Heinz-Harald Abholz

Advance directives in nursing homes: prevalence, validity, significance, and nursing staff adherence.

BACKGROUNDnThe German Advance Directives Act of 2009 confirms that advance directives (ADs) are binding. Little is known, however, about their prevalence in nursing homes, their quality, and whether they are honored.nnnMETHODSnIn 2007, we carried out a cross-sectional survey in all 11 nursing homes of a German city in the state of North Rhine-Westphalia (total nursing home population, 1089 residents). The ADs were formally analyzed and assessed by 3 raters with respect to 5 clinical decision-making scenarios. The specifications of the ADs were compared with what the nurses reported that they would do in each scenario.nnnRESULTSn11% of the nursing home residents had a personal AD, and a further 1.4% an AD by proxy. 52% of the 119 ADs that we analyzed contained no documentation of the patients decision-making capacity and/or voluntariness, and only 3% contained documentation of a medical consultation. Most ADs failed to state what should be done in case the patient acutely became incapable of consenting to treatment (inter-rater agreement [IRA] >83%). For the case of permanent decisional incapacity, many ADs contained ambiguous information (IRA<43%). 23 directives stated that the patient should not have cardiopulmonary resuscitation in case an arrest occurred in the patients current clinical condition, but the nurses reported a corresponding do-not-resuscitate agreement for only 9 of these 23 patients.nnnCONCLUSIONnIn 2007, ADs were rare in these German nursing homes, and most of the existing ones were invalid, of little meaning, and/or disregarded by the nursing staff. There is little reason to believe that the Advance Directives Act of 2009 will bring about any major change in this miserable status quo. Advance care planning, a system-oriented concept still uncommon in Germany, could give new impulses to promote a cultural change in this respect.

Willingness to Participate in Mammography Screening: A Randomized Controlled Questionnaire Study of Responses to Two Patient Information Leaflets With Different Factual Content

BACKGROUNDnFrom 2010 onward, a new leaflet about mammography screening for breast cancer, more informative than the preceding version, has been sent to women in Germany aged 50 to 69 with the invitation to undergo screening. The purpose of this study was to determine the effect of different informational content on the decision whether or not to be screened.nnnMETHODSnIn a randomized and blinded design, 792 women aged 48 to 49 were sent either the old or the new leaflet. Questionnaires were sent together with the leaflets in order to assess the following: willingness to undergo mammography screening, knowledge, decisional confidence, personal experiences of breast cancer, and demographic data.nnnRESULTSn370 (46.7%) of the questionnaires were returned, and 353 were evaluable. The two groups did not differ significantly in their willingness to be screened: 81.5% (95% confidence interval [CI] 75.8%-87.2%) versus 88.6% (95% CI 83.9%-91.3%, p = 0.060). A post-hoc analysis showed that women who reported having had personal experience of breast cancer (18.7%) were more willing to be screened if they were given the new leaflet, rather than the old one (interaction p = 0.014). The two groups did not differ in their knowledge about screening (p = 0.260). Women who received the old leaflet reported a higher decisional confidence (p = 0.017). The most commonly mentioned factors affecting the decision were experience of breast cancer in relatives and close acquaintances (26.5% of mentions) and a doctors recommendation (48.2%). Leaflets (3.6%) and all other factors played only a secondary role.nnnCONCLUSIONnThe greater or lesser informativeness of the leaflet affected neither the participants knowledge of mammography screening nor their willingness to undergo it. The leaflet was not seen as an aid to decision-making. The best way to assure an informed decision about screening may be for the patient to discuss the matter personally with a qualified professional.

The Prevention and Treatment of Retinal Complications in Diabetes.

BACKGROUNDnMicrovascular 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.nnnMETHODSnThe 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.nnnRESULTSnRegular 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.nnnCONCLUSIONnRegular, 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.

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

Correspondence (letter to the editor): Possible Overcoding

As commendable as secondary analyses of routine hospital data are, one should ponder the results in particular if they conflict substantially with everyday experience in the extramural sector —even if these empirical data appear more imprecise. Such a result as presented in the article with an incidence rate of 365 sepsis patients per 100 000 persons in the general population represents just such a discrepancy.

Understanding the concept of medical risk reduction: A comparison between the UK and Germany

Objective: To explore the views of German general practitioners, healthcare assistants, and laypeople about the minimum absolute risk reduction needed to justify drug treatment to prevent heart attacks, and to compare these views with those found in the UK. Method: Qualitative content analysis study using the same clinical risk scenario and semi-structured interview schedule concerning a “pill” reducing cardiovascular risk as a recent UK study. The similarly recruited participants included six general practitioners (GPs), four healthcare assistants, and 12 laypeople, interviewed in 10 GP surgeries, two community settings, and five private homes. Results: In both countries, most participants, health professionals as well as laypeople, used risk numbers inconsistently in preventive treatment decisions. In Germany, some people explicitly rejected the probabilistic risk concept as a basis for such decisions. In the UK, people were generally more aware of cost for society than in Germany. Other factors were similar in both countries. Conclusion: In both countries, preventive risk information is not well understood. Our results suggest that this is not only a technical communication problem.

One-year evaluation of a neonatal screening program for cystic fibrosis in Switzerland. Problems.

All the problems associated with screening that would need clarification before screening is introduced can be deduced from the article by Rueegg et al. (1). n nThe first screening step will result in psychological stress for the parents because of numerous false-positive findings that will require further investigation. Furthermore, there are those false-positive findings which cannot be excluded by further diagnostics, due to the nature of the genetic findings and the disease itself—with subsequent de facto unnecessary treatment and impaired quality of life (2, 3). For it is known that among those being positive in the genetic a nalysis (CFTR variants) as well as in the sweat test, some will be affected by the effects not at all or only later in life, and these effects then can also be mild in some cases (2, 3). n nThe biggest problem with introducing screening, however, is one that is regularly left out in German discussion—in spite of the German Medical Association’s hesitant prioritization committee: There have to be economical limits concerning medical interventions, including screenings. n nAccording to Rueegg et al. and other publications (2, 3), the incidence of cystic fibrosis is 1 in 3500 neonates; this means 200 children per year in Germany with its 700 000 births. If the 20-year mortality in cystic fibrosis is 25%—as, for example, found in Dijk et al. (4) and Scott et al. (3)—and owing to screening this can be reduced by 50%, this means that mortality and lung replacement (according to [2], but not achieved according to [1]) would be reduced in a maximum of 25 children in Germany per year. For their sake a very large program requiring the highest quality (and expenditure) would be conducted—one which also includes undesirable side effects. n nTo counter any accusation of heartlessness on my part I would like to mention: Priorities have to be set, if a healthcare system is to be maintained that remains open to everybody.

Correspondence (letter to the editor): Extremely low numbers of cases.

A topical CME article (1) should provide guidance that is evidence based. This was often not the case in the article under discussion. An example: The authors say that the serum calcitonin concentration should be measured in every patient with euthyroid nodular goiter, in order to ensure that medullary thyroid carcinoma (MTC) is not missed. Medullary thyroid cancers constitute 7% of all thyroid cancers. n nIn Germany, 5350 cases of thyroid cancer are diagnosed every year (Robert Koch–Institute, 2010); this translates into 400 cases of MTC. 780 patients die from thyroid cancer, among them 250 from MTC. These are extremely low case numbers compared with other preventable causes of death. n n400 cases of MTC have to be seen against 10 million people with nodular goiter (20% of the adult population) who should have their calcitonin measured. This corresponds to 1 patient with MTC in every 25 000 cases of nodular goiter. When conducting investigations with such poor ratios of examined patients to actually affected patients, the result—in contrast to targeted diagnostic evaluation—will always be more false-positive findings than true-positive ones. n nThis means: Herrmann et al (2) found a prevalence of MTC in their German studies of 0.2%; international rates are comparable (3). When a specificity of calcitonin testing of 95% and a sensitivity of 100% is assumed, the positive predictive value is 4%. This means that on the basis of a positive calcitonin test—even if a pentagastrin-stimulated test is used additionally—25 patients would have to to be operated in order to maybe help one of them. An operation is always necessary since CT and fine needle aspiration biopsy are less exact than the calcitonin test and therefore cannot be used to safely rule out cancer. n nAll this is not discussed in the article, but—in contrast to international perspectives (3, 4)—the test is recommended as a routine. One might assume that it is up to anybody to make a “recommendation.” However, in the context of a CME article, a recommendation becomes binding in a way that should not be underestimated—and can be risky in this setting.

Cancer incidence on a small island — Research opportunities in general practice

OBJECTIVEnTo test the impression of an increased cancer incidence on the island of Pellworm (in the far North of Germany) and to illustrate the feasibility of a general practice-based approach in epidemiological research.nnnDESIGNnCancer incidence on Pellworm was prospectively registered in the only general practice on the island from 1986 to 1992. Age-standardized rates and expected rates were calculated on the basis of the Saarland cancer registry, the only registry in Germany. Standardized incidence ratios and 95% confidence intervals (CI) for Poisson-distributed events were also calculated. The cancer data were summed up over a seven-year period.nnnSETTINGnThe only general practice on the island of Pellworm, a North Frisian marshland-island.nnnSUBJECTSnThe total practice population between 1986 and 1992 (N = 1172)nnnRESULTSnThe crude annual cancer incidence rate for Pellworm was, according to the impression, unexpectedly high: 634/100 000 for men and 502/100 000 for women. After age standardization, however, this increased rate of cancer incidence was even lower than in the Saarland (ratios: 0.86 for men and 0.95 for women). Only the incidence of neoplasms of the lymphatic and haematopoietic tissue in men exceeded the limits of statistical likelihood (ratio: 3.21; 95% CI: 1.17-7.10).nnnCONCLUSIONnThe impression of an increased rate of cancer on Pellworm could not be validated. The overall incidence rate was even lower than expected. Only the rate of leukaemia/lymphoma (men) was significantly higher. Reasons for this result could not be detected by a descriptive approach. General practice is a suitable place for studies in cancer epidemiology, especially in such ideal circumstances as a clearly limited area and complete and reliable documentation.