[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: 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. · 1.77 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: 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.
PLoS ONE 01/2014; 9(7):e101981. · 3.53 Impact Factor
[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.
[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.
DMW - Deutsche Medizinische Wochenschrift 08/2013; · 0.65 Impact Factor
[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.
[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;
[Show abstract][Hide abstract] ABSTRACT: Local governments have a crucial role in dealing with the primary care physicians shortage (PS). The aim of this study is to evaluate the perspectives and experiences of the local mayors on this issue.In May 2011, all 1101 mayors in the Federal State of Baden-Wuerttemberg (BW) were invited to participate in the study by filling out a survey developed by the authors. Data were analysed descriptively.Of the contacted mayors in BW, 63% (n=698) responded. More than 90% of the participants consider it their duty to ensure future primary care. 16% experienced local practice closures due to PS. The infrastructure provided by the communities seems to be at a high level, whereas emergency practices exist in only 15% of the communities at present. Supportive actions to attract new GPs are evaluated as appropriate by almost half of the participants.The PS topic is of high relevance for communities in BW. In order to gain future physicians for their region, the majority of the communities are maintaining a high level of infrastructure and are willing to offer more actions. The young generation physicians need to be informed about these existing conditions. Innovative ideas should be implemented in individual communities as pilot projects.
Das Gesundheitswesen 04/2012; 74(10):612-7. · 0.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Patient Assessment of Chronic Illness Care (PACIC) is a widely used instrument to evaluate the quality and patient-centeredness of chronic illness care based on the Chronic Care Model (CCM). It is a validated and reliable instrument which consists of 20 items. Additionally, a short form with 11 items was developed. The aim of this study was to translate this short form into German and examine the psychometric properties among patients with a chronic illness in Germany.
Observational study design.
We performed a translation and cultural adaptation of the PACIC short form into German. The German version was externally validated with the 20-item PACIC. Cronbach a, descriptive statistics, and principal component analysis were used to assess psychometric properties.
In total, 264 primary care patients completed the PACIC short form. The PACIC short form showed good convergent construct validity to the 20-item PACIC (Spearman rank correlation 0.82, P < .001) and high internal consistency (Cronbach a 0.87). Principal component analysis underlined the 1-dimensional structure of the instrument. No correlation between the mean overall score of the PACIC short form and the number of chronic conditions (r = 0.068; P = .273) was found.
The PACIC short form showed good to very good psychometric properties and reliable measures regarding patient assessment of receiving care congruent with the CCM. It is a less burdensome instrument which can be used for further research of patients with more than 1 chronic condition.
The American journal of managed care 02/2012; 18(2):e55-60. · 2.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Manual medicine (MM) has high importance in the ambulant treatment of complaints of the musculoskeletal system. Although there are several randomized controlled trials and meta-analyses, evidence about its efficacy is limited due to different organizations offering MM courses teaching different techniques. The aim of this study was to gain an understanding of the motivation and experiences of physicians using MM in daily practice.
In a qualitative study, 21 semi-structured phone call interviews were performed with physicians who have an additional qualification in MM. Recruitment was done by sending an e-mail to every physician listed on the homepage of the German Society for Manual Medicine or known to be interested in MM research from a previous study. Interviews were performed, recorded, transcribed and evaluated content-analytically using the software program Atlas.ti.
One of the main motivations for using MM therapy was a better doctor-patient relationship because of improved patient access, with often rapid treatment success. Further advantages were the relative simplicity of the method, the independence from spatial or apparatus conditions and the associated low costs. Positive factors discussed as directly influencing the satisfaction with MM are the possibility to use own skills, the gratitude of the patient, and the possibility to influence the patient towards a healthy lifestyle. Factors negatively influencing the satisfaction were named as follows: the low gratification for the therapy, heterogeneous evidence, the indication in often self-limiting diseases, the risk of serious adverse effects and the risk of iatrogenic fixation.
The results of this study show a wide range of mostly positive views and experiences of physicians when applying MM. The immediate curative action seems to be a welcome change for physicians who perceive the practice of their profession seen as distant from the patient.
Forschende Komplementärmedizin / Research in Complementary Medicine 01/2012; 19(3):137-42. · 1.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Since 2008 the Verbundweiterbildung(plus) programme of the Competence Centre General Practice Baden-Wuerttemberg offers continual improvement with regards to content and structure of general practice training. The programme uses the didactical concept of the CanMEDs competencies, which were developed in Canada, as a postgraduate medical training framework. Train the trainer (TTT)-programmes are an additional important element of these contentual optimisations of postgraduate training. Within this article we describe the conception and evaluation of the first TTT-workshop within the programme Verbundweiterbildung(plus).
The conception of the first TTT-workshop was influenced by results of a survey of general practitioner (GP) trainers and by experiences with teaching GP trainers involved in medical undergraduate teaching. A questionnaire was designed to get a self-assessment about organisational and didactic aspects oriented on the CanMEDs competencies of postgraduate medical training. In addition, the workshop was evaluated by the participants.
The workshop lasted 12 teaching units and included the following elements: introduction into the CanMEDs competencies, feedback training, fault management, legal and organisational aspects of post graduate training. From the 29 participating trainers 76% were male and on average 57 years old. The evaluation showed a good to very good acceptance of the workshop. Initial self-rating showed the need of improving in the fields of determining learning objectives, providing formative feedback and incorporation of a trainee. Most trainers rated themselves as very good in procure CanMEDs competencies with the exclusion of the competencies "Manager" and "Scholar".
A TTT-programme is an important method to improve GP training which has not been used in Germany so far. Such a GP TTT-programme should highlight especially training in providing feedback and teaching in management aspects. Results of this article add information that can be used for developing TTT-programmes also in other specialties.
GMS Zeitschrift für medizinische Ausbildung. 01/2012; 29(3):Doc43.
[Show abstract][Hide abstract] ABSTRACT: Primary care teams' job satisfaction is an important issue in quality of care. The purpose of our study was to evaluate the job satisfaction of general practitioners (GPs) and non-physician staff and to explore the elements that may impact on overall job satisfaction for GPs and non-physician staff separately.
The study was based on data from the European Practice Assessment and used an observational design. Job satisfaction was measured with the 10-items Warr-Cook-Wall questionnaire with 7-point-Likert scales. Job satisfaction of GPs and non-physician staff was compared and impact on overall job satisfaction was analysed with stepwise linear regression analyses for both samples separately.
The study population consisted of 2878 non-physician staff (mean age: 38 years) and 676 GPs (mean age: 50 years). The actual mean working time per week of GPs was 50.0 hours and of practice staff 26.0 hours. Both were satisfied with colleagues and fellow workers (mean = 5.99 and mean = 6.18 respectively) and mostly dissatisfied with their income (mean = 4.40 and mean = 4.79 respectively). For GPs the opportunity to use their abilities (β = 0.638) and for non-physician staff recognition for their work (β = 0.691) showed the highest scores of explained variance (R² = 0.406 and R² = 0.477 respectively) regarding overall job satisfaction.
Non-physician staff evaluate their job satisfaction higher than GPs except recognition for work. Job satisfaction of members of primary care teams is important because poor satisfaction is associated with suboptimal healthcare delivery, poor clinical outcomes and higher turnover of staff.
BMC Family Practice 12/2011; 12:137. · 1.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Chronic Care Model (CCM) is an evidence-based approach to improving the structure of care for chronically ill patients with multimorbidity. The Assessment of Chronic Illness Care (ACIC), an instrument commonly used in international research, includes all aspects of the CCM, but cannot be easily extended to the German context. A new instrument called the "Questionnaire of Chronic Illness Care in Primary Care" (QCPC) was developed for use in Germany for this reason. Here, we present the results of the psychometric properties and test-retest reliability of QCPC.
A total of 109 family doctors from different German states participated in the validation study. Participating physicians completed the QCPC, which includes items concerning the CCM and practice structure, at baseline (T0) and 3 weeks later (T1). Internal consistency reliability and test-retest reliability were evaluated using Cronbach's alpha and Pearson's r, respectively.
The QCPC contains five elements of the CCM (decision support, delivery system design, self-management support, clinical information systems, and community linkages). All subscales demonstrated moderate internal consistency and moderate test-retest reliability over a three-week interval.
The QCPC is an appropriate instrument to assess the structure of chronic illness care. Unlike the ACIC, the QCPC can be used by health care providers without CCM training. The QCPC can detect the actual state of care as well as areas for improvement of care according to the CCM.
BMC Health Services Research 11/2011; 11:295. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The greatest proportion of basic health care for patients with a migrational background living in Germany is provided by general practitioners. There is evidence that patients with a migrational background see a general practitioner as a gate keeper in case of physical or mental complaints even more frequently than the native German population. In contrast, the impact of migration-specific tasks in general practice appears to be relatively low in the medical and public discourse. This article analyzes the current situation of medical care for migrant patients in general practice and shows its potential to offer low-threshold high quality health care services to migrant patients and the whole population. In addition, an overview on migration-specific issues in research, teaching, and continuous medical education of general practitioners is provided. Finally, the implications of these findings for future research questions on migration-sensitive interventions are discussed.
[Show abstract][Hide abstract] ABSTRACT: In times of shortage of general practitioners (GPs), especially in rural areas, it is of particular interest to explore expectations and interests of GP trainees relating to their future work. The aim of this study was, to survey the willingness of trainee doctors to work in or open a general practice, as well as their expectations and plans concerning future work as a GP in a rural area.
The survey was conducted online between April to October 2010 with trainee doctors. The questionaire contained 25 questions about the trainees' sociodemographic status, expectations and conception of their future work, factors influencing setting up a GP practice and their ideas about working in a rural area.
528 trainee doctors from across Germany responded. More than half of them were female, more than 40% older than 35 years. 89% could image themselves settling in a GP practice, 77% in a rural area. The three most important factors influencing working in a rural practice were family friendly surrounding, the rural village itself and cooperation with colleagues. Most trainees would accepted having to travel 30 minutes to work.
As the basic willingness to set up practice in rural areas is quite high, relevant influencing factors such as family friendly surroundings, out-of-hour services arrangements und working models offering the opportunity to work in group handed practices should be emphasized in recruitment.