Hagen Sandholzer

Three- and four-digit ICD-10 is not a reliable classification system in primary care.

Objective. The International Classification of Diseases 10th revision (ICD-10) is a standard international diagnostic classification for medical diagnoses. Reliable diagnostic coding is of high medical and epidemiological importance. Coding diagnoses with ICD-10 is the basis of reimbursement in some healthcare systems. Design. The ICD-10 coding of each case was performed by two raters to investigate the inter-rater agreement. The degree of agreement was assessed using Cohens kappa. Kappa was divided into two groups: Kappa >/ = 0.61 meaning high or satisfactory and kappa </ = 0.6 (incl. </ = 0.000 and 0.000*) meaning low or unsatisfactory. Subjects. Cross-sectional data were collected from 8877 randomly selected patients. The 209 participating general practitioners used a standardized data collection form. The first of the reasons for encounter was taken into account on new and chronic managed problems. Results. Kappa values were satisfactory on the chapter level with on average 0.685 (chronic managed problems) and 0.675 (new managed problems). Kappa was unsatisfactory when the three-digit level was used (0.428) and lower for terminal codes (four-digit level) at 0.199 on average (chronic managed problems). For new managed problems the kappa values were at 0.384 (three-digit level) and 0.166 (four-digit level) on average. Conclusion. The ICD-10 is reliable for coding managed problems on the chapter level. Further refinement of ICD-10 with three- and four-digit codes leads to significant coding uncertainties. There is no reliable coding scheme that meets the demands of general practice. The use of coded data for healthcare reimbursement requires a simplification of ICD-10 to provide a realistic picture of morbidity.

Dyspnea as the Reason for Encounter in General Practice

Background Dyspnea is a common reason for consulting a physician. Data from the primary care setting on the epidemiology, management, and underlying causes of dyspnea have seldomly been published. The present study is aimed to explore the consultation prevalence of dyspnea, frequency of diagnostic and therapeutic procedures, accompanying symptoms and results of encounter or diagnoses of patients with dyspnea in a day-to-day primary care setting. Methods Cross-sectional data were collected from randomly selected patients during the SESAM 2 study (October 1, 1999 to September 30, 2000). Unpublished but publicly available data from the Dutch Transition Project were also analysed. Results One (n = 93; SESAM 2) and 3.9% (n = 7,855; Transition Project) of the patients consulted the practioner for dyspnea. The male to female ratio was almost 1 : 1. Half of the patients sought medical advice for not previously known dyspnea (Transition Project). Dyspnea occurs more frequently among small children (0 to 4 years) and elderly adults (> 64 years of age). Nearly all patients received a physical examination. Many causes were examined with the help of electrocardiograms but spirometry and laboratory tests were also used. Drug prescription was the most frequent (79.6%) therapeutic procedure. Acute bronchitis was the most common diagnosis. Dyspnea was significantly associated to cough, dysphagia, abnormal sputum, airway pain, sweating, and thoracic pain. There was also a significant association to chronic obstructive pulmonary disease. Conclusions Dyspnea is a common reason for seeking medical advice. Emergency cases (e.g. myocardial infarction) are rarely present in the general practitioner’s consultation. The majority of underlying causes are respiratory tract infections and exacerbated, previously known chronic diseases. Keywords Dyspnea; General practice; Primary care; Reason for encounter

Inter-rater reliability of the ICPC-2 in a German general practice setting

QUESTIONS Three- and four-digit International Classification of Diseases (ICD-10) is not a reliable classification system in primary care. The reliability of the International Classification of Primary Care (ICPC-2) as an alternative coding system has not yet been investigated in a German general practice setting. METHODS Cross-sectional data were collected during a one year period in a general practice setting. PARTICIPANTS A total of 8,877 patients were randomly selected. MAIN OUTCOME MEASURES The first of the reasons for encounter was taken into account on new and chronic managed problems. The ICPC-2 coding of each case was performed by two raters to investigate the inter-rater agreement. The degree of agreement between the raters was assessed by using Cohens kappa (κ ≥ 0.61 meaning high or satisfactory and κ ≤ 0.6 (incl. ≤ 0.000) meaning low or unsatisfactory). RESULTS The reliability was good to excellent at the chapter level, at the component level the reliability was moderate though good in the components 1-symptoms and 7-diseases. At single code level the agreement was only fair to moderate in both chapters and components. One third to half of the used codes showed good inter-rater agreement. CONCLUSION The ICPC-2 is an adequate and feasible instrument for routine use in general practice. The fair to moderate reliability on the single code level should be considered when designing studies and interpreting data that are based on the ICPC-2.

In-home preventive comprehensive geriatric assessment (CGA) reduces mortality—A randomized controlled trial

The study should prove the effectiveness of a preventive in-home CGA regarding mortality and time able to stay in the community. We performed a randomized controlled trial with a mean follow-up of 6.2 years. The home visits were performed in Germany. 1620 community-living persons aged 70 years and older (n=630 intervention; 990 controls) from 20 general practitioner surgeries were visited. The intervention was performed by trained medical students it included a CGA using the STEP-tool (standardized assessment of elderly people in primary care in Europe; a combination of a structured questionnaire and a structured physical examination) and additional tests, followed by recommendations for the general practitioner. The controls received usual general practitioner care. Follow-up visit was made at mean 6.2 years after randomization. The main outcome parameters were mortality and time able to stay at home. Follow-up-rate was 75%. In COX-regression-analyses, a 20% reduction of mortality and a 22% lower risk of nursing-home admission were shown in the intervention group at the follow up. Despite the main limitations of the study (general practitioners volunteered to participate, follow-up-rate <80%, possible performance of geriatric assessments also in the control group, intervention group had poorer health status than the control group, adherence to recommendations from the assessment was not verified) we conclude that the implementation of a preventive geriatric assessment into primary care in Germany seems to be reasonable.

Early community-based family practice elective positively influences medical students' career considerations - a Pre-post-comparison

BackgroundDemographic change and recruitment problems in family practice are increasingly threatening an adequate primary care workforce in many countries. Thus, it is important to attract young physicians to the field. The purpose of the present study was to examine the effect of an early community-based 28-h family practice elective with one-to-one mentoring on medical students’ consideration of family practice as a career option, their interest in working office-based, and several perceptions with regard to specific aspects of a family physician’s work.MethodsFirst- and second-year medical students completed questionnaires before and after a short community-based family practice elective, consisting of a preparatory course and a community-based practical experience with one-to-one mentoring by trained family physicians.ResultsWe found a significantly higher rate of students favoring family practice as a career option after the elective (32.7% vs. 26.0%, p = 0.039). Furthermore, the ranking of family practice among other considered career options improved (p = 0.002). Considerations to work office-based in the future did not change significantly. Perceptions regarding a family physician’s job changed positively with regard to the possibility of long-term doctor-patient relationships and treatment of complex disease patterns. The majority of the students described identification with the respective family physician tutor as a professional role model and an increased interest in the specialty.ConclusionsOur results indicate that a short community-based family practice elective early in medical education may positively influence medical students’ considerations of a career in family practice. Furthermore, perceptions regarding the specialty with significant impact on its attractiveness may be positively adjusted. Further research is needed to evaluate the influence of different components of a family practice curriculum on the de facto career decisions of young physicians after graduation.

A comparison of Kneipp hydrotherapy with conventional physiotherapy in the treatment of osteoarthritis of the hip or knee: protocol of a prospective randomised controlled clinical trial

BackgroundThe increasing age of the population, especially in the western world, means that the prevalence of osteoarthritis is also increasing, with corresponding socioeconomic consequences. Although there is no curative intervention at present, in accordance with US and European guidelines, pharmacotherapeutic and non-pharmacological approaches aim at pain control and the reduction of functional restriction.It has been established that hydrotherapy for osteoarthritis of the hip or knee joint using serial cold and warm water stimulation not only improves the range of movement but also reduces pain significantly and increases quality of life over a period of up to three months. Weight reduction is important for patients with osteoarthritis of the hip or knee. In addition, conventional physiotherapy and exercise therapy have both been shown, at a high level of evidence, to be cost-effective and to have long-term benefits for pain relief, movement in the affected joint, and patient quality of life.Methods/designThe study design consists of a prospective randomised controlled three-armed clinical trial, which will be carried out at a specialist clinic for integrative medicine, to investigate the clinical effects of hydrotherapy on osteoarthritis of the knee or hip joint, in comparison with conventional physiotherapy.One hundred and eighty patients diagnosed with osteoarthritis of hip or knee will be randomly assigned to one of three intervention groups: hydrotherapy, physiotherapy, and both physiotherapy and hydrotherapy of the affected joint. In the first group, patients will receive Kneipp hydrotherapy daily, with water applied in the form of alternate cold and warm thigh affusions (alternating cold and warm water stimulation is particularly relevant to the knee and hip regions).Patients in the second group will receive physiotherapy of the hip or knee joint three times a week. Patients in the physiotherapy-hydrotherapy combination group will receive both joint-specific physiotherapy three times a week and alternate cold and warm thigh affusions every day. Follow-up assessments will be on three levels: clinical assessment by the investigator; subjective patient assessment consisting of a patient diary, and questionnaires on admission and at the end of the treatment phase; and a final telephone assessment by the external evaluation centre. Assessments will be made at baseline, after two weeks of inpatient treatment, and finally after a further ten weeks of follow-up. The primary outcome measure will be pain intensity of the affected joint in the course of inpatient treatment, judged by the patient and the investigator. Secondary outcomes include health-related quality of life and joint-specific pain and mobility in the course of the study. Statistical analysis of the results will be on an intention-to-treat basis.ConclusionThis study methodology has been conceived according to the standards of the CONSORT recommendations. The results will contribute to establishing hydrotherapy as a non-invasive, non-interventional, reasonably priced, therapeutic option with few side effects, in the concomitant treatment of osteoarthritis of the hip or knee.Trial RegistrationTrial registration number: NCT 00950326

Primary care research - trade-off between representativeness and response rate of GP teachers for undergraduates.

PRINCIPLES Low response rates are common in primary care research. Our study examines the representativeness of respondents in a survey among general practitioners (GPs). One special aim was to evaluate the representativeness of the subgroup of GP teachers for undergraduates (GPTUs) and to investigate the option of a panel of GPTUs. METHODS The representativeness of the respondents was assessed by the use of pooled public data to compare the respondents and all GPs in the German federal state of Saxony on the basis of socio-demographic and subject-specific characteristics. The representativeness of the GPTUs was examined in the same way. For the analysis, two-sided t-tests and Chi2 tests were used. RESULTS The total response rate was low (32.87%). The respondents were not a representative sample; in particular, they were more highly qualified than the mean. However, the response rate among the special group of university-associated GP teachers for undergraduates was significantly higher than among other general practitioners. Because of this, the creation of a panel of these GPTUs for further primary care research was investigated. Unfortunately, analysis of this group showed that GPTUs were not a representative sample as they tended to be younger and more highly qualified. CONCLUSIONS In general it is possible to create a panel of GPTUs to obtain higher response rates, but investigation of the panels representativeness is definitely required. If the panel is not representative another option is the creation of a stratified sample according to the target population.

Children and Adolescents as Patients in General Practice - The Reasons for Encounter

Background The SESAM 2 study was performed to estimate consultations of general practitioners. In the recent work we focused on the reasons for encounter of children and adolescents consulting the general practitioner. Methods Cross-sectional study with general practices in Saxony (Germany) as setting. Two hundred and seventy of the 2510 (10.8%) Saxon general practitioners agreed to participate and recorded data of 8877 patients. Evaluation of the data was organized by the Saxon Society of General Medicine (SGAM). Cross-sectional data were collected during a one-year period. One day of the week (Monday till Friday) was chosen at random for recording. Data were documented from every tenth patient with personal contact to the practitioner using a standardized report form at either the morning or afternoon consulting hours. Main outcome measures: reasons for encounter, the investigations and treatments performed and also the results of the consultation. Unpublished but publicly available data from the Dutch Transition Project were also analysed. Results Eight hundred and five of 8877 patients were aged under 20 years. The mean percentage of children and adolescents in the general practice consultation was 9.1%. The mean number of reasons for encounter per child patient was about 1.5 and did not differ between the age groups. Most consultations were due to respiratory, digestive, skin or general symptoms with typical seasonal variations regarding the most frequent reasons for encounter caused by infectious diseases. Conclusions As there is limited access to pediatric specialists, German general practitioners have to deal with children quite frequently. The number of child reasons for encounter is manageable for the general practitioner with an increasing spectrum of reasons for encounter among adolescents. In agreement with other publications most of the young patients consult for respiratory or general symptoms, or require preventive immunization or injection. Keywords Children; Adolescents; Reason for encounter; General practice; Primary care

Who wants to become a general practitioner? Student and curriculum factors associated with choosing a GP career - a multivariable analysis with particular consideration of practice-orientated GP courses

Abstract Objective. Because of the increasing shortage of general practitioners (GPs) in many countries, this study aimed to explore factors related to GP career choice in recent medical graduates. Particular focus was placed on the impact of specific practice-orientated GP courses at different stages of the medical undergraduate curriculum. Design. Observational study. Multivariable binary logistic regression was used to reveal independent associations with career choice. Setting. Leipzig Medical School, Germany. Subjects. 659 graduates (response rate = 64.2%). Main outcome measure. Choice of general practice as a career. Results. Six student-associated variables were found to be independently related to choice of general practice as a career: age, having family or friends in general practice, consideration of a GP career at matriculation, preference for subsequent work in a rural or small-town area, valuing the ability to see a broad spectrum of patients, and valuing long-term doctor–patient relationships. Regarding the curriculum, after adjustment independent associations were found with a specific pre-clinical GP elective (OR = 2.6, 95% CI 1.3–5.3), a four-week GP clerkship during the clinical study section (OR = 2.6, 95% CI 1.3–5.0), and a four-month GP clinical rotation during the final year (OR = 10.7, 95% CI 4.3–26.7). It was also found that the work-related values of the female participants were more compatible with those of physicians who opt for a GP career than was the case for their male colleagues. Conclusion. These results support the suggestion that a practice-orientated GP curriculum in both the earlier and later stages of undergraduate medical education raises medical schools’ output of future GPs. The findings are of interest for medical schools (curriculum design, admission criteria), policy-makers, and GPs involved in undergraduate medical education. More research is needed on the effectiveness of specific educational interventions in promoting interest in general practice as a career.

The risk for nursing home admission (NHA) did not change in ten years—A prospective cohort study with five-year follow-up

In an aging population the burden on health care systems depends on the proportion of lifetime spent in good or poor health. The objective of this study was to examine the effect of a ten-year cohort difference on NHA, indicating changes in lifetime spent without severe disabilities. Additionally, important risk factors for NHA were identified. The data were obtained from two cohort studies of elderly people. Cohort A (1991-1993) comprised 74+ patients from 20 German general practices and cohort B (2002-2003) 70+ patients from 14 general practices. The merged sample consisted of 2301 community dwelling patients that contacted their general practitioner within a 12-month period during the respective enquiry period. After an initial assessment at study entry, participants were monitored over a five-year period respective NHA and death. The Cox proportional hazards model was used including socio-epidemic data, state of health, chronic diseases, dementia, health system usage, and social support. The ten-year cohort-difference was no predictor of NHA within a 5-year period. Significant influencing variables were: age (OR 1.10), living with others (OR 0.59), no auxiliary person (OR 1.69), mild forgetfulness (OR 2.12), clear cognitive impairment (OR 3.74), severe cognitive disturbance (3.61), loss of memory (11.83), walking difficulties (OR 1.53), impaired vision (OR 1.90), and cancer (OR 0.22). This study could not find a cohort effect on NHA. With regard to increased life expectancy the findings do not support the compression of morbidity hypothesis. The identified influencing variables contribute to the understanding of NHA risk factors.