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.

Burden Experienced by Family Caregivers of Patients at the End of Life: What do General Practice Teams Offer?

The aim of the study: was to determine how far general practice teams are prepared to relieve family caregivers of palliative patients from their caregiving burden, the support they actually offer, and where they identify needs for improvement. Method: Focus groups and interviews on the issues of identification and support of family caregivers were conducted with practice teams (general practitioners, GPs, and medical assistants, MAs) and the results qualitatively analyzed. Results: 21 participants (14 GPs, 7 MAs) from 13 practices identified burdened family caregivers, thereupon offered support and provided contact details to local consultation services. They suggested to family caregivers that they should use their social network to create room for meeting their own needs. Conclusions: Practice teams use a multitude of individualized and unsystematic approaches to support family caregivers. In further studies within the framework of this project, systematic approaches will be identified and tried out.

[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.

[Recommendations of the updated LONTS guidelines. Long-term opioid therapy for chronic noncancer pain]. / Empfehlungen der aktualisierten Leitlinie LONTS. Langzeitanwendung von Opioiden bei chronischen nicht-tumorbedingten Schmerzen.

BACKGROUND: The regular update of the German S3 guidelines on long-term opioid therapy for chronic noncancer pain (CNCP), the"LONTS" (AWMF registration number 145/003), began in November 2013. METHODS: The guidelines were developed by 26 scientific societies and two patient self-help organisations under the coordination of the Deutsche Schmerzgesellschaft (German Pain Society). A systematic literature search in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Scopus databases (up until October 2013) was performed. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of the recommendations was established by multistep formal procedures, in order to reach a consensus according to German Association of the Medical Scientific Societies ("Arbeitsgemeinschaft der Wissenschaftlich Medizinischen Fachgesellschaften", AWMF) regulations. The guidelines were reviewed by the Drug Commission of the German Medical Association, the Austrian Pain Society and the Swiss Association for the Study of Pain. RESULTS: Opioids are one drug-based treatment option for short- (4-12 weeks), intermediate- (13-25 weeks) and long-term (≥ 26 weeks) therapy of chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia and low back pain. Contraindications are primary headaches, as well as functional somatic syndromes and mental disorders with the (cardinal) symptom pain. For all other clinical presentations, a short- and long-term therapy with opioid-containing analgesics should be evaluated on an individual basis. Long-term therapy with opioid-containing analgesics is associated with relevant risks (sexual disorders, increased mortality). CONCLUSION: Responsible application of opioid-containing analgesics requires consideration of possible indications and contraindications, as well as regular assessment of efficacy and adverse effects. Neither an uncritical increase in opioid application, nor the global rejection of opioid-containing analgesics is justified in patients with CNCP.

[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.

Eligibility of patients with peripheral arterial disease for participation in a community-based walking exercise program: a single-centre experience.

AIM: Eligibility of patients with peripheral arterial disease (PAD) for exercise therapy is the most important requirement for predicting their training group adherence. METHODS: In this prospective, exploratory study over a period of 1 year, a total of 462 PAD patients of an angiological outpatient routine care setting were consecutively recruited to the study. As non-eligibility criteria for exercise therapy were defined: resting pain or gangrene (Fontaine stage III and IV PAD), the inability to complete treadmill exercise, or premature treadmill discontinuation due to non-vascular walking pain. Also, PAD patients without subjective walking limitation (Fontaine stage I PAD) were assessed as unwilling, i.e. non-eligible for exercise training adherence. Criterion for patients eligibility was the occurrence of intermittent claudication on treadmill test (Fontaine stage II PAD). RESULTS: A total of 346 patients (age median 71 years, males 58.5%) were candidates for conservative therapy. Of them, 166 subjects (48%) were assessed as eligible for participation in walking exercise program. 180 of the patients (52%) were deemed as non-eligible to perform walking exercise therapy. 115 patients (33%) were physically limited by critical limb ischemia (Fontaine stage III and IV PAD), severe comorbid cardiovascular disease or orthopaedic disorder. In 65 PAD patients (19%) the subjective walking capacity was not restricted. Social, logistical or other factors were found in 27 patients (8%) to be barriers for exercise training commencement. CONCLUSION: In half of the PAD patients whose attendance in a community-based walking exercise program would be a therapeutically reasonable activity, a range of vascular and non-vascular factors are obstacles for participation. Further research is needed to investigate what measures might enhance the proportion of exercise therapy participants.

Low attendance of patients with intermittent claudication in a German community-based walking exercise program.

AIM: Exercise therapy is an efficacious treatment for patients with peripheral arterial disease (PAD). The study aimed to determine the initiation and adherence of PAD patients with intermittent claudication in a supervised community-based walking exercise program. METHODS: Over a period of one year, PAD patients with Fontaine stage II attending an angiological outpatient setting were consecutively recruited to the study. Willingness, commencement and adherence of patients in the training program were recorded. RESULTS: Of 462 patients with intermittent claudication, only 166 (36%) subjects fulfilled the requirements for participation in physical exercise training. Of these eligible patients, 110 (66%) persons accepted the invitation to attend exercise therapy. However, despite the commitment, 58 (35%) subjects failed to initiate attendance in the training program. Fifty-two (24%) patients did start the program but 16 (8%) patients did not complete more than three initial training sessions. Over a three-month period, regular attendance was registered for 36 (16%) patients. CONCLUSION: Although physical exercise improves symptoms and mobility of patients with intermittent claudication, only about one-third of them is commencing an exercise program. Through lacking initiation and discontinuation, only a small percentage of claudicants permanently engages in a walking exercise program.

[Specialized outpatient palliative care. The expectations of general practitioners]. / Spezialisierte ambulante Palliativversorgung. Die Erwartungen von Hausärzten.

BACKGROUND: The aim was to explore the expectations of general practitioners (GPs) towards specialized outpatient palliative care (SAPV) focused on older patients in the last phase of life. METHODS: A standardized postal survey was carried out with 1,962 GPs in Lower Saxony with an analysis of physician and practice-related factors. RESULTS: The response rate was 46% (n=897) and SAPV was known to 68% of the participants (n=599) of whom 48% (n=288) assumed that SAPV will improve the healthcare for older patients in the last phase of life. The GPs favored advice by and collaborative patient care with SAPV teams. Younger and female GPs, and GPs who had been practicing for a shorter period or working in a group practice showed greater interest in collaboration than other colleagues. CONCLUSIONS: The perception of patients in specialized palliative care with its current focus on cancer patients is different from the perception in general practice with its focus on geriatric and multimorbid patients. This may be a reason for the skepticism showed in this study whether SAPV will actually improve healthcare in the community. However, with respect to the concept and framework SAPV has the potential to fulfill GPs expectations and should be focused on counseling and collaborative services. The knowledge about physician and practice-related factors shaping GPs attitudes towards SAPV can be helpful to further implement SAPV into practice.

[Quality of primary medical care after in-patient stroke rehabilitation]. / Versorgungsqualität von Patienten nach Schlaganfallrehabilitation. (Hausärztliche Nordbaden-Schlaganfallnachsorgestudie [HANS]).

PURPOSE: Since only insufficient information concerning the further development of patients after stroke and rehabilitation is currently available, and since the quality of care provided by family doctors is often classified as insufficient, this quality of care was to be examined on the basis of the rehabilitation results. Of particular interest were the co-operation, the therapeutical quality standards and the risk management, as well as the quality of life and compliance of the patients. METHODS: In 2000, all 223 stroke patients were asked prior to their discharge from three large rehabilitation clinics in North Baden, and subsequently their 210 family doctors, whether they were prepared to participate in this follow-up study. The participating patients were examined at their discharge from the clinic as well as 6 and 18 months later using a standardised documentation package, and quality circles for family doctors were initiated. RESULTS: All patients with atrial fibrillation were treated to prevent thrombosis. Smoking showed a positive trend. Quality of life and knowledge of the sickness trend to increase, depressiveness decreases. 60 % of the contacted family doctors participated in the study, 29 % (33 out of 114 physicians at the end of the study) contributed to improve interdisciplinary co-operation. Although 87 % of the patients said to be well informed, 25 % were dissatisfied with their own compliance. CONCLUSION: The quality of care of stroke patients by family doctors as assessed by indicators for secondary prevention and quality of life is satisfactory under present conditions. Apart from the hypertension control there was no negative trend. However, participation of GPs was insufficient. Co-operative after-care by GP can relatively easily stabilise health conditions following inpatient rehabilitation.

[What students and teaching doctors in Heidelberg think about early patient contact and tasks in general practice]. / Was denken Heidelberger Studierende und Lehrärzte über frühzeitige Patientenkontakte und Aufgaben in der Hausarztpraxis?

BACKGROUND: In Heidelberg, the clinical curriculum of medical education was fundamentally changed in 2001 due to co-operation with the Harvard Medical School. The pre-clinical curriculum has also already been undergoing reform since 1995: the benefits of two new lectures with early patient contact and special tasks in the subject of family medicine were to be assessed. METHODS: In the first year, the students therefore had to assess the seminars, tutorials, and the internships in GP by means of a standardised questionnaire. In addition, reports had to be produced on teaching practice. The teachers were also questioned following agreement with and introduction of quality assurance measures. RESULTS: 66-89% of students assigned good marks to the internships in GP, 40-58% for the accompanying seminars, and 70% for the tutors. The results of a general external evaluation which was carried out slightly differently were not quite so good. 87-89% of teachers agreed upon the elaborated criteria for the quality of teaching practice. CONCLUSIONS: The results show that GP-based education is already well accepted in the first year of training, and that early patient contact in primary care is highly appreciated by the students. On their part, the teaching GPs assess the quality promotion sessions as instruments towards continuous quality support in pre-clinical training as meaningful and necessary, especially with regard to licensing for teaching in General practice.

[Quality assurance (general) at the medical school of Heidelberg as a model]. / Qualitätsförderung (allgemein-) medizinischen Hochschulunterrichts im Rahmen des Heidelberger Modells.

Because of new social and professional challenges, especially in the developed countries, there is a trend towards change and quality assurance is taking place in medical education over the past 20 years. In Heidelberg, the new way of teaching the students by general practitioners includes quality assurance by questionnaires, reports of practice visits, quality conferences of the teachers, and co-operation of the students. 90% of the students recommended the practice-based structured program as very useful, especially the work with the patients in the general practices, 87% of the teaching general practitioners accepted special criteria for teaching; by this way an academic general practice can be established to meet the future expectations of primary medical care.

[Therapy of recurrent exudative erythema multiforme. Effectiveness of thalidomide--report of a case]. / Therapie des rezidivierenden Erythema exsudativum multiforme. Wirksamkeit von Thalidomid--ein Fallbericht.

The authors report on the efficacy of thalidomide used to treat recurrent erythema exsudativum multiforme associated with herpes simplex with massive involvement of the entire skin and also the nasal mucosa in a 73-year-old woman. Efficacy in terms of healing and the prevention of recurrence proved to be very good.

The antidote effect of thiosulphate and hydroxocobalamin in formation of nitroprusside intoxication of rabbits.

Sodium nitroprusside (SNP) and hydroxocobalamin (HC) - in molar ratios of 1:4, 1:5, and 1:8, respectively - were infused simultaneously during 4 h into two veins of separate ears of conscious rabbits. Controls received HC only. Sodium thiosulphate (ST) was infused with SNP at molar ratios of 1:4, 1:5, and 1:10. The observation period was 48 h. With the lowest dose of HC (1:4), SNP produced a severe metabolic acidosis; three of ten animals died during the infusion, an additional six within 24 h. When the 1:5 ratio was administered, the acidosis was less marked, but still three of seven animals succumbed within 24 h. The highest dose (1:8) prevented acidosis, however three of eight animals died. All doses of HC caused histological changes in the liver, the myocardium, and the kidney, independently if given alone or with SNP. In contrast to this, ST had a complete antidote effect, if administered in a 1:5 ratio; no acidosis was demonstrable and death did not occur. In neither dosage ST could prevent histological changes in the liver, but the kidney and the heart were not affected. In contrast to HC ST alone did not cause histological alterations. Consequently, ST is the preferable antidote and is superior to HC for preventing or treating intoxications with SNP.