Stefanie Joos

German Diabetes Disease Management Programs Are Appropriate for Restructuring Care According to the Chronic Care Model An evaluation with the Patient Assessment of Chronic Illness Care instrument

OBJECTIVE—With the introduction of diabetes disease management programs (DMPs) in Germany, there is a necessity to evaluate whether patients receive care that is congruent to the Chronic Care Model (CCM) and evidence-based behavioral counseling. We examined differences as perceived and experienced by patients with type 2 diabetes between those enrolled in a DMP compared with patients receiving usual care in two federal states of Germany. RESEARCH DESIGN AND METHODS—A random, heterogeneous sample of 3,546 patients (59.3% female) received a mailed questionnaire from their regional health fund, including the German version of the Patient Assessment of Chonic Illness Care (PACIC) instrument, which had additional items for behavioral advice (5A). Two weeks later, a general reminder was sent out. RESULTS—A total of 1,532 questionnaires were returned (response rate 42.2%), and valid data could be obtained for 1,399 patients. Mean age of responders was 70.3 years, of which 53.6% were female. Overall, patients enrolled in a DMP scored significantly higher (3.21 of a possible 5) than patients not enrolled in a DMP (2.86) (P < 0.001). Significant differences in the same direction were found on all five subscales of the PACIC. For the 5A scales, similar differences were found for all five subscales plus the sum score (P < 0.001; mean for DMP = 3.08, mean for non-DMP = 2.78). CONCLUSIONS—DMPs, as currently established in primary care in Germany, may impact provided care significantly. The changes in daily practice that have been induced by the DMPs are recognized by patients as care that is more structured and that to a larger extent reflects the core elements of the CCM and evidence-based counseling compared with usual care.

Use of complementary and alternative medicine in Germany – a survey of patients with inflammatory bowel disease

BackgroundPrevious studies have suggested an increasing use of complementary and alternative medicine (CAM) in patients with inflammatory bowel disease (IBD). The aim of our study was to evaluate the use of CAM in German patients with IBD.MethodsA questionnaire was offered to IBD patients participating in patient workshops which were organized by a self-help association, the German Crohns and Colitis Association. The self-administered questionnaire included demographic and disease-related data as well as items analysing the extent of CAM use and satisfaction with CAM treatment. Seven commonly used CAM methods were predetermined on the questionnaire.Results413 questionnaires were completed and included in the analysis (n = 153 male, n = 260 female; n = 246 Crohns disease, n = 164 ulcerative colitis). 52 % of the patients reported CAM use in the present or past. In detail, homeopathy (55%), probiotics (43%), classical naturopathy (38%), Boswellia serrata extracts (36%) and acupuncture/Traditional Chinese Medicine (TCM) (33%) were the most frequently used CAM methods. Patients using probiotics, acupuncture and Boswellia serrata extracts (incense) reported more positive therapeutic effects than others. Within the statistical analysis no significant predictors for CAM use were found. 77% of the patients felt insufficiently informed about CAM.ConclusionThe use of CAM in IBD patients is very common in Germany, although a large proportion of patients felt that information about CAM is not sufficient. However, to provide an evidence-based approach more research in this field is desperately needed. Therefore, physicians should increasingly inform IBD patients about benefits and limitations of CAM treatment.

Acupuncture and Moxibustion in the Treatment of Active Crohn’s Disease: A Randomized Controlled Study

Background: Acupuncture has traditionally been used in the treatment of inflammatory bowel disease in China and is increasingly being applied in Western countries. The purpose of this study was to investigate the efficacy of acupuncture in the treatment of active Crohn’s disease (CD). Methods: A prospective, randomized, controlled, single-blind clinical trial was carried out to analyze the change in the CD activity index (CDAI) after treatment as a main outcome measure, and the changes in quality of life and general well-being, serum markers of inflammation (α1-acid glycoprotein, C-reactive protein) as secondary outcome measures. 51 patients with mild to moderately active CD were treated in a single center for complementary medicine by three trained acupuncturists and randomly assigned to receive either traditional acupuncture (TCM group, n = 27) or control treatment at non-acupuncture points (control group, n = 24). Patients were treated in 10 sessions over a period of 4 weeks and followed up for 12 weeks. Results: In the TCM group the CDAI decreased from 250 ± 51 to 163 ± 56 points as compared with a mean decrease from 220 ± 42 to 181 ± 46 points in the control group (TCM vs. control group: p = 0.003). In both groups these changes were associated with improvements in general well-being and quality of life. With regard to general well-being, traditional acupuncture was superior to control treatment (p = 0.045). α1-acid glycoprotein concentration fell significantly only in the TCM group (p = 0.046). Conclusions: Apart from a marked placebo effect, traditional acupuncture offers an additional therapeutic benefit in patients with mild to moderately active CD.

Acupuncture and moxibustion in the treatment of ulcerative colitis: A randomized controlled study

Objective. Acupuncture has traditionally been used in the treatment of inflammatory bowel disease in China and is increasingly applied in Western countries. The objective of this study was to investigate the efficacy of acupuncture and moxibustion in the treatment of active ulcerative colitis (UC). Material and methods. In a prospective, randomized, controlled clinical trial 29 patients with mild to moderately active UC (mean age 37.8±12.0 years) were randomly assigned to receive either traditional acupuncture and moxa (TCM group, n=15), or sham acupuncture consisting of superficial needling at non-acupuncture points (control group, CG, n = 14). All patients were treated in 10 sessions over a period of 5 weeks and followed-up for 16 weeks. The main outcome measure was the change in the Colitis Activity Index (CAI) after treatment; secondary outcome measures were changes in quality of life, general well-being and serum markers of inflammation. Results. In the TCM group, the CAI decreased from 8.0 (±3.7) to 4.2 (±2.4) points and in the control group from 6.5 (±3.4) to 4.8 (±3.9) points (TCM versus CG: p=0.048). In both groups these changes were associated with significant improvements in general well-being (TCM group: from 3.0 (±1.8) to 1.8 (±1.0); CG: from 3.2 (±1.9) to 2.2 (±1.7)) and quality of life (TCM group: from 146 (±23) to 182 (±18); CG: from 157 (±20) to 183 (±23)). No significant differences between the TCM and CG were found regarding these secondary outcome measures. Conclusions. Differences in efficacy between traditional acupuncture and sham acupuncture were small and significant only for CAI as the main outcome measure. Both traditional and sham acupuncture seem to offer an additional therapeutic benefit in patients with mild to moderately active UC.

Impact of Primary Care–Based Disease Management on the Health-Related Quality of Life in Patients With Type 2 Diabetes and Comorbidity

OBJECTIVE This study examined the effectiveness of the German diabetes disease management program (DMP) for patients with varying numbers of other medical conditions with respect to their health-related quality of life (HRQoL). RESEARCH DESIGN AND METHODS A questionnaire, including the HRQoL-measured EQ-5D, was mailed to a random sample of 3,546 patients with type 2 diabetes (59.3% female). The EQ-5D score was analyzed by grouping patients according to those on a DMP and those receiving routine care. RESULTS The analysis showed that participation in the DMP (P < 0.001), the number of other medical conditions (P < 0.001), and the interaction between the DMP and the number of other conditions (P < 0.05) had a significant impact on the EQ-5D score. CONCLUSIONS Our findings suggest that the number of other medical conditions may have a negative impact on the HRQoL of patients with type 2 diabetes. The results demonstrate that the German DMP for type 2 diabetes may help counterbalance this effect.

Additional impact of concomitant hypertension and osteoarthritis on quality of life among patients with type 2 diabetes in primary care in Germany – a cross-sectional survey

BackgroundPatients with type 2 diabetes are likely to have comorbid conditions which represent a high burden for patients and a challenge for primary care physicians. The aim of this cross-sectional survey was to assess the impact of additional comorbidities on quality of life within a large sample of patients with type 2 diabetes in primary care.MethodsA cross-sectional survey within a large sample (3.546) of patients with type 2 diabetes in primary care was conducted. Quality of life (QoL) was assessed by means of the Medical Outcome Study Short Form (SF-36), self reported presence of comorbid conditions was assessed and groups with single comorbidities were selected. QoL subscales of these groups were compared to diabetes patients with no comorbidities. Group comparisons were made by ANCOVA adjusting for sociodemographic covariates and the presence of depressive disorder.ResultsOf 3546 questionnaires, 1532 were returned, thereof 1399 could be analysed. The mean number of comorbid conditions was 2.1. 235 patients declared to have only hypertension as comorbid condition, 97 patients declared to have osteoarthritis only. Patients suffering from diabetes and hypertension reached similar scores like diabetic patients with no comorbidities. Patients with diabetes and osteoarthritis reached remarkable lower scores in all subscales. Compared to patients with diabetes alone these differences were statistically significant in the subscales representing pain and physical impairment.ConclusionThe impact of osteoarthritis as an often disabling and painful condition on QoL in patients with type 2 diabetes is higher than the impact of hypertension as common but often asymptomatic comorbidity. Individual care of patients with chronic conditions should aim at both improving QoL and controlling risk factors for severe complications.

Integration of Complementary and Alternative Medicine into German Medical School Curricula – Contradictions between the Opinions of Decision Makers and the Status Quo

Introduction: There is a growing demand for complementary and alternative medicine (CAM) in Western societies. This trend has lead to the gradual integration of CAM courses into medical school curricula. The aim of this study was to survey key decision makers at German medical schools with regard to their views on CAM and to examine the extent to which CAM has already been integrated in the German medical school system. Materials and Methods: A questionnaire was sent to 753 clinic and institute directors at German medical schools. Results: A total of 500 questionnaires (66%) were returned. 39% of respondents had a positive opinion of CAM, 27% had a neutral opinion and 31% had a negative opinion. 3% of respondents were unsure. The CAM therapies viewed most positively were osteopathy (52%), acupuncture (48%), and naturopathy (41%). Most respondents were in favor of integrating CAM into the medical system. However, a larger percentage favored its use in research (61%) and teaching (59%) rather than in the treatment of patients (58%). Only 191 respondents (38%) indicated that CAM treatment methods had been integrated into the curriculum of their respective medical schools. In these schools, CAM was mainly used in patient treatment (35%), followed by research (22%) and education (21%). Conclusions: Our data show that the majority of respondents were in favor of integrating CAM into medical school curricula. However, at the time of our survey, only a small percentage of medical schools had actually put this into practice. The reasons for this discrepancy are unclear and should be further investigated.

ELSID-Diabetes study-evaluation of a large scale implementation of disease management programmes for patients with type 2 diabetes. Rationale, design and conduct – a study protocol [ISRCTN08471887]

BackgroundDiabetes model projects in different regions of Germany including interventions such as quality circles, patient education and documentation of medical findings have shown improvements of HbA1c levels, blood pressure and occurrence of hypoglycaemia in before-after studies (without control group). In 2002 the German Ministry of Health defined legal regulations for the introduction of nationwide disease management programs (DMP) to improve the quality of care in chronically ill patients. In April 2003 the first DMP for patients with type 2 diabetes was accredited. The evaluation of the DMP is essential and has been made obligatory in Germany by the Fifth Book of Social Code. The aim of the study is to assess the effectiveness of DMP by example of type 2 diabetes in the primary care setting of two German federal states (Rheinland-Pfalz and Sachsen-Anhalt).Methods/DesignThe study is three-armed: a prospective cluster-randomized comparison of two interventions (DMP 1 and DMP 2) against routine care without DMP as control group. In the DMP group 1 the patients are treated according to the current situation within the German-Diabetes-DMP. The DMP group 2 represents diabetic care within ideally implemented DMP providing additional interventions (e.g. quality circles, outreach visits). According to a sample size calculation a sample size of 200 GPs (each GP including 20 patients) will be required for the comparison of DMP 1 and DMP 2 considering possible drop-outs. For the comparison with routine care 4000 patients identified by diabetic tracer medication and age (> 50 years) will be analyzed.DiscussionThis study will evaluate the effectiveness of the German Diabetes-DMP compared to a Diabetes-DMP providing additional interventions and routine care in the primary care setting of two different German federal states.

Review on efficacy and health services research studies of complementary and alternative medicine in inflammatory bowel disease

ObjectiveTo assess the evidence of the use and efficacy for complementary and alternative medicine (CAM) in inflammatory bowel disease (IBD).MethodsA systematic literature search in MEDLINE was performed for randomized controlled trials (RCTs) in Crohn’s disease and ulcerative colitis. Moreover, a selective literature search for health services research studies on the use of CAM in patients with IBD was performed.ResultsHealth services research studies showed a high use of CAM in adult and pediatric patients with IBD worldwide. In contrast to the high use among IBD patients, there was a lack of high-quality data for many of the used CAM methods. Although most of the studies showed positive results, the methodological quality of most studies was rather low; therefore, the results had to be interpreted with caution. While there were many studies for probiotics and fish oil, RCTs for the highly used method homeopathy, for most herbal products, and for traditional Chinese medicine methods apart from acupuncture RCTs were completely lacking.ConclusionsThe lack of high-quality studies might be the consequence of the problems: associated with the funding of clinical trials involving CAM. However, having the high user rates in mind, high-quality studies assessing efficacy and safety of those methods are urgently needed. Furthermore, there is a quality need for better representation of CAM in undergraduate and postgraduate medical education.

Die Verwendung von Naturheilverfahren, komplementären und alternativen Therapien in Deutschland - eine systematische Übersicht bundesweiter Erhebungen

The Use of Complementary and Alternative Therapies in Germany - a Systematic Review of Nationwide Surveys. Ziel der vorliegenden systematischen Übersichtsarbeit war es, Daten zur Inanspruchnahme von Naturheilverfahren, komplementärer und alternativer Medizin (NHV/CAM) durch die deutsche Bevölkerung und zur Verwendung durch Ärzte und Heilpraktiker zusammenzustellen. Bundesweite Repräsentativbefragungen der letzten 20 Jahre (echte Zufallsstichproben, Stichprobenziehung über Paneloder Quotenverfahren), die in der Bevölkerung oder unter Ärzten durchgeführt worden waren, wurden mittels Pub-Med, Google Scholar und Google sowie Durchsicht von Literaturverzeichnissen und Expertenkontakten identifiziert. Zusätzlich wurden Daten aus behördlichen Statistiken und Markterhebungen berücksichtigt. 16 Befragungen von Stichproben der erwachsenen Bevölkerung und 4 Arztbefragungen konnten eingeschlossen werden. Der Bevölkerungsanteil, der in den vergangenen Jahren mindestens eine NHV/CAM-Methode in Anspruch genommen hatte, schwankte zwischen 40 und 62%. Im Vergleich zu anderen Arztgruppen scheinen Hausärzte und Orthopäden NHV/CAM in besonders breitem Umfang anzuwenden. Phytotherapie und Chirotherapie werden dabei besonders häufig eingesetzt. Untersuchungen zur Verwendung durch Heilpraktiker liegen nicht vor. Die vorliegenden Erhebungen belegen eine breite Verwendung von NHV/CAM durch die Bevölkerung und niedergelassene Ärzte. In den letzten Jahren scheint die Inanspruchnahme jedoch nicht weiter gestiegen zu sein; bei einzelnen Verfahren (insbesondere der Phytotherapie) ist ein Rückgang zu beobachten.