Core values of employed general practitioners in Germany - a qualitative study.

BACKGROUND: "Core values" help to guide practice of health care delivery. The core values of general practice are described in the European definition of general practice by WONCA, e.g. a holistic, comprehensive and continuous care. They may be associated with the idea that the general practitioner is the owner of the practice rather than an employee. OBJECTIVES: The objective was to examine the core values of employed GPs in their professional setting and their practical manifestation. METHODS: From April to May 2021, we conducted 17 semi-structured telephone-interviews with employed GPs in two districts in Baden-Wuerttemberg, Germany. The data were analysed using qualitative content analysis. RESULTS: We identified twelve core values, including values relevant to patient care and values relevant to the lives of employed GPs. Values with high relevance were job satisfaction, the professional distance from patients, collaboration and collegial exchange, comprehensive care, adequate consultation time and availability to patients. Values with heterogeneous relevance were continuity of care, waiting times and medical autonomy. The value "availability" of employed GPs to patients was associated with both patient care and personal life. The limited availability of employed GPs was accompanied by tensions between these two trends and other values. CONCLUSION: The values of employed GPs are partly consistent with the current WONCA definition of general practice. There were also indications of new values. The increase in the proportion of employed GPs implies a need to reflect on the core values of general practice, taking into account factors on the part of employed GPs, patients, and practice organisation.

[Integrated Care for Patients with Somatic Symptom Disorder in Primary Care - A Qualitative Participatory Evaluation of a Randomised Feasibility Trial]. / Integrierte Behandlung von Patient*innen mit somatischer Belastungsstörung in Hausarztpraxen ­ Eine qualitative, patient*innenbeteiligende Evaluation einer randomisierten Machbarkeitsstudie.

OBJECTIVE: The VISION intervention is a manualized short-term treatment for people with somatic symptom disorder, integrated into the primary care and delivered by psychotherapists via video consultations. As an innovative technology-based approach, the intervention was most recently piloted in a randomized feasibility trial. During the qualitative accompanying study presented here, the intervention was evaluated and optimised from the user perspective of patients who participated in the feasibility study. METHODS: We interviewed a total of N=10 patients included in the intervention group in three semi structured focus group discussions focusing on how they (1) assess the intervention in terms of acceptance and individual benefit and (2) which adjustments are necessary from the user perspective for further optimization of the intervention. We performed a qualitative content analysis using MAXQDA Plus 2022. RESULTS: Respondents reported initial reservations on their part regarding care via video consultation. After a brief period of habituation, the intervention was universally accepted. Main suggestions for improvement included a stronger focus on supporting patients find follow-up psychotherapy (if indicated) more flexible settings (e. g., location of video consultation), and a stronger integration of treatment into primary care. DISCUSSION AND CONCLUSION: The study provides systematically elaborated comprehensive findings on participants' practical experiences with the intervention. The model is appropriate for treating people with somatic symptom disorder. Before implementation, important suggestions for improvement should be thoroughly considered with continued patient and public involvement.

Protocol for the process evaluation of a counselling intervention designed to educate cancer patients on complementary and integrative health care and promote interprofessional collaboration in this area (the CCC-Integrativ study).

BACKGROUND: Conducting a process evaluation is essential to understand how health interventions work in different healthcare settings. Particularly in the case of complex interventions, it is important to find out whether the intervention could be carried out as planned and which factors had a beneficial or hindering effect on its implementation. The aim of this study is to present the detailed protocol of the process evaluation embedded in the controlled implementation study CCC-Integrativ aiming to implement an interprofessional counselling program for cancer patients on complementary and integrative health care (CIH). METHODS: This mixed methods study will draw upon the "Consolidated Framework for Implementation Research" (CFIR) combined with the concept of "intervention fidelity" to evaluate the quality of the interprofessional counselling sessions, to explore the perspective of the directly and indirectly involved healthcare staff, as well as to analyze the perceptions and experiences of the patients. The qualitative evaluation phase consists of analyzing audio-recorded counselling sessions, as well as individual and group interviews with the involved persons. The quantitative evaluation phase applies questionnaires which are distributed before (T0), at the beginning (T1), in the middle (T2) and at the end (T3) of the intervention delivery. DISCUSSION: This protocol provides an example of how a process evaluation can be conducted parallel to a main study investigating and implementing a complex intervention. The results of this mixed methods research will make it possible to identify strengths and weaknesses of the team-based intervention, and to target more specifically the key factors and structures required to implement healthcare structures to meet patients' unmet needs in the context of CIH. To our knowledge, this study is the first applying the CFIR framework in the context of interprofessional CIH counselling, and its results are expected to provide comprehensive and multidisciplinary management of cancer patients with complex supportive healthcare needs.

[Quo vadis 116117? Nationwide Overview of the Status Quo and Current Changes]. / Quo vadis 116117? Bundesweiter Überblick über den Status quo und aktuelle Veränderungen.

BACKGROUND: The on-call service (emergency service) has been reachable under 116117 in Germany since 2012. Nevertheless, this number is almost unknown to most Germans. A literature review of emergency service has shown that information which can be found is often incomplete and unclear. Thus, the aim of this study was to cover the status quo regarding 116117 at the federal level in Germany. METHODS: In February 2019 all physicians working with a statutory health insurance were asked to fill in an online survey. The survey was based on a literature review regarding emergency service and on-call service at the federal level in Germany. The questionnaire covered different areas. In this paper only results regarding 116117 will be reported. Data were analyzed descriptively. RESULTS: The organization and range of services as well as the qualifications of the staff are structured differently at the federal level. Services provided by 116117 are arrangements for home visits, out-of-hours service appointments, consulting, and forwarding to 112. Staff includes physician assistants, nurses, and physicians. CONCLUSION: Standardized regulations at the federal level might improve transparency. The planned extension of 116117 to include a standardized initial medical assessment as well as 24/7 accessibility could facilitate patient access to adequate medical treatment.

[Psychotherapeutic Video Consultations in Primary Care - Concept of the PROVIDE Intervention and Results on the Intent to Adopt in Psychotherapists]. / Videokonsultationen durch Psychotherapeuten in der Hausarztpraxis.

Mental health conditions represent a significant burden to the individual as well as the society. Within the health care system, the general practitioner is the first and, in most cases, the only provider. Timely referral of patients to specialized care is often difficult due to several barriers, particularly in rural areas. These barriers comprise long waiting times, the rising prevalence of psychosomatic and somatopsychic comorbidity, immobility in the elderly and stigmatisation related to mental health conditions. Following the Integrated Health Care approach, diagnosis and therapy of mental health conditions by psychotherapists directly within the general practice constitute an effective care model. We present a care model that is based on a telemental treatment approach for depression and anxiety disorders. Central is the piloting of psychotherapeutic video consultations in the general practice. The following article provides an overview of the care model and provides results concerning the intent to adopt the model in office-based psychotherapists.

Novel oral anticoagulants in primary care in patients with atrial fibrillation: a cross-sectional comparison before and after their introduction.

BACKGROUND: Novel oral anticoagulation (NOAC) has been introduced in recent years, but data on use in atrial fibrillation (AF) in primary care setting is scarce. In Germany, General Practitioners are free to choose type of oral anticoagulation (OAC) in AF. Our aim was to explore changes in prescription-rates of OAC in German primary care before and after introduction of NOAC on the market. METHODS: Data of a representative morbidity registration project in primary care in Germany (CONTENT) were analysed. Patients with AF in 2011 or 2014 were included (before and after broad market authorization of NOAC, respectively). We defined three independent groups: patients from 2011 without follow-up (group A), patients from 2014 but without previous record in 2011 (group B) and patients with AF and records in 2011 and 2014 (group C). RESULTS: 2642 patients were included. Group A (n = 804) and B (n = 755) were comparable regarding patient characteristics. 87.3% of group A and 84.8% of group B had CHA2DS2-VASc-Score ≥ 2, indicating a need for oral anticoagulation (OAC). Prescription of OAC increased from 23.1% (n = 186) to 42.8% (n = 323, p < .01) with stable use of vitamin-k-antagonist (22.6-24.9%). NOAC increased from 0.6 to 19.2% (p < .01). Monotherapy with Acetylsalicylic acid (ASA) decreased from 15.3% (n = 123) to 8.2% (n = 62, p < .01). In group C (n = 1083), OAC increased from 35.3 to 55.4% (p < .01), with stable prescription rate of vitamin-k-antagonist (34.4-35.7%). NOAC increased from 0.9 to 21.5% (p < .01). CONCLUSIONS: In summary, our study showed a significant increase of OAC over time, which is fostered by the use of NOAC but with a stable rate of VKA and a sharp decrease of ASA. Patients on VKA are rarely switched to NOAC, but new patients with AF are more likely to receive NOAC.

How the Consolidated Framework for Implementation Research Can Strengthen Findings and Improve Translation of Research Into Practice: A Case Study.

PURPOSE/OBJECTIVES: To answer how the planned intervention was performed in routine care, which factors supported or distracted from its implementation, and how key organizational structures have been built and sustained.
. RESEARCH APPROACH: Mixed-methods process evaluation.
. SETTING: Two German outpatient cancer clinics.
. PARTICIPANTS: Purposive sampling of 297 recruited patients with gynecologic cancer, their treating oncology nurses, and their interprofessional healthcare team, and the clinical stakeholders of two different outpatient cancer clinics.
. METHODOLOGIC APPROACH: Guided by the Consolidated Framework for Implementation Research (CFIR), five distinct interrelated substudies were designed to evaluate intervention characteristics, inner and outer settings, characteristics of the individuals involved, and the process of implementation. Quantitative and qualitative data will be analyzed separately and then integrated into a framework analysis.
. FINDINGS: Oncology nurses found the regular process analytic sessions to be beneficial, not only for sharing their experience, but also for experiencing social support and social connectedness.
. INTERPRETATION: Key implementation facets of the nurse-led intervention will be examined systematically. The results can guide future implementation processes, which need to be tailored to interested facilities.
. IMPLICATIONS FOR NURSING: The CFIR framework is well established but not yet widely applied in supportive treatment research. The current study aims to apply and combine this framework with the concept of intervention fidelity.

Emerging trends in diabetes care practice and policy in The Netherlands: a key informants study.

BACKGROUND: Effective self-management is viewed as the cornerstone of diabetes care. Many interventions and policies are available to support self-management, but challenges remain regarding reaching specific subgroups and effectively changing lifestyles. Here, our aim was to identify emerging policies and practices regarding diabetes care in The Netherlands. METHODS: Study with a purposeful sample of key informants, covering a range of stakeholders. They were individually interviewed, using a flexible and semi-structured approach. A thematic analysis was done, guided by an international framework, which resulted in 28 themes. RESULTS: After a decade of investing in diabetes care in The Netherlands, stakeholders seem to have shifted their focus towards a view that effective self-management is expected in most people. The expectation is that individuals' personal networks, community organizations and emerging information technologies will facilitate this. If support of self-management is required, this has to be provided by local coalitions of health and social care organizations, with involvement of municipalities. Poor reach in specific subgroups of the population, such as economically deprived people, is recognized but has not led to targeted policies. CONCLUSIONS: The role of healthcare providers in supporting patients' self-management in diabetes care seems to be changing in The Netherlands.

Motivation for career choice and job satisfaction of GP trainees and newly qualified GPs across Europe: a seven countries cross-sectional survey.

BACKGROUND: Recruitment to general practice is a major concern in many countries. Cross-national exploration of motivation for career choice and career satisfaction could help inform workforce planning. OBJECTIVES: Our aim was to explore motivation for career choice and job satisfaction of GP trainees and newly qualified GPs (NQGP) across seven European countries. METHODS: We surveyed GP trainees and recently qualified GPs in the Czech Republic, Denmark, Germany, Italy, Norway, Portugal and the United Kingdom using a web-based questionnaire. RESULTS: The number of individuals who responded was 3722 (2533 GP trainees; 1189 NQGP). The most frequently cited reasons for choosing GP were 'compatibility with family life' (59.5%), 'challenging medically broad discipline' (58.9%), 'individual approach to people' (40.1%), 'holistic approach' (37.8%) and 'autonomy and independence' (30.4%). Despite differences in workload, work-life balance and earnings, overall job satisfaction was high, with over 80% saying that they would choose to be a doctor again; of these 78.4% would choose to be a GP again. CONCLUSION: In our sample reasons for choosing general practice as a career were strongly positive, with compatibility with family life the most frequently cited reason overall. This has implications for workforce planning. Further qualitative studies are needed to explore issues raised in more detail.

[Developing a tailored intervention: implementing recommendations for polypharmacy in multimorbid patients (PomP)]. / Entwicklung einer maßgeschneiderten Intervention (Tailoring) am Beispiel der Implementierung von Empfehlungen zur Polypharmakotherapie bei multimorbiden Patienten (PomP).

INTRODUCTION: Implementation research deals with the question of how to ensure that evidence-based knowledge is put into practice. One approach is the development of "tailored interventions (TI)". These are designed to address previously identified barriers and enablers. A common definition or methodological concept for TI has not yet been established. In this paper, a concept for TI is introduced. We describe the stepwise development of an implementation intervention for GP settings where recommendations based on current evidence are provided for the treatment of multimorbid patients receiving polypharmacy. Each step will be explained and illustrated by original data. METHODS/RESULTS: A stepwise approach was used to develop a TI: problem analysis, identification and prioritisation of determinants, identification and prioritisation of strategies and the design of a complex intervention and its underlying logic model. DISCUSSION: The stepwise exemplary description of this tailoring strategy may support other researchers in this field when designing a TI.

Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis.

BACKGROUND: This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety. METHODS: We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes. RESULTS: Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks. CONCLUSIONS: Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.

Patient safety in midwifery-led care in the Netherlands.

OBJECTIVE: to describe the incidence and characteristics of patient safety incidents in midwifery-led care for low-risk pregnant women. DESIGN: multi-method study. SETTING: 20 midwifery practices in the Netherlands; 1,000 patient records. POPULATION: low-risk pregnant women. METHODS: prospective incident reporting by midwives during 2 weeks; questionnaire on safety culture and retrospective content analysis of 1,000 patient records in 2009. MAIN OUTCOME MEASURES: incidence, type, impact and causes of safety incidents. RESULTS: in the 1,000 patient records involving 14,888 contacts, 86 safety incidents were found with 25 of these having a noticeable effect on the patient. Low-risk pregnant women in midwifery care had a probability of 8.6% for a safety incident (95% CI 4.8-14.4). In 9 safety incidents, temporary monitoring of the mother and/or child was necessary. In another 6 safety incidents, reviewers reported psychological distress for the patient. Hospital admission followed from 1 incident. No safety incidents were associated with mortality or permanent harm. The majority of incidents found in the patient records concerned treatment and organisational factors. CONCLUSIONS: a low prevalence of patient safety incidents was found in midwifery care for low-risk pregnant women. This first systematic study of patient safety in midwifery adds to the base of evidence regarding the safety of midwifery-led care for low-risk women. Nevertheless, some areas for improvement were found. Improvement of patient safety should address the better adherence to practice guidelines for patient risk assessment, better implementation of interventions for known lifestyle risk factors and better availability of midwives during birthing care.

Patient safety in midwifery care for low-risk women: instrument development.

INTRODUCTION: Few studies have examined the safety of midwife-led care for low-risk childbearing women. While most women have a low-risk profile at the start of pregnancy, validated measures to detect patient safety risks for this population are needed. The increased interest of midwife-led care for childbearing women to substitute for other models of care requires careful evaluation of safety aspects. In this study, we developed and tested an instrument for safety assessment of midwifery care. METHODS: A structured approach was followed for instrument development. First, we reviewed the literature on patient safety in general and obstetric and midwifery care in particular. We identified 5 domains of patient risk: organization, communication, patient-related risk factors, clinical management, and outcomes. We then developed a prototype to assess patient records and, in an iterative process, reviewed the prototype with the help of a review team of midwives and safety experts. The instrument was pilot tested for content validity, reliability, and feasibility. RESULTS: Trained reviewers with clinical midwifery expertise applied the instrument. We were able to reduce the original 100-item screening instrument to 32 items and applied the instrument to patient records in a reliable manner. With regard to the validity of the instrument, review of the literature and the validation procedure produced good content validity. DISCUSSION: A valid and feasible instrument to assess patient safety in low-risk childbearing women is now available and can be used for quantitative analyses of patient records and to identify unsafe situations. Identification and analysis of patient safety incidents required clinical judgment and consultation with the panel of safety experts. The instrument allows us to draw conclusions about safety and to recommend steps for specific, domain-based improvements. Studies on the use of the instrument for improving patient safety are recommended.

Factors associated with the impact of quality improvement collaboratives in mental healthcare: an exploratory study.

BACKGROUND: Quality improvement collaboratives (QICs) bring together groups of healthcare professionals to work in a structured manner to improve the quality of healthcare delivery within particular domains. We explored which characteristics of the composition, participation, functioning, and organization of these collaboratives related to changes in the healthcare for patients with anxiety disorders, dual diagnosis, or schizophrenia. METHODS: We studied three QICs involving 29 quality improvement (QI) teams representing a number of mental healthcare organizations in the Netherlands. The aims of the three QICs were the implementation of multidisciplinary practice guidelines in the domains of anxiety disorders, dual diagnosis, and schizophrenia, respectively. We used eight performance indicators to assess the impact of the QI teams on self-reported patient outcomes and process of care outcomes for 1,346 patients. The QI team members completed a questionnaire on the characteristics of the composition, participation in a national program, functioning, and organizational context for their teams. It was expected that an association would be found between these team characteristics and the quality of care for patients with anxiety disorders, dual diagnosis, and schizophrenia. RESULTS: No consistent patterns of association emerged. Theory-based factors did not perform better than practice-based factors. However, QI teams that received support from their management and both active and inspirational team leadership showed better results. Rather surprisingly, a lower average level of education among the team members was associated with better results, although less consistently than the management and leadership characteristics. Team views with regard to the QI goals of the team and attitudes towards multidisciplinary practice guidelines did not correlate with team success. CONCLUSIONS: No general conclusions about the impact of the characteristics of QI teams on the quality of healthcare can be drawn, but support of the management and active, inspirational team leadership appear to be important. Not only patient outcomes but also the performance indicators of monitoring and screening/assessment showed improvement in many but not all of the QI teams with such characteristics. More studies are needed to identify factors associated with the impact of multidisciplinary practice guidelines in mental healthcare.

Clinical risk management of interactions between natural products and drugs.

Clinical risk management offers a systematic approach to minimize healthcare-related risks by paying attention to: (1) risk identification and assessment; (2) development and execution of risk reduction strategies; (3) evaluation of risk reduction strategies. This paper reviews these key areas for the risk of interactions between natural products and drugs (NPDIs) to explore how the impact of these interactions on public health can be minimized. It argues that specific components of clinical risk management need to be evaluated, before adoption, and then actively implemented if proven valuable.

Economic barriers to implementation of innovations in health care: is the long run-short run efficiency discrepancy a paradox?

Favourable cost-effectiveness of innovative technologies is more and more a necessary condition for implementation in clinical practice. But proven cost-effectiveness itself does not guarantee successful implementation. The reason for this is a potential discrepancy between long run efficiency, on which cost-effectiveness is based, and short run efficiency. Long run and short run efficiency is dependent upon economies of scale. This paper addresses the potential discrepancy between long run and short run efficiency of innovative technologies in healthcare, explores diseconomies of scale in Dutch hospitals and suggests what strategies might help to overcome hurdles to implement innovations due to that discrepancy.

Effects of a nationwide programme: interventions to reduce perceived barriers to collaboration and to increase structural one-on-one contact.

OBJECTIVE: To describe the implementation of a nationwide programme and to determine the effects of specific quality improvement (QI) interventions within this programme on perceived barriers to collaboration between general practitioner (GPs) and mental health professionals and frequency of structural one-on-one contact regarding individual patients. METHODS: The implementation of regional QI-interventions, perceived barriers to collaboration, and frequency of structural one-on-one contact, were assessed in a cohort study involving two surveys (2001 and 2003) among a random sample of 2757 GPs. RESULTS: 1336 and 1358 GPs returned baseline and follow-up questionnaires respectively. Most of the interventions were only offered to a minority of GPs. Less than 25% of GPs that had been offered interventions actually participated. The frequency of structural one-on-one contact with mental health professionals did not change, but barriers to collaboration decreased between 2001 and 2003. For GPs who actually participated in interactive small group meetings or in intervention in which mental health professionals were integrated in general practice, a reduction of perceived barriers could be observed as well as an increase in the frequency of structural one-on-one contact. CONCLUSION: Interventions that could be characterized as interactive small group meetings as well as interventions that involved the integration of mental health professionals in general practice led to a reduction of perceived barriers as well as an increase in the frequency of structural one-on-one contact. These findings add to the knowledge of which interventions have an effect on the collaboration between different health care providers.

Treatment of myofascial trigger points in common shoulder disorders by physical therapy: a randomized controlled trial [ISRCTN75722066].

BACKGROUND: Shoulder disorders are a common health problem in western societies. Several treatment protocols have been developed for the clinical management of persons with shoulder pain. However available evidence does not support any protocol as being superior over others. Systematic reviews provide some evidence that certain physical therapy interventions (i.e. supervised exercises and mobilisation) are effective in particular shoulder disorders (i.e. rotator cuff disorders, mixed shoulder disorders and adhesive capsulitis), but there is an ongoing need for high quality trials of physical therapy interventions. Usually, physical therapy consists of active exercises intended to strengthen the shoulder muscles as stabilizers of the glenohumeral joint or perform mobilisations to improve restricted mobility of the glenohumeral or adjacent joints (shoulder girdle). It is generally accepted that a-traumatic shoulder problems are the result of impingement of the subacromial structures, such as the bursa or rotator cuff tendons. Myofascial trigger points (MTrPs) in shoulder muscles may also lead to a complex of symptoms that are often seen in patients diagnosed with subacromial impingement or rotator cuff tendinopathy. Little is known about the treatment of MTrPs in patients with shoulder disorders.The primary aim of this study is to investigate whether physical therapy modalities to inactivate MTrPs can reduce symptoms and improve shoulder function in daily activities in a population of chronic a-traumatic shoulder patients when compared to a wait-and-see strategy. In addition we investigate the recurrence rate during a one-year-follow-up period. METHODS/DESIGN: This paper presents the design for a randomized controlled trial to be conducted between September 2007 - September 2008, evaluating the effectiveness of a physical therapy treatment for non-traumatic shoulder complaints. One hundred subjects are included in this study. All subjects have unilateral shoulder pain for at least six months and are referred to a physical therapy practice specialized in musculoskeletal disorders of the neck-, shoulder-, and arm. After the initial assessment patients are randomly assigned to either an intervention group or a control-group (wait and see). The primary outcome measure is the overall score of the Dutch language version of the DASH (Disabilities of Arm, Shoulder and Hand) questionnaire. DISCUSSION: Since there is only little evidence for the efficacy of physical therapy interventions in certain shoulder disorders, there is a need for further research. We found only a few studies examining the efficacy of MTrP therapy for shoulder disorders. Therefore we will perform a randomised clinical trial of the effect of physical therapy interventions aimed to inactivate MTrPs, on pain and impairment in shoulder function in a population of chronic a-traumatic shoulder patients. We opted for an intervention strategy that best reflects daily practice. Manual high velocity thrust techniques and dry-needling are excluded. Because in most physical therapy interventions, blinding of the patient and the therapist is not possible, we will perform a randomised, controlled and observer-blinded study. TRIAL REGISTRATION: This randomized clinical trial is registered at current controlled trials ISRCTN75722066.

Health service utilization patterns of primary care patients with osteoarthritis.

BACKGROUND: To assess factors associated with visits to GPs, orthopaedists, and non-physician practitioners of complementary medicine (alternative practitioners) by primary care patients with osteoarthritis (OA). METHODS: Cross-sectional survey among 1250 consecutively addressed patients from 75 primary care practices in Germany. All patients suffered from OA of the knee or hip according to ACR criteria. They received questionnaires collecting sociodemographic data, data about health service utilisation, prescriptions, comorbidities. They also included established instruments as the Arthritis Impact Measurement Scale (AIMS2-SF) to assess disease-specific quality of life and the Patient Health Questionnaire (PHQ-9) to assess depression. Hierarchical stepwise multiple linear regression models were used to reveal significant factors influencing health service utilization. RESULTS: 1021 of 1250 (81.6%) questionnaires were returned. Nonrespondents did not differ from participants. Factors associated with health service use (HSU) varied between providers of care. Not being in a partnership, achieving a high score on the PHQ-9, increased pain severity reflected in the "symptom" scale of the AIMS2-SF, and an increased number of drug prescriptions predicted a high frequency of GP visits. The PHQ-9 score was also a predictor for visits to orthopaedists, as were previous GP contacts, a high score in the "symptom" scale as well as a high score in the "lower limb scale" of the AIMS2-SF. Regarding visits to alternative practitioners, a high score in the AIMS -"social" scale was a positive predictor as older people were less likely to visit them. CONCLUSION: Our results emphasize the need for awareness of psychological factors contributing to the use of health care providers. Addressing the revealed factors associated with HSU appropriately may lead to decreased health care utilization. But further research is needed to assess how this can be done successfully.

Physician workload in primary care: what is the optimal size of practices? A cross-sectional study.

OBJECTIVE: To determine the impact of practice size and scope of services on average physician workload in primary care practices in The Netherlands, and to examine the associations between average physician workload, average assistant volume and organisational practice characteristics. METHODS: This was a cross-sectional study in 1188 general practices in The Netherlands. Measures included physician workload per week per 1000 patients, assistant volume per 1000 patients, practice size defined by number of registered patients (10 classes), scope of disease management services (seven classes), and nine organisational characteristics of the practice. RESULTS: Physician workload per 1000 patients differed across levels of practice size, but was not related with the range of disease management services provided. In the smallest practices physicians worked on average 26.2h per 1000 patients and in the largest practices 18.1h. A higher average assistant volume was overall not associated with a lower average physician workload. Large practices had lower assistant volume per 1000 patients, but provided a wider range of disease management services compared to small practices. Delegation of medical tasks was associated with reduced physician workload per 1000 patients, mainly in smaller practices, and with higher assistant volume per 1000 patients, particularly in larger practices. CONCLUSIONS: In The Netherlands the optimum regarding average physician workload was found in the largest practices, while no obvious association with scope of disease management services appeared. It may be that in large practices medical tasks were delegated to practice assistants to provide a wider scope of disease management services and in small practice to reduce average physician workload.