German General Practices Research Articles

Bias in obtaining broad consent in a German general practice? - Preliminary results from a cross-sectional study.

The growing importance of collecting Broad Consent (BC) for research utilizing electronic health records in Germany has brought attention to the need for a deeper understanding of potential selection bias in the process. Since 2020, the BeoNet-Halle outpatient database has been collecting anonymous and pseudonymous patient data from primary care and specialty practices throughout Germany, with the practice being an integral part of this data collection effort. The primary objective of the pilot study is to explore potential socioeconomic discrepancies between patients who provided BC and the general practice population. This is a single-center, cross-sectional study. The study was performed with patients from one Medical Care Center including eight GPs. We categorized patients with at least one interaction with a general practitioner from March 2021 to January 2023 into two sets: patients who approved BC versus a randomly chosen representative sample (RS) of non-BC inquirers. We mailed a sociodemographic survey to both groups. A total of 561 patients were analyzed, with the BC group responding more actively (60.7%) than the RS group (29.7%). Age and gender were similar between the BC group and RS group. Being widowed, divorced, or unmarried and being neither open nor hostile toward research was associated with an increased likelihood of giving consent. Analysis of personality traits did not show any impact on giving consent. Overall, this study outlines that there is some bias between BC and RS. Possible associations in BC decisions that offer insights into complex decisions to participate in medical research are marital status, immigrant background, income, and age. Findings emphasize the potential of BC for outpatient research, warranting further investigation to optimize its application in the general practice setting.

Utilization and consequences of CRP point-of-care-testing in primary care practices: a real-world multicentre observational study with 1,740 patient cases in Germany.

Point-of-care tests (POCTs) for C-reactive protein can support clinical decision-making of general practitioners (GPs) but are not widely used in German general practices. To investigate the utilization of semi-quantitative CRP-POCTs in routine primary care. Prospective observational study in 49 general practices in Germany (Nov/2022 to Apr/2023). GPs were provided with CRP-POCTs and collected data for each CRP-POCT use using standardized data collection sheets. Data from 1,740 CRP-POCT uses were recorded. GPs employed CRP-POCTs mainly for patients with respiratory tract infections (RTIs, 70.9% of all cases) and to a lesser extent for gastrointestinal infections (GIs, 10.3%). In RTIs, CRP-POCTs were frequently used to distinguish between bacterial and viral aetiology (60.8%) and to guide decisions on antibiotic prescribing (62.8%). In GIs, CRP-POCTs were mainly used to rule out severe disease progressions (53.2%) and for decisions on further diagnostic procedures (45.6%). In RTIs, CRP-POCTs influenced antibiotic prescribing in 77.5 % of the cases (32.3% in favour vs. 45.2% waiver). In GIs, CRP levels mainly affected decisions on further diagnostic procedures. GPs reported that CRP-POCTs were helpful in 88.6% of all cases. When available, German GPs predominantly use semi-quantitative CRP-POCTs to guide decisions on antibiotic prescribing in patients with RTI. CRP-POCT use improves clinical decision-making and increases the GPs' clinical confidence.

Elevated Colon Cancer Rates Linked to Prior Appendicitis: A Retrospective Cohort Study Based on Data from German General Practices.

Background/Objective: The association between appendicitis and colon cancer is not yet fully understood. Previous studies have shown contradictory results. Currently, no population-based data from Germany are available with regard to the incidence of colon cancer following appendicitis. This study investigated the association between appendicitis and the incidence of colon cancer in Germany. Methods: In this retrospective cohort study, the incidence of colon cancer was compared for patients with appendicitis and patients without appendicitis, matched for age, sex, index year, average annual consultation frequency, and comorbidity. The aim of the study was to explore the relationship between appendicitis and the incidence of colon cancer. The evaluation was carried out using logistic regression analyses. Results: The study included 49,790 people with and without appendicitis, with a median age of 41 years. During a follow-up period of up to 15 years, 1.04% of cases with appendicitis and 0.60% of cases without appendicitis were newly diagnosed with colon cancer, with some 36.4% of colon cancer cases diagnosed within the first six months after appendicitis. Regression analyses revealed a significant association between appendicitis and colon cancer, particularly in men and in the age groups 41-50 (HR: 10.30; 95% CI: 1.03-43.82) and 18-30 years (HR: 8.17; 95% CI: 1.03-64.58). Conclusions: The present retrospective cohort study suggests an association between appendicitis and the incidence of colon cancer in Germany. Based on our results, we recommend offering a colonoscopy or at least a stool test within 12 months after appendicitis, especially for 18-50-year-olds and >60-year-olds in good general health.

InspeCKD - Analysis of the use of diagnostics in patients at high risk for chronic kidney disease in German general practitioner (GP) practices

Despite the high prevalence of chronic kidney disease (CKD) in Germany, only a small proportion of patients are currently diagnosed with CKD. Patients with hypertension, diabetes mellitus, and/or cardiovascular disease have a significantly increased risk of developing CKD and rapid disease progression and should therefore be screened and monitored in accordance with the guidelines. The aim of this retrospective, cross-sectional study was to gain insights into appropriate diagnosis of patients at risk for CKD in German general practitioner practices. For the analysis of the use of CKD-relevant diagnostics, electronic patient records from German general practitioner practices were analyzed. Adults with hypertension and/or diabetes mellitus and/or cardiovascular disease with a documented observation period of at least one year were included in the study. Data from a total of 448,837 patients from 1244 general practitioner practices were analyzed. 75.8% of patients had hypertension, 35.1% had cardiovascular disease, and 32.4% had diabetes mellitus. During a mean observation period of 1.7 years, serum creatinine was assessed at least once in 45.5% of patients. A urine dipstick test for albuminuria was performed in 7.9% of patients and in 0.4% of patients, urine albumin-to-creatine ratio (UACR) was measured. Laboratory diagnostics were initiated a little more frequently in high-risk patients compared to the overall cohort. The study highlights that despite known risk factors, guideline compliant CKD screening is rarely performed in German general practitioner practices, which implicates the need to increase the awareness of early diagnosis of CKD in patients at risk.

Cancer Risk in Patients with Down Syndrome-A Retrospective Cohort Study from Germany.

Individuals with Down syndrome are thought to have a unique tumor profile. Using the IQVIA Disease Analyzer database, patients aged ≥18 years diagnosed with Down syndrome in German general practices between 2005 and 2021 were compared with patients without Down syndrome for cancer incidence, adjusting for age, sex, average annual visit frequency, and comorbidity. The 5-year cumulative incidence of cancer overall and specific cancers was analyzed using Kaplan-Meier curves and compared using the log-rank test. In addition, univariable Cox regression analysis was performed. A total of 2438 patients with Down syndrome and 12,190 patients without Down syndrome were included; 3.9% of patients without Down syndrome and 3.1% of patients with Down syndrome were diagnosed with cancer (p = 0.143). Regression analysis showed no significant association between Down syndrome and subsequent cancer in the total population (HR: 0.79; 95% CI: 0.57-1.09), in women (HR: 0.89; 95% CI: 0.56-1.37), or in men (HR: 0.69; 95% CI: 0.43-1.11). Analyses by cancer type and sex showed a strong but not significant negative association between Down syndrome and breast cancer in women (HR: 0.33; 95% CI: 0.12-0.93). Our results could form the basis for future studies to clarify whether and to what extent an adapted screening program needs to be modified for individuals with Down syndrome due to the particular cancer distribution pattern.

Associations between COVID-19 Pandemic-Related Overtime, Perceived Chronic Stress and Burnout Symptoms in German General Practitioners and Practice Personnel-A Prospective Study.

The mental burdens of general practitioners (GPs) and practice assistants (PrAs) during the COVID-19 pandemic are well investigated. Work-related conditions like overtime are known to contribute to perceived chronic stress and burnout symptoms. However, there is limited evidence regarding the specific mechanisms, which link pandemic-related overtime, chronic stress and burnout symptoms. This study used data from the IMPROVEjob trial to improve psychological well-being in general practice personnel. This prospective study with 226 German GPs and PrAs used the baseline (pre-pandemic: October 2019 to March 2020) and follow-up data (pandemic: October 2020 to April 2021) of the IMPROVEjob trial. Overtime was self-reported as hours above the regular work time. Perceived chronic stress was assessed using the Trier Inventory for the Assessment of Chronic Stress Screening Scale (TICS-SSCS), while burnout symptoms were evaluated using a short version of the Maslach Burnout Inventory (MBI). A mediation analysis investigated the differences of the three main variables between pre-pandemic and pandemic periods. Burnout symptoms increased significantly from baseline to follow-up (p = 0.003). Overtime correlated positively with burnout symptoms (Total Effect: 0.13; 95% CI: 0.03, 0.23). Decomposition of the total effect revealed a significant indirect effect over perceived chronic stress (0.11; 95% CI: 0.06, 0.18) and no significant direct effect (0.02; 95% CI: -0.08, 0.12), indicating a full mediation. In this large longitudinal study, pandemic-related overtime led to significantly higher levels of burnout symptoms, linked by a pathway through perceived chronic stress. Future prevention strategies need to aim at reducing the likelihood of overtime to ensure the mental well-being of practice personnel.

Student supervision by trainee doctors in GP teaching practices: Win-win situation or additional burden? An interview study on current practices and acceptance.

Teaching by trainee doctors is also established practice in general practice in English-speaking countries. This study examines the involvement of trainee doctors in the supervision of students in German general practices and the acceptance of trainee doctors as teachers from the perspective of physicians with a license for post-graduate training (PLT) and the trainee doctors themselves. Semi-structured qualitative interviews were conducted with 9 PLTs and 9 trainees. The interview guide was developed based on the Theoretical Framework of Acceptance. Interviews were recorded, transcribed and evaluated using Kuckartz's qualitative analysis. Trainee doctors are involved in student supervision in GP teaching practices to varying degrees and often in unstructured ways. Supervision by trainees is considered advantageous as they are closer in terms of hierarchy, possess more up-to-date knowledge and are less far ahead in terms of knowledge and function as role models. However, professional uncertainty or revealing knowledge gaps to patients and students is experienced as difficult by some trainees. Competing for time with patient care is seen as a challenge. Better time planning and didactic preparation could avoid pressure in this area. Teaching is seen as part of the GP profession, especially by trainee doctors. However, a potential obligation to teach is seen as more of a hindrance to encouraging the next generation of doctors by both trainee doctors and PLTs. The inclusion of trainee doctors in student teaching is frequently practiced by those surveyed, which suggests a high level of acceptance but is not consistently implemented. Structured organization of teaching in real life, didactic qualifications and offering credits for teaching activities might further improve inclusion and acceptance.

EPH10 ICD-10 Surrogates of the Modified Frailty Index Predict Hospital Referrals in Outpatients Followed in German General Practices

EPH10 ICD-10 Surrogates of the Modified Frailty Index Predict Hospital Referrals in Outpatients Followed in German General Practices

180° view on general practitioners’ leadership skills: practice-level comparisons of leader and staff assessments using data from the cluster-randomised controlled IMPROVEjob study

ObjectivesStrong primary care leaders are needed to assure high quality services for patient populations. This study analysed general practitioners’ (GP) leadership skills comparing practice-level self and staff assessments based on...

Are Nurse-Led Patient Consultations and Nurse-Led Dose Adjustments of Permanent Medication Acceptable for Patients with Diabetes Mellitus and Hypertension in General Practice? - Results of a Focus Group Study.

Practice nurse (PN)-led patient consultations and PN-led dosage adjustments of permanent medication are uncommon and not well studied in general practice (GP) in Germany. We investigated the perspectives of patients with common chronic diseases in Germany, diabetes mellitus (DM) type 2 and/or arterial hypertension (AT), on PN-led patient consultations and dosage adjustments of permanent medications in GP. In this exploratory qualitative study, online focus groups were conducted using a semi-structured interview guide. Patients were recruited from collaborating GPs according to a predefined sampling plan. Patients were eligible for this study if they had DM or AT treated by their GP, were on at least one permanent medication and were aged 18 years or older. Focus group transcripts were analyzed using thematic analyses. Analyses of two focus groups, involving a total of 17 patients, revealed four main themes: (1) openness to the PN-led care and perceived benefits, eg because of patients' confidence in PNs' skills, or patients' impression that PN-led care would better meet their needs and increase their compliance. Some patients had (2) reservations and perceived risks, especially for PN-led medication changes eg feeling that medication adjustments were a GP's issue. Patients identified (3) reasons for encounters where they were likely to accept PN-led consultation and medication advice, eg management of DM, AT and thyroid disease. Patients also saw several important general requirements for the implementation of PN-led care in German general practice (4). There is a potential for openness towards PN-led consultation and PN-led medication adjustment for permanent medication in patients with DM or AT. This study is the first qualitative study to investigate PN-led consultations and medication advice in German general practice. If the implementation of PN-led care is planned, our findings add the patients' perspectives of acceptable reasons for encounter for PN-led care and their general requirements.

Instruments in general practice to identify and to measure (over)burden due to informal care for caring relatives: a scoping review protocol

IntroductionFamily caregivers provide by far the largest share of long-term, unpaid care for their primarily elderly and chronically ill relatives or friends. This is associated with a higher risk of...

Dementia Screening and Test Psychology in German General and Specialist Practices under Conditions of the Corona Pandemic

To analyse changes in frequencies of test psychology examinations (TPE) relevant to detect change in dementia diagnosis in general (GP) and neuropsychiatric (NP) practices during the Covid 19 pandemic. Cross-sectional study analysis comparing the number of patients aged ≥ 70 with at least one TPE in 908 GP and 107 NP-practices in 2018-2019 (prepandemic) and 2020-2021 (pandemic) using descriptive statisics and correlations. While there was a large decrease in TPE between 2018-2019 and 2020-2021 (- 18.4%) conducted in NP-practices, it remained stable in GP-practices (+ 2.6%). In both GP and NP, there was a strong correlation between the number of patients tested and newly diagnosed with dementia. TPE in performing in GP practices appears less susceptible to a pandemic-related decline in the provision compared to NP practices. Further research is needed to reveal the reasons for these differences.

Establishment of electronic prescriptions in German general practice

Establishment of electronic prescriptions in German general practice

Etablierung des elektronischen Rezepts in deutschen Hausarztpraxen

BackgroundThe establishment of the electronic prescription (e-prescription) in a German general practice is associated with technical, organizational, and data protection-related challenges. A step-by-step approach makes the changeover easier and sources of error must be systematically avoided. The e‑prescription is also of political importance.The e‑prescription was supposed to start in Germany by January 1, 2022. Various challenges in the process prevented the comprehensive introduction in general practitioners’ practices.ObjectivesIdentification of challenges and opportunities in the process of introducing e‑prescriptions in a family physician’s practice.Materials and methodsField reports from two general practitioners’ practices on the establishment of the e‑prescription and the accompanying error management.ResultsIntroduction of the e‑prescription in a family physician’s practice is feasible. Sources of error offer the potential to significantly disrupt the practice process.ConclusionPossible sources of error in the process change must be anticipated and avoided. The e‑prescription offers the potential for resource conservation.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the diagnosis of neck and low back pain in outpatient practices in Germany

Little is known about how COVID-19 has impacted the diagnosis of neck and low back pain in outpatient practices in Germany. Thus, this study aimed to compare the number of new diagnoses of neck and low back pain in German general and orthopedic practices between 2020 and 2021 and 2019. This retrospective study included patients aged ≥ 18 years with at least one visit to one of 915 general and 145 orthopedic practices in Germany in March – December 2019 (N = 2,842,145), March – December 2020 (N = 2,810,179), or March – December 2021 (N = 3,214,419). The number of patients newly diagnosed with neck and low back pain per general and orthopedic practice was compared between March – December 2020 and March – December 2019, and between March – December 2021 and March – December 2019 using Wilcoxon signed-rank tests. Analyses were conducted in general and orthopedic practices separately and were also stratified by sex and age. There was a decrease in new diagnoses of neck and low back pain in general and orthopedic practices between 2020 and 2019, and between 2021 and 2019. This decrease reached statistical significance for neck pain in general practices in 2020 (−12.4 %) and 2021 (−6.1 %), and for low back pain in general practices in 2020 (−9.3 %). Similar findings were obtained in sex- and age-stratified analyses. The COVID-19 pandemic had a negative impact on the diagnosis of neck and low back pain in general and orthopedic practices in Germany. More data from other settings and countries are warranted to confirm or refute these results.

Prevalence of Spirometry Testing among Patients with Asthma and COPD in German General Practices.

The goal of this study was to estimate the prevalence of spirometry testing among patients with asthma and chronic obstructive pulmonary disease (COPD) in general practices (GPs) in Germany. This retrospective cross-sectional study was based on data from the Disease Analyzer database (IQVIA), This retrospective cross-sectional study included all patients with at least one confirmed asthma or COPD diagnosis in one of those 50 general practices in Germany between January 2020, and January 2021, as well as at least one visit to these general practices between January 2021, and January 2022. The main outcomes of the study aimed to ascertain the proportion of spirometry testing among asthma and COPD patients between January 2021, and January 2022, overall, and separately, in men, women, six age groups (≤30, 31-40, 41-50, 51-60, 61, 70, >70), and patients who received at least one prescription of anti-asthma or anti-COPD drugs. This study included 8835 patients with asthma only, 5597 with COPD only, and 1897 with both asthma and COPD diagnoses. Of these, 27.2% of COPD patients, 7% of asthma patients, and 54.7% of asthma + COPD patients, received spirometry testing during the study period. Among COPD and asthma + COPD patients, the prevalence of spirometry testing was much higher in women than in men (COPD: 31.6% vs. 23.2%; asthma + COPD: 59.6% vs. 46.3%) and much higher in treated than in non-treated patients (COPD: 31.7% vs. 15.0%; asthma + COPD: 57.5% vs. 27.8%). The prevalence of spirometry testing was relatively low among COPD and asthma patients followed in GP practices, but usually higher in female patients, treated patients, and patients suffering from both asthma and COPD.

Differences in Demographics of Vaccinees, Access to, and Satisfaction with SARS-CoV-2 Vaccination Procedures between German General Practices and Mass Vaccination Centers.

In the European Union, SARS-CoV-2 vaccines became available in December 2020. The vaccination campaign in Germany was initially implemented through mass vaccination centers and later joined by general practitioners (GPs) in spring 2021. This study compared population characteristics, perceived access barriers, and satisfaction with the vaccination procedure between vaccination centers and GP practices. A paper-based survey was distributed (07/2021-10/2021) among newly vaccinated individuals in ten GP practices (n = 364) and two vaccine centers (n = 474). Participants in vaccine centers were younger compared to participants in GP practices. GP preference was higher in older participants and those with pre-existing illnesses. Wait time at vaccination site was longer in GP practices, whereas travel distance to site was longer for participants in vaccine centers. However, satisfaction with patient education and recommendation of site were more likely with increasing comprehensibility of the vaccination procedure and physicians' information as well as perceived sufficiency of patient education duration, factors that can be easily modified by all vaccination sites. Our results demonstrate that both types of vaccination sites complement each other in terms of accessibility and target population and that satisfaction with the vaccination procedure can be promoted at all sites by an easy-to-understand process.

Leadership program with skills training for general practitioners was highly accepted without improving job satisfaction: the cluster randomized IMPROVEjob study

Leadership has become an increasingly important issue in medicine as leadership skills, job satisfaction and patient outcomes correlate positively. Various leadership training and physician psychological well-being programmes have been developed internationally, yet no standard is established in primary care. The IMPROVEjob leadership program was developed to improve job satisfaction among German general practitioners and practice personnel. Its acceptance and effectiveness were evaluated. The IMPROVEjob intervention is a participatory, interdisciplinary and multimodal leadership intervention that targets leadership, workflows and communication in general practices using three elements: (1) two leadership workshops with skills training; (2) a toolbox with printed and online material, and (3) a 9-month implementation phase supported by facilitators. A cluster-randomised trial with a waiting-list control evaluated the effectiveness on the primary outcome job satisfaction assessed by the Copenhagen Psychosocial Questionnaire (range 0–100). A mixed-methods approach with questionnaires and participant interviews evaluated the acceptance of the intervention and factors influencing the implementation of intervention content. Statistical analyses respected the clustered data structure. The COVID-19 pandemic necessitated intervention adjustments: online instead of on-site workshops, online material instead of facilitator practice visits. Overall, 52 of 60 practices completed the study, with altogether 70 practice leaders, 16 employed physicians, and 182 practice assistants. According to an intention-to-treat analysis, job satisfaction decreased between baseline and follow-up (not significantly) in the total study population and in both study arms, while the subgroup of practice leaders showed a non-significant increase. A mixed multilevel regression model showed no effect of the intervention on job satisfaction (b = − 0.36, p > 0.86), which was influenced significantly by a greater sense of community (b = 0.14, p < 0.05). The acceptance of the IMPROVEjob workshops was high, especially among practice leaders compared to assistants (1 = best to 5 = worst): skills training 1.78 vs. 2.46, discussions within the practice team 1.87 vs. 2.28, group discussions 1.96 vs. 2.21. The process evaluation revealed that the COVID-19 pandemic complicated change processes and delayed the implementation of intervention content in practice routines. The workshops within the participatory IMPROVEjob intervention were rated very positively but the multimodal intervention did not improve job satisfaction 9 months into the pandemic. Qualitative data showed an impairment of implementation processes by the unforeseeable COVID pandemic.Trial registration Registration number: DRKS00012677 on 16/10/2019.

Tooth loss in periodontally treated patients: A registry- and observation-based analysis.

According to retrospective clinical studies, periodontal treatment retains teeth. However, evidence on the effectivity of periodontal treatment stemming from the general population is lacking. We analysed data of periodontally treated patients from routine data of a major German national health insurance (BARMER-MV; sub-sample of the Federal State of Mecklenburg-Vorpommern) and from a clinical cohort (Greifswald Approach to Individualized Medicine, GANI_MED), as well as periodontally untreated and treated participants of the Study of Health in Pomerania (SHIP-TREND) with either ≥2 or ≥4 teeth with pocket depths ≥4 mm. Yearly tooth loss (YTL) estimates and incidence rates were evaluated. For moderately to severely affected groups, YTL and incidence rates were higher in BARMER-MV patients (0.35 and 0.18, respectively) than in untreated SHIP-TREND controls (0.19 and 0.08, respectively). In line, treated SHIP-TREND participants exhibited higher YTL rates than untreated SHIP-TREND controls (0.26 vs. 0.19). For severely affected groups, results with respect to tooth loss were inconclusive regarding the beneficial effects of periodontal treatment conducted either in the university (GANI_MED data) or in the general practice. Until 2021, periodontal treatment performed in German general dental practices within the national health insurance system was probably not efficient in retaining more teeth in the short- to mid-term. Since reimbursement schemes were changed in 2021 and now cover periodontal treatment to a much larger extent, the future will show whether these new reimbursement codes will improve the quality of periodontal treatment and whether they will lead to more long-term tooth retainment.

GPs´ Personal Spirituality, Their Attitude and Spiritual Competence: A Cross-Sectional Study in German General Practices

To understand if GPs’ spiritual competence, their personal spirituality and attitude towards enquiring about spirituality in practice interrelate, we conducted a cross-sectional survey of 30 German GPs regarding issues of SC. We found correlations between GPs’ personal spirituality, their spiritual competence and their attitudes towards SC. The ability to perceive spiritual needs of patients was the competence most strongly related to GPs’ attitude towards SC. The competence with the strongest correlation to personal spirituality was Self-awareness and Proactive opening. No correlation was found between affiliation to a spiritual community and GPs’ attitude towards SC. The results show that GPs’ personal spirituality and spiritual competence are indeed related to addressing spirituality with their patients. To foster SC, training programmes should raise awareness for one’s personal spirituality and encourage one to reflect on spiritual competence.