Thomas Rosemann

Co- and multimorbidity patterns in primary care based on episodes of care: results from the German CONTENT project

BackgroundDue to technological progress and improvements in medical care and health policy the average age of patients in primary care is continuously growing. In equal measure, an increasing proportion of mostly elderly primary care patients presents with multiple coexisting medical conditions. To properly assess the current situation of co- and multimorbidity, valid scientific data based on an appropriate data structure are indispensable. CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork) is an ambitious project in Germany to establish a system for adequate record keeping and analysis in primary care based on episodes of care. An episode is defined as health problem from its first presentation by a patient to a doctor until the completion of the last encounter for it. The study aims to describe co- and multimorbidity as well as health care utilization based on episodes of care for the study population of the first participating general practices.MethodsThe analyses were based on a total of 39,699 patients in a yearly contact group (YCG) out of 17 general practices in Germany for which data entry based on episodes of care using the International Classification of Primary Care (ICPC) was performed between 1.1.2006 and 31.12.2006. In order to model the relationship between the explanatory variables (age, gender, number of chronic conditions) and the response variables of interest (number of different prescriptions, number of referrals, number of encounters) that were applied to measure health care utilization, we used multiple linear regression.ResultsIn comparison to gender, patients age had a manifestly stronger impact on the number of different prescriptions, the number of referrals and number of encounters. In comparison to age (β = 0.043, p < 0.0001), multimorbidity measured by the number of patients chronic conditions (β = 0.51, p < 0.0001) had a manifestly stronger impact the number of encounters for the observation period. Moreover, we could observe that the number of patients chronic conditions had a significant impact on the number of different prescriptions (β = 0.226, p < 0.0001) as well as on the number of referrals (β = 0.3, p < 0.0001).ConclusionDocumentation in primary care on the basis of episodes of care facilitates an insight to concurrently existing health problems and related medical procedures. Therefore, the resulting data provide a basis to obtain co- and multimorbidity patterns and corresponding health care utilization issues in order to understand the particular complex needs caused by multimorbidity.

Osteoarthritis: quality of life, comorbidities, medication and health service utilization assessed in a large sample of primary care patients

ObjectiveTo assess the gender related impact of osteoarthritis (OA) on quality of life (QoL) and health service utilization (HSU) of primary care patients in Germany.MethodsCross sectional study with 1250 OA patients attending 75 primary care practices from March to May 2005. QoL was assessed using the GERMAN-AIMS2-SF. Data about comorbidities, prescriptions, health service utilization, and physical activity were obtained by questioning patients or from the patients medical files. Depression was assessed by means of the Patient Health Questionnaire (PHQ-9).Results1021 (81.7%) questionnaires were returned. 347 (34%) patients were male. Impact of OA on QoL was different between gender: women achieved significantly higher scores in the AIMS 2-SF dimensions lower body (p < 0.01), symptom (p < 0.01), affect (p < 0.01) and work (p < 0.05). Main predictors of pain and disability were a high score in the upper body scale of the AIMS2-SF (beta = 0.280; p < 0.001), a high score in the PHQ-9 (beta = 0.214; p < 0.001), duration of OA (beta = 0.097; p = 0.004), age (beta = 0.090; p = 0.023) and the BMI (beta = 0.069; p = 0.034). Predictors of pain and disability did not differ between gender. 18.8 % of men and 19.7% of women had a concomitant depression. However, no gender differences occurred. Women visited their GP (mean 5.61 contacts in 6 months) more often than men (mean 4.08; p < 0.01); visits to orthopedics did not differ between gender.ConclusionThe extent to which OA impacts men and women differs in primary care patients. This might have resulted in the revealed differences in the pharmacological treatment and the HSU. Further research is needed to confirm our findings and to assess causality.

General practitioners' attitudes towards research in primary care: qualitative results of a cross sectional study

BackgroundResearch in General Practice requires the participation of General practitioners (GPs). In Germany there is little tradition of research in this field, and GPs are not used to be participants in research. Little is known about German GPs attitudes towards research. Therefore the aim of our study was to assess the willingness of German General Practitioners to participate in primary care research and their attitude towards research in general practice. The results should enable a more successful approach to GPs in further studies.MethodsCross sectional study using semi-structured interviews with a random sample of 76 General Practitioners who participate in the teaching of medical students at the University of Heidelberg.ResultsDespite little experience, over 85 % of GPs appreciated research in their field. Important reasons for scepticism about research were the gap between theoretical research and practical work of GPs and the domination of research by specialists. Main barriers for participation are clinical workload, administrative overload and the newly introduced Disease Management Programs. The highest motivation for GPs to participate in research emanates from the will to substantiate their quality of care with solid research data.ConclusionsFinancial incentives and personal support e.g. with study nurses are certainly necessary to establish a research culture and to overcome main barriers against participation. The most successful approach to motivate GPs to participate is to convince them that research documents their quality of care. This data may reflect the facts on which the financial resources are provided in the future health care system.

The role of complementary and alternative medicine (CAM) in Germany – A focus group study of GPs

BackgroundThere has been a marked increase in the use of complementary and alternative medicine (CAM) in recent years worldwide. In Germany, apart from Heilpraktiker (= state-licensed, non-medical CAM practitioners), some general practitioners (GPs) provide CAM in their practices. This paper aims to explore the attitudes of GPs about the role of CAM in Germany, in relation to the healthcare system, quality of care, medical education and research. Furthermore, experiences of GPs integrating CAM in their daily practice were explored.MethodsUsing a qualitative methodological approach 3 focus groups with a convenience sample of 17 GPs were conducted. The discussions were transcribed verbatim and analysed using qualitative content analysis.ResultsThe majority of the participating GPs had integrated one or more CAM therapies into their every-day practice. Four key themes were identified based on the topics covered in the focus groups: the role of CAM within the German healthcare system, quality of care, education and research. Within the theme role of CAM within the healthcare system there were five categories: integration of CAM, CAM in the Statutory Health Insurance, modernisation of the Statutory Health Insurance Act, individual healthcare services and Heilpraktiker. Regarding quality of care there were two broad groups of GPs: those who thought patients would benefit from standardizing CAM and those who feared that quality control would interfere with the individual approach of CAM. The main issues identified relating to research and education were the need for the development of alternative research strategies and the low quality of existing CAM education respectively.ConclusionThe majority of the participating GPs considered CAM as a reasonable complementary approach within primary care. The study increased our understanding of GPs attitudes about the role of CAM within the German healthcare system and the use of Heilpraktiker as a competing CAM-provider. It seems to be a need for increased funding for research, better education and remuneration by the Statutory Health Insurance in order to improve access to Integrative medicine in Germany.

Osteoarthritis of the knee and hip: a comparison of factors associated with physical activity

To assess factors associated with physical activity (PA) in a large sample of primary care patients, 1,250 outpatients from 75 general practices were approached consecutively. Of these, 1,021 (81.7%) returned short forms of the international physical activity questionnaire (IPAQ) and the arthritis impact measurement scale (AIMS2-SF). In addition, the patient health questionnaire (PHQ-9) was used to assess concomitant depression. A stepwise multiple linear regression analysis with the IPAQ score as dependent variable was performed separately for knee and hip patients. The impact of osteoarthritis (OA) on patients with an affected knee (594/58.2%) was more severe, as reflected in higher scores in the “symptom”, “lower body”, and “affect” scales of the AIMS2-SF (pu2009<u20090.01 for all). These patients were also less active than patients with OA to the hip (pu2009=u20090.02 for IPAQ score). Main predictors of PA [change in p(F) for all factors ≤0.001] in knee OA patients were physical limitation to the lower limb (R2u2009=u20090.180), social network (R2u2009=u20090.121), pain (R2u2009=u20090.111), body mass index (R2u2009=u20090.041), and age (R2u2009=u20090.032). Predictors for OA at the hip (427/41.8%) differed slightly [change in p(F) for all factors ≤0.003): physical limitation to the lower limb (R2u2009=u20090.162), pain (R2u2009=u20090.131), PHQ-9 score (R2u2009=u20090.092), social network (R2u2009=u20090.078), and disease duration (R2u2009=u20090.043). Our findings suggest that factors associated with PA differ depending on the localization of the OA. Our results may help to tailor future interventions more appropriately. Further research is needed to determine whether these tailored interventions will result in increased PA.

Health service utilization patterns of primary care patients with osteoarthritis

BackgroundTo assess factors associated with visits to GPs, orthopaedists, and non-physician practitioners of complementary medicine (alternative practitioners) by primary care patients with osteoarthritis (OA).MethodsCross-sectional survey among 1250 consecutively addressed patients from 75 primary care practices in Germany. All patients suffered from OA of the knee or hip according to ACR criteria. They received questionnaires collecting sociodemographic data, data about health service utilisation, prescriptions, comorbidities. They also included established instruments as the Arthritis Impact Measurement Scale (AIMS2-SF) to assess disease-specific quality of life and the Patient Health Questionnaire (PHQ-9) to assess depression. Hierarchical stepwise multiple linear regression models were used to reveal significant factors influencing health service utilization.Results1021 of 1250 (81.6%) questionnaires were returned. Nonrespondents did not differ from participants. Factors associated with health service use (HSU) varied between providers of care. Not being in a partnership, achieving a high score on the PHQ-9, increased pain severity reflected in the “symptom” scale of the AIMS2-SF, and an increased number of drug prescriptions predicted a high frequency of GP visits. The PHQ-9 score was also a predictor for visits to orthopaedists, as were previous GP contacts, a high score in the symptom scale as well as a high score in the lower limb scale of the AIMS2-SF. Regarding visits to alternative practitioners, a high score in the AIMS -social scale was a positive predictor as older people were less likely to visit them.ConclusionOur results emphasize the need for awareness of psychological factors contributing to the use of health care providers. Addressing the revealed factors associated with HSU appropriately may lead to decreased health care utilization. But further research is needed to assess how this can be done successfully.

Osteoarthritis and functional disability: results of a cross sectional study among primary care patients in Germany

BackgroundThe aim of the study was to determine factors associated with functional disability in patients with OA.Methods1250 questionnaires were distributed to OA outpatients from 75 general practices; 1021 (81.6%) were returned. Questionnaires included sociodemographic data, the short form of the Arthritis Impact Measurement Scale (AIMS2-SF), and the Patient Health Questionnaire (PHQ-9) to assess concomitant depression. A hierarchical stepwise multiple regression analysis with the AIMS2-SF dimension lower body as dependent was performed.ResultsMain factors associated with functional disability were depression symptoms, as reflected in a high score of the PHQ-9 (beta = 0.446; p < 0.0009), pain as reflected in the AIMS2-SF symptom scale (beta = 0.412; p = 0.001), and few social contacts (beta = 0.201; p < 0.042). A high body mass index was associated with lower functional ability (beta = 0.332; p = 0.005) whereas a higher educational level (beta = -0.279; p = 0.029) predicted less impairment. Increased age was a weak predictor (beta = 0.178; p = 0.001) of disability. With a p of 0.062 the radiological severity according to the grading of Kellgren and Lawrence slightly surpassed the required significance level for remaining in the final regression model.ConclusionThe results emphasize that psychological as well as physical factors need to be addressed similarly to improve functional ability of patients suffering from OA. More research with multifaceted and tailored interventions is needed to determine how these factors can be targeted appropriately.

The care of patients with subthreshold depression in primary care: Is it all that bad? A qualitative study on the views of general practitioners and patients

BackgroundStudies show that subthreshold depression is highly prevalent in primary care, has impact on the quality of life and causes immense health care costs. Although this points to the clinical relevance of subthreshold depression, contradictory results exist regarding the often self-remitting course of this state. However, first steps towards quality improvement in the care of subthreshold depressive patients are being undertaken. This makes it important to gather information from both a GPs and a patients point of view concerning the clinical relevance as well as the status quo of diagnosis and treatment in order to appraise the need for quality improvement research.MethodWe conducted qualitative, semi-structured interviews for the questioning of 20 GPs and 20 patients with subthreshold depression on aspects of clinical relevance and on the status quo of diagnosis and treatment. Interviews were transcribed and analyzed on a content analytical theoretical background using Atlas.ti software.ResultsMost of the GPs found subthreshold depression to be clinically significant. Although some problems in diagnosis and treatment were mentioned, the GPs had sensible diagnostic and treatment strategies at hand which resulted from the long and trustful relationship with the patients and which corresponded to the patients expectations. The patients rather expected their GP to listen to them than to take specific actions towards symptom relief and, in the main, were satisfied with the GPs care.ConclusionThe study shows that subthreshold depression is a clinically relevant issue for GPs but raises the possibility that quality improvement might not be as necessary as past studies showed. Further quantitative research using larger random samples is needed to determine the effectiveness of the strategies used by the GPs, patients satisfaction with these strategies and the course of these patients symptoms in primary care.

The PAMINO-project: evaluating a primary care-based educational program to improve the quality of life of palliative patients

AbstractBackgroundThe care of palliative patients challenges the health care system in both quantity and quality. Especially the role of primary care givers needs to be strengthened to provide them with the knowledge and the confidence of applying an appropriate end-of-life care to palliative patients. To improve health care services for palliative patients in primary care, interested physicians in and around Heidelberg, Germany, are enabled to participate in the community-based program Palliative Medical Initiative North Baden (PAMINO) to improve their knowledge in dealing with palliative patients. The impact of this program on patients health and quality of life remains to be evaluated.Methods/DesignThe evaluation of PAMINO is a non-randomized, controlled study. Out of the group of primary care physicians who took part in the PAMINO program, a sample of 45 physicians and their palliative patients will be compared to a sample of palliative patients of 45 physicians who did not take part in the program. Every four weeks for 6 months or until death, patients, physicians, and the patients family caregivers in both groups answer questions to therapy strategies, quality of life (QLQ-C15-PAL, POS), pain (VAS), and burden for family caregivers (BSFC). The inclusion of physicians and patients in the study starts in March 2007.DiscussionAlthough participating physicians value the increase in knowledge they receive from PAMINO, the effects on patients remain unclear. If the evaluation reveals a clear benefit for patients quality of life, a larger-scale implementation of the program is considered.nTrial registration: The study was registered at ‘current controlled trials (CCT)’, registration number: ISRCTN78021852.

Validation and cultural adaptation of a German version of the Physicians' Reactions to Uncertainty scales

BackgroundThe aim of the study was to examine the validity of a translated and culturally adapted version of the Physicians Reaction to Uncertainty scales (PRU) in primary care physicians.MethodsIn a structured process, the original questionnaire was translated, culturally adapted and assessed after administering it to 93 GPs. Test-retest reliability was tested by sending the questionnaire to the GPs again after two weeks.ResultsThe principal factor analysis confirmed the postulated four-factor structure underlying the 15 items. In contrast to the original version, item 5 achieved a higher loading on the concern about bad outcomes scale. Consequently, we rearranged the scales. Good item-scale correlations were obtained, with Pearsons correlation coefficient ranging from 0.56–0.84. As regards the item-discriminant validity between the scales anxiety due to uncertainty and concern about bad outcomes, partially high correlations (Pearsons correlation coefficient 0.02–0.69; p < 0.001) were found, indicating an overlap between both constructs. The assessment of internal consistency revealed satisfactory values; Cronbachs alpha of the rearranged version was 0.86 or higher for all scales. Test-retest-reliability, assessed by means of the intraclass-correlation-coefficient (ICC), exceeded 0.84, except for the reluctance to disclose mistakes to physicians scale (ICC = 0.66). In this scale, some substantial floor effects occurred, with 29.3% of answers showing the lowest possible value.ConclusionDealing with uncertainty is an important issue in daily practice. The psychometric properties of the rearranged German version of the PRU are satisfying. The revealed floor effects do not limit the significance of the questionnaire. Thus, the German version of the PRU could contribute to the further evaluation of the impact of uncertainty in primary care physicians.