Jost Steinhäuser

Tailored Implementation of Evidence-Based Practice for Patients with Chronic Diseases

Background When designing interventions and policies to implement evidence based healthcare, tailoring strategies to the targeted individuals and organizations has been recommended. We aimed to gather insights into the ideas of a variety of people for implementing evidence-based practice for patients with chronic diseases, which were generated in five European countries. Methods A qualitative study in five countries (Germany, Netherlands, Norway, Poland, United Kingdom) was done, involving overall 115 individuals. A purposeful sample of four categories of stakeholders (healthcare professionals, quality improvement officers, healthcare purchasers and authorities, and health researchers) was involved in group interviews in each of the countries to generate items for improving healthcare in different chronic conditions per country: chronic obstructive pulmonary disease, cardiovascular disease, depression in elderly people, multi-morbidity, obesity. A disease-specific standardized list of determinants of practice in these conditions provided the starting point for these groups. The content of the suggested items was categorized in a pre-defined framework of 7 domains and specific themes in the items were identified within each domain. Results The 115 individuals involved in the study generated 812 items, of which 586 addressed determinants of practice. These largely mapped onto three domains: individual health professional factors, patient factors, and professional interactions. Few items addressed guideline factors, incentives and resources, capacity of organizational change, or social, political and legal factors. The relative numbers of items in the different domains were largely similar across stakeholder categories within each of the countries. The analysis identified 29 specific themes in the suggested items across countries. Conclusion The type of suggestions for improving healthcare practice was largely similar across different stakeholder groups, mainly addressing healthcare professionals, patient factors and professional interactions. As this study is one of the first of its kind, it is important that more research is done on tailored implementation strategies.

Tailored Implementation for Chronic Diseases (TICD): a protocol for process evaluation in cluster randomized controlled trials in five European countries

BackgroundIn the ‘Tailored Implementation for Chronic Diseases (TICD)’ project, five tailored implementation programs to improve healthcare delivery in different chronic conditions have been developed. These programs will be evaluated in distinct cluster-randomized controlled trials. This protocol describes the process evaluation across these trials, which aims to identify determinants of change in chronic illness care, to examine the validity of the tailoring methods that were applied, and to analyze the association of implementation activities and the effectiveness of the program.MethodsA multilevel approach was used to develop five tailored implementation interventions. In order to guide the process evaluation in five distinct trials, the study protocols for the cluster randomized trials and the related process evaluations were developed simultaneously and iteratively.ResultsThe process evaluation comprises three main components: a structured survey with health professionals in the trials, semi-structured interviews with a purposeful sample of this study population, and standardized documentation of organizational practice characteristics. Norway will only conduct the qualitative part of the analysis because the survey and documentation of practice characteristics are considered to be not feasible. The evaluation is guided by ‘logic models’ of the implementation programs: frameworks that specify the linkages between the strategies used, the determinants addressed by tailoring, and the anticipated outcomes. Standardization of measures across trials is sought to facilitate analysis of aggregated data from the trials.ConclusionsThis process evaluation will need to find a balance between standardization of methods across trials and the tailoring of measures to the specificities of each trial.

General Practitioners Views of Implementing a Stratified Treatment Approach for Low Back Pain in Germany: A Qualitative Study.

Background and Objective The STarT Back stratified primary care approach has demonstrated clinical and cost effectiveness in the UK, and is commonly used by General Practitioners (GPs). However, it remains unknown how this approach could be implemented into the German healthcare system. The aim of this study was therefore to explore the views and perceptions of German GPs in respect to using a stratified primary care for low back pain (LBP). Methods A 90-minute think-tank workshop was conducted with 14 male and five female GPs, during which the STarT-Back-Screening-Tool (SBST) and related research evidence was presented. This was followed by two focus groups, based on a semi-structured interview guideline to identify potential implementation barriers and opportunities. Discussions were audiotaped, transcribed and coded using a content analysis approach. Results For the three deductively developed main themes, 15 subthemes emerged: (1) application of the SBST, with the following subthemes: which health profession should administer it, patients known to the GP practice, the reason for the GP consultation, scoring the tool, the tool format, and the anticipated impact on GP practice; (2) psychologically informed physiotherapy, with subthemes including: provision by a physiotherapist, anticipated impact, the skills of physiotherapists, management of patients with severe psychosocial problems, referral and remuneration; (3) the management of low-risk patients, with subthemes including: concern about the appropriate advising health professional, information and media, length of consultation, and local exercise venues. Conclusions The attitudes of GPs towards stratified primary care for LBP indicated positive support for pilot-testing in Germany. However, there were mixed reactions to the ability of German physiotherapists to manage high-risk patients and handle their complex clinical needs. GPs also mentioned practical difficulties in providing extended advice to low-risk patients, which nevertheless could be addressed by involvement of specifically trained medical assistants.

Projektion des Bedarfs an hausärztlicher Versorgung auf Gemeindeebene

BACKGROUND Within the next 8 years about 2 000 general practitioners (GPs) will be seeking a successor in the federal state of Baden-Württemberg, Germany. Both the small number of newly qualified GPs and the wish to work as an employee or in a group practice will lead to a situation in which about 500 practices will likely not find a successor. Using a single administrative district, the aim of this analysis was to develop a projection of the demand for GP health care at the community level. METHODS Using the administrative district of Rottweil with its 21 communities, a community-based demographic forecast on the basis of current birth and death probabilities was performed. From the projected population structure, the demand for GP care in the year 2023 was derived under the assumption of unchanged age- and gender-specific numbers of GP visits. The anticipated deficit or, respectively, overrun of GPs at the community level was calculated as the difference between expected demand and number of GPs not retiring for age-related reasons. RESULTS Until the year 2023 the demographic change will cause a shrinking population. However, with unchanged age- and gender-specific numbers of GP visits, a slightly higher demand of 0.6 GPs will occur as a result of population-aging. The expected age-related retirement of physicians will have a stronger impact on primary care demand than demography. Up to 32 (37%) GPs might need a successor. In addition to 4 communities today, this would result in another 5 communities not having a GP in 10 years. CONCLUSION Communities that are at higher risk of GP shortage based on demographic changes and age of practicing GPs, can be identified by the approach described and applied here in order to implement targeted comprehensive community models of care.

Design and Delivery of a Tailored Intervention to Implement Recommendations for Multimorbid Patients Receiving Polypharmacy into Primary Care Practices

Introduction. Managing polypharmacy is particularly demanding for general practitioners as coordinators of care. Recently, a German guideline for polypharmacy in primary care has been published. This paper describes the content and delivery of a tailored intervention, which aims at improving the implementation of guideline recommendations for polypharmacy into practice, considering individual barriers. Materials and Methods. Firstly, barriers for implementation and the corresponding strategies to address them have been identified. On this basis, an intervention consisting of a workshop for health care professionals and educational materials for patients has been developed. The workshop focused on knowledge, awareness, and skills. The educational materials included a tablet computer. Practice teams will elaborate individual concepts of how to implement the recommendations into their practice. The workshop has been evaluated by the participants by means of a questionnaire. Results. During the workshop 41 possible sources of medication errors and 41 strategies to improve medication management have been identified. Participants evaluated the workshop overall positively, certifying its relevancy to practice. Discussion. The concept of the workshop seemed appropriate to impart knowledge about medication management to the participants. It will have to be evaluated, if the intervention finally resulted in an improved implementation of the guideline recommendations.

Die Sichtweise der kommunalen Ebene über den Hausärztemangel – eine Befragung von Bürgermeistern in Baden-Württemberg

BACKGROUND Local governments have a crucial role in dealing with the primary care physicians shortage (PS). The aim of this study is to evaluate the perspectives and experiences of the local mayors on this issue. METHODS In May 2011, all 1101 mayors in the Federal State of Baden-Wuerttemberg (BW) were invited to participate in the study by filling out a survey developed by the authors. Data were analysed descriptively. RESULTS Of the contacted mayors in BW, 63% (n=698) responded. More than 90% of the participants consider it their duty to ensure future primary care. 16% experienced local practice closures due to PS. The infrastructure provided by the communities seems to be at a high level, whereas emergency practices exist in only 15% of the communities at present. Supportive actions to attract new GPs are evaluated as appropriate by almost half of the participants. CONCLUSIONS The PS topic is of high relevance for communities in BW. In order to gain future physicians for their region, the majority of the communities are maintaining a high level of infrastructure and are willing to offer more actions. The young generation physicians need to be informed about these existing conditions. Innovative ideas should be implemented in individual communities as pilot projects.

Herausforderungen und Potenziale hausärztlicher Versorgung in einer multikulturellen Gesellschaft

ZusammenfassungHausärzte leisten in Deutschland den quantitativ größten Anteil an der gesundheitlichen Basisversorgung von Menschen mit Migrationshintergrund. Es gibt Hinweise darauf, dass Patienten mit Migrationshintergrund Hausärzte im gleichen oder sogar stärkeren Maß als die einheimische Bevölkerung als erste Anlaufstelle bei körperlichen und psychischen Beschwerden in Anspruch nehmen. Versorgungsdefizite von Patienten mit Migrationshintergrund bestehen besonders in Kernbereichen der hausärztlichen Versorgung wie der Prävention und Rehabilitation. Demgegenüber erscheint der Stellenwert der hausärztlichen Versorgung von Patienten mit Migrationshintergrund bislang im fachinternen und öffentlichen Diskurs verhältnismäßig gering. Der vorliegende Beitrag zeigt zunächst ausgehend von einer Analyse der aktuellen (allgemein)medizinischen Versorgungssituation von Menschen mit Migrationshintergrund Potenziale auf, die speziell im Fachgebiet der Allgemeinmedizin liegen, um allen Bevölkerungsgruppen in Deutschland einen niederschwelligen, migrations- und kulturkompetenten Zugang zu Gesundheitsleistungen zu ermöglichen. Anschließend werden der derzeitig in den Bereichen allgemeinmedizinische Forschung, Lehre, Fort- und Weiterbildung beobachtbare Stellenwert migrationsspezifischer Inhalte beleuchtet sowie Anregungen für zukünftige Forschungsfragen beziehungsweise für migrations- und kultursensible Interventionen gegeben.AbstractThe greatest proportion of basic health care for patients with a migrational background living in Germany is provided by general practitioners. There is evidence that patients with a migrational background see a general practitioner as a gate keeper in case of physical or mental complaints even more frequently than the native German population. In contrast, the impact of migration-specific tasks in general practice appears to be relatively low in the medical and public discourse. This article analyzes the current situation of medical care for migrant patients in general practice and shows its potential to offer low-threshold high quality health care services to migrant patients and the whole population. In addition, an overview on migration-specific issues in research, teaching, and continuous medical education of general practitioners is provided. Finally, the implications of these findings for future research questions on migration-sensitive interventions are discussed.The greatest proportion of basic health care for patients with a migrational background living in Germany is provided by general practitioners. There is evidence that patients with a migrational background see a general practitioner as a gate keeper in case of physical or mental complaints even more frequently than the native German population. In contrast, the impact of migration-specific tasks in general practice appears to be relatively low in the medical and public discourse. This article analyzes the current situation of medical care for migrant patients in general practice and shows its potential to offer low-threshold high quality health care services to migrant patients and the whole population. In addition, an overview on migration-specific issues in research, teaching, and continuous medical education of general practitioners is provided. Finally, the implications of these findings for future research questions on migration-sensitive interventions are discussed.

Überversorgt? Unterversorgt? – die Sicht von Bürgermeistern in Baden-Württemberg: Ein Beitrag zur Diskussion um die wohnortnahe medizinische Versorgung

BACKGROUND The ageing of physicians working in ambulatory care make regional health planning a challenging task. This study examines the current supply of general practitioners (GP) within the communities from the perspective of mayors. The information gained on a community level can be used when discussing over- and undersupply as well as future health care planning. METHODS A questionnaire was sent to all 1101 mayors of the Federal state of Baden-Württemberg (BW) in May 2011. For the evaluation of the location of the communities, subjective ratings by the mayors were compared with official criteria, provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR). RESULTS The participation rate was 63% (n=698). According to the mayors about 70% (n=468) were located in a rural area, according to BBSR criteria were about 26% (n=177) of answers given by rural communities. Of the participating mayors about 54% (n=355) stated that their community is cared for merely by GPs. From this information there was a locally experienced undersupply of GPs calculated for 13.5% (n=86) of the communities. This affected rural as well as non-rural communities. In communities up to 20 000 inhabitants, the ratio between GPs and other specialists seems to be 60:40 whereas in bigger cities the proportion of other specialists appears to be much higher. CONCLUSION Half of the participating communities seem to not have a practicing specialised physician. An accumulation of specialised physicians in larger cities was reported. The GP shortage appears to mainly be experienced subjectively. Regarding the location (urban vs. rural) of the community, subjective views differ distinctly from the BBSR criteria. This discrepancy could influence a communitys marketing strategy when competing for new physicians.

A tailored programme to implement recommendations for multimorbid patients with polypharmacy in primary care practices-process evaluation of a cluster randomized trial

BackgroundWe developed and evaluated a tailored programme to implement three evidence-based recommendations for multimorbid patients with polypharmacy into primary care practices: structured medication counselling including brown bag reviews, the use of medication lists and medication reviews. No effect on the primary outcome was found. This process evaluation aimed to identify factors associated with outcomes by exploring nine hypotheses specified in the logic model of the tailored programme.MethodsThe tailored programme was developed with respect to identified determinants of practice and consisted of a workshop for practice teams, elaboration of implementation action plans, aids for medication reviews, a multilingual info-tool for patients on a tablet PC, posters and brown paper bags as reminders for patients. The tailored programme was evaluated in a cluster randomized trial. The process evaluation was based on various data sources: interviews with general practitioners and medical assistants of the intervention group and a survey with general practitioners of the intervention and control group, written reports on the implementation action plans, documentation forms for structured medication counselling and the log file of the info-tool.ResultsWe analyzed 12 interviews, 21 questionnaires, 120 documentation forms for medication counselling, 5 implementation action plans and one log file of the info-tool. The most frequently reported effect of the tailored programme was the increase of awareness for the health problem and the recommendations, while implementation of routine processes was only reported for structured medication counselling. The survey largely confirmed the usefulness of the applied strategies, yet the interviews provided a more detailed understanding of the actual use of the strategies and several suggestions for modifications of the tailored programme.ConclusionsThe tailored programme seemed to have induced awareness as a first step of behaviour change. Several modifications of the tailored programme may enhance its effectiveness such as conducting outreach visits instead of a workshop, improved targeting, provision of evidence, integration of tools into the practice software and information materials in tailored formats.Trial registrationThis study is linked to an outcome evaluation study with the registration ISRCTN34664024, assigned 14/08/2013.

Manuelle Medizin in Deutschland

ZusammenfassungHintergrundManuelle Medizin (MM) ist in Deutschland unter Ärzten eine weit verbreitete Therapieform. Ziel dieser Studie war es, aus versorgungsforscherischer Perspektive eine schulenübergreifende Übersicht über wesentliche Aspekte zur MM zu erhalten.MethodenEin selbstkonzipierter Fragebogen wurde nach Pilotierung von April 2009 bis März 2010 ins Internet gestellt. Die Schulen machten ihre Teilnehmer auf unterschiedliche Weise auf die Befragung aufmerksam.ErgebnisseInsgesamt haben 60 Ärztinnen und 241 Ärzte an der Befragung teilgenommen. Als häufigste Indikation für eine manualmedizinische Behandlung wurde eine Blockierung des Ileosakralgelenks angegeben; 73% gaben an, dass ihrer Erfahrung nach bereits eine einmalige Behandlung Symptome verändert. Dass bei der Therapie mögliche unspezifische Effekte eine mittelmäßige bis große Rolle spielen, gaben 47% der Teilnehmer an. Als Faktoren, die die Durchführung einer MM-Behandlung beeinflussen, wurden insbesondere Zeitdruck und das eigene Wohlbefinden angegeben. Zwischen den unterschiedlichen Schulen und Gebietsärzten konnten keine Unterschiede bzgl. des beobachteten Therapieeffekts und der Notwendigkeit, Patienten wieder einzubestellen, aufgezeigt werden.SchlussfolgerungZukünftige Studienansätze können schulenübergreifend geplant werden.AbstractBackgroundIn Germany manual medicine (MM) is widely used by physicians. The purpose of this study was to give a first description of relevant health service research aspects of MM.MethodsA structured questionnaire was placed online between April 2009 and March 2010 after pilot testing. Cooperating MM schools invited their members to take part in the study through different media.ResultsA total of 60 female and 241 male physicians participated in this survey. The most common indication for MM is the ileosacral joint syndrome, 73% stated that from their experience a single therapy does change symptoms and 47% stated that there are average to severe unspecific effects involved in MM therapy. Factors most influencing current MM treatment are time pressure and own wellbeing. There were no differences between the schools or specialties with respect to experienced effects of MM and frequency of therapy.ConclusionFuture study research can be planned to cover all schools of MM.BACKGROUND In Germany manual medicine (MM) is widely used by physicians. The purpose of this study was to give a first description of relevant health service research aspects of MM. METHODS A structured questionnaire was placed online between April 2009 and March 2010 after pilot testing. Cooperating MM schools invited their members to take part in the study through different media. RESULTS A total of 60 female and 241 male physicians participated in this survey. The most common indication for MM is the ileosacral joint syndrome, 73% stated that from their experience a single therapy does change symptoms and 47% stated that there are average to severe unspecific effects involved in MM therapy. Factors most influencing current MM treatment are time pressure and own wellbeing. There were no differences between the schools or specialties with respect to experienced effects of MM and frequency of therapy. CONCLUSION Future study research can be planned to cover all schools of MM.