[Show abstract][Hide abstract] ABSTRACT: For general practioners (GP) the treatment of patients suffering from multimorbidity is an everyday challenge. For these patients guidelines which each focus on a specific chronic disease cannot be applied comprehensively and equally; therefore, it is necessary to prioritize.
Zeitschrift fur Gerontologie und Geriatrie. 10/2014;
[Show abstract][Hide abstract] ABSTRACT: Introduction: We investigated persistences and changes of career preferences of medical residents in Germany after two years of postgraduate training with regard to future working place and position. The results are compared with those forwarded at graduation from medical school in a gender comparative perspective. Methods: The study is based on a standardized postal survey among the participants in the "KarMed" study, originally based on 1012 graduates of the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg in 2009. 2107 persons were contacted. The return rate at baseline was 48 %, and the two surveys after the baseline reached return rates of 87 % and 89 % respectively. In all samples 2/3 were women as in actual medical undergraduate education. Descriptive statistics and regression analysis were performed. Results: After 2 years of residency, residents after 2 years of postgraduate training still preferred the hospital over private practice as their final workplace after postgraduate training. The attractiveness of leading positions in the hospital declined among men, whereas it was already low for women at graduation. A large proportion of those physicians preferring the ambulatory sector, especially women, wishes to work as employee instead of private practice. At the personal level, almost 60 % forwarded the same preferences as those at graduation. Gender, parenthood and region of study (East vs. West Germany) did not influence stability or change of preferences. Conclusion: The results demonstrate the persistence of professional preferences regarding future sector and position of medical work during postgraduate training. These preferences do neither match with principles of gender equality nor with future workforce needs (e. g. in primary care).
Deutsche medizinische Wochenschrift (1946). 10/2014; 139(43):2173-2177.
[Show abstract][Hide abstract] ABSTRACT: AimThis study explores the current state of collaboration and communication between nurses and general practitioners in nursing homes, as well as needs and expectations of nursing home residents and their families. Finally, we aim to develop a new model of collaboration and communication.Background
Rising numbers of residents in nursing homes present a challenge for general practice and nursing in most Western countries. In Germany, general practitioners visit their patients in nursing homes, where nurses work in shifts. This leads to a big variety of contacts with regard to persons involved and ways of communication.DesignQualitative multicentre study.Methods
Study part 1 explores needs and problems in interprofessional collaboration in interviews with nursing home residents and their relatives, general practitioners and nurses. Simultaneously, general practitioners' visits in nursing homes are observed directly. In study part 2, general practitioners and nurses will discuss findings from study part 1 in focus groups, aiming to develop strategies for the improvement of shortcomings in a participatory way. Based on the results, experts will contribute to the emerging model of collaboration and communication in a multi-professional workshop. Finally, this model will be tested in a small feasibility study. The German Federal Ministry of Education and Research approved funding in March 2011.DiscussionThe study is expected to uncover deficits and opportunities in interprofessional collaboration in nursing homes. It provides deeper understanding of the concepts of all involved person groups and adds important clues for the interaction between professionals and older people in this setting.
Journal of Advanced Nursing 10/2014; · 1.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The objective of the study was to compare General Practitioners׳ (GPs) diagnosis of depression and depression diagnosis according to Geriatric Depression Scale (GDS) and to identify potential factors associated with both depression diagnosis methods.
The data were derived from the baseline wave of the German MultiCare1 study, which is a multicentre, prospective, observational cohort study of 3177 multimorbid patients aged 65+ randomly selected from 158 GP practices. Data were collected in GP interviews and comprehensive patient interviews. Depressive symptoms were assessed with a short version of the Geriatric Depression Scale (15 items, cut-off 6). Cohen׳s kappa was used to assess agreement of GP and GDS diagnoses. To identify factors that might have influenced GP and GDS diagnoses of depression, binary logistic regression analyses were performed.
Depressive symptoms according to GDS were diagnosed in 12.6% of the multimorbid subjects, while 17.8% of the patients received a depression diagnosis by their GP. The agreement between general practitioners and GDS diagnosis was poor. To summarize we find that GPs and the GDS have different perspectives on depression. To GPs somatic and psychological comorbid conditions carry weight when diagnosing depression, while cognitive impairment in form of low verbal fluency, pain and comorbid somatic conditions are relevant for a depression diagnosis by GDS.
Each depression diagnosing method is influenced by different variables and therefore, has advantages and limitations. Possibly, the application of both, GP and GDS diagnoses of depression, could provide valuable support in combining the different perspectives of depression and contribute to a comprehensive view on multimorbid elderly in primary care setting.
Journal of Affective Disorders 10/2014; 168:276–283. · 3.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: The introduction of occupational and physical therapy as academic disciplines is evidence of radical changes in the therapeutic health care professions. Therapists' professional associations are planning and negotiating both with health insurance companies and with other branches of the health care professions concerning future spheres of activity. In order to find out what the therapists in these professions think about their future, we conducted a survey of physical and occupational therapists through-out Germany. Our findings regarding profes-sional life, job satisfaction, competition and cooperation have already been published. This article presents therapists' assessments of the future of their professions. Method: From May until December 2008 we performed a cross-sectional survey, interviewing physical and occupational therapists throughout Germany. Statements were answered on a 6-step Likert scale; open questions were answered in free-text fields. The evaluation was performed quantitatively; the free texts were also evaluated qualitatively. Results: A total of 3 506 questionnaires were evaluated; 1 273 were completed by occupational therapists and 2 233 by physical therapists. Nearly half of the therapists (n=1 687; 48.4%) used the opportunity to emphasise the need for change. We identified 4 026 statements about 8 general topics: remuneration, employee co-determination, professional recognition, continuing education, cooperation, initial access to the professions, and their academic status. Therapists illustrated certain items in the questionnaire with examples from their professional experience, suggested add-itional topics, and proposed concrete changes. We document a broad range of opinions and concerns, especially in regard to such subjects concerning the future of the professions as their new academic status and initial access. Conclusion: Physical and occupational therapists are concerned about the future development of their professions. They see a need for change in the following areas: remuneration, employee co-determination, initial access and cooperation as well as in the development of their profession as an academic discipline. Policy makers need to heed therapists' assessments of the state of their professions and their calls for its increased professionalisation.
Gesundheitswesen (Bundesverband der Arzte des Offentlichen Gesundheitsdienstes (Germany)). 09/2014;
[Show abstract][Hide abstract] ABSTRACT: The impact of self-efficacy on pain-related disability in multimorbid elderly patients in primary care is not known. The aim of our study was to analyze the influence of self-efficacy on the relation between pain intensity and pain-related disability, controlled for age and disease count, in aged multimorbid primary care patients with osteoarthritis and chronic pain. Patients were recruited in the German MultiCare study (trial registration: ISRCTN89818205). Pain was assessed using the Graded Chronic Pain Scale, and self-efficacy using the General Self-Efficacy Scale. We employed SPSS for statistical analysis. One thousand eighteen primary care patients were included in the study. Correlation analyses showed significant correlations between pain intensity and pain-related disability (r = 0.591, p < 0.001), pain intensity and general self-efficacy (r = 0.078, p < 0.05), and between general self-efficacy and pain-related disability (r = 0.153, p < 0.001). Multiple mediator analysis gives indications that self-efficacy partially mediates the relation between pain intensity and pain-related disability. In our results, we found little evidence that self-efficacy partially mediates the relation between pain intensity and pain-related disability in aged multimorbid primary care patients with osteoarthritis and chronic pain. Further research is necessary to prove the effect.
[Show abstract][Hide abstract] ABSTRACT: In primary care, patients with multiple chronic conditions are the rule rather than the exception. The Chronic Care Model (CCM) is an evidence-based framework for improving chronic illness care, but little is known about the extent to which it has been implemented in routine primary care. The aim of this study was to describe how multimorbid older patients assess the routine chronic care they receive in primary care practices in Germany, and to explore the extent to which factors at both the practice and patient level determine their views.
BMC Health Services Research 08/2014; 14(1):336. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Dementia is a main reason for nursing home admission. Information on institutionalization is often based on studies of limited methodological quality. We aimed to analyze time until nursing home admission since first coding of dementia diagnosis and factors associated with institutionalization in incident dementia patients compared to non-demented controls.
Social Psychiatry and Psychiatric Epidemiology 06/2014; · 2.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Not only single, but also multiple, chronic conditions are becoming the normal situation rather than the exception in the older generation. While many studies show a correlation between multimorbidity and various health outcomes, the long-term effect on care dependency remains unclear. The objective of this study is to follow up a cohort of older adults for 5 years to estimate the impact of multimorbidity on long-term care dependency.
[Show abstract][Hide abstract] ABSTRACT: It is not well established how psychosocial factors like social support and depression affect health-related quality of life in multimorbid and elderly patients. We investigated whether depressive mood mediates the influence of social support on health-related quality of life.
Cross-sectional data of 3,189 multimorbid patients from the baseline assessment of the German MultiCare cohort study were used. Mediation was tested using the approach described by Baron and Kenny based on multiple linear regression, and controlling for socioeconomic variables and burden of multimorbidity.
Mediation analyses confirmed that depressive mood mediates the influence of social support on health-related quality of life (Sobel's p < 0.001). Multiple linear regression showed that the influence of depressive mood (beta = -0.341, p < 0.01) on health-related quality of life is greater than the influence of multimorbidity (beta = -0.234, p < 0.01).
Social support influences health-related quality of life, but this association is strongly mediated by depressive mood. Depression should be taken into consideration in research on multimorbidity, and clinicians should be aware of its importance when caring for multimorbid patients.Trial register: ISRCTN89818205.
BMC Family Practice 04/2014; 15(1):62. · 1.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We investigated the use of prescription and non-prescription (over-the-counter, OTC) analgesics and the associated risks in elderly patients with multiple morbidities.
Pain medication use was evaluated from the baseline data (2008/2009) of the MultiCare cohort enrolling elderly patients with multiple morbidities who were treated by primary care physicians (trial registration: ISRCTN89818205). We considered opioids (N02A), other analgesics, and antipyretics (N02B) as well as nonsteroidal anti-inflammatory drugs (NSAIDs; M01A). OTC use, duplicate prescription, dosages, and interactions were examined for acetylsalicylic acid, diclofenac, (dex)ibuprofen, naproxen, and acetaminophen.
Of 3,189 patients with multiple morbidities aged 65-85 years, 1,170 patients reported to have taken at least one prescription or non-prescription analgesic within the last 3 months (36.7 %). Of these, 289 patients (24.7 % of 1,170) took at least one OTC analgesic. Duplicate prescription was observed in 86 cases; 15 of these cases took the analgesics regularly. In two cases, the maximum daily dose of diclofenac was exceeded due to duplicate prescription. In 235 cases, patients concurrently took a drug with a potentially clinically relevant interaction. In 43 cases (18.3 % of 235) an OTC analgesic, usually ibuprofen, was involved.
About one third of the elderly patients took analgesics regularly or as needed. Despite the relatively high use of OTC analgesics, the proportions of duplicate prescription, medication overdoses, and adverse interactions due to OTC products was low.
Der Schmerz 04/2014; 28(2):175-82. · 1.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We compared the prevalence of dementia in nursing home residents and community-dwelling older adults .
Using health insurance claims data for the year 2009, we estimated the prevalence of at least three of four quarters with a diagnosis of dementia in persons aged ≥65 years.
Of 213,694 persons aged 65+ years, 4,584 (2.2 %) lived in nursing homes. The prevalence of dementia was 51.8 % (95 % CI 50.4-53.3) in nursing home residents and 2.7 % (95 % CI 2.6-2.8) in community-dwelling elderly. Increasing prevalences with age were found in both sexes in community-dwelling elderly. These trends were not seen in nursing home residents where prevalences were already high for the age group 65-69 years (35.7 % in males and 40.9 % in females, respectively).
More than half of nursing home residents suffer from dementia, which is about 19-fold higher than the prevalence in insured living in the community.
Aging - Clinical and Experimental Research 03/2014; · 1.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Multimorbidity is a common phenomenon in primary care. Until now, no clinical guidelines for multimorbidity exist. For the development of these guidelines, it is necessary to know whether or not patients are aware of their diseases and to what extent they agree with their doctor. The objectives of this paper are to analyze the agreement of self-reported and general practitioner-reported chronic conditions among multimorbid patients in primary care, and to discover which patient characteristics are associated with positive agreement.
The MultiCare Cohort Study is a multicenter, prospective, observational cohort study of 3,189 multimorbid patients, ages 65 to 85. Data was collected in personal interviews with patients and GPs. The prevalence proportions for 32 diagnosis groups, kappa coefficients and proportions of specific agreement were calculated in order to examine the agreement of patient self-reported and general practitioner-reported chronic conditions. Logistic regression models were calculated to analyze which patient characteristics can be associated with positive agreement.
We identified four chronic conditions with good agreement (e.g. diabetes mellitus kappa = 0.80;PA = 0,87), seven with moderate agreement (e.g. cerebral ischemia/chronic stroke kappa = 0.55;PA = 0.60), seventeen with fair agreement (e.g. cardiac insufficiency kappa = 0.24;PA = 0.36) and four with poor agreement (e.g. gynecological problems kappa = 0.05;PA = 0.10).Factors associated with positive agreement concerning different chronic diseases were sex, age, education, income, disease count, depression, EQ VAS score and nursing care dependency. For example: Women had higher odds ratios for positive agreement with their GP regarding osteoporosis (OR = 7.16). The odds ratios for positive agreement increase with increasing multimorbidity in almost all of the observed chronic conditions (OR = 1.22-2.41).
For multimorbidity research, the knowledge of diseases with high disagreement levels between the patients' perceived illnesses and their physicians' reports is important. The analysis shows that different patient characteristics have an impact on the agreement. Findings from this study should be included in the development of clinical guidelines for multimorbidity aiming to optimize health care. Further research is needed to identify more reasons for disagreement and their consequences in health care.Trial registration: ISRCTN89818205.
BMC Family Practice 03/2014; 15(1):39. · 1.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The evidence of undertreatment of pain in patients with dementia is inconsistent. This may largely be due to methodological differences and shortcomings of studies. In a large cohort of patients with incident dementia and age- and sex-matched controls we examined (1) how often they receive diagnoses indicating pain, (2) how often they receive analgesics and (3) in which agents and formulations.
Using health insurance claims data we identified 1,848 patients with a first diagnosis of dementia aged >= 65 years and 7,385 age- and sex-matched controls. We analysed differences in diagnoses indicating pain and analgesic drugs prescribed between these two groups within the incidence year. We further fitted logistic regression models and stepwise adjusted for several covariates to study the relation between dementia and analgesics.
On average, patients were 78.7 years old (48% female). The proportions receiving at least one diagnosis indicating pain were similar between the dementia and control group (74.4% vs. 72.5%; p = 0.11). The proportion who received analgesics was higher in patients with dementia in the crude analysis (47.5% vs. 44.7%; OR: 1.12; 95% CI: 1.01-1.24), but was significantly lower when adjusted for socio-demographic variables, care dependency, comorbidities and diagnoses indicating pain (OR: 0.78; 95% CI: 0.68-0.88). Analgesics in liquid form such as metamizole and tramadol were more often used in dementia.
Our findings show a comparable documentation of diagnoses indicating pain in persons with incident dementia compared to those without. However, there still seems to be an undertreatment of pain in patients with dementia. Irrespective of dementia, analgesics seem to be more often prescribed to sicker patients and to control pain in the context of mobility.
[Show abstract][Hide abstract] ABSTRACT: We analyzed the differences in morbidity patterns of chronic diseases between long-term care dependent persons in nursing homes compared to those dwelling in the community. We also investigated morbidity differences between long-term care need stages in Germany.
The study included claims data of one nationwide operating statutory health insurance in 2006. Inclusion criteria were age ≥ 65 years, minimum 1 out of 46 diagnoses in at least 3 quarters of the year (n = 8,670). A comparison population was formed with n = 114,962. Prevalences, relative risks, and odds ratios for the risk of nursing home care were calculated.
In the bivariate analysis, only three chronic diseases - dementia, urinary incontinence, and chronic heart failure - showed a higher risk for nursing home care. Regression analysis revealed that only dementia showed higher odds related to the stage of nursing needs.
Among the chronic diseases, only dementia shows a substantially elevated risk for nursing home care. Risk studies on other chronic diseases associated with higher risks of long-term care dependency and specific intervention strategies aiming at delaying or preventing nursing home admission should be developed.
Zeitschrift für Gerontologie + Geriatrie 02/2014; · 0.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: With increasing life expectancy the number of people affected by multimorbidity rises. Knowledge of factors associated with health-related quality of life in multimorbid people is scarce. We aimed to identify the factors that are associated with self-rated health (SRH) in aged multimorbid primary care patients.
Cross-sectional study with 3,189 multimorbid primary care patients aged from 65 to 85 years recruited in 158 general practices in 8 study centers in Germany. Information about morbidity, risk factors, resources, functional status and socio-economic data were collected in face-to-face interviews. Factors associated with SRH were identified by multivariable regression analyses.
Depression, somatization, pain, limitations of instrumental activities (iADL), age, distress and Body Mass Index (BMI) were inversely related with SRH. Higher levels of physical activity, income and self-efficacy expectation had a positive association with SRH. The only chronic diseases remaining in the final model were Parkinson's disease and neuropathies. The final model accounted for 35% variance of SRH. Separate analyses for men and women detected some similarities; however, gender specific variation existed for several factors.
In multimorbid patients symptoms and consequences of diseases such as pain and activity limitations, as well as depression, seem to be far stronger associated with SRH than the diseases themselves. High income and self-efficacy expectation are independently associated with better SRH and high BMI and age with low SRH.Trial registration: MultiCare Cohort study registration: ISRCTN89818205.
BMC Family Practice 01/2014; 15(1):1. · 1.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Obesity and the accompanying increased morbidity and mortality risk is highly prevalent among older adults. As obese elderly might benefit from intentional weight reduction, it is necessary to determine associated and potentially modifiable factors on senior obesity. This cross-sectional study focuses on multi-morbid patients which make up the majority in primary care. It reports on the prevalence of senior obesity and its associations with lifestyle behaviors.
PLoS ONE 01/2014; 9(7):e102587. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Diabetes mellitus is highly prevalent and can lead to serious complications and mortality. Patient education can help to avoid negative outcomes, but up to half of the patients do not participate. The aim of this study was to analyze patients' attitudes towards diabetes education in order to identify barriers to participation and develop strategies for better patient education.
We conducted a qualitative study. Seven GP practices were purposively selected based on socio-demographic data of city districts in Hamburg, Germany. Study participants were selected by their GPs in order to increase participation. Semi-structured face-to-face interviews were conducted with 14 patients. Interviews were audiotaped and transcribed verbatim. The sample size was determined by data saturation. Data were analysed by qualitative content analysis. Categories were determined deductively and inductively.
The interviews yielded four types of barriers: 1) Statements and behaviour of the attending physician influence the patients' decisions about diabetes education. 2) Both, a good state of health related to diabetes and physical/psychosocial comorbidity can be reasons for non-participation. 3) Manifold motivational factors were discussed. They ranged from giving low priority to diabetes to avoidance of implications of diabetes education as being confronted with illness narratives of others. 4) Barriers also include aspects of the patients' knowledge and activity.
First, physicians should encourage patients to participate in diabetes education and argue that they can profit even if actual treatment and examination results are promising. Second, patients with other priorities, psychic comorbidity or functional limitations might profit more from continuous individualized education adapted to their specific situation instead of group education. Third, it might be justified that patients do not participate in diabetes education if they have slightly increased blood sugar values only and no risk for harmful consequences or if they already have sufficient knowledge on diabetes.
PLoS ONE 01/2014; 9(4):e95035. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to describe and analyze the effects of depression on health care utilization and costs in a sample of multimorbid elderly patients.
This cross-sectional analysis used data of a prospective cohort study, consisting of 1,050 randomly selected multimorbid primary care patients aged 65 to 85 years. Depression was defined as a score of six points or more on the Geriatric Depression Scale (GDS-15). Subjects passed a geriatric assessment, including a questionnaire for health care utilization. The impact of depression on health care costs was analyzed using multiple linear regression models. A societal perspective was adopted.
Prevalence of depression was 10.7%. Mean total costs per six-month period were €8,144 (95% CI: €6,199-€10,090) in patients with depression as compared to €3,137 (95% CI: €2,735-€3,538; p<0.001) in patients without depression. The positive association between depression and total costs persisted after controlling for socio-economic variables, functional status and level of multimorbidity. In particular, multiple regression analyses showed a significant positive association between depression and pharmaceutical costs.
Among multimorbid elderly patients, depression was associated with significantly higher health care utilization and costs. The effect of depression on costs was even greater than reported by previous studies conducted in less morbid patients.
PLoS ONE 01/2014; 9(3):e91973. · 3.53 Impact Factor