[How Patients View and Accept Health Care Services Provided by Health Care Assistants in the General Practice: Survey of Participants of the GP-centered Health Care Program in Baden-Wuerttemberg]. / Wie bewerten und akzeptieren Patienten die Betreuung durch Medizinische Fachangestellte in der Hausarztpraxis? Ergebnisse einer Patienten-Befragung in der HzV in Baden-Württemberg.

BACKGROUND: In recent years, models for the delegation of GP tasks to non-physician medical staff have been tested, implemented in a general practice setting and, to some extent, funded by health insurance companies. AIM: How were changes in the spectrum of tasks performed by non-physician staff viewed and accepted by patients? METHODS: Between October 2014 and January 2015, a written survey was conducted among chronically ill patients (≥ 65 years of age) receiving health care from health care assistants (HCA) with or without the additional "health care assistant in the family practice", or VERAH qualification. Using a self-developed survey, based on a previous collection of data, patients were asked about various aspects of health care provided by HCAs. RESULTS: 77 practices participated and a total of 1 266 patients were surveyed. The patients said the HCAs had a role to play in many aspects of their health care. More than half the patients said HCAs could take responsibility for some of the home visits and contacts in the practice. Almost without exception, patients regarded the organisational, healthcare and other supporting services performed by the HCAs as very good. The results were more heterogeneous for specific consulting services. While consultations on vaccinations, preventive services, medical examinations and medication adherence were well accepted, this was much less often the case with advice on lifestyle. Many patients see HCAs as additional and competent persons they can trust, and could well imagine HCAs taking on responsibility for further delegable services. CONCLUSION: At least among GP-centered health care programme participants, many healthcare services delegated to HCAs were appreciated and accepted by patients. Home visits and case management, in the sense of structured individual health care for patients with special needs, are further services that may be well suited for delegation. This should be investigated in further studies (including qualitative studies).

[Delegation of GP Work to Qualified Medical Staff in Germany - An Overview]. / Delegation hausärztlicher Tätigkeiten an qualifiziertes medizinisches Fachpersonal in Deutschland - eine Übersicht.

AIM: To assure nationwide provision of family medical care, a greater involvement of non-physician healthcare professionals has been discussed in Germany for some time. Currently, there are various delegation models. The aim of this study is to provide an overview of existing delegation models in a German family practice setting and to investigate to what extent they are implemented in practice. METHOD: Internet search was made for delegation models for non-physician healthcare staff, and various experts were contacted in April 2014. Models that explicitly addressed family practice, involved continuing education of more than 80 h, and for which health insurance funds bore the costs, were taken into consideration. The models were judged in accordance with the PDCA implementation cycle (Plan-Do-Check-Act). RESULTS: 6 delegation models used in family practice were identified for which only 4 qualifications were still available in 2014. The duration, content and aims of the training courses differed markedly. Since 2015, training to become a NäPA non-physician practice assistant (or a VERAH healthcare assistant in the family practice if the necessary supplementary qualification is achieved) is the basic qualification for which costs are reimbursed. However, one important quality criterion for its broad implementation, namely evaluation, is missing in NäPA training. Only the VERAH qualification fulfills all quality criteria. CONCLUSIONS: In order to fully implement the delegation models and to strengthen and promote the healthcare assistant profession, the delegation models for which training costs are generally reimbursable should satisfy all quality criteria and also be subject to continual evaluation.

Effects of a team-based assessment and intervention on patient safety culture in general practice: an open randomised controlled trial.

BACKGROUND: The measurement of safety culture in healthcare is generally regarded as a first step towards improvement. Based on a self-assessment of safety culture, the Frankfurt Patient Safety Matrix (FraTrix) aims to enable healthcare teams to improve safety culture in their organisations. In this study we assessed the effects of FraTrix on safety culture in general practice. METHODS: We conducted an open randomised controlled trial in 60 general practices. FraTrix was applied over a period of 9 months during three facilitated team sessions in intervention practices. At baseline and after 12 months, scores were allocated for safety culture as expressed in practice structure and processes (indicators), in safety climate and in patient safety incident reporting. The primary outcome was the indicator error management. RESULTS: During the team sessions, practice teams reflected on their safety culture and decided on about 10 actions per practice to improve it. After 12 months, no significant differences were found between intervention and control groups in terms of error management (competing probability=0.48, 95% CI 0.34 to 0.63, p=0.823), 11 further patient safety culture indicators and safety climate scales. Intervention practices showed better reporting of patient safety incidents, reflected in a higher number of incident reports (mean (SD) 4.85 (4.94) vs 3.10 (5.42), p=0.045) and incident reports of higher quality (scoring 2.27 (1.93) vs 1.49 (1.67), p=0.038) than control practices. CONCLUSIONS: Applied as a team-based instrument to assess safety culture, FraTrix did not lead to measurable improvements in error management. Comparable studies with more positive results had less robust study designs. In future research, validated combined methods to measure safety culture will be required. In addition, more attention should be paid to evaluation of process parameters. Implemented actions and incident reporting may be more appropriate target endpoints. TRIAL REGISTRATION: German Clinical Trials Register (Deutsches Register Klinischer Studien, DRKS) No. DRKS00000145.

Practice-based depression case management in primary care: a qualitative study on family doctors' perspectives.

BACKGROUND: Case management provided by health care assistants (HCAs) is effective in improving primary care for depressive patients. Little is known on the implementation-related aspects of case management performed in small family practices. OBJECTIVE: To explore family doctors' perspectives on clinical and organizational aspects of implementation of case management and perceived practice-related aspects associated with patient care after 1 year's experience of HCAs providing case management for depressive patients in their practices. METHODS: This qualitative study was nested in a cluster-randomized trial on case management provided by practice-based HCAs for patients with major depression in Germany. We used semi-structured interview guides and performed audio-taped interviews with family doctors. Full transcription and thematic content analysis were carried out. RESULTS: Twenty-three family doctors were interviewed. The family doctors perceived case management as beneficial to patients and reported that it improved their consultation styles and doctor-patient relationships. They implemented case management elements into their everyday day work using 'concrete', 'subsumed' or 'progressive' implementation styles. CONCLUSIONS: Family doctors perceived practice-based case management by HCAs as beneficial for patient care. Different implementation styles may be appropriate, depending on the health care setting, and this requires further evaluation.

The Patient Assessment of Chronic Illness Care questionnaire: evaluation in patients with mental disorders in primary care.

The Chronic Care Model provides evidence-based recommendations to improve the care for patients with chronic conditions. The Patient Assessment of Chronic Illness Care questionnaire (PACIC) is an instrument to evaluate the patient's perspective on receipt of care delivered in the five domains patient activation, delivery system, goal setting, problem solving, and follow-up. The aim of this study was to assess the psychometric characteristics of the PACIC in 442 primary care patients with major depression. The psychometric properties were good. We found possible ceiling effects in the two subscales 'patient activation' (12.9%) and 'problem solving/contextual' (8.9%), as well as floor effects in 'goal setting/tailoring' (4.6%). The Cronbach's α coefficient for the total scale was excellent (0.91). We found two major factors, which we labeled according to the PACIC domains as composite factors 'patient activation and problem solving' as well as 'goal setting and coordination'. The perspective of patients with mental disorders, such as depression, on primary chronic illness care can be assessed adequately by the PACIC.

[Garbage in - garbage out? Validity of coded diagnoses from GP claims records]. / Garbage in - Garbage out? Validität von Abrechnungsdiagnosen in hausärztlichen Praxen.

CONTEXT: ICD-10-coded diagnoses from claims records are frequently used as morbidity indicators for research as well as for risk adjustment purposes in quality management and remuneration. A requirement for this application is the high validity of the diagnoses. In GP practices in particular, it is questionable whether claims-based diagnoses realistically reflect the health problems of patients treated over a one year period. METHODS: In a retrospective cross-sectional study of a random sample of 250 patients from 10 GP practices we examined whether, on the basis of the patients' medical records, health problems treated in the year 2003 matched claims-based diagnoses within the same time period. RESULTS: In spite of a high mean of 6.1 claims-based diagnoses per patient, health problems treated within the study period were under-reported in 30% of the cases, mainly relating to non-severe diagnoses frequently encountered in GP practice, chronic conditions not requiring medication, and diagnoses justifying a screening test. An over-reporting for diseases not treated within the study period was observed in 19% of the cases, most often in the case of permanent chronic conditions. In 11% of cases the ICD-10 codes of claims-based diagnoses and the diagnoses in the medical records did not match ("erroneous codes"). For six of the diagnoses most common in GP practice (hypertension, diabetes, hyperlipoproteinemia, cardiovascular disease, back pain, and acute respiratory tract infections) correctness at 71-93% was higher than completeness (56-86%). CONCLUSION: The low validity of ICD-10-coded diagnoses from GP claims records calls their usefulness as morbidity indicators into question.

Appropriateness and surveillance of medication in a cohort of diabetic patients on polypharmacy.

CONTEXT: It is assumed that with increasing polypharmacy, medication surveillance by the General Practitioner (GP) and adherence to the therapy regimen by the patient will both decline. AIM OF THE STUDY: We evaluated clinical and medication records taken from GP documentations in a cohort of 102 diabetic patients (48 f, 54 m, median age 70, range 39 - 81) with 3 or more chronic prescriptions. Patients were asked about their current medication and its tolerability by means of a structured telephone interview. RESULTS: 45% of the patients received up to 6 medications, 36% 7 - 9 and 19% > 10. The main comorbidity was hypertension (93%) and symptomatic CAD (39%). The use of established medications (beta-blockers and ACE inhibitors) for these comorbidities was appropriate. Although 76% were eligible for a statin therapy, only 51% actually took a statin, and 28% had a dose lower than the defined daily dose. 68% of the patients had no prescriptions other than those recorded in the GP documentation, but 8% of the total number of medicines taken by the patients were not recorded in the GP's database. 62% of patients took all the medication prescribed by the GP, while 7% of all medicines recorded in the GP's database were not taken by the patients. In 10% of cases, an incompatible medication (defined in accordance with a consented list) was taken by the patient. 81% of patients regularly (twice per year) had their HbA1c checked, but only 62% had their potassium levels checked, despite the use of ACI and diuretics. Most patients knew the reason for taking at least one medication, but 18% knew this for less than half of their (multiple) medications. 70% of the patients said they had been informed about the possible risks of their medication by the GP, and 7% knew the risks for only one medication. CONCLUSION: In this cohort of patients on polypharmacy and with a high risk profile for adverse drug reactions, we found a mismatch between GPs' documentation of prescriptions and the medication taken by the patient. Patients had no detailed knowledge about indications and almost no knowledge about risks. Although the overall performance of therapy (appropriateness) was deemed sufficient, there would appear to be room for improvement in order to fill information gaps and strive for stricter surveillance.

"Every error counts": a web-based incident reporting and learning system for general practice.

BACKGROUND: Incident reporting systems have been established primarily in the inpatient setting. Their goal is the identification of safety risks in healthcare as a precondition for improvements in the overall quality of care. Knowledge about medical errors in general practice is sparse, as are reporting systems for patient safety in this setting. This article describes the development, structure and initial results of an incident reporting system for general practices in German-speaking countries. METHODS: Jeder Fehler Zaehlt (JFZ; www.jeder-fehler-zaehlt.de) is a web-based reporting system that receives incident reports from anonymous German-speaking users. Reports are fed into a database, classified and analysed by a team of experts. Exemplary reports are published on the internet and in journals, and the reporting system provides the opportunity for users to comment on and learn from these incidents. RESULTS: The incident reporting system received 199 reports in the 17 months following its launch, of which 188 were classifiable. Of these, 72.9% were classified as process errors and 26.1% as knowledge/skills errors. The most frequently reported process errors were treatment errors (32.2%), communication errors (12.6%) and investigation errors (8.5%). Of the classified errors, 41.5% were associated with harm to the patient. More than 300 comments were made, mostly by anonymous users of the system. CONCLUSIONS: JFZ is a well-functioning and growing incident reporting system. Future efforts to improve the benefits of incident reporting will concentrate on increasing the utilisation of the system and broadening the spectrum of reported incidents.

Case management to improve major depression in primary health care: a systematic review.

BACKGROUND: Deficits in the care of depression lead to poor medication adherence, which increases the risk of an unfavourable outcome for this care. This review evaluates effects on symptoms and medication adherence of case management in primary health care. METHOD: A systematic literature search was performed. The quality of the studies was rated according to the Cochrane Effective Practice and Organization of Care Group (EPOC) criteria. To conduct a subgroup analysis interventions were classified as either 'standard' or 'complex' case management. RESULTS: Thirteen studies met the inclusion criteria. In a meta-analysis we calculated a standard mean difference/effect size on symptom severity after 6-12 months of -0.40 (95% CI -0.60 to -0.20). Patients in the intervention groups were more likely to achieve remission after 6-12 months [relative risk (RR) 1.39, 95% CI 1.30-1.48]. The relative risk for clinical response was 1.82 (95% CI 1.68-2.05). Patients in intervention groups had better medication adherence than the control group (RR 1.5, 95% CI 1.28-1.86). We found heterogeneous results when assessing effects of different types of intervention. CONCLUSIONS: We conclude that case management improves management of major depression in primary health-care settings.

The development of quality circles/peer review groups as a method of quality improvement in Europe. Results of a survey in 26 European countries.

BACKGROUND: Peer review groups (PRGs) and quality circles (QCs) commenced in The Netherlands and have grown to become an important method of quality improvement in primary care in several other European countries. OBJECTIVE: Our aim was to provide an overview of QC/PRG activities and exemplary programmes in European countries. METHODS: A survey was performed in three consecutive steps by EQuiP (European Working Party on Quality in Family Practice), which is a representative association of experts from 26 European countries. The national representatives initially completed a structured questionnaire documenting the number and objectives of QCs/PRGs, sources of support and special programmes in their countries (step 1). In step 2, these sources were used to extend and validate the expert statements. Step 3 studied paradigmatic initiatives in depth. RESULTS: Step 1 took place in 2000; the response rate was 100% (26 countries). QCs/PRGs were very active in 10 countries; 16 countries showed little or no activity. Participation ranged from <2 to 86% of all GPs. Step 2 concentrated upon the countries with a high level of activity. Development appeared to be associated with establishment in private practice and the portion of GPs with vocational training. Eight programmes from six countries describing the establishment and the targeting of QC/PRG work are presented as case reports (step 3). CONCLUSION: In the last 10 years, substantial development of QCs/PRGs has taken place in The Netherlands, the UK, Denmark, Belgium, Ireland, Sweden, Norway, Germany, Switzerland and Austria. Further evaluation is needed to clarify the impact on quality of care.

[Importance and possibilities of general guidelines in family practice strategies--do we need 'basic guidelines' in general practice?]. / Bedeutung und Möglichkeiten von allgemeinen Leitlinien für hausärztliche Versorgungsstrategien--Brauchen wir 'Basisleitlinien' in der Allgemeinmedizin?

General practice is distinguished particularly by complex patient problems and generic competencies to act and counsel as a family practitioner. Guidelines which are only centered on clinical topics like diagnoses, treatments etc. are not sufficient to support action and decision in general practice. The article proposes the concept of generic guidelines (basic guidelines) for family medicine. A need for basic guidelines in general practice is established in three areas: 1) cross sectional patient problems (e.g. care for immigrants, common strain and distress, counselling of screening procedures), 2) basic skills and strategies in family practice (e.g. problem-oriented consultation, home visits, patient information and informed consent), and 3) practice management and documentation. The development of generic guidelines seems to be difficult as the efforts to evidence-based professional practice are only recently started, but this is matched by the high importance of guidance for general practice, and certain concepts of family medicine support it. It is concluded that the development of basic guidelines in general practice will have a considerable impact on structuring the framework and fostering the quality improvement of general practice.

[Continuing medical education from the view of ambulatory care physicians--representative outcomes and needs in Bremen and Saxony-Anhalt]. / Arztliche Fortbildung aus der Sicht niedergelassener Arztinnen und Arzte--repräsentative Ergebnisse aus Bremen und Sachsen-Anhalt.

RESEARCH QUESTION: To study the habits of ambulatory care physicians in CME, and to investigate the motivating and negative experiences with different types of CME in Germany. METHODS/SETTING: Survey with a five-page questionnaire posted to all ambulatory care physicians in the German states of Saxony-Anhalt (n = 3139) and Bremen (n = 1131). RESULTS: Response rates were 61.8% in Saxony-Anhalt and 41.7% in Bremen. 2412 questionnaires were available in this largest survey on that topic in Germany. Mean time devoted to CME was 4.6 hours per week, the respondents participated on the average at 14 CME-events per year. A content analysis was made to investigate positive and negative experiences. Practice orientation and personal exchange in small groups was appraised; criticism was mostly directed towards the efficiency and effectiveness of CME at large events (e.g. congresses). CONCLUSIONS AND SUGGESTIONS: Regionally performed surveys are able to guide the planning of CME about habits, wants and needs of the target group and may increase the attendance as well as the involvement. Motivating as well as critical experiences of the participants should be regarded more rigorously in the planning. Consideration can increase the quality and the impact of CME. This applies the more, when certification of the quality of CME and of individual CME-efforts are planned. This article will be followed in one of the next issues by a second from the same survey focusing on the attitudes of ambulatory care physicians towards quality improvement and their intentions to join quality circles (peer review groups).

[The DEGAM-concept--development, dissemination, implementation and evaluation of guidelines for general practice]. / Das DEGAM-Konzept--Entwicklung, Verbreitung, Implementierung und Evaluation von Leitlinien für die hausärztliche Praxis.

The German Society for General Practice/Family Medicine (DEGAM) has launched a project to develop and implement national guidelines for general practice accordingly to international models. Guidelines are seen as statements to assist practitioners and patients in deciding about appropriate, effective and efficient health care. They should be evidence-based, feasible for primary care practices, and purposefully addressing to physicians as well as practice staff and patients. The development follows a comprehensive and well-structured programme (10 stages) which requires the appraisal of medical evidence, the involvement of experienced general practitioners on various stages (primary review, feasibility testing), and comments of concerned specialists, before a guideline is promulgated. Implementation of each guideline is promoted by at least five tools (full text, quick reference guide, telephone card for practice staff; patient leaflet, and information-prescription--"infozept"). Methodological quality is checked for the first time in Germany according to the standards of the German Agency for Quality Assurance. Different targets and criteria for evaluation of guidelines in primary care are mandatory part of the DEGAM-concept.

[Promoting quality and quality circles from the viewpoint of established physicians--representative Bremen and Saxony-Anhalt results]. / Qualitätsförderung und Qualitätszirkel aus der Sicht niedergelassener Arztinnen und Arzte--repräsentative Ergebnisse aus Bremen und Sachsen-Anhalt.

RESEARCH QUESTION: To study the attitudes of ambulatory care physicians towards quality improvement, the intentions to join quality circles (QCs, peer review groups) and the expectations directed towards them. METHODS/SETTING: Survey with a five-page questionnaire posted to all ambulatory care physicians in the German states of Saxony-Anhalt (n = 3139) and Bremen (n = 1131). RESULTS: Response rates were 61.8% in Saxony-Anhalt and 41.7% in Bremen. 2412 questionnaires were available in this largest survey on that topic in Germany. Necessity of quality improvement (QI) in ambulatory care was approved by the majority of the respondents (1.7 on a 5-point Lickert scale). Concerns existed about a rise in control and the risk of abuse of QI measures. 56.4% in Saxony-Anhalt and 52.3% in Bremen had the intention to join a QC. Motives and impediments of participation in QCs were investigated by content analysis. A causal dominance analysis was performed to identify the key elements for the decision to participate. The main benefits of QC-participation were expected as assistance in daily practice and exchange of experiences. The major obstacles were professional and private duties, fear of control and inefficiency. CONCLUSIONS: Policies that could be adequate to rise motivations and tackle on widespread fears should be purposely adapted to the needs and expectations of the physicians.

[Quality management in medicine--definitions and goals]. / Qualitätsmanagement in der Medizin--Definitionen und Ziele.

The meanings of the terms "quality", "quality of care", and "quality management" were clarified with common international definitions. Based on that, the basic ideas, concepts, and objectives of quality management in medicine were explained. Finally some future trends related to quality were viewed, which represent challenges for the medical profession and entire medicine.

Quality circles in ambulatory care: state of development and future perspective in Germany.

OBJECTIVE: To survey the quantitative development of quality circles (peer review groups; QC) and their moderators in ambulatory care in Germany, to describe approaches to documentation and evaluation, to establish what types of facilities and support is available and to assess opinions on the future importance of QC. DESIGN: Cross-sectional survey using a standardized questionnaire and supplementary telephone interviews. SETTING: All 23 German regional Associations of Statutory Health Insurance Physicians (ASHIP) were surveyed. RESULTS: The total number of QC in ambulatory care in Germany increased rapidly from 16 in 1993 to 1633 in June 1996, with about 17% (range 1.0-52.1%) of all practicing physicians (112 158) currently involved. Throughout Germany, 2403 moderators were trained in 168 training courses by the qualifying date. Follow-up meetings were held or being planned in 20 ASHIP, with approximately 39% (23-95%) of the moderators participating. Systematic documentation of QC work was undertaken or planned in all 23 ASHIIP, and 10 ASHIP carried out comparative evaluation, with at least five others planning to start it. The ASHIP promoted the work of QC by providing organizational (22) or financial (20) support, materials (20) or mediation of resource persons (16). Eleven ASHIP received grants from drug companies. ASHIP rated the future importance of QC as increasing (18) or stable (four), but in no case as decreasing. CONCLUSIONS AND RECOMMENDATIONS: The quantitative growth of QC in Germany is encouraging, but the extent of support and evaluation appears insufficient. Increased methodological support and facilitation, follow-up meetings on a more regular basis, improved documentation and evaluation of individual QC, and problem oriented evaluation of their impact on health care are essential for further successful development. Principles, problems and solutions discussed may be relevant for similar QI activities in other countries.

[Case-oriented work in the quality circle]. / Fallorientiertes Arbeiten im Qualitätszirkel.

Considering the discrepancy between scientific knowledge and definite behaviour during consultation ("performance gap"), acceptance, proceedings and case oriented work in quality circles/peer review groups are described. 79% of 138 general practitioners declared that working in quality circles should base on cases from daily practice. Exchange of experiences and the expectation to get help for solving specific problems in the daily practice are the most important motives for participating in quality circles. For one circle as an example, the process of topic and case oriented work on the basis of objective documents from the practices of the participants and the following case oriented development of guidelines are described. Finally, the implicit chances of case oriented work in quality circles are shown with respect to existing experiences.

[Evaluation of a training program for moderators of panel doctor quality circles: a progress assessment]. / Evaluation eines Trainingsprogramms für Moderatoren von vertragsärztlichen Qualitätszirkeln: Eine Zwischenbilanz.

We report about the first 7 seminars of a training programme for presenters of quality circles for panel doctors. The seminars aim to train techniques of moderating a group and to give a methodological background for the work with quality circles. 65 (44.2%) of the 147 participants were general practitioners, 34 (23.1%) were internists and 32 (21.8%) were specialists of other disciplines. 16 (10.9%) were not physicians or not working as a physician. An evaluation of the seminars by a structured questionnaire showed mean ratings of 2.1 for lectures [in terms of school-marks from 1 (very good) to 6 (very poor)] and 1.8 for the work in small groups. Working atmosphere and opportunities for active participation were rated most positively. 6 months after the course, 64.9% of the participants already had arranged dates for meetings or had started with own quality circles.