Challenges and opportunities for general practice specific CME in Europe - a narrative review of seven countries.

BACKGROUND: Several changes have led to general practitioners (GPs) working in a more differentiated setting today and being supported by other health professions. As practice changes, primary care specific continuing medical education (CME) may also need to adapt. By comparing different primary care specific CME approaches for GPs across Europe, we aim at identifying challenges and opportunities for future development. METHODS: Narrative review assessing, analysing and comparing CME programs for general practitioners across different north-western European countries (UK, Norway, the Netherlands, Belgium (Flanders), Germany, Switzerland, and France). Templates containing detailed items across seven dimensions of country-specific CME were developed and used. These dimensions are role of primary care within the health system, legal regulations regarding CME, published aims of CME, actual content of CME, operationalisation, funding and sponsorship, and evaluation. RESULTS: General practice specific CME in the countries under consideration are presented and comparatively analysed based on the dimensions defined in advance. This shows that each of the countries examined has different strengths and weaknesses. A clear pioneer cannot be identified. Nevertheless, numerous impulses for optimising future GP training systems can be derived from the examples presented. CONCLUSIONS: Independent of country specific CME programs several fields of potential action were identified: the development of curriculum objectives for GPs, the promotion of innovative teaching and learning formats, the use of synergies in specialist GP training and CME, the creation of accessible yet comprehensive learning platforms, the establishment of clear rules for sponsorship, the development of new financing models, the promotion of fair competition between CME providers, and scientifically based evaluation.

Protection against the overuse and underuse of health care - methodological considerations for establishing prioritization criteria and recommendations in general practice.

BACKGROUND: Initiatives such as "Choosing Wisely" in the USA and "Smarter Medicine" in Switzerland have published lists of widely overused health care services. The German initiative "Choosing Wisely Together (Gemeinsam Klug Entscheiden)" follows this example. The goal of our study was to prioritize important recommendations against the overuse and underuse of health care services. The final list of recommendations will be published in the German guideline "Protection against the overuse and underuse of health care". METHODS: First, a multidisciplinary expert panel established a catalogue of prioritization criteria. Second, we extracted all the recommendations from evidence- and consensus-based German College of General Practice and Family Medicine (DEGAM) guidelines and National Health Care Guidelines (NVL). Third, the recommendations were rated by two independent panels (general practitioners and other health care professionals involved/not involved in guideline development). The prioritization process was finalized in a consensus conference held by DEGAM's Standing Guideline Committee (SLK). RESULTS: Eleven prioritization criteria were established. A total of 782 recommendations were extracted and rated by 98 physicians and other health care professionals in a survey. In the voting process, more than 80% of the recommendations were eliminated. After the final consensus conference, twelve recommendations from DEGAM guidelines, nine DEGAM addenda and 17 NVL recommendations were chosen for inclusion in the guideline, for a total of 38 recommendations. CONCLUSION: The selection procedure proved helpful in identifying the highest priority recommendations with which to combat the overuse and underuse of health care services. To date, in Germany there has been no attempt to compile such a list by using a systematic and transparent methodology. Hence, the guideline that results from this process can fill an important gap.

DEGAM criteria catalogue for training practices in primary care--a proposal for the assessment of the structural quality of training practices.

BACKGROUND: Whilst the structure of primary care vocational training in Germany is being increasingly formalized there remains an abundance of disparate locally defined criteria for the training practices. Advanced medical training in the ambulatory setting has also been identified as an area of need by other specialties. GOAL: In contrast to the current practice of a unregulated authorization by regional medical associations this catalogue provide transparent, clearly defined criteria for the assignment of training practice status. METHODS: The first draft of the criteria catalogue integrates feedback from 30 academic general practitioners. The feasibility of the catalogue was tested by a further 30 surgeries. Analysis included an assessment of the sociodemographic characteristics of the trainers and their practices as well as satisfaction of the participants with the approved authorization period. RESULTS: The criteria catalogue comprises 19 items within the domains of trainer qualification, practice infrastructure and patient specific factors as well as mandatory criteria. The points scored through this system confer a variable period of authorization. Of the 30 participants 17 were satisfied with the period of authorization they received, 10 were dissatisfied, and one was indifferent. Satisfaction showed no correlation with sex, experience as a trainer, or with the score achieved through the criteria catalogue. It correlated little with the length of time practicing as a doctor. CONCLUSION: The criteria catalogue reflects both the breadth of general practice as well as the skills of the trainers. Satisfaction of participants in the test group was good, and infers a basis for applying the catalogue through regional medical associations to assign teaching practice status. It may also be used as a blue-print for other medical specialties.

[The Bremen periodic health exam - feasibility of a new concept]. / Die Bremer Gesundheitsuntersuchung - Machbarkeit eines neuen Vorsorgekonzeptes.

BACKGROUND: All members of the Statutory Health Insurance are entitled to receive preventive health examinations. The current concept, however, does not take individual risk factors into account systematically. To improve this, the "Bremen Health Examination" was developed. The central component is a screening questionnaire to be completed by the patient, which is stratified by age, i.e., 35 to 69 years and ≥ 70 years. The feasibility and acceptance of this concept have been assessed. METHODS: In a prospective observational study, a selected sample of general practitioners (GPs) was asked to implement the questionnaires during all preventive health examinations within a four-week period. The GPs subsequently answered content-related questions as well as Likert-scaled questions on the relevance of the issues addressed, and the feasibility of the new concept. RESULTS: 17 out of 20 GPs approached for the study included a total of 171 patients. On average, the patients in the two groups were 52 and 75 years of age, respectively, and answered 4.4 prompting questions positively. Age and gender had no significant effect on the frequency of "positively" answered questions. Implementing the questionnaire extended the duration of the health examination, however, GPs overall rated the time required for discussing newly assessed problems as adequate (four-level Likert scale, 1=yes; 4=no; Ø 1.59; SD 0.77). CONCLUSION: The implementation of the Bremen Health Examination appears to be feasible from the GP perspective.

[The Quality indicator project of the German college of general practice and family medicine (DEGAM): development of indicators based on the guidelines dementia, neck pain and sore throat]. / Entwicklung und Bewertung von Qualitätsindikatoren aus den Leitlinien Halsschmerzen, Nackenschmerzen und Demenz der Deutschen Gesellschaft für Allgemeinmedizin und Familienmedizin (DEGAM).

A debate on the application of quality indicators (QIs) arose among the members of the German College of General Practitioners and Family Physicians (DEGAM) when two QI systems for ambulatory care (QISA and AQUIK) were published in a short time interval. A research question that emanated from this discussion was whether appropriate QI might be developed based on German general practice guidelines. In spring 2010, the DEGAM guideline committee (SLK) decided to conduct a project on guideline-based development of QIs using the DEGAM guidelines for dementia, neck pain and sore throat. All members of the SLK were invited to participate in the development process which comprised three face-to-face meetings and four paper-pencil ratings. Finally, 17 QIs for the three guidelines on dementia (n=8), neck pain (n=7) and sore throat (n=2) emerged. These QIs received different ratings in the dimensions relevance, practicability, and appropriateness for public reporting as well as for pay for performance. In this project, guideline authors themselves developed QIs based on German general practice guidelines for the first time ever. Not before practice administration systems facilitate the availability of data in the context of clinical documentation, the practicability of the new QIs can be proven in real every-day practice.

Prevalence of hyperaldosteronism in primary care patients with resistant hypertension.

INTRODUCTION: Because hyperaldosteronism is the most common curable reason for secondary hypertension, screening is recommended. However, prevalence among general practice patients and feasibility of screening is still unclear. A design to assess prevalence in general practice and barriers against screening was created. METHODS: This was an open, observational pilot study and focus group. In 2 general practices, all patients with arterial hypertension were included. Those with resistant hypertension (>140/90 mm Hg and taking ≥3 antihypertensive drugs) were eligible for screening. The design and feasibility of the study were discussed in a focus group of experienced general practitioners. RESULTS: Of 3107 patients visiting the practices, 564 were diagnosed as having arterial hypertension. Seventy-nine fulfilled criteria for resistant hypertension. Aldosterone:renin ratio (ARR) could be measured in 63 of those patients. Withdrawal of ß-blocker was feasible in 34 of the 63 with measurable ARR. ARR was positive in 15, and in 3 of those 15 with positive ARR, it was caused by elevated aldosterone levels. Focus group discussion revealed barriers and concerns regarding organizational, financial, and practical aspects of a systematic screening. CONCLUSIONS: Screening for hyperaldosteronism in general practice seems possible in selected patients, but not in a systematic way. Barriers against systematic screening were a necessity for ß-blocker cessation as well as structural prerequisites for patient identification.

[Development and implementation of the dementia guideline of the German Society of General Practice and Family Medicine]. / Entwicklung und Implementierung der Leitlinie "Demenz" der Deutschen Gesellschaft für Allgemeinmedizin und Familienmedizin.

The evidence-based guidelines of the German Society of General Practice and Family Medicine (DEGAM) are developed according to an established ten-stage plan. The twelfth guideline addresses the health care problem of dementia. The main focus is the sensitive handling of patients and their relatives, e.g., although the goal is an early diagnosis, patients should also be protected against overdiagnosis. The treatment of Alzheimer's disease consists of three components: optimal care and supervision, the use of nondrug therapy, and a critically weighed administration of medications. The successful implementation of the guideline should be achieved by a multimodal strategy. This includes not only the direct integration of general practitioners (GPs) in developing the guideline, but also a comprehensive publication offensive, a wide use in training sessions including new media, the testing of complex implementation approaches in trials, and the use of the guideline in the context of GP contracts.