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Places to study at medical schools are scarce, which makes well-designed selection procedures employing criteria with predictive validity for good students and doctors necessary. In Germany, the pre-university grade point average (pu-GPA) is the main selection criterion for medical school application. However, this is criticised. According to a decision by the Federal Constitutional Court, selection must be supplemented with a criterion other than the pu-GPA. Empathy is a core competency in medical care. Therefore, it seems to be an appropriate criterion. This study evaluates the feasibility of an empathy questionnaire and empathy appraisal by a panel for applicant selection. We employed a sequential explanatory mixed-methods design. Results of self- and external assessments of empathy were compared in a quantitative analysis. Thereafter, the concept of empathy and the approach to empathy appraisal by the selection panel members were explored qualitatively in six focus groups with 19 selection panel members using a semi-structured guideline. Transcripts were content analysed using both deductive and inductive coding. We found no significant correlation of self- and external empathy assessment (ρ(212) = − .031, p > .05). The results of the focus groups showed that, while panel members judged the external empathy assessment to be useful, they had neither a homogenous concept of empathy nor an implicit basis for this assessment. This diversity in panel members’ concepts of empathy and differences in the concepts underlying the Davis Interpersonal Reactivity Index seem to be the main reasons for the lack of correlation between self- and external empathy assessments. While empathy is a possible amendment to established selection criteria for medical education in Germany, its external assessment should not be employed without training panel members based on an established theoretical concept of empathy and an objective self-assessment measure.

Background: The therapeutic alliance is considered to be one of the most important factors of psychotherapy and is a necessary requirement for a successful treatment in interpreter-mediated psychotherapy. Patients and Methods: Using interpreter-mediated guided interviews, 10 refugee patients who experienced interpreter-mediated psychotherapy were asked about factors influencing the development of a trusting therapeutic alliance in the triad. The analysis of the interviews followed the rules of content-structuring qualitative content analysis. Results: A total of 11 factors were identified which could be assigned to the interpreter, therapist, or patient. In the analysis, the central role of the interpreter in establishing a therapeutic alliance in the triad became particularly clear. Conclusions: Consideration of the factors that, from the patients’ perspective, influence the establishment and maintenance of a trusting alliance within the triad, as well as the recommendations for action derived from this for psychotherapists and interpreters can lead to an improvement in the therapeutic treatment of refugees.

ZusammenfassungDer vorliegende Beitrag ist die Fortsetzung des – ebenfalls im Rahmen der Arbeitsgruppe Qualitative Methoden des Deutschen Netzwerks Versorgungsforschung (DNVF) e.V. entstandenen – ersten Artikels zu Gruppendiskussionen in der Versorgungsforschung. Beginnend mit theoretischen Überlegungen zum Gruppenbegriff wird spezifisches Wissen über Gruppen im Allgemeinen und das Verhalten einzelner Gruppenmitglieder im Besonderen zugrunde gelegt, welches sich insbesondere für die Gestaltung und Interpretation von Interaktionsprozessen im Gruppenkontext relevant zeigt. Es folgen Abschnitte mit Auseinandersetzungen zur Prozesshaftigkeit von Gruppendiskussionen, zu Moderationsstilen und -techniken sowie Reflexionen über mögliche Analysegegenstände und -verfahren. Dabei wird auch die Darstellung von Ergebnissen und Textpassagen diskutiert, in denen das Interaktionsgefüge mehrerer Diskussionsteilnehmer_innen sichtbar wird. Schließlich werden Einblicke in die Besonderheiten, Potenziale und Herausforderungen der Erhebung über Online-Plattformen gewährt. Zusammen geben beide Artikel einen Überblick über die wichtigsten Aspekte der Anwendung von Gruppendiskussionen im Bereich der Versorgungsforschung.

Hintergrund: Die Therapiebeziehung gilt als einer der wichtigsten Wirkfaktoren der Psychotherapie und ist auch in der dolmetschergestützten Psychotherapie für eine erfolgreiche Behandlung notwendig. Patienten und Methoden: Mittels dolmetschergestützter Leitfadeninterviews wurden 10 geflüchtete Patienten, die eine dolmetschergestützte Psychotherapie in Anspruch genommen haben, zu Faktoren befragt, die den Aufbau einer vertrauensvollen therapeutischen Beziehung in der Triade beeinflussen. Die Auswertung der Interviews folgte der inhaltlich strukturierenden qualitativen Inhaltsanalyse. Ergebnisse: Insgesamt wurden 11 Faktoren identifiziert, die sich dem Dolmetscher, Therapeuten oder Patienten zuordnen ließen. Deutlich wurde die zentrale Rolle des Dolmetschers für die therapeutische Beziehungsgestaltung in der Triade. Schlussfolgerungen: Die Berücksichtigung der Faktoren, die aus Perspektive der Patienten den Aufbau und die Aufrechterhaltung einer vertrauensvollen Beziehung in der Triade bedingen, sowie der daraus abgeleiteten Handlungsempfehlungen für Psychotherapeuten und Dolmetscher kann zu einer Verbesserung der therapeutischen Behandlung von Geflüchteten führen.

ZusammenfassungDie Qualitative Inhaltsanalyse (QIA) wird in der deutschen Rehabilitationsforschung häufig angewendet. Im vorliegenden Artikel wird eine kurze Entstehungsgeschichte der Qualitativen Inhaltsanalyse aufgezeigt. Es folgt die ausführlichere Darstellung des von Mayring vorgeschlagenen Verfahrens der QIA in seinen drei Varianten: zusammenfassende, explikative sowie strukturierende QIA und seines allgemeinen Ablaufmodells. Des Weiteren wird auf die Bedeutung des Kategoriensystems und der verschiedenen Formen der Kategorienbildung (deduktiv vs. induktiv) eingegangen. Diese Ausführungen werden durch Überlegungen zur Nutzung von Software, Präsentation der Ergebnisse und Quantifizierungen ergänzt. Abschließend werden der Aspekt der Vertrauenswürdigkeit der Analyse und die von Mayring vorgeschlagenen Gütekriterien für qualitative (inhaltsanalytische) Forschung aufgegriffen.

IntroductionProgressive chronic, non-malignant diseases (CNMD) like congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are of growing relevance in primary care. Most of these patients suffer from severe symptoms, reduced quality of life and increased numbers of hospitalisations. Outpatient palliative care can help to reduce hospitalisation rate by up to 50%. Due to the complex medical conditions and prognostic uncertainty of the course of CNMD, early interprofessional care planning among general practitioners who provide general palliative care and specialist palliative home care (SPHC) teams seems mandatory. The KOPAL study (a concept for strenghtening interprofessional collaboration for patients with palliative care needs) will test the effectiveness of a SPHC nurse–patient consultation followed by an interprofessional telephone case conference.Methods and analysisMulticentre two-arm cluster randomised controlled trial KOPAL with usual care as control arm. The study is located in Northern Germany and aims to recruit 616 patients in 56 GP practices (because of pandemic reasons reduced to 191 participants). Randomisation will take place on GP practice level immediately after inclusion (intervention group/control group). Allocation concealment is carried out on confirmation of participation. Patients diagnosed with CHF (New York Heart Association (NYHA) classification 3–4), COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage classification 3–4, group D) or dementia GDS stage 4 or above). Primary outcome is a reduced hospital admission within 48 weeks after baseline, secondary outcomes include symptom burden, quality of life and health costs. The primary analysis will follow the intention-to-treat principle. Intervention will be evaluated after the observation period using qualitative methods.Ethics and disseminationThe responsible ethics committees of the cooperating centres approved the study. All steps of data collection, quality assurance and data analysis will continuously be monitored. The concept of KOPAL could serve as a blueprint for other regions and meet the challenges of geographical equity in end-of-life care.Trial registration numberDRKS00017795; German Clinical Trials Register.

BackgroundPrevalence of people with multimorbidity rises. Multimorbidity constitutes a challenge to the healthcare system, and treatment of patients with multimorbidity is prone to high-quality variations. Currently, no set of quality indicators (QIs) exists to assess quality of care, let alone incorporating the patient perspective. We therefore aim to identify aspects of quality of care relevant to the patients’ perspective and match them to a literature-based set of QIs.MethodsWe conducted eight focus groups with patients with multimorbidity and three focus groups with patients’ relatives using a semistructured guide. Data were analysed using Kuckartz’s qualitative content analysis. We derived deductive categories from the literature, added inductive categories (new quality aspects) and translated them into QI.ResultsWe created four new QIs based on the quality aspects relevant to patients/relatives. Two QIs (patient education/self-management, regular updates of medication plans) were consented by an expert panel, while two others were not (periodical check-ups, general practitioner-coordinated care). Half of the literature-based QIs, for example, assessment of biopsychosocial support needs, were supported by participants’ accounts, while more technical domains regarding assessment and treatment regimens were not addressed in the focus groups.ConclusionWe show that focus groups with patients and relatives adding relevant aspects in QI development should be incorporated by default in QI development processes and constitute a reasonable addition to traditional QI development. Our QI set constitutes a framework for assessing the quality of care in the German healthcare system. It will facilitate implementation of treatment standards and increase the use of existing guidelines, hereby helping to reduce overuse, underuse and misuse of healthcare resources in the treatment of patients with multimorbidity.Trial registration numberGerman clinical trials registry (DRKS00015718), Pre-Results.

Background Many patients consult their primary care physician with persistent somatic symptoms such as pain or sickness. Quite often these consultations and further diagnostic measures yield no medical explanation for the symptoms – patients and physicians are left in uncertainty. In fact, diagnostic and treatment barriers in primary care hinder timely health-care provision for patients suffering from persistent somatic symptoms (PSS). The significance of individual barriers is still unknown. We compare and quantify these barriers from the perspective of primary care physicians and identify subpopulations of primary care physicians who experience particular barriers as most severe. Methods We mailed a questionnaire to primary care physicians (PCP) in Germany and asked them which barriers they consider most important. We invited a random sample of 12,004 primary care physicians in eight federal states in Germany. Physicians provided anonymous mailed or online responses. We also mailed a postcard to announce the survey and a mail reminder. Main measures were Likert rating scales of items relating to barriers in the diagnosis and treatment of PSS in primary care. Information on demography and medical practice were also collected. Results We analyzed 1719 data sets from 1829 respondents. PCPs showed strongest agreement with statements regarding (1.) their lack of knowledge about treatment guidelines, (2.) their perceptions that patients with PSS would expect symptom relief, (3.) their concern to overlook physical disease in these patients, and (4.) their usage of psychotropic drugs with these patients. More experienced PCPs were better able to cope with the possibility of overlooking physical disease than those less experienced. Conclusions The PCPs in our survey answered that the obligation to rule out severe physical disease and the demand to relieve patients from symptoms belong to the most severe barriers for adequate treatment and diagnosis. Moreover, many physicians admitted to not knowing the appropriate treatment guidelines for these patients. Based on our results, raising awareness of guidelines and improving knowledge about the management of persistent somatic symptoms appear to be promising approaches for overcoming the barriers to diagnosis and treatment of persistent somatic symptoms in primary care. Trial registration German Clinical Trials Register (Deutschen Register Klinischer Studien, DRKS) https://www.drks.de/drks_web/setLocale_EN.do The date the study was registered: October 2nd 2017 The date the first participant was enrolled: February 9th 2018 DRKS-ID: DRKS00012942

Background: Primary care plays a key role in pandemics like the SARS-CoV-2 pandemic in 2020. We aimed to investigate the challenges faced and the solutions implemented in primary care.Methods: One hundred and twenty-one general practitioners in Germany completed the online survey. We used open questions to examine challenges experienced and solutions implemented during the early pandemic and chose qualitative content analysis to extract and describe the meaning of the answers. We derived deductive categories from the research questions and formed inductive categories during the material reviews.Results: Main challenges were: insufficient information, lack of protective equipment, need to restructure practice procedures and insufficient individual and structural pandemic preparedness, resulting in secondary challenges: fear of infection, impaired patient care, aggravated steering of patients, difficult cooperation with external entities and a not viable hygiene concept advised by authorities. Strategies to address these challenges included establishing regular team-meetings to develop new solutions, focusing on few reliable sources of information, working in alternating shifts, increasing telemedicine, establishing window and open-air practices and building networks with other health care providers. Respondents criticized the lack of consideration of their experiences in planning pandemic measures within primary care.Conclusions: General practitioners successfully applied pragmatic and creative strategies in their practices during the early phase of the pandemic. Among these, communication within and between practices emerged as a key strategy. These strategies should be provided with pandemic preparedness plans. The lacking consideration of the primary care providers' experiences in planning and implementing pandemic measures needs to be addressed by stakeholders.

Background Oldest-old persons frequently receive potentially inappropriate medication. Medication use takes place under the patients’ informal caregivers’ influence. We explored informal caregivers’ perspectives on medication of (relatively) independent oldest-old persons to identify starting points for safer medication prescription/handling. Methods In this exploratory qualitative interview study we interviewed 45 informal caregivers of 45 oldest-old persons (23 with potentially inappropriate medication/22 without potentially inappropriate medication). Interviews were recorded, transcribed and content analyzed (deductive/inductive coding). Results Interviewees had little knowledge about/influence on oldest-old persons’ medication, but declared to monitor oldest-old persons’ needs for assistance. They were unaware of the concept of potentially inappropriate medication but sometimes sensitive to substance dependency. Most informal caregivers were satisfied with the oldest-old persons’ medication and viewed medication as increasing the patients’ quality of life. Inadequate communication was found between informal caregivers and general practitioners. Conclusions Influence of informal caregivers on (relatively) independent oldest-old persons’ medication seems low. Stakeholders need to be aware that there is a transitional period where independency of oldest-old persons decreases and support needs increase which may be missed by (in-)formal caregivers or concealed by oldest-old persons. Monitoring patients’ medication competencies; measures supporting communication between informal caregivers and health care professionals; provision of educational and support resources for informal caregivers and the acceptance of oldest-old persons’ increasing assistance needs may increase medication safety.

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.

ZusammenfassungVersorgungsforscher_innen beschäftigen sich mit den Akteur_innen, Strukturen und Auswirkungen von Gesundheitsversorgung. Dies umfasst z. B. die Frage, wie soziale Faktoren, Finanzierungssysteme, Organisationsstrukturen, Technologien und persönliche Verhaltensweisen sich auf die Akteure und Ergebnisse des Versorgungsprozesses auswirken. Im Zuge dessen finden auch qualitative Methoden, die das Handeln von Menschen unter ihren jeweiligen Lebensbedingungen und nicht im klinisch-experimentellen Kontext betrachten, Anwendung. Gruppenverfahren gehören dabei zu den grundlegenden Erhebungszugängen der qualitativen Versorgungsforschung. Um die Potenziale von Gruppenverfahren (Gruppendiskussion bzw. Fokusgruppen) innerhalb der Versorgungsforschung sichtbar zu machen, sollen diese im Rahmen von 2 Artikeln in ihren Facetten und bezogen auf die Anwendung in der Versorgungsforschung dargestellt werden. Wir möchten mit diesem ersten Artikel Versorgungsforscher_innen dazu anregen, über bestimmte Fragen zu Wahl und Varianten der Methode sowie zur Planung von Gruppenverfahren nachzudenken, wie z. B. Stichprobenbildung und Gruppenzusammensetzung, aber auch die konkrete Datenerhebung und Aspekte des Datenschutzes. Im (in Vorbereitung befindlichen) Folgeartikel zum Thema Gruppendiskussion wird eine theoretische Betrachtung des Begriffs der ‚Gruppe‘ ebenso im Fokus stehen wie die Moderation, unterschiedliche mögliche Auswertungsverfahren/-strategien und der Bereich der qualitativen Online-Forschung.

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.

This article is the second of 2 articles on group discussions in health services research, written by the Qualitative Methods Working Group of the German Network for Health Care Research (DNVF). It starts with theoretical considerations on the concept of groups, and provides specific knowledge about groups in general and the behaviour of individual group members in particular, which is relevant for the design and interpretation of interaction processes in the group context. The following sections deal with the processuality of group discussions, moderation styles and techniques as well as reflections on possible subjects and methods of analysis. Presentation of results and text passages which unveil the interaction structure of several discussion participants are also discussed here. Finally, insights into the special features, potentials and challenges of group discussions via online platforms are provided. Together, the two articles provide an overview of the most important aspects of the application of group discussions in the field of health services research.Der vorliegende Beitrag ist die Fortsetzung des – ebenfalls im Rahmen der Arbeitsgruppe Qualitative Methoden des Deutschen Netzwerks Versorgungsforschung (DNVF) e.V. entstandenen – ersten Artikels zu Gruppendiskussionen in der Versorgungsforschung. Beginnend mit theoretischen Überlegungen zum Gruppenbegriff wird spezifisches Wissen über Gruppen im Allgemeinen und das Verhalten einzelner Gruppenmitglieder im Besonderen zugrunde gelegt, welches sich insbesondere für die Gestaltung und Interpretation von Interaktionsprozessen im Gruppenkontext relevant zeigt. Es folgen Abschnitte mit Auseinandersetzungen zur Prozesshaftigkeit von Gruppendiskussionen, zu Moderationsstilen und -techniken sowie Reflexionen über mögliche Analysegegenstände und -verfahren. Dabei wird auch die Darstellung von Ergebnissen und Textpassagen diskutiert, in denen das Interaktionsgefüge mehrerer Diskussionsteilnehmer_innen sichtbar wird. Schließlich werden Einblicke in die Besonderheiten, Potenziale und Herausforderungen der Erhebung über Online-Plattformen gewährt. Zusammen geben beide Artikel einen Überblick über die wichtigsten Aspekte der Anwendung von Gruppendiskussionen im Bereich der Versorgungsforschung.

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

Background Empathy is beneficial for patients and physicians. It facilitates treatment and improves physical and psychosocial outcomes. The therapeutic relevance of empathy emphasizes the need to help medical students develop their empathic abilities. Our study aimed to identify factors which promote or hinder the development and expression of empathy in medical students during the course of their studies. Methods We interviewed 24 medical students (six male and six female students in their 6th semester as well as six male and six female students in their final clinical year) using semi-structured interviews. The interviews were recorded, transcribed verbatim and analyzed using Braun & Clarke’s thematic analysis. Results We identified four main themes influencing the development and expression of empathy. 1) Course of studies: hands-on-experience, role models, science and theory, and emphasis on the importance of empathy; 2) students: insecurities and lack of routine, increasing professionalism, previous work experiences, professional distance, mood, maturity, and personal level of empathy; 3) patients: “easy” and “difficult” patients including their state of health; and 4) surrounding conditions: time pressure/stress, work environment, and job dissatisfaction. Conclusions The development and use of empathy could be promoted by increasing: hands-on-experiences, possibilities to experience the patient’s point of view and offering patient contact early in the curriculum. Students need support in reflecting on their actions, behavior and experiences with patients. Instructors need time and opportunities to reflect on their own communication with and treatment of patients, on their teaching behavior, and on their function as role models for treating patients empathically and preventing stress. Practical experiences should be made less stressful for students. The current changes implemented in some medical school curriculums (e.g., in Germany) seem to go in the right direction by integrating patient contact early on in the curriculum and focusing more on teaching adequate communication and interaction behaviors.

Background Medically unexplained symptoms (MUS) and somatoform disorders are common in general practices, but there is evidence that general practitioners (GPs) rarely use these codes. Assuming that correct classification and coding of symptoms and diseases are important for adequate management and treatment, insights into these processes could reveal problematic areas and possible solutions. Our study aims at exploring general practitioners’ views on coding and reasons for not coding MUS/somatoform disorders. Methods We invited GPs to participate in six focus groups (N = 42). Patient vignettes and a semi-structured guideline were used by two moderators to facilitate the discussions. Recordings were transcribed verbatim. Two researchers analyzed the data using structuring content analysis with deductive and inductive category building. Results Three main categories turned out to be most relevant. For category a) “benefits of coding” GPs described that coding is seen as being done for reimbursement purposes and is not necessarily linked to the content of their reference files for a specific patient. Others reported to code specific diagnoses only if longer consultations to explore psychosomatic symptoms or psychotherapy are intended to be billed. Reasons for b) “restrained coding” were attempting to protect the patient from stigma through certain diagnoses and the preference for tentative diagnoses and functional coding. Some GPs admitted to c) “code inaccurately” attributing this to insufficient knowledge of ICD-10-criteria, time constraints or using “rules of thumb” for coding. Conclusions There seem to be challenges in the process of coding of MUS and somatoform disorders, but GPs appear not to contest the patients’ suffering and accept uncertainty (about diagnoses) as an elementary part of their work. From GPs’ points of view ICD-10-coding does not appear to be a necessary requirement for treating patients and coding might be avoided to protect the patients from stigma and other negative consequences. Our findings supply a possible explanation for the commonly seen difference between routine and epidemiological data. The recent developments in the DSM-5 and the upcoming ICD-11 will supposedly change acceptance and handling of these diagnoses for GPs and patients. Either way, consequences for GPs’ diagnosing and coding behavior are not yet foreseeable. Electronic supplementary material The online version of this article (10.1186/s12875-018-0812-8) contains supplementary material, which is available to authorized users.

Although potentially inappropriate medication (PIM) is associated with risk of harm due to adverse effects, it is frequently prescribed for elderly patients. The aim of this qualitative multi-center study was to gain insight into contextual factors that might lead to chronic PIM use. We conducted semi-structured interviews with elderly patients with or without chronic PIM use (patient interviews: n = 52). Patients were between 86 and 96 years old. The participants were recruited from the AgeCoDe study. Interviews were audiotaped and transcribed verbatim. The transcripts of the interviews were analysed using qualitative content analysis. Deductive and inductive categories were determined. We found contextual factors related to the patient and related to patient-general practitioner (GP) communication that might lead to chronic PIM use (i.e., positive features of PIM, maintaining characteristics of medication intake, barriers to deprescribe PIM, external actors supporting PIM intake, system-related factors). Besides certain health-related behaviours (e.g., own obligation to report to GP) and medication-related attitudes and knowledge (e.g., awareness of side effects and interaction of medicines), patient-GP-interactions that were characterised by mutual agreements on drugs (e.g., concerning dosage or discontinuation of a drug) might be advantageous to reduce the probability of chronic PIM use. The results might assist in the development of guidelines and educational programs aiming to reduce PIM use in the elderly.

Introduction Medical education is considered very challenging and connected with high levels of psychosocial stress for students. The aim of this study was to identify stressors and possible starting points for health-promoting interventions from the perspective of the students themselves. Methods We conducted two focus groups with medical students from pre-clinical and clinical semesters. We analyzed the data using content analysis following Mayring’s approach. Results The stressors in the pre-clinical stage of medical education were more diverse and perceived as more intense than those in the clinical stage. They comprised contextual factors and individual behaviour. Participants mentioned the weekly examinations as a specific stressor. The existing absence regulations gave the participants the impression that they should not be absent through illness at any point during the course, and this idea further promoted presenteeism. Peer groups and mentoring programmes were perceived as helpful. Conclusions Stressors and starting points for health-promoting interventions are closely related to the medical curriculum and its organization. As such, the curriculum itself—in addition to programmes aimed at improving stress management—should primarily stand at the centre of activities for enhancing students’ health.

Ziel der Studie: In dieser qualitativen Studie wurde herausgearbeitet, welche Relevanz die bisherigen Qualitatsindikatoren der Nationalen VersorgungsLeitlinie Chronische Herzinsuffizienz aus der Sicht von Patientengruppen haben. Methodik: Es wurden 6 Gruppendiskussionen durchgefuhrt. Das Sample setzt sich aus 4 gemischt-geschlechtlichen, einer Manner- und einer Frauengruppe zusammen. Die Teilnehmer der Gruppendiskussionen wurden aus Herzsportgruppen rekrutiert. Zur Auswertung der Daten wurde ein an die Grounded Theory angelehntes Verfahren genutzt. Ergebnisse: Das zentrale Ergebnis der Datenauswertung ist, dass die Qualitatsindikatoren prinzipiell akzeptiert werden, allerdings viele die Alltagswelt der Patienten beruhrende Aspekte vernachlassigen. Die Gruppendiskussionsmitglieder nehmen eine Disposition des „ja-aber“ gegenuber den Qualitatsindikatoren ein. Dieses Phanomen konnte theoretisch mit dem Konzept der Wissensordnungen gefasst werden. Wahrend sich die Patientengruppen in ihren Ausfuhrungen auf eine Alltagswissensordnung beziehen, rekurrieren die Qualitatsindikatoren auf eine medizinische Wissensordnung. Zwischen den Wissensordnungen treten Konkurrenzen auf. Schlussfolgerungen: Die Wissensordnung der Medizin muss sich gegenuber der Alltagswissensordnung der Patienten offnen, wenn sie patientenrelevante Aspekte aufgreifen will. Patientenvertreter in Gremien des Gesundheitswesens sollten geschult werden, einen reflexiven Umgang mit unterschiedlichen Wissensordnungen auszubilden, damit sie selbstbewusster das Alltagswissen der Patienten vertreten konnen. Ansonsten besteht die Gefahr, dass sie sich aus dem Wunsch, auf Augenhohe mitreden zu konnen, an die Wissensordnung der Medizin anpassen.

Hintergrund: Das Nachsorge-Konzept „neues Credo“ wurde in einer kontrollierten Langsschnittstudie erprobt und evaluiert. Die Rehabilitanden der Interventionsgruppe konnten Reha-Inhalte und Reha-Ziele im Jahr nach der stationaren Reha-Masnahme signifikant besser im Alltag umsetzen und fur diese Gruppe waren signifikant bessere Langzeiteffekte nachweisbar; jedoch profitierten nicht alle Rehabilitanden der Interventionsgruppe. Der Fokus der vorliegenden Analyse gilt dieser speziellen Subgruppe: Wodurch unterscheiden sich Rehabilitanden, die nicht vom „neuen Credo“ profitieren im Vergleich zu den Rehabilitanden, die daraus einen Nutzen ziehen? Methode: Die Daten einer kontrollierten Originalstudie, deren Ergebnisse und Inhalte an anderer Stelle beschrieben sind, wurden zu einer Sekundaranalyse herangezogen. 3 Interventionskliniken setzten das neue Credo in ihren Kliniken um. Als primare Zielgrosen wurden Einschrankungen der Teilhabe (IMET) sowie Funktionsbehinderungen im Alltag (FFbH-R) definiert. Die Interventionskliniken rekrutierten zusammen 166 Rehabilitanden, diese bilden die Basisstichprobe fur die vorliegenden Analysen. 163 Falle konnten quantitativ, 7 Interviews mit Rehabilitanden aus der Gruppe der Erfolglosen zusatzlich qualitativ analysiert werden. Ergebnisse: 102 (63%) Rehabilitanden verbesserten ihre Werte im FFbH oder im IMET um wenigstens 0,3 Effektstarken (Gruppe der Erfolgreichen). Unter den 61 Rehabilitanden, die dies nicht erreichten, waren 17 (10%) Rehabilitanden mit so positiven Ausgangslagenwerten, dass sie die festgesetzte minimale Verbesserung nicht erreichen konnten (Gruppe der „gering Belasteten“). Sie wurden von den weiteren Analysen ausgeschlossen. Die ubrigen 44 (27%) Rehabilitanden bildeten die Gruppe der Erfolglosen. Auch die Erfolglosen erreichten am Reha-Ende Verbesserungen in den erfassten Gesundheitsparametern von mittlerer bis groser Effektstarke. Ein Jahr spater fallen ihre Werte jedoch in allen Parametern wieder auf das Beeintrachtigungsniveau vor der Reha zuruck, wahrend die Erfolgreichen die unmittelbar nach der Reha erzielten Effekte weitgehend stabil uber den Katamnesezeitraum aufrecht erhalten konnen. Die beiden Gruppen bewerteten die nachsorgenden Interven­tionselemente in mehreren Aspekten unterschiedlich und die Vorbereitung auf die Zeit nach der Reha bewertet die Gruppe der Erfolglosen insgesamt schlechter. Die Anzahl wahrgenommener Nachsorgeelemente erweist sich in der multivariaten Auswertung als starkster Prognosefaktor fur Misserfolg, die Klinikeinrichtung ist der einzig weitere unabhangige Pradiktor. In den Interviews berichten Erfolglose von individuellen Barrieren fur die Umsetzung korperlicher Aktivitaten im Alltag. Schlussfolgerungen: Rehabilitanden, die nicht vom neuen Reha- und Nachsorgekonzept profitierten, unterschieden sich weder in soziodemografischen noch in krankheitsspezifischen Merkmalen von den Erfolgreichen. Unterschiede in der Umsetzung der neuen Reha-Philosophie und ihrer einzelnen Bausteine in den Reha-Kliniken sind hingegen signifikant mit dem Eintreten von Erfolg oder Misserfolg assoziiert. Insgesamt legen die Ergebnisse unserer Studie eine flexibilisierte Ausgestaltung des Reha- und Nachsorgeangebots – dem jeweiligen individuellen Bedarf angepasst – nahe.

Erhebungsinstrumente zum subjektiven Gesundheitszustand sind ein wichtiger Bestandteil der Rehabilitationsforschung. Angaben zur Gute dieser Erhebungsinstrumente stutzen sich zumeist auf quantitative psychometrische Analysen. Diese Analysen konnen jedoch keine explizite Auskunft daruber geben, ob und wie die Befragten die Fragen des Erhebungsinstruments verstehen. Die Methode des kognitiven Interviews wird in den letzten Jahren zunehmend in der Entwicklung und Uberprufung von Erhebungsinstrumenten eingesetzt. Sie dient der Identifikation von potentiell problematischen Fragen bzw. Unklarheiten oder Schwierigkeiten, die zu nicht intendierten Antworten fuhren konnen. Sie ermoglichen zu uberprufen, ob die von den Befragten gegebenen Antworten das reprasentieren, was mit der Frage intendiert war. Die durch das kognitive Interview gewonnenen Erkenntnisse konnen der Uberarbeitung und Verbesserung neu entwickelter bzw. Uberprufung schon etablierter Erhebungsinstrumente dienen. Das 4-Stufen-Modell von Tourangeau hat sich als konzeptuelle Basis kognitiver Interviewmethoden etabliert. Die 2 prominentesten kognitiven Interviewmethoden sind das laute Denken und das verbal probing. Es gibt von verschiedenen Autoren Empfehlungen zur Durchfuhrung kognitiver Interviews, jedoch kaum Empfehlungen dazu, unter welchen Bedingungen welche Methode zum Einsatz kommen sollte. Die Anwendungsmoglichkeiten des kognitiven Interviews gehen uber die Entwicklung und Validierung von Erhebungsinstrumenten hinaus. Aufgrund seiner Verankerung in der Kognitionswissenschaft kann es auch zur Klarung von inhaltlichen Fragen, z. B. nach den Ursachen von Diskrepanzen zwischen 2 verschiedenen Arten der Veranderungsmessung, genutzt werden.

Health services researchers focus on the players, structures and impact of health care in "real life". They investigate how social aspects, financing, organizational structures, technologies and personal attitudes affect the process and outcomes of health care. Qualitative research methods are used here, which address how people act according to their unique living conditions (outside the context of experimental studies). Different methods of debriefing groups are essential for qualitative health services research. In 2 subsequent articles, we aim to outline the diverse facets and possible range of implementation of the above-mentioned methods, in order to highlight the potential of debriefing groups in health services research (focus groups or group discussions) using these methods. In the current article, we would like to encourage researchers to reflect on relevant topics such as the selection of an appropriate method, the planning and undertaking of investigations including sampling methods, and questions regarding ethics and privacy. A follow-up article (in preparation) will deal with theoretical considerations of the term "group", as well as with the process of moderating discussions, methods of analyzing data and (qualitative) online research.Versorgungsforscher_innen beschäftigen sich mit den Akteur_innen, Strukturen und Auswirkungen von Gesundheitsversorgung. Dies umfasst z. B. die Frage, wie soziale Faktoren, Finanzierungssysteme, Organisationsstrukturen, Technologien und persönliche Verhaltensweisen sich auf die Akteure und Ergebnisse des Versorgungsprozesses auswirken. Im Zuge dessen finden auch qualitative Methoden, die das Handeln von Menschen unter ihren jeweiligen Lebensbedingungen und nicht im klinisch-experimentellen Kontext betrachten, Anwendung. Gruppenverfahren gehören dabei zu den grundlegenden Erhebungszugängen der qualitativen Versorgungsforschung. Um die Potenziale von Gruppenverfahren (Gruppendiskussion bzw. Fokusgruppen) innerhalb der Versorgungsforschung sichtbar zu machen, sollen diese im Rahmen von 2 Artikeln in ihren Facetten und bezogen auf die Anwendung in der Versorgungsforschung dargestellt werden. Wir möchten mit diesem ersten Artikel Versorgungsforscher_innen dazu anregen, über bestimmte Fragen zu Wahl und Varianten der Methode sowie zur Planung von Gruppenverfahren nachzudenken, wie z. B. Stichprobenbildung und Gruppenzusammensetzung, aber auch die konkrete Datenerhebung und Aspekte des Datenschutzes. Im (in Vorbereitung befindlichen) Folgeartikel zum Thema Gruppendiskussion wird eine theoretische Betrachtung des Begriffs der ‚Gruppe‘ ebenso im Fokus stehen wie die Moderation, unterschiedliche mögliche Auswertungsverfahren/-strategien und der Bereich der qualitativen Online-Forschung.

Background Potentially inappropriate medication (PIM) is defined as medication with uncertain therapeutic effects and/or potential adverse drug reactions outweighing the clinical benefits. The prescription rate of PIM for oldest-old patients is high despite the existence of lists of PIM (e.g. the PRISCUS list) and efforts to raise awareness. This study aims at identifying general practitioners’ views on PIM and aspects affecting the (long-term) use of PIM. Methods As part of the CIM-TRIAD study, we conducted semi-structured, qualitative interviews with 47 general practitioners, discussing 25 patients with and 22 without PIM (according to the PRISCUS list). The interview guideline included generic and patient-specific questions. Interviews were digitally recorded and transcribed verbatim. We content analyzed the interviews using deductive and inductive category development. Results The majority of the general practitioners were not aware of the PRISCUS list. Agents deemed potentially inappropriate from the general practitioners’ point of view and the PRISCUS list are not completely superimposable. General practitioners named their criteria to identify appropriate medication for elderly patients (e.g. renal function, cognitive state) and emphasized the importance of monitoring. We identified prescription- (e.g. benzodiazepines on alternative private prescription), medication- (e.g. subjective perception that PIM has no alternative), general practitioner- (e.g. general practitioner relies on specialists), patient- (e.g. “demanding high-user”, positive subjective benefit-risk-ratio) and system-related aspects (e.g. specialists lacking holistic view, interface problems) related to the (long term) use of PIM. Conclusions While the PRISCUS list does not seem to play a decisive role in general practice, general practitioners are well aware of risks associated with PIM. Our study identifies some starting points for a safer handling of PIM, e.g. stronger dissemination of the PRISCUS list, better compensation of medication reviews, “positive lists”, adequate patient information, multifaceted interventions and improved communication between general practitioners and specialists. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0595-3) contains supplementary material, which is available to authorized users.

Ob und inwieweit findet sich ein an Selbstbestimmung und Teilhabe im Sinne des SBG IX § 1 ausgerichtetes Verstandnis der Rehabilitation in den Vorstellungen von Rehabilitandinnen und Rehabilitanden uber ihren Reha-Aufenthalt wieder? Aussagen von Rehabilitandinnen und Rehabilitanden wurden im Rahmen einer Sekundaranalyse inhaltsanalytisch und typologisierend ausgewertet. Datengrundlagen waren 1. eine qualitative Untersuchung mit 10 leitfadengestutzten Fokusgruppen (71 Personen aus 5 verschiedenen Indikationsbereichen, 26–80 Jahre alt), 2. Einzelinterviews von 19 Rehabilitandinnen und Rehabilitanden mit chronischen Ruckenschmerzen (28–59 Jahre alt). Insgesamt wurden 8 Vorstellungstypen aus dem Material abgeleitet: Reha als Unterstutzungsangebot fur den Umgang mit gesundheitlichen Problemen im Alltag, Reha als Reparaturwerkstatt, Reha als Trainingsort, Reha als Praventionsmasnahme, Reha als Zeit zur Erholung, Reha als Ort der Entlastung, Reha als Komplexangebot und Reha als Ort fur gebrechliche Personen. Aspekte von Selbstbestimmung und Teilhabe zeigten sich nur indirekt in den Vorstellungen der Befragten. Schwerpunkte der Vorstellungstypen waren primar korperliche Wiederherstellung und psychische Unterstutzung. Unterschiede zeigten sich in der Vorstellung uber die eigene Rolle beim Erreichen der Reha-Ziele (passivere und aktivere Haltung). Die Rehabilition scheint eher als vom Alltag getrennte Einheit wahrgenommen zu werden. Aspekte von Selbstbestimmung und Teilhabe bilden sich nicht direkt in den untersuchten Vorstellungsbildern ab.

Background The innovations concerning the new diagnosis somatic symptom disorder (SSD) in the DSM-5 include the introduction of psychological diagnostic criteria and the elimination of the need to exclude all potential somatic causes of the symptoms. Thus far, it is unknown how general practitioners (GPs) evaluate the innovations conceptually and regarding their applicability in primary care. Method We performed six focus groups with GPs. A semi-structured interview-guideline included a presentation of the innovations of SSD and questions about the innovations and their potential (dis-)advantages from the GPs' points of view. The material was analyzed using structuring qualitative content analysis. Results A total of 41 GPs participated (mean (sd) age = 51 (8.5) years, female = 17, male = 24). The GPs assessed that the diagnostic innovations could help them to focus on symptom-related concerns and anxiety as core aspects of the patients' complaints. However, the meaning of the term excessive in the psychological diagnostic criteria (i.e., excessive worries, anxiety, time and energy) was ambiguous for the GPs. The GPs appreciated that a mental disorder can be assigned in addition to a severe physical disease. The GPs found it unlikely that diagnostic workup of somatic symptoms would be cut short if the diagnostic criteria of SSD were fulfilled in a given patient. Conclusion Altogether, for the GPs, the advantages of the new diagnostic criteria for SSD outweighed the disadvantages. In particular, the newly included psychological criteria were seen as an important advancement in comparison to the previous need of merely excluding a physical disease.