Satisfaction with general practice care in German patients with multimorbidity: a cross-sectional study.

Background: Little is known about the quality of general practice care received by patients suffering from multimorbidity. Objectives: To assess how patients with multimorbidity evaluate their General Practitioners (GPs') performance and to identify factors associated with high patient satisfaction levels. Methods: Cross-sectional study in Germany using the EUROPEP questionnaire consisting of 23 items with a five-point Likert scale and covering two dimensions: clinical performance of the GP and organisation of care. Mixed logistic regression was used in the analysis, with the EUROPEP score as a dependent variable. Results: The study included 651 patients (54.8% female), with a mean age of 73.7 ± 4.9 years. Of 22 of 23 questionnaire items, >80% of patients rated their satisfaction as 'good' or 'excellent'. The highest level of satisfaction (excellent) varied among items between 28.0 and 73.1%. Lower age and female sex of GPs were associated with better patient evaluations in 15 and 12 of the 23 items, respectively. Patient characteristics were not associated with their satisfaction with their GP. Conclusions: This study found high levels of satisfaction with primary care in patients with multimorbidity. However, since high levels of patient satisfaction are not necessarily equivalent to high quality of care, a broader view is necessary to integrate the subjective views of patients and objective quality indicators into a comprehensive concept of good quality of care.

Activating GENeral practitioners dialogue with patients on their Agenda (MultiCare AGENDA) study protocol for a cluster randomized controlled trial.

BACKGROUND: This study investigates the efficacy of a complex multifaceted intervention aiming at increasing the quality of care of GPs for patients with multimorbidity. In its core, the intervention aims at enhancing the doctor-patient-dialogue and identifying the patient's agenda and needs. Also, a medication check is embedded. Our primary hypothesis is that a more patient-centred communication will reduce the number of active pharmaceuticals taken without impairing the patients' quality of life. Secondary hypotheses include a better knowledge of GPs about their patients' medication, a higher patient satisfaction and a more effective and/or efficient health care utilization. METHODS/DESIGN: Multi-center, parallel group, cluster randomized controlled clinical trial in GP surgeries. INCLUSION CRITERIA: Patients aged 65-84 years with at least 3 chronic conditions. INTERVENTION: GPs allocated to this group will receive a multifaceted educational intervention on performing a narrative doctor-patient dialogue reflecting treatment targets and priorities of the patient and on performing a narrative patient-centred medication review. During the one year intervention GPs will have a total of three conversations à 30 minutes with the enrolled patients. CONTROL: Care as usual. Follow-up per patient: 14 months after baseline interview. Primary efficacy endpoints: Differences in medication intake and health related quality of life between baseline and follow-up in the intervention compared to the control group. Randomization: Computer-generated by an independent institute. It will be performed successively when patient recruitment in the respective surgery is finished. Blinding: Participants (GPs and patients) will not be blinded to their assignment but will be unaware of the study hypotheses or outcome measures. DISCUSSION: There is growing evidence that the phenomenon of polypharmacy and low quality of drug use is substantially due to mis-communication (or non-communication) in the doctor patient interaction. We assume that the number of pharmaceutical agents taken can be reduced by a communicational intervention and that this will not impair the patients' health-related quality of life. Improving communication is a core issue of future interventions, especially for patients with multimorbidity. TRIAL REGISTRATION: Current CONTROLled Trials ISRCTN46272088.

A complex regional intervention to implement advance care planning in one town's nursing homes: Protocol of a controlled inter-regional study.

BACKGROUND: Advance Care Planning (ACP) is an emerging strategy to ensure that well-reflected, meaningful and clearly documented treatment preferences are available and respected when critical decisions about life-sustaining treatment need to be made for patients unable to consent. In Germany, recent legislation confirms that advance directives (AD) have to be followed if they apply to the medical situation, but implementation of ACP has not yet been described. METHODS/DESIGN: In a longitudinal controlled study, we compare 1 intervention region (4 nursing homes [n/hs], altogether 421 residents) with 2 control regions (10 n/hs, altogether 985 residents). Inclusion went from 01.02.09 to 30.06.09, observation lasted until 30.06.10. Primary endpoint is the prevalence of ADs at follow-up, 17 (12) months after the first (last) possible inclusion. Secondary endpoints compare relevance and validity of ADs, process quality, the rate of life-sustaining interventions and, in deceased residents, location of death and intensity of treatment before death. The regional multifaceted intervention on the basis of the US program Respecting Choices® comprises training of n/h staff as facilitators, training of General Practitioners, education of hospital and ambulance staff, and development of eligible tools, including Physician Orders for Life-Sustaining Treatment in case of Emergency (POLST-E). Participation data: Of 1406 residents reported to live in the 14 n/hs plus an estimated turnover of 176 residents until the last possible inclusion date, 645 (41%) were willing to participate. Response rates were 38% in the intervention region and 42% in the control region. Non-responder analysis shows an equal distribution of sex and age but a bias towards dependency on nursing care in the responder group. Outcome analysis of this study will become available in the course of 2011. DISCUSSION: Implementing an ACP program for the n/hs and related health care providers of a region requires a complex community intervention with the effect of nothing less than a cultural shift in this health care sector. This study is to our knowledge the first to develop a strategy for regional implementation of ACP, and to evaluate its feasibility in a controlled design.

Narrative medicine-based intervention in primary care to reduce polypharmacy: results from the cluster-randomised controlled trial MultiCare AGENDA.

OBJECTIVES: To determine if patient-centred communication leads to a reduction of the number of medications taken without reducing health-related quality of life. DESIGN: Two-arm cluster-randomised controlled trial. SETTING: 55 primary care practices in Hamburg, Düsseldorf and Rostock, Germany. PARTICIPANTS: 604 patients 65 to 84 years of age with at least three chronic conditions. INTERVENTIONS: Within the 12-month intervention, general practitioners (GPs) had three 30 min talks with each of their patients in addition to routine consultations. The first talk aimed at identifying treatment targets and priorities of the patient. During the second talk, the medication taken by the patient was discussed based on a 'brown bag' review of all the medications the patient had at home. The third talk served to discuss goal attainment and future treatment targets. GPs in the control group performed care as usual. PRIMARY OUTCOME MEASURES: We assumed that the number of medications taken by the patient would be reduced by 1.5 substances in the intervention group and that the change in the intervention group's health-related quality of life would not be statistically significantly inferior to the control group. RESULTS: The patients took a mean of 7.0±3.5 medications at baseline and 6.8±3.5 medications at follow-up. There was no difference between treatment and control group in the change of the number of medications taken (0.43; 95% CI -0.07 to 0.93; P=0.094) and no difference in health-related quality of life (0.03; -0.02 to 0.08; P=0.207). The likelihood of receiving a new prescription for analgesics was twice as high in the intervention group compared with the control group (risk ratio, 2.043; P=0.019), but the days spent in hospital were reduced by the intervention (-3.07; -5.25 to -0.89; P=0.006). CONCLUSIONS: Intensifying the doctor-patient dialogue and discussing the patient's agenda and personal needs did not lead to a reduction of medication intake and did not alter health-related quality of life. TRIAL REGISTRATION NUMBER: ISRCTN46272088; Pre-results.

Implementing an advance care planning program in German nursing homes: results of an inter-regionally controlled intervention trial.

BACKGROUND: Advance Care Planning (ACP) is a systematic approach to ensure that effective advance directives (ADs) are developed and respected. We studied the effects of implementing a regional ACP program in Germany. METHODS: In a prospective, inter-regionally controlled trial focusing on nursing homes (n/hs), we compared the number, relevance and validity of new ADs completed in the intervention region versus the control region. Intervention n/h residents and their families were offered professional facilitation including standardized documentation. RESULTS: Data from 136 residents of three intervention n/hs were compared with data from 439 residents of 10 control n/hs over a study period of 16.5 months. In the intervention region, 49 (36.0%) participating residents completed a new AD over the period of the study, compared to 18 (4.1%) in the control region; these ADs included 30 ADs by proxy in the intervention region versus 10 in the control region. Proxies were designated in 94.7% versus 50.0% of cases, the AD was signed by a physician in 93.9% versus 16.7%, and an emergency order was included in 98.0% versus 44.4%. Resuscitation status was addressed in 95.9% versus 38.9% of cases (p<0.01 for all of the differences mentioned above). In the intervention region, new ADs were preceded by an average of 2.5 facilitated conversations (range, 2­5) with a mean total duration of 100 minutes (range, 60­240 minutes). CONCLUSION: The implementation of an ACP program in German nursing homes led, much more frequently than previously reported, to the creation of advance directives with potential relevance to medical decision-making. Future research should assess the effect of such programs on clinical and structural outcomes.