Search

Purpose To describe the prevalence of complexity factors in the medication regimens of community-dwelling patients with more than five drugs and to evaluate the relevance of these factors for individual patients. Methods Data were derived from the HIOPP-6 trial, a controlled study conducted in 9 general practices which evaluated an electronic tool to detect and reduce complexity of drug treatment. The prevalence of complexity factors was based on the results of the automated analysis of 139 patients’ medication data. The relevance assessment was based on the patients’ rating of each factor in an interview (48 patients included for analysis). Results A median of 5 (range 0–21) complexity factors per medication regimen were detected and at least one factor was observed in 131 of 139 patients. Almost half of these patients found no complexity factor in their medication regimen relevant. Conclusion In most medication regimens, complexity factors could be identified automatically, yet less than 15% of factors were indeed relevant for patients as judged by themselves. When assessing complexity of medication regimens, one should especially consider factors that are both particularly frequent and often challenging for patients, such as use of inhalers or tablet splitting. Trial registration The HIOPP-6 trial was registered retrospectively on May 17, 2021, in the German Clinical Trials register under DRKS-ID DRKS00025257.

ImportanceFor older adults with frailty syndrome, reducing polypharmacy may have utility as a safety-promoting treatment option.ObjectiveTo investigate the effects of family conferences on medication and clinical outcomes in community-dwelling older adults with frailty receiving polypharmacy.Design, Setting, and ParticipantsThis cluster randomized clinical trial was conducted from April 30, 2019, to June 30, 221, at 110 primary care practices in Germany. The study included community-dwelling adults aged 70 years or older with frailty syndrome, daily use of at least 5 different medications, a life expectancy of at least 6 months, and no moderate or severe dementia.InterventionsGeneral practitioners (GPs) in the intervention group received 3 training sessions on family conferences, a deprescribing guideline, and a toolkit with relevant nonpharmacologic interventions. Three GP-led family conferences for shared decision-making involving the participants and family caregivers and/or nursing services were subsequently held per patient at home over a period of 9 months. Patients in the control group received care as usual.Main Outcomes and MeasuresThe primary outcome was the number of hospitalizations within 12 months, as assessed by nurses during home visits or telephone interviews. Secondary outcomes included the number of medications, the number of European Union list of the number of potentially inappropriate medication (EU[7]-PIM) for older people, and geriatric assessment parameters. Both per-protocol and intention-to-treat analyses were conducted.ResultsThe baseline assessment included 521 individuals (356 women [68.3%]; mean [SD] age, 83.5 [6.17] years). The intention-to-treat analysis with 510 patients showed no significant difference in the adjusted mean (SD) number of hospitalizations between the intervention group (0.98 [1.72]) and the control group (0.99 [1.53]). In the per-protocol analysis including 385 individuals, the mean (SD) number of medications decreased from 8.98 (3.56) to 8.11 (3.21) at 6 months and to 8.49 (3.63) at 12 months in the intervention group and from 9.24 (3.44) to 9.32 (3.59) at 6 months and to 9.16 (3.42) at 12 months in the control group, with a statistically significant difference at 6 months in the mixed-effect Poisson regression model (P = .001). After 6 months, the mean (SD) number of EU(7)-PIMs was significantly lower in the intervention group (1.30 [1.05]) than in the control group (1.71 [1.25]; P = .04). There was no significant difference in the mean number of EU(7)-PIMs after 12 months.Conclusions and RelevanceIn this cluster randomized clinical trial with older adults taking 5 or more medications, the intervention consisting of GP-led family conferences did not achieve sustainable effects in reducing the number of hospitalizations or the number of medications and EU(7)-PIMs after 12 months.Trial RegistrationGerman Clinical Trials Register: DRKS00015055

Objective Due to the increasing concerns about polypharmacy, there is a growing need for clinical recommendations for drug discontinuation. This requires studies investigating the process on several levels. This paper addresses the methodological problems of drug discontinuation trials (DDTs). To that end, we offer a new typology of research aims and corresponding methodological recommendations for trials evaluating drug discontinuation. Study Design and Setting Multi-stage development process, including literature search and expert panels. Results Clinical trials are only required in cases of scientific uncertainty. We identified three situations of uncertainty associated with drug discontinuation from which we derived three study types: 1) Uncertainty regarding the effectiveness and/or safety of a drug; 2) Uncertainty regarding the procedure of discontinuing a previously taken drug; 3) Uncertainty regarding the effectiveness of complex strategies used to discontinue one or more drugs. We developed specific methodological recommendations for each study type. Conclusion We offer a comprehensive definition of research aims, study designs, and methodological recommendations regarding DDTs. The typology we propose can help investigators clarify their research aims and study design. The type-specific methodological recommendation should improve the quality of future drug discontinuation trials.

Background: Video consultations can complement primary care patient care, but they can also pose challenges for the physicians involved. A need exists to familiarize medical students with the specifics of video consultations. This paper presents the concept and testing of a digitally synchronous distance seminar in which medical students practice and work through the performance of video consultations as an aid to family physicians activity in a patient-oriented manner. The aim of the evaluation was to analyze the strengths, weaknesses, opportunities, and threats (S.W.O.T.) of the teaching concept.Methods:Within the seminar, 12 students carried out video consultations independently under medical supervision, observed the conversations of their fellow students and processed the experiences in the group. The seminar consisted of two elements: A) The whole group of students and teachers was video consulted in a family practice. B) A small group performed a videoconsultation with connection to the home environment of a patient.The evaluation by the students was done by two questionnaires (pre/post), which were analyzed with descriptive statistics and qualitative content analysis. The S.W.O.T. analysis was elaborated by the author team based on the results of the questionnaires and interviews with the teachers.Results:The students learned the limits and possibilities of teleconsultations and deepened their family medical knowledge. The pilot project has strengthened the interest in video consultations among many participants. Patient contact and focused work were seen as strengths of the tested learning model. Above all, technical difficulties and the time required were mentioned as weaknesses. The seminar should also be held after the COVID-19 pandemic. It would bring the chance to involve especially students with multiple workloads in patient teaching. The risks lie in the fact that it still has to be integrated into the curriculum and there are few personnel resources for the organization.Conclusions:The learning model familiarizes medical students with competences in family medical patient care using video communication. Various strengths, weaknesses, opportunities and threads of the learning concept can be weighted differently. Hereby, project groups can decide individually if they want to integrate the learning concept in their curriculum and which further improvements are necessary.

BackgroundIn Germany, there are neither guidelines provided by the medical associations nor a public discussion about general practitioners (GPs) treating their family members. Only few studies on this topic from the primary care setting exist. The aim of this study is to describe GPs’ treatment of family members and to generate empirical data on the most common reasons for this.MethodsIn June 2018 we conducted a postal survey among GPs in the North Rhine region of Germany. The questionnaire was developed in a stepwise process including initial expert panels, interviews with GPs, item construction workshops, cognitive pre-tests and pilot testing with 40 questionnaires. The final questionnaire addressed: type and frequency of treatment, documentation and place of treatment, engagement as the official GP as well as reasons for and against the treatment. For data evaluation, descriptive and explorative statistical analyses were conducted.ResultsOverall, 393 questionnaires were returned (response rate 39.8%). 96.7% of the GPs had treated at least one family member during the last 12 months. Services that were provided frequently (more than three times in the last 12 months) included the prescription or dispensing of medication (partner 45%, children 37%, parents 43%, partner’s parents 26%), physical examinations (partner 18%, children 24%, parents 25%, partner’s parents 15%), and the arrangement or provision of laboratory tests (partner 14%, children 7%, parents 16%, partner’s parents 9%). Less than one third of the study participants always treated their relatives in their office. Male GPs more often provided care to family members (except children) registered in their practice. Senior male GPs treated their relatives more often than junior female GPs. Family members were most commonly treated for practical reasons.ConclusionThe subject of GPs treating their relatives is of high everyday relevance, since nearly all GPs are involved in the treatment of their family members. Frequent at-home treatments and low documentation rates may indicate risks due to deviating from the professional routine.

IntroductionWith respect to patient-centred care and shared decision-making, measuring care effects based on outcomes relevant to patients is becoming increasingly important. Recently, a scoping review of the international literature revealed a wide range of supposedly patient-relevant outcomes and found that there is neither a sound definition of patient relevance nor a consistent set of outcomes relevant to patients. To close this gap, this study aims to develop an agreed concept on patient relevance including a set of outcomes relevant to patients irrespective of diseases, which grades outcomes according to their importance.Methods and analysisThis prospective mixed-methods study will integrate the perspectives of patients across diseases, healthcare professionals and researchers. The consensus process will consist of four phases. Based on the results of the recent scoping review, a patient survey will be conducted first, followed by a multiprofessional group discussion. Finally, a two-round online Delphi approach based on data from the previous phases will be applied to agree on a concept.Ethics and disseminationEthics approval for the study was granted on 26 August 2020 by the Ethics Commission of Witten/Herdecke University (reference number: 156/2020). In the long run, the implementation of an agreed concept on patient relevance will help improve the comparability of study results regarding the patient benefit and thereby strengthen the role of patients in the decision-making process. Also, the experiences regarding grading outcomes according to importance will help to develop a method on how to individualise clinical trial outcomes according to each patient’s individual specifics and priorities in order to more adequately represent the patient perspective in clinical research.Trial registration numberCore Outcome Measures in Effectiveness Trials Initiative (registration number: 1685).

Background Little is known about the quality of general practice care received by patients suffering from multimorbidity. Objectives To assess how patients with multimorbidity evaluate their General Practitioners (GPs') performance and to identify factors associated with high patient satisfaction levels. Methods Cross-sectional study in Germany using the EUROPEP questionnaire consisting of 23 items with a five-point Likert scale and covering two dimensions: clinical performance of the GP and organisation of care. Mixed logistic regression was used in the analysis, with the EUROPEP score as a dependent variable. Results The study included 651 patients (54.8% female), with a mean age of 73.7 ± 4.9 years. Of 22 of 23 questionnaire items, >80% of patients rated their satisfaction as 'good' or 'excellent'. The highest level of satisfaction (excellent) varied among items between 28.0 and 73.1%. Lower age and female sex of GPs were associated with better patient evaluations in 15 and 12 of the 23 items, respectively. Patient characteristics were not associated with their satisfaction with their GP. Conclusions This study found high levels of satisfaction with primary care in patients with multimorbidity. However, since high levels of patient satisfaction are not necessarily equivalent to high quality of care, a broader view is necessary to integrate the subjective views of patients and objective quality indicators into a comprehensive concept of good quality of care.

Ziel der Studie: Pravention und Gesundheitsberatung sollen in der Hausarztpraxis zukunftig eine grosere Rolle spielen. Die europaische Fragebogenstudie EUROPREVIEW verfolgte das Ziel, Einstellungen, subjektiven Beratungsbedarf und erhaltene Praventionsangebote unter hausarztlichen Patienten abzufragen. Methodik: Multizentrische Querschnittsbefragung in 22 europaischen Landern mit konsekutivem Einschluss von 40 Patienten zwischen 30 und 70 Jahren in jeweils 10 Hausarztpraxen. Die Validitat des in die jeweiligen Landessprachen ubersetzten Patientenfragebogens wurde durch Ruck-Ubersetzungen sowie Pilotierungen uberpruft. Diese explorative Analyse vergleicht deutsche Daten zu den Lebensstilfaktoren Ernahrung, Ubergewicht, Bewegung, Rauchen und Alkohol mit den ubrigen europaischen Landern. Ergebnisse: Im europaischen Vergleich ausern Patienten in Deutschland fur samtliche Lebensstilfaktoren einen ahnlich grosen Veranderungsbedarf und werden von ihren Hausarzten etwa gleich haufig auf diese Faktoren angesprochen. Patienten mit subjektiv als notwendig erachtetem Veranderungsbedarf wunschen sich in Deutschland signifikant seltener Unterstutzung durch Ihren Hausarzt (Ernahrung 41,1 (Deutschland %) vs. 66,6 (Rest-Europa %), Bewegung 31,0 vs. 57,0, Gewicht 44,1 vs. 67,1, Rauchen 49,1 vs. 63,3, Alkohol 43,5 vs. 55,9). Schlussfolgerung: Die Ursachen fur die geringere patientenseitige Nachfrage nach hausarztlicher Gesundheitsberatung in Deutschland sollten genauer erforscht werden. Im Falle eines prinzipiell gegebenen Beratungsbedarfs seitens der Patienten sollte untersucht werden, ob und wie Hausarzte diesen Bedarf decken konnen.

Objective To evaluate the summative assessment (OSCE) of a communication training programme for dealing with challenging doctor–patient encounters in the 4th study year. Methods Our OSCE consists of 4 stations (breaking bad news, guilt and shame, aggressive patients, shared decision making), using a 4-item global rating (GR) instrument. We calculated reliability coefficients for different levels, discriminability of single items and interrater reliability. Validity was estimated by gender differences and accordance between GR and a checklist. Results In a pooled sample of 456 students in 3 OSCEs over 3 terms, total reliability was α =0.64, reliability coefficients for single stations were >0.80, and discriminability in 3 of 4 stations was within the range of 0.4–0.7. Except for one station, interrater reliability was moderate to strong. Reliability on item level was poor and pointed to some problems with the use of the GR. Conclusion The application of the GR on regular undergraduate medical education shows moderate reliability in need of improvement and some traits of validity. Ongoing development and evaluation is needed with particular regard to the training of the examiners. Practice implications Our CoMeD-OSCE proved suitable for the summative assessment of communication skills in challenging doctor–patient encounters.

Objective To identify inter-individual examiner factors associated with interrater reliability in a summative communication OSCE in the 4th study year. Methods The OSCE consists of 4 stations assessed with a 4-item 5-point global rating instrument. A bivariate secondary analysis of interrater reliability in relation to 4 examiner factors (gender, profession, OSCE experience, examiner training) was conducted. Intraclass correlation coefficients (ICC) were calculated and compared between examiner dyads of different similarity. Results 169 pairwise ratings from 19 different examiners in 16 dyads were analysed. Interrater reliability is significantly higher in examiner dyads of same vs. different gender (ICC = 0.76 (95%CI = 0.65-0.83) vs. ICC = 0.41 (95%CI = 0.21-0.57)), in dyads of two clinicians vs. non-clinical/mixed professions (ICC = 0.72 (95%CI = 0.56-0.83) vs. ICC = 0.57 (95%CI = 0.41-0.69)), and in dyads with high vs. low/mixed OSCE experience (ICC = 0.73 (95%CI 0.50-0.87) vs. ICC = 0.56 (95%CI = 0.41-0.69)). Participation in recent examiner training had no influence on ICCs. Conclusion Better concordance of ratings between clinically active examiners might be a hint for context specificity of good communication. Higher interrater reliability between examiners with same gender may indicate gender-specific communication concepts. Practice implications Medical faculties introducing summative assessment of communication competence should focus the influence of examiner characteristics on interrater reliability.

Background: Imparting communication skills has been given great importance in medical curricula. In addition to standardized assessments, students should communicate with real patients in actual clinical situations during workplace-based assessments and receive structured feedback on their performance. The aim of this project was to pilot a formative testing method for workplace-based assessment. Our investigation centered in particular on whether or not physicians view the method as feasible and how high acceptance is among students. In addition, we assessed the reliability of the method. Method: As part of the project, 16 students held two consultations each with chronically ill patients at the medical practice where they were completing GP training. These consultations were video-recorded. The trained mentoring physician rated the student’s performance and provided feedback immediately following the consultations using the Berlin Global Rating scale (BGR). Two impartial, trained raters also evaluated the videos using BGR. For qualitative and quantitative analysis, information on how physicians and students viewed feasibility and their levels of acceptance was collected in written form in a partially standardized manner. To test for reliability, the test-retest reliability was calculated for both of the overall evaluations given by each rater. The inter-rater reliability was determined for the three evaluations of each individual consultation. Results: The formative assessment method was rated positively by both physicians and students. It is relatively easy to integrate into daily routines. Its significant value lies in the personal, structured and recurring feedback. The two overall scores for each patient consultation given by the two impartial raters correlate moderately. The degree of uniformity among the three raters in respect to the individual consultations is low. Discussion: Within the scope of this pilot project, only a small sample of physicians and students could be surveyed to a limited extent. There are indications that the assessment can be improved by integrating more information on medical context and student self-assessments. Despite the current limitations regarding test criteria, it is clear that workplace-based assessment of communication skills in the clinical setting is a valuable addition to the communication curricula of medical schools., Hintergrund: Die Vermittlung kommunikativer Kompetenzen hat eine größere Bedeutung in den Curricula der Humanmedizin bekommen. Ergänzend zu standardisierten Prüfungen sollten Studierende im Rahmen arbeitsplatzbasierter Prüfungen in realen klinischen Situationen mit richtigen Patienten kommunizieren und ein strukturiertes Feedback bekommen. Ziel des Projektes war, eine solche formative Prüfmethode zum arbeitsplatzbasierten Assessment zu pilotieren. Von besonderem Interesse war zu ermitteln, ob Ärzt/innen die Methode für praktikabel halten und inwiefern die Studierenden sie akzeptieren. Darüber hinaus sollte die Reliabilität der Methode eingeschätzt werden. Methode: Hierzu führten 16 Studierende in ihren hausärztlichen Lehrpraxen je zwei Beratungsgespräche mit chronisch kranken Patienten und zeichneten diese per Video auf. Bewertung und Feedback erfolgten jeweils unmittelbar nach dem Gespräch durch den geschulten Lehrarzt anhand des Berlin Global Rating (BGR). Ferner erfolgte eine Bewertung der Gespräche mit dem BGR durch zwei externe geschulte Prüfer anhand der Videos. Die Angaben der Ärzte und Studierenden zur Praktikabilität und Akzeptanz wurden schriftlich und teilstandardisiert erhoben und quantitativ sowie qualitativ ausgewertet. Zur Prüfung der Reliabilität wurde die Retest-Reliabilität der beiden Gesamtbewertungen durch die jeweiligen Prüfer berechnet sowie die Inter-Rater-Reliabilität der drei Bewertungen aller Einzelgespräche. Ergebnisse: Die formative Prüfmethode wird von den Ärzten und Studierenden als gut bewertet. Sie ist relativ gut in den Arbeitsalltag zu integrieren. Der besondere Mehrwert besteht im persönlichen, strukturierten und wiederholten Feedback. Die beiden Gesamtbewertungen des Patientengespräches durch den jeweiligen Prüfer korrelieren mäßig. Die Übereinstimmung der drei Prüfer hinsichtlich der Einzelgespräche ist gering. Diskussion: Im Rahmen des Pilotprojektes konnte nur eine kleine Stichprobe von Ärzten und Studierenden in begrenztem Umfang befragt werden. Hierbei ergaben sich Hinweise zur Verbesserung der Prüfung durch die Integration von Kontextinformationen und studentischen Selbsteinschätzungen. Trotz der bislang noch vorhandenen Einschränkungen bezüglich der Testgüte ist deutlich geworden, dass die arbeitsplatzbasierte Bewertung kommunikativer Kompetenzen im klinischen Setting eine sinnvolle Ergänzung im Kommunikations-Curriculum einer medizinischen Fakultät ist., GMS Journal for Medical Education; 33(5):Doc70

To compare a cardiovascular risk (CVR)-adjusted with the traditional blood pressure (BP) control rate for assessing BP control and consequent target populations for intensified treatment.Model calculation using cross-sectional data retrieved from 89 German general practices; a random sample of 3355 patients with known hypertension was consecutively enrolled by their general practitioners. Cardiovascular history and risk factors were documented. In addition to the traditional control rate (fixed BP target140/90), we calculated CVR-adjusted control rates, stratifying analyses according to three CVR categories and their corresponding BP targets on the basis of the European Cardiovascular Society's SCORE tables: (1) very high CVR, owing to manifest cardiovascular disease (CVD), BP target130/80; (2) high CVR, BP target140/90; and (3) low CVR, BP target160/100 mmHg.Traditional vs. CVR-adjusted BP control rates were 55.1 vs. 14.9% (manifest CVD, kappa 0.27), 36.7 vs. 35.8% (high CVR, kappa 0.98), 52.6 vs. 88.5% (low CVR, kappa 0.25), and 45.8 vs. 46.5% (overall, kappa 0.61). Among the study patients, 19.2% switched from 'controlled' to 'uncontrolled' or vice versa depending on the criterion applied.Compared with the traditional BP control rate, the CVR-adjusted approach identifies a substantially different - although overall similarly large - target group for intensified cardiovascular risk reduction. Using CVR-adjusted BP control rates in surveys describing hypertension management could help to focus attention and resources on reducing CVR in patients who are likely to benefit from additional treatment efforts.

Eine Patientenverfugung (PV) ist nach dem sog. Patientenverfugungsgesetz vom 01.09.2009 unter bestimmten Bedingungen – auch fur arztliche und nichtarztliche Mitarbeiter des Rettungsdienstes – formal rechtlich bindend. Doch sind diese Bedingungen in Notfallsituationen derzeit nur selten erfullt, sodass das Rettungspersonal auch bei Vorliegen einer PV meist in Unkenntnis des (mutmaslichen) Patientenwillens entscheiden muss. Dies fuhrt regelmasig zu Unsicherheit und Konflikten und belastet alle Beteiligten erheblich. Verschiedene internationale und deutsche Modellprojekte haben gezeigt, dass regionale Initiativen zum Advance Care Planning in Verbindung mit arztlich (mit)verantworteten Notfallbogen tief greifende Strukturveranderungen bewirken konnen, durch die Patientenverfugungen im Rettungsdienst regelmasig grose Relevanz erhalten. Grundlegend sind eine professionelle Gesprachsbegleitung zur Entwicklung der personlichen PV und ein regionales System zur Beachtung solcherart entstandener PV. Dieses System muss alle an der Betreuung chronisch kranker, multimorbider und in ihrer Mobilitat eingeschrankter Menschen beteiligten Berufsgruppen und Versorgungsebenen einbeziehen. Darauf aufbauend konnen Rettungsdienstmitarbeiter dem einer PV zugrunde liegenden Gesprachs- und Entscheidungsprozess vertrauen. Damit konnen sie guten Gewissens den prazisen Festlegungen eines regional eingefuhrten Notfallbogens wie der „Hausarztlichen Anordnung fur den Notfall“ (HAnNo) folgen.

Guidelines on hypertension management recommend adjusting therapeutic efforts in accordance with global cardiovascular risk (CVR) rather than by blood pressure levels alone. However, this paradigm change has not yet arrived in German General Practice. We have evaluated the effect of an educational outreach visit with general practitioners (GPs), encouraging them to consider CVR in treatment decisions for patients with hypertension. Prospective cluster-randomised trial comprising 3443 patients with known hypertension treated by 87 GPs. Practices were randomly assigned to complex (A) or simple (B) intervention. Both groups received a guideline by mail; group A also received complex peer intervention promoting the concept of global CVR. Clinical data were collected at baseline and 6-9 months after intervention. Main outcome was improvement of calculated CVR in the predefined subpopulation of patients with a high CVR (10-year mortality ≥5%), but no manifest cardiovascular disease. Adjusted for baseline the follow-up CVR were 13.1% (95% CI 12.6%-13.6%) (A) and 12.6% (95% CI 12.2%-13.1%) (B) with a group difference (A vs. B) of 0.5% (-0.2%-1.1%), p = 0.179. The group difference was -0.05% in patients of GPs familiar with global CVR and 1.1% in patients of GPs not familiar with with global CVR. However, this effect modification was not significant (p = 0.165). Pooled over groups, the absolute CVR reduction from baseline was 1.0%, p

Objectives To determine if patient-centred communication leads to a reduction of the number of medications taken without reducing health-related quality of life. Design Two-arm cluster-randomised controlled trial. Setting 55 primary care practices in Hamburg, Düsseldorf and Rostock, Germany. Participants 604 patients 65 to 84 years of age with at least three chronic conditions. Interventions Within the 12-month intervention, general practitioners (GPs) had three 30 min talks with each of their patients in addition to routine consultations. The first talk aimed at identifying treatment targets and priorities of the patient. During the second talk, the medication taken by the patient was discussed based on a ‘brown bag’ review of all the medications the patient had at home. The third talk served to discuss goal attainment and future treatment targets. GPs in the control group performed care as usual. Primary outcome measures We assumed that the number of medications taken by the patient would be reduced by 1.5 substances in the intervention group and that the change in the intervention group’s health-related quality of life would not be statistically significantly inferior to the control group. Results The patients took a mean of 7.0±3.5 medications at baseline and 6.8±3.5 medications at follow-up. There was no difference between treatment and control group in the change of the number of medications taken (0.43; 95% CI −0.07 to 0.93; P=0.094) and no difference in health-related quality of life (0.03; −0.02 to 0.08; P=0.207). The likelihood of receiving a new prescription for analgesics was twice as high in the intervention group compared with the control group (risk ratio, 2.043; P=0.019), but the days spent in hospital were reduced by the intervention (−3.07; −5.25 to −0.89; P=0.006). Conclusions Intensifying the doctor–patient dialogue and discussing the patient’s agenda and personal needs did not lead to a reduction of medication intake and did not alter health-related quality of life. Trial registration number NCT46272088; Pre-results.

Background From 2010 onward, a new leaflet about mammography screening for breast cancer, more informative than the preceding version, has been sent to women in Germany aged 50 to 69 with the invitation to undergo screening. The purpose of this study was to determine the effect of different informational content on the decision whether or not to be screened.

Background This study investigates the efficacy of a complex multifaceted intervention aiming at increasing the quality of care of GPs for patients with multimorbidity. In its core, the intervention aims at enhancing the doctor-patient-dialogue and identifying the patient’s agenda and needs. Also, a medication check is embedded. Our primary hypothesis is that a more patient-centred communication will reduce the number of active pharmaceuticals taken without impairing the patients’ quality of life. Secondary hypotheses include a better knowledge of GPs about their patients’ medication, a higher patient satisfaction and a more effective and/or efficient health care utilization. Methods/design Multi-center, parallel group, cluster randomized controlled clinical trial in GP surgeries. Inclusion criteria: Patients aged 65–84 years with at least 3 chronic conditions. Intervention: GPs allocated to this group will receive a multifaceted educational intervention on performing a narrative doctor-patient dialogue reflecting treatment targets and priorities of the patient and on performing a narrative patient-centred medication review. During the one year intervention GPs will have a total of three conversations à 30 minutes with the enrolled patients. Control: Care as usual. Follow-up per patient: 14 months after baseline interview. Primary efficacy endpoints: Differences in medication intake and health related quality of life between baseline and follow-up in the intervention compared to the control group. Randomization: Computer-generated by an independent institute. It will be performed successively when patient recruitment in the respective surgery is finished. Blinding: Participants (GPs and patients) will not be blinded to their assignment but will be unaware of the study hypotheses or outcome measures. Discussion There is growing evidence that the phenomenon of polypharmacy and low quality of drug use is substantially due to mis-communication (or non-communication) in the doctor patient interaction. We assume that the number of pharmaceutical agents taken can be reduced by a communicational intervention and that this will not impair the patients’ health-related quality of life. Improving communication is a core issue of future interventions, especially for patients with multimorbidity. Trial registration Current Controlled Trials ISRCTN46272088.

Background: For preventive interventions in general practice to succeed, patients' points of view must be taken into account in addition to those of GPs. Objective: To explore patients' views and beliefs about the importance of lifestyle and preventive interventions, to assess their readiness to make changes to their lifestyle and their willingness to receive support from GPs. Methods: Cross-sectional survey conducted by EUROPREV in primary care practices in 22 European countries. Patients were consecutively selected and interviewed from September 2008 to September 2009. Results: Seven thousand nine hundred and forty-seven participants, 52.2% females. Only 30.5% of risky drinkers think they need to change, as opposed to 64% of smokers, 73.5% of patients with unhealthy eating habits and 73% with lack of physical activity. Risky drinkers reported that GPs initiated a discussion on alcohol consumption less often (42%) than on smoking (63%), eating habits (59%) or physical activity (55%). Seventy-five per cent, 66% and 63% of patients without hypertension, diabetes or hypercholesterolaemia, respectively, think blood pressure, blood sugar and serum cholesterol should be checked yearly. Women (80%) think they should be screened with the cervical smear test and 72.8% of women aged 30-49 years with mammography, yearly or every 2 years. Conclusions: A high proportion of patients attending primary care with unhealthy lifestyles (especially risky drinkers) do not perceive the need to change their habits, and about half the patients reported not having had any discussion on healthy lifestyles with their GPs. Patients overestimate their need to be screened for cardiovascular risk factors and for cancer., peer-reviewed

BackgroundRecent guidelines for the management of hypertension focus on treating patients according to their global cardiovascular risk (CVR), rather than strictly keeping blood pressure, or other risk factors, below set limit values. The objective of this study is to compare the effect of a simple versus a complex educational intervention implementing this new concept among General Practitioners (GPs).Methods/designA prospective longitudinal cluster-randomised intervention trial with 94 German GPs consecutively enroling 40 patients each with known hypertension. All GPs then received a written manual specifically developed to transfer the global concept of CVR into daily General Practice. After cluster-randomisation, half of the GPs additionally received a clinical outreach visit, with a trained peer discussing with them the concept of global CVR referring to example study patients from the respective GP. Main outcome measure is the improvement of calculated CVR six months after intervention in the subgroup of patients with high CVR (but no history of cardiovascular disease), defined as 10-year-mortality ≥ 5% employing the European SCORE formula. Secondary outcome measures include the intervention's effect on single risk factors, and on prescription rates of drugs targeting CVR. All outcome measures are separately studied in the three subgroups of patients with 1. high CVR (defined as above), 2. low CVR (SCORE < 5%), and 3. a history of cardiovascular disease. The influence of age, sex, social status, and the perceived quality of the respective doctor-patient-relation on the effects will be examined.DiscussionTo our knowledge, no other published intervention study has yet evaluated the impact of educating GPs with the goal to treat patients with hypertension according to their global cardiovascular risk.Trial registrationISRCTN44478543

Background Treatment decisions in emergencies when the patient is (acutely) incapable pose a challenge for nursing and emergency staff, especially if the attending physician and/or the designated proxy are not available. In Germany, advance directives usually provide insufficient guidance for these situations. Methods In a controlled regional intervention study to implement advance care planning (ACP) in one town9s nursing homes and the related caregivers9 network, we introduced a new form, the POLST-E. It differs from many POLST forms common in the US in two major respects: (1) it is only available as an integral part of a comprehensive advance directive resulting from a facilitated ACP process; (2) its scope is restricted to specific options for emergency treatment. Results We presented a descriptive analysis of all POLST-Es completed in the intervention region during the study period, and compare it with any ACP for emergencies found in the control region (data analysis will be completed by May). Discussion The POLST-E bridges the gap between individual planning and honouring the resulting plans in emergency situations by professionals. It therefore is a crucial tool for effective ACP. Further, it changes the facilitation process fundamentally in that patients or proxies are now offered choices with regard to medical emergencies arising from current (not only future hypothetical) health statuses – a choice missing in the traditional development of advance directives in Germany.