicians have been working in hospitals than in outpatient care since 2010. In the outpatient setting the trend is moving away from establishing one's own practice and full-time work towards salaried and part-time employment. Employed physicians have lower average working hours than self-employed physicians. The proportion of women among physicians has steadily increased, with female physicians more likely to be employed and working part-time compared with male physicians. Nevertheless, part-time employment is also prominent among male physicians in some specialties today. CONCLUSION: The trend towards practicing in salaried and part-time positions continues unabated and is represented across all specialties, suggesting that more physicians are needed to maintain the number of working hours over time. In addition to incentives and subsidies, this reality must be taken into account when planning care. At the same time, it is questionable whether increasing medical school places without managing them according to need is the right way to address the shortage of physicians in outpatient care when an ever-increasing proportion of physicians is working in inpatient care.

Implementation of an internet-based asthma patient education program in primary care: results of a single-arm trial.

Asthma education programs (AEPs) for patients are known to be important to provide skills to effectively manage the disease. We developed an electronic AEP (eAEP) and assessed the extent to which patients with asthma in primary care are capable to use the eAEP and whether asthma knowledge improved after eAEP.A single-arm pilot study was performed between November 2019 and December 2020 in 12 general practices in Upper Bavaria, Germany. Asthma knowledge was assessed by the Asthma Knowledge Test (AKT) at baseline, 2 weeks after completion of the eAEP, as well as after 3 and 6 months. AKT sum scores at baseline and follow-up were compared with each other using the Wilcoxon test.In total, 72 patients with asthma were included, of whom all participated in the 2-week follow-up, while data on the 3- and 6-month follow-up was available in 62 and 51 patients, respectively. The eAEP was well accepted and positively evaluated by participants. The mean AKT score significantly (p < .001) increased from 22.8 ± 11.0 at baseline to 44.6 ± 8.3 two weeks after completion of the eAEP. After 3 months, the mean score was still 41.8 ± 7.6, and after 6 months it was 40.2 ± 9.3 (p < .001 each compared to baseline).The internet-based asthma education program was well accepted by primary care patients and resulted in a major increase of asthma knowledge. Thus, it has the potential to be an important adjunct in the treatment of patients with asthma in general practice.

Deconstructing depression by machine learning: the POKAL-PSY study.

Unipolar depression is a prevalent and disabling condition, often left untreated. In the outpatient setting, general practitioners fail to recognize depression in about 50% of cases mainly due to somatic comorbidities. Given the significant economic, social, and interpersonal impact of depression and its increasing prevalence, there is a need to improve its diagnosis and treatment in outpatient care. Various efforts have been made to isolate individual biological markers for depression to streamline diagnostic and therapeutic approaches. However, the intricate and dynamic interplay between neuroinflammation, metabolic abnormalities, and relevant neurobiological correlates of depression is not yet fully understood. To address this issue, we propose a naturalistic prospective study involving outpatients with unipolar depression, individuals without depression or comorbidities, and healthy controls. In addition to clinical assessments, cardiovascular parameters, metabolic factors, and inflammatory parameters are collected. For analysis we will use conventional statistics as well as machine learning algorithms. We aim to detect relevant participant subgroups by data-driven cluster algorithms and their impact on the subjects' long-term prognosis. The POKAL-PSY study is a subproject of the research network POKAL (Predictors and Clinical Outcomes in Depressive Disorders; GRK 2621).

[Effects of the Risk of Recourse Claims on the Work of General Practitioners and Orthopedists - A Nationwide Survey]. / Auswirkungen der Regressgefahr auf die Tätigkeit von Hausärzt*innen und Orthopäd*innen ­ Bundesweite Befragung.

OBJECTIVE: The aim of this study was to investigate the influence of the perceived risk of recourse claims and the extent of personal recourse experience among general practitioners (GPs) and orthopedists in private practice. METHODS: A four-page questionnaire on the effects and consequences of the threat of recourse or recourse actually experienced was sent to a nationwide random sample of 1000 GPs and 1000 orthopedists. RESULTS: The response rate was 41% for GPs and 39% for orthopedists; 47% of the participating GPs and 55% of the orthopedists stated that the risk of recourse was a heavy burden in everyday practice, 37/47% that it had a strong influence on their medical practice. 51/25% stated that they referred to a (different) specialist at least occasionally despite the indication of a prescription. 72% of GPs and 59% of orthopedists had recourse at least once, 36 and 19%, respectively more than 3 times. 18% of GPs and 26% of orthopedists had experienced recourse claims of more than € 5000. The emotional burden caused by the worst regress was perceived by 72 and 78%, respectively of those affected by recourse as severe or very severe. CONCLUSION: The risk of recourse can have a strong impact on the work of GPs and orthopedists in private practice. Recourse is often felt to be emotionally stressful and sometimes seen as inhibiting establishing a practice.

HPV vaccination leads to decrease of anogenital warts and precancerous lesions of the cervix uteri in young women with low vaccination rates: a retrospective cohort analysis.

BACKGROUND: Although the human papillomavirus (HPV) vaccine has been recommended in Germany for girls since 2007, no organised vaccination programme was introduced and HPV vaccine coverage remains low. We investigated the HPV vaccination rates from 2008 to 2018 and the effects of HPV vaccination on anogenital warts and precancerous lesions in young women in Bavaria, Germany, a state with low vaccination rates. METHODS: Retrospective analyses of claims data from the Bavarian Association of Statutory Health Insurance Physicians (KVB) on females born between 1990 and 2009 (9 to 28 years old in 2018) were conducted to calculate vaccination rates by birth cohort, proportion of vaccine types administered and incidence of anogenital warts and precancerous lesions of the cervix uteri. 942 841 Bavarian females 9 to 28 years old with available information on HPV vaccination were included to calculate vaccination rates. For the outcome analyses, data from 433 346 females 19 to 28 years old were analysed. Hazard ratios (HR) were computed from univariable and multivariable Cox regression models comparing vaccinated and unvaccinated women, considering type of vaccine used and contraceptive prescription. RESULTS: 40·9% of 18-year-olds and only 13·3% of 12-year-olds were fully vaccinated in 2018 in Bavaria. Gardasil® and Gardasil9® were most commonly administered. Vaccinated compared to unvaccinated women had a lower incidence of anogenital warts and cervical lesions, however only small differences were detected between fully and partially vaccinated women. Fully vaccinated women had a 63% (HR 0·37 (95% confidence interval (CI) 0·34 to 0·40) and 23% (HR 0·77, 95%CI 0·71 to 0·84) lower risk of anogenital warts and cervical lesions, respectively. Women who were prescribed contraceptives prior to vaccination had a 49% higher risk of developing anogenital warts (HR 1·49, 95%CI 1·25 to 1·79) or cervical lesions (HR 1·49, 95%CI 1·27 to 1·75) compared to vaccinated women without contraceptive prescription. CONCLUSIONS: The evaluation of the effects of HPV vaccination in Bavaria showed a promising decline of anogenital warts and precancerous lesions in vaccinated young women. However, an increase in vaccination rates is necessary to achieve a greater population impact in preventing HPV-related diseases.

Association of pregnancies with risk of multiple sclerosis.

BACKGROUND: Pregnancies have an impact on the disease course of multiple sclerosis (MS), but their relationship with MS risk is yet unclear. OBJECTIVE: To determine the relationships of pregnancies and gynecological diagnoses with MS risk. METHODS: In this retrospective case-control study, we assessed differences in gynecological International Classification of Diseases, 10th Revision (ICD-10) code recording rates between women with MS (n = 5720), Crohn's disease (n = 6280), or psoriasis (n = 40,555) and women without these autoimmune diseases (n = 26,729) in the 5 years before diagnosis. RESULTS: Twenty-eight ICD-10 codes were recorded less frequently for women with MS as compared to women without autoimmune disease, 18 of which are pregnancy-related. After adjustment for pregnancies, all codes unrelated to pregnancies were still negatively associated with MS. In a sensitivity analysis excluding women with evidence for possible demyelinating events before diagnosis, all associations were more pronounced. In comparison to women with psoriasis, most associations could be confirmed; that was not true in comparison to women with Crohn's disease. CONCLUSION: Our findings provide evidence for a possible protective effect of pregnancies on MS risk likely independent of or in addition to a previously suggested reversed causality. The negative associations of gynecological disorders with disease risk need further investigation. The associations might be shared by different autoimmune diseases.

Effectiveness of an online education program for asthma patients in general practice: study protocol for a cluster randomized controlled trial.

BACKGROUND: Asthma education programs (AEPs) have been shown to increase quality of life and reduce emergency treatments and hospital admissions. Despite the proven benefits, only a minority of asthma patients attend such programs. To increase the number of educated patients, an online education program (electronic AEP, eAEP) for asthma patients has been developed. The present study aims to investigate the effectiveness of the eAEP in terms of asthma knowledge, asthma control and emergency treatments in general practice settings. METHODS: This is a cluster randomized controlled trial including 100 patients with bronchial asthma from 20 general practices in Bavaria, Germany. General practices will be randomly assigned to either the intervention or control group. Patients in the intervention group will receive access to the eAEP and instructions to complete this program within two weeks. Patients in the control group will receive usual care including a referral to face-to-face AEP (fAEP) by a certified primary care physician or a pulmonologist according to guideline recommendations. Furthermore, patients of both the intervention and control groups will be invited to a follow-up consultation in their general practice after completion of the eAEP and fAEP (three weeks and twelve weeks after study inclusion, respectively) to discuss any open issues. Outcomes for both groups will be assessed at baseline (t0), after two weeks (t1), three months (t2) and six months (t3). The primary outcome is the comparison of asthma knowledge gain between intervention and control groups after completion of the eAEP (two weeks after study inclusion) and fAEP (twelve weeks after study inclusion), respectively. Secondary outcomes include asthma control, frequency of emergency treatments, patient autonomy as well as attitudes towards asthma medication. DISCUSSION: The results of the present trial will provide knowledge about the effectiveness of an online education program for asthma patients compared to usual care in primary care. TRIAL REGISTRATION: German Clinical Trials Register (DRKS), DRKS00028805 . Registered 22 April 2022.

Programs to encourage working as a general practitioner in rural areas: why do medical students not want to participate? A cross-sectional study.

BACKGROUND: In many countries, not enough students are interested to work as general practitioners in rural areas. To solve this problem, several, sometimes partly extracurricular, programs have been developed. Most of these programs are based on continuity, which means that students stay in a rural region for an extended period of time, by completing clerkships. Although the effects of these programs are positive, it is often difficult to motivate students to participate. The purpose of the present study is to get insight into the reasons why students choose not to participate in these programs. METHODS: We carried out a questionnaire study among medical students in the clinical phase of the Technical University of Munich in Germany. First, we asked the students whether they actively informed themselves about the program which aims to reduce the shortage of general practitioners in rural areas in Bavaria. Furthermore, the questionnaire focused on the reasons for not participating in this program. RESULTS: Based on the answers of 442 students from study years 3-6, the most frequently chosen reason for not participating in the program is "identification with another discipline" with 61.0%, directly followed by "not willing to commit long-term" (56.1%). In third place is "personal connections to another region" with 30.5%. In the open comments, we find the same reasons: many students do not want to commit to a certain direction too early. In addition, students indicate that the number of regions where this program is offered is too limited for them. CONCLUSIONS: Offering programs to prepare and motivate students for work as general practitioners in rural areas can contribute to increasing the pool of future general practitioners. To encourage students to participate in such a program, it is important to consider the motives of students. Many students who might be interested in general practice do not choose to take part in such a program because they do not want to commit to a particular specialty or region at an early stage. It is important to take these insights into account when designing and implementing these programs.

[The Development of General Practices in Ambulatory Care in the Last Decades - An Analysis of the Physicians' Registry of Bavaria]. / Entwicklung der hausärztlichen Versorgung innerhalb der letzten Jahrzehnte ­ eine Analyse des Basisdatensatzes der Kassenärztlichen Vereinigung Bayerns.

AIM OF THE STUDY: There is an increasing shortage of general practitioners (GPs) in Germany. An in-depth understanding of the variation regarding the characteristics of the GPs in the last decades might help to optimize primary health care. The aim of the analysis of the characteristic features of GPs as preserved by the registry of the Bavarian Association of Statutory Health Insurance of Physicians (KVB) was to delineate the time interval between passing the medical state examination and establishment of one's own private practice, the development of group practices and employments, and the number of additional qualifications. METHODS: The physicians' registry of the KVB was used to analyse the time intervals, additional qualifications, and development of group practices and employments. Data were analysed descriptively. RESULTS: The time interval from passing the medical state examination and establishing one's own private practice increased remarkably since the 70s from 5 years to 12 years on average. There was an increasing trend towards group practices. The number of newly established practices remained constant around 200 practices per year. Beyond that, there was an increasing trend towards employment in practices. The number of additional qualifications decreased over time, which was in particular true of complementary medicine and sports medicine. CONCLUSIONS: The period of vocational traineeship should be organised efficiently to decrease the length of training. Young GPs should be motivated and receive incentives to establish their own private practice. However, it is also necessary to facilitate employment in the practices.

[Experiences with Regional Medical Coordinators in Ambulatory Care in the Early COVID-19 Phase 2020 in Bavaria: Survey of Regional Ambulatory Coordinators and General Practitioners]. / Erfahrungen mit Versorgungsärzt*innen in der frühen COVID-19-Phase 2020 in Bayern ­ Befragung von Versorgungs- und Hausärzt*innen.

BACKGROUND: During the state of emergency in Bavaria in the early Corona phase 2020, some physicians in ambulatory care were appointed as regional medical coordinators (RMCs). The aim of the present study was to evaluate this newly introduced but temporary position. METHODS: In November 2020, a paper-based questionnaire was sent out to all 85 RMCs who could be identified through an internet research and to all 197 teaching practices of the Institute of General Practice and Health Services Research at the Technical University of Munich. The data analysis was descriptive and anonymised. RESULTS: Overall, 75 (88%) RMCs and 156 (79%) general practitioners (GPs) were included. 97% of the RMCs and 67% of the GPs assessed the introduction of RMCs in ambulatory care as reasonable, but also as an intervention concerning the self-administration of physicians (RMCs: 59% and GPs: 42%). 37% of the GPs stated that RMCs should be avoided as far as possible in future pandemic situations. Overall, GPs with more intensive contact to an RMC showed higher levels of agreement. Both groups rated the collaboration and communication strategies of politics, authorities and the Bavarian Association of Statutory Health Insurance Physicians as difficult and often contradictory. However, most of the RMCs assessed the cooperation with politics and authorities at the local level as positive. The lack of medical protective equipment at the beginning of the pandemic was judged critically by both groups of the respondents. CONCLUSIONS: The establishment of RMCs in the early Corona phase 2020 in Bavaria was considered sensible by almost all RMCs and the majority of the surveyed GPs. For the future, it seems necessary to involve primary care physicians more intensively and permanently in decision-making processes and to strengthen existing structures.

Prediction of lung emphysema in COPD by spirometry and clinical symptoms: results from COSYCONET.

BACKGROUND: Lung emphysema is an important phenotype of chronic obstructive pulmonary disease (COPD), and CT scanning is strongly recommended to establish the diagnosis. This study aimed to identify criteria by which physicians with limited technical resources can improve the diagnosis of emphysema. METHODS: We studied 436 COPD patients with prospective CT scans from the COSYCONET cohort. All items of the COPD Assessment Test (CAT) and the St George's Respiratory Questionnaire (SGRQ), the modified Medical Research Council (mMRC) scale, as well as data from spirometry and CO diffusing capacity, were used to construct binary decision trees. The importance of parameters was checked by the Random Forest and AdaBoost machine learning algorithms. RESULTS: When relying on questionnaires only, items CAT 1 & 7 and SGRQ 8 & 12 sub-item 3 were most important for the emphysema- versus airway-dominated phenotype, and among the spirometric measures FEV1/FVC. The combination of CAT item 1 (≤ 2) with mMRC (> 1) and FEV1/FVC, could raise the odds for emphysema by factor 7.7. About 50% of patients showed combinations of values that did not markedly alter the likelihood for the phenotypes, and these could be easily identified in the trees. Inclusion of CO diffusing capacity revealed the transfer coefficient as dominant measure. The results of machine learning were consistent with those of the single trees. CONCLUSIONS: Selected items (cough, sleep, breathlessness, chest condition, slow walking) from comprehensive COPD questionnaires in combination with FEV1/FVC could raise or lower the likelihood for lung emphysema in patients with COPD. The simple, parsimonious approach proposed by us might help if diagnostic resources regarding respiratory diseases are limited. Trial registration ClinicalTrials.gov, Identifier: NCT01245933, registered 18 November 2010, https://clinicaltrials.gov/ct2/show/record/NCT01245933 .

COVID-19 vaccine hesitancy in people with migratory backgrounds: a cross-sectional study among Turkish- and German-speaking citizens in Munich.

BACKGROUND: This study aimed to investigate the knowledge, attitudes, behaviors, and COVID-19 vaccine hesitancy of people with migratory backgrounds among Turkish- and German-speaking patients in Munich. METHODS: Primary outcomes were the intention to get vaccinated for COVID-19 and COVID-19 knowledge levels (25 true/false items). Other variables included demographics, attitudes to COVID-19 and vaccination (7 items), and behaviors regarding COVID-19 (7 items). The attitude and behavior questions had 5-point Likert scales. Of the 10 Turkish-speaking family physicians in Munich, six agreed to administer Turkish or German questionnaires to consecutive patients in February 2021. Furthermore, participants with either citizenship, country of origin, native language, or place of birth being non-German were categorized as "Having a migratory background." Data from 420 respondents were analyzed. RESULTS: Women constituted 41.4% (n = 174), the mean age was 42.2 ± 15.5 years, 245 (58.3%) preferred the Turkish questionnaire, 348 (82.9%) had a migratory background, and 197 (47.9%) intended to be vaccinated. The mean knowledge, attitude, and behavioral scores were 21.5 ± 3.2 (max = 25), 3.7 ± 0.8 (max = 5), and 4.0 ± 0.5 (max = 5). While 42.3% (n = 145) of the participants with a migratory background considered getting vaccinated, this proportion was 76.5% (n = 52) for non-immigrant Germans (Chi-square = 26.818, p < 0.001). Non-migratory background (odds ratio (OR): 3.082), high attitude scores (OR: 2.877), male sex (OR: 2.185), years of schooling (OR: 1.064), and age (OR: 1.022) were positively associated with vaccination intention. CONCLUSIONS: We suggest initiating or supporting projects run by persons or groups with immigrant backgrounds to attempt to elaborate and change their vaccination attitudes.

Health literacy and eHealth among adult asthma patients - results of a cross sectional survey.

Background: To investigate HL (health literacy) and eHealth literacy (eHL) among two groups of asthma outpatients, those with prior asthma education and those without. In addition, we aimed to compare two shortened versions of a HL measure instrument.Methods: A cross-sectional survey was conducted with a sample of adult asthma patients (n = 129). Half of them had received asthma patient education prior to the study (n = 64). The study collected demographic data, questions on HL (HLS-EU-Q16) and eHL (eHEALS).Results: In the main analysis respondents' mean HL values were almost identical in both groups, 11.9 (SD = 3.1) among trained and 11.8 (SD = 3.5) among untrained patients, demonstrating a problematic level of HL, according to the instrument. In the subdivision of sum scores, the HL level of trained patients was categorized more often as problematic (43%) than among untrained patients (20%). Bland-Altman plots of the 6-item and 16-item versions of the HLS-EU suggest only limited agreement between the versions. In terms of eHL, trained patients showed a mean of 3.0 (SD = 1.1) and untrained patients a mean of 3.2 (SD = 1.0). Analysis of HL and eHL showed no difference between groups.Conclusions: No consistent differences between groups were found, suggesting that trained patients did not benefit from asthma education regarding HL and eHL. The 6-item and 16-item versions of the HLS-EU were not easily interchangeable, limiting its use in a busy outpatient practice.AbbreviationseHEALSElectronic Health Literacy ScaleeHLElectronic Health Literacy HLS-EUEuropean Health Literacy Survey.

The "General practitioner learning stations"-development, implementation and optimization of an innovative format for sustainable teaching in general practice.

BACKGROUND: Teaching general practice in a university setting is still challenging. In our department we have developed a teaching format with content from a previous lecture-style-teaching into an interactive small group format taught by frontline general practitioners (GPs). The "GP learning stations" introduce students to the skills and attributes of a GP working in primary care in a university setting. Our main objective was to understand whether the teaching format had proven itself sustainable in a university setting over eight years. Furthermore, we wanted to better understand the role of the GP as a medical educator. METHODS: More than eight years of experience in organizational and staff expenses were collected and analyzed. In addition, the grade point average of the students' evaluation was calculated and their free text answers were categorized and evaluated descriptively. During two teach-the-teacher seminars attending GPs were asked why they teach and if they feel equipped to teach the format. RESULTS: The initially high organizational and staff expenses were significantly reduced. The recruitment of GPs, their didactic contribution, and their joint creation of content went smoothly throughout the whole period. A total of 495 students participated in the regular evaluation. The analysis yielded a grade point average of 1.9, on a scale from 1 = very good to 6 = insufficient. In the free text answers students praised the educators, the format and the practical relevance. The interactive transfer of the content, the didactic competence of the educators and the spatial environment were viewed critically. Reasons for GPs to teach were the joy to pass on knowledge and experience, and to make the work of GPs more attractive to students. Most GPs felt prepared to teach through their experience as a physician although some felt unprepared to teach through their lack of didactic knowledge. CONCLUSION: Despite reducing the costs of the format, a grade point average of 1.9 could be achieved in the long term. This supports the teaching concept of learning stations and its "mixture of discussion, scientific background and role play, combined with (…) experiences and exciting individual cases from (GPs) everyday life", hopefully making general practice more attractive to the students.

Correspondence between Capnovolumetric and Conventional Lung Function Parameters in the Diagnosis of Obstructive Airway Diseases.

BACKGROUND: Capnovolumetry is of interest as a method for the diagnosis of obstructive airway diseases, requiring little cooperation from the patient. OBJECTIVE: To help in the interpretation of capnovolumetric parameters, we aimed to identify their correspondence to conventional lung function indices. METHODS: We studied 978 patients from a diagnostic study with complete functional data and the clinical diagnosis of asthma, chronic obstructive pulmonary disease (COPD), or no respiratory disease. Using path analysis, four capnovolumetric parameters (slope of expiratory phase 3, ratio of slopes of phases 3 and 2, volume of phase 2, and the ratio area/volume of phase 3) previously identified as predictors of airway obstruction in terms of spirometry and body ple-thysmography, were analyzed regarding their relationship to each other and the diagnostic categories of asthma or COPD versus control, or obstruction versus no obstruction. We then identified four lung function parameters showing relationships as much as possible isomorphic to those between capnovolumetric parameters. RESULTS: The four capnovolumetric parameters were related to COPD and obstruction via both direct and indirect influences, but only two of them to asthma. Regarding the correspondence to lung function parameters, the slope of expiratory phase 3 corresponded best to the ratio of residual volume to total lung capacity, the ratio of slopes of phases 3 and 2 to forced expiratory volume in 1 s, the volume of phase 2 to forced expired flow at 50% of vital capacity, and the ratio area/volume of phase 3 to forced vital capacity. CONCLUSIONS: Our results indicated an intricate relationship of capnovolumetric parameters to each other and to airway obstruction, asthma, or COPD. The correspondence to conventional lung function measures seemed to reflect the entities lung hyperinflation, overall ventilatory impairment, bronchoconstriction, and ventilated lung volume, in that order. These findings might be helpful for clinicians in the interpretation of capnovolumetry.

Diagnostic accuracy of capnovolumetry for the identification of airway obstruction - results of a diagnostic study in ambulatory care.

BACKGROUND: One of the known weaknesses of spirometry is its dependence on patients' cooperation, which can only partially be alleviated by educational efforts. Therefore, procedures less dependent on cooperation might be of value in clinical practice. We investigated the diagnostic accuracy of ultrasound-based capnovolumetry for the identification of airway obstruction. METHODS: Consecutive patients from a pulmonary outpatient clinic were included in the diagnostic study. As reference standard, the presence of airway obstruction was evaluated via spirometry and bodyplethysmography. Capnovolumetry was performed as index test with an ultrasound spirometer providing a surrogate measure of exhaled carbon dioxide. Receiver operating characteristic (ROC) analysis was performed using the ratio of slopes of expiratory phases 3 and 2 (s3/s2) ≥ 0.10 as primary capnovolumetric parameter for the recognition of airway obstruction. Logistic regression was performed as secondary analysis to identify further useful capnovolumetric parameters. The diagnostic potential of capnovolumetry to identify more severe degrees of airway obstruction was evaluated additionally. RESULTS: Of 1400 patients recruited, 1287 patients were included into the analysis. Airway obstruction was present in 29% of patients. The area under the ROC-curve (AUC) of s3/s2 was 0.678 (95% CI 0.645, 0.710); sensitivity of s3/s2 ≥ 0.10 was 47.7 (95% CI 42.7, 52.8)%, specificity 79.0 (95% CI 76.3, 81.6)%. When combining this parameter with three other parameters derived from regression analysis (ratio area/volume phase 3, slope phase 3, volume phase 2), an AUC of 0.772 (95% CI 0.743, 0.801) was obtained. For severe airway obstruction (FEV1 ≤ 50% predicted) sensitivity of s3/s2 ≥ 0.10 was 75.9 (95% CI 67.1, 83.0)%, specificity 75.8 (95% CI 73.3, 78.1)%; for very severe airway obstruction (FEV1 ≤ 30% predicted) sensitivity was 86.7 (95% CI 70.3, 94.7)%, specificity 72.8 (95% CI 70.3, 75.2)%. Sensitivities increased and specificities decreased considerably when the combined capnovolumetric score was used as index test. CONCLUSIONS: Capnovolumetry by way of an ultrasound spirometer had a statistically significant albeit moderate potential for the recognition of airway obstruction in a heterogeneous population of patients typically found in clinical practice. Diagnostic accuracy of the capnovolumetric device increased with the severity of airway obstruction. TRIAL REGISTRATION: The study is registered under DRKS00013935 at German Clinical Trials Register (DRKS).

Participation factors for asthma education programs - a cross sectional survey.

BACKGROUND: Although the impact of asthma education on important outcomes (e.g. emergency visits) has been well established, only an estimated quarter of asthma patients in Germany have received patient education yet. The aim of the study was to identify patient factors that could increase participation in asthma education programs. METHODS: This cross-sectional study investigated participation factors and differences between trained (n = 64) and untrained (n = 65) asthma patients from a large outpatient center in Germany. The survey included answers to asthma-related questions and open questions on patient education as well as such about knowledge of health literacy and eHealth. RESULTS: Mean age of participants was 55 ± 19 years and 61% were female. Trained patients were more likely to participate in disease management programs (odds ratio (OR) 6.85; 95%CI 2.17-21.59), were more frequently non-smokers (OR 0.07; 95%CI 0.01-0.85) and more often had an asthma action plan (OR 20.2; 1.55-263.41). Open questions' analysis of untrained asthma patients revealed that patients felt they were not adequately informed about asthma education (37%). About one-third of all patients (27%) showed openness to online asthma education. Analysis of HL and eHealth showed no difference between the groups. CONCLUSION: Untrained asthma patients should be informed even more intensively by their physicians about the importance and value of asthma education. Asthma education does not seem to benefit patients' health literacy. Online asthma education is of interest to approximately one-third of asthma patients. This should be motivation to develop and implement online asthma education concepts.

On the edges of medicine - a qualitative study on the function of complementary, alternative, and non-specific therapies in handling therapeutically indeterminate situations.

BACKGROUND: In routine practice, general practitioners (GPs) see many patients for whom treatment might not be necessary, or evidence-based treatments are not available, yet often a treatment is prescribed. We denote such situations as therapeutically indeterminate. We aimed to investigate 1) whether therapeutically indeterminate situations play a role in the accounts of GPs in their practical work; 2) the role of complementary and alternative medicine (CAM) modalities or non-specific therapies, and of other strategies used in handling therapeutically indeterminate situations; and 3) factors associated with preferences for specific strategies. METHODS: We performed semi-structured, individual face-to-face interviews with 20 purposively sampled, experienced GPs from Bavaria, Germany. A grounded theory approach was used for data analysis. RESULTS: Participants reported that therapeutically indeterminate situations recur often in their daily practice. Professionally legitimate strategies such as empathetic consultations without providing a treatment intervention did not seem to suffice for coping with all of these situations. CAM treatments were used frequently, but motives varied. While some participants were convinced that these treatments were active and effective, others were uncertain or had doubts and used them as a relational tool, as a non-specific treatment or as a beneficial placebo. Conventional drugs were also used in a non-specific manner or despite doubts regarding the risk-benefit ratio. The extent to which GPs felt responsible for offering solutions in therapeutically indeterminate situations seemed to influence their preference for specific strategies. CONCLUSION: Our results demonstrate the important role of CAM and the somewhat smaller role of non-specific therapies for German general practitioners in dealing with therapeutically indeterminate situations. The concept of therapeutically indeterminate situations may be helpful in better understanding why many general practitioners treat patients in situations where treatment does not appear to be clearly indicated.

[Health Information Behavior of the South Tyrolean Population: An Epidemiological Cross-Sectional Study]. / Informationsverhalten der Südtiroler Bevölkerung zu Gesundheitsfragen ­ eine epidemiologische Querschnittsstudie.

OBJECTIVES: Investigation of the health information behavior, self-rated health, confidence in health issues and specific attitudes to health among the South Tyrolean population. METHODS: Our study is an epidemiological cross-sectional study; data were collected via telephone interviews, using a questionnaire developed for this purpose that covered various aspects of information and health-related behavior. For the elaboration of the typology of the most distinctive stereotypes in terms of health information and health-related behavior, a hierarchical cluster analysis was performed. RESULTS: We assessed 504 correct telephone interviews. The majority of the respondents considered themselves health-conscious and preferred heterogeneous information media. The most used information media for health issues were mass media, i. e. newspapers or magazines and television or radio. The internet was used less as a source of information. Younger individuals assessed themselves to be healthier than older people, and older women aged 65 years or more were the most health-impaired group. Respondents had greatest confidence in their general practitioner, their own feeling or experience. Thus, in terms of health information and health behavior, the following four classes of people could be distinguished, namely "internet information elite", "robust fatalists", "stricken" and "health-conscious mainstreamers". CONCLUSION: Our results show that the South Tyrolean population has a high level of health consciousness and gathers health information from various media. The characterization of different patient typologies of information processing in combination with health-related behavior indicates that information about health and illness should be appropriately addressed to the respective stereotype.

Incidence of irritable bowel syndrome and chronic fatigue following GI infection: a population-level study using routinely collected claims data.

OBJECTIVES: To investigate the occurrence of postinfectious IBS in routine outpatient care, comparing different types of GI infection and its interaction with psychosomatic comorbidity. DESIGN: Retrospective cohort study using routinely collected claims data covering statutorily insured patients in Bavaria, Germany. Cases were defined as patients without prior record of functional intestinal disorder with a first-time diagnosis of GI infection between January 2005 and December 2013 and classed according to the type of infection. Each case was matched by age, sex and district of residence to a patient without history of GI infection. Prior psychological disorder (depression, anxiety or stress reaction disorder) was assessed in the 2 years prior to inclusion. Proportional hazards regression models were used to estimate the HRs for GI infection and psychological disorder. Chronic fatigue syndrome (CFS) was assessed as a comparator outcome. RESULTS: A total of 508 278 patients with first diagnosis of GI infection were identified, resulting in a matched cohort of 1 016 556 patients. All infection types were associated with an increased risk of IBS (HR: 2.19-4.25) and CFS (HR 1.35-1.82). Prior psychological disorder was a distinct risk factor for IBS (HR: 1.73) and CFS (HR: 2.08). Female sex was a further risk factor for both conditions. CONCLUSION: Psychological disorder and GI infections are distinct risk factors for IBS. The high incidence of non-specific GI infection suggests that postinfectious IBS is a common clinical occurrence in primary care. Chronic fatigue is a further significant sequela of GI infection.