Wolfgang Himmel

What happens to long-term medication when general practice patients are referred to hospital?

Objective: The aim of the study was to determine changes in drug treatment of general practitioners’ patients on hospital admission and after discharge, and to identify communication problems.Methods:During 15 months all chronically ill patients of one general practice who were referred to hospital (n = 130) were followed-up prospectively with regard to long-term medication in general practice, drugs recommended in hospital for continuing treatment and medication after discharge from hospital.Results:Before hospital admission the 130 patients were receiving 420 medicines long-term (14% generic drugs). The hospital doctors cancelled 28% (116/420) of the drugs, 6% were replaced by other drugs, 11% by another brand name (identical chemical substance but different producer) and 31 generics were replaced by brand name drugs. Hospitals exhibited specific drug profiles (e.g., total replacement of some generics by brand name drugs; and exclusive administration of a certain preparation regardless of the general practitioner’s prescription). After discharge from hospital, the general practitioner continued 329 of the 496 drugs (66.1%) recommended by hospital, 105 (21%) drugs were replaced by other drugs (49 of them by generics) and 62 drugs (13%) were cancelled. The general practitioner received detailed information about drug change in only five of the 130 hospital discharge letters.Conclusion:50% turnover in drug use between general practice and hospital and some of the patterns of drug change in hospital may be unnecessary. They may also complicate the difficult task of the general practitioner of maintaining a patient’s drug regimen.

Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice

OBJECTIVE To test the hypotheses that patient expectations are a driving force in drug prescribing and that fulfilment of expectations is followed by higher satisfaction. DESIGN Pre- and post-consultation survey of patients; parallel doctor survey (matched pairs). SETTING Primary health care in Göttingen, a town of about 130,000 inhabitants in Germany. SUBJECTS Ten general practitioners and 185 randomly addressed patients. MAIN OUTCOME MEASURES Patient expectations with respect to the result of the consultation; doctors perception of patient expectations; agreement between patient and doctor; patient satisfaction. RESULTS Nearly half of the patients (86/185) expected a drug prescription from their doctor; 68% (125/185) received a prescription. The doctors recognized the expectation of a prescription in only 40.7% of the patients. A high percentage (82.6%) of patients expecting a drug were issued a prescription. Nearly all the patients (45/48) who expected a drug according to their doctors judgement left the surgery with a prescription, and 58.4% of the remaining patients were prescribed a drug. There was no difference in satisfaction scores between patients whose expectations were or were not fulfilled. CONCLUSION These results are in some contrast to the main hypotheses. As fulfilment of expectations was not associated with higher satisfaction, physicians need not necessarily worry that patients will change their doctor if he or she refuses a pharmacologically dubious prescription.

Drug changes at the interface between primary and secondary care

OBJECTIVE To analyze the frequency and factors associated with drug change in a sample of patients referred to hospital by their general practitioner. METHODS This observational study is based on a chart review of 100 consecutively recruited patients with a chronic disease who were referred to the general internal medicine wards in each of 3 district general hospitals in Germany (total 300 patients). The frequency of drug cancellation, replacement, dosage alteration, change in manufacturer and of commencing treatment with a new drug were recorded. RESULTS Half of the drugs used in chronic treatment (644/1,330) and prescribed by general practitioners were continued during hospitalization. The fraction canceled was 36%. In the rest of the drugs in this group, there were some minor changes carried out by the hospital. On the day of the drug survey, a total of 1,572 drugs were being taken by the patients and 724 of these drugs were newly prescribed by hospital. Only 13 patients experienced no change to their drug regimen during their stay in hospital. In more than 60% of patients (184/300), there were 3 or more changes made in their drug regimen. The rate of drug cancellation for antihypertensive and cardiac drugs in patients referred to hospital for cardiovascular and non-cardiovascular problems did not differ. CONCLUSION During hospitalization, nearly every patient is confronted with some form of drug change. Of major concern is the high rate of drug change affecting drugs being taken for diseases other than that associated with the hospitalization. Hospital drug policy should encourage clinicians to continue drug regimens in newly admitted patients whenever medically appropriate and caution clinicians against making unnecessary changes to drug regimens prescribed by general practitioners.

Depression and anxiety as major determinants of neck pain: a cross-sectional study in general practice

BackgroundAlthough psychosocial factors are known to be highly linked with neck pain, current therapies focus on somatically based interventions such as medicinal or manipulatory therapies. This study examines how socio-demographic, psychosocial and medical history and health-promoting lifestyle factors interact with neck pain in general practice patients.MethodsThis is a cross-sectional survey including 448 patients from a general practice setting in Germany. Participants completed a comprehensive questionnaire including the Neck Pain and Disability Scale German version (NPAD-d) and the Hospital Anxiety and Depression Scale. Crude and adjusted regression analyses were done to assess the relationship between neck pain and socio-demographic, psychosocial and medical history and health-promoting lifestyle factors.ResultsBoth in crude and adjusted regression analyses, depression and anxiety were highly significantly linked with increasing levels of neck pain. Educational level, deficits in social support and physical exercise were associated with neck pain in bivariate analyses, but these associations did not persist with adjustment for depression and anxiety. When investigating levels of depression and anxiety by NPAD-d quartile subgroups, those who were identified to have depressive mood or to be anxious were very likely to be in the group with the highest levels of neck pain.ConclusionThe higher the neck pain level, the more attention should be paid to psychosocial distress as a related burden. Further research is needed to elucidate the causality and the direction of the association between psychosocial distress and neck pain and to determine the benefit of psychosocial interventions.

The influence of hospitalisation on drug prescription in primary care – a large-scale follow-up study

AbstractObjective To explore the influence of hospitalisation on the prescription of drugs in the primary care sector using prescription data of a major statutory health insurance (SHI) organisation, with a special focus on the so-called “Me-Too” drugs – in particular, 3-hydroxy-3-methyl-glutaryl (HMG) CoA reductase inhibitors (statins) and proton pump inhibitors (PPIs). Methods A comprehensive outpatient drug prescription analysis was conducted on members of a SHI who had been hospitalised during the first 3 months of 2004. The number and costs of all prescriptions of 2426 patients during a 3-month period before admission and after discharge, respectively, were compared using Wilcoxon’s signed rank test. Data are shown in absolute and relative numbers as well as relative risks (RR) and their 95% confidence intervals (CIs). Results The total number of prescriptions before hospitalisation and after discharge remained nearly the same, while the number of different active substances prescribed per patient decreased by 4%. However, overall costs increased after discharge by 15% due to the higher cost per prescription. Changes in medication affected nearly every patient (98.1%), and 60% had at least five changes. Of the substances prescribed to an individual before admission, 57% were cancelled after discharge, and 55% of all substances prescribed after discharge were novel prescriptions. Significantly more patients received a PPI or statin after hospitalisation (RR for a PPI: 1.27; 95% CI: 1.12 –1.45; RR for a statin: 1.16; 95% CI: 1.02–1.32). The increase in PPI medication was due to a 58% increase in the number of patients receiving pantoprazole, a “Me-Too” drug. Conclusion Hospitalisation exerts a marked influence on drug therapy in ambulatory care, with a significant increase in the prescription of novel, on-patent drugs instead of less expensive alternatives.

Psychometric properties of a German version of the neck pain and disability scale

The aim of this study is to evaluate the validity and the psychometric properties of a German version of the 20-item neck pain and disability scale (NPAD) for use in primary care settings. Four hundred and forty-eight participants from 15 general practices in the area of Göttingen Germany completed a multidimensional questionnaire including a newly developed German version of the NPAD (NPAD-d) and self-reported demographic and clinical information. Reliability was tested using Cronbach’s alpha. Item-to-total score correlations were analysed. Factor structure was explored by using unrestricted principal factor analysis. Construct validity of the NPAD-d was evaluated by simple correlation analyses (Pearson’s rho) with social and clinical characteristics. The discriminative abilities of the NPAD-d were examined by comparing differences between subgroups stratified on non-NPAD-d pain related characteristics using t tests for mean scores. Cronbach’s alpha of NPAD-d was 0.94. Item-to-total scale correlations ranged between 0.414 and 0.829. Exploratory principal factor analysis indicated that the NPAD-d covers one factor with an explained variance of 48%. Correlation analysis showed high correlations with criterion variables. The NAPD-d scores of subgroups of patients were significantly different showing good discriminative validity of the scale. The NPAD-d demonstrated good validity and reliability in this general practice setting. The NPAD-d may be useful in the clinical assessment process and the management of neck pain.

Can student tutors act as examiners in an objective structured clinical examination

Context  The dissemination of objective structured clinical examinations (OSCEs) is hampered by requirements for high levels of staffing and a significantly higher workload compared with multiple‐choice examinations. Senior medical students may be able to support faculty staff to assess their peers. The aim of this study is to assess the reliability of student tutors as OSCE examiners and their acceptance by their peers.

Polypharmacy in primary care practices: an analysis using a large health insurance database

To ascertain the rate and range of continuous polypharmacy in German general practices and compare practice characteristics and prescribing profiles in practices with a high rate of polypharmacy patients (HPP) and a low rate of polypharmacy patients (LPP), respectively.

Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care.

Background:  Inappropriate prescriptions of proton pump inhibitors (PPI) in hospital and primary care have been widely reported. Recommendations from hospital have been implicated as one reason for inappropriate prescriptions of PPI in primary care.

Text Mining and Natural Language Processing Approaches for Automatic Categorization of Lay Requests to Web-Based Expert Forums

Background Both healthy and sick people increasingly use electronic media to obtain medical information and advice. For example, Internet users may send requests to Web-based expert forums, or so-called “ask the doctor” services. Objective To automatically classify lay requests to an Internet medical expert forum using a combination of different text-mining strategies. Methods We first manually classified a sample of 988 requests directed to a involuntary childlessness forum on the German website “Rund ums Baby” (“Everything about Babies”) into one or more of 38 categories belonging to two dimensions (“subject matter” and “expectations”). After creating start and synonym lists, we calculated the average Cramer’s V statistic for the association of each word with each category. We also used principle component analysis and singular value decomposition as further text-mining strategies. With these measures we trained regression models and determined, on the basis of best regression models, for any request the probability of belonging to each of the 38 different categories, with a cutoff of 50%. Recall and precision of a test sample were calculated as a measure of quality for the automatic classification. Results According to the manual classification of 988 documents, 102 (10%) documents fell into the category “in vitro fertilization (IVF),” 81 (8%) into the category “ovulation,” 79 (8%) into “cycle,” and 57 (6%) into “semen analysis.” These were the four most frequent categories in the subject matter dimension (consisting of 32 categories). The expectation dimension comprised six categories; we classified 533 documents (54%) as “general information” and 351 (36%) as a wish for “treatment recommendations.” The generation of indicator variables based on the chi-square analysis and Cramer’s V proved to be the best approach for automatic classification in about half of the categories. In combination with the two other approaches, 100% precision and 100% recall were realized in 18 (47%) out of the 38 categories in the test sample. For 35 (92%) categories, precision and recall were better than 80%. For some categories, the input variables (ie, “words”) also included variables from other categories, most often with a negative sign. For example, absence of words predictive for “menstruation” was a strong indicator for the category “pregnancy test.” Conclusions Our approach suggests a way of automatically classifying and analyzing unstructured information in Internet expert forums. The technique can perform a preliminary categorization of new requests and help Internet medical experts to better handle the mass of information and to give professional feedback.