National Disease Management Guidelines Research Articles

Impact of a national guideline for the management of peripheral arterial disease on revascularization rates in England: interrupted time series analysis.

A national guideline on peripheral arterial disease management in England was issued in August 2012. The impact on revascularization rates was examined and variation with socioeconomic deprivation assessed. Annual hospital admissions for England over 10 years (2008-2009 to 2017-2018) were examined using interrupted time series analysis. A pragmatic approach was used to classify admissions for revascularization into moderate and severe categories. There were 309 839 admissions (56% for moderate peripheral arterial disease), with an overall annual admission rate for revascularization of 86 per 100 000 population aged 25+ years. The rate for moderate peripheral arterial disease marginally increased by 0.29 per 100 000 per year (95% c.i. -0.22 to 0.80) from 2008-2009 to 2012-2013. Following guideline introduction, this rate decreased. The equivalent for severe peripheral arterial disease increased by 1.33 per 100 000 (0.78 to 1.88). Following guideline introduction, this rate plateaued. The change in rate (slope) for moderate peripheral arterial disease of -2.81 per 100 000 per year (-3.52 to -2.10) after guideline introduction was greater than the change in rate for severe peripheral arterial disease of -1.95 per 100 000 per year (-2.73 to -1.17). For moderate peripheral arterial disease, the annual rate in the most socioeconomically deprived category was 15.6 per 100 000 lower in 2017-2018 compared with 2012-2013 (24.3% decrease). The impact progressively diminished with decreasing deprivation. In the least deprived category, the reduction was 5.2 per 100 000 (12.9% decrease). For severe peripheral arterial disease, the decrease was 1.2 per 100 000 (3.1% reduction) with no consistent variation in relation to deprivation. Introduction of the national peripheral arterial disease management guideline in England was associated with a reduction in admission rates for revascularization, especially for moderate peripheral arterial disease, with greater reduction in rates for moderate peripheral arterial disease in more socioeconomically deprived areas. Association, however, does not necessarily imply causation and alternative explanations cannot be ruled out.

Clinical Practice Guideline: The Diagnosis and Treatment of Unipolar Depression- National Disease Management Guideline.

Depression is one of the most common mental disorders worldwide. The German National Disease Management Guideline (Nationale Versorgungsleitlinie, NVL) on Unipolar Depression, updated in 2022, contains recommendations on the diagnosis and treatment of acute and chronic depressive disorders. The update was based on the findings of a systematic review of the evidence (2013- 2022) and was issued by a multidisciplinary panel after a formalized consensus process. The structure of the guideline was fundamentally revised and is now based on the phases of depression and/or its treatment, as well as on the severity of the disease. There is newly added material with recommendations on Internet- and mobile-device based treatments, esketamine, repetitive magnetic stimulation, psychosocial therapies, rehabilitation, social participation, and complex forms of care. The guideline also emphasizes better coordination of all services in the care of patients with depression. This article covers the most important changes and additions among the 156 recommendations in the guideline. More information and accompanying materials are available at www.leitlinien.de/depression. There are now effective treatments for depression and a variety of supportive measures that can be applied with great benefit by primary care physicians, psychiatrists, psychotherapists, and complementary care providers. It is hoped that the updated guideline will improve the early detection, definitive diagnosis, treatment, and interdisciplinary care of people suffering from depression.

Health economic consequences of optimal vs. observed guideline adherence of coronary angiography in patients with suspected obstructive stable coronary artery in Germany: a microsimulation model.

While the number of patients with stable coronary artery disease (SCAD) is similar across European countries, Germany has the highest per capita volume of coronary angiographies (CA). This study evaluated the health economic consequences of guideline-non-adherent use of CA in patients with SCAD. As part of the ENLIGHT-KHK trial, a prospective observational study, this microsimulation model compared the number of major adverse cardiac events (MACE) and the costs of real-world use of CA with those of (assumed) complete guideline-adherent use (according to the German National Disease Management Guideline 2019). The model considered non-invasive testing, CA, revascularization, MACE (30 days after CA), and medical costs. Model inputs were obtained from the ENLIGHT-KHK trial (i.e. patients' records, a patient questionnaire, and claims data). Incremental cost-effectiveness ratios were calculated by comparing the differences in costs and MACE avoided from the perspective of the Statutory Health Insurance (SHI). Independent on pre-test probability (PTP) of SCAD, complete guideline adherence for usage of CA would result in a slightly lower rate of MACE (-0.0017) and less cost (€-807) per person compared with real-world guideline adherence. While cost savings were shown for moderate and low PTP (€901 and €502, respectively), for a high PTP, a guideline-adherent process results in slightly higher costs (€78) compared with real-world guideline adherence. Sensitivity analyses confirmed the results. Our analysis indicates that improving guideline adherence in clinical practice by reducing the amount of CAs in patients with SCAD would lead to cost savings for the German SHI.

German S3 Guideline - Oxygen Therapy in the Acute Care of Adult Patients

Oxygen (O2) is a drug with specific biochemical and physiologic properties, a range of effective doses and may have side effects. In 2015, 14 % of over 55 000 hospital patients in the UK were using oxygen. 42 % of patients received this supplemental oxygen without a valid prescription. Healthcare professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. A S3-guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. Literature search was performed until Feb 1st 2021 to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used and for assessing the quality of evidence and for grading guideline recommendation and a formal consensus-building process was performed. The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. This is the first national guideline on the use of oxygen in acute care. It addresses healthcare professionals using oxygen in acute out-of-hospital and in-hospital settings. The guideline will be valid for 3 years until June 30, 2024.

Physical therapy for patients with low back pain in Germany: a survey of current practice

BackgroundLow back pain (LBP) is one of the most common musculoskeletal disorders worldwide. The National Disease Management Guideline (NVL) “Non-specific LBP” is a practical decision-making aid for both physicians and non-medical professionals in Germany to improve quality of health care. Although LBP is the most frequent diagnosis resulting in physical therapy treatment, information on the current management of patients with LBP and guideline adherence is limited. The objective of this study was to evaluate the current physical therapy management of patients with LBP in Germany, and to explore guideline adherence to the NVL “Non-specific LBP” recommendations.MethodsAn online survey among physical therapists working in Germany was conducted based on the recommendations given in the NVL “Non-specific LBP”. Participants were recruited using a snowball sampling approach and invited to complete the questionnaire. Guideline adherence was evaluated by comparing the survey findings with the recommendations of the NVL.ResultsIn total, 1361 physical therapists (41 years of age (SD 11); 839 female, 514 male; 16 years of clinical experience (SD 10)) completed the survey.Fifty percent (n = 675) of our respondents adhered to the recommendations of the NVL on the therapeutic diagnostic process, and 72% (n = 973) to the recommendations concerning treatment. The guideline adherence across the entire management process (i.e., both diagnosis and treatment) of LBP was 38% (n = 513). German physical therapists predominantly provide active interventions, e.g., exercise therapy, but also use interventions with low or conflicting evidence, respectively. Massage and Kinesio Taping were frequently used despite being not recommended. Less than one third of study participants (n = 400, 29%) answered to know the NVL or had dealt with its recommendations.ConclusionsIn the management of LBP, overall guideline adherence among German physical therapists was 38% with higher adherence in the treatment section than in the physical therapeutic diagnostic process. Widespread employment of implementation strategies and removal of existing barriers against the application of evidence-based guidelines could facilitate the transfer of scientific evidence into clinical practice and contribute to optimize the quality of health care.Trial registrationGerman Clinical Trials Register (DRKS00012607). Registered 04 October 2017.

National Disease Management Guideline Type 2 Diabetes. Part 1: Pharmacotherapy of glucose metabolism plus shared decision making and participation in all relevant areas of life

National Disease Management Guideline Type 2 Diabetes. Part 1: Pharmacotherapy of glucose metabolism plus shared decision making and participation in all relevant areas of life

Conceptualising equity in the impact evaluation of chronic disease management programmes: a capabilities approach.

Chronic diseases are highly important for the future level and distribution of health and well-being in western societies. Consequently, it seems pertinent to assess not only efficiency of chronic care but also its impact on health equity. However, operationalisation of health equity has proven a challenging task. Challenges include identifying a relevant and measurable evaluative space. Various schools of thought in health economics have identified different outcomes of interest for equity assessment, with capabilities as a proposed alternative to more conventional economic conceptualisations. The aim of this paper is to contribute to the conceptualisation of health equity evaluation in the context of chronic disease management. We do this by firstly introducing an equity enquiry framework incorporating the capabilities approach. Secondly, we demonstrate the application and relevance of this framework through a content analysis of equity-related principles and aims in national chronic disease management guidelines and the national diabetes action plan in Denmark. Finally, we discuss how conceptualisations of equity focused on capabilities may be used in evaluation by scoping relevant operationalisations. A promising way forward in the context of chronic care evaluation may emerge from a combination of concepts of capabilities developed in economics, health sciences and psychology.

Chronic Heart Failure.

Chronic heart failure (CHF) is the most common reason for hospital admissions in Germany. For the National Disease Management Guideline (NDMG) on CHF, a multidisciplinary expert panel revised the chapters on drug therapy, invasive therapy, and care coordination, following the methods of evidence-based medicine. Recommendations are based on international guideline adaptations or systematic literature search. They were developed by a multidisciplinary expert panel, approved in a formal consensus procedure, and tested in open consultation, as specified by the requirements for S3 guidelines. The pharmacological treatment is based on ACE inhibitors, beta-blockers and mineralocorticoid receptor antagonists as well as diuretics to treat fluid retention, if present. Sacubitril/Valsartan and ivabradine showed positive effects on mortality in large but methodologically limited RCT. They are recommended if established combination therapy is not sufficient for symptom control, or if drugs are not tolerated/contraindicated. The indications for pacemakers or defibrillators have been confined to patient subgroups in which clinical trials have shown a clear benefit. Moreover, the goals of treatment and the patient's expectations should be aligned with each other. Structured care programs, specialized nurses, remote, or telephone monitoring showed moderate effects on patient related outcomes in RCT. All patients with heart failure are suggested to be enrolled in a structured program (e.g., a disease management program) including coordinated multidisciplinary care and continuous educational interventions. In patients with a poor prognosis, more intensive care is recommended, e.g. specialized nurses, or telephone support.

Psychotherapy of depressive disorders: Evidence in chronic depression and comorbidities

Psychotherapy has been shown to be an effective treatment option for depressive disorders; however, its effectiveness varies depending on patient and therapist characteristics and the individual form of the depressive disorder. The aim of this article is to present the current evidence for psychotherapeutic antidepressive treatments for patients with chronic and treatment-resistant depression as well as for patients with mental and somatic comorbidities. During the revision of the currently valid German S3- and National Disease Management Guideline (NDMG) on unipolar depression published in 2015, acomprehensive and systematic evidence search including psychotherapy for specific patient groups was conducted. The results of this search along with asystematic update are summarized. Psychotherapy has been shown to be effective in reducing depressive symptoms in patients suffering from chronic and treatment-resistant depression and in patients with mental and somatic comorbidities. The evidence is insufficient particularly for patients with mental comorbidities. Based on the current evidence and clinical expertise the NDMG recommends psychotherapy alone or in combination with pharmacotherapy to treat most of these depressive patient groups. Evidence gaps were identified, which highlight the need for further research.

Psychotherapy of depressive disorders : Procedures, evidence and perspectives

Depressive disorders are associated with ahigh burden of suffering and significantly reduce the well-being and the self-esteem of affected patients. Psychotherapy is one of the main treatment options for depressive disorders. The aim of this article is to present the current evidence for antidepressive psychotherapeutic treatments. During the revision of the German S3- and National Disease Management Guideline (NDMG) on unipolar depression in 2015, acomprehensive and systematic evidence search was conducted. The results of this search along with asystematic update are summarized. The most intensively investigated psychotherapeutic method is cognitive behavioral therapy (CBT), which proved to be effective in many trials. Evidence also exists for psychodynamic psychotherapy and interpersonal therapy (IPT), followed by systemic therapy and client-centered psychotherapy; however, the evidence is less robust. Psychotherapy alone or in combination with pharmacotherapy was shown to be an effective treatment option. Psychotherapy represents akey element in the treatment of depressive disorders.

Implementation of the National Guidelines for the treatment of Diabetes mellitus type 2 in secondary diabetes centers

Background The German National Disease Management Guideline (NVL) on treatment of Type 2 Diabetes recommends lowering of blood glucose in four therapy steps. There is little evidence, how NVL is implemented for the individual patients. Methods 810 patients in secondary diabetes centers were examined within the DiabCheckOCTplus trial. Data about the patient's health status (electronic medical record) were classified according to the NVL treatment steps. The degree of implementation was assessed for every person with diabetes type 2 (NCT02 311 504). Results Related to the levels of treatment, 81 % of patients received metformin in level 2, 48 % the dual combination of metformin with DPP4-Inhibitors (level 3) and 41 % an intensified insulin therapy in combination with metformin (level 4). The overall percentage for metformin was 67 %, for DPP4-Inhibitors 20 % and 10 % for sulfonylureas.The duration of diabetes significantly increased with higher NVL level. After 3 years of diabetes 55 % received more than one antihyperglycemic drug. Half of the patients were treated with complex insulin strategies after 9 years, however almost all after 25 years. Conclusion The therapy in secondary care centers met national guidelines to a large extent. Similar proof of implementation would be important for primary care by general practitioners. As the factual information of the therapy level strongly correlated with the duration of disease, it might be used for structured communication (risk profile).

The Prevention and Treatment of Retinal Complications in Diabetes.

Microvascular complications of diabetes mellitus can cause retino pathy and maculopathy, which can irreversibly damage vision and lead to blindness. The prevalence of retinopathy is 9-16% in patients with type 2 diabetes and 24-27% in patients with type 1 diabetes. 0.2-0.5% of diabetics are blind. The National Disease Management Guideline on the prevention and treatment of retinal complications in diabetes was updated according to recommendations developed by seven scientific medical societies and organizations and by patient representatives and then approved in a formal consensus process. These recommendations are based on international guidelines and systematic reviews of the literature. Regular ophthalmological examinations enable the detection of retinopathy in early, better treatable stages. The control intervals should be based on the individual risk profile: 2 years for low-risk patients and 1 year for others, or even shorter depending on the severity of retinopathy. General risk factors for retinopathy include the duration of diabetes, the degree of hyperglycemia, hypertension, and diabetic nephropathy. The general, individually adapted treatment strategies are aimed at improving the risk profile. The most important specifically ophthalmological treatment recommendations are for panretinal laser coagulation in proliferative diabetic retinopathy and, in case of clinically significant diabetic macular edema with foveal involvement, for the intravitreal application of medications (mainly, vascular endothelial growth factor [VEGF] inhibitors), if an improvement of vision with this treatment is thought to be possible. Regular, risk-adapted ophthalmological examinations, with standardized documentation of the findings for communication between ophthalmologists and the patients' treating primary care physicians/diabetologists, is essential for the prevention of diabetic retinal complications, and for their optimal treatment if they are already present.

National disease management guidelines (NVL) for chronic CAD : What is new, what is particularly important?

Coronary heart disease (CAD) is widespread and affects 1 in 10 of the population in the age group 40-79years in Germany. The German national management guidelines on chronic CAD comprise evidence and expert-based recommendations for the diagnostics of chronic stable CAD as well as for interdisciplinary/multidisciplinary therapy and care of patients with stable CAD. The focus is on the diagnostics, prevention, medication therapy, revascularization, rehabilitation, general practitioner care and coordination of care. Recommendations for optimizing cooperation between all medical specialties involved as well as the definition of mandatory and appropriate measures are essential aims of the guidelines both to improve the quality of care and to strengthen the position of the patient.

Acute Lumbar Back Pain.

Back pain has many causes. In Germany, about 70% of adults have at least one episode of back pain per year. This review is based on a selective literature search and on the German National Disease Management Guideline for Low Back Pain. The physician taking the history from a patient with back pain should ask about the nature, onset, course, localization, and radiation of the pain and its dependence on physical activity and/or emotional stress. In the differential diagnosis, neurologic deficits and any "red flags" suggesting dangerous conditions such as spinal fracture, bacterial infection, and tumors must be ruled out. If no specific cause of the pain can be identified, no imaging studies are indicated on initial presentation. The treatment of acute, nonspecific low back pain focuses on pain relief and functional improvement. Adequate patient education and counseling are essential. Exercise therapy is no more effective than the continuation of normal daily activities. Restriction of activity, including bed rest, is of no benefit and merely prolongs recovery and the resumption of normal activity. Further diagnostic testing is indicated if there is any suspicion of a fracture, infection, or tumor. After dangerous conditions have been ruled out, low back pain can be pragmatically classified as either nonspecific or specific. More research is needed so that the diagnostic assessment and individualized treatment of acute lower back pain can be further refined.

Bridging the gap between patient needs and quality indicators: a qualitative study with chronic heart failure patients.

BackgroundThe German National Disease Management Guideline (NDMG) on chronic heart failure (CHF) derived nine clinical quality indicators (QIs) to enable assessment of quality of health care in patients with CHF. These QIs epitomize an evidence-based and somatic point of view of guided treatment, but little is known about the experiences and views of patients with their guideline-based treatment across multiple health care sectors.ObjectiveThe purpose of this qualitative study was to explore patient perspectives on guided treatment of CHF across multiple health care sectors. Furthermore, it was investigated to what extent patient perspectives are represented by the QIs of the German NDMG.MethodsUsing a qualitative approach, semistructured interviews were carried out with 17 CHF patients. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using qualitative content analysis.ResultsPatient-identified needs focused primarily on aspects like the doctor–patient relationship, communication, quality of individual-tailored information, and professional advice. Patients perceived shortcomings in processes of care such as communication and cooperation across health care sectors, especially at the transition between hospital and outpatient care.DiscussionFrom the patient perspectives, the QIs do represent relevant somatic and clinical aims for quality measurement. However, deficits were identified, especially related to communication and cooperation across health care sectors. Given the fact that the inclusion of patient perspectives in quality improvement processes provides an important contribution to patient-centered health care, possible approaches for QI development such as direct and indirect patient involvement or generic vs disease-specific patient-related QIs should be the subject of future discussions.

Patient Participation in Development of Quality Indicators using the Example of National Disease Management Guidelines for Chronic Heart Failure - A Qualitative Analysis of Collective Perspectives

In this qualitative study it was investigated by group discussions with patients suffering from chronic heart failure, how relevant the existing quality indicators of the National Disease Management Guidelines for Chronic Heart Failure are being estimated. 6 group discussions were performed. The sample was formed from 4 mixed-gender groups, a male group and a female group. Participants were recruited from local heart sports groups. For the interpretation a method similar to the grounded theory was used. The main conclusion is that in principle quality indicators are accepted. However, many of these indicators neglect the everyday aspects of patients' life. Participants show a disposition of "yes - but" regarding the quality indicators. This phenomenon could be theoretically grasped using the concept of order of knowledge. While participants keep referring to an order of everyday knowledge, quality indicators make recourse to a medical order of knowledge. Both orders of knowledge may compete with each other. The professional knowledge order of medicine needs to open up to a patients' knowledge order. Patient representatives in health care bodies need to be trained to develop a reflexive point of view to different knowledge orders enabling them to represent patients' everyday knowledge more confidently. Otherwise there is danger of conformation to the professional knowledge order of medicine only for reasons of being recognised as equal partners.

An informed shared decision making programme on the prevention of myocardial infarction for patients with type 2 diabetes in primary care: protocol of a cluster randomised, controlled trial.

BackgroundInternational and national societies claim a patient centred approach including shared decision making (SDM) in diabetes care. In a previous project, a SDM programme on the prevention of myocardial infarction has been developed. It is aimed at supporting patients with type 2 diabetes to make informed choices on preventive options, to share the decision making process with the health care team, and to improve adherence to the chosen treatment. In this study, the programme will be implemented and evaluated in primary care practices.Methods/DesignA cluster randomised, controlled trial will be conducted to compare the SDM programme with standard care enrolling patients with type 2 diabetes (N = 306) from primary care practices (N = 24). The intervention programme comprises a six hours provider training, a patient decision aid including evidence-based information, a 90 minutes structured teaching session provided by medical assistants, a sheet to document the patients’ individual treatment goals, and a structured consultation with the general practitioner for sharing information, setting treatment goals, and for adapting treatment regimens if necessary. Patients in the control group receive a brief extract of recommendations of the German National Disease Management Guideline on the treatment of patients with type 2 diabetes. Primary outcome measure is adherence to blood pressure treatment and statin treatment at 6 months follow-up. Secondary outcome measures comprise informed choice and the achievement of patients’ treatment goals. Analyses will be carried out on intention-to-treat basis. Concurrent qualitative methods will be used to explore the implementation processes.DiscussionAt the end of this study, information on the efficacy of the SDM programme in the primary care context will be available. In addition, processes that might interfere with or that might promote a successful implementation will be identified.Trial registrationISRCTN77300204.

The professional perspective on patient involvement in the development of quality indicators: a qualitative analysis using the example of chronic heart failure in the German health care setting.

PurposeThere is an international consensus that quality indicators (QIs) of health care ought to represent patient-relevant aspects. Therefore, patient involvement in the development process is essential. However, there is no methodological gold standard for involving patients in QI development. The aim of this study is to explore experts’ views on the representation of patient-relevant aspects in the QI development process using the QIs developed in the context of the German National Disease Management Guideline for Heart Failure as an example.MethodsSemi-structured, open telephone interviews were conducted with 15 German experts (patient representatives, physicians, researchers, and methodologists involved in guideline development or quality assessment). Interview themes were the relevance of the exemplary set of QIs for patients, as well as the legitimacy of, competence of, and collaboration with the patient representative who participated in the development process. Interviews were fully transcribed and content analyzed. Deductive categories derived from the research questions were supplemented by inductively formed categories during the review of the interview material.ResultsThe qualitative analysis suggests a discrepancy between the guidelines’ QIs and those relevant to patients from an expert’s point of view, such as physician-patient communication and quality of counseling. Experts reported only minor communication and cooperation problems while working together in the guideline/QI development team. Concerns existed, for example, regarding the recruitment of patient representatives for diseases without self-help organizations, the financing of patient representation, and the training of patient representatives. Only few potential strategies for improving the process of patient involvement were mentioned.ConclusionIntegrating the patients’ perspectives through the recruitment of a patient representative to participate in the development team was well established and broadly accepted. However, experts stated that the finally selected QIs represent only a small part of the patient-relevant aspects of medical care. According to the experts’ perceptions, the current processes provide a very limited scope for integrating the patients’ perspectives in a more extensive way. Supplementing the set of “conventional” QIs with additional, separately developed, “patient-side” QIs might help to include patient priorities in quality measurement.

Patientenleitlinien in der Onkologie: Zielsetzung, Vorgehen und erste Erfahrungen mit dem Format

For several years patient versions of guidelines have become mandatory in the German Guidelines Program in Oncology (GGPO). Based on the methodology that has been developed for the German National Disease Management Guidelines Program, patient versions of guidelines translate the recommendations of clinical practice guideline into plain language and provide information about the harms and benefits of the interventions being addressed in the guideline. They are developed by a group of guideline authors (experts as well as patients), they are consensus-based and aim to create transparency in recommendations for physicians and their rationales. An automated analysis of readability shows that patient versions of guidelines are specific to the target group of educated lay people. Moreover, the responses to a reader feedback questionnaire indicate that comprehensibility, level of detail and depth of information are considered highly relevant and positive by users. Thus, patient versions of guidelines meet the needs of a specific target group. Nevertheless, the development of other formats for readers with low levels of health literacy or cognitive competencies is desirable. Currently it remains unclear if these simplified formats are able to reflect the complexity of high quality clinical practice guidelines.

Leitlinien-Implementierungs-Studie Asthma (L.I.S.A.): Ergebnisse eines pragmatischen Implementierungsansatzes

Knowledge transfer from theory to practice in healthcare systems poses a challenge worldwide. Typical examples include national disease management guidelines. The present study contributes towards improving implementation strategies for an asthma guideline. A guideline implementation strategy was examined in a four-armed, non-randomised, controlled intervention study with an additional control group. The study participants were general practitioners and paediatricians recruited from primary care quality circles. All study participants attended an interactive seminar on the evidence-based recommendations for patients with asthma. In addition, the participants were asked to choose among the following options: no further intervention, additional e-learning, training of their practice nurses, or e-learning and training of their practice nurses. The success of the intervention was measured by questionnaire (and the success rate expressed as a percentage). About one third of all participants (n=313) opted for the combination of an interactive seminar and a training of practice nurses; two third preferred the classic way of continuing medical education with an interactive seminar without a further intervention. Just 10 % of the physicians participated in e-learning. Independently of their choice for continuing medical education, all participants demonstrated an increase in knowledge about asthma and an improvement in the management of asthma. The physicians exhibited an average increase in both categories of about 10 % of the percentage values, compared to an increase of about 28 % among the practice nurses without continuing medical education. The physicians' free choice of the educative modules might be an integral part of successful implementation strategies. However, this will require a change of focus from general continuing medical education packages to a more individualised culture of continuing professional development in Germany.