Communication training and the prescribing pattern of antibiotic prescription in primary health care.

BACKGROUND: The treatment of upper respiratory tract infections (URTIs) accounts for the majority of antibiotic prescriptions in primary care, although an antibiotic therapy is rarely indicated. Non-clinical factors, such as time pressure and the perceived patient expectations are considered to be reasons for prescribing antibiotics in cases where they are not indicated. The improper use of antibiotics, however, can promote resistance and cause serious side effects. The aim of the study was to clarify whether the antibiotic prescription rate for infections of the upper respiratory tract can be lowered by means of a short (2 x 2.25h) communication training based on the MAAS-Global-D for primary care physicians. METHODS: In total, 1554 primary care physicians were invited to participate in the study. The control group was formed from observational data. To estimate intervention effects we applied a combination of difference-in-difference (DiD) and statistical matching based on entropy balancing. We estimated a corresponding multi-level logistic regression model for the antibiotic prescribing decision of German primary care physicians for URTIs. RESULTS: Univariate estimates detected an 11-percentage-point reduction of prescriptions for the intervention group after the training. For the control group, a reduction of 4.7% was detected. The difference between both groups in the difference between the periods was -6.5% and statistically significant. The estimated effects were nearly identical to the effects estimated for the multi-level logistic regression model with applied matching. Furthermore, for the treatment of young women, the impact of the training on the reduction of antibiotic prescription was significantly stronger. CONCLUSIONS: Our results suggest that communication skills, implemented through a short communication training with the MAAS-Global-D-training, lead to a more prudent prescribing behavior of antibiotics for URTIs. Thereby, the MAAS-Global-D-training could not only avoid unnecessary side effects but could also help reducing the emergence of drug resistant bacteria. As a consequence of our study we suggest that communication training based on the MAAS-Global-D should be applied in the postgraduate training scheme of primary care physicians.

[Regional differences between general practitioners and general internal medicine physicians in primary care]. / Regionale Unterschiede zwischen Fachärztinnen und Fachärzten für Allgemeinmedizin und hausärztlich tätigen Internistinnen und Internisten in der hausärztlichen Versorgung.

OBJECTIVE: In many places in Germany, the need for primary care physicians has been steadily increasing for several years, especially in rural areas. It is hypothesized that physicians are more likely to practice in rural areas if they have received a broad education and vocational training. Differences between general practitioners (GPs) and physicians in general internal medicine (GIM) in the breadth of their vocational training are created by the underlying distinct training schemes. The aim of the analysis was to test whether GPs and GIM physicians differ in their distribution between urban and rural regions of Schleswig-Holstein and whether there are differences in the rate and frequency of performing home visits. METHODS: Based on invoicing data of the Association of Statutory Health Insurance Physicians in the federal state of Schleswig-Holstein (Northern Germany) covering the years 2015 up to the third quarter (Q3) of 2018, we analysed differences between GPs and GIM physicians in their regional distribution. Furthermore, we looked at differences between both specialties regarding the application rate and the number of home visits performed and unforeseen physician visits. In addition to bivariate approaches, we also used multivariate regression analysis. RESULTS: Between 2017 (Q4) and 2018 (Q3), 1,378 GPs and 585 GIM physicians provided medical services in Schleswig-Holstein. While 27.5 % of the GPs had practices in rural areas, the share of GIM physicians was 14.5 % (p < 0.001). Home visits were performed by 97.8 % of the GPs and 93.2 % of the GIM physicians (p < 0.001). This difference was even more pronounced in rural areas (99.5 % vs. 94.1 % (p = 0.002)). Significant differences have also been found in the number of billed home visits. GPs made 36 % more home visits than GIM physicians. In rural areas, the difference was 60 %. CONCLUSION: The analysis revealed significant differences between GPs and GIM physicians regarding the type of region where they work, the application rate and the number of performed home visits. The findings could foster a discussion about how GIM physicians can be better prepared to provide primary care, especially in rural areas.

Routine Data Analyses to Compare Outpatient Depression Treatment Regimens.

BACKGROUND: Routine data analyses are becoming increasingly important for health policy decision making. However such databases often vary in data quality, completeness and accessibility. The aim of this study is to describe the quality of a large outpatient healthcare database, the process of data extraction and to give a brief overview of data-structure with focusing on provider-type and disease severity in an example of the treatment of depressive disorders. METHOD: The quality of the database is described and diagnosis rates of depression in outpatient care (ICD-10 diagnoses F32/33) in relation to the provider-type (i.e. general or somatic physician vs. physicians specialized in mental-health vs. psychotherapist) were calculated using Cramers V as a measure for effect size. RESULTS: The database consisted of 2,383,672 cases from 2015. Most depressive patients were diagnosed and treated by general or somatic physicians. A clear relationship between the severity of depression and provider-type is shown. In contrast to psychotherapists or physicians specialized in mental-health, general or somatic physicians diagnose a higher rate of unspecified depressive episodes.

Analysis of Age and Gender Structures for ICD-10 Diagnoses in Outpatient Treatment Using Shannon's Entropy.

INTRODUCTION: Diagnostic diversity has been in the focus of several studies of health services research. As the fraction of people with statutory health insurance changes with age and gender it is assumed that diagnostic diversity may be influenced by these parameters. METHODS: We analyze fractions of patients in Schleswig-Holstein with respect to the chapters of the ICD-10 code in outpatient treatment for quarter 2/2016 with respect to age and gender/sex of the patient. In a first approach we analyzed which diagnose chapters are most relevant in dependence of age and gender. To detect diagnostic diversity, we finally applied Shannon's entropy measure. Due to multimorbidity we used different standardizations. RESULTS: Shannon entropy strongly increases for women after the age of 15, reaching a limit level at the age of 50 years. Between 15 and 70 years we get higher values for women, after 75 years for men. DISCUSSION: This article describes a straight forward pragmatic approach to diagnostic diversity using Shannon's Entropy. From a methodological point of view, the use of Shannon's entropy as a measure for diversity should gain more attraction to researchers of health services research.

Markov Model of the Outpatient Classification System Morbidity Related Groups (MRG).

BACKGROUND: Benchmarking and guidance of outpatient physicians in Germany are almost always based on one year data. This also holds true for morbidity related groups, a classification system applied in northern Germany since 2017. A study of the markov properties of prescription based grouping algorithms is reported here. RESULTS: There is a strongly connected graph for almost all components and the resulting markov chain has a unique stationary solution. CONCLUSIONS: Target values based on the status quo of prescription behavior can provide stable guidelines for outpatient physicians. Every set of partitions converging like MRG should be considered for controlling measures.

Morbidity Related Groups (MRG) for Epidemiological Analysis in Outpatient Treatment.

Each patient in outpatient treatment is assigned per quarter and corresponding physician to a case group that is strongly related to the morbidity (Morbidity Related Group, MRG). MRG is defined by the drug group on a four character level in the international anatomic-therapeutic-chemical (ATC) classification with the largest costs as an indicator for the severity of the drug treatment. Using severity levels we get a risk adjustment with respect to age and polypharmacy as an indicator for multimorbidity and treatment intensity. By application of MRG groups we generate a patient type classification in relation to physicians and a distance structure of the medical disciplines.

Effects of communication training with the MAAS-Global-D instrument on the antibiotic prescribing for respiratory infections in primary care: study protocol of a randomised controlled trial.

BACKGROUND: Primary care physicians account for the majority of antibiotic prescribing in ambulatory care in Germany. Respiratory diseases are, regardless of effectiveness, often treated with antibiotics. Research has found this use without indication to be caused largely by communication problems (e.g. expectations on the patient's part or false assumptions about them by the physician). The present randomised controlled trial (RCT) study evaluates whether communication training for primary care physicians can reduce the antibiotic prescribing rate for respiratory tract infections. METHODS/DESIGN: The study consists of three groups: group A will receive communication training; group B will be given the same, plus additional, access to an evidence-based point-of-care tool; and group C will function as the control group. The primary endpoint is the difference between intervention and control groups regarding the antibiotic prescribing rate before and after the intervention assessed through routine data. The communication skills are captured with the help of the communication instrument MAAS-Global-D, as well as individual videos of physician-patient consultations recorded by the primary care physicians. These skills will also be regarded with respect to the antibiotic prescribing rate. A process evaluation using qualitative as well as quantitative methods should provide information about barriers and enablers to implementing the communication training. DISCUSSION: The trial contributes to an insight into the effectiveness of the different components to reduce antibiotic prescribing, which will also be supported by an extensive evaluation. Communication training could be an effective method of reducing antibiotic prescribing in primary care. TRIAL REGISTRATION: DRKS00009566 DATE REGISTRATION: 5 November 2015.