The effect of depressive symptoms on quality of life and its different facets in the oldest age population: evidence from the AgeQualiDe prospective cohort study.

PURPOSE: The present study aims to investigate the prospective effect of depressive symptoms on overall QoL in the oldest age group, taking into account its different facets. METHODS: Data were derived from the multicenter prospective AgeCoDe/AgeQualiDe cohort study, including data from follow-up 7-9 and n = 580 individuals 85 years of age and older. Overall QoL and its facets were assessed using the WHOQOL-OLD instrument. The short form of the geriatric depression scale (GDS-15) was applied to assess depressive symptoms. Cognitively impaired individuals were excluded. Linear mixed-effects models were used to assess the effect of depressive symptoms on QoL. RESULTS: Depressive symptoms were significantly associated with overall QoL and each of the different facets of WHOQOL-OLD, also after adjustment for time and sociodemographic characteristics such as age, gender, education, marital status, living situation, and cognitive status. Higher age and single as well as divorced marital status were also associated with a lower QoL. CONCLUSION: This work provides comprehensive longitudinal results on the relationship between depressive symptoms and QoL in the oldest age population. The results underscore the relevance of tailored and targeted care planning and the development of customized interventions.

[Actual Duration of Postgraduate Training of Medical Residents in Germany: Results of the KarMed Study Ten Years After Physician Licensure]. / Reale Dauer der fachärztlichen Weiterbildung in Deutschland ­ Ergebnisse der KarMed-Studie zehn Jahre nach Approbation.

BACKGROUND: Professional qualification as a doctor of medicine includes completion of medical studies and residency. Data on the real duration of residency are currently not assessed systematically in Germany. OBJECTIVES: Our study aimed to analyze data on the real length of residency under consideration of area of expertise (specialization), part-time working, grades after school and medical studies, gender, and parenthood of the physicians in residency. MATERIAL AND METHODS: The KarMed Study's database consists of annual postal surveys throughout the entire residency of medical students, beginning with their "Practical Year" in 2008/2009 until 2019. The study analyzed data six and ten years within this residency period. RESULTS: The majority of the residents was capable of finishing their residency within the minimal time. One significant effect on actual duration of residency was the subject choice. One-third of the female residents had not yet finished their residency after ten years. Partenhood had a significant effect on female residents, but not on male residents. A regression analysis showed (R²corr=0.03, p<0.001) that the duration of residency was associated with the grade received after studying (ß=0.30). Male residents were more satisfied with the overall residency then female residents. DISCUSSION: Structural improvement in postgraduate training needs to be adjusted in terms of parental status. Prospective studies should take the selection process of universities into account and examine its association with the time required to complete residency.

Factors Leading to Institutionalization among the Oldest Old: Longitudinal Findings from the AgeCoDe-AgeQualiDe Study.

INTRODUCTION: Due to the strong association between old age and the need for long-term care, the number of individuals in need for care is projected to increase noticeably. The aim of this study was to examine the determinants of institutionalization among the oldest old longitudinally. METHODS: Longitudinal data (follow-up [FU] wave 7-9) were gathered from a multicenter prospective cohort study ("Study on needs, health service use, costs and health-related quality of life in a large sample of oldest old primary care patients [85+]," AgeQualiDe). At FU wave 7, in 2014, complete measures were available for 763 individuals. The average age was 88.9 (standard deviation 2.9) years (range 85-100), and 68% were female. Sociodemographic and health-related independent variables (e.g., depressive symptoms or functioning) were included in the regression model. Institutionalization (admission to assisted living home or nursing home) was used as an outcome measure. Logistic random-effects models were used. RESULTS: Regressions revealed that among oldest old, the odds of being institutionalized were lower for men (odds ratio [OR] = 0.03; 95% confidence interval [CI] 0.00-0.16). Institutionalization was associated with an increased age (OR = 1.27; 95% CI 1.04-1.55). Additionally, widowed individuals (ref. non-widowed) had higher odds of being institutionalized (OR = 8.95; 95% CI 1.61-49.81). Institutionalization was also associated with functional decline (OR = 0.16; 95% CI 0.11-0.23), whereas it was not significantly associated with cognitive decline, depressive symptoms, and social support. CONCLUSION: Our findings stress the importance of gender, age, widowhood, and functional decline for institutionalization among the oldest old. Preventing or at least postponing functional decline might help to delay institutionalization as far as possible.

The moderating effects of social support and depressive symptoms on pain among elderly multimorbid patients-data from the multicentre, prospective, observational cohort study MultiCare.

OBJECTIVES: Depressive symptoms and chronic pain are common among patients with multimorbidity creating a complex medical condition for both the patient and the general practitioner. Perceived social support may function as a protective measure.To examine the impact of perceived social support as a potential moderator between depressive symptoms and pain intensity and pain disability in daily activities in multimorbid patients aged 75+. METHOD: Data from 3,189 patients of the German longitudinal cohort study MultiCare were obtained at baseline and follow-ups during 5 years. Multilevel linear mixed-effects analyses were conducted for pain intensity (model 1) and pain disability in daily activities (model 2). The interaction term social support by depression score was included to test for moderation. RESULTS: The interaction between social support and depressive symptoms was significantly associated with the pain intensity score 0.41 (SE=.17; 95-CI[.08;.74]) but not with the pain disability score 0.35 (SE=.19; 95-CI[-.01;.72]). Additionally, men and individuals with medium or higher educational level showed reduced pain intensity and disability scores. Pain disability scores increased with age and depressive symptoms. Increased pain scores were also found for body mass index and burden of multimorbidity. CONCLUSION: Perceived social support amplified the association of depressive symptoms on pain intensity and did not show a protective function. The high scores of perceived social support among the participants may point to the practice of secondary gain due to the patients immense health burden.

Predictors of change in depressive symptoms in older and multimorbid patients: a longitudinal analysis of the multicare cohort.

BACKGROUND: Depression in older adults is becoming an increasing concern. As depressive symptoms change over time, it is important to understand the determinants of change in depressive symptoms. The aim of our study is to use a longitudinal study design to explore the predictors of change, remission and incident depression in older patients with multimorbidity. METHODS: Data from the MultiCare cohort study were used. The cohort studied 3,189 multimorbid general practice patients aged 65-85. Data were collected during personal interviews. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS-15). Predictors of change in depressive symptoms were determined using multivariate linear regression, while multivariate logistic regression was used to analyze predictors of remission and incident depression. Models included depressive symptoms at baseline and follow-up, socio-demographics and data on health status and social support. RESULTS: Overall, 2,746 participants with complete follow-up data were analyzed. Mean age was 74.2 years, 59.2% were female, and 11.3% were classified as depressed at baseline. Burden of multimorbidity and social support were statistically significant predictors in all regression analyses. Further predictors of change in depressive symptoms were: income, pain, nursing grade, self-rated health and self-efficacy. LIMITATIONS: The sample size for prediction of remission limited statistical certainty. Assessment of depressive symptoms using GDS-15 differs from routine clinical diagnoses of depression. CONCLUSIONS: Predictors of change in depressive symptoms in older multimorbid patients are similar to those predicting remission and incident depression, and do not seem to differ significantly from other older patient populations with depressive symptoms.

Final-year medical students' self-assessment of facets of competence for beginning residents.

BACKGROUND: Final-year undergraduate medical students often do not feel well prepared for their start of residency training. Self-assessment of competences is important so that medical trainees can take responsibility for their learning. In this study, we investigated how final-year medical students self-assessed their competences as they neared their transition to postgraduate training. The aim was to identify areas for improvement in undergraduate training. METHODS: In the academic year 2019/2020, a national online survey was sent to final-year undergraduate medical students via their respective medical schools. The survey included ten facets of competence (FOC) most relevant for beginning residents. The participants were asked to self-assess their competence for each FOC on a 5-point Likert scale (1: strongly disagree to 5: strongly agree). We established an order of self-assessed FOC performance by means and calculated paired t-tests. Gender differences were assessed with independent t-tests. RESULTS: A total of 1083 students from 35 medical schools completed the questionnaire. Mean age was 27.2 ± 3.1 years and 65.8% were female. Students rated their performance highest in the FOCs 'Teamwork and collegiality' and 'Empathy and openness' (97.1 and 95.0% 'strongly agree' or 'agree', respectively) and lowest in 'Verbal communication with colleagues and supervisors' and 'Scientifically and empirically grounded method of working' (22.8 and 40.2% 'strongly disagree', 'disagree', or 'neither agree nor disagree', respectively). Women rated their performance of 'Teamwork and collegiality', 'Empathy and openness', and 'Knowing and maintaining own personal bounds and possibilities' significantly higher than men did (Cohen's d > .2), while men showed higher self-assessed performance in 'Scientifically and empirically grounded method of working' than women (Cohen's d = .38). The FOCs 'Responsibility', 'Knowing and maintaining own personal bounds and possibilities', 'Structure, work planning, and priorities', 'Coping with mistakes', and 'Scientifically and empirically grounded method of working' revealed lower self-assessed performance than the order of FOC relevance established by physicians for beginning residents. CONCLUSIONS: The differences between the level of students' self-assessed FOC performance and physicians' ranking of FOC relevance revealed areas for improvement in undergraduate medical education related to health system sciences. Final-year students might benefit from additional or better training in management skills, professionalism, and evidence-based medicine. Surveys of self-assessed competences may be useful to monitor competence development during undergraduate training.

[The Impact of Parenthood, Support, and Short-Term Contracts on Work-Family Conflict of Female and Male Residents' Career]. / Der Einfluss von Elternstatus, erlebter Unterstützung und Befristung auf das Belastungserleben und die Karriereentwicklung von Ärztinnen und Ärzten am Ende der Weiterbildung.

BACKGROUND: Work factors and work-family interference play an important role in physicians leaving clinical practice. OBJECTIVES: The purpose of this study was to examine residents' work-family conflict and family-work conflict in association with parental status, perceived support, and short-term contracts. MATERIAL AND METHODS: Data acquisition was carried out within the multi-centric and prospective "KarMed" study in Germany at the end of the postgraduate training in 2016 (N=433). The Work-Family Conflict and Family-Work Conflict scales were used. Further independent variables were gender, parental status, short-term contracts, and perceived support from partner. Results Female physicians with children interrupted postgraduate training five times more often then female physicians without children and 18 times more often than male physicians with children. Female as well as male physicians with children showed greater family-work conflicts, and female physicians without children scored higher on work-family conflict. Male physicians did not show significant results on work-family conflict. Neither short-term contracts nor perceived support from the partner had a significant influence on work-family or family work conflict. CONCLUSIONS: There is a need to reduce work-family conflicts and their associated factors in female resident physicians.

[Influence of partnership on burnout and gratification crisis in residents considering the distribution of house work and working time]. / Zum Einfluss von Partnerschaft auf Burnout und Gratifikationskrisen bei Ärzten und Ärztinnen in fachärztlicher Weiterbildung unter Berücksichtigung der Aufteilung von beruflicher Tätigkeit und Hausarbeit.

Background: Social support through the partner can have an impact on work related stress perception of physicians. So far, there is no empirical data on the association of gratification crisis and social support through the partner in physician's profession. Objectives: This study evaluates the effects of social support, in terms of distribution of house work and amount of working time within a partnership, on burnout and gratification crisis of residents. Material and Methods: Data acquisition was carried out within the multi-centric and prospective "KarMed" study in Germany at the end of the postgraduate training in 2016 (N = 433). The ERI and MBI scales were used. Results: Results yielded significant effects of distribution of house work and the amount of working time on gratification crisis and burnout. Conclusions: The satisfaction with the distribution of house work as well as working time in a partnership plays an important role for the wellbeing of residents. In terms of decreasing numbers of outpatient practices, the results of the present study underlie the relevance of work-life balance.

Correlates of institutionalization among the oldest old-Evidence from the multicenter AgeCoDe-AgeQualiDe study.

OBJECTIVES: There is a lack of studies identifying the correlates of institutionalization specifically among the oldest old. Therefore, our aim was to fill this gap in knowledge. METHODS: Cross-sectional data (Follow up wave 9; n = 633 observations in the analytical sample) were used from the multicenter prospective cohort study "Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" Correlates of institutionalization among the oldest old-Evidence from a multicenter cohort study. The sample consists of primary care patients aged 86 years and over (mean 90.5 years, SD: 2.9 years). Sociodemographic and health-related independent variables were included in our regression model. Institutionalization was defined as living in a nursing home or an old-age home (not including assisted living facilities). RESULTS: Out of the 633 participants, 502 individuals (79.3%) did not live in an institutionalized setting, whereas 73 individuals (20.7%) lived in an institutionalized setting. Multiple logistic regressions showed that the likelihood of institutionalization increased with being divorced/widowed/single (compared to being married; OR: 5.35 [95% CI: 1.75-16.36]), the presence of social isolation (OR: 2.07 [1.20-3.59]), more depressive symptoms (OR: 1.11 [1.01-1.23]), increased cognitive impairment (OR: 1.67 [1.31-2.15]) and higher levels of frailty (OR: 1.48 [1.07-2.06]). CONCLUSION: The study findings identified various sociodemographic and health-related factors associated with institutionalization among the oldest old. Longitudinal studies are required to gain further insights into these associations.

Effects of APOE e4-allele and mental work demands on cognitive decline in old age: Results from the German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe).

OBJECTIVES: Previous studies have observed protective effects of high mental demands at work on cognitive functioning and dementia risk. However, it is unclear what types of demands drive this effect and whether this effect is subject to a person's genetic risk. We investigated to what extent eight different types of mental demands at work together with the APOE e4 allele, a major risk gene for late-onset Alzheimer's disease, affect cognitive functioning in late life. METHODS/DESIGN: The population-based German Study on Ageing, Cognition, and Dementia in Primary Care Patients (AgeCoDe, n = 2 154) followed cognitively healthy individuals aged 75 years and older in seven assessment waves. Cognitive functioning was assessed via the mini-mental status examination. RESULTS: Mixed-effects modeling (adjusted for education, gender, marital status, stroke, depression, and diabetes) indicated that participants who had an occupational history of working in jobs with high compared to low demands in "Language & Knowledge", "Pattern detection", "Information processing", and "Service" had a slower cognitive decline. APOE e4-allele carriers had an accelerated cognitive decline, but this decline was significantly smaller if they had a medium compared to a low level of demands in contrast to non-carriers. CONCLUSIONS: Our longitudinal observations suggest that cognitive decline could be slowed by an intellectually enriched lifestyle even in risk gene carriers. Fostering intellectual engagement throughout the life-course could be a key prevention initiative to promote better cognitive health in old age.

Low health literacy is associated with higher risk of type 2 diabetes: a cross-sectional study in Germany.

BACKGROUND: Low health literacy is believed to be associated with behaviours that increase the risk of type 2 diabetes. But there is limited knowledge on the relation between health literacy (HL) and diabetes risk, and whether improving HL could be a potential prevention strategy. Therefore, the main purpose of this study was to examine the link between HL and diabetes risk among non-diabetic adults. METHODS: We used data from the Hamburg Diabetes Prevention Survey, a population-based cross-sectional study in Germany. One thousand, two hundred and fifty-five non-diabetic subjects aged 18-60 years were eligible. The German Diabetes Risk Score (GDRS, ranging 0 to 123 points) was used to determine the individual risk of type 2 diabetes. The short version of the European Health Literacy Questionnaire (HLS-EU-Q16, ranging 0 to 16 points) was applied to assess the individual self-reported HL. Subjects were asked to self-estimate their diabetes risk, which was then compared with the calculated GDRS. Descriptive statistics were calculated to investigate group differences in the GDRS and self-estimated diabetes risk. Linear as well as logistic regression models were performed to analyse potential influencing variables of the GDRS as well as incorrect self-estimated diabetes risk. In three nested statistical models for each outcome, these analyses were adjusted for age, gender, educational level and the presence of chronic conditions. RESULTS: According to the criteria of the GDRS, 996 (79.4%) subjects showed "low risk", 176 (14.0%) "still low risk", 53 (4.2%) "elevated risk", and 30 (2.4%) "high to very high risk" to develop type 2 diabetes within the next 5 years. In the statistical models including all control variables, subjects with "inadequate HL" scored 2.38 points higher on the GDRS (95% CI 0.378 to 4.336; P = 0.020) and had a 2.04 greater chance to estimate their diabetes risk incorrectly (OR 2.04; 95% CI 1.33 to 3.14; P = 0.001) compared to those with "sufficient HL". CONCLUSION: The risk of type 2 diabetes is increased in people with inadequate self-reported HL. People with high diabetes risk and inadequate HL might be provided with educational programs to improve diabetes knowledge and reduce behavioural risk factors.

Driving status and health-related quality of life among the oldest old: a population-based examination using data from the AgeCoDe-AgeQualiDe prospective cohort study.

BACKGROUND: It is almost unknown whether the driving status is associated with HRQOL among individuals in highest age. AIMS: Based on a multicenter prospective cohort study, the objective of this study was to examine whether the driving status is associated with health-related quality of life (HRQOL) among the oldest old in Germany. METHODS: Cross-sectional data from follow-up wave 9 (n = 544) were derived from the "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe). Average age was 90.3 years (± 2.7; 86 to 101 years). The current driver status (no; yes) was used in our analysis. The EuroQoL EQ-5D questionnaire was used to assess HRQOL in this study. RESULTS: Regression analysis showed that being a current driver was associated with the absence of problems in 'self-care' [OR 0.41 (95%-CI 0.17 to 0.98)], and 'usual activities' [OR 0.48 (0.26 to 0.90)], whereas it was not significantly associated with problems in 'pain/discomfort' [OR  0.82 (0.47 to 1.45)] and 'anxiety/depression' [OR  0.71 (0.36 to 1.39)]. Being a current driver was marginally significantly associated with the absence of problems in 'mobility' [OR 0.60 (0.34 to 1.06)]. While being a current driver was not associated with the EQ-VAS in the main model, it was positively associated with the driving status (ß = 5.00, p < .05) when functional impairment was removed from the main model. DISCUSSION: Our findings provide first evidence for an association between driving status and HRQOL among the oldest old. CONCLUSIONS: Future longitudinal studies are required to evaluate a possible causal relationship between driving status and HRQOL in very old individuals.

[Reflections on the attractiveness of General Internal Medicine and its Sub-Specialties in German Postgraduate Medical Education]. / Eine Abstimmung mit den Füßen gegen die Spezialisierung in der Inneren Medizin? ­ Zur Attraktivität der internistischen Fachrichtungen im Verlauf der ärztlichen Weiterbildung.

OBJECTIVE: The aim of the present study was to examine the number of physicians who chose internal medicine for their postgraduate training, their development over the 6-year period of training and whether there were changes in their preferences regarding future work sector and working hours, with a focus on gender-specific differences. METHODOLOGY: Annual postal surveys were conducted of a cohort of undergraduate students (N=1.012) in their final year of study 2008/09, and during the six years of their postgraduate training. Descriptive statistics were used for analysis. RESULTS: The study showed that internal medicine was a sought-after medical discipline, which recruited up to 25% of medical graduates. However, over the course of the six years of postgraduate training, the attractiveness shifted from the specialized sub-disciplines of internal medicine to general internal medicine, especially among male physicians. General internal medicine was particularly attractive to female physicians who intended to work part-time after completion of their specialization. CONCLUSIONS: Internal medicine in Germany is still the most frequently chosen field of specialization. However, the proportion of physicians intending to work ina hospital after specialization is decreasing. This fact, together with the decreasing attractiveness of sub-disciplines in this field, must be taken into account when planning the staff in hospitals.

Frequent attendance in primary care in the oldest old: evidence from the AgeCoDe-AgeQualiDe study.

BACKGROUND: There are very few studies examining the determinants of frequent attendance in primary care among the oldest old. AIMS: The purpose of this study was to determine the characteristics of frequent attendance among individuals aged 85 years or older. METHODS: Cross-sectional data stem from the multicenter prospective cohort "Study on needs, health service use, costs and health-related quality of life in a large sample of oldest old primary care patients (85 +)" (AgeQualiDe). This study covers very old primary care patients (n = 861, mean age of 89.0 years ± 2.9; 85-100 years). The number of self-reported GP visits in the preceding 3 months was used to quantify frequent attenders. We defined patients in the top decile as frequent attenders. RESULTS: Multiple logistic regressions showed that frequent attendance was associated with more chronic diseases (adjusted OR 1.12, 95% CI 1.01-1.23), worse functioning (OR 0.97, 95% CI 0.95-0.99), worries about one's financial situation (OR 2.20, 95% CI 1.07-4.53) and it was inversely associated with depression (OR 0.26, 95% CI 0.08-0.80). DISCUSSION: In contrast to studies based on younger samples, different factors were associated with frequent users in our study, showing that it is important to study the determinants of frequent attendance among the oldest old. CONCLUSION: In Germany, among the group of the oldest old, frequent attendance was positively associated with worse physical health status (e.g., number of chronic diseases), but negatively with depression. This might indicate that the German health care system is responsive to the physical, but not psychological needs of the oldest old.

Burnout is associated with work-family conflict and gratification crisis among German resident physicians.

BACKGROUND: Studies investigating the longitudinal predictive value of burnout on both effort-reward imbalance (within the working place) and work-family conflict (between work and private life) in residents are lacking. Former cross-sectional studies showed an association of effort-reward imbalance and work family conflict with an elevated burnout risk in physicians. METHODS: Data acquisition was carried out within the multi-centric, longitudinal, and prospective "KarMed" study in Germany from 2009 until 2016. Yearly surveys including validated scales: the Maslach Burnout Inventory with its three subscales (emotional exhaustion, personal accomplishment, depersonalisation), the Work-Family Conflict Scale, and the Effort-Reward Imbalance Inventory. Further independent variables were gender and parental status.The analyses were based on general linear models and general linear mixed models with repeated measures designs. RESULTS: Significant time-fixed effects were found for all three subscales of the Maslach Burnout Inventory, with gender effects on the subscales emotional exhaustion and depersonalisation. The parental status had no significant effect on burnout. All estimated means for burnout during 6 years of post-graduate training were higher when work-family conflict and gratification crisis were taken into account. Personal accomplishment increased continuously over time as well showing neither gender differences nor influences by the parental status. CONCLUSIONS: Personal accomplishments might act as a buffer compensating to some extent for the physicians' stress experience. Given that burnout may be associated with poor patient care, there is a need to reduce burnout rates and their associated factors in resident physicians.

Association of anxiety symptoms with health care use and costs in people aged 85 and over.

OBJECTIVE: To analyze the association of anxiety symptoms with health care use and costs in people aged 85 and older. METHODS: Baseline data from AgeQualiDe (N = 856), a multicenter prospective cohort study of primary care patients aged 85 and older, were analyzed. Anxiety symptoms (Geriatric Anxiety Inventory-Short Form) and health care use were assessed via questionnaires. Health care use was monetarily valued using German unit costs to obtain sectoral (inpatient, outpatient, nursing care, medical supplies, and medication) and total costs. Health care use and costs were analyzed in regression models as a function of anxiety symptoms, as well as relevant covariates (predisposing, enabling, and other need characteristics based on the Behavioral Model of Health Care Use). RESULTS: On a descriptive level, people with increased anxiety symptoms (12% of the sample) incurred on average € 10 909 (SD: 16 023) in the last 6 months, 31% more than those without increased anxiety (€ 8303, SD: 11 175; P = 0.12). Adjusting for predisposing, enabling, and other need characteristics, anxiety symptoms were not significantly associated with health care use or costs. Specifically, need characteristics (morbidity, cognitive decline, and functional impairment) were associated with total or sectoral costs, depending on the cost category analyzed. CONCLUSION: In a sample of people of the oldest-old age group, the severity of anxiety symptoms was not associated with health care use or costs, when adjusting for relevant covariates. A longitudinal analysis could assess whether a change in anxiety symptom severity is associated with health care use or costs in old age.

[The future problems of general practice in Germany: current trends and necessary measures]. / Die Zukunftsprobleme der hausärztlichen Versorgung in Deutschland: Aktuelle Trends und notwendige Maßnahmen.

In Germany there is a threat of a shortage of junior general practitioners (GPs). One third of currently employed GPs are 60 years and older. Every year, 1700 GPs leave the profession, while only about 1350 new GP-specialist approvals are issued. The Advisory Council on the Assessment of Developments in the Health Care Sector estimates that there will be around 20,000 unmet replacement needs by 2025. By 2017, 2600 GP seats were already vacant.Based on the results of the KarMed study, this paper examines the questions as to how many residents intend to become general practitioners after graduation and how they develop during postgraduate training. Furthermore, the consequences of the increasing proportion of female physicians in primary care in terms of the possible volume of work will be investigated. Finally, measures that could reduce a possible personnel shortage are discussed.The attractiveness of general practice has increased considerably during residency over the last six years of observation. The preference for GP work is linked to parenthood. More female doctors strive for part-time work and an employment contract instead of a private practice. On this basis, it can be estimated that the volume of work performed by these female GPs will be half that of the traditional (male) working model in private practice.The forecasted numbers of new recruits are unlikely to be sufficient to cover the demand for GP care in Germany. Possible effective measures would be, for example, the introduction of a gatekeeper system, creation of multi-professional centers, a quota system for access to postgraduate training of specialists, a reformed national planning of GP supply in the country, and a shortening and flexibilization of postgraduate training for general practice.

Impact of falls on depressive symptoms among the oldest old: Results from the AgeQualiDe study.

OBJECTIVE: The purpose of this study was to examine the impact of falls on depressive symptoms among the oldest old in Germany longitudinally. METHODS: Data were used from 2 waves of the multicenter prospective cohort "Study on needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe). This study covers primary care patients ≥85 years (at baseline: n = 547, average age of 88.9 ± 3.0 years; ranging from 85 to 100 years). General practitioner-diagnosed falls were used as explanatory variable. The Geriatric Depression Scale was used as outcome measure. RESULTS: Linear fixed effects regressions showed that the occurrence of falls is associated with an increase in depressive symptoms (ß = .60, P = .02), whereas changes in marital status, ageing, social support, functional decline (instrumental activity of daily living), cognitive impairment, and an increase in chronic diseases did not affect depressive symptoms. In sensitivity analysis, an increase in depressive symptoms was associated with functional impairment (basic activities of daily living; Barthel index; ß = -.04, P = .005). CONCLUSIONS: Based on a large, population-based longitudinal study, this study underlined the impact of falls on depressive symptoms and consequently extended previous knowledge about an association between falls and depressive symptoms in the oldest old. Developing strategies to prevent falls might also help to prevent depressive symptoms.

Cross-cultural validation of the German version of the Four-Dimensional Symptom Questionnaire (4DSQ) in multimorbid elderly people.

PURPOSE: Psychosomatic symptoms and mental health problems are highly prevalent in multimorbid elderly people challenging general practitioners to differentiate between normal stress and psychopathological conditions. The 4DSQ is a Dutch questionnaire developed to detect anxiety, depression, somatization, and distress in primary care. This study aims to analyze measurement equivalence between a German version and the original Dutch instrument. METHODS: A Dutch and a German sample of multimorbid elderly people, matched by gender and age, were analyzed. Equivalence of scale structures was assessed by confirmatory factor analysis (CFA). To evaluate measurement equivalence across languages, differential item functioning (DIF) was analyzed using Mantel-Haenszel method and hybrid ordinal logistic regression analysis. Differential test functioning (DTF) was assessed using Rasch analysis. RESULTS: A total of 185 German and 185 Dutch participants completed the questionnaire. The CFA confirmed one-factor models for all scales of both 4DSQ versions. Nine items in three scales were flagged with DIF. The anxiety scale showed to be free of DIF. DTF analysis revealed negligible scale impact of DIF. CONCLUSIONS: The German 4DSQ demonstrated measurement equivalence to the original Dutch instrument. Hence, it can be considered a valid questionnaire for the screening for mental health problems in primary care.

[Shortage of physicians in rural areas and in the public health service : A critical analysis of the evidence on the role of medical education and training]. / Ärztemangel in der hausärztlichen Versorgung auf dem Lande und im Öffentlichen Gesundheitsdienst : Eine kritische Analyse der Evidenz bezüglich der Rolle von Aus- und Weiterbildung.

BACKGROUND: A shortage of medical personnel has been seen for several decades in at least two sectors of the healthcare system: primary care in remote areas as well as medical care in the state public health departments (Öffentliches Gesundheitswesen). Strategies to reduce these problems are being sought. OBJECTIVE: This review examines the proposals, practical initiatives and empirical studies in under- and postgraduate medical education in order to estimate their potential impact on the solution of these problems. The analysis covers both Germany and Anglo-Saxon countries. MATERIALS AND METHODS: The study is based on a literature search in PubMed and Medline covering the last 20 years. With regard to Germany, programmatic documents and studies published in the German Journal of General Practice (Zeitschrift für Allgemeinmedizin) were also included. RESULTS AND DISCUSSION: Foreign empirical studies identify almost equal two factors with regard to primary care in remote areas: the recruitment of students from rural areas combined with special educational programs with a rural primary care orientation both in under- and postgraduate medical education. These programs should include several and longer practical working periods in primary care units and be well coordinated between the medical school and the local teaching physicians. As for the state public health sector, comparable initiatives are still lacking.