How to strengthen basic competencies in self-care - a pre-post interventional study with postgraduate trainees in family medicine in Germany.

Introduction: Self-care includes taking care of our psychosocial health. Many experts agree that self-care should be included in training for Family Medicine (FM) residents, though it is unclear to what extent and by what means. Objective: The aim of this study was to evaluate competencies of FM residents in self-care and changes in knowledge, skills and attitudes after an educational compact intervention.Methods: The authors performed a pre-post comparison on residents who were registered in the FM residency program KWBW VerbundweiterbildungPLUS© (n = 401). FM residents were offered participation in a self-care training (270 minutes featuring a broad spectrum of input and practical experience). The intervention group (IG) completed a questionnaire directly before the seminar (T1) and 10 weeks afterwards (T2). Non-attendees (=control group; CG) were asked to fill out a basic questionnaire once. Basic questionnaires for IG and CG covered previous experiences and skills while the follow-up questionnaire at T2 also focused on change of competencies and attitudes. All questionnaires contained free-text questions to capture qualitative impressions.Results: 287 FM residents (IG: n = 212; CG: n = 75) participated in the study. Generally, 86.4% of FM residents had worried that their profession might endanger their personal health (T1: n = 180, CG: n = 68). At T2, 59.5% of IG (n = 66/111) declared that they would not worry about their personal health anymore (T1:T2, p < .01). IG learned to facilitate time for recreation (T1:T2, p = .04) and to use relaxation techniques (T1:T2, p = .01). Gain in competence was described in awareness of stress, self-reward, activation of personal resources, and time management. A total of 85.6% of IG reflected their attitudes towards psychosocial health of physicians in general (n = 95/111) and 22.5% of IG changed the views on their own health (n = 25/111) in terms of improved risk-awareness, increased intention for self-care and change of behavior.Conclusion: A compact intervention in self-care strengthens competencies, increases awareness, and helps FM residents identify their psychosocial health risks. Further research is necessary to specify the effectiveness of similar compact interventions in self-care and their long-term results.

Job satisfaction and stressors for working in out-of-hours care - a pilot study with general practitioners in a rural area of Germany.

BACKGROUND: Challenging work environment, high workload, and increasing physician shortages characterize current rural general practice in Germany and in most European Countries. These factors extend into Out-Of-Hours Care (OOHC). However, little research about potential stressors for general practitioners (GPs) in OOHC settings is available. This pilot study aimed to evaluate workload, different elements of job satisfaction and stressors for GPs in OOHC and to analyze whether these aspects are associated with overall job satisfaction. METHODS: Cross-sectional survey with a sample of 320 GPs who are working in OOHC was used to measure workload in OOHC, job satisfaction (using the Warr-Cook-Wall scale) and stressors with the effort-reward imbalance questionnaire. In order to assess associations between workload, job satisfaction and stressors at work we performed descriptive analyses as well as multivariable regression analyses. RESULTS: The response rate was 40.9%. Over 80% agreed that OOHC was perceived as a stressor and 79% agreed that less OOHC improved job satisfaction. Only 42% of our sample were satisfied with their overall job satisfaction. The regression analysis showed that the modification of current OOHC organization was significantly associated with overall job satisfaction. CONCLUSIONS: Our results suggest that OOHC in the current form is a relevant stressor in daily work of rural GPs in Germany and one of the reasons for a decreasing overall job satisfaction. Strategic changes such as the implementation of structural reforms e.g. reducing frequency of OOHC duties for each GP and improving continuing professional development options related to OOHC are needed to address current workload challenges experienced by GPs providing OOHC in Germany.

A longitudinal communication approach in advanced lung cancer: A qualitative study of patients', relatives' and staff's perspectives.

Communication and the care of patients with advanced cancer are a dynamic, interactive and challenging process, often characterised in every day practice by discontinuity and lack of coordination. The objective of this study was to explore the patients' and family-caregivers' needs and preferences regarding communication, quality of life and care over the trajectory of disease. The second aim was to assess health professionals' views on a longitudinally structured, forward-thinking communication approach based on defined milestones. A qualitative approach was chosen incorporating semi-structured interviews with nine patients with metastatic lung cancer and nine relatives, and focus groups with 15 healthcare providers from different professions involved in the care of these patients. Patients and relatives described a situation of shock and coping deficits with moments of insufficient communication and lack of continuity in care. Healthcare providers reported the strong need for improvement in communication within the team and between patients and professionals and welcomed the implementation of a longitudinal communication approach. Requirements for the implementation of a longitudinal communication approach include specific communication training with focus on the process that patients and relatives are involved in. Team-building measures and the necessary flexibility to respect individuality in life should be incorporated.

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

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

Cross-sectoral cancer care: views from patients and health care professionals regarding a personal electronic health record.

Cross-sectoral cancer care is complex and involves collaboration from health care professionals (HCPs) across multiple sectors. However, when health information exchange (HIE) is not adequate, it results in impeded coordination and continuity of care. A web-based personal electronic health record (PEPA) under patients' control, providing access to personal health data across sectors, is being developed. Aim of this study was to explore perceived benefits and concerns. Using a qualitative approach, 10 focus groups were performed collecting views of three prospective user groups: patients with colorectal cancer (n = 12), physicians (n = 17) and other HCPs (n = 16). Representatives from different health sectors across the Rhine-Neckar region (Germany) participated. Data were audio- and videotaped, transcribed verbatim and thematically analysed. Our study shows that patients and HCPs expected a PEPA to enhance cross-sectoral availability of information, cross-sectoral cooperation and facilitate data management. Quality of cancer care was expected to be improved. Concerns were expressed in terms of data protection and data security. Concepts like a PEPA offer the chance to support HIE and avoid gaps of information in cross-sectoral cancer care. This may lead to improvements in coordination and continuity of care. Issues concerning data security and protection have to be addressed.

[Procedures Performed in General Practice - a Cross-sectional Study]. / Prozeduren, die in der Allgemeinmedizin durchgeführt werden ­ eine Querschnittstudie.

OBJECTIVE: General practice offers basic medical care to patients. Therefore, general practitioners (GPs) perform a variety of medical procedures. In order to estimate GPs array of services from the perspective of health services research, it is indispensable to know the procedures that are carried out by GPs and identify relevant influencing factors. METHODS: Based on the results of a selective literature search, the Medical Association's regulations on specialty training and experiences gained so far in developing the competence-based curriculum for general practice, a questionnaire covering 89 procedures was developed and sent to 1 576 general practitioners all over Germany. RESULTS: The response rate was 42%; 42 of 89 procedures were carried out by at least 50% of the participants. These procedures include the anatomical areas skin, eyes, ears, nose, gastrointestinal tract, urological tract and musculoskeletal system. Significant differences were shown in 25 of the most frequent procedures regarding practices in urban and rural areas, in 9 procedures with regard to the participant's length of occupation in general practice and in 19 procedures regarding male and female participants. CONCLUSION: This is the first survey that shows which procedures are performed by German GPs and how often they are performed. Factors such as practice location in either rural or urban area, physician's gender and years practiced as GP have been identified as important influences on the spectrum of services provided.

Process evaluation of five tailored programs to improve the implementation of evidence-based recommendations for chronic conditions in primary care.

BACKGROUND: Although there is evidence that tailored implementation strategies can be effective, there is little evidence on which methods of tailoring improve the effect. We designed and evaluated five tailored programs (TPs) each consisting of various strategies. The aim of this study was to examine (a) how determinants of practice prioritized in the design phase of the TPs were perceived by health care professionals who had been exposed to the TPs and whether they suggested other important determinants of practice and (b) how professionals used the offered strategies and whether they suggested other strategies that might have been more effective. METHODS: We conducted a mixed-method process evaluation linked to five cluster-randomized trials carried out in five European countries to implement recommendations for five chronic conditions in primary care settings. The five TPs used a total of 28 strategies which aimed to address 38 determinants of practice. Interviews of professionals in the intervention groups and a survey of professionals in the intervention and control groups were performed. Data collection was conducted by each research team in the respective national language. The interview data were first analyzed inductively by each research team, and subsequently, a meta-synthesis was conducted. The survey was analyzed descriptively. RESULTS: We conducted 71 interviews; 125 professionals completed the survey. The survey showed that 76 % (n = 29) of targeted determinants of practice were perceived as relevant and 95 % (n = 36) as being modified by the implementation interventions by 66 to 100 % of professionals. On average, 47 % of professionals reported using the strategies and 51 % considered them helpful, albeit with substantial variance between countries and strategies. In the interviews, 89 determinants of practice were identified, of which 70 % (n = 62) had been identified and 45 % (n = 40) had been prioritized in the design phase. The interviewees suggested 65 additional strategies, of which 54 % (n = 35) had been identified and 20 % (n = 13) had been prioritized, but not selected in the final programs. CONCLUSIONS: This study largely confirmed the perceived relevance of the targeted determinants of practice. This contrasts with the fact that no impact of the trials on the implementation of the recommendations could be observed. The findings suggest that better methods for prioritization of determinants and strategies are needed. TRIAL REGISTRATION: Each of the five trials was registered separately in recognized trial registries. Details are given in the respective trial outcome papers.

Structures and processes necessary for providing effective home treatment to severely mentally ill persons: a naturalistic study.

BACKGROUND: Home treatment for severely mentally ill persons is becoming increasingly popular. This research aims to identify structures and processes in home treatment that impact on patient-related outcomes. METHODS: We analysed 17 networks that provide home treatment to severely mentally ill persons using a naturalistic approach. The networks were similar with regard to central components of home treatment such as case management, 24 h crisis hotline and home visits, but differed in all other aspects such as the multidisciplinary teams, time spent with patients, etc. To determine treatment outcome, patients' psychosocial functioning was measured using the Health of the Nation Outcome Scales (HoNOS). Structures and processes were assessed using claims data and questionnaires answered by the different networks. Primary outcome was highlighted by the change in HoNOS scores from the start of home treatment compared with 6 months later. We sought to explain this outcome through patient and network characteristics using regression analysis. Data on 3,567 patients was available. RESULTS: On average, psychosocial functioning improved by 0.84 across networks between t0 and t1. There were more similarities than differences between the networks with regard to the structures and processes that we tested. A univariate regression analysis found staff's prior experience in mental health care and the effort that they invested in their work correlated positively with patient outcome. This needs to be interpreted under considering that univariate analysis does not show causal relationship. A high case load per case manager, increased and longer patient contact and more family intervention were correlated with worse patient outcome, probably indicating that sicker patients receive more care and intervention. CONCLUSION: Home treatment networks succeed in delivering care tailored to the needs of patients. In order to improve the quality of care in home treatment, this study suggests employing experienced staff who is ready to invest more effort in their patients. Further research needs to consider a longer follow-up time.

[Care of patients with cancer pain in general practices in Germany]. / Versorgung von Patienten mit Tumorschmerzen in hausärztlichen Praxen in Deutschland.

BACKGROUND: In line with the increased life expectancy of people in Germany, the probability of falling ill with a malignant disease is continuously increasing. About 480,000 people in Germany contract cancer every year. One of the most important symptoms of a malignant disease is pain. Between 40 and 100% of patients with advanced cancer suffer from pain. The aim of this investigation is to show how German general practitioners care for these patients using analgetics. MATERIALS AND METHODS: The data were extracted from the CONTENT database (CONTinuous morbidity registration Epidemiologic NeTwork) of the Department of General Practice and Health Services Research at the University Hospital in Heidelberg. This database has data from more than 200,000 patients and more than 3 million physician/patient contacts. The prescriptions were classified using the ATC code. RESULTS: Patients experiencing pain from cancer received all kinds of analgetic drugs. The data comprises 9752 prescriptions for 1362 patients. There were 4975 (51.1 %) prescriptions for Class 1 analgesics, 929 (9.5 %) for Class 2 analgetics and 1918 (19.7 %) prescriptions for Class 3 analgetics. Coanalgetics were prescribed 1930 (19.7 %) times. 1,167 patients (85.7 %) were treated in the correct manner according to the guidelines of the World Health Organisation and 195 (14.3 %) were not. CONCLUSIONS: Most GPs in Germany follow the principles of WHO structured pain therapy. However, further improvement of the results may be achieved through intensive training of colleagues.

[Prevention and Information for Patients Undergoing Periodontal Treatment: Potentials for Improvement from the Patients' Perspective]. / Prävention und Aufklärung im Rahmen der Parodontitisbehandlung: Verbesserungspotenziale aus Patientensicht.

2 334 patients from 29 dental practices took part in a written survey on their experiences with dental treatment in general as well as treatment of periodontal disease (response rate 80.8%). 72.6% of all participating patients fully agreed that they could recommend their dentist to their friends. 63.6% of patients undergoing treatment of periodontitis (N=328) rated this treatment as "excellent". However, for important aspects (prevention, patient information, treatment) potentials for improvement became obvious. 43.7% of patients treated for periodontitis were not completely satisfied with information on how this disease develops; 40.7% saw potentials for better information on preventive care (dental-hygiene, nutrition). An even higher percentage of patients actually not treated for periodontitis was interested in more information on prevention (51.4%). The results of the survey show that dentists should offer information and exercise on how to prevent periodontal desease more actively. There is a lack of research on the present state of affairs and potentials for improvement concerning treatment and prevention of periodontitis including the patients' perspective.

[Voluntary and mandatory quality assurance in mental health care: European examples]. / Freiwillige und verpflichtende Qualitätssicherung psychiatrischer Versorgung : Beispiele aus Europa.

Since the turn of the century, quality assurance (QA) programs are increasingly being implemented; both generally in health systems and specifically for mental health services. These QA programs can be implemented on a mandatory basis as well as voluntarily. Benefits of mandatory QA programs are a reliable, country-wide dataflow, as well as their long-term sustainability and comparability. Shortcomings relate to the limitations imposed by legal requirements. Benefits of voluntary QA programs are their freedom and flexibility in terms of methods and data sources. Shortcomings relate to the impossibility of country-wide implementation and a lack of sustainability, as well as to the data quality. Examples for QA in mental health care from different European countries show that mandatory and voluntary QA initiatives could complement each other. Specialist medical societies play an important role in the development of voluntary QA and the promotion of high quality care. An example is the accreditation to mental health services offered by the Royal College of Psychiatrists in the United Kingdom.

[Projection of General Practitioner Care Demand at the Community Level]. / Projektion des Bedarfs an hausärztlicher Versorgung auf Gemeindeebene.

BACKGROUND: Within the next 8 years about 2 000 general practitioners (GPs) will be seeking a successor in the federal state of Baden-Württemberg, Germany. Both the small number of newly qualified GPs and the wish to work as an employee or in a group practice will lead to a situation in which about 500 practices will likely not find a successor. Using a single administrative district, the aim of this analysis was to develop a projection of the demand for GP health care at the community level. METHODS: Using the administrative district of Rottweil with its 21 communities, a community-based demographic forecast on the basis of current birth and death probabilities was performed. From the projected population structure, the demand for GP care in the year 2023 was derived under the assumption of unchanged age- and gender-specific numbers of GP visits. The anticipated deficit or, respectively, overrun of GPs at the community level was calculated as the difference between expected demand and number of GPs not retiring for age-related reasons. RESULTS: Until the year 2023 the demographic change will cause a shrinking population. However, with unchanged age- and gender-specific numbers of GP visits, a slightly higher demand of 0.6 GPs will occur as a result of population-aging. The expected age-related retirement of physicians will have a stronger impact on primary care demand than demography. Up to 32 (37%) GPs might need a successor. In addition to 4 communities today, this would result in another 5 communities not having a GP in 10 years. CONCLUSION: Communities that are at higher risk of GP shortage based on demographic changes and age of practicing GPs, can be identified by the approach described and applied here in order to implement targeted comprehensive community models of care.

[Oversupplied? Undersupplied? - The Perspective of Local Governments of the Federal State of Baden-Württemberg: A Contribution to the Discussion of Close-to-Home Health Care]. / Überversorgt? Unterversorgt? - die Sicht von Bürgermeistern in Baden-Württemberg: Ein Beitrag zur Diskussion um die wohnortnahe medizinische Versorgung.

BACKGROUND: The ageing of physicians working in ambulatory care make regional health planning a challenging task. This study examines the current supply of general practitioners (GP) within the communities from the perspective of mayors. The information gained on a community level can be used when discussing over- and undersupply as well as future health care planning. METHODS: A questionnaire was sent to all 1101 mayors of the Federal state of Baden-Württemberg (BW) in May 2011. For the evaluation of the location of the communities, subjective ratings by the mayors were compared with official criteria, provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR). RESULTS: The participation rate was 63% (n=698). According to the mayors about 70% (n=468) were located in a rural area, according to BBSR criteria were about 26% (n=177) of answers given by rural communities. Of the participating mayors about 54% (n=355) stated that their community is cared for merely by GPs. From this information there was a locally experienced undersupply of GPs calculated for 13.5% (n=86) of the communities. This affected rural as well as non-rural communities. In communities up to 20 000 inhabitants, the ratio between GPs and other specialists seems to be 60:40 whereas in bigger cities the proportion of other specialists appears to be much higher. CONCLUSION: Half of the participating communities seem to not have a practicing specialised physician. An accumulation of specialised physicians in larger cities was reported. The GP shortage appears to mainly be experienced subjectively. Regarding the location (urban vs. rural) of the community, subjective views differ distinctly from the BBSR criteria. This discrepancy could influence a community's marketing strategy when competing for new physicians.

[GP-centered health care in Baden-Württemberg, Germany: Results of a quantitative and qualitative evaluation]. / Hausarztzentrierte Versorgung in Baden-Württemberg : Ergebnisse einer qualitativen und querschnittlich quantitativen Evaluation.

BACKGROUND: GP-centered health care ("Hausarztzentrierte Versorgung", HzV)-the terms of which are described in § 73b of the Social Code Book V-came into effect in Baden-Württemberg, Germany, on 1 July 2008. The HzV is aimed at enhancing health care for patients with chronic diseases and complex health care needs (e.g., those requiring long-term care). OBJECTIVES: On the basis of four working packages (WP I-WP IV), the present paper examines the impact that GP-centered health care has had on patients insured by the "AOK" regional sickness fund and their GPs. WP I addresses the association between HzV participation and the corresponding health care utilization of patients on the basis of claims data. WP II looks at any changes that GPs and patients noticed were potentially attributable to HzV participation. WP III focuses on health care assistants in primary care ("Versorgungsassistenten in der Hausarztpraxis", VERAH). These assistants play a special role within the framework of the HzV. WP IV analyzes the quality of health care for patients aged 65 years and over, also on the basis of claims data. MATERIALS AND METHODS: A mixed methods design was used for this evaluation, and quantitative and qualitative approaches taken. This design enabled insights into the implementation of the HzV in regular health care to be obtained from different perspectives. RESULTS: Numerous positive associations between HzV participation and the variables of interest were observed for all WPs. These are presented in detail in the paper. CONCLUSION: The results obtained so far clearly support the continuation of HzV and associated evaluations.

[Joint replacement quality index: the perspective of resident physicians]. / "Qualitätsindex Endoprothetik" aus Sicht von niedergelassenen Ärzten.

BACKGROUND AND AIM: Joint replacement is an established therapy for arthrosis. The quality index for joint replacement (knee and hip) should include screening for quality of patient-centred care in hospitals providing replacements, on the basis of administrative data. The quality index summarizes 16 inpatient and posthospital complications (indicators). The aim of the study was to evaluate this quality index from the medical practitioner's viewpoint. METHODS: Four semistructured focus groups with 11 family physicians and 8 orthopaedic/trauma surgeons were conducted. The discussions were recorded, transcribed and analysed qualitatively according to Mayring. RESULTS: Infections and the revision of a total joint arthroplasty have been weighted as the most important indicators from the existing quality indicators. Between the participants some differences regarding the relevance of the indicators thrombosis and pulmonary embolism occurred. These indicators were weighted as more important by family physicians than orthopedic/trauma surgeons. For eight of the indicators, imprecision in words/meaning was criticized. In an open-ended second section, 20 new indicators within the areas complications, management and overall sector communication were identified. CONCLUSION: Major amendments of the quality index for the joint replacement are necessary. The knowledge gained from this study may serve as a basis for this development.

[Characteristics of Health-Care Provision for Patients in Out-of-Hours Care and Regular Care]. / Charakteristika primärärztlicher Versorgung von Patienten außerhalb regulärer Sprechstundenzeiten im Vergleich zur Routineversorgung.

BACKGROUND: Little is known of the primary care characteristics in out of hours care centres (OOHC) as compared to regular care in Germany. Obviously the provision of patients in OOHC exhibits special characteristics concerning supply requirements, occupation and physician services, that require a first approximation. METHODS: The data retrieval is managed within the CONTENT (CONTinous morbidity registration Epidemiologic NeTwork) research network. The used software allows for classifying reasons for encounter (RFE), health-problems (diagnoses) and processes of care (prescriptions, referrals, hospitalisations) with the International Classification of Primary Care (ICPC). Furthermore the software allows for pseudonymised data export. One OOHC Centre in South Hessen is part of the network. Therefore, this allows the comparison of this OOHC centre with the regular care of the included 5 physicians in 4 practices of the same region. RESULTS: A 3-year period (01 April 2010-31 March 2013) with 192,827 patient contacts of 13,394 patients (58.1% female) in regular care and 14,354 patient contacts with 9,208 patients (64.1% female) in OOHC was described. Medium age of the patients of the regular provision was 59.6 vs. 45.7 years in the OOHC centre based on the contacts (p<0.0001). The most frequent RFE in the OOHC centre were fever and pain predominantly caused by acute infections, injuries or acute pain of the musculoskeletal system. In regular care there could be documented predominantly chronic health issues and vaccinations. The prevalent prescriptions in OOHC were therefore antibiotics and analgesics in regular care blood pressure medication and antidiabetic drugs. The rate of referrals was obviously lower than in regular care (7.1 vs. 22.7; p<0.0001), whereas the rate of hospitalisations was obviously higher in OOHC than in regular care (5.6 vs. 1.1; p<0.0001). CONCLUSION: With the help of the data, requirements, occupation, resulting diagnoses and care processes in regular and out of hours care can be compared and described in detail. We could document major differences between the provision in OOHC and regular care. The results encourage initiating further studies to ensure the supply of primary care in OOHC.

[Symptom control and place of death in palliative cancer patients in primary care. Results of the controlled PAMINO evaluation study]. / Symptomkontrolle und Sterbeort hausärztlich versorgter Palliativpatienten. Ergebnisse der kontrollierten PAMINO-Evaluationsstudie.

BACKGROUND: The care of patients at the end of life focuses on preservation of the quality of life, symptom control and fulfillment of the preferred place of death. Only few care and outcome-related data for primary palliative care in Germany are available; therefore, the objective was to examine the quality of life, symptom control and place of death of patients with palliative treatment by general practitioners (GP). MATERIAL AND METHODS: The study is part of the PAMINO project, a non-randomized, controlled trial evaluating the effectiveness of continuing medical education for GPs (≥ 40 h) in palliative care (ISRCTN78021852). Cancer patients with an estimated life expectancy of less than 6 months were recruited by GPs with (PG) or without (CG) continuing education and documented the diagnosis, medication based on the hospice and palliative care collation ( Hospiz- und Palliativ-Erfassung, HOPE) core documentation and the preferred place of death. Patients rated their symptom burden and health-related quality of life using the quality of life questionnaire (QLQ-C15-PAL). Baseline (t0) data at enrollment and the last individual (t1) assessment were used for the analysis. RESULTS: Data of 68 patients (PG: n = 43, CG: n = 25, mean age 69.2 ± 12 years, average time since cancer diagnosis 14 months) were available at t0 and t1 (mean period 4.0 ± 2.1 months). Physical function decreased while emotional functioning remained stable. Patient-perceived pain did not increase; however, GPs intensified the pain therapy. The PGs prescribed non-opioid analgesics more frequently than CGs. During the observation period 59 patients died of which 40 out of 48 (83 %) as preferred at home. CONCLUSIONS: Stable emotional functioning, good symptom control in cancer patients at the end of life and the high rate of dying at home as preferred suggest that GPs with specific training can ensure high-quality general palliative care.

[Patients' perspectives beyond sectoral borders between inpatient and outpatient care - patients' experiences and preferences along cross-sectoral episodes of care]. / Die Patientenperspektive jenseits ambulant-stationärer Sektorengrenzen - Was ist Patientinnen und Patienten in der sektorenübergreifenden Versorgung wichtig?

AIM: Patient perspective is crucial concerning health care and quality improvement. During episodes of care, patients come into contact with multidisciplinary health-care providers in inpatient and outpatient settings and are in a unique position to describe processes throughout the entire chain of care. The aim of this study was to identify patients' experiences and preferences with fragmented cross-sectoral care to develop a patient-centred cross-sectoral quality-assessment instrument. METHOD: Patient perspective was analysed using qualitative focus-group methods. Patients were recruited from general practices if they had experienced cross-sectoral care. Focus group discussions were audiotaped, transcribed and analysed using ATLAS.ti software. Categories were extracted deductively according to a previously developed focus group guide and supplemented by inductive analyses. RESULTS: Patients identified quality gaps mainly concerning communication and coordination of care mostly along the cross-sectoral interfaces. Referrals and hospitalisations were characterised by redundant examinations and deficits in forwarding clinical findings. Support and organisation of follow-up care was rated to be improvable mainly during inpatient care and discharge. Patients identified also quality deficits concerning inpatient hygiene factors and changes of medication. Lack of transparency and responsibility within the entire chain of care caused anxiety and unstableness of patients. CONCLUSION: Patients' experiences provide important information to identify quality gaps along the entire chain of care. Study results can be used to develop a cross-sectoral patient-centred quality assessment instrument.

Specific collaborative group intervention for patients with medically unexplained symptoms in general practice: a cluster randomized controlled trial.

BACKGROUND: Patients with medically unexplained symptoms (MUS) are frequent in primary care and substantially impaired in their quality of life (QoL). Specific training of general practitioners (GPs) alone did not demonstrate sustained improvement at later follow-up in current reviews. We evaluated a collaborative group intervention. METHODS: We conducted a cluster randomized controlled trial. Thirty-five GPs recruited 304 MUS patients (intervention group: 170; control group: 134). All GPs were trained in diagnosis and management of MUS (control condition). Eighteen randomly selected intervention GPs participated in training for a specific collaborative group intervention. They conducted 10 weekly group sessions and 2 booster meetings in their practices, together with a psychosomatic specialist. Six and 12 months after baseline, QoL was assessed with the Short-Form 36. The primary outcome was the physical composite score (PCS), and the secondary outcome was the mental composite score (MCS). RESULTS: At 12 months, intention-to-treat analyses showed a significant between-group effect for the MCS (p = 0.023) but not for the PCS (p = 0.674). This effect was preceded by a significant reduction of somatic symptom severity (15-item somatic symptom severity scale of the Patient Health Questionnaire, PHQ-15) at 6 months (p = 0.008) that lacked significance at 12 months (p = 0.078). As additional between-group effects at 12 months, per-protocol analyses showed less health anxiety (Whiteley-7; p = 0.038) and less psychosocial distress (PHQ; p = 0.024); GP visits were significantly (p = 0.042) reduced in the intervention group. CONCLUSIONS: Compared to pure GP training, collaborative group intervention achieved a progressive, clinically meaningful improvement in mental but not physical QoL. It could bridge gaps between general practice and mental health care.