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Objectives The aims of our study were to describe the effect of the COVID-19 pandemic and lockdown on primary care in Germany regarding the number of consultations, the prevalence of specific reasons for consultation presented by the patients, and the frequency of specific services performed by the GP. Methods We conducted a longitudinal observational study based on standardised GP interviews in a quota sampling design comparing the time before the COVID-19 pandemic (12 June 2015 to 27 April 2017) with the time during lockdown (21 April to 14 July 2020). The sample included GPs in urban and rural areas 120 km around Hamburg, Germany, and was stratified by region type and administrative districts. Differences in the consultation numbers were analysed by multivariate linear regressions in mixed models adjusted for random effects on the levels of the administrative districts and GP practices. Results One hundred ten GPs participated in the follow-up, corresponding to 52.1% of the baseline. Primary care practices in 32 of the 37 selected administrative districts (86.5%) could be represented in both assessments. At baseline, GPs reported 199.6 ± 96.9 consultations per week, which was significantly reduced during COVID-19 lockdown by 49.0% to 101.8 ± 67.6 consultations per week (p p Conclusions We observed a dramatic reduction of the number of consultations in primary care. This effect was independent of age, sex and specialty of the GP and independent of the practice location in urban or rural areas. Consultations for complaints like low back pain, gastrointestinal complaints, vertigo or fatigue and services like house calls/calls at nursing homes, wound treatments, pain therapy or screening examinations for the early detection of chronic diseases were particularly affected.

Background In most countries, the general practitioner (GP) is the first point of contact in the healthcare system and coordinator of healthcare. However, in Germany it is possible to consult an outpatient specialist even without referral. Coordination by a GP might thus reduce health expenditures and inequalities in the healthcare system. The study describes the patients’ willingness/commitment to use the GP as coordinator of healthcare and identifies regional and patient-related factors associated with the aforementioned commitment to the GP. Methods Cross-sectional observational study using a standardised telephone patient survey in northern Germany. All counties and independent cities within a radius of 120 km around Hamburg were divided into three regional categories (urban areas, environs, rural areas) and stratified proportionally to the population size. Patients who had consulted the GP within the previous three months, and had been patients of the practice for at least three years were randomly selected from medical records of primary care practices in these districts and recruited for the study. Multivariate linear regression models adjusted for random effects at the level of federal states, administrative districts and practices were used as statistical analysis methods. Results Eight hundred eleven patients (25.1%) from 186 practices and 34 administrative districts were interviewed. The patient commitment to a GP attained an average of 20 out of 24 possible points. Significant differences were found by sex (male vs. female: + 1.14 points, p p = 0.043), education (high vs. low: − 1.74, p p = 0.004), regional category (urban areas: − 0.85, p = 0.022; environs: − 0.80, p = 0.045) and healthcare utilisation (each GP contact: + 0.30, p p = 0.018). Professional situation and age were not significantly associated with the GP commitment. Conclusion On average, the patients’ commitment to their GP was relatively strong, but there were large differences between patient groups. An increase in the patient commitment to the GP could be achieved through better patient information and targeted interventions, e.g. to women or patients from regions of higher urban density. Trial registration The study was registered in ClinicalTrials.gov (NCT02558322).

In den Notaufnahmen wachst die Arbeitsbelastung durch Patienten ohne medizinischen Notfall. Unterstutzungsangebote aus dem ambulanten Sektor haben sich noch nicht ausreichend etabliert. Um festzustellen, inwieweit es sich bei Patienten in Notaufnahmen um echte medizinische Notfalle handelt, sollen Patienten mit mindestens 2 und solche mit maximal 1 chronischen Erkrankung verglichen werden. Zudem sollen Einflussfaktoren auf die vorherige Inanspruchnahme ambulanter Strukturen identifiziert werden. Die Studienklientel stammt aus der Querschnittsstudie „PiNo-Nord“. In 5 Notaufnahmen wurden zwischen 10/2015 und 07/2016 alle „nicht sofort“ oder „nicht sehr dringend“ Behandlungsbedurftigen interviewt. Die Datenanalyse erfolgte explorativ und mithilfe multivariater logistischer Regression. Die 293 Patienten mit ≥2 chronischen Erkrankungen stellten verglichen mit den 847 Patienten mit max. 1 chronischen Erkrankung etwa genauso haufig einen medizinischen Notfall dar. Konsultationsanlasse (und Entlassungsdiagnosen) waren v. a. Traumata am Bewegungsapparat (33 %, n = 293 vs. 42 %, n = 847) oder der Haut (11 %, n = 293 vs. 13 %, n = 847). In beiden Gruppen spielten die haus- oder facharztliche Versorgung sowie diagnostische oder Behandlungsmoglichkeiten fur das Aufsuchen der Notaufnahme selten eine Rolle. Starkste Pradiktoren fur eine vorherige ambulante Behandlung waren langere Beschwerdedauer, subjektiv hohe Behandlungsdringlichkeit, mindestens zwei chronische Erkrankungen und eine den Bewegungsapparat betreffende Konsultation. In beiden Patientengruppen wurde kein Anhaltspunkt fur unnotiges Aufsuchen der Notaufnahme gefunden. Zum grosten Teil werden vorab ambulante Strukturen genutzt und die Notaufnahme nur bei tatsachlichem medizinischen Notfall aufgesucht.

Background Among other factors, the patients’ consultation reasons and GPs’ spectrum of services determine the process and outcome of the medical treatment. So far, however, there has been little information on differences in reasons for consultation and GPs’ services between urban and rural areas. Our study’s goal was thus to investigate these factors in relation to the regional location of GPs’ practices. Methods We conducted a cross-sectional observational study based on standardised GP interviews in a quota sampling design. All counties and independent cities within a radius of 120 km around Hamburg were divided into three regional categories (urban area, environs, rural area) and stratified proportionally to the population size. Differences in the number of reasons for consultation and services were analysed by multivariate linear regressions in mixed models adjusted for random effects on the levels of the German federal states and administrative districts. Differences in individual consultation reasons and services were identified by logistic regression via stepwise forward and backward selection. Results Primary care practices in 34 of the 37 selected administrative districts (91.9%) were represented in the dataset. In total, 211 GPs were personally interviewed. On average, GPs saw 344 patients per month with a slightly higher number of patients in rural areas. They reported 59.1 ± 15.4 different reasons for consultation and 30.3 ± 3.9 different services. There was no statistically significant regional variation in the number of different consultation reasons, but there was a broader service spectrum by rural GPs (ß = − 1.42; 95% confidence interval − 2.75/− 0.08; p = 0.038) which was statistically explained by a higher level of medical training. Additionally, there were differences in the frequency of individual consultation reasons and services between rural and urban areas. Conclusion GPs in rural areas performed more frequently services usually provided by medical specialists in urban areas. This might be caused by a low availability of specialists in rural areas. The association between medical training and service spectrum might imply that GPs compensate the specific needs of their patients by completing advanced medical training before or after setting up a medical practice. Trial registration The study was registered in ClinicalTrials.gov (NCT02558322).

International audience; En 2013, une mission archéologique conduite par les co-auteurs, confiée au Laboratoire d’Archéologie Médiévale et Moderne en Méditerranée (LA3M UMR 7298 Université d’Aix-Marseille/CNRS) et à l’Inrap (Institut national de recherches archéologiques préventives), eut pour objet la réalisation d’une première campagne d’étude du mobilier lapidaire ex situ de l’abbaye cistercienne de Silvacane dans la basse vallée de la Durance. Le classement des éléments architecturaux en tout genre, mal identifiés, très partiellement inventoriés et inégalement préservés, déposés à l’intérieur comme à l’extérieur du monument, a permis de rassembler, d’identifier et de resituer dans leur contexte architectural des fragments appartenant à un tombeau monumental gothique de la famille des Baux, bienfaiteurs de l’abbaye à l’époque de sa fondation. Or, la conception, l’ordonnance, le style, la modénature et le décor sculpté du prestigieux monument funéraire étaient étroitement apparentés à ceux du tombeau d’Alphonse II, comte de Provence, à l’église Saint-Jean-de-Malte d’Aix, commandé par Charles Ier d’Anjou dans les années 1270, détruit à la Révolution mais connu par une gravure publiée au début du XIXe siècle par Aubin-Louis Millin d’après un dessin de la fin du XVIIIe siècle. L’analogie étroite qui lie les deux monuments, et qui pourrait relever de l’intervention d’une même équipe de sculpteurs qu’il est toutefois impossible de prouver, pose la question du commanditaire du monument, posthume sans doute à l’instar du tombeau aixois, et de sa relation avec la famille comtale. En outre, un examen minutieux des murs de la nef de l’église a mis en évidence des traits d’épure gravés dans le parement, dont le tracé s’accorde à la géométrie du remplage du baldaquin couronnant le gisant, ainsi que du remplage des baies du réfectoire de l’abbaye, dont l’architecture appartient à la même époque précoce du gothique méridional que l’église des Hospitaliers d’Aix : un indice des pratiques de chantier de l’équipe qui pose la question de l’emplacement du tombeau à l’intérieur de l’église abbatiale et qui associe la réalisation du monument à l’achèvement du réfectoire. Ces éléments entrent manifestement dans une stratégie dynastique de la famille de Baux nouvellement liée aux comtes angevins.; Nel 2013, una missione archeologica guidata dagli autori di questo contributo, membri del Laboratorio di archeologia medievale e moderna nel Mediterraneo (LA3M UMR 7298 Università di Aix-Marsiglia / CNRS), mirava a realizzare una prima campagna di studio di vari frammenti lapidari ex situ dell'abbazia cistercense di Silvacane nella bassa valle della Durance. La classificazione di elementi architettonici di ogni tipo, scarsamente identificati, in parte inventariati e conservati in modo diseguale, depositati all'interno e all'esterno del monumento, ha permesso di raccogliere, identificare e collocare nel loro contesto architettonico frammenti appartenenti a una monumentale tomba gotica della famiglia Des Baux (dei Balci), benefattori dell'abbazia al momento della sua fondazione nel XII secolo. Tuttavia, la manifattura, lo stile, la modenatura e la decorazione scolpita del prestigioso monumento funebre si è rivelata essere strettamente correlata a quella della tomba di Alfonso II, conte di Provenza, situata nella chiesa di Saint-Jean-de-Malte d'Aix, commissionata da Carlo I d'Angiò nel 1270, e distrutta durante la Rivoluzione francese ma conosciuta da un'incisione pubblicata all'inizio dell'Ottocento da Aubin-Louis Millin grazie ad un disegno della fine del Settecento. La stretta analogia che collega i due monumenti da cui si potrebbe dedurre che ci sia stato un intervento dello stesso laboratorio di scultori, è tuttavia impossibile da provare, e pone la domanda del committente del monumento, senza dubbio postumo come quello di Aix, e il suo rapporto con la famiglia contale. Lo stesso vale per l'influenza della dinastia angioina sulla diffusione dello stilo gotico in Provenza, tra cui si ricordano la chiesa dei Cavalieri Ospitalieri di Aix, la cappella dei Templari di Avignone e il refettorio di Silvacane, probabilmente contemporanei alla tomba. Oltre al rilevamento dettagliato dei frammenti della tomba in previsione della loro restituzione, un attento esame delle pareti della navata della chiesa ha rivelato un tracciato di linee geometriche la cui disposizione concorda con la geometria del baldacchino della tomba e delle finestre del refettorio, forse lavorati insieme per la stessa officina: un indizio delle pratiche di cantiere che pone, tra l'altro, la questione della posizione, ad ora sconosciuta, della tomba all'interno della chiesa dell'abbazia.

Background Inadequate recruitment numbers for GPs in rural regions give cause for concern. Working in rural regions is less attractive among medical students because of strong associations concerning a higher workload, restriction of privacy and demands exceeding their competences. We aimed to explore perceptions of GPs working in urban versus rural regions to contrast these prejudices. Methods We conducted nine focus groups with GPs [female = 21, male = 44] from urban and rural regions, using a semi-structured guideline. Transcripts were content analyzed using deductive and inductive categories. Results Urban GPs perceived themselves as a provider of medical services and rural GPs as being a medical companion. Compared to urban GPs, GPs from non-urban regions portray themselves more strongly as a family physician that accompanies patients ‘from the cradle to the grave’ and is responsible for the treatment of any medical issue. They emphasized their close relationship with their patients. Rural GPs establish a close relationship with their patients and considered this as beneficial for the treatment relationship. This aspect seems to play a subordinate role for urban GPs. Conclusions GPs enjoy their work and the role they play in their patients’ lives. Being a rural GP was described very positively. Greater emphasis should be made on positive aspects of being a GP in rural regions, e.g. by university lectures given by rural GPs, campaigns emphasizing the positive aspects of working as a GP [in rural regions], promotion of work placements or incentives for working in rural general practices.

Background Patients from rural and urban regions should have equitable access to health care. In Germany, the physician-patient-ratio and the supply of medical services vary greatly between urban and rural areas. The aim of our study was to explore the regional variations of the perceived health care problems in ambulatory care from the perspective of affected professionals and laypersons i.e. general practitioners and their patients. Methods We conducted 27 focus groups with general practitioners ( n = 65) and patients ( n = 145) from urban areas, environs and rural areas in northern Germany. Discussions were facilitated by two researchers using a semi-structured guideline. The transcripts were content analyzed using deductive and inductive categories. Results General practitioners and patients reported problems due to demographic change and patient behaviour, through structural inequalities and the ambulatory reimbursement system as well as with specialist care and inpatient care. A high physician density, associated with high competition between general practitioners, a high fluctuation of patients and a low status of general practitioners were the main problems reported in urban areas. In contrast, participants from rural areas reported an insufficient physician density, a lack of young recruits in primary care and a resulting increased workload as problematic. All regions are concerned with subjectively inadequate general practitioners’ budgets, insufficiently compensated consultations and problems in the cooperation with specialists and inpatient care institutions. Most problems were mentioned by GPs and patients alike, but some (e.g. high competition rates in urban regions and problems with inpatient care) were only mentioned by GPs. Conclusions While many problems arise in urban regions as well as in rural regions, our results support the notion that there is an urgent need for action in rural areas. Possible measures include the support of telemedicine, delegation of medical services and reoccupation of vacant practices. The attractiveness of working in rural areas for general practitioners, specialists and clinicians must be increased by consolidating and expanding rural infrastructure (e.g. child care and cultural life). The above mentioned results also indicate that the ambulatory reimbursement system should be examined regarding the reported inequalities. Measures to further enhance the cooperation between general practitioners, specialists and inpatient care should be taken to solve supra-regionally reported problems. Problems showing regional variations indicate the need for measures to balance these variations between the regions. This is the first German study to analyze subjective views of the stakeholders concerned on regionally variating problems in ambulatory care. Further studies are needed to quantify the extent of the identified problems and differences. A corresponding survey is currently under way.

Background Among other factors, the patients’ consultation reasons and the GPs’ spectrum of services determine process and outcome of the medical treatment. So far, however, there has been little information on differences in reasons for consultations and performed services between urban and rural areas. Thus, the goal of the study was to investigate these factors in relation to the regional location of the GP practices.Methods We conducted a cross-sectional observational study based on standardised GP interviews in a quota sampling design. All counties and independent cities within a radius of 120km around Hamburg were divided in three regional categories (urban, rural, environs) and stratified proportionally to the population size. Differences in the number of reasons for consultation and services were analysed by multivariate linear regressions in mixed models adjusted for random effects on the levels of the German federal states and administrative districts. Differences in individual consultation reasons and services were identified by logistic regression models via stepwise forward and backward selection.Results Primary care practices in 34 of the 37 selected administrative districts (91.9%) were represented in the dataset. In total, 211 GPs were personally interviewed. On average, GPs saw 1,032 patients per quarter (3-month period) with a slightly higher number of patients in rural areas. They reported 59.1 ± 15.4 different reasons for consultations and 30.3 + 3.9 different services. There was no statistically significant regional variation in the number of different consultation reasons, but there was broader service spectrum by rural GPs (ß=-1.42; 95% confidence interval -2.75/-0.08; p=0.038), which was statistically explained by a higher level of postgraduate training. Additionally, there were differences in the frequency of individual consultation reasons and services between rural and urban areas.Conclusions GPs in rural areas spent less time on communicative, preventive, and consultant medicine than GPs in urban areas. In contrast, GPs in rural areas more often performed services that are usually provided by ambulatory specialist care in urban areas. Depending on the analysed item, primary care in the environs was either similar to “urban areas” or to “rural areas”.

The number of patients in emergency rooms without a medical emergency is increasing. Outpatient services for mutual support and relief between the in-patient and out-patient sector are not yet fully established.The aim was to determine the extent to which patients in emergency rooms have real medical emergencies by comparing patients with at least two and those with a maximum of one chronic illness. An additional aim was to identify factors influencing the previous use of outpatient structures.The study participants included emergency room patients from the cross-sectional study "PiNo-Nord." All persons in five emergency rooms in northern Germany between October 2015 and July 2016 who were not treated as "immediate" or "very urgent" were interviewed. An exploratory data analysis and multivariate logistic regression were performed.The 293 patients with ≥2 chronic diseases were just as often a medical emergency compared to the 847 patients with a maximum of 1 chronic disease. The most frequent occasions for consultation were musculoskeletal trauma (33%, n = 293 vs. 42%, n = 847) or trauma of the skin (11%, n = 293 vs. 13%, n = 847). In both groups, the general practitioner or specialist caregiver, as well as diagnostic or treatment options, rarely played a role in visiting the emergency department. The strongest predictors of previous outpatient treatment were the duration of the appeal in the last six months, a high subjective treatment urgency, the presence of at least two chronic conditions, and a consultation event concerning the musculoskeletal injuries.In both patient groups, no evidence of unnecessary visits to the emergency room was found. For the most part, outpatient structures are used in advance and the emergency department is only visited in the event of an actual medical emergency.

ObjectivesThe aim of our study was to explore patient types in general practitioner (GP) practices and to quantify the regional differences of the frequencies of these patient types in northern Germany.Design and settingWe conducted a mixed-methods study based on focus groups and standardised interviews with GPs. All counties and independent cities within a radius of 120 km around Hamburg were assigned one of three regional categories (urban areas, environs, rural areas). The focus groups were analysed using qualitative content analysis. Relative frequencies of consultations by patient types and differences between the regions were calculated. Logistic regression analyses were used to identify differences among regions.ParticipantsNine focus groups with 65 GPs (67.7% male). From the 280 initially recruited GPs 211 (65.4% male) could be personally interviewed.ResultsFour themes with 27 patient types were derived from the focus groups: patients classified by morbidity, sociodemographic characteristics, special care needs and patient behaviour. Five patient characteristics were significantly more prevalent in urban areas than rural areas: patients with migration background and culturally different disease concepts (OR 1.23; 95% CI 1.06 to 1.42), privately insured patients (OR 1.17; 95% CI 1.05 to 1.31), educationally disadvantaged patients with low health literacy (OR 1.11; 95% CI 1.04 to 1.19), patients with psychiatric disorders (OR 1.07; 95% CI 1.02 to 1.12) and senior citizens living on their own without caregivers (OR 1.05; 95% CI 1.05 to 1.31). Three patient types were significantly less prevalent in urban areas: minors accompanied by their parents (OR 0.71; 95% CI 0.61 to 0.83), patients with poor therapy adherence (OR 0.87, 95% CI 0.80 to 0.95) and patients with dementia (OR 0.90; 95% CI 0.82 to 0.99).ConclusionsGPs could compensate the specific needs of their patients with medical training aligned with the requirements of their region. Urban GPs need skills treating patients with psychiatric, social and cultural problems, rural GPs regarding the care for children or noncompliant patients.Trial registration numberNCT02558322

International audience

Background The number of patients in emergency departments has risen steadily in recent years, with a particular increase in patients not requiring urgent treatment. The aim of this study is to characterize this group of patients with respect to their sociodemographic features, health status, and reasons for attending an emergency department. Methods PiNo Nord is a cross-sectional observational study representing two full working weeks in five different hospitals. Patients were questioned in personal interviews, and medical diagnoses were documented. The data were analyzed with multivariate logistic regressions in mixed multilevel models. Predictors for the subjectively perceived treatment urgency were identified by stepwise backward selection. Results The 1175 patients questioned had an average age of 41.8 years and 52.9% were male. 54.7% said the degree of their treatment urgency was low. 41.3% had visited the emergency department on their own initiative, 17.0% on the advice or referral of their primary care physician, and 8.0% on the advice or referral of a specialist. The strongest predictors for low subjective treatment urgency were musculoskeletal trauma (odds ratio [OR] 2.18), skin conditions (OR 2.15), and the momentary unavailability of a primary care physician (OR 1.70). Conclusion More than half of the patients do not think their condition requires urgent treatment and thus do not meet the definition of a medical emergency. Patients' reasons for visiting the emergency department are varied; aside from the treatment urgency of the health condition itself, the reason may lie in perceived structural circumstances and individual preferences.

Wir untersuchten bei alteren, multimorbiden Patienten den Gebrauch von verschreibungspflichtigen und nicht verschreibungspflichtigen Schmerzmitteln (OTC, „over the counter“) und damit verbundene Risiken. Insbesondere uber deren kombinierten Einsatz ist in Deutschland wenig bekannt. Der Schmerzmittelgebrauch wurde in den Baselinedaten (2008/2009) der MultiCare-Kohorte mit primararztlich versorgten alteren multimorbiden Patienten untersucht (Trial registration: ISRCTN89818205). Berucksichtigt wurden Opioide, andere Analgetika und Antipyretika sowie nichtsteroidale Antirheumatika. Gebrauch von OTC-Praparaten, Dosierungen, Doppelmedikation und Interaktionen wurden fur Acetylsalicylsaure, Diclofenac, (Dex)Ibuprofen, Naproxen und Paracetamol untersucht. Von 3189 multimorbiden 65- bis 85-jahrigen Patienten gaben 1170 Patienten an, innerhalb der letzten 3 Monate mindestens ein Schmerzmittel eingenommen zu haben (36,7 %). Mindestens ein OTC-Schmerzmittel nahmen 289 Patienten (24,7 % von 1170) ein. Doppelmedikation mit wirkstoffgleichen Praparaten erfolgte in 86 Fallen, von diesen regelmasig in 15 Fallen. In 2 Fallen wurde durch Doppelmedikation die maximale Tagesdosis an Diclofenac uberschritten. In 235 Fallen nahmen Patienten parallel einen potenziell klinisch relevanten interagierenden Wirkstoff ein. In 43 Fallen (18,3 %) Fallen war ein OTC-Schmerzmittel, meist Ibuprofen, beteiligt. Uber ein Drittel der alteren Patienten nahm regelmasig oder bei Bedarf Schmerzmittel ein. Trotz des relativ hohen Gebrauchs von OTC-Schmerzmitteln ist der Anteil an Doppelmedikationen, Uberdosierungen und Interaktionen durch OTC-Praparate gering.

Background: Multimorbidity in elderly patients is a major challenge for physicians, because of a high prevalence of and associations with many adverse outcomes. However, the mechanisms of progressing multimorbidity are not well-understood. The aim of our study was to determine if the progression of multimorbidity is influenced by health behaviour and social support and to analyse if the patients’ socio-economic status had an effect on these prognostic factors. Methods: The study was designed as prospective cohort study based on interviews of 158 GPs and 3189 patients randomly selected from GP records (response rate: 46.2%). Patients were aged 65–85 years at recruitment and observed in four waves of data collection (dropout rate: 41.5%). Statistical analyses of the ‘hot deck’ imputed data included multilevel mixed-effects linear regression allowing for random effects at the study centre and GP practice within study centre level. Results: Regarding cardiovascular and metabolic diseases, multimorbidity progressed more rapidly in patients who reported less physical activity ( ß = −0.28; 95% confidence interval = −0.35 to −0.20), had more tobacco-related pack years (0.15; 0.07–0.22) and consumed less alcohol (−0.21; −0.31 to −0.12) at baseline. Multimorbidity related to psychiatric and pain-related disorders progressed more rapidly if the patients had less perceived social support (−0.31; −0.55 to −0.07) and reported less physical activity (−0.08; −0.15 to −0.02) at baseline. Education and income only slightly modified the effects of these variables. Conclusion: Depending on the multimorbidity cluster, different strategies should be used for slowing down the progression of multimorbidity. Changing lifestyle and increasing social support are beneficial for the entire group of elderly multimorbid patients – regardless of their socio-economic status. Registration: ISRCTN89818205

Allgemein wird angenommen, dass chronische Krankheiten und insbesondere Multimorbiditat das Risiko fur Pflegebedurftigkeit erhohen. Dennoch ist bisher fur Deutschland nicht systematisch untersucht worden, welche chronischen Krankheiten wie mit Pflegebedurftigkeit zusammenhangen. Die Untersuchung erfolgte auf der Basis von Abrechnungsdaten der Gmunder ErsatzKasse 2006. Einschlusskriterien waren: Alter ≥ 65 Jahre, mindestens eine von 46 Diagnosen in mindestens 3 Quartalen sowie eine Pflegestufe (n = 8678). Eine Vergleichsgruppe wurde gebildet mit n = 114.962. Berechnet wurden: Pravalenzunterschiede, relative Risiken sowie – mittels nominaler Regression – Einflussfaktoren auf die Pflegebedurftigkeit. Nur wenige Krankheiten (Demenz, Harninkontinenz, Zustand nach Schlaganfall und Herzinsuffizienz) weisen hohe Pravalenzen bei den Pflegebedurftigen (> 20 %) und zugleich grose Pravalenzunterschiede im Vergleich zu den Nichtpflegebedurftigen auf. Diese Daten sind essenziell fur eine Optimierung der medizinischen Versorgung von pflegebedurftigen Menschen. Weiterhin erforschungsbedurftig ist, uber welche Mechanismen die wenigen pflegespezifischen Krankheiten Behinderung und Gebrechlichkeit und damit Pflegebedurftigkeit verursachen.

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.

Saint-Gilles-du-Gard. Die Abteikirche und die Klosteranlage. Neue archäologische Forschungen. Die seit 2009 im Rahmen zweier aufeinanderfolgender Projekte mit Unterstützung der Nationalagentur für Forschung (Agence nationale de la recherche), der Deutschen Forschungsgemeinschaft, des Regionalamtes für Denkmal-und Bodendenkmalpflege (Direction régionale des affaires culturelles Languedoc-Roussillon) und der Stadtverwaltung durchgeführten bau-und grabungsarchäologischen Forschungen zur ehemaligen Benediktinerabtei Saint-Gilles-du-Gard, einer der bedeutendsten Wallfahrtsorte auf der nach ihr benannten Via Egidiana, dem südlichsten Pilgerweg nach Santiago de Compostela, erneuern den Kenntnisstand zu der in ihrer Gesamtheit bisher kaum erforschten Klosteranlage. Durch eine umfangreiche, auf ein stein-und verformungsgerechtes Gesamtaufmaß gestützte Bauanalyse, archäologische Grabungen und begleitende archivalische Forschungen konnte die komplexe Chronologie von den Resten einer ersten, vorkarolingischen Bebauung unter dem späteren Kreuzganghof bis zu den Restaurierungen des 19. Jahrhunderts neu aufgeschlüsselt werden. Die Verknüpfung stratigraphischer Befunde mit Radiokarbondatierungen und einer numismatischen Studie der Münzdarstellungen der Fassade bestätigt die späte Zeitstellung der heutigen Abteikirche, die ab dem letzten Drittel oder Viertel des 12. Jahrhunderts anstelle des schriftlich und inschriftlich belegten Vorgängerbaus des frühen 12. Jahrhunderts, mit dem sie bisher verwechselt wurde, unter Einbeziehung der Nordgalerie des zu diesem Zeitpunkt bereits bestehenden romanischen Klosterbereichs neu errichtet wurde. Die laufenden Bauuntersuchungen zeichnen ein genaueres Bild vom Bauablauf des spätromanischen Großprojektes, das von Anbeginn an durch die Instabilität der Fundamente beeinträchtigt wurde und zu Beginn des 13. Jahrhunderts erstmalig zum Stillstand kam. Sie ermöglichen zudem eine Teilrekonstruktion der durch jahrhundertelange Vernachlässigung und Zerstörung stark verkommenen Klausurgebäude. Weitere Bauforschungen, Grabungen und Untersuchungen in den umliegenden Wohnbauten lassen schon jetzt neue Erkenntnisse erwarten, die zukünftig vorgestellt werden sollen. Teilweise unklar bleiben die Ergebnisse einer in 15 Zonen von insgesamt 1670 Quadratmeter durchgeführten Georadar-Prospektion der Gesamtanlage. Neben Mauerresten in den Eckbereichen der abgebrochenen Sockelmauern der Kreuzgangarkaden sowie im ehemaligen Ostflügel ergaben die Befunde in Krypta, Querhaus und Chor keine klaren Anhaltspunkte zu den mutmaßlichen Resten älterer Bebauung unter der heutigen Kirche (Agathe Crespin, Gérald Vacheyroux, Michel Dabas, Andreas Hartmann-Virnich). Die Erstellung eines 3D-Modells der Abteikirche von Saint-Gilles unter Einbeziehung der konstruktiven Unregelmäßigkeiten und steten Veränderungen im Bauverlauf war ein wichtiges Anliegen des Projekts. Die teils aufwendige Erfassung der exakten Form und Abmessungen der einzelnen Bauteile, die jegliche schematisierende Wiederholung verhindert, ist zugleich Vorbedingung für einen sinnvollen Einsatz im Rahmen der bauforscherischen Studien (Götz Echtenacher, Heike Hansen et Andreas Hartmann-Virnich)., Saint-Gilles-du-Gard. The abbatial church and monastic buildings. New archaeological research. Research conducted since 2009 has renewed our knowledge about the construction of the Benedictine abbey of Saint-Gilles-du-Gard. The two consecutive archaeological investigations of this major monument on the southernmost route to Santiago de Compostella, known as the via Egidiana, were subventioned by the Agence nationale de la recherche, the Deutsche Forschungsgemeinschaft, the Direction régionale des affaires culturelles Languedoc-Roussillon and the municipality. The first project included a stone by stone inventory and analysis, archaeological excavations, and archival research, which have revised the complex chronology, beginning with the pre-Carolingian vestiges within the Romanesque cloister and finishing with the nineteenth-century restorations. An impressive cluster of new stratigraphic, archeometric and numismatic indicators confirm the late dating of the present church, begun in the last third or quarter of the twelfth century, after the destruction of the early twelfth-century church with which it has often been confused. Also at that time, the northern third of the claustral space was already in place. The archaeological study, still underway, has clarified the construction process of the second Romanesque church, which was troubled from the beginning by the instability of the foundations and interrupted a first time in the early thirteenth century, and has reconstituted some of the Romanesque monastic buildings, which had been altered over the centuries. Further study of the building, future excavations, preventive conservation, and prospection into the surrounding habitat promises new discoveries, which will be presented in due course. A campaign of GPR (ground penetrating radar) soundings, applied to fifteen zones covering a total of 1670 m2, gave uneven results. Some of them were pertinent for localizing the probable remains of the coping walls at the angles of the cloister and the wall attributable to the former east wing, but others were inconclusive for the identification of the vestiges of earlier buildings under the actual abbatial church (Agathe Crespin, Gérald Vacheyroux, Michel Dabas and Andreas Hartmann-Virnich). The creation of a 3D model of the abbey church of Saint-Gilles confronted the difficulty of accounting for the irregularities and changes during the course of construction. As an accompaniment to the archaeological study, the model must account for the real form of each component of the edifice and avoid any schematic repetition (Götz Echtenacher, Heike Hansen and Andreas Hartmann-Virnich)., Conduites depuis 2009 dans le cadre de deux projets successifs grâce au soutien de l’Agence nationale de la recherche, de la Deutsche Forschungsgemeinschaft, de la Direction régionale des affaires culturelles Languedoc-Roussillon et de la municipalité, les recherches archéologiques sur l’ancienne abbaye bénédictine de Saint-Gilles-du-Gard, lieu de pèlerinage éponyme de la via Egidiana, la plus méridionale des grandes routes vers Saint-Jacques de Compostelle, renouvellent les connaissances sur ce monument majeur encore largement méconnu. La mise en oeuvre d’un vaste programme de relevé et d’analyses pierre-à-pierre, de fouilles archéologiques et de recherches archivistiques donne lieu à une révision de la chronologie complexe, depuis les traces des premières constructions d’époque précarolingienne sur l’emplacement du futur cloître roman aux restaurations du XIXe siècle. Un dense faisceau d’indices stratigraphiques, archéométriques et numismatiques inédits confirme la date tardive de l’abbatiale actuelle, commencée au dernier tiers ou quart du XIIe siècle en détruisant, avec le tiers nord de l’espace claustral roman déjà en place, l’église du début du XIIe siècle avec laquelle elle a souvent été confondue. L’étude archéologique en cours conduit à préciser le processus constructif du vaste chantier de cette seconde église romane , perturbé dès le départ par l’instabilité des fondations et interrompu une première fois dès le début du XIIIe siècle, et à restituer une partie des bâtiments monastiques romans, altérés par une déchéance pluriséculaire. D’ores et déjà, la poursuite de l’étude du bâti, des fouilles programmées et préventives, et des prospections dans l’habitat environnant augure de nouvelle découvertes dont les apports seront présentés ultérieurement. Une campagne de prospections par géoradar, répartie sur quinze zones d’une superficie totale de 1670 m2, a donné lieu à un résultat mitigé, pertinent pour le repérage de probables restes des murs-bahuts aux angles du cloître et de murs attribuables à l’ancienne aile orientale, mais non concluant pour l’identification des vestiges attendus d’édifices antérieurs sous l’abbatiale actuelle (Agathe Crespin, Gérald Vacheyroux, Michel Dabas et Andreas Hartmann-Virnich). La création d’un modèle 3D de l’abbatiale de Saint-Gilles se heurte aux irrégularités et changements au cours de la construction. La prise en compte de la forme réelle des composantes de l’édifice, qui interdit toute répétition schématique, est indispensable pour l’accompagnement de l’étude archéologique (Götz Echtenacher, Heike Hansen et Andreas Hartmann-Virnich)., Hartmann-Virnich Andreas, Hansen Heike. Saint-Gilles-du-Gard. L’église abbatiale et les bâtiments monastiques. Nouvelles recherches archéologiques. In: Bulletin Monumental, tome 171, n°4, année 2013. Saint-Gilles-du-Gard. Nouvelles recherches sur un monument majeur de l’art roman. pp. 293-338.

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.

Introduction Inappropriate supply and an increasing demand on the healthcare system have been of concern for health policy in Germany for at least 15 years. In the primary care setting, this especially relates to an undersupply of general practitioners (GPs) in the countryside. In addition, there seem to be other regional differences, for example, a difference in accessing primary and secondary care between rural and urban areas. Despite these findings, regional differences in health services have not been studied extensively in Germany. Therefore, this study aims to explore regional variations of patient populations and reasons for accessing primary medical care. Methods and analysis We will conduct a cross-sectional observational study based on standardised interviews with 240 GPs and ∼1200 patients. Data collection started on 10 June 2015 and will probably be completed by 31 October 2016. We will include all districts and cities within 100 km from Hamburg and assign them according to the type of regions: rural, urban and environs. All eligible GPs will be invited to participate. Each practice will recruit up to 15 patients, aged 18 years or older. Questionnaires are based on a preliminary qualitative study and were pretested. Data will be analysed with descriptive statistics and regression modelling strategies adjusted for confounders and the GP-induced cluster structure. Ethics and dissemination Our study was approved by the Ethics Committee of the Medical Association of Hamburg and is conducted in accordance with the Declaration of Helsinki. Study participants give written informed consent before data collection and data is pseudonymised. Survey data and person identifiers are stored separately in locked cabinets and have restricted availability. The results of our study will be presented at conferences and published in peer-reviewed journals. Trial registration number NCT02558322; Pre-results.

Background By definition, high utilizers receive a large proportion of medical services and produce relatively high costs. The authors report the results of a study on the utilization of ambulatory medical care by the elderly population in Germany in comparison to other OECD countries. Evidence points to an excessive utilization in Germany. It is important to document these utilization figures and compare them to those in other countries since the healtcare system in Germany stopped recording ambulatory healthcare utilization figures in 2008. Methods The study is based on the claims data of all insurants aged ≥ 65 of a statutory health insurance company in Germany (n = 123,224). Utilization was analyzed by the number of contacts with physicians in ambulatory medical care and by the number of different practices contacted over one year. Criteria for frequent attendance were ≥ 50 contacts with practices or contacts with ≥ 10 different practices or ≥ 3 practices of the same discipline per year. Descriptive statistical analysis and logistic regression were applied. Morbidity was analyzed by prevalence and relative risk for frequent attendance for 46 chronic diseases. Results Nineteen percent of the elderly were identified as high utilizers, corresponding to approximately 3.5 million elderly people in Germany. Two main types were identified. One type has many contacts with practices, belongs to the oldest age group, suffers from severe somatic diseases and multimorbidity, and/or is dependent on long-term care. The other type contacts large numbers of practices, consists of younger elderly who often suffer from psychiatric and/or psychosomatic complaints, and is less frequently multimorbid and/or nursing care dependent. Conclusion We found a very high rate of frequent attendance among the German elderly, which is unique among the OECD countries. Further research should clarify its reasons and if this degree of utilization is beneficial for elderly people.

Background Chronic conditions are the most common themes in doctor-patient communication, especially for older patients with multimorbidity and their GPs. Former quantitative studies identified a variety of socio-demographic and health-related factors which were associated with the (dis-)agreement between medical records and patient self-reported diseases. The aim of this qualitative study was to identify reasons for disagreement regarding illnesses between patients and their GPs. Methods We conducted three focus groups with GPs (n = 15) and three focus groups with multimorbid patients aged 65 to 85 (n = 21). The participants were recruited from the MultiCare Cohort Study. Focus groups were audiotaped and transcribed verbatim. The transcripts of the focus groups were analysed using the qualitative content analysis according to Mayring. Categories were determined deductively and inductively. Results The analysis revealed seven themes concerning reasons for disagreement regarding illnesses between patients and their GPs: problems with communication and cooperation between health care professionals, disease management by the GP and the patient, the documentation behaviour of the GP, communication challenges between GP and patient, differences in the understanding of a disease between GP and patient, the prioritization and rating of diseases by GP and patient and obliviousness, repression and avoidance by the patient. Conclusions For older patients with multimorbidity, our study demonstrated that there is a need to enhance the cooperation between GPs, specialists and outpatient care, a demand to improve doctor-patient communication and a need for interventions to increase patients’ knowledge of diseases. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0286-x) contains supplementary material, which is available to authorized users.

Background Not only single, but also multiple, chronic conditions are becoming the normal situation rather than the exception in the older generation. While many studies show a correlation between multimorbidity and various health outcomes, the long-term effect on care dependency remains unclear. The objective of this study is to follow up a cohort of older adults for 5 years to estimate the impact of multimorbidity on long-term care dependency. Methods This study is based on claims data from a German health insurance company. We included 115,203 people (mean age: 71.5 years, 41.4% females). To identify chronic diseases and multimorbidity, we used a defined list of 46 chronic conditions based on ICD-10 codes. Multimorbidity was defined as three or more chronic conditions from this list. The main outcome was “time until long-term care dependency”. The follow-up started on January 1st, 2005 and lasted for 5 years until December 31st, 2009. To evaluate differences between those with multimorbidity and those without, we calculated Kaplan–Meier curves and then modeled four distinct Cox proportional hazard regressions including multimorbidity, age and sex, the single chronic conditions, and disease clusters. Results Mean follow-up was 4.5 years. People with multimorbidity had a higher risk of becoming care dependent (HR: 1.85, CI 1.78–1.92). The conditions with the highest risks for long-term care dependency are Parkinson’s disease (HR: 6.40 vs. 2.68) and dementia (HR: 5.70 vs. 2.27). Patients with the multimorbidity pattern “Neuropsychiatric disorders” have a 79% higher risk of care dependency. Conclusions The results should form the basis for future health policy decisions on the treatment of patients with multiple chronic diseases and also show the need to introduce new ways of providing long-term care to this population. A health policy focus on chronic care management as well as the development of guidelines for multimorbidity is crucial to secure health services delivery for the older population.

Background Multimorbidity is a common phenomenon in primary care. Until now, no clinical guidelines for multimorbidity exist. For the development of these guidelines, it is necessary to know whether or not patients are aware of their diseases and to what extent they agree with their doctor. The objectives of this paper are to analyze the agreement of self-reported and general practitioner-reported chronic conditions among multimorbid patients in primary care, and to discover which patient characteristics are associated with positive agreement. Methods The MultiCare Cohort Study is a multicenter, prospective, observational cohort study of 3,189 multimorbid patients, ages 65 to 85. Data was collected in personal interviews with patients and GPs. The prevalence proportions for 32 diagnosis groups, kappa coefficients and proportions of specific agreement were calculated in order to examine the agreement of patient self-reported and general practitioner-reported chronic conditions. Logistic regression models were calculated to analyze which patient characteristics can be associated with positive agreement. Results We identified four chronic conditions with good agreement (e.g. diabetes mellitus κ = 0.80;PA = 0,87), seven with moderate agreement (e.g. cerebral ischemia/chronic stroke κ = 0.55;PA = 0.60), seventeen with fair agreement (e.g. cardiac insufficiency κ = 0.24;PA = 0.36) and four with poor agreement (e.g. gynecological problems κ = 0.05;PA = 0.10). Factors associated with positive agreement concerning different chronic diseases were sex, age, education, income, disease count, depression, EQ VAS score and nursing care dependency. For example: Women had higher odds ratios for positive agreement with their GP regarding osteoporosis (OR = 7.16). The odds ratios for positive agreement increase with increasing multimorbidity in almost all of the observed chronic conditions (OR = 1.22-2.41). Conclusions For multimorbidity research, the knowledge of diseases with high disagreement levels between the patients’ perceived illnesses and their physicians’ reports is important. The analysis shows that different patient characteristics have an impact on the agreement. Findings from this study should be included in the development of clinical guidelines for multimorbidity aiming to optimize health care. Further research is needed to identify more reasons for disagreement and their consequences in health care. Trial registration ISRCTN89818205

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.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.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.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.

Die ehemalige Abtei von Saint-Gilles-du-Gard und die in den archäologischen Grabungen erfassten Baubefunde. Die archäologische Bodenforschung zur ehemaligen Abtei von Saint-Gilles-du-Gard war unlängst auf wenige Bereiche beschränkt geblieben. Seit 2004 haben Sondierungen vor der Westfassade und im südlichen Seitenschiff der Unterkirche sowie eine Teilgrabung des ehemaligen Klosterhofs neue Erkenntnisse zur vorromanischen Bebauungsgeschichte erbracht. Die in den Fundamenten des Fassadensockels und der nördlichen Begrenzungswand des Raumes unter der Fassadentreppe erhaltenen Mauerreste sowie zwei Chorschrankenplatten in den mit dem romanischen Bauvorgang verbundenen Füllschichten belegen die Existenz von Vorgängerbauten. Das bei der Fundamentierung und Errichtung der romanischen Fassade bewahrte ältere Mauerwerk lässt erkennen, dass die heutige Abteikirche weit über die frühere Nordbegrenzung des Klosterbereichs hinaus auf den nach Süden anschließenden Kreuzgang übergriff. Im Areal des zukünftigen Kreuzganghofes befand sich ehemals ein auf einer frühmittelalterlichen Geländeanschüttung angelegter vorkarolingischer Bau, der jedoch bereits nicht mehr bestand, als im 10. Jh an derselben Stelle mehrere große Vorratsgruben ausgehoben wurden. Zwar deuten geringfügige Spuren auf eine Bebauung vor dem 12. Jahrhundert, doch stellt die Errichtung der Klausurgebäude und des Kreuzganges mit dessen gleichzeitig beginnender Nutzung als Friedhof einen tiefgreifenden Wendepunkt in der Bebauungs-und Nutzungsgeschichte dieses Bereichs dar. Reste qualitätvoller Bauplastik im Stil der Fassaden-und Chorskulptur sowie Baubefunde lassen vermuten, dass die mit der heutigen Abteikirche neu errichtete Nordgalerie des Kreuzgangs einen vergleichbaren Skulpturenschmuck besaß. Noch vor der französischen Revolution besiegelte die Zerstörung der bis zur Fundamentsohle ausgebrochenen Arkadenmauern sowie die offensichtliche Verwertung der zerkleinerten Säulen und zu rekonstruierenden Grabmonumenten als Rohmaterial für die Kalkbrennerei das Schicksal des Kreuzganges, der schon seit geraumer Zeit als Laienfriedhof genutzt wurde. Die Reste der seit der Säkularisation 1538 aufgegebenen und zweckentfremdeten Klausurgebäude wurden wenig später als Bien National verkauft., The façade of the abbey church of Saint-Gilles-du-Gard. Archaeological research on the assembling of stones in its construction. The article presents an up-dated résumé of the author’s doctoral thesis, written between 1999 and 2006. The detailed archaeological analysis, based on a stone-by-stone inventory of the façade and the results of archaeological soundings made in 2004, renew the approach to this famous monument by a close examination of details of construction that show the progressive adaptation of the building to accommodate a structural instability that appears from the beginning of the works. The integration of vestiges of an older building in the foundations of the central west-work led to the weakening of the southern half of the new construction, which was built in part on the former claustral area ; excavation of the cloister brought to light the instability of the terrain. The chronological study of the works, which were integrally linked to the phases of construction of the church itself, resolves a long-standing controversy concerning the real or supposed incoherencies in the façade which, apart from the central portion, appears intentional and homogeneous. The central portion and the related bays of the crypt were left unfinished because of constant movements in the masonry ; these were unsuccessfully treated with compensatory measures whose nature and effect on the building can be precisely gauged. The central portal was only finished, at the earliest, when the side aisles were vaulted, at which time the project of a protiro was abandoned. Its structural outlines, which were left in place, and the upper consoles, which were reintegrated in the final superstructure, give an idea of its form. The hierarchy of the decoration, emphasized by the distribution of the marble, was thus more accentuated in the original project. The archaeological arguments in favour of a late date for the monument show that the façade of Saint-Gilles, begun in the last third of the twelfth century or even in the first quarter of the thirteenth, is contemporary with buildings in Provence, Languedoc, and Italy in the same period, which contradicts its long assumed role of precursor., L’article présente un résumé actualisé de la thèse de doctorat de l’auteur, réalisée entre 1999 et 2006. L’analyse archéologique détaillée, fondée sur un relevé pierre-à-pierre exhaustif de la façade et les résultats de sondages archéologiques conduits en 2004, renouvelle l’approche de cette célèbre façade sculptée par un inventaire minutieux de particularités constructives trahissant l’adaptation progressive de l’ouvrage à une instabilité structurelle apparue dès le début du chantier. L’intégration des vestiges d’un édifice plus ancien dans les fondations de l’avant-corps central de son soubassement entraîna en effet un affaissement de la moitié sud du nouvel ouvrage, bâti à cheval sur l’ancienne aire claustrale dont la fouille archéologique du préau a mis en évidence l’instabilité structurelle du terrain. L’étude de la chronologie de la mise en oeuvre, indissociable des phases du chantier de l’église elle-même, met un terme à une longue controverse sur les incohérences réelles ou supposées de l’ordonnance du frontispice qui, à l’exception de la partie centrale, s’avère intentionnelle et homogène. Celle-ci, de même que les travées attenantes de la crypte, fut en effet laissée en attente en raison des mouvements incessants dans les maçonneries, contrés en vain par des mesures compensatoires dont la nature et l’effet peuvent être mesurés avec précision sur l’édifice. Ce ne fut au plus tôt que lorsque l’on procéda au voûtement des collatéraux de l’église que le portail central fut terminé, avec l’abandon définitif d’un projet de protiro dont les structures laissées en attente et les consoles sommitales réintégrés dans la superstructure définitive laissent deviner la forme. La hiérarchisation du décor, que souligne la distribution des marbres, était donc davantage accentuée encore dans le projet initial. Les arguments archéologiques en faveur de la date tardive du monument montrent que la façade de Saint-Gilles, commencée au cours du dernier tiers voire du dernier quart du XIIe et terminée seulement vers le premier quart du XIIIe siècle, est contemporaine des monuments provençaux, languedociens et italiens de cette époque, ce qui contredit le rôle de précurseur qui lui avait été longtemps attribué., Hansen Heike, Hartmann-Virnich Andreas. La façade de l’ancienne abbatiale de Saint-Gilles-du-Gard. Recherches d’archéologie du bâti sur la construction. In: Bulletin Monumental, tome 171, n°4, année 2013. Saint-Gilles-du-Gard. Nouvelles recherches sur un monument majeur de l’art roman. pp. 345-374.

Die ehemalige Abtei von Saint-Gilles-du-Gard und die in den archäologischen Grabungen erfassten Baubefunde. Die archäologische Bodenforschung zur ehemaligen Abtei von Saint-Gilles-du-Gard war unlängst auf wenige Bereiche beschränkt geblieben. Seit 2004 haben Sondierungen vor der Westfassade und im südlichen Seitenschiff der Unterkirche sowie eine Teilgrabung des ehemaligen Klosterhofs neue Erkenntnisse zur vorromanischen Bebauungsgeschichte erbracht. Die in den Fundamenten des Fassadensockels und der nördlichen Begrenzungswand des Raumes unter der Fassadentreppe erhaltenen Mauerreste sowie zwei Chorschrankenplatten in den mit dem romanischen Bauvorgang verbundenen Füllschichten belegen die Existenz von Vorgängerbauten. Das bei der Fundamentierung und Errichtung der romanischen Fassade bewahrte ältere Mauerwerk lässt erkennen, dass die heutige Abteikirche weit über die frühere Nordbegrenzung des Klosterbereichs hinaus auf den nach Süden anschließenden Kreuzgang übergriff. Im Areal des zukünftigen Kreuzganghofes befand sich ehemals ein auf einer frühmittelalterlichen Geländeanschüttung angelegter vorkarolingischer Bau, der jedoch bereits nicht mehr bestand, als im 10. Jh an derselben Stelle mehrere große Vorratsgruben ausgehoben wurden. Zwar deuten geringfügige Spuren auf eine Bebauung vor dem 12. Jahrhundert, doch stellt die Errichtung der Klausurgebäude und des Kreuzganges mit dessen gleichzeitig beginnender Nutzung als Friedhof einen tiefgreifenden Wendepunkt in der Bebauungs-und Nutzungsgeschichte dieses Bereichs dar. Reste qualitätvoller Bauplastik im Stil der Fassaden-und Chorskulptur sowie Baubefunde lassen vermuten, dass die mit der heutigen Abteikirche neu errichtete Nordgalerie des Kreuzgangs einen vergleichbaren Skulpturenschmuck besaß. Noch vor der französischen Revolution besiegelte die Zerstörung der bis zur Fundamentsohle ausgebrochenen Arkadenmauern sowie die offensichtliche Verwertung der zerkleinerten Säulen und zu rekonstruierenden Grabmonumenten als Rohmaterial für die Kalkbrennerei das Schicksal des Kreuzganges, der schon seit geraumer Zeit als Laienfriedhof genutzt wurde. Die Reste der seit der Säkularisation 1538 aufgegebenen und zweckentfremdeten Klausurgebäude wurden wenig später als Bien National verkauft., The earlier abbey church of Saint-Gilles-du-Gard. Architectural vestiges excavated beneath the floor. The exploration of the ground under the old abbey church of Saint-Gilles-du-Gard has been very limited until now. Since 2004 soundings made at the base of the façade and in the south side aisle of the church, and excavations of part of the old claustral area have contributed new elements to our knowledge of the construction before the Romanesque period. Under the base of the façade and continuing to the north, vestiges were found of walls that belong to two earlier buildings oriented east-west, as well as a deposit of two sculpted early medieval chancel plaques buried in the Romanesque rubble filling. The masonry left in place when the foundations of the façade were laid shows that the construction of the actual abbey church encroached on the former cloister, well past the limit respected by the earlier construction. In the area of the future courtyard, a pre-Carolingian building, installed on earlier rubble filling, had disappeared when, in the tenth century, large storage silos were dug on this location. While there is evidence of the destruction of earlier masonry buildings, the erection of the cloister galleries in the twelfth century and the installation of a cemetery mark a radical turning point. In the northern part of the area, fragments of an extensive sculpted decoration were found. They present the same stylistic characteristics as the sculpture of the west façade of the abbey church, suggesting that the north gallery of the cloister was built at the same time as the latter. Before the Revolution, the complete walling up of the coping walls, down to the foundations, and the transformation of the colonnettes and remains of the funeral monuments into quick lime sealed the fate of the cloister, which was hereafter used as a cemetery for the laity. The remains of the ancient monastic buildings, disaffected since the secularisation in 1538, were sold at the time as state property., L’exploration du sous-sol archéologique de l’ancienne abbaye de Saint-Gilles-du-Gard n’avait été que très limitée jusqu’à présent. Depuis 2004, des sondages réalisés au pied de la façade et dans le collatéral sud de l’église, ainsi que la fouille d’une partie de l’ancienne aire claustrale, ont apporté de nouveaux éléments à la connaissance du bâti antérieur à l’époque romane. Sous le socle de la façade et au nord de celle-ci, les vestiges de murs appartenant à deux édifices orientés est-ouest et le dépôt, dans les remblais du chantier roman, de deux plaques de chancel sculptées du haut Moyen Âge, attestent la présence d’édifices plus anciens. Des maçonneries laissées en place lors du creusement des fondations de la façade montrent que la construction de l’abbatiale actuelle empiéta largement sur l’ancien cloître, au-delà de la limite respectée par le bâti antérieur. À l’endroit du futur préau, un bâtiment précarolingien, installé sur d’anciens remblais, avait disparu lorsque, au Xe siècle, de grands silos de stockage furent creusés à cet emplacement. Si quelques traces suggèrent la destruction de structures maçonnées antérieures, la mise en oeuvre des galeries du cloître, au XIIe siècle, et l’installation d’un cimetière, marquèrent de toute évidence un tournant radical. Retrouvés au nord, les fragments d’un important décor sculpté présentant les mêmes caractères stylistiques que celui de la façade occidentale et du chevet de l’abbatiale, permettent de supposer que la galerie septentrionale du cloître, reconstruite avec l’église, avait reçu un décor comparable. Dès avant la Révolution, l’épierrement complet des murs-bahuts jusqu’aux fondations et la transformation des colonnettes et de vestiges de monuments funéraires en chaux, scella le destin du cloître, utilisé depuis longtemps comme cimetière laïc. Ce qui restait des anciens bâtiments monastiques, désaffectés depuis la sécularisation en 1538, fut ensuite vendu comme biens nationaux., Hartmann-Virnich Andreas, Buffat Loïc, Schneider Laurent, Legrand Alexandrine, Masbernat-Buffet Aurélie, Hansen Heike, Markiewicz Christian. L’ancienne abbaye de Saint-Gilles-du-Gard. Les vestiges architecturaux du sous-sol d’après les investigations archéologiques. In: Bulletin Monumental, tome 171, n°4, année 2013. Saint-Gilles-du-Gard. Nouvelles recherches sur un monument majeur de l’art roman. pp. 377-390.

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.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.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.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.

Background Multimorbidity is a phenomenon with high burden and high prevalence in the elderly. Our previous research has shown that multimorbidity can be divided into the multimorbidity patterns of 1) anxiety, depression, somatoform disorders (ADS) and pain, and 2) cardiovascular and metabolic disorders. However, it is not yet known, how these patterns are influenced by patient characteristics. The objective of this paper is to analyze the association of socio-demographic variables, and especially socio-economic status with multimorbidity in general and with each multimorbidity pattern. Methods The MultiCare Cohort Study is a multicentre, prospective, observational cohort study of 3.189 multimorbid patients aged 65+ randomly selected from 158 GP practices. Data were collected in GP interviews and comprehensive patient interviews. Missing values have been imputed by hot deck imputation based on Gower distance in morbidity and other variables. The association of patient characteristics with the number of chronic conditions is analysed by multilevel mixed-effects linear regression analyses. Results Multimorbidity in general is associated with age (+0.07 chronic conditions per year), gender (-0.27 conditions for female), education (-0.26 conditions for medium and -0.29 conditions for high level vs. low level) and income (-0.27 conditions per logarithmic unit). The pattern of cardiovascular and metabolic disorders shows comparable associations with a higher coefficient for gender (-1.29 conditions for female), while multimorbidity within the pattern of ADS and pain correlates with gender (+0.79 conditions for female), but not with age or socioeconomic status. Conclusions Our study confirms that the morbidity load of multimorbid patients is associated with age, gender and the socioeconomic status of the patients, but there were no effects of living arrangements and marital status. We could also show that the influence of patient characteristics is dependent on the multimorbidity pattern concerned, i.e. there seem to be at least two types of elderly multimorbid patients. First, there are patients with mainly cardiovascular and metabolic disorders, who are more often male, have an older age and a lower socio-economic status. Second, there are patients mainly with ADS and pain-related morbidity, who are more often female and equally distributed across age and socio-economic groups. Trial registration ISRCTN89818205

Objective: We investigated the degree of comparability of the prevalence of chronic diseases and disease combinations in the elderly in two databases comparable with regard to diseases included, sex and age of the patients (65e85 years), and cutoff score for case definition. Study Design and Setting: One study is based on chart-supported interviews with the primary care physicians within a cohort study of 3,189 multimorbid elderly patients. The second study analyzed claims data from ambulatory care delivered to the multimorbid members of one German Health Insurance (n 5 70,031). Multimorbidity was defined by the presence of three or more chronic conditions from an identical list of 46 diseases. Results: The difference of the median number of chronic conditions was 1 (mean 6.7 vs. 5.7). The prevalences of individual conditions were approximately one-third lower in the claims data, but the relative rank order corresponded well between the two databases. These relatively small prevalence differences cumulate when combinations of chronic conditions are investigated, for example, the prevalence differences between the two databases increased to nearly 100% for triadic combinations and nearly 170% for quartets. Conclusion: The study shows that conclusions regarding the prevalence of combinations of diseases should be drawn with caution

Background Growing interest in multimorbidity is observable in industrialized countries. For Germany, the increasing attention still goes still hand in hand with a small number of studies on multimorbidity. The authors report the first results of a cross-sectional study on a large sample of policy holders (n = 123,224) of a statutory health insurance company operating nationwide. This is the first comprehensive study addressing multimorbidity on the basis of German claims data. The main research question was to find out which chronic diseases and disease combinations are specific to multimorbidity in the elderly. Methods The study is based on the claims data of all insured policy holders aged 65 and older (n = 123,224). Adjustment for age and gender was performed for the German population in 2004. A person was defined as multimorbid if she/he had at least 3 diagnoses out of a list of 46 chronic conditions in three or more quarters within the one-year observation period. Prevalences and risk-ratios were calculated for the multimorbid and non-multimorbid samples in order to identify diagnoses more specific to multimorbidity and to detect excess prevalences of multimorbidity patterns. Results 62% of the sample was multimorbid. Women in general and patients receiving statutory nursing care due to disability are overrepresented in the multimorbid sample. Out of the possible 15,180 combinations of three chronic conditions, 15,024 (99%) were found in the database. Regardless of this wide variety of combinations, the most prevalent individual chronic conditions do also dominate the combinations: Triads of the six most prevalent individual chronic conditions (hypertension, lipid metabolism disorders, chronic low back pain, diabetes mellitus, osteoarthritis and chronic ischemic heart disease) span the disease spectrum of 42% of the multimorbid sample. Gender differences were minor. Observed-to-expected ratios were highest when purine/pyrimidine metabolism disorders/gout and osteoarthritis were part of the multimorbidity patterns. Conclusions The above list of dominating chronic conditions and their combinations could present a pragmatic start for the development of needed guidelines related to multimorbidity.

OBJECTIVE: Multimorbidity is a common problem in the elderly that is significantly associated with higher mortality, increased disability and functional decline. Information about interactions of chronic diseases can help to facilitate diagnosis, amend prevention and enhance the patients' quality of life. The aim of this study was to increase the knowledge of specific processes of multimorbidity in an unselected elderly population by identifying patterns of statistically significantly associated comorbidity. METHODS: Multimorbidity patterns were identified by exploratory tetrachoric factor analysis based on claims data of 63,104 males and 86,176 females in the age group 65+. Analyses were based on 46 diagnosis groups incorporating all ICD-10 diagnoses of chronic diseases with a prevalence ≥ 1%. Both genders were analyzed separately. Persons were assigned to multimorbidity patterns if they had at least three diagnosis groups with a factor loading of 0.25 on the corresponding pattern. RESULTS: Three multimorbidity patterns were found: 1) cardiovascular/metabolic disorders [prevalence female: 30%; male: 39%], 2) anxiety/depression/somatoform disorders and pain [34%; 22%], and 3) neuropsychiatric disorders [6%; 0.8%]. The sampling adequacy was meritorious (Kaiser-Meyer-Olkin measure: 0.85 and 0.84, respectively) and the factors explained a large part of the variance (cumulative percent: 78% and 75%, respectively). The patterns were largely age-dependent and overlapped in a sizeable part of the population. Altogether 50% of female and 48% of male persons were assigned to at least one of the three multimorbidity patterns. CONCLUSION: This study shows that statistically significant co-occurrence of chronic diseases can be subsumed in three prevalent multimorbidity patterns if accounting for the fact that different multimorbidity patterns share some diagnosis groups, influence each other and overlap in a large part of the population. In recognizing the full complexity of multimorbidity we might improve our ability to predict needs and achieve possible benefits for elderly patients who suffer from multimorbidity.

Background Multimorbidity is a highly frequent condition in older people, but well designed longitudinal studies on the impact of multimorbidity on patients and the health care system have been remarkably scarce in numbers until today. Little is known about the long term impact of multimorbidity on the patients' life expectancy, functional status and quality of life as well as health care utilization over time. As a consequence, there is little help for GPs in adjusting care for these patients, even though studies suggest that adhering to present clinical practice guidelines in the care of patients with multimorbidity may have adverse effects. Methods/Design The study is designed as a multicentre prospective, observational cohort study of 3.050 patients aged 65 to 85 at baseline with at least three different diagnoses out of a list of 29 illnesses and syndromes. The patients will be recruited in approx. 120 to 150 GP surgeries in 8 study centres distributed across Germany. Information about the patients' morbidity will be collected mainly in GP interviews and from chart reviews. Functional status, resources/risk factors, health care utilization and additional morbidity data will be assessed in patient interviews, in which a multitude of well established standardized questionnaires and tests will be performed. Discussion The main aim of the cohort study is to monitor the course of the illness process and to analyse for which reasons medical conditions are stable, deteriorating or only temporarily present. First, clusters of combinations of diseases/disorders (multimorbidity patterns) with a comparable impact (e.g. on quality of life and/or functional status) will be identified. Then the development of these clusters over time will be analysed, especially with regard to prognostic variables and the somatic, psychological and social consequences as well as the utilization of health care resources. The results will allow the development of an instrument for prediction of the deterioration of the illness process and point at possibilities of prevention. The practical consequences of the study results for primary care will be analysed in expert focus groups in order to develop strategies for the inclusion of the aspects of multimorbidity in primary care guidelines.

International audience; Dans un programme continu et croisé entre chantiers archéologiques, étude de bâti et suivi de la restauration de la cathédrale Saint-Étienne d’Auxerre, le Centre d’études médiévales, en concertation avec le Conseil scientifique de la cathédrale, poursuit ses recherches. Nous livrons comme l’an passé dans ce bulletin, les premiers résultats, en annonçant dès à présent le colloque international envisagé les 27-28 septembre 2007 à Auxerre, où sera présenté et discuté l’ensemble des travaux, des observations et des relevés des campagnes 2002-2006. Une publication complète de ces recherches est également prévue à cette occasion ainsi qu’une exposition.

The development of high-level fluoroquinolone resistance has rarely been observed in salmonellae and, in contrast to other Gram-negative bacteria mutations affecting topoisomerase IV, a known secondary target of quinolones in Escherichia coli has not been described except for one recent report. The present study used quinolone-susceptible field isolates representing epidemiologically relevant serovars and phage types Salmonella Hadar and Salmonella Typhimurium DT104 and DT204c to select fluoroquinolone-resistant mutants in vitro. Three selection steps were necessary to obtain high-level fluoroquinolone-resistant mutants (MICCip > or = 8 microg/ml). All first-step mutants examined had a single gyrA mutation (affecting either Ser83 or Asp87). Additional topoisomerase mutations affecting gyrA (Asp87), gyrB (Ser464), and parC (Gly78) were detected in second- and third-step mutants. Introducing into the respective mutants the corresponding plasmid-coded quinolone-susceptible allele of either gyrA, gyrB, or parC resulted in reduction of quinolone resistance, indicating a role for these mutations in quinolone resistance. In the presence of an inhibitor of RND-type efflux pumps, the susceptibilities to ciprofloxacin and chloramphenicol of second- and third-step mutants increased by two to four serial dilution steps, providing evidence that an efflux-mediated resistance mechanism contributes to the development of high-level fluoroquinolone resistance in salmonellae.

Background Adherence to current monomorbidity-focused, mono-disciplinary guidelines may result in undesirable effects for persons with several comorbidities, in adverse interactions between drugs and diseases, conflicting management strategies, and polypharmacy. As yet no satisfactory approaches exist to address multimorbidity (MM) in clinical guidelines since this patient group is too heterogeneous as to be met by guideline recommendations. Objectives to develop a set of case-based (N = 1) guidelines for common disease combinations identified through epidemiological research and expert (GP) consultations. Methods We followed a new 5-step, mixed methods approach comprising: (1) review of epidemiological data on MM patterns; (2) interdisciplinary focus groups developed case vignettes according to both internal evidence and the results of step 1; (3) development of case-based recommendations according to case vignettes (N of one guidelines); (4) informal consensus of recommendations; (5) formal consensus. Results Step one revealed three different approaches for the selection criteria of case vignettes: first, cases addressing MM disease patterns from epidemiological studies (MM clusters); second, cases addressing triads of the 6 most prevalent chronic conditions; third, cases according to a problem-oriented prioritisation of focus group participants. All in all 10 N-of-one guidelines according to 10 cases could be developed according to the new 5-step-process. Discussion We present a new approach in order to capture the complex and heterogeneous problems of MM through evidence-based and case-based recommendations. This set of N-of-one-guidelines may serve as a framework of evidence-based recommendations for MM patients as the base for the development of meta-tools for both guideline developers and clinicians.

Echtenacher Götz, Hansen Heike, Hartmann-Virnich Andreas. Saint-Gilles-du-Gard. La restitution 3D : un outil au service de la réflexion archéologique. In: Bulletin Monumental, tome 171, n°4, année 2013. Saint-Gilles-du-Gard. Nouvelles recherches sur un monument majeur de l’art roman. p. 341.