Achim Mortsiefer

Patientenverfügungen im Rettungsdienst (Teil 2)@@@Patient advance directives in the emergency medical service setting (Part 2): Neue Perspektiven durch Advance Care Planning und die „Hausärztliche Anordnung für den Notfall“@@@New perspectives through advance care planning and the physician orders for life-sustaining treatment

ZusammenfassungEine Patientenverfügung (PV) ist nach dem sog. Patientenverfügungsgesetz vom 01.09.2009 unter bestimmten Bedingungen – auch für ärztliche und nichtärztliche Mitarbeiter des Rettungsdienstes – formal rechtlich bindend. Doch sind diese Bedingungen in Notfallsituationen derzeit nur selten erfüllt, sodass das Rettungspersonal auch bei Vorliegen einer PV meist in Unkenntnis des (mutmaßlichen) Patientenwillens entscheiden muss. Dies führt regelmäßig zu Unsicherheit und Konflikten und belastet alle Beteiligten erheblich. Verschiedene internationale und deutsche Modellprojekte haben gezeigt, dass regionale Initiativen zum Advance Care Planning in Verbindung mit ärztlich (mit)verantworteten Notfallbögen tief greifende Strukturveränderungen bewirken können, durch die Patientenverfügungen im Rettungsdienst regelmäßig große Relevanz erhalten. Grundlegend sind eine professionelle Gesprächsbegleitung zur Entwicklung der persönlichen PV und ein regionales System zur Beachtung solcherart entstandener PV. Dieses System muss alle an der Betreuung chronisch kranker, multimorbider und in ihrer Mobilität eingeschränkter Menschen beteiligten Berufsgruppen und Versorgungsebenen einbeziehen. Darauf aufbauend können Rettungsdienstmitarbeiter dem einer PV zugrunde liegenden Gesprächs- und Entscheidungsprozess vertrauen. Damit können sie guten Gewissens den präzisen Festlegungen eines regional eingeführten Notfallbogens wie der „Hausärztlichen Anordnung für den Notfall“ (HAnNo) folgen.AbstractAccording to recent German legislation, an advance directive (AD) is legally binding, also for the physician and paramedic staff of emergency teams, as long as certain conditions are fulfilled. However, these conditions are rarely met in the daily practice of emergency care. So even when an AD is present, the emergency team has to make difficult decisions without guidance by the (presumed) patient preferences. This leads regularly to uncertainties and conflicts, and may become a significant burden for all involved. Various international model projects have shown that regional advance care planning (ACP) programs can bring about profound structural changes – especially with respect to the care of chronically ill, multimorbid individuals with impaired mobility. A regional ACP program rests essentially on two pillars: (1) the provision of a professional facilitation process for every single person to develop individual, meaningful ADs, and (2) the implementation of a comprehensive system ensuring that these such created ADs are recognized and followed by all professions and individuals involved. In a system where ACP has been successfully implemented, also emergency physicians and paramedic staff can trust the facilitation and shared decision-making process underlying an AD, and may rely on the preferences precisely stated in the regionally established emergency directive form such as the physician orders for life-sustaining treatment (POLST).

Activating GENeral practitioners dialogue with patients on their Agenda (MultiCare AGENDA) study protocol for a cluster randomized controlled trial

BackgroundThis study investigates the efficacy of a complex multifaceted intervention aiming at increasing the quality of care of GPs for patients with multimorbidity. In its core, the intervention aims at enhancing the doctor-patient-dialogue and identifying the patient’s agenda and needs. Also, a medication check is embedded. Our primary hypothesis is that a more patient-centred communication will reduce the number of active pharmaceuticals taken without impairing the patients’ quality of life. Secondary hypotheses include a better knowledge of GPs about their patients’ medication, a higher patient satisfaction and a more effective and/or efficient health care utilization.Methods/designMulti-center, parallel group, cluster randomized controlled clinical trial in GP surgeries. Inclusion criteria: Patients aged 65–84 years with at least 3 chronic conditions. Intervention: GPs allocated to this group will receive a multifaceted educational intervention on performing a narrative doctor-patient dialogue reflecting treatment targets and priorities of the patient and on performing a narrative patient-centred medication review. During the one year intervention GPs will have a total of three conversations à 30 minutes with the enrolled patients. Control: Care as usual. Follow-up per patient: 14 months after baseline interview. Primary efficacy endpoints: Differences in medication intake and health related quality of life between baseline and follow-up in the intervention compared to the control group. Randomization: Computer-generated by an independent institute. It will be performed successively when patient recruitment in the respective surgery is finished. Blinding: Participants (GPs and patients) will not be blinded to their assignment but will be unaware of the study hypotheses or outcome measures.DiscussionThere is growing evidence that the phenomenon of polypharmacy and low quality of drug use is substantially due to mis-communication (or non-communication) in the doctor patient interaction. We assume that the number of pharmaceutical agents taken can be reduced by a communicational intervention and that this will not impair the patients’ health-related quality of life. Improving communication is a core issue of future interventions, especially for patients with multimorbidity.Trial registrationCurrent Controlled Trials ISRCTN46272088.

Summative assessment of undergraduates' communication competence in challenging doctor-patient encounters. Evaluation of the Dusseldorf CoMeD-OSCE

OBJECTIVE To evaluate the summative assessment (OSCE) of a communication training programme for dealing with challenging doctor-patient encounters in the 4th study year. METHODS Our OSCE consists of 4 stations (breaking bad news, guilt and shame, aggressive patients, shared decision making), using a 4-item global rating (GR) instrument. We calculated reliability coefficients for different levels, discriminability of single items and interrater reliability. Validity was estimated by gender differences and accordance between GR and a checklist. RESULTS In a pooled sample of 456 students in 3 OSCEs over 3 terms, total reliability was α=0.64, reliability coefficients for single stations were >0.80, and discriminability in 3 of 4 stations was within the range of 0.4-0.7. Except for one station, interrater reliability was moderate to strong. Reliability on item level was poor and pointed to some problems with the use of the GR. CONCLUSION The application of the GR on regular undergraduate medical education shows moderate reliability in need of improvement and some traits of validity. Ongoing development and evaluation is needed with particular regard to the training of the examiners. PRACTICE IMPLICATIONS Our CoMeD-OSCE proved suitable for the summative assessment of communication skills in challenging doctor-patient encounters.

CRISTOPH - A cluster-randomised intervention study to optimise the treatment of patients with hypertension in General Practice

BackgroundRecent guidelines for the management of hypertension focus on treating patients according to their global cardiovascular risk (CVR), rather than strictly keeping blood pressure, or other risk factors, below set limit values. The objective of this study is to compare the effect of a simple versus a complex educational intervention implementing this new concept among General Practitioners (GPs).Methods/designA prospective longitudinal cluster-randomised intervention trial with 94 German GPs consecutively enroling 40 patients each with known hypertension. All GPs then received a written manual specifically developed to transfer the global concept of CVR into daily General Practice. After cluster-randomisation, half of the GPs additionally received a clinical outreach visit, with a trained peer discussing with them the concept of global CVR referring to example study patients from the respective GP. Main outcome measure is the improvement of calculated CVR six months after intervention in the subgroup of patients with high CVR (but no history of cardiovascular disease), defined as 10-year-mortality ≥ 5% employing the European SCORE formula. Secondary outcome measures include the interventions effect on single risk factors, and on prescription rates of drugs targeting CVR. All outcome measures are separately studied in the three subgroups of patients with 1. high CVR (defined as above), 2. low CVR (SCORE < 5%), and 3. a history of cardiovascular disease. The influence of age, sex, social status, and the perceived quality of the respective doctor-patient-relation on the effects will be examined.DiscussionTo our knowledge, no other published intervention study has yet evaluated the impact of educating GPs with the goal to treat patients with hypertension according to their global cardiovascular risk.Trial registrationISRCTN44478543

Risk-adjusted versus overall blood pressure control rate for identifying the need for intensified cardiovascular risk reduction: lessons from a cross-sectional study

Objective To compare a cardiovascular risk (CVR)-adjusted with the traditional blood pressure (BP) control rate for assessing BP control and consequent target populations for intensified treatment. Methods Model calculation using cross-sectional data retrieved from 89 German general practices; a random sample of 3355 patients with known hypertension was consecutively enrolled by their general practitioners. Cardiovascular history and risk factors were documented. In addition to the traditional control rate (fixed BP target <140/90), we calculated CVR-adjusted control rates, stratifying analyses according to three CVR categories and their corresponding BP targets on the basis of the European Cardiovascular Society’s SCORE tables: (1) very high CVR, owing to manifest cardiovascular disease (CVD), BP target <130/80; (2) high CVR, BP target <140/90; and (3) low CVR, BP target <160/100 mmHg. Results Traditional vs. CVR-adjusted BP control rates were 55.1 vs. 14.9% (manifest CVD, kappa 0.27), 36.7 vs. 35.8% (high CVR, kappa 0.98), 52.6 vs. 88.5% (low CVR, kappa 0.25), and 45.8 vs. 46.5% (overall, kappa 0.61). Among the study patients, 19.2% switched from ‘controlled’ to ‘uncontrolled’ or vice versa depending on the criterion applied. Conclusions Compared with the traditional BP control rate, the CVR-adjusted approach identifies a substantially different – although overall similarly large – target group for intensified cardiovascular risk reduction. Using CVR-adjusted BP control rates in surveys describing hypertension management could help to focus attention and resources on reducing CVR in patients who are likely to benefit from additional treatment efforts.

Narrative medicine-based intervention in primary care to reduce polypharmacy: results from the cluster-randomised controlled trial MultiCare AGENDA

Objectives To determine if patient-centred communication leads to a reduction of the number of medications taken without reducing health-related quality of life. Design Two-arm cluster-randomised controlled trial. Setting 55 primary care practices in Hamburg, Düsseldorf and Rostock, Germany. Participants 604 patients 65 to 84 years of age with at least three chronic conditions. Interventions Within the 12-month intervention, general practitioners (GPs) had three 30 min talks with each of their patients in addition to routine consultations. The first talk aimed at identifying treatment targets and priorities of the patient. During the second talk, the medication taken by the patient was discussed based on a ‘brown bag’ review of all the medications the patient had at home. The third talk served to discuss goal attainment and future treatment targets. GPs in the control group performed care as usual. Primary outcome measures We assumed that the number of medications taken by the patient would be reduced by 1.5 substances in the intervention group and that the change in the intervention group’s health-related quality of life would not be statistically significantly inferior to the control group. Results The patients took a mean of 7.0±3.5 medications at baseline and 6.8±3.5 medications at follow-up. There was no difference between treatment and control group in the change of the number of medications taken (0.43; 95% CI −0.07 to 0.93; P=0.094) and no difference in health-related quality of life (0.03; −0.02 to 0.08; P=0.207). The likelihood of receiving a new prescription for analgesics was twice as high in the intervention group compared with the control group (risk ratio, 2.043; P=0.019), but the days spent in hospital were reduced by the intervention (−3.07; −5.25 to −0.89; P=0.006). Conclusions Intensifying the doctor–patient dialogue and discussing the patient’s agenda and personal needs did not lead to a reduction of medication intake and did not alter health-related quality of life. Trial registration number ISRCTN46272088; Pre-results.

Examiner characteristics and interrater reliability in a communication OSCE

OBJECTIVE To identify inter-individual examiner factors associated with interrater reliability in a summative communication OSCE in the 4th study year. METHODS The OSCE consists of 4 stations assessed with a 4-item 5-point global rating instrument. A bivariate secondary analysis of interrater reliability in relation to 4 examiner factors (gender, profession, OSCE experience, examiner training) was conducted. Intraclass correlation coefficients (ICC) were calculated and compared between examiner dyads of different similarity. RESULTS 169 pairwise ratings from 19 different examiners in 16 dyads were analysed. Interrater reliability is significantly higher in examiner dyads of same vs. different gender (ICC=0.76 (95%CI=0.65-0.83) vs. ICC=0.41 (95%CI=0.21-0.57)), in dyads of two clinicians vs. non-clinical/mixed professions (ICC=0.72 (95%CI=0.56-0.83) vs. ICC=0.57 (95%CI=0.41-0.69)), and in dyads with high vs. low/mixed OSCE experience (ICC=0.73 (95%CI 0.50-0.87) vs. ICC=0.56 (95%CI=0.41-0.69)). Participation in recent examiner training had no influence on ICCs. CONCLUSION Better concordance of ratings between clinically active examiners might be a hint for context specificity of good communication. Higher interrater reliability between examiners with same gender may indicate gender-specific communication concepts. PRACTICE IMPLICATIONS Medical faculties introducing summative assessment of communication competence should focus the influence of examiner characteristics on interrater reliability.