[Show abstract][Hide abstract] ABSTRACT: Background and objective:
The STarT Back stratified primary care approach has demonstrated clinical and cost effectiveness in the UK, and is commonly used by General Practitioners (GPs). However, it remains unknown how this approach could be implemented into the German healthcare system. The aim of this study was therefore to explore the views and perceptions of German GPs in respect to using a stratified primary care for low back pain (LBP).
A 90-minute think-tank workshop was conducted with 14 male and five female GPs, during which the STarT-Back-Screening-Tool (SBST) and related research evidence was presented. This was followed by two focus groups, based on a semi-structured interview guideline to identify potential implementation barriers and opportunities. Discussions were audiotaped, transcribed and coded using a content analysis approach.
For the three deductively developed main themes, 15 subthemes emerged: (1) application of the SBST, with the following subthemes: which health profession should administer it, patients known to the GP practice, the reason for the GP consultation, scoring the tool, the tool format, and the anticipated impact on GP practice; (2) psychologically informed physiotherapy, with subthemes including: provision by a physiotherapist, anticipated impact, the skills of physiotherapists, management of patients with severe psychosocial problems, referral and remuneration; (3) the management of low-risk patients, with subthemes including: concern about the appropriate advising health professional, information and media, length of consultation, and local exercise venues.
The attitudes of GPs towards stratified primary care for LBP indicated positive support for pilot-testing in Germany. However, there were mixed reactions to the ability of German physiotherapists to manage high-risk patients and handle their complex clinical needs. GPs also mentioned practical difficulties in providing extended advice to low-risk patients, which nevertheless could be addressed by involvement of specifically trained medical assistants.
PLoS ONE 08/2015; 10(8):e0136119. DOI:10.1371/journal.pone.0136119 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although demands on family physicians (FP) are to a large extent similar in the European Union, uniform assessment standards for family medicine (FM) specialty training and assessment do not exist. Aim of this pilot study was to elicit and compare the different modalities and assessment methods of FM specialty training in five European countries.
A semi structured survey was undertaken based on a convenient sample in five European countries (Denmark, Germany, Poland, the Netherlands and the United Kingdom). The respondents were asked to respond to ten items about aspects of FM specialty training and assessment methods in their respective countries. If available, this data was completed with information from official websites of the countries involved.
FM specialty training is performed heterogeneously in the surveyed countries. Training time periods range from three to five years, in some countries requiring a foundation program of up to two years. Most countries perform longitudinal assessment during FM specialty training using a combination of competence-based approach with additional formative and summative assessment. There is some evidence on the assessments methods used, however the assessment method used and costs of assessment differs remarkably between the participating countries.
Longitudinal and competence-based assessment is the presently preferred approach for FM specialty training. Countries which use less multifaceted methods for assessment could learn from best practice. Potential changes have significant cost implications.
GMS Zeitschrift fü medizinische Ausbildung 06/2015; 32(2):Doc21. DOI:10.3205/zma000963
[Show abstract][Hide abstract] ABSTRACT: Background: Nonspecific low back pain (LBP) is a common reason for accessing primary care. Manual therapy (MT) may be an effective treatment, but data from clinical studies including relevant subgroups and clinical settings are sparse. The objective of this article is to describe the protocol of a study that will measure whether an MT protocol provided by general medical practitioners will lead to a faster pain reduction in patients with nonspecific LBP than does standard medical care. Methods/Design: The study is an experimental pre-/postintervention design. The intervention consists of add-on MT treatment by general medical practitioners who have received MT training but are otherwise inexperienced in mobilization techniques. Participating general medical practitioners (n = 10) will consecutively recruit and treat patients before and after their training, serving as their own internal controls. The primary end point is a combined outcome assessing change in pain score over days 0 to 3 and time until pain is reduced by 2 points on an 11-point numeric pain scale and painkiller use is stopped. Secondary outcomes are patients' functional capacities assessed using a questionnaire, amount of sick leave taken, patient satisfaction, and referrals for further treatment. Trial registration: German clinical trials register: DRKS-ID DRKS00003240.
[Show abstract][Hide abstract] ABSTRACT: 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 (), distortions of fingers (), and shoulder pain (). 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.
Evidence-based Complementary and Alternative Medicine 03/2015; 2015:1-4. DOI:10.1155/2015/507051 · 1.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction. Managing polypharmacy is particularly demanding for general practitioners as coordinators of care. Recently, a German guideline for polypharmacy in primary care has been published. This paper describes the content and delivery of a tailored intervention, which aims at improving the implementation of guideline recommendations for polypharmacy into practice, considering individual barriers. Materials and Methods. Firstly, barriers for implementation and the corresponding strategies to address them have been identified. On this basis, an intervention consisting of a workshop for health care professionals and educational materials for patients has been developed. The workshop focused on knowledge, awareness, and skills. The educational materials included a tablet computer. Practice teams will elaborate individual concepts of how to implement the recommendations into their practice. The workshop has been evaluated by the participants by means of a questionnaire. Results. During the workshop 41 possible sources of medication errors and 41 strategies to improve medication management have been identified. Participants evaluated the workshop overall positively, certifying its relevancy to practice. Discussion. The concept of the workshop seemed appropriate to impart knowledge about medication management to the participants. It will have to be evaluated, if the intervention finally resulted in an improved implementation of the guideline recommendations.
[Show abstract][Hide abstract] ABSTRACT: Joint replacement is an established therapy for arthrosis. The quality index for joint replacement (knee and hip) should include screening for quality of patient-centred care in hospitals providing replacements, on the basis of administrative data. The quality index summarizes 16 inpatient and posthospital complications (indicators). The aim of the study was to evaluate this quality index from the medical practitioner's viewpoint.
Four semistructured focus groups with 11 family physicians and 8 orthopaedic/trauma surgeons were conducted. The discussions were recorded, transcribed and analysed qualitatively according to Mayring.
Infections and the revision of a total joint arthroplasty have been weighted as the most important indicators from the existing quality indicators. Between the participants some differences regarding the relevance of the indicators thrombosis and pulmonary embolism occurred. These indicators were weighted as more important by family physicians than orthopedic/trauma surgeons. For eight of the indicators, imprecision in words/meaning was criticized. In an open-ended second section, 20 new indicators within the areas complications, management and overall sector communication were identified.
Major amendments of the quality index for the joint replacement are necessary. The knowledge gained from this study may serve as a basis for this development.
Der Orthopäde 11/2014; 44(3). DOI:10.1007/s00132-014-3043-2 · 0.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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).ResultsA 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.
[Show abstract][Hide abstract] ABSTRACT: Background
When designing interventions and policies to implement evidence based healthcare, tailoring strategies to the targeted individuals and organizations has been recommended. We aimed to gather insights into the ideas of a variety of people for implementing evidence-based practice for patients with chronic diseases, which were generated in five European countries.
A qualitative study in five countries (Germany, Netherlands, Norway, Poland, United Kingdom) was done, involving overall 115 individuals. A purposeful sample of four categories of stakeholders (healthcare professionals, quality improvement officers, healthcare purchasers and authorities, and health researchers) was involved in group interviews in each of the countries to generate items for improving healthcare in different chronic conditions per country: chronic obstructive pulmonary disease, cardiovascular disease, depression in elderly people, multi-morbidity, obesity. A disease-specific standardized list of determinants of practice in these conditions provided the starting point for these groups. The content of the suggested items was categorized in a pre-defined framework of 7 domains and specific themes in the items were identified within each domain.
The 115 individuals involved in the study generated 812 items, of which 586 addressed determinants of practice. These largely mapped onto three domains: individual health professional factors, patient factors, and professional interactions. Few items addressed guideline factors, incentives and resources, capacity of organizational change, or social, political and legal factors. The relative numbers of items in the different domains were largely similar across stakeholder categories within each of the countries. The analysis identified 29 specific themes in the suggested items across countries.
The type of suggestions for improving healthcare practice was largely similar across different stakeholder groups, mainly addressing healthcare professionals, patient factors and professional interactions. As this study is one of the first of its kind, it is important that more research is done on tailored implementation strategies.
PLoS ONE 07/2014; 9(7):e101981. DOI:10.1371/journal.pone.0101981 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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).
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.
BMC Health Services Research 04/2014; 14(1):147. DOI:10.1186/1472-6963-14-147 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the 'Tailored Implementation for Chronic Diseases (TICD)' project, five tailored implementation programs to improve healthcare delivery in different chronic conditions have been developed. These programs will be evaluated in distinct cluster-randomized controlled trials. This protocol describes the process evaluation across these trials, which aims to identify determinants of change in chronic illness care, to examine the validity of the tailoring methods that were applied, and to analyze the association of implementation activities and the effectiveness of the program.
A multilevel approach was used to develop five tailored implementation interventions. In order to guide the process evaluation in five distinct trials, the study protocols for the cluster randomized trials and the related process evaluations were developed simultaneously and iteratively.
The process evaluation comprises three main components: a structured survey with health professionals in the trials, semi-structured interviews with a purposeful sample of this study population, and standardized documentation of organizational practice characteristics. Norway will only conduct the qualitative part of the analysis because the survey and documentation of practice characteristics are considered to be not feasible. The evaluation is guided by 'logic models' of the implementation programs: frameworks that specify the linkages between the strategies used, the determinants addressed by tailoring, and the anticipated outcomes. Standardization of measures across trials is sought to facilitate analysis of aggregated data from the trials.
This process evaluation will need to find a balance between standardization of methods across trials and the tailoring of measures to the specificities of each trial.
[Show abstract][Hide abstract] ABSTRACT: Implementation research deals with the question of how to ensure that evidence-based knowledge is put into practice. One approach is the development of "tailored interventions (TI)". These are designed to address previously identified barriers and enablers. A common definition or methodological concept for TI has not yet been established. In this paper, a concept for TI is introduced. We describe the stepwise development of an implementation intervention for GP settings where recommendations based on current evidence are provided for the treatment of multimorbid patients receiving polypharmacy. Each step will be explained and illustrated by original data.
Zeitschrift für Evidenz Fortbildung und Qualität im Gesundheitswesen 01/2014; 108(5-6):270-7.
[Show abstract][Hide abstract] ABSTRACT: Multimorbid patients frequently receive complex medication regimens and are at higher risk for adverse drug reactions and hospitalisations. Managing patients with polypharmacy is demanding, because it requires coordination of multiple prescribers and intensive monitoring. Three evidence-based recommendations addressing polypharmacy in primary care are structured medication counselling, use of medication lists and medication reviews to avoid potentially inappropriate medication (PIM). Although promising to improve patient outcomes, these recommendations are not well implemented in German routine care. Implementation of guidelines is often hindered by specific "determinants of change". "Tailored" interventions are designed to specifically address previously identified determinants. This study examines a tailored intervention to implement the aforementioned recommendations into primary care practices. This study is part of the European Tailored Interventions for Chronic Diseases project, which aims at contributing knowledge about the methods used for tailoring.
The study is designed as a cluster randomized controlled trial with primary care practices of general practitioners (GPs) who are organized in quality circles. Quality circles will be the unit of randomization with a 1:1 ratio. Follow-up time is 6 months. GPs and healthcare assistants in the intervention group will receive training on medication management. Each GP will create a tailored concept of how to implement the three recommendations into his/her practice. Evidence-based checklists for medication counselling and medication reviews will be provided for physicians. A tablet PC with an interactive educational tool and information leaflets will be provided for use by patients to inform about the necessity of continuous medication management. Control practices will not receive special training and will provide care as usual. Primary outcome is the degree of implementation of the three recommendations, which will be measured using a prespecified set of indicators. Additionally, the PIM prescription rate, patient activation, patients' beliefs about medicine, medication adherence and patients' social support will be measured.
This study will contribute knowledge about the feasibility of implementing recommendations for managing patients with polypharmacy in primary care practices. Additionally, this study will contribute knowledge about methods for tailoring of implementation interventions.Trial registration: Clinicaltrials.gov ISRCTN34664024.
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
BMC Research Notes 08/2013; 6(1):314. DOI:10.1186/1756-0500-6-314
[Show abstract][Hide abstract] ABSTRACT: Background: In the context of physician shortages, critical factors influencing career choice need to be better understood. The aim of this study was to explore experiences students have had with family medicine in order to develop additional strategies for recruiting family medicine trainees.Methods: Students from the five medical faculties in the federal state of Baden-Wuerttemberg were invited to participate in an online-survey via email. A purpose-built questionnaire was used. In addition to descriptive statistics, analysis included linear partial correlations controlled for age, gender, and semester, which were calculated between the variable "I believe family medicine is an attractive job" and the 31 variables of the survey. Linear regression was used to analyze the influence of experiences with family medicine and statements about family medicine to the perception of family medicine as an attractive specialty.Results: 1299 students participated in the survey. About half of the participants (49.7 %) considered working as a primary care physician to be attractive or partly attractive. 49.6 % of students reported positive experiences with family medicine as a patient and 33.1 % as a family member. 24.3 % reported positive experiences during the compulsory 1-2 weeks general practice internship and 18.1 % during a four weeks elective placement. For 302 participants (23.3 %), family medicine is presented positively in the media. 178 (13.7 %) consider family medicine to have high importance in both undergraduate and postgraduate education. Positive influences on judging attractiveness of family medicine were: own experience with family medicine as a clinical elective (rpart= + 0.450), own experience with family medicine as a patient (rpart= + 0.218), perception that family medicine offers a diversified working day (rpart= + 0.259), and perception that family medicine offers a good salary (rpart= + 0.242).Conclusion: To enable students during undergraduate studies to have practical experience with family medicine seems to be an important influence on judging family medicine attractive.
[Show abstract][Hide abstract] ABSTRACT: 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.
Family Practice 04/2013; 30(4). DOI:10.1093/fampra/cmt015 · 1.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction
Implementation research deals with the question of how to ensure that evidence-based knowledge is put into practice. One approach is the development of “tailored interventions (TI)”. These are designed to address previously identified barriers and enablers. A common definition or methodological concept for TI has not yet been established. In this paper, a concept for TI is introduced. We describe the stepwise development of an implementation intervention for GP settings where recommendations based on current evidence are provided for the treatment of multimorbid patients receiving polypharmacy. Each step will be explained and illustrated by original data.
Methods / Results
A stepwise approach was used to develop a TI: problem analysis, identification and prioritisation of determinants, identification and prioritisation of strategies and the design of a complex intervention and its underlying logic model.
The stepwise exemplary description of this tailoring strategy may support other researchers in this field when designing a TI.
Zeitschrift für Evidenz Fortbildung und Qualität im Gesundheitswesen 01/2013; 108(5-6). DOI:10.1016/j.zefq.2013.08.014