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Background Due to differences of residency training programs’ emphases – inpatient vs office-based – internal medicine and family medicine residents consistently reported differences in preparedness to care for common adult conditions. Study’s aim was to add knowledge about procedures that a) are performed by general internists working in primary care and b) should be learned during residency in general internists’ appraisal. Methods A cross-sectional postal survey was carried out by using a questionnaire that comprised 90 procedures relevant in primary care. Each procedure implied the two questions “Do you perform this procedure in your own practice?” and “How important do you think it is to learn this procedure during residency?” The final questionnaire was sent to 1002 general internists working in primary care in Germany in May 2015. Data analysis was performed using SPSS Version 24.0 (SPSS inc., IBM). Next to descriptive statistics subgroup analyses were performed using cross tabulation and Chi-square tests for evaluation of differences in the performance of most frequently performed procedures in urban or rural areas as well as by male or female physicians. Results Twenty-eight percent of sent questionnaires (276/1002) could be included in analysis. Mean age of participants was 52 years with 13 years of practice experience; 40% were female. Twenty-nine (32%) of 90 given procedures were performed by at least half of the participants, foremost technical diagnostics, punctures, procedures of the integument and resuscitation. After Bonferroni correction, five of those procedures were performed by more male than female physicians and two procedures by more physicians working in a rural practice than physicians practicing in an urban location. Moreover, 46 (51%) procedures were assessed as important to learn during residency by at least 50% of participants. Conclusions General internists working in German primary care perform a narrow scope of procedures offered by primary care physicians. In order to provide best ambulatory care for patients, residency training programs must ensure training in procedures that are necessary for providing high quality care. Therefore, a consensus aligned with patients’ and health-systems’ needs on procedures required for working as a general internist in primary care is necessary.

Zusammenfassung Hintergrund In der deutschen Approbationsordnung für Ärzte sind Inhalte aus den Bereichen der Naturheilverfahren und Komplementärmedizin im Querschnittsbereich 12 „Rehabilitation, physikalische Medizin, Naturheilverfahren“ (QB12) curricular verankert. Diese werden an der Universität Heidelberg als Pflicht- und Prüfungsfach in Form von Vorlesungen und Praktika in Kleingruppen unterrichtet. In der vorliegenden Studie wurde die Evaluation von Medizinstudierenden im Bereich der Komplementärmedizin ausgewertet mit dem Ziel, Haltung, Lernbedürfnisse und Interessen von Studierenden in diesem Bereich zu explorieren. Methoden Die Lehrveranstaltungen wurden von Beginn an im Rahmen der fakultätseigenen Lehrevaluation wissenschaftlich begleitet. Die Freitexte der Evaluationen zwischen dem Wintersemester 2011/2012 und dem Sommersemester 2013 wurden gesammelt und mittels qualitativer Inhaltsanalyse nach Mayring ausgewertet. Ergebnisse Die Freitexte wurden in 3 deduktive Hauptkategorien (Haltung, Lernbedürfnisse und Interessen) und in weitere Subkategorien unterteilt. Als zentrales Thema fällt die Polarisierung unter den Medizinstudierenden im Hinblick auf Komplementärmedizin auf, die von regem Widerstand bis zu großer Begeisterung reicht. Auffällig häufig waren Kommentare, die erkennen ließen, dass Studierende eine hohe Erwartungshaltung in dem Sinne zeigen, dass sie von einem komplementärmedizinischen Thema oder einer Methode überzeugt werden wollen. Dies war insbesondere bei Lehrinhalten zu nicht medikamentösen Verfahren zu erkennen. Diskussion Aus den Ergebnissen geht hervor, dass die theoretische Vermittlung komplementärmedizinischer Lehrinhalte kombiniert mit praktischen Erfahrungen „am eigenen Leib“ zur kritischen Reflexion und zur Entwicklung einer ganzheitlichen, patientenorientierten Haltung unter Medizinstudierenden beitragen kann. Diese Ergebnisse können als Grundlage für die Planung, Implementierung und Umsetzung komplementärmedizinischer Lehre an anderen universitären Standorten dienen.

Background The treatment of upper respiratory tract infections (URTIs) accounts for the majority of antibiotic prescriptions in primary care, although an antibiotic therapy is rarely indicated. Non-clinical factors, such as time pressure and the perceived patient expectations are considered to be reasons for prescribing antibiotics in cases where they are not indicated. The improper use of antibiotics, however, can promote resistance and cause serious side effects. The aim of the study was to clarify whether the antibiotic prescription rate for infections of the upper respiratory tract can be lowered by means of a short (2 x 2.25h) communication training based on the MAAS-Global-D for primary care physicians. Methods In total, 1554 primary care physicians were invited to participate in the study. The control group was formed from observational data. To estimate intervention effects we applied a combination of difference-in-difference (DiD) and statistical matching based on entropy balancing. We estimated a corresponding multi-level logistic regression model for the antibiotic prescribing decision of German primary care physicians for URTIs. Results Univariate estimates detected an 11-percentage-point reduction of prescriptions for the intervention group after the training. For the control group, a reduction of 4.7% was detected. The difference between both groups in the difference between the periods was -6.5% and statistically significant. The estimated effects were nearly identical to the effects estimated for the multi-level logistic regression model with applied matching. Furthermore, for the treatment of young women, the impact of the training on the reduction of antibiotic prescription was significantly stronger. Conclusions Our results suggest that communication skills, implemented through a short communication training with the MAAS-Global-D-training, lead to a more prudent prescribing behavior of antibiotics for URTIs. Thereby, the MAAS-Global-D-training could not only avoid unnecessary side effects but could also help reducing the emergence of drug resistant bacteria. As a consequence of our study we suggest that communication training based on the MAAS-Global-D should be applied in the postgraduate training scheme of primary care physicians.

Introduction The increasing shortage of physicians, especially general practitioners (GPs), in rural areas is an issue in most western countries. Many redistribution strategies have been utilized in the past to counter this shortage. The physician's perception of rural areas might be an underestimated aspect of a subsequent choice of living and working environment. The aim of this study was to explore determinants influencing this subjective perception of rurality and to develop further strategies to resolve the physician shortage in rural areas. Methods A qualitative study with semi-structured interviews and focus groups consisting of medical students and postgraduate trainees in Germany was conducted. The interviews and focus groups were recorded, transcribed and evaluated both deductively and inductively by two independent researchers using qualitative content analysis. Results Participants had an average age of 28 years. Of 16 medical students and 17 postgraduate trainees, there were 24 women and 9 men. The perception of rurality was strongly influenced by a personal connection (eg family background or personal experiences), which resulted in positive and/or negative associations with rural life and was also a decisive factor for the decision to live in rural areas. Without any kind of personal connection, the choice to work in a rural area was unlikely. Depending on life stage (eg having partners and/or children), different factors were relevant, such as cultural offerings, diversity, accessibility and quality of educational structures (kindergarten/school). Prejudices and a negative image of family medicine deterred students from choosing a career as a GP, whereas postgraduate trainees didn't feel adequately prepared to be fully competent to practice as a GP outside a metropolitan area. Conclusions Strategies must be developed to raise awareness and create a personal connection to rural areas during under- and postgraduate medical training. Attention should be given to highlighting family friendliness (child care, schools), the attractiveness of working conditions and to improving deficiencies in local infrastructure (internet and or traffic connections). Additionally, there is a need to strengthen the national standardized and structured postgraduate training as well as collegial exchange and the possibility to work in a group practice or as an employee in rural areas.

In 2002, the new version of the German Medical Licensure Act integrated Naturopathy and Complementary Medicine into the cross-sectoral unit 12 "Rehabilitation, Physical Medicine and Naturopathy" (QB12) of the medical undergraduate course. At the University of Heidelberg, Complementary Medicine (CAM) is an obligatory clinical subject of the medical undergraduate curriculum and is delivered in the form of lectures and small group work. As a central educational objective, medical students should be able to explain the principles of classical Naturopathy and the most commonly used CAM procedures. The aim was to explore the attitudes, learning needs and interests of medical students with regard to Naturopathy and CAM, and thus establish the teaching requirements. The lectures and internships were evaluated using a faculty-based teaching evaluation form. The free-text of the evaluation forms between winter semester 2011/2012 and summer semester 2013 were assessed using Mayring qualitative content analysis. The free-texts were divided into three deductive main categories (Attitudes, Learning Needs and Interests) and further subcategories. A central topic was the polarization of views in medical students regarding CAM; it ranged from lively resistance to great enthusiasm. Strikingly, comments often showed that students had significant reservations with respect to CAM and would require further evidence from the teachers in order to embrace this concept. This was particularly prominent in the use of non-pharmaceutical methods. Our results show that evidence-based teaching, combined with practical experience, contributes positively to the critical appraisal of CAM amongst medical students. These findings can serve as the basis for planning, implementation and realization of CAM teaching within mainstream undergraduate medical education. In der deutschen Approbationsordnung für Ärzte sind Inhalte aus den Bereichen der Naturheilverfahren und Komplementärmedizin im Querschnittsbereich 12 „Rehabilitation, physikalische Medizin, Naturheilverfahren“ (QB12) curricular verankert. Diese werden an der Universität Heidelberg als Pflicht- und Prüfungsfach in Form von Vorlesungen und Praktika in Kleingruppen unterrichtet. In der vorliegenden Studie wurde die Evaluation von Medizinstudierenden im Bereich der Komplementärmedizin ausgewertet mit dem Ziel, Haltung, Lernbedürfnisse und Interessen von Studierenden in diesem Bereich zu explorieren. Die Lehrveranstaltungen wurden von Beginn an im Rahmen der fakultätseigenen Lehrevaluation wissenschaftlich begleitet. Die Freitexte der Evaluationen zwischen dem Wintersemester 2011/2012 und dem Sommersemester 2013 wurden gesammelt und mittels qualitativer Inhaltsanalyse nach Mayring ausgewertet. Die Freitexte wurden in 3 deduktive Hauptkategorien (Haltung, Lernbedürfnisse und Interessen) und in weitere Subkategorien unterteilt. Als zentrales Thema fällt die Polarisierung unter den Medizinstudierenden im Hinblick auf Komplementärmedizin auf, die von regem Widerstand bis zu großer Begeisterung reicht. Auffällig häufig waren Kommentare, die erkennen ließen, dass Studierende eine hohe Erwartungshaltung in dem Sinne zeigen, dass sie von einem komplementärmedizinischen Thema oder einer Methode überzeugt werden wollen. Dies war insbesondere bei Lehrinhalten zu nicht medikamentösen Verfahren zu erkennen. Aus den Ergebnissen geht hervor, dass die theoretische Vermittlung komplementärmedizinischer Lehrinhalte kombiniert mit praktischen Erfahrungen „am eigenen Leib“ zur kritischen Reflexion und zur Entwicklung einer ganzheitlichen, patientenorientierten Haltung unter Medizinstudierenden beitragen kann. Diese Ergebnisse können als Grundlage für die Planung, Implementierung und Umsetzung komplementärmedizinischer Lehre an anderen universitären Standorten dienen.

Item does not contain fulltext BACKGROUND: Job satisfaction of practice staff is important for optimal health care delivery and for minimizing the turnover of non-medical professions. OBJECTIVE: To document the job satisfaction of practice assistants in German general practice and to explore associations between job satisfaction, staff characteristics and culture in general practice organizations. METHODS: The study was based on data from the European Practice Assessment accreditation scheme for general practices and used an observational design. The study population consisted of 1158 practice assistants from 345 general practices across Germany. Job satisfaction was measured with the 10-item Warr-Cook-Wall questionnaire. Organizational culture was evaluated with four items. A linear regression analysis was performed in which each of the job satisfaction items was handled as dependent variable. RESULTS: Out of 1716 staff member questionnaires handed out to practice assistants, 1158 questionnaires were completed (response rate: 67.5%). Practice assistants were most satisfied with their colleagues and least satisfied with their income. Higher job satisfaction was associated with issues of organizational culture, particularly a good working atmosphere, opportunities to suggest and influence areas for improvement and clear responsibilities within the practice team. CONCLUSIONS: Prioritizing initiatives to maintain high levels of, or to improve the job satisfaction of practice assistants, is important for recruitment and retention. It will also help to improve working conditions for both practice assistants and GPs and create an environment to provide better quality care.

Primary care physicians account for the majority of antibiotic prescribing in ambulatory care in Germany. Respiratory diseases are, regardless of effectiveness, often treated with antibiotics. Research has found this use without indication to be caused largely by communication problems (e.g. expectations on the patient’s part or false assumptions about them by the physician). The present randomised controlled trial (RCT) study evaluates whether communication training for primary care physicians can reduce the antibiotic prescribing rate for respiratory tract infections. The study consists of three groups: group A will receive communication training; group B will be given the same, plus additional, access to an evidence-based point-of-care tool; and group C will function as the control group. The primary endpoint is the difference between intervention and control groups regarding the antibiotic prescribing rate before and after the intervention assessed through routine data. The communication skills are captured with the help of the communication instrument MAAS-Global-D, as well as individual videos of physician-patient consultations recorded by the primary care physicians. These skills will also be regarded with respect to the antibiotic prescribing rate. A process evaluation using qualitative as well as quantitative methods should provide information about barriers and enablers to implementing the communication training. The trial contributes to an insight into the effectiveness of the different components to reduce antibiotic prescribing, which will also be supported by an extensive evaluation. Communication training could be an effective method of reducing antibiotic prescribing in primary care. DRKS00009566 5 November 2015.

INTRODUCTION The 'Verbundweiterbildung(plus) Baden-Wurttemberg' (Verbundweiterbildung(plus)) - a structured general practice (GP) postgraduate training program - developed a 'rural day' as an intervention to ensure rural health exposure for GP trainees. This project report presents the outcome of the intervention: intention to work in a rural area. METHODS At the time of the study, 500 GP trainees were enrolled in Verbundweiterbildung(plus). Invitations to complete an internet-based questionnaire were distributed by email to the 274 GP trainees who had previously been asked to participate in one of eight rural days. The questionnaire contained 4 generic and 10 specific items for participants in the rural days and 4 items specific to non-participants. Mixed-methods analyses were performed using the Statistical Package for the Social Sciences. RESULTS Of the 274 GP trainees invited to complete the questionnaire, 38 of 80 rural day participants and 72 of 194 non-participants completed the questionnaire (overall response rate 40%). Participants and non-participants did not differ significantly regarding age, sex and origin. Nearly half of the participants claimed the rural day changed their overall attitudes towards rural areas positively. However, there was no significant difference in the intention to work in a rural area for participants before and after the rural day experience. CONCLUSIONS The rural day increased positive attitudes towards rural areas in general but had no influence on intention to work in rural practice. More awareness and responsibility regarding workforce shortages in rural primary health care among political stakeholders, trainers and trainees is needed. Duration of the intervention should be extended and possibly complemented by offering rotations in rural practices to increase the effect. Enabling factors and barriers regarding working in rural areas are already known by political stakeholders, trainers and trainees and need to be more adequately addressed during GP postgraduate training.

Introduction For the effective and safe management of complex care needs for patients in community settings, high quality family medicine (FM) training programmes are needed. In less primary care oriented countries, training standards statements for FM postgraduate training are less commonly found. The aim of this study was to review international training standards statements in FM postgraduate training and to catalogue these statements to be used as a best practice standard guide for FM training programs in Germany. Materials and Methods A structured three-tiered search was performed: a systematic literature search in MEDLINE®; a search of international indicator databases; and a search in grey literature, consisting of a survey of international experts and a search in “Google (Scholar)”. From all identified documents, training standards statements were extracted, translated and summarized into categories referring to the same quality aspect. Results The search strategy revealed 25 relevant documents (MEDLINE® n = 15, databases n = 2, experts n = 7, “Google” n = 1), containing 337 training standards statements. These were summarized into 80 statements. They covered structure quality (n = 35); process quality (n = 43); and two training standards statements referred to outcome quality (n = 2). Conclusion A broad range of internationally sourced training standards statements for FM postgraduate training could be identified from countries with well-established primary care systems. Only few statements internationally referred to outcome quality, expressing the difficulty in assessing outcome. The resulting inventory of training standards statements for FM postgraduate training can serve as a resource for institutions seeking to formalise and systematise FM training at regional or national levels.

Internationally there is an ongoing debate on diuretics as first-line therapy for most patients with hypertension. In spite of many arguments against them in antihypertensive monotherapy, the authors of the present study perceived them to be regularly prescribed in combination therapy in Germany. The study objective was to look for this discrepancy in prescribing reality as a contribution from clinical practice to an academic debate.A descriptive cross-sectional study in a yearly contact group (YCG; 1.7.2007-31.06.2008) was conducted based on data from a scientific network of 22 general practitioners in Germany. All patients with hypertension as diagnosed by their general practitioner were included. Antihypertensives were grouped according to the ATC classification. To assess for potential design effects by the given two-level setting, 95% confidence intervals (CI) were adjusted for clustering.Hypertension had been diagnosed in 9.3% of the 58 852 patients. Of these, 21.6% received no antihypertensives. Of those who were treated, 30.6% (CI [28.6-32.6]) had monotherapy. In monotherapy, 8.6% (CI [7.1-10.2]) were prescribed some diuretic, 1.5% (CI [0.5-3.0]) received hydrochlorothiazide (HCT). Combination therapy was prescribed to 69.4% (CI [67.2-71.6]). These patients received some diuretic in 79.0% (CI [76.9-81.0]) of the cases, of which 80.8% (CI [78.5-83.1]) had a combination with HCT. HCT was prescribed in 76.2% (CI [73.5-78.9]) in fixed-dose formulations.In spite to the many arguments against them, leading to their almost complete disregard in monotherapy, thiazide-diuretics seem to be standard in combination therapy in Germany. This inconsistency can not be explained by the arguments of the current debate. Key limitations of the present study include the lack of ability to tell whether a given monotherapy is the first-line medication, the small sample size and the possible selection bias.

Katja Goetz,1 Jessica Bungartz,2 Joachim Szecsenyi,1 Jost Steinhaeuser3 1Department of General Practice and Health Services Research, University of Heidelberg, Heidelberg, Germany; 2Praxis Medizin im Zentrum, München, Germany; 3Institute of Family Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany Background: Patients’ evaluation of medical care is an essential dimension of quality of care and an important aspect of the feedback cycle for health care providers. The aim of this study was to document how patients with a Turkish background evaluate primary care in Germany and determine which aspects of care are associated with language abilities.Methods: The study was based on an observational design. Patients with a Turkish background from German primary care practices completed the EUROPEP (European Project on Patient Evaluation of General Practice Care) questionnaire consisting of 23items. Seventeen primary care practices were involved with either German (n=8) or Turkish (n=9) general practitioners (GPs).Results: A convenience sample of 472 patients with a Turkish background from 17 practices participated in the study (response rate 39.9%). Practices with a German GP had a lower response rate (19.6%) than those with a Turkish GP (57.5%). Items evaluated the highest were “keeping data confidential” (73.4%) and “quick services for urgent health problems” (69.9%). Subgroup analysis showed lower evaluation scores from patients with good or excellent German language abilities. Patients who consulted a Turkish GP had higher evaluation scores.Conclusion: The evaluation from patients with a Turkish background living in Germany with either Turkish or German GPs showed lower scores than patients in other studies in Europe using EUROPEP. However, our results had higher evaluation scores than those of Turkish patients evaluating GPs in Turkey. Therefore, different explanation models for these findings should be explored in future studies. Keywords: migrant health, quality of care, primary health care, patient satisfaction, patient evaluations

Background Current research emphasizes the high prevalence and costs of low back pain (LBP). The STarT Back Tool was designed to support primary care decision making for treatment by helping to determine the treatment prognosis of patients with non-specific low back pain. The German version is the STarT-G. The cross-cultural translation of the tool followed a structured and widely accepted process but to date it was only partially validated with a small sample. The aim of the study was to test the psychometric properties construct validity, discriminative ability, internal consistency and test-retest-reliability of the STarT-G and to compare them with values given for the original English version. Methods A consecutive cohort study with a two-week retest was conducted among patients with non-specific LBP, aged 18 to 60 years, from primary care practices. Questionnaires were collected before the first consultation, and two weeks later by post, using the following reference standards: the Roland and Morris disability questionnaire, the Tampa Scale of Kinesiophobia, the Pain Catastrophizing Scale and the Hospital Anxiety and Depression Scale. Psychometric properties examined included the tool’s discriminative abilities, whether the psychosocial subscale was one factor, internal consistency, item redundancy, test-retest reliability and floor and ceiling effects. Results There were 228 patients recruited with a mean age of 42.2 (SD 11.0) years, and 53 % were female. The areas under the curve (AUC) for discriminative ability ranged from 0.70 (STarT-G Subscale - Pain Catastrophizing Scale; CI95 0.63, 0.78) to 0.77 (STarT-G Total - Composite reference standard, CI95 0.60, 0.94). Factor loadings ranged from 0.49 to 0.74. Cronbach’s alpha testing the internal consistency and redundancy for the total/subscale scores were α = 0.52/0.55 respectively. The STarT-G test-retest reliability Kappa values for the total/subscale scores were 0.67/0.68 respectively. No floor or ceiling effects were present. Conclusions The STarT-G shows acceptable psychometric properties although not in exact agreement with the original English version. The items previously regarded as a psychosocial subscale may be better seen as an index of different individual psychosocial constructs. The relevance of using the tool at the point of consultation should be further examined.

Background.In 2010 Manual Medicine (MM) was the second most common additional qualification among physicians in Germany, which is recommended to be used in several guidelines. Aim of this analysis was to raise the amount of information on MM related injuries (MMri) experienced by physicians at any point of their career while applying MM.Methods.Data on MMri of a questionnaire that was used to gain first insights into MM in Germany from a health services research perspective was analysed.Results.A total of 301 physicians (20% female) participated in this study. The participants’ mean age was 46. 11% of the participants experienced some kind of MMri during their career as a MM provider. In the three worst cases these MMri were fractures and therefore classified as moderate. Mild MMri were joint dysfunction syndromes (N=30), distortions of fingers (N=7), and shoulder pain (N=3). Subgroup analyses showed no significant differences in the rate of MMri when comparing gender, provider organizations for postgraduate MM courses, and medical disciplines.Conclusion.Our analysis shows risks for providers of MM. As this analysis suffers from the risk of recall bias, future studies should be performed to get more insights into this aspect of MM.

Introduction. Medication lists and structured medication counselling (SMC) including “brown bag reviews” (BBR) are important instruments for medication safety. The aim of this study was to explore whether patients’ use of a medication list is associated with their beliefs about their medicine and their memory of SMC. Methods. Baseline data of 344 patients enrolled into the “Polypharmacy in Multimorbid Patients study” were analysed. Linear regression models were calculated for the “specific necessity subscale” (SNS) and the “specific concerns subscale” (SCS) of the German “Beliefs About Medicine Questionnaire,” including self-developed variables assessing patients’ use of a medication list, their memory of SMC, and sociodemographic data. Results. 62.8% (n=216) remembered an appointment for SMC and 32.0% (n=110) BBR. The SNS correlated positively with regular receipt of a medication list (β=0.286, p<0.01) and negatively with memory of a BBR (β=-0.268; p<0.01). The SCS correlated positively with memory of a BBR (β=0.160, p=0.02) and negatively with the comprehensiveness of the mediation list (β=-0.224; p<0.01). Conclusions. A comprehensive medication list may reduce patients’ concerns and increase the perceived necessity of their medication. A potential negative impact of BBR on patients’ beliefs about their medicine should be considered and quality standards for SMC developed.

Background The tailoring of implementation interventions includes the identification of the determinants of, or barriers to, healthcare practice. Different methods for identifying determinants have been used in implementation projects, but which methods are most appropriate to use is unknown. Methods The study was undertaken in five European countries, recommendations for a different chronic condition being addressed in each country: Germany (polypharmacy in multimorbid patients); the Netherlands (cardiovascular risk management); Norway (depression in the elderly); Poland (chronic obstructive pulmonary disease—COPD); and the United Kingdom (UK) (obesity). Using samples of professionals and patients in each country, three methods were compared directly: brainstorming amongst health professionals, interviews of health professionals, and interviews of patients. The additional value of discussion structured through reference to a checklist of determinants in addition to brainstorming, and determinants identified by open questions in a questionnaire survey, were investigated separately. The questionnaire, which included closed questions derived from a checklist of determinants, was administered to samples of health professionals in each country. Determinants were classified according to whether it was likely that they would inform the design of an implementation intervention (defined as plausibly important determinants). Results A total of 601 determinants judged to be plausibly important were identified. An additional 609 determinants were judged to be unlikely to inform an implementation intervention, and were classified as not plausibly important. Brainstorming identified 194 of the plausibly important determinants, health professional interviews 152, patient interviews 63, and open questions 48. Structured group discussion identified 144 plausibly important determinants in addition to those already identified by brainstorming. Conclusions Systematic methods can lead to the identification of large numbers of determinants. Tailoring will usually include a process to decide, from all the determinants that are identified, those to be addressed by implementation interventions. There is no best buy of methods to identify determinants, and a combination should be used, depending on the topic and setting. Brainstorming is a simple, low cost method that could be relevant to many tailored implementation projects. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0102-3) contains supplementary material, which is available to authorized users.

Background Improving postgraduate medical training is one important step to attract more medical students into general practice. Keeping pace with international developments moving to competence-based curricula for general practice training, the aim of this project was to develop and implement such a curriculum in Germany. Methods A five-step, peer-based method was used for the curriculum development process including panel testing and a “test version” of the curriculum for the pilot implementation phase. The CanMEDS framework served as a basis for a new German competence-based curriculum in general practice training. Four curricula from European countries and Canada were reviewed and, following required cultural adaptions, key strengths from these were integrated. For the CanMEDS “medical expertise” element of the curriculum, the WONCA ICPC-2 classification of patient’s “reason for encounters” was also integrated. Results Altogether, 37 participants were involved in the development process representing 12 different federal states in Germany, and including an expert advisor from Denmark. An official “test version” of the curriculum consisting of three parts: medical expertise, additional competencies and medical procedures was established. A system of self-assessment for trainees was integrated into the curriculum using a traffic light scale. Since March 2012, the curriculum has been made freely available online as a “test version”. In 2014, an evaluation is planned using feedback from users of the test model as a further stage of the implementation process. Conclusions The first German competence-based curriculum for general practice training has been developed using a pragmatic peer controlled approach and implementation is being trialed with a “test version” of the curriculum. This model project and its peer-based methodology may support competence-based curriculum development for other medical specialties both inside and outside Germany.

The Patient Assessment of Chronic Illness Care (PACIC) is a widely used instrument to evaluate the quality and patient-centeredness of chronic illness care based on the Chronic Care Model (CCM). It is a validated and reliable instrument which consists of 20 items. Additionally, a short form with 11 items was developed. The aim of this study was to translate this short form into German and examine the psychometric properties among patients with a chronic illness in Germany.Observational study design.We performed a translation and cultural adaptation of the PACIC short form into German. The German version was externally validated with the 20-item PACIC. Cronbach a, descriptive statistics, and principal component analysis were used to assess psychometric properties.In total, 264 primary care patients completed the PACIC short form. The PACIC short form showed good convergent construct validity to the 20-item PACIC (Spearman rank correlation 0.82, P.001) and high internal consistency (Cronbach a 0.87). Principal component analysis underlined the 1-dimensional structure of the instrument. No correlation between the mean overall score of the PACIC short form and the number of chronic conditions (r = 0.068; P = .273) was found.The PACIC short form showed good to very good psychometric properties and reliable measures regarding patient assessment of receiving care congruent with the CCM. It is a less burdensome instrument which can be used for further research of patients with more than 1 chronic condition.

Background Primary care teams' job satisfaction is an important issue in quality of care. The purpose of our study was to evaluate the job satisfaction of general practitioners (GPs) and non-physician staff and to explore the elements that may impact on overall job satisfaction for GPs and non-physician staff separately. Methods The study was based on data from the European Practice Assessment and used an observational design. Job satisfaction was measured with the 10-items Warr-Cook-Wall questionnaire with 7-point-Likert scales. Job satisfaction of GPs and non-physician staff was compared and impact on overall job satisfaction was analysed with stepwise linear regression analyses for both samples separately. Results The study population consisted of 2878 non-physician staff (mean age: 38 years) and 676 GPs (mean age: 50 years). The actual mean working time per week of GPs was 50.0 hours and of practice staff 26.0 hours. Both were satisfied with colleagues and fellow workers (mean = 5.99 and mean = 6.18 respectively) and mostly dissatisfied with their income (mean = 4.40 and mean = 4.79 respectively). For GPs the opportunity to use their abilities (β = 0.638) and for non-physician staff recognition for their work (β = 0.691) showed the highest scores of explained variance (R2 = 0.406 and R2 = 0.477 respectively) regarding overall job satisfaction. Conclusions Non-physician staff evaluate their job satisfaction higher than GPs except recognition for work. Job satisfaction of members of primary care teams is important because poor satisfaction is associated with suboptimal healthcare delivery, poor clinical outcomes and higher turnover of staff.

Background The Chronic Care Model (CCM) is an evidence based, population based approach to improve care for people with chronic conditions. The Assessment of Chronic Illness Care (ACIC) instrument is widely used to measure to what extent within a healthcare system the CCM is implemented. The aim of this study was to translate and culturally adapt the ACIC Instrument for the German healthcare system. Methods For translating the ACIC instrument, principles of Good Practice for the Translation and Cultural Adaptation Process by the ISPOR Task Force were followed. Focus groups were additionally conducted with general practitioners to adapt the items culturally. Results The ACIC instrument can not be used in the German healthcare system easily due to a multifaceted understanding of words, different levels of knowledge of the CCM and fundamental differences between health systems. Conclusions As following the CCM leads to benefits for patients with chronic illnesses, measuring to which extent it is implemented is of major interest. A new questionnaire using the CCM as its theoretical basis, sensitive to the healthcare systems of the host country has to be created. Knowledge transfer between countries by using an instrument from a different healthcare system can lead to a completely new questionnaire.

Background In many countries, rural areas are facing a shortage of general practitioners (GPs). Appropriate strategies to address this challenge are needed. From a health care delivery point of view, the term rural area is often poorly defined. However rural areas have to be adequately defined to ensure specific strategies are tailored to these environments. The aims of this study were to translate the New Zealand 6-item Rural Ranking Scale (RRS), to culturally adapt it and to implement it to identify rural areas from a health care delivery perspective. Therefore we aimed to validate the RRS by defining cut-off scores for urban, semi-rural and rural areas in Germany. Methods After receiving permission, two researchers independently translated the RRS. In a consensus meeting, four items were identified that had to be culturally adapted. The modified RRS-Germany (mRRS-G) was sent to 724 GPs located in urban, semi-rural and rural areas to validate the “rurality” scoring system for conditions in Germany. Results Four items, “travelling time to next major hospital”, “on-call duty”, “regular peripheral clinic” and “on-call for major traumas” had to be adapted due to differences in the health care system. The survey had a response rate of 33.7%. A factor analysis showed a three dimensional structure of the mRRS-G scale with a poor internal consistency. Nevertheless, the three items regarding “on-call duty”, “next major hospital” and “most distant boundary covered by your practice” were identified as significant predictors for rurality. The adapted cut-off point for rurality in Germany was 16. From this study’s participants, 9 met the RRS cut-off point for rurality (a score of 35 or more). Conclusion Compared with New Zealand rurality scores based on this tool, German scores are far less rural from a health care delivery point of view. We consider that the construct of rurality has more aspects than those assessed by the mRRS-G. Nevertheless, rural areas from a health care delivery viewpoint can be effectively defined using mRRS-G and therefore it can support tailored strategies against GPs shortage.

Background The Chronic Care Model (CCM) is an evidence-based approach to improving the structure of care for chronically ill patients with multimorbidity. The Assessment of Chronic Illness Care (ACIC), an instrument commonly used in international research, includes all aspects of the CCM, but cannot be easily extended to the German context. A new instrument called the "Questionnaire of Chronic Illness Care in Primary Care" (QCPC) was developed for use in Germany for this reason. Here, we present the results of the psychometric properties and test-retest reliability of QCPC. Methods A total of 109 family doctors from different German states participated in the validation study. Participating physicians completed the QCPC, which includes items concerning the CCM and practice structure, at baseline (T0) and 3 weeks later (T1). Internal consistency reliability and test-retest reliability were evaluated using Cronbach's alpha and Pearson's r, respectively. Results The QCPC contains five elements of the CCM (decision support, delivery system design, self-management support, clinical information systems, and community linkages). All subscales demonstrated moderate internal consistency and moderate test-retest reliability over a three-week interval. Conclusions The QCPC is an appropriate instrument to assess the structure of chronic illness care. Unlike the ACIC, the QCPC can be used by health care providers without CCM training. The QCPC can detect the actual state of care as well as areas for improvement of care according to the CCM.