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Introduction: During the COVID-19 pandemic, many people were anxious about a coronavirus infection due to the high infection rate and the mortality risk associated with the disease. Fear of COVID-19 might have influenced patients' utilisation of medical services, even if it meant that a postponed therapy had severe consequences. Our aims were to analyse (a) to what extent fear of COVID-19 contributes to forgone consultations, (b) if patient characteristics, health literacy and social support influence the effect of fear of COVID-19 on the utilisation behaviour and (c) whether interactions between these possible predictor variables are responsible for a higher extent of avoided consultations due to fear of COVID-19., Methods: We conducted a retrospective, cross-sectional observational study in an emergency department. The study was based on personal standardized interviews of patients. The interviews took place between July 15 and August 5, 2020. Patients over the age of 18 were included if there was no urgent need for treatment on the day of the interview, no severe functional limitations, sufficient knowledge of German, ability to consent and health problems requiring treatment between March 13 and June 13, 2020. Differences between patient subgroups were described and analysed using the t-test and chi 2 test. Data were analysed by logistic regression including socio-demographic data, health literacy and social support assessed by standardised instruments. Additionally, we assessed interactions between possible predictor variables by a descriptive tree analysis., Results: 103 patients participated in personal standardized interviews. 46 patients (44.6%) reported that at least one necessary consultation did not take place in the observation period. Among those, 29 patients (63.0%) avoided consultations due to fear of COVID-19. Women had 3.36 times higher odds (95% confidence interval: 1.25 to 9.04, p = 0.017) for avoiding a consultation due to fear of COVID-19. There were no other statistically significant predictors in our analysis., Discussion: Almost half of the required consultations did not take place. Avoidance of consultations needs to be closely monitored during the pandemic. Policy makers as well as health care providers should give consideration to the collateral effects of COVID-19 and COVID-19-related reactions of patients, especially women., Conclusion: In the course of the COVID-19 pandemic, physicians should ensure that their patients take advantage of necessary consultations in order to avoid negative effects of a delayed examination or treatment. Particular attention should be paid to anxious female patients. Studies are needed to analyse the association between health literacy, social support and avoidance of consultations triggered by fear of COVID-19., (Copyright © 2023. Published by Elsevier GmbH.)

Introduction: High utilization of emergency departments by low-acuity patients remains a major challenge for the health care system. Surveys of treatment urgency show that a considerable part of the emergency department population could also be cared for in the outpatient sector. Little is known about the contributing circumstances of non-utilization of outpatient care (despite indication). The expression of health literacy is often called to explain non-urgent use of emergency departments. The extent to which a distinguished commitment to primary care might have a moderating effect is currently not known., Methods: The data for this secondary evaluation of a non-urgent emergency department population were taken from the cross-sectional observational study PiNo Nord ("Patients in the emergency departments of hospitals in Northern Germany") (Scherer et al. 2017). In five hospitals in Hamburg and the federal state of Schleswig-Holstein, health literacy and 'intensity of the commitment to a general practitioner' were measured by self-assessment questionnaires (HLS-EU-Q16, F-HaBi). In addition to descriptive data analysis, linear regression was used to estimate the 'intensity of the commitment to a general practitioner' and other somatic, psychological, and sociodemographic characteristics of the population on health literacy., Results: 548 non-urgent adult patients (mean age 41.5 years, 54.4% men) were included in the evaluation: 55.5% had sufficient, 31.4% problematic and 13.1% inadequate health literacy. 88.3% of the population had a general practitioner. A higher 'intensity of the commitment to a general practitioner', female gender, a higher subjective urgency for treatment, better self-efficacy and better social support were associated with higher health literacy. No associations were found with regard to age, household income, education and migration background, current pain or the degree of physical complaints., Discussion: The extent of health literacy of a non-urgent sample of the PiNo North study population, responding to the HLS-EU-Q16, was comparable to the health literacy of the general population. Health literacy and intensity of commitment to a general practitioner were positively associated. However, the intensity of GP commitment was rather low. The fact that younger respondents were more likely to provide information about their health literacy and the availability of specialists in urban areas could explain these findings., Conclusion: Improving commitment to primary care physicians could include providing individualized information on how to navigate the health care system. This could make it easier for patients to choose an adequate level of care - and thus have a steering effect on emergency department utilization., (Copyright © 2022. Published by Elsevier GmbH.)

Objective: Former results of the KarMed study revealed a significant decrease in the career satisfaction of female physicians with children in the course of their postgraduate training compared to male physicians with children. Yet, female physicians with children showed the highest scores on satisfaction with life at the fourth year of postgraduate training. The present study evaluates whether the different courses of career satisfaction and life satisfaction of female physicians compared to male physicians are caused by parental status., Methods: Data were collected in the course of the KarMed study (2008-2016). A cross-lagged panel design was used to analyze data from T2 to T5., Results: The results indicate an inverse association of career satisfaction with life satisfaction. Women physicians with a low level of career satisfaction were more likely to have children than those with a higher career satisfaction. Furthermore, we found a causal effect of parental status on career satisfaction in male physicians. For female physicians, yet not for male physicians, life satisfaction predicts the parental status., Conclusions: The structural improvement in postgraduate training needs to be adjusted in terms of parental status. Prospective studies should take medical leave during pregnancy as well as parental leave of male medical residents into account., (Copyright © 2021. Published by Elsevier GmbH.)

Introduction: For patients with diabetes mellitus, training is an essential part of therapy. There is a lack of empirical data regarding training experiences for people with a (Turkish) migration background and low literacy skills concerning the established training programmes. The objective of this research was to collect data from general practices based on their experiences in training these particular groups of patients., Methods: In a quantitative cross-sectional study design, 795 general practices throughout Germany with the additional designation of diabetology were invited via e-mail to participate in a fully structured, standardised online survey. An exploratory data analysis was performed using the statistics software IBM SPSS., Results: Out of 146 participating practices (response rate 18%), 66 (45%) estimated the proportion of patients with migration background in their practice to be more than 20%. Approximately 76% of the practices providing diabetes training (n=119) trained patients of Turkish origin. Forty six percent of these practices estimated the ratio of patients of Turkish origin with low literacy skills to be 10 to 50%. Less than 36% of the practices were aware of suitable training programmes for this target group. Existing programmes were modified to special needs and new materials creatively developed. Additional culturally sensitive and visually enriched materials are needed. Forty two percent of the interviewed practices reported billing difficulties concerning frequently needed individual trainings., Discussion: Training was carried out in different ways due to individual addition or deletion of content elements. There is a lack of evaluated materials that are adapted to the users' cultural background and level of education. In the face of a significantly changed immigration structure, information and materials as well as interpreters for additional languages are increasingly required., Conclusion: Further development of evidence-based, multi-lingual, image-based, culturally sensitive and educationally diverse materials and training units and their scientific evaluation is needed. Learning contents adapted to the level of education and promoting cultural sensitivity in the provision of healthcare should be implemented increasingly in the training and continuous professional development of health professionals., (Copyright © 2020. Published by Elsevier GmbH.)

Objective: Evaluation of longitudinal data of German medical residents' career satisfaction and its dependency on perceived delays in obtaining the degree as a medical specialist, as well as postgraduate training quality, controlled for gender, parental status, and specialty choice., Methods: Data was collected within the KarMed study. The first data collection (T0) was conducted in 2008/2009 at the end of the practical year. Hierarchical linear models and path analysis were used to analyse longitudinal associations after three and five years (T3 to T5)., Results: A positive residents' career satisfaction had a small causal effect on the training quality. A delay in obtaining the degree as a medical specialist had a small negative effect on residents' career satisfaction. A high residents' career satisfaction was negatively associated with a delay in training. Gender predicted the career satisfaction of physicians with children. The career satisfaction of female physicians with children decreased significantly in the course of their postgraduate training compared to male physicians with children. The speciality choice had no significant impact on residents' career satisfaction., Conclusion: Residents who were satisfied with their job subjectively rated the quality of postgraduate training conditions more positively. The anticipated delays in obtaining the degree as a medical specialist and the residents' career satisfaction were reciprocally related. The improvement of career satisfaction in female physicians with children needs special attention in the future., (Copyright © 2019. Published by Elsevier GmbH.)

Background: Very often patients utilize primary care services for health conditions related to social problems. These problems, which are not primarily medical, can severely influence the course of an illness and its treatment. Little is known about the extent to which problems like unemployment or loneliness occur in a general practice setting., Objectives: What are the most frequent health-related social problems perceived by general practitioners (GPs)? How are these problems associated with GP- or practice characteristics? How do general practitioners deal with the social problems they perceive and what kind of support do they need?, Materials and Methods: Cross-sectional, postal questionnaire survey with questions derived from "Chapter Z social problems" of the International Classification of Primary Care - 2 nd edition. The questionnaire was mailed to available GP addresses in the federal states of Hamburg (n=1,602) and Schleswig-Holstein (n=1,242)., Results: N=489 questionnaires (17.2 %) were analyzed. At least three times a week, GPs were consulted by patients with poverty/financial problems (53.4 %), work/unemployment problems (43.7 %), patients with loneliness (38.7 %) as well as partnership issues (25.5 %). Only rarely did GPs report having perceived assault/harmful event problems (0.8 %). The highest frequency of problems was encountered by practices with a high proportion of a migrant population., Conclusions: Social problems are a common issue in routine primary care. GPs in Northwestern Germany usually try to find internal solutions for social problems but also indicated further interest in institutionalized support. A possible approach to solving these issues are community-based, locally organized networks., (Copyright © 2018. Published by Elsevier GmbH.)

Objective: To evaluate German residents' career satisfaction and its dependency on intrinsic and extrinsic factors after four years of postgraduate training. Gender, parental status, training conditions and specialty choice were of particular interest., Methods: Postal questionnaires were sent to medical graduates from seven different German faculties annually, starting in 2009. This paper presents cross-sectional data of domestic, working and training conditions four years after graduation. We used descriptive statistics and t-tests. In order to identify factors with an impact on career satisfaction, multiple regression analyses were calculated., Results: Male residents who have children tended to be more satisfied with their career than residents without children. For female residents, however, having children was associated with lower career satisfaction. Those who chose training in general surgery or orthopedic surgery were less satisfied with their career progress. Residents with prolonged specialty training showed lower career satisfaction. Junior doctors who rated the quality of their residency training higher were more satisfied with their career. Those who perceived their job as particularly demanding were less satisfied. Concerning intrinsic factors, occupational self-efficacy and overall satisfaction with life were significantly associated with career satisfaction., Conclusion: Residents in general are quite satisfied with their career after four years of training. Opportunities to work part-time during residency as well as structured training programs should be implemented in order to overcome parenthood as a career obstacle for female residents. The quality of specialty training is particularly important for career satisfaction and has to be ensured across specialties., (Copyright © 2017. Published by Elsevier GmbH.)

Introduction: Medical guidelines focusing on monomorbidities can be associated with adverse events in multimorbid patients. This study investigates how comorbidities are actually particularised in a set of German guidelines. In addition, it evaluates whether two epidemiologic approaches (disease combinations or clusters of comorbidities) can be used to systematically integrate multimorbidity in guideline development., Methods: Based on a matrix of 30 comorbidities, mentioning of comorbidities in 8 current German guidelines (diabetes mellitus, hypertension, heart failure, coronary heart disease, chronic obstructive lung disease/asthma, coxarthrosis, low back pain, osteoporosis) was investigated. These so called index diseases were selected on the basis of the hypothetical case of a multimorbid patient published by Cynthia Boyd and colleagues in 2005. Mentioning of comorbidities in the guidelines was compared to the epidemiologic approaches of disease combinations and clusters of comorbidities. In addition, using the comorbidity matrix, 36 physicians involved in everyday care of multimorbid patients assessed whether an explicit recommendation for the listed comorbidities would be helpful., Results: Mentioning of comorbidities was very heterogeneous across the guidelines investigated, ranging from 0 to more than 10. The proportion of the comorbidities that were considered relevant by the survey participants ranged from 0 % to 62 % with a focus on cardiovascular and metabolic diseases. When using disease combinations, only 0 to 3 of the "relevant" comorbidities were identified. Using the cluster model may be helpful in identifying whether a particular comorbidity is thematically close to the index disease or whether it is associated with an interacting thematic area., Conclusions: Methodological support is needed for addressing comorbidities in guidelines in a more consistent way. The currently existing epidemiologic approaches should not be used in their current form without being further developed and re-evaluated. Expert opinion of physicians involved in the care of multimorbid patients should be systematically included in methodological refinement studies., (Copyright © 2014. Published by Elsevier GmbH.)

Background: Frequent attenders utilise a high proportion of medical services and therefore produce relatively high costs. Questions of utility and adequacy and, also, about the reasons for high use arise. The authors report the results of a study on the association between morbidity of the elderly and various forms of frequent attendance in ambulatory medical care in Germany., Methods: The study is based on claims data of all policyholders aged 65 and over of a statutory health insurance company operating nationwide in Germany in 2004 (n = 123,224). Utilisation was analysed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different practices contacted. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 individual practices or ≥ 3 practices of the same discipline per year. We analysed prevalences and relative risks for frequent attendance for 46 chronic diseases., Results: Frequent attendance in ambulatory medical care among the elderly is related to both severe somatic and psychic diagnoses. Five chronic diseases showed the highest relative risks for all types of frequent attendance in general: urinary incontinence, anaemia, neuropathies, renal insufficiency, and cancer. Psychic syndromes mainly led to the utilisation of many different physicians., Conclusion: Frequent attendance in ambulatory medical care among the elderly is related to a large number of diseases, both somatic and psychic. Frequent attendance is a complex phenomenon which cannot be addressed by mono-dimensional approaches., (Copyright © 2013. Published by Elsevier GmbH.)

Background: Disease Management Programmes (DMPs) are structured treatment programmes for chronic diseases. The DMP requirements are primarily derived from evidence-based guidelines. DMPs are regularly revised to ensure that they reflect current best practice and medical knowledge. The aim of this study was to assess the need for updating the German DMP module on heart failure by comparing it to relevant guidelines and identifying recommendations that should be revised., Methods: We systematically searched for clinical guidelines on heart failure published in German, English or French, and extracted relevant guideline recommendations. All included guidelines were assessed for methodological quality. To identify revision needs in the DMP, we performed a synoptic analysis of the extracted guideline recommendations and DMP requirements., Results: 27 guidelines were included. The extracted recommendations covered all aspects of the management of heart failure. The comparison of guideline recommendations with DMP requirements showed that, overall, guideline recommendations were more detailed than DMP requirements, and that the guidelines covered topics not included in the DMP module., Conclusions: The DMP module is largely consistent with current guidelines on heart failure. We did not identify any need for significant revision of the DMP requirements. However, some specific recommendations of the DMP module could benefit from revision., (Copyright © 2013. Published by Elsevier GmbH.)

A debate on the application of quality indicators (QIs) arose among the members of the German College of General Practitioners and Family Physicians (DEGAM) when two QI systems for ambulatory care (QISA and AQUIK) were published in a short time interval. A research question that emanated from this discussion was whether appropriate QI might be developed based on German general practice guidelines. In spring 2010, the DEGAM guideline committee (SLK) decided to conduct a project on guideline-based development of QIs using the DEGAM guidelines for dementia, neck pain and sore throat. All members of the SLK were invited to participate in the development process which comprised three face-to-face meetings and four paper-pencil ratings. Finally, 17 QIs for the three guidelines on dementia (n=8), neck pain (n=7) and sore throat (n=2) emerged. These QIs received different ratings in the dimensions relevance, practicability, and appropriateness for public reporting as well as for pay for performance. In this project, guideline authors themselves developed QIs based on German general practice guidelines for the first time ever. Not before practice administration systems facilitate the availability of data in the context of clinical documentation, the practicability of the new QIs can be proven in real every-day practice., (Copyright © 2012. Published by Elsevier GmbH.)

Background: The authors report the results of a study on frequent attenders in ambulatory medical care among elderly people in Germany and on the factors related to frequent attendance such as age, sex, multi-morbidity and long-term care dependency., Methods: The study was based on claims data of all policy holders aged 65 and over of a statutory health insurance company operating nationwide in Germany in 2004 (n=123,224). Utilisation was analysed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different practices contacted. The criteria for frequent attendance included greater than or equal to 50 contacts and/or greater than or equal to 10 different practices contacted and/or greater than or equal to 3 practices of the same discipline contacted within one year. Descriptive statistical analysis and logistic regression were used., Results: 19% of the elderly were identified as frequent attenders, which corresponds to some 3.5 million people in Germany. Two main types of frequent attendance were identified: one is characterised by very many contacts, old age, frequent presence of multi-morbidity, and/or long-term care dependency. The other type is the younger, less frequently multi-morbid attender who is considerably less often dependent on long-term care, and characterised by large numbers of contacted practices and/or practices of the same discipline., Conclusion: Frequent attendance is due to several factors. The problem of frequent attendance needs further research that is not exclusively based on claims data. We found a high rate of frequent attendance. Further research should clarify if this is to the benefit of elderly people., (Copyright © 2013. Published by Elsevier GmbH.)

In December 2010, the Institutes for Social Medicine and Cancer Epidemiology of the University of Lübeck hosted the first Workshop for Early Career Investigators in the area of Health Services Research. This workshop was funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) with the aim to promote young scientists and researchers that wish to pursue research in the field of Health Services Research in an early phase of their career. The following report addresses the background, concept and progress of the initiative. All applicants had to submit a detailed project proposal and underwent a rigorous selection process. The projects presented at the workshop covered a wide range of topics, such as, for example, access to health care, common elements of mental illnesses and psychosomatic disorders, quality assurance in medical practices (i.e., evaluation of disease management programmes) and targets in rehabilitation. A major subject was migration as a challenge to Health Services Research. The 20 best applicants out of 121 were invited to attend the programme. During five days the participants had the opportunity to present their projects and discuss current issues as well as fundamental themes in study design. At the same time, national and international leading experts gave a series of lectures on current topics of Health Services Research. In numerous discussion groups and topical workshops participants and speakers explored and sought solutions to specific research issues. Following the programme participants are expected to finalise their research proposals and apply for funding to the DFG. To foster networking among early-career researchers, an alumni meeting is scheduled after 12 months. The DFG Workshop for Early Career Investigators was the first of its kind in the field of Health Services Research in Germany. However, evidence of its sustainability will have to be obtained from the future development of the German Health Services Research., (Copyright © 2011. Published by Elsevier GmbH.)

In December 2009, the first version of the German Disease Management Guideline (DM-CPG) for chronic heart failure was completed, including a set of proposed quality indicators for heart failure. This article explores whether proposed indicators can be derived from data collected routinely in general practices. For this purpose, previous experiences and data from the research project CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork) conducted under guidance of the Department of General Medicine and Health Services Research at the University of Heidelberg, Germany, were applied. The availability of numerators and denominators needed for calculating the four quality indicators for diagnosis and pharmacotherapy proposed in the DM-CPG was checked within so-called "routine data" from the existing dataset of the CONTENT project. Within the given context, routine data are defined as data that are periodically transmitted from health care providers to cost units within the health care system. A thorough assessment has revealed that within the given context only one indicator could be deduced from routine data collection. This was the indicator measuring the proportion of patients receiving beta receptor antagonists, compared to all patients with heart failure NYHA class II to IV. Indeed, this single indicator will only be computable if the NYHA grade of heart failure severity and the presence or absence of contraindications to beta receptor antagonist therapy are routinely collected and the data merged into a central database. Against the background of these results it is obvious that a fully developed, transsectoral concept for data collection and data transfer needs to be implemented.

Quality indicators (QIs) are used in many areas of health care in order to measure, compare, and improve quality. QIs are specific, measurable aspects of care that can be used to assess its quality. Assessing the quality of care contributes to quality improvement. Amongst other applications, QIs are used in quality management for comparisons between providers and in pay-for-performance systems. QIs can be developed on the basis of expert opinion, scientific evidence or clinical practice guidelines. For the efficient development of high quality QIs, rigorous, approved, and evidence-based development methods are needed. At present, there is no gold standard for the development of QIs.