Attila Altiner

The influence of age, gender and socio-economic status on multimorbidity patterns in primary care. first results from the multicare cohort study

BackgroundMultimorbidity is a phenomenon with high burden and high prevalence in the elderly. Our previous research has shown that multimorbidity can be divided into the multimorbidity patterns of 1) anxiety, depression, somatoform disorders (ADS) and pain, and 2) cardiovascular and metabolic disorders. However, it is not yet known, how these patterns are influenced by patient characteristics. The objective of this paper is to analyze the association of socio-demographic variables, and especially socio-economic status with multimorbidity in general and with each multimorbidity pattern.MethodsThe MultiCare Cohort Study is a multicentre, prospective, observational cohort study of 3.189 multimorbid patients aged 65+ randomly selected from 158 GP practices. Data were collected in GP interviews and comprehensive patient interviews. Missing values have been imputed by hot deck imputation based on Gower distance in morbidity and other variables. The association of patient characteristics with the number of chronic conditions is analysed by multilevel mixed-effects linear regression analyses.ResultsMultimorbidity in general is associated with age (+0.07 chronic conditions per year), gender (-0.27 conditions for female), education (-0.26 conditions for medium and -0.29 conditions for high level vs. low level) and income (-0.27 conditions per logarithmic unit). The pattern of cardiovascular and metabolic disorders shows comparable associations with a higher coefficient for gender (-1.29 conditions for female), while multimorbidity within the pattern of ADS and pain correlates with gender (+0.79 conditions for female), but not with age or socioeconomic status.ConclusionsOur study confirms that the morbidity load of multimorbid patients is associated with age, gender and the socioeconomic status of the patients, but there were no effects of living arrangements and marital status. We could also show that the influence of patient characteristics is dependent on the multimorbidity pattern concerned, i.e. there seem to be at least two types of elderly multimorbid patients. First, there are patients with mainly cardiovascular and metabolic disorders, who are more often male, have an older age and a lower socio-economic status. Second, there are patients mainly with ADS and pain-related morbidity, who are more often female and equally distributed across age and socio-economic groups.Trial registrationISRCTN89818205

Relative Impact of Multimorbid Chronic Conditions on Health-Related Quality of Life – Results from the MultiCare Cohort Study

Background Multimorbidity has a negative impact on health-related quality of life (HRQL). Previous studies included only a limited number of conditions. In this study, we analyse the impact of a large number of conditions on HRQL in multimorbid patients without preselecting particular diseases. We also explore the effects of these conditions on the specific dimensions of HRQL. Materials and Methods This analysis is based on a multicenter, prospective cohort study of 3189 multimorbid primary care patients aged 65 to 85. The impact of 45 conditions on HRQL was analysed. The severity of the conditions was rated. The EQ-5D, consisting of 5 dimensions and a visual-analogue-scale (EQ VAS), was employed. Data were analysed using multiple ordinary least squares and multiple logistic regressions. Multimorbidity measured by a weighted count score was significantly associated with lower overall HRQL (EQ VAS), b = −1.02 (SE: 0.06). Parkinson’s disease had the most pronounced negative effect on overall HRQL (EQ VAS), b = −12.29 (SE: 2.18), followed by rheumatism, depression, and obesity. With regard to the individual EQ-5D dimensions, depression (OR = 1.39 to 3.3) and obesity (OR = 1.44 to 1.95) affected all five dimensions of the EQ-5D negatively except for the dimension anxiety/depression. Obesity had a positive effect on this dimension, OR = 0.78 (SE: 0.07). The dimensions “self-care”, OR = 4.52 (SE: 1.37) and “usual activities”, OR = 3.59 (SE: 1.0), were most strongly affected by Parkinson’s disease. As a limitation our sample may only represent patients with at most moderate disease severity. Conclusions The overall HRQL of multimorbid patients decreases with an increasing count and severity of conditions. Parkinson’s disease, depression and obesity have the strongest impact on HRQL. Further studies should address the impact of disease combinations which require very large sample sizes as well as advanced statistical methods.

Are women getting relevant information about mammography screening for an informed consent: a critical appraisal of information brochures used for screening invitation in Germany, Italy, Spain and France.

BACKGROUND The aim was to find out if information brochures on mammography screening in Germany, Italy, Spain and France contain more information to facilitate informed consent than in similar studies carried out over the last few years in Sweden, Canada, USA and the UK, countries with different medical cultures. METHODS We generated a list of essential information items on mammography screening for the purpose of informed consent. We mostly used the same items of information as had been used in previous studies and analysed the information brochures of major national initiatives in Germany and France, and three brochures each from regionalized programmes in Italy and Spain. We cross-checked which of our items were covered in the brochures and if correct numbers were given. RESULTS We found that the information brochures contained only about half of the information items we defined. Six of the eight brochures mentioned the reduction in breast-cancer fatalities. Four of the eight provided information on false positives, and four of the brochures highlighted the side-effects of radiation. The information on side-effects and risks provided by the brochures was generally of poor quality, and none of them referred to over diagnosis. When numbers were given, they were only indicated in terms of relative numbers. CONCLUSION The information brochures currently being used in Germany, Italy, Spain and France are no better than the brochures analysed some years ago. Our results suggest that the providers of mammography screening programmes continue to conceal information from women that is essential when making an informed decision.

Coping with multimorbidity in old age – a qualitative study

BackgroundComparatively few studies address the problems related to multimorbidity. This is surprising, since multimorbidity is a particular challenge for both general practitioners and patients. This study focuses on the latter, analyzing the way patients aged 65–85 cope with multimorbidity.Methods19 narrative in-depth interviews with multimorbid patients were conducted. The data was analysed using grounded theory. Of the 19 interviewed patients 13 were female and 6 male. Mean age was 75 years. Participating patients showed a relatively homogeneous socio-economic status. Patients were recruited from the German city of Hamburg and the state of North Rhine-Westphalia.ResultsDespite suffering from multimorbidity, interviewees held positive attitudes towards life: At the social level, patients tried to preserve their autonomy to the most possible extent. At the emotional level, interviewees oscillated between anxiety and strength - having, however, a positive approach to life. At the practical level, patients aimed at keeping their diseases under control. The patients tended to be critical in regards to medication.ConclusionsThese findings might have implications for the treatment of multimorbid patients in primary care and further research: The generally presumed passivity of older individuals towards medical treatment, which can be found in literature, is not evident among our sample of older patients. In future, treatment of these patients might take their potential for pro-active cooperation more strongly into account than it is currently the case.

Prävalenz und Diagnostik depressiver Störungen in der Allgemeinarztpraxis

OBJECTIVE Up to 50 % of patients suffering from major depression are not recognised by their general practitioners. On the other hand general practitioners do rate some of their patients as depressive despite the fact that psychiatric diagnostic instruments do not. In this study we wanted to not only analyse the number and proportion of concordant diagnoses between GP and an established psychiatric diagnostic instrument (PHQ-9), but also to analyse the modalities of non-concordant diagnostic classifications. METHODS 34 participating GPs asked all their patients visiting them at one ordinary work-day to fill in a questionnaire that included the German version of PHQ-9. Independently GPs documented their diagnostic judgement. If they saw a mental affection, they were asked to choose between eight different affections, with depression being just one of them. RESULTS 1 277 patients filled in the questionnaires; from these 902 questionnaires could be analysed, because a pair of GP and patient could be identified. The prevalence of major-depression in the study-population was 9 %. GPs and PHQ-9 diagnoses were concordant in 45 %. However, GPs rated two thirds of patients that were classified as depressed by the PHQ-9 as psychologically affected. In these patients they also devoted more than half of the consultation time to mental problems. CONCLUSIONS GPs do often not diagnose patients as depressive even though they clearly realise their mental affection. Simple explanations like lack of time or conscious or unconscious avoidance to make a psychiatric diagnosis cannot explain this phenomenon.

Prescriber and Patient Responsibilities in Treatment of Acute Respiratory Tract Infections — Essential for Conservation of Antibiotics.

Inappropriate antibiotic use in normally self-limiting acute respiratory tract infections (RTIs), such as sore throat and the common cold, is a global problem and an important factor for increasing levels of antibiotic resistance. A new group of international experts—the Global Respiratory Infection Partnership (GRIP)—is committed to addressing this issue, with the interface between primary care practitioners and their patients as their core focus. To combat the overuse of antibiotics in the community, and facilitate a change from prescribing empiric antibiotic treatment towards cautious deferment combined with symptomatic relief, there is a need to introduce and enhance evidence-based dialogue between primary care practitioners and their patients. Communication with patients should focus on the de-medicalisation of self-limiting viral infections, which can be achieved via a coherent globally endorsed framework outlining the rationale for appropriate antibiotic use in acute RTIs in the context of antibiotic stewardship and conservancy. The planned framework is intended to be adaptable at a country level to reflect local behaviours, cultures and healthcare systems, and has the potential to serve as a model for change in other therapeutic areas.

Fluoroquinolones to treat uncomplicated acute cough in primary care: predictors for unjustified prescribing of antibiotics

BACKGROUND Despite efforts to ensure more accurate prescribing of antibiotics for respiratory tract infections, inappropriate selection of antibiotic treatment remains a big issue. We tried to ascertain which factors best predict the nature of fluoroquinolone prescribing for acute cough in primary care. METHODS Random effects logistic regression models were applied to the baseline prescription data taken from a cluster-randomized controlled trial based on 104 general practitioners (GPs) and 2745 patients. RESULTS Significant predictors for the prescription of fluoroquinolones from both patient and GP data were identified. Predictors from a patients perspective were the severity of illness {odds ratio (OR) 3.56 [95% confidence interval (CI) 2.45-5.19] P < 0.001}, the duration of illness before seeing the GP [OR 1.09 (95% CI 1.04-1.14) P < 0.020] and the individual patients age [OR 1.01 (95% CI 1.00-1.01) P < 0.015]. Predictors from the GPs perspective were extent/lack of specific vocational training [OR 3.10 (95% CI 1.54-6.22) P < 0.001], status as a general internist [OR 2.00 (95% CI 1.10-3.70) P < 0.002], the physicians overall antibiotic prescription rate for acute cough [OR 1.02 (95% CI 1.01-1.04) P < 0.001], the duration of illness before contact with patient [OR 0.81 (95% CI 0.69-0.95) P < 0.010] and the severity of illness [OR 0.27 (95% CI 0.12-0.63) P < 0.002]. DISCUSSION Whether a fluoroquinolone is prescribed by a GP seems to be determined not only by the patients characteristics but also by the GPs vocational training and overall antibiotic prescribing rate. As the prescription of fluoroquinolones for the treatment of acute coughing can rarely be justified, such prescriptions may serve as a quality indicator for antibiotic prescribing in primary care.

General practice-based clinical trials in Germany - a problem analysis

BackgroundIn Germany, clinical trials and comparative effectiveness studies in primary care are still very rare, while their usefulness has been recognised in many other countries. A network of researchers from German academic general practice has explored the reasons for this discrepancy.MethodsBased on a comprehensive literature review and expert group discussions, problem analyses as well as structural and procedural prerequisites for a better implementation of clinical trials in German primary care are presented.ResultsIn Germany, basic biomedical science and technology is more reputed than clinical or health services research. Clinical trials are funded by industry or a single national programme, which is highly competitive, specialist-dominated, exclusive of pilot studies, and usually favours innovation rather than comparative effectiveness studies. Academic general practice is still not fully implemented, and existing departments are small. Most general practitioners (GPs) work in a market-based, competitive setting of small private practices, with a high case load. They have no protected time or funding for research, and mostly no research training or experience. Good Clinical Practice (GCP) training is compulsory for participation in clinical trials. The group defined three work packages to be addressed regarding clinical trials in German general practice: (1) problem analysis, and definition of (2) structural prerequisites and (3) procedural prerequisites. Structural prerequisites comprise specific support facilities for general practice-based research networks that could provide practices with a point of contact. Procedural prerequisites consist, for example, of a summary of specific relevant key measures, for example on a web platform. The platform should contain standard operating procedures (SOPs), templates, checklists and other supporting materials for researchers.ConclusionAll in all, our problem analyses revealed that a substantial number of barriers contribute to the low implementation of clinical research in German general practice. Some issues are deeply rooted in Germany’s market-based healthcare and academic systems and traditions. However, new developments may facilitate change: recent developments in the German research landscape are encouraging.

Cued Recall and Other Cognitive Tasks to Facilitate Dementia Recognition in Primary Care

To compare the accuracy of commonly used tasks with that of the Visual Association Test (VAT), a conceptually different test involving cued recall of pictorial stimuli, in the recognition of dementia within primary care.

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.