German General Practices Research Articles

Effects of Two Guideline Implementation Strategies on Patient Outcomes in Primary Care

Cluster randomized controlled trial. To improve quality of care for patients with low back pain (LBP) a multifaceted general practitioner education alone and in combination with motivational counseling by practice nurses has been implemented in German general practices. We studied effects on functional capacity (main outcome), days in pain, physical activity, quality of life, or days of sick leave (secondary outcomes) compared with no intervention. International research has lead to the development of the German LBP guideline for general practitioners. However, there is still doubt about the most effective implementation strategy. Although effects on process of care have been observed frequently, changes in patient outcomes are rarely seen. We recruited 1378 patients with LBP in 118 general practices, which were randomized to 1 of 3 study arms: a multifaceted guideline implementation (GI), GI plus training of practice nurses in motivational counseling (MC), and the postal dissemination of the guideline (controls, C). Data were collected (questionnaires and patient interviews) at baseline and after 6 and 12 months. Multilevel mixed effects modeling was used to adjust for clustering of data and potential confounders. After 6 months, functional capacity was higher in the intervention groups with a cluster adjusted mean difference of 3.650 between the MC group and controls (95% CI = 0.320-6.979, P = 0.032) and 2.652 between the GI group and controls (95% CI = -0.704 to 6.007, P = 0.120). Intervention effects were more pronounced regarding days in pain per year with an average reduction of 16 (GI) to 17 days (MC) after 6 months (12 and 9 days after 12 months) compared with controls. Active implementation of the German LBP guideline results in slightly better outcomes during 6 months follow-up than its postal dissemination. Results are more distinct when practice nurses are trained in motivational counseling.

Evaluation of the efficacy of subcutaneous carbon dioxide insufflations for treating acute non specific neck pain in general practice: A sham controlled randomized trial

Background Subcutaneous carbon dioxide insufflations are a safe and inexpensive treatment modality in complementary medicine and are used mainly in musculoskeletal pain and vascular conditions. However, no rigorous trial exists on their efficacy. Aims To evaluate whether patients with acute non specific neck pain get pain free sooner, if treated with subcutaneous carbon dioxide insufflations compared to sham ultrasound. Methods One hundred and twenty-six persons from one German general practice with acute non specific neck pain less than 7 days and a current pain intensity ⩾40 mm on a 100 mm visual analogue scale were included into the trial. Participants received either a maximum number of nine subcutaneous carbon dioxide insufflations or a maximum number of nine sham ultrasound administered by four therapists in a randomized order, thrice weekly. Main outcome measure was time to neck pain relief during a 28 days follow-up period from baseline analyzed by intention to treat. Results Twenty-seven of 63 patients (43%) got neck pain free in the subcutaneous carbon dioxide insufflations group compared to 29 of 63 (46%) in the sham ultrasound group. Median time to neck pain relief was 28 days in both groups ( p = .77; logrank test). Secondary analyses yielded similar results. Conclusions The study indicates that subcutaneous carbon dioxide insufflations are not superior to sham ultrasound for treating patients with acute non specific neck pain. Because course of pain did not differ from the one expected from self limitation, it is likely that non specific effects played only a minor role, if any, in both interventions.

Primary prevention of cardiovascular diseases by lipid-lowering treatment in German general practice: Results from GPs ignoring guidelines and risk calculators

Objective: Guidelines/risk calculators for the primary prevention of cardiovascular disease have been developed, which could make decisions for or against therapy easier. However, it has been shown for different countries that there is still quite a discrepancy between what is done and what should be done according to guidelines/risk calculators. Usually, in Germany, neither guidelines nor risk calculators are used. On what basis, then, and with what result do German general practitioners decide for or against a treatment? Methods: 26 GPs agreed to participate in the study. From their surgeries, data from a random sample of 401 patients diagnosed with hyperlipidaemia were taken, of which 290 were eligible for the study on primary prevention. Patient risk factors were taken from their files to analyse their need for treatment using risk calculators for ERCP III (US guideline) and the European guideline. These results were compared with the treatment they received from their GPs. In semi-structured interviews, GPs were asked about their decision-making process (in four randomly chosen patients from each surgery) concerning the chosen treatment. Additionally, GPs were asked about their attitude towards guidelines/risk calculators. Results: 89% of the patients who received treatment would also have received it according to ERCP III. According to European guidelines, only 38% of those receiving treatment need it. Concerning those not receiving treatment, 54% would not receive it according to NCEP III and 89% would not according to the European guideline. In interviews, around 75% of doctors demonstrated that they follow a multifactorial approach and a high-risk strategy. However, about 50% and 70% explicitly stated not using guidelines or risk calculators, respectively, and even among those stating that they used them, the majority were unaware of names/sources. Patient values or wishes as well as the healthcare system influenced their decisions.Conclusion: German GPs seem to follow quite effectively a high-risk strategy in primary prevention, usually using a multifactorial approach, even without using risk calculators/guidelines. This kind of personalized care is also reflected in the considered importance of patient wishes and values. It is difficult to judge GPs concerning their quality of care having as a “gold standard” different risk calculators/guidelines that define whether such different populations receive treatment or not.

GENETIC STUDY: Association between the BclI glucocorticoid receptor polymorphism and smoking in a sample of patients with obstructive airway disease

Glucocorticoids seem to mediate the effect of stimulant drugs such as nicotine. Several studies have pointed to an association between the BclI polymorphism in the glucocorticoid receptor gene and increased glucocorticoid effects. We analysed the association of smoking behaviour and the BclI polymorphism using a case-control design within the framework of a larger pharmacogenetic study. A total of 327 Caucasian patients with asthma or chronic obstructive pulmonary disease from 39 German general practices gave informed consent to take part in the study. They filled in questionnaires concerning their smoking behaviour and were genotyped for the BclI polymorphism. The genotype frequencies for non-smokers (n = 251; CC, 0.42; CG, 0.46; GG, 0.12) as well as for smokers (n = 76; CC, 0.29; CG, 0.55; GG, 0.16) were consistent with the Hardy-Weinberg equilibrium. The proportion of smokers was significantly lower among carriers of the CC-genotype (22/127 = 17%) compared with carriers of the G-allele (54/200 = 27%; chi2 = 4.08; P = 0.04). Within the group of smokers, the proportion of heavy smokers (> 19 cigarettes/day; median) was reduced in C-homozygous patients when compared with carriers of the G-allele (7/22 = 32% versus 31/54 = 57%; chi2 = 4.09; P = 0.04). Stepwise logistic regression analysis also pointed to an association between the CC-genotype and a reduced probability of being a smoker (odds ratio = 0.55; 95% confidence interval = 0.30-1.00; P = 0.05) controlling for other predictors. In summary, this study provides evidence that the BclI polymorphism might play a role in the maintenance and severity of nicotine dependence.

The Reliability and Validity of the Alcohol Use Disorders Identification Test (AUDIT) in a German General Practice Population Sample

Our goal was to analyze the retest reliability and validity of the Alcohol Use Disorders Identification Test (AUDIT) in a primary-care setting and recommend a cut-off value for the different alcohol-related diagnoses. Participants recruited from general practices (GPs) in two northern German cities received the AUDIT, which was embedded in a health-risk questionnaire. In total, 10,803 screenings were conducted. The retest reliability was tested on a subsample of 99 patients, with an intertest interval of 30 days. Sensitivity and specificity at a number of different cut-off values were estimated for the sample of alcohol consumers (n=8237). For this study, 1109 screen-positive patients received a diagnostic interview. Individuals who scored less than five points in the AUDIT and also tested negative in a second alcohol-related screen were defined as "negative" (n=6003). This definition was supported by diagnostic interviews of 99 screen-negative patients from which no false negatives could be detected. As the gold standard for detection of an alcohol-use disorder (AUD), we used the Munich-Composite International Diagnostic Interview (MCIDI), which is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. On the item level, the reliability, measured by the intraclass correlation coefficient (ICC), ranged between .39 (Item 9) and .98 (Item 10). For the total score, the ICC was .95. For cut-off values of eight points and five points, 87.5% and 88.9%, respectively, of the AUDIT-positives, and 98.9% and 95.1%, respectively, of the AUDIT-negatives were identically identified at retest, with kappa = .86 and kappa = .81. At the cut-off value of five points, we determined good combinations of sensitivity and specificity for the following diagnoses: alcohol dependence (sensitivity and specificity of .97 and .88, respectively), AUD (.97 and .92), and AUD and/or at-risk consumption (.97 and .91). Embedded in a health-risk questionnaire in primary-care settings, the AUDIT is a reliable and valid screening instrument to identify at-risk drinkers and patients with an AUD. Our findings strongly suggest a lowering of the recommended cut-off value of eight points.

Anxiety and depression in primary care patients: Predictors of symptom severity and developmental correlates

Objective A study in a German general practice used the Hospital Anxiety and Depression Scale (HADS) to determine the prevalence of anxiety and depression in 242 consecutive patients. The study had two additional goals: (1) to identify indicators of symptom severity and (2) to validate the HADS by relating it to measures of developmental psychopathology. Methods In addition to the HADS, clinical/sociodemographic data were collected. Patients filled up additional questionnaires measuring attachment characteristics, recalled parental rearing behavior, resilience, adverse childhood experiences, and physical complaints. Results Using HADS cutoff scores of ≥11 in total, we found that 21.1% of the patients showed clinically relevant anxiety levels; the rate for depression was 12.0%, that for anxiety or depression was 26.1%, and that for anxiety and depression combined was 7%. With the exception of psychiatric disorders, the HADS did not differentiate between subgroups with different somatic diseases. HADS scores were shown to be predicted by the patients' sex, family status, number of consultations, and subjective physical complaints. Patients with higher HADS scores also indicated lower resilience, more insecure attachment, and negative recalled parental rearing behavior. Resilience, attachment security, and specific parental behavior (control/warmth) independently predicted anxiety, depression, and physical complaints. Conclusion This study provides further support for the usefulness of the HADS as a measure for routine screening for anxiety and depression and its relationship with constructs from developmental psychopathology. We recommend the use of the HADS in combination with potential indicators of symptom severity (fatigue, cardiovascular symptoms, high number of consultations) to identify patients needing psychosocial support.

Management of urinary tract infections in female general practice patients

Though guidelines for the management of urinary tract infections (UTI) exist in several European countries, little is known about GPs' adherence, and the appropriateness of their management with regard to antibiotic resistance. To describe German GPs' management of female patients with symptoms of UTI, to assess the diagnostic accuracy of dipsticks in a German general practice setting, to develop diagnostic prediction rules for culture-confirmed UTI, and to compare the adequacy of empirical treatment strategies and GPs' actual prescriptions. In 36 (of 118 invited) teaching general practices, urine cultures and resistance testing were performed during 4 months on all symptomatic patients. GPs completed a questionnaire on each patients' symptoms, risk factors and treatment. Adequacy of different treatment approaches was calculated based on culture results. 445 adult women (76% of all patients) were included, with a median age of 53 years. Complicating factors were present in 27%. Urine culture revealed UTI in 77%. GPs' diagnostic accuracy, using both dipsticks and clinical impressions, was low. A positive nitrite test, dysuria and older age were the only predictive factors of culture-confirmed UTI, however the negative predictive value of dipsticks is low (35%). Empirical treatment of all symptomatic patients with either nitrofurantoin or fluoroquinolones would result in a higher rate of appropriate therapies than the individualized approach chosen by the GPs. Most patients with urinary symptoms were not treated according to current guidelines, and GPs' diagnostic and therapeutic accuracy was low. Empirical treatment of all symptomatic patients is probably the most effective policy, but implies unnecessary antibiotic prescriptions.

»Medizinische Versorgung in der Praxis« - eine Modellstudie zur Verbesserung der hausärztlichen Versorgungsforschung in Deutschland

primary care using computerized patient records. These data are used to assess adherence to evidence-based guidelines (process measures) and clinical results (outcome measures) considering selected diseases as examples (asthma/COPD, heart failure, urinary tract infection). Several other aspects of the mentioned diseases are investigated in patients from the participating practices: • Modification of the responsiveness to topical steroids by genetic polymorphisms in patients with asthma/COPD and their influence on the course of disease. Acceptance of genetic testing in patients with asthma and COPD. • Integration of clinical guidelines for urinary tract infection in German general practices and adjustment to the needs of individual patients. • Problems of care for patients with heart failure at the interface general practice/ hospital and improvement of early diagnosis of the disease.

Nutritional counseling in German general practices: a holistic approach

There is consensus among all German health professionals, including primary care physicians, that a holistic approach to healthy living begins with good nutrition. In northern Baden, 2100 general practitioners and internists were asked about their nutritional attitudes and preventive counseling in daily practice. Of responding physicians, 75% attributed great importance to prevention in general and 92% to nutrition in particular, 65% were providing special programs such as "How to treat diabetes by myself" or "Reducing hypertension by losing weight." Together with the highest German Committee of Physicians, the Lectures in General Medicine of the University of Heidelberg held a meeting on nutritional counseling in general practice. The 23 participants collected statements and information on the topics of education and counseling, support for improved teaching, and knowledge about nutritional attitudes and food. The Heidelberg agreements are as follows: 1) good nutritional counseling can reduce morbidity of important diseases, 2) nutritional counseling must be improved in general practice, 3) diagnosis-related written cases for systematic counseling should be available, 4) family doctors should cooperate with nutritionists, and 5) for quality assurance, the three-level strategy of primary care should be recommended because of the positive results of the Bruchsal-Oestringen program (reduction of obesity and hypercholesterolemia). General practice can become a place of improved nutritional counseling and education if the use of programs proven to be successful, additional exercise-based community approaches, and quality assurance can be facilitated. The outcome of practice-based studies may encourage primary care physicians to spend more time and training on nutrition guidance.

Hypotension--does it make sense in family practice?

In general practice many diagnostic labels are used that are related to cultural background rather than a scientific basis. To estimate the use of diagnoses like 'hypotension' and depression, a cross-sectional survey in German and British GPs' surgeries was performed. Prevalence of related symptoms, sociodemographic and medical data were recorded as well as actual and previous blood pressure levels. In German general practice, where 'hypotension' is an established entity, 17% of all patients attending were reported as hypotensive either by their doctor or by themselves. The proportion was twice as high among women than among men. It was more common among the young. One-quarter of these patients were on medication to raise their blood pressure. Actual and previous blood pressure levels failed to explain the occurrence of symptoms like tiredness, dizziness, headache etc. Demographic characteristics of patients diagnosed as depressed were similar in both countries. Presumably for economic reasons there is a tendency for German GPs to use more diagnostic labels of any kind. It was concluded that diagnostic labels attached to vague but frequently presented symptoms vary considerably between countries. They often lack a physiologic rationale. Nevertheless they often support the tendency to somatize common problems.