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Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental health disorders among children, and it is rapidly surging among adults as well. The aim of this study was to investigate the role of community neurologists and psychiatrists as well as general practitioners and paediatricians in prescribing ADHD medications in Germany and whether their role has changed over the 10-year period from 2008 and 2018., Methods: In this secondary analysis of anonymized prescribing data, we calculated the absolute and relative frequencies of ADHD prescriptions by neurologists and psychiatrists, summarized as specialists, and family physicians and paediatricians, summarized as generalists, and how it has changed during the years 2008 to 2018., Results: A total of 620 practices delivered data on 77,504 patients diagnosed with ADHD, 38% (29,396/77,504) of them had received a prescription for ADHD medicine at least once in the study period. Over time, we observed a shift from generalists to specialists. While 59% of patients received their prescription from a generalist and 41% from a specialist in 2008, there was reverse in the ratio in 2018: only 37% received their medication from a generalist and the vast majority (63%) from a specialist. This trend was particularly evident among adults: 58% of them received their ADHD medication from a specialist in 2008, but 80% in 2018. The proportion of children and adolescents who received their prescriptions from a specialist rose from 38% to 51% over the same period., Conclusion: There is a shift in drug prescription away from generalists to specialists, without any discussion of advantages or disadvantages so far. However, this would be desirable, not least because specialists alone may not have sufficient resources to care for all ADHD patients., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Objectives: Many patients receive benzodiazepines or Z-drugs during hospitalisation due to sleeping problems. In a pilot study, we aimed to find out whether, and to what degree, a multi-faceted intervention can reduce the use of these drugs, especially in older patients and those without a psychiatric or neurological disorder. The results of this pilot study should inform the design of a randomised controlled trial (RCT)., Methods: In a quasi-experimental design, we implemented the intervention in a German hospital with the support of the hospital director, medical and nursing staff and employee representatives. We compared prescription data for sleep-inducing drugs before and after the intervention by Fisher's exact test and used odds ratios (ORs) with their 95% CIs as a measure of effect size., Results: The data from 960 patients aged ≥65 years before intervention and 1049 patients after intervention were analysed. Before intervention, 483 (50.3%) of the patients received sleep-inducing drugs at some time during their hospital stay. After the intervention, 381 (36.3%) patients received a sleep-inducing drug, resulting in an OR of 0.56 (95% CI 0.47 to 0.68) (p<0.001). The reduction was particularly pronounced in patients without a psychiatric or neurological disorder (from 45.0% to 28.8%). In particular, the consumption of benzodiazepines declined from 24.3% to 8.5% (OR 0.31; 95% CI 0.23 to 0.4) (p<0.001)., Conclusions: A multi-faceted intervention to change the practice of the use of sleep-inducing drugs in one hospital was successful in terms of drug reduction, particularly for benzodiazepines. The intervention was effective especially for target persons-that is, those without a psychiatric or neurological disease. Awareness of the magnitude of the change and the role of important stakeholders could help researchers and hospital staff to design a large RCT, including control hospitals, to evaluate the success of a multi-faceted intervention on a scientifically sound basis., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2024. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Background and Objective: Benzodiazepines and Z-drugs are prescribed to a considerable extent as private prescription also for persons insured by a statutory health insurance (SHI), with formerly large differences between East and West Germany. The aim of the present study was to investigate whether these differences still exist today., Method: This secondary data analysis used anonymized prescription data from general practitioners (GPs), community neurologists, and psychiatrists. SHI-insured patients with at least one prescription for a benzodiazepine or Z-substance between 2014 and 2020 were included. Differences between East and West Germany in the proportion of private prescriptions were the central outcome. Multiple regression analyses were performed to test whether the factors region (eastern vs. western Germany) and specialist group (GPs vs. neurologists/psychiatrists) were statistically significant predictors of the proportion of private prescriptions - taking into account the age and gender composition of patients in a practice., Results: From 867 practices, 2,200,446 prescriptions for Z-substances, benzodiazepine anxiolytics, and benzodiazepine hypnotics/sedatives were evaluated. More than 38% of these prescriptions were issued as private prescriptions: 53.6% in eastern Germany and 34.8% in western Germany. For Z-substances, the proportion of private prescriptions was particularly high (70.7% in eastern and 43.0% in western Germany). GPs issued private prescriptions far more frequently than neurologists and psychiatrists. The proportion of private prescriptions increased during the study period, comparatively strongly in the western states (from 33% to 39%) and slightly in the eastern states (from 53% to 54%). In the multivariate model, practice area (east/west) and specialist group were similarly strong predictors of the extent of private prescriptions, especially for Z-substances., Conclusion: Contrary to a general alignment in life expectancy, morbidity risks, and health behaviour in East and West Germany, there is, despite convergence, still a significant difference in the proportion of private prescriptions for benzodiazepines and especially for Z-substances between the two regions. The groups of physicians who mainly prescribe these substances, namely neurologists and psychiatrists, on the one hand, and GPs, on the other, also differ considerably in the proportion of their private prescriptions for these substances., Competing Interests: Wir danken der Fa. IQVIA (Frankfurt), die uns Zugang zu Teilen ihrer Datenbank gewährte. Professor Karel Kostev, wissenschaftlicher Leiter von IQVIA, unterstützte uns bei der Nutzung der Datenbank. Ein Vertrag garantierte den Autoren Unabhängigkeit beim Studiendesign, bei der Analyse und Interpretation der Daten, beim Verfassen des Berichts und bei der Entscheidung, den Artikel zur Veröffentlichung einzureichen.Die Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Purpose: To analyse (1) how often patients insured under the statutory health insurance (SHI) scheme received repeated prescriptions for benzodiazepines or Z-drugs as private prescriptions and (2) how often doctors switched from SHI prescriptions to private prescriptions and vice versa when issuing repeat prescriptions., Methods: On basis of anonymized prescriptions from 874 ambulatory practices in Germany, we analysed the percentage of private prescriptions for Z-drugs, benzodiazepines/anxiolytics, and benzodiazepines/hypnotics and sedatives over 6 years (2014 to 2020)., Results: Of 2 200 446 prescriptions for a benzodiazepine or Z-drug, 38% were private prescriptions. In case of Z-drugs, the rate of private prescriptions was 44.1% for single prescriptions and 48.9% for refills. The difference was smaller for anxiolytics (23.3% vs. 26.0%) and, for benzodiazepine/hypnotics and sedatives, the proportion of private prescriptions for refills was even lower than for single prescriptions. In case of Z-drugs, the proportion of private prescriptions was, on average, 42.7% for the first prescription of a series of repeat prescriptions and 49.6% for the tenth prescription. The increase was smaller for anxiolytics and negligible for benzodiazepine/hypnotics and sedatives. Doctors stayed with their initial decision in more than three quarters of repeat prescriptions, be it a SHI or private prescription., Conclusion: While we observed a large number of private prescriptions for benzodiazepines and Z-drugs, the proportion was only slightly higher for refills than for single prescriptions. Doctors do not seem to issue private prescriptions as a strategy to mask especially long-term use of these substances., (© 2022 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.)

Background: PCR testing is considered the gold standard for SARS-CoV-2 diagnosis but its results are earliest available hours to days after testing. Rapid antigen tests represent a diagnostic tool enabling testing at the point of care. Rapid antigen tests have mostly been validated by the manufacturer or in controlled laboratory settings only. External validation at the point of care, particularly in general practice where the test is frequently used, is needed. Furthermore, it is unclear how well point of care tests are accepted by the practice staff., Methods: In this prospective multicenter validation study in primary care, general practitioners included adult individuals presenting with symptoms suggesting COVID-19. Each patient was tested by the general practitioner, first with a nasopharyngeal swab for the point of care test (Roche SARS-CoV-2 Rapid Antigen Test) and then with a second swab for PCR testing. Using the RT-PCR result as a reference, we calculated specificity, sensitivity, positive predictive value and negative predictive value, with their 95% confidence intervals. General practitioners and medical assistants completed a survey to assess feasibility and usefulness of the point of care tests., Results: In 40 practices in Würzburg, Germany, 1518 patients were recruited between 12/2020 and 06/2021. The point of care test achieved a sensitivity of 78.3% and a specificity of 99.5% compared to RT-PCR. With a prevalence of 9.5%, the positive predictive value was 93.9% and the negative predictive value was 97.8%. General practitioners rated the point of care test as a helpful tool to support diagnostics in patients with signs and symptoms suggestive for infection, particularly in situations where decision on further care is needed at short notice., Conclusion: The point of care test used in this study showed a sensitivity below the manufacturer's specification (Sensitivity 96.25%) in the practice but high values for specificity and high positive predictive value and negative predictive value. Although widely accepted in the practice, measures for further patient management require a sensitive interpretation of the point of care test results., (© 2022. The Author(s).)

Background: Multimorbidity is common among general practice patients and increases a general practitioner's (GP's) workload. But the extent of multimorbidity may depend on its definition and whether a time delimiter is included in the definition or not., Aims: The aims of the study were (1) to compare practice prevalence rates yielded by different models of multimorbidity, (2) to determine how a time delimiter influences the prevalence rates and (3) to assess the effects of multimorbidity on the number of direct and indirect patient contacts as an indicator of doctors' workload., Methods: This retrospective observational study used electronic medical records from 142 German general practices, covering 13 years from 1994 to 2007. The four models of multimorbidity ranged from a simple definition, requiring only two diseases, to an advanced definition requiring at least three chronic conditions. We also included a time delimiter for the definition of multimorbidity. Descriptive statistics, such as means and correlation coefficients, were applied., Findings: The annual percentage of multimorbid primary care patients ranged between 84% (simple model) and 16% (advanced model) and between 74% and 13% if a time delimiter was included. Multimorbid patients had about twice as many contacts annually than the remainder. The number of contacts were different for each model, but the ratio remained similar. The number of contacts correlated moderately with patient age (r = 0.35). The correlation between age and multimorbidity increased from model to model up to 0.28 while the correlations between contacts and multimorbidity varied around 0.2 in all four models., Conclusion: Multimorbidity seems to be less prevalent in primary care practices than usually estimated if advanced definitions of multimorbidity and a temporal delimiter are applied. Although multimorbidity increases in any model a doctor's workload, it is especially the older person with multiple chronic diseases who is a challenge for the GP.

Experiences when handling sleep medicines: Group discussions with nursing students about benzodiazepines and Z-drugs Abstract. Background and aims: Helping patients who have difficulties falling or staying asleep is one of the challenges of hospital care. The goal of this study was to explore how nursing students experience patients' sleeping problems as well as the usage of sleep-inducing drugs, especially benzodiazepines and Z-drugs in the hospital setting. Methods: In four focus group discussions, we collected data exploring the experiences of nursing students with regards to sleeping problems and sleep-inducing drugs. The transcripts of the discussion were analysed, using documentary method. Results were finally summarized to main categories, using qualitative content analysis. Results: Students experience a generous distribution of sleep-inducing drugs, which are considered as the best possible solution for sleeping problems - in spite of weak evidence. Non-drug alternatives are seldom taught, are often unavailable on the ward and their use is rarely trained. Pharmacological knowledge is too shallow and / or the transfer of theoretical knowledge to practical action is unsuccessful. Sleep and sleeping problems, e. g. in contrast to pain management, are not a topic of priority in the hospital setting. Conclusions: More knowledge and greater sensibility about sleeping problems is needed. For example, nurses' training should incorporate knowledge about medications and non-drug alternatives and how to apply them in critical situations. Doctors and nurses should offer nursing students good role models in these situations.

Objectives: To validate the urinary tract infection-Symptom and Impairment Questionnaire (UTI-SIQ-8), a questionnaire that consists of four items to assess the symptom severity for dysuria, urgency, frequenc, and low abdominal pain and four items to assess the resulting impairment of activity by UTIs., Design: Prospective observation study., Setting: German primary care practices., Participants: An unselected population of women with UTI. Women could participate online via a web application for smartphones, smartwatches and tablets or use a paper-and-pencil version., Main Outcomes: Psychometric properties of the UTI-SIQ-8 regarding reliability, validity and sensitivity to change by using factor analysis and multilevel and network analysis., Results: Data from 120 women with a total of 769 symptom reports across 7 days of measurement were analysed. The majority of the participating patients (87/120) used the web application via smartphones or other devices. The reliability of the UTI-SIQ-8 was high, with Cronbach's alpha of .86 at intake; convergent and discriminant validity was satisfactory. Intraclass correlation demonstrated high sensitivity to change, with 68% of the total variance being due to time differences. These daily changes in an individual's symptoms moved parallel with daily changes in the EQ-5D-5L (b=1.68, SE=0.12, p<0.001) and the visual analogue scale (b=0.03, SE=0.003, p<0.001), also highlighting convergent validity with respect to daily changes in symptom severity., Conclusions: The present findings support the UTI-SIQ-8 questionnaire as an economic, reliable and valid instrument for the assessment of symptom severity and symptom change in women with uncomplicated UTI. The web application helped patients to report symptoms on a daily basis. These findings may encourage primary care physicians to use the UTI-SIQ-8 in their daily practice and researchers to apply it to studies involving patients with uncomplicated UTI., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The aim of this study was to analyse whether the global trend in drug prescriptions for attention-deficit hyperactivity disorders (ADHD), as observed during the last years and often criticized as medicalization, have remained stable or shifted., Methods: This observational study was based on a secondary analysis of data from a large German database including patients with an ADHD diagnosis between 2008 and 2018. Prescription data comprised all important ADHD drugs., Results: A total of 620 practices delivered data from a total of 77,504 patients (31% of them females) with a diagnosis of AHDH. Nearly 38% (29,396/77,504) of all patients received, at least, one prescription for an ADHS medicine between 2008 and 2018. The number of patients receiving a drug steadily increased annually until 2012 and then slowly fell, but unevenly distributed across the age groups. While the number of younger patients ( ≤ 16 years) receiving a prescription fell by 24% and the defined daily doses (DDDs) remained stable, the number of patients between 17 and 24 years receiving a prescription increased by 113% and the DDDs by 150%. Respectively, the number of older adults (≥ 25 years) with a prescription increased by 355% and the DDDs by 515%. Nearly one-third of older adults received an ADHD medicine only once., Conclusion: The ever-increasing prescription of ADHD medicines stopped some years ago for children. ADHS and its pharmacological management are increasingly observed among older adolescents and adults, with a different pattern of drug persistence compared with children.

Background: Uncomplicated urinary tract infections (UTIs) in women are usually managed in primary care with antibiotics. However, many women seem to prefer to handle UTI symptoms with nonsteroidal anti-inflammatory drugs (NSAIDs) and other remedies. The aim of this study was to compare UTI management as recommended by physicians with the patients' management at home., Methods: This prospective cohort study in German primary care is based on clinical data from local practices and patient questionnaires. Participating women completed a baseline data sheet in the practice; their urine sample was tested by a dipstick in the practice and cultured by a laboratory. The women reported treatment and symptom-related impairment on an eight-item symptom questionnaire daily for 7 days. Using growth curve models, we analysed the influence of time on the total severity score to examine how symptoms changed across days. We then examined whether symptom severity and symptom course differed between patients who took antibiotics or NSAIDs., Results: A total of 120 women (mean age of 43.3 ± 16.6 years) were enrolled. The urine dipstick was positive for leucocytes in 92%, erythrocytes in 87%, and nitrites in 23%. Physicians prescribed antibiotics for 102 (87%) women and recommended NSAIDs in 14 cases. According to the women's reports, only 60% (72/120) took antibiotics, while the remainder took NSAIDs and other remedies. Symptoms declined from day 0 to day 6, irrespective of whether women decided to take an antibiotic, NSAIDs, none or both, as confirmed by a significant curvilinear time effect (B = 0.06, SE = 0.005, p < .001). The symptom course, however, was moderated by taking antibiotics so that the change in symptom severity was somewhat more pronounced in women taking antibiotics (B = 0.06) than in the remainder (B = 0.04)., Conclusion: A substantial proportion of women did not follow their physicians' treatment recommendations, and many used NSAIDs. All women had a good chance of recovery irrespective of whether they decided to take antibiotics. A sensitive listening to patient preferences in the consultation may encourage physicians to recommend and prescribe symptomatic treatment with NSAID more often than antibiotic medicines.

Background: Many patients receive Z-drugs for hospital-associated sleep problems, in spite of well-known risks. The aim of this study was to learn more about the attractiveness of Z-drugs, seen from the doctors' and nurses' perspective., Methods: Using a standardized questionnaire, doctors (63/116) and nurses (73/243) in a German general hospital were surveyed about the risks and benefits of Z-drugs, compared with benzodiazepines., Result: "Reduced time to get to sleep" was perceived by doctors (51%) and nurses (53%) to be a strong benefit of Z-drugs; "confusion" and "falls" were perceived by ca. 10% of doctors and ca. 15% of nurses to be a frequent problem. Compared with benzodiazepines, respondents more often answered "unable to judge" for Z-drugs; e.g. for doctors, 18% (benzodiazepines) vs. 45% (Z-drugs) were unable to judge "improved daytime functioning" and 12% (benzodiazepines) vs. 37% (Z-drugs) were unable to judge "falls.", Conclusion: Z-drugs seem to be attractive because experiential knowledge overemphasizes their benefits and fails to take risks such as drug-related falls and confusion into account. Difficulties to judge a drug's risk-benefit ratio do not prevent doctors and nurses from using them. Interventions for reducing Z-drug usage should incorporate local quality assurance data about relevant patient risks.

Background and Objectives: The use of primary care data gathered from electronic health records in local practices could be an important building block for the future of health services research. However, the risks and reservations associated with using this data for research purposes should not be underestimated. We show the data protection and privacy problems that may arise through secondary analysis of routine primary care data and describe the technical solutions that are available to address these concerns - as a trust-building measure., Methods: We screened 40 variables that are deemed important for documentation in the electronic health records of primary care physicians and rated the risk of patient re-identification when using these records from routine medical data for research purposes. The criteria used to rate the risk of re-identification were "expert perception" (inferences of a professional observer of phenotypical characteristics which are documented in the 40 variables), "researchable additional knowledge" (knowledge of characteristics of a person through publicly available information and social media networks), and "statistic frequency" according to diagnosis and medication statistics., Results: Diagnoses and reasons for contacting a general practitioner can contain particularly identifiable characteristics such as "obesity" (ICD-10 E66) and "nicotine dependence" (F17). About half of all ICD codes documented in primary care fall below a critical threshold value in their absolute frequency; this is all the more problematic if diagnoses allow for re-identification due to phenotypical characteristics. Medication information holds little potential risk of re-identification of a person. However, the application of medications could be a source of re-identification, e. g., self-injections of insulin or use of inhalators. Information about times and dates are especially sensitive for the re-identification of a person. Sex and age of a patient generally pose no problems, except in the case of very young or very old individuals when these age groups are seldom represented in the practice., Discussion: Routine health data are, in principle, sensitive data. Knowledge about the variables in primary care data gathered from electronic health records in local practices and the evaluation of this data allow us to more accurately estimate the risk of re-identification for the persons concerned. In particular, chronic diagnoses and/or diagnoses in long text, calendar dates for patient contacts and therapies bear a high risk of re-identification. Technical measures such as removing data, masking values and coding should make re-identification considerably more difficult. There will always be a remaining risk of re-identification which should be openly discussed to counteract concerns about a lack of data protection or a sweeping critique of digitization in healthcare., (Copyright © 2019.)

Objective: To examine the impact of medication and medical conditions on the fall risk in older hospitalized patients., Design: Matched case-control study., Setting: Large regional hospital in a mid-sized German city., Subjects: Four hundred eighty-one inpatients aged ≥ 65 years who fell during hospitalization ("cases") and a control group of 481 controls, matched for age, gender, and hospital department., Methods: Diagnosis, medication, vital parameters, and injuries were compared between cases and controls. Univariate and multivariable odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) were calculated., Main Results: Several drugs were significantly associated with falls in multivariate analyses: long-acting benzodiazepines (adjusted OR = 3.49; 95%-CI = 1.16-10.52), serotonin-noradrenalin reuptake inhibitors (SNRI) (2.57; 1.23-5.12), Z-drugs (2.29; 1.38-3.59), low-potency neuroleptics (1.87; 1.08-3.23), ACE inhibitors/sartans (1.42; 1.07-1.89). Digoxin (0.32; 0.11-0.99) and aldosterone receptor antagonists (0.54; 0.33-0.88) were negatively associated with falls. No significant association in multivariate analyses was found for short- and intermediate-acting benzodiazepines, mirtazapine, and opioids. Hyponatremia (1.52; 1.15-2.03) and leukocytosis (1.39; 1.05-1.87) in blood examination on admission showed significant association with falls. As secondary diagnoses, Parkinson syndrome (2.38; 1.27-4.46) and delirium (3.74; 2.26-6.21) were strongly associated with falls. The use of more than one psychoactive drug was a separate risk factor for falls (p < 0.0001)., Conclusion: Several drugs including SNRI, neuroleptics, and Z-drugs showed a significant association with inpatient falls. The frequently prescribed tetracyclic antidepressant mirtazapine did not appear to increase the risk of falls. Psychoactive polypharmacy should be avoided.

Purpose: To find out whether any prior experiences with sleep-inducing drugs before hospitalization and positive experiences with these drugs during hospitalization influence a patient's wish to continue taking sleep-inducing drugs after hospitalization., Methods: We surveyed older hospital patients about use of sleep-inducing drugs before, during, and after hospitalization and compared these answers with their hospital chart using the kappa statistic. The association between the wish to continue these drugs after discharge and the perceived benefits, experience of side effects, and prior experience with sleep-inducing drugs was determined by multivariable logistic regression., Results: Agreement between patient responses and the hospital file was high (κ = 0.7). Seventeen percent (83/483) of the participants reported prior experience before their hospital stay; 45% received a sleep-inducing drug during hospitalization; 17% wished to continue taking them after discharge. Of the 400 patients who had no prior experience with sleep-inducing drugs, 147 (37%) became first-time users in the hospital, and 27% (40/147) of these wished to continue this medication after discharged. Strong predictors for this wish were the reduction of sleep onset problems (adjusted odds ratio, 6.26; 95% confidence interval, 2.38-16.44) and any prior experience with sleep-inducing drugs (4.08; 1.97-8.48)., Conclusions: Many older patients become first-time users of sleep-inducing drugs in the hospital. Especially the experience of sleep onset improvements influences the wish to continue sleep-inducing drug use after discharge. Avoiding first-time use should become a goal of hospital policy and be taken into account when weighing the benefits and risks of sleep-inducing drugs., (© 2019 The Authors Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons Ltd.)

Background: General practitioners (GPs), nurses and informal caregivers are often jointly involved in healthcare situations in which ethical issues play an important role., Objectives: To describe ethical problems from the perspective of these three groups and to investigate whether there is a common experience of ethical issues in primary care., Methods: We conducted six focus groups with general practitioners, nurses and informal caregivers in Germany. We asked the participants to describe at least one experience of ethical problem in detail and documented the findings by an illustration software that visualized and structured the discussion. We used thematic analysis to identify ethical problems and to develop categories of ethical issues., Results: Problems reported barely overlapped. GPs had to do mainly with uncertainty about the scope and limits of their responsibility for patients. Nurses were concerned about bureaucratic and other barriers to professional care and about dual loyalty if they had to consider the conflicting interests of patients and family members. They often felt powerless and unable to act according to their professional standards. Informal caregivers reported problems that resulted from role strain and being both a family member and a caregiver. GPs, nurses and informal caregivers sometimes perceived the other parties as a source of ethical problems., Conclusions: All parties may benefit from ethics support services, a rarity in German primary care so far. Furthermore, nurses' self-confidence towards GPs, demanding patients and family members has to be strengthened. Informal caregivers, the most vulnerable group, need more attendance and tailored support., (© The Author(s) 2018. Published by Oxford University Press.)

Objective: Social support is considered an important resource in coping with chronic conditions. By conducting a series of interviews with people who suffer from inflammatory bowel disease (IBD), we received the impression that social support in face-to-face or online communication could also be a source of stress and strain. The aim of our study was to better understand and describe possible negative effects of social support., Design: This is a secondary analysis of narrative interviews. The interviewees were selected using a maximum-variation sampling approach. Grounded theory and the 'OSOP' (one sheet of paper) method were applied to categorise those parts of the interviews that touched on the negative effects of social support., Setting: The open-end interview collection took place throughout Germany from September 2011 to June 2012. Most of the participants were interviewed in their homes, some in the Department of General Practice in Göttingen., Participants: 42 patients with IBD., Results: Two interrelated categories emerged: (1) unwanted confrontation and (2) undesirable reactions. The interviewees perceived social support as negative, especially if they felt overwhelmed and/or if they had not asked for it. Consequently, some of our interview partners developed strategies to prevent coming into social contact with others or stopped talking entirely about their disease., Conclusion: While social support is usually conceptualised and perceived as a positive resource in chronic disease, it sometimes turns into a negative experience and may end in social isolation and deteriorate health. This process also happens in online support groups and increases anxiety when exchanging with other people on the internet. Before motivating ill people to seek contact with others, they should know about the negative effects of social support., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Non-medical or contextual factors strongly influence physicians' prescribing behavior and may explain why drugs, such as benzodiazepines and Z-drugs, are still frequently prescribed in spite of well-known adverse effects. This study aimed to explore which contextual factors influence the prescription of hypnotics and sedatives and to compare their role in primary and secondary care., Methods: Understanding medical practices as games with specific rules and strategies and performed in a largely habitual, not fully conscious manner, we asked a maximum variation sample of 12 hospital doctors and 12 general practitioners (GPs) about their use of hypnotics and sedatives. The interviews were analyzed by qualitative content analysis., Results: Hospital doctors' and GPs' use of hypnotics and sedatives was influenced by a variety of contextual factors, such as the demand of different patient groups, aims of management, time resources, or the role of nurses and peers. Negotiating patient demands, complying with administrative regulations, and finding acceptable solutions for patients were the main challenges, which characterized the game of drug use in primary care. Maintaining the workflow in the hospital and finding a way to satisfy both nurses and patients were the main challenges in secondary care., Conclusions: Even if doctors try to act rationally, they cannot escape the interplay of contextual factors such as handling patient needs, complying with administrative regulations, and managing time resources. Doctors should balance these factors as if they were challenges in a complex game and reflect upon their own practices.

Background: Routinely recorded data from everyday ambulatory medical care are urgently needed for health services and systems research, but this faces major limitations in Germany. In 2018, European General Data Protection Regulation (GDPR) and new German Federal Data Protection Act (FDPA) become effective. Via simulated real-life scenarios it may be possible to find out if access to and utilization of routine data for research becomes easier or faces additional obstacles., Methods: General practitioners, information scientists, data trustees and privacy protection experts create concepts, processes and standards for lawful handling of routinely recorded data for secondary research and study their feasibility in 2 scenarios (anonymous and pseudonymous data utilization). From the point of view of technical assessment and privacy protection, technical and organizational obstacles are presented as well as the legal framework., Results: Outdated software interface, insufficient maintenance by software vendors, burdens associated with organization and cost as well as poor IT standards place obstacles to systematic and longitudinal use of healthcare routine data. Future pan-European law for privacy protection will allow research utilization of ambulatory data in principle. However, there are persisting conflicts between individual (fundamental right of privacy protection) and public interests (research for quality and efficiency of public spending; European market's free exchange of goods and services). This becomes evident especially when using routine data via pseudonymization., Discussion: Neither insurmountable hurdles by privacy protecting law nor a threat from Big Data are currently the major obstacles to secondary utilization of routine data but real-life problems at the technology and operational level. GDPR and FDPA that have become into effect in May 2018 have improved European legal unity and transparency of patients' interests. Tension between privacy protection of data on an identified or identifiable person and scientific utilization and exchange of such data in public interest necessitates additional legal clarification. One possible solution, an advanced and ready-to-use software interface, awaits implementation., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Our knowledge about ethical conflicts in primary care is limited. The aim of this study was to ascertain the frequency of ethical conflicts and the need of professional consultation services - seen from the perspective of general practitioners (GPs)., Methods:  A random sample of GPs from Lower Saxony, a federal state of Germany, received a standardized questionnaire about their experiences with ethical conflicts and their need for an ethical consultation., Results:  A total of 456 GPs took part in the survey (response rate = 45.6 %). Eighty percent experienced the conflict of a "withdrawal of medicines due to questionable benefit for the patient" once in 3 months, at least (95 % confidence interval: 76.0 to 83.6 %). Further frequent conflicts were "the continuation of a therapy of questionable benefit" (68 %; 63.3 to 72.0 %) and the "usefulness of diagnostic procedures for early detection of diseases and risk factors in seriously ill patients" (62 %; 57.7 to 66.8 %). About one-third (138/451) of the participants requested an ethical consultation. GPs frequently wished an ethical consultation by phone., Conclusions:  Although GPs experienced several of the ethical conflicts frequently, only one-third requested an ethical consultation. Low threshold offers may be a way to make ethical consultations more attractive for GPs., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The mini clinical evaluation exercise (mini-CEX)-a tool used to assess student-patient encounters-is increasingly being applied as a learning device to foster clinical competencies. Although the importance of eliciting self-assessment for learning is widely acknowledged, little is known about the validity of self-assessed mini-CEX scores. The aims of this study were (1) to explore the variability of medical students' self-assessed mini-CEX scores, and to compare them with the scores obtained from their clinical supervisors, and (2) to ascertain whether learners' self-assessed mini-CEX scores represent a global dimension of clinical competence or discrete clinical skills., Methods: In year 4, medical students conducted one to three mini-CEX per clerkship in gynaecology, internal medicine, paediatrics, psychiatry and surgery. Students and clinical supervisors rated the students' performance on a 10-point scale (1 = great need for improvement; 10 = little need for improvement) in the six domains history taking, physical examination, counselling, clinical judgement, organisation/efficiency and professionalism as well as in overall performance. Correlations between students' self-ratings and ratings from clinical supervisors were calculated (Pearson's correlation coefficient) based on averaged scores per domain and overall. To investigate the dimensionality of the mini-CEX domain scores, we performed factor analyses using linear mixed models that accounted for the multilevel structure of the data., Results: A total of 1773 mini-CEX from 164 students were analysed. Mean scores for the six domains ranged from 7.5 to 8.3 (student ratings) and from 8.8 to 9.3 (supervisor ratings). Correlations between the ratings of students and supervisors for the different domains varied between r = 0.29 and 0.51 (all p < 0.0001). Mini-CEX domain scores revealed a single-factor solution for both students' and supervisors' ratings, with high loadings of all six domains between 0.58 and 0.83 (students) and 0.58 and 0.84 (supervisors)., Conclusions: These findings put a question mark on the validity of mini-CEX domain scores for formative purposes, as neither the scores obtained from students nor those obtained from clinical supervisors unravelled specific strengths and weaknesses of individual students' clinical competence.

Background and Objectives: Hospitalisation influences drug therapy in ambulatory care and this influence is generally negatively perceived. The few studies that have explored changes in benzodiazepine or sleep medication use as a function of hospitalisation failed to precisely determine the hospital's role in initiating, continuing and discontinuing these drugs on a valid basis. The aim of the study was to ascertain the overall influence of hospitalisation on the prescription of benzodiazepines and Z-drugs in outpatient care with a special focus on the role of different hospital departments and drug classes., Methods: In a secondary data analysis, we used prescription data for 181 037 patients who visited 127 hospitals and compared the numbers of patients with prescriptions of benzodiazepines and Z-drugs 50 days before and 50 or 100 days after hospitalisation., Results: The proportion of patients who received benzodiazepines or Z-drugs increased from 3.1% before admission to 3.6% at 50 days after discharge and fell to the former level after an additional 50 days. A multivariable logistic regression showed that gender and department had an additional impact on these results. Of those patients without a prescription for a benzodiazepine or Z-drug before admission, 0.6% received a prescription in both time-windows after discharge. Of those patients who were prescribed a benzodiazepine, 38.0% received short-acting substances and 40.3% received long-acting substances before hospitalisation. After hospitalisation, these rates changed to favour short-acting substances (44.4% and 34.4%, respectively)., Conclusions: The hospital effect on initiating and increasing hypnotic or sedative drug use seems to be only moderate and temporary. A change in favour of short-acting substances is even welcome. In less than 1% of patients, the hospital initiated the continuous use of benzodiazepines and Z-drugs, which may put pressure on primary care physicians. However, the widespread use of these drugs in hospitals does not seem to be continued on a large scale in primary care.

Non-pharmacological treatment of hospital patients with sleeping problems - the nurse perspective Abstract., Background: Elderly patients suffer from sleep disturbances during hospitalization. These patients often receive hypnotics and sedatives; despite of the known risks and although non-pharmacological treatments are available., Aim: The study investigates the experiences of nurses when using non-pharmacological treatments for elderly patients with sleeping problems., Methods: Semi-structured interviews with 13 nurses from a general hospital were analyzed according to Mayring's qualitative content analysis., Results: Nurses used a variety of non-pharmacological treatments for elderly inpatients with sleeping problems: (1) structural measures (regulation of temperature and light), (2) organizational measures (more time for conversation during the nightshift), (3) nursing measures (asking about night-time routines) and (4) household remedies. From the nurses' perspective, the more intensive contact required when applying non-pharmacological treatments can lead to higher patient satisfaction and a lower bell frequency during the night shift. Barriers result from limited time and personnel, a lack of standards and individual patient needs., Conclusion: Nurses know several kinds of non-pharmacological treatments to help elderly inpatients sleep better. A lack of resources as well as a lack of professional consensus about the treatment of temporary sleeping disturbances can be an obstacle to their use. A professional climate should restrict the use of drugs for sleeping problems as far as possible.

Background: Many elderly patients receive psychotropic drugs. Treatment with psychotropic agents is associated with serious side effects including an increased risk of falls and fractures. Several psychotropic drugs are considered potentially inappropriate for treatment of the elderly., Methods: A retrospective chart review was conducted covering all patients aged ≥ 65 years who were admitted to Evangelisches Krankenhaus Göttingen-Weende between 01/01/2013 and 03/31/2013. Psychotropic drugs reviewed for included benzodiazepines, Z-drugs, antidepressants and neuroleptics, but not drugs for sedation during artificial ventilation or pre-medication before surgery. Potentially inappropriate drugs were identified according to the PRISCUS list. To assess which factors were associated with the administration of psychotropic drugs, univariate and multivariable logistic regression analyses were performed., Results: The charts of 2130 patients (1231 women) were analyzed. 53.9% of all patients received at least one psychotropic medication (29.5% benzodiazepines, 12.6% Z-drugs, 22.2% antidepressants, 11.9% neuroleptics). The mean number of psychotropic drugs prescribed per patient with at least one prescription was 1.6. Patients treated in the geriatric department most often received antidepressants (45.0%), neuroleptics (20.6%) and Z-drugs (27.5%). Benzodiazepines and Z-drugs were prescribed mostly as medication on demand (77.7% of benzodiazepines, 73.9% of Z-drugs). Surgical patients most frequently received benzodiazepines (37.1%). Nearly one-third of all patients ≥ 65 years was treated with at least one potentially inappropriate psychotropic medication. The mean number of potentially inappropriate psychotropic medications per patient with at least one psychotropic prescription was 0.69. The percentage of patients with potentially inappropriate psychotropic medication was highest in the surgical departments (74.1%). Female gender (adjusted OR 1.36; 95% CI 1.14 to 1.63), stay in the Department of Geriatrics (2.69; 2.01 to 3.60) or the interdisciplinary intensive care unit (1.87; 1.33 to 2.64) and age ≥ 85 years (1.33; 1.10 to 1.60) were associated with psychotropic drug treatment., Conclusions: A high percentage of patients aged ≥ 65 years received psychotropic drugs. The chance that a potentially inappropriate psychotropic drug would be administered was highest in the surgical departments. Antidepressants, neuroleptics and Z-drugs were used surprisingly often in geriatric medicine. Educational strategies could reduce the use of psychotropic drugs and the prescription of potentially inappropriate medications.

A chart review at a mid-sized German general hospital found a high usage of benzodiazepines among older patients. Therefore, all doctors and nurses of this hospital were surveyed about the benefits and risks of benzodiazepines that they considered to be the strongest and their own overall assessment of the risk-benefit ratio for their patients Response rate was 54% (63/116) for doctors and 30% (73/243) for nurses. "Reduced fear or agitation" was perceived by many doctors (71%) and nurses (49%) to be a strong benefit of benzodiazepines. With regards to the overall risk-benefit ratio, doctors who indicated that "falls" and/or "craving" often occur in combination with benzodiazepines were more likely to estimate that the risks of benzodiazepines outweigh the benefits. For nurses, "confusion" strongly influenced their overall assessment of the risk-benefit ratio. The results of this study will be incorporated into interventions for reducing benzodiazepine prescriptions.
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Patient centeredness is a central concept in the treatment and rehabilitation of persons with chronic illness in Germany. There are various concepts of and approaches to patient centeredness, most of them developed from the perspective of health care research and the institutions. In terms of participation requirements, there has been a lack of understanding of the patient's perspective and experiences so far. In this article, the authors assume that the collection and analysis of patient experiences can improve patient participation and provide access to the experience of living and coping with an illness, including the patient's interactions with the health care system, their participation, and their preferences for participation. Potential uses for and the limits and risks of utilizing patient experiences are discussed, using the example of the website project Krankheitserfahrungen.de (DIPEx Germany). The project collects patient experiences in the form of narrative interviews. In the course of sharing their stories, the speakers become experts on their own lives and describe where and how they feel engaged in their health care and how they wish to become further engaged, thereby experiencing participation in terms of the International Classification of Functioning. The experience of rehabilitation is viewed in a comprehensive manner for those affected. It is not limited to experiences in specific institutions, but rather, the patient experience includes the context and processes, and describes how patients can find their way back to their lives after the interruption of an illness.

Objectives: The aim of the study was to compare therapy persistence among patients who started with one of three drug regimens: a monotherapy, or combination therapy either as a fixed combination (ie, 'single pill') or as a free combination (ie, two separate antihypertensive agents)., Design: In a secondary data analysis, we used descriptive statistics and multivariate logistic regression to measure the effect of the three therapy regimens on therapy persistence over 4 years., Setting: Prescription data from a large German statutory health insurance provider., Participants: All patients who started with a new antihypertensive therapy in 2007 or 2008 (n=8032) were included and followed for 4 years., Primary Outcome Measure: Therapy persistence, defined as receiving a refill prescription no later than within 180 days., Results: The persistence rates after 4 years were nearly identical among patients who started with a monotherapy (40.3%) or a fixed combination of two drugs (39.8%). However, significantly more patients who started with free-drug combinations remained therapy persistent (56.4%), resulting in an OR of 2.00 (95% CI 1.6 to 2.5; p<0.0001) for free combinations versus fixed combinations. This trend was observed in all age groups and for men and women. At the end of the study period, the number of different antihypertensive agents was still similar between patients who started with a fixed combination (2.41) and patients who started with a free combination (2.28)., Conclusions: While single-pill combinations make it easier to take different drugs at once, the risk is high that these several substances are stopped at once. Therapy persistence was significantly better for patients who started with a free-drug combination without taking much fewer different antihypertensive drugs as those with a fixed combination., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Introduction: Hypnotics and sedatives, especially benzodiazepines and Z-drugs, are frequently prescribed for longer periods than recommended-in spite of potential risks for patients. Any intervention to improve this situation has to take into account the interplay between different actors, interests and needs. The ultimate goal of this study is to develop-together with the professionals involved-ideas for reducing the use of hypnotics and sedatives and then to implement and evaluate adequate interventions in the hospital and at the primary and secondary care interface., Methods and Analysis: The study will take place in a regional hospital in northern Germany and in some general practices in this region. We will collect data from doctors, nurses, patients and a major social health insurer to define the problem from multiple perspectives. These data will be explored and discussed with relevant stakeholders to develop interventions. The interventions will be implemented and, in a final step, evaluated. Both quantitative and qualitative data, including surveys, interviews, chart reviews and secondary analysis of social health insurance data, will be collected to obtain a full understanding of the frequency and the reasons for using hypnotics and sedatives., Ethics and Dissemination: Approval has been granted from the ethics review committee of the University Medical Center Göttingen, Germany. Results will be disseminated to researchers, clinicians and policy makers in peer-reviewed journal articles and conference publications. One or more dissemination events will be held locally during continuous professional development events for local professionals, including (but not confined to) the study participants., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: An increase in a patient's visits to doctors usually raises concerns and may be a 'red flag' for a patient's deterioration of health. The aim of this study was to analyze whether an increase of patient-physician contacts is a first sign of a malignancy in a patient's near future., Methods: This is a retrospective case-control study. From 153 German general practices' electronic patient records (EPR), cases with at least one new malignancy diagnosis and no-malignancy controls were matched for gender and age. We calculated (1) the number of contacts in the first quarter up to the sixth quarter before a malignancy diagnosis was made and (2) the inter-contact interval (ICI), i.e. the time lag between two consecutive patient-physician contacts measured in days. Differences between cases and controls were investigated in several analyses of variance, with group and time as main factors., Results: A total of 3,310 cases and 3,310 controls could be included. The number of contacts for cases in the six quarters before a malignancy diagnosis increased from 4.8 contacts (SD 4.3) to 5.5 contacts (SD 4.8). The number of contacts for controls increased only marginally from 4.3 contacts (SD 3.6) to 4.5 (SD 4.2). The factor 'group' (cases vs. controls) was highly significant in the analyses of variance, also 'time' and the interaction 'group * time'. The effect size, however, was very small (R(2) being less than 0.02), which is the equivalent for about one additional contact per quarter in cases directly before a newly made malignancy diagnosis., Conclusion: An increase in contact frequency is a call for GPs to become more attentive towards these patients. It may raise the suspicion of an impending serious disease but the increase is not so dramatic and unique that it can be interpreted a reliable sign of a malignant diagnosis.

Aim | Benzodiazepines and Z-drugs are frequently prescribed sleep medications in spite of their poor risk-benefit ratio when used over a longer period of time. The aim of the study was to find out how the medical and nursing staff in a general hospital estimated the frequency of use for these drugs, and the risk-benefit ratio for elderly patients as well as the factors which positively influence the perceived use of these drugs. Methods | All members of the medical and nursing staff of a hospital received a questionnaire about their use of, and attitudes towards, benzodiazepines and Z-drugs. Absolute and relative frequencies were calculated to estimate the perceived frequency of use and the risk-benefit ratio. Multiple logistic regressions were used to analyze which factors are associated with a perceived high use of benzodiazepines or Z-drugs for insomnia. Results | More nurses than hospital doctors believed that they dispensed benzodiazepines often or always (57 % vs. 29 %) to patients with insomnia; this was also the case for Z-drugs (66 % vs. 29 %). Nearly half of the hospital doctors and 29 % of the nurses perceived more harms than benefits for benzodiazepines in the elderly. The following factors were associated with a high perceived usage of Z-drugs: working as a nurse (OR: 13,95; 95%-CI: 3,87-50,28), working in a non-surgical department (5,41; 2,00-14,61), having < 5 years of professional experience (4,90; 1,43-16,81) and feeling that the benefits of Z-drugs outweigh the risks for elderly patients (5,07; 1,48-17,35). For benzodiazepines, only the perceived positive risk-benefit ratio had an influence on the perceived use (3,35; 1,28-8.79). Conclusion | The medical and nursing staff perceived the frequency of prescription of benzodiazepines and Z-drugs and the risk-benefit ratio in different ways. Other aspects, such as working in a non-surgical department or having a smaller amount of working experience may also influence the decision to use Z-drugs., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Persons who simulate patients during medical education understand the routines and the underlying script of medical consultations better. We aimed to explore how simulated patients (SPs) integrated this new understanding into their daily life, how this work affected their private life as patients, and what we can learn from these changes for concepts of empowerment., Design, Setting, and Participants: A qualitative interview study. All SPs of Göttingen medical school who had been working longer than three semesters (n=14) were invited and agreed to take part in an open interview about their daily experience with real doctors. Documentary method was used to identify the main issues. Several cases were chosen according to maximum contrast and analysed by in-depth analysis to provide vivid examples of how simulations may affect the real life of the SPs as patients., Results: Our analysis revealed three main changes in the behaviour of SPs as real patients. They were more attentive, had a better understanding of the circumstances under which doctors work, and acted more self-confidently. From the selected cases it became apparent that working as a SP may lead to a constant and significant decrease of fear of hospitals and medical procedures or, in other cases, may enable the SPs to develop new abilities for giving feedback, questioning procedures, and explanations for real doctors., Conclusion: working as a simulated patient seems to be well-suited to understand own progression of diseases, to increase self-responsibility and to a confident attitude as patient.

Background: Uncomplicated urinary tract infection (UTI) is often treated with antibiotics, resulting in increasing resistance levels. A randomised controlled trial showed that two-thirds of females with UTI treated symptomatically recovered without subsequent antibiotic treatment., Aim: To investigate whether there are differences between females with a UTI who were subsequently prescribed antibiotics and those who recovered with symptomatic treatment only, and to develop a model to predict those who can safely and effectively be treated symptomatically., Design and Setting: This is a subgroup analysis of females assigned to ibuprofen in a UTI trial in general practices., Method: Multiple logistic regression analysis was used to select variables for a prediction model, The discriminative value of the model was estimated by the area under the receiver operator curve (AUC) and the effects of different thresholds were calculated within the model predicting antibiotic prescription and need for follow-up visits., Results: Of the 235 females in the ibuprofen group, 79 were subsequently prescribed antibiotics within 28 days of follow-up. The final model included five predictors: urgency/frequency, impaired daily activities, and positive dipstick test results for erythrocytes, leucocytes, and nitrite. The AUC was 0.73 (95% CI = 0.67 to 0.80). A reasonable threshold for antibiotic initiation would result in 58% of females presenting with UTI being treated with antibiotics. Of the remaining females, only 6% would return to the practice because of symptomatic treatment failure., Conclusion: The present model revealed moderately good accuracy and could be the basis for a decision aid for GPs and females to find the treatment option that fits best., (© British Journal of General Practice 2016.)

Objective: People with type 2 diabetes often report pressure to abstain from many of life's pleasures. We tried to reconstruct these patients' sense of pressure to better understand how people with diabetes make sense of, and integrate, these feelings into their life., Design, Setting and Participants: A secondary analysis of narrative interviews with 14 patients with type 2 diabetes who are part of a website project., Main Outcome Measures: Grounded theory-based analysis of narrative interviews, consisting of open, axial and selective coding., Results: People with type 2 diabetes felt obliged to give up many pleasures and live a life of abstinence. They perceived a pressure to display a modest culinary lifestyle via improved laboratory test results and weight. Their verbal efforts to reassure and distance themselves from excessiveness indicate a high moral pressure. With regard to the question of how to abstain, food and behaviour were classified into healthy and unhealthy. Personal rules sometimes led to surprising experiences of freedom., Conclusions: People with diabetes have internalised that their behaviour is a barrier to successful treatment. They experience an intensive pressure to show abstinence and feel misjudged when their efforts have no visible effect. Taking into account this moral pressure, and listening to patients' personal efforts and strategies to establish healthy behaviours, might help to build a trusting relationship with healthcare providers., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Although determinants of place of death have been investigated in several studies, there is a lack of knowledge on factors associated with dying at home from the general practice perspective., Objectives: To identify factors associated with dying at home for patients in German general practice., Methods: In a retrospective study, general practitioners of 30 general practices were asked to provide data for all patients aged 18 years or older who died within the last 12 months, using a self-developed questionnaire. 'Dying in hospital' was defined as dying in hospital or hospice and 'dying at home' as dying at one's usual residence including the nursing home. Multiple logistic regression analyses were used to determine factors associated with 'dying at home'; odds ratios (ORs) and their 95% confidence intervals (CI) were calculated as measures of effect size., Results: Of 439 deceased patients, 52.2% died at home, and 47.8% died in hospital or hospice. Determinants for dying at home were patients' care in the last 48 hours of life by family members (OR: 7.8, 95% CI: 3.4-18.0), by general practitioners (GPs) (OR: 7.3, 4.2-12.9) and living in a nursing home (OR: 3.8, 1.7-8.3). In the adjusted model, low comorbidity was positively associated (OR: 3.2, 1.4-7.0), and low functional health status (Karnofsky performance status) was negatively associated with dying at home (OR: 0.3, 0.1-0.7)., Conclusion: Apart from patient-related factors such as comorbidity and health status, care by family members and GPs respectively, were determinants of dying at home.

Background: In contrast to objective structured clinical examinations (OSCEs), mini-clinical evaluation exercises (mini-CEXs) take place at the clinical workplace. As both mini-CEXs and OSCEs assess clinical skills, but within different contexts, this study aims at analyzing to which degree students' mini-CEX scores can be predicted by their recent OSCE scores and/or context characteristics., Methods: Medical students participated in an end of Year 3 OSCE and in 11 mini-CEXs during 5 different clerkships of Year 4. The students' mean scores of 9 clinical skills OSCE stations and mean 'overall' and 'domain' mini-CEX scores, averaged over all mini-CEXs of each student were computed. Linear regression analyses including random effects were used to predict mini-CEX scores by OSCE performance and characteristics of clinics, trainers, students and assessments., Results: A total of 512 trainers in 45 clinics provided 1783 mini-CEX ratings for 165 students; OSCE results were available for 144 students (87%). Most influential for the prediction of 'overall' mini-CEX scores was the trainers' clinical position with a regression coefficient of 0.55 (95%-CI: 0.26-0.84; p < .001) for residents compared to heads of department. Highly complex tasks and assessments taking place in large clinics significantly enhanced 'overall' mini-CEX scores, too. In contrast, high OSCE performance did not significantly increase 'overall' mini-CEX scores., Conclusion: In our study, Mini-CEX scores depended rather on context characteristics than on students' clinical skills as demonstrated in an OSCE. Ways are discussed which focus on either to enhance the scores' validity or to use narrative comments only.

Background: Many patients with inflammatory bowel disease strongly believe that food or certain food products heavily influence the symptoms or even trigger acute flare-ups. Unfortunately, there is no generalizable information for these patients, and therefore no effective diet has been identified to date., Methods: The narrative interviews we used for this study provide the basis for the German website www.krankheitserfahrungen.de . Maximum-variation sampling was used to include a broad range of experiences and a variety of different factors that might influence people's experiences. The sample included men and women of different age groups and social and ethnic backgrounds from across Germany. The interviews were analyzed using grounded theory., Results: Four interrelated categories emerged: managing uncertainty, eating: between craving and aversion, being different and professional help as a further source of uncertainty. The most important issue for our responders was the handling of uncertainty and to find a way between desire for, and aversion against, eating. Many participants described difficulties during formal social occasions such as weddings, birthdays, or when going out to a restaurant., Conclusions: Many of the experiences the participants reported in their daily struggle with food and their illness, such as cravings for and abstaining from certain foods, were rather unusual and often stressful. Because they decided not to go out in public any longer, some of the interviewees experienced even more social isolation than they did before. Health professionals need to become more involved and not only advice about food and eating, but also help their patients find strategies for avoiding social isolation.

Background: The vascular hypothesis of multiple sclerosis (MS), called chronic cerebrospinal venous insufficiency (CCSVI), and its treatment (known as liberation therapy) was immediately rejected by experts but enthusiastically gripped by patients who shared their experiences with other patients worldwide by use of social media, such as patient online forums. Contradictions between scientific information and lay experiences may be a source of distress for MS patients, but we do not know how patients perceive and deal with these contradictions., Objective: We aimed to understand whether scientific and experiential knowledge were experienced as contradictory in MS patient online forums and, if so, how these contradictions were resolved and how patients tried to reconcile the CCSVI debate with their own illness history and experience., Methods: By using critical discourse analysis, we studied CCSVI-related posts in the patient online forum of the German MS Society in a chronological order from the first post mentioning CCSVI to the time point when saturation was reached. For that time period, a total of 117 CCSVI-related threads containing 1907 posts were identified. We analyzed the interaction and communication practices of and between individuals, looked for the relation between concrete subtopics to identify more abstract discourse strands, and tried to reveal discourse positions explaining how users took part in the CCSVI discussion., Results: There was an emotionally charged debate about CCSVI which could be generalized to 2 discourse strands: (1) the "downfall of the professional knowledge providers" and (2) the "rise of the nonprofessional treasure trove of experience." The discourse strands indicated that the discussion moved away from the question whether scientific or experiential knowledge had more evidentiary value. Rather, the question whom to trust (ie, scientists, fellow sufferers, or no one at all) was of fundamental significance. Four discourse positions could be identified by arranging them into the dimensions "trust in evidence-based knowledge," "trust in experience-based knowledge," and "subjectivity" (ie, the emotional character of contributions manifested by the use of popular rhetoric that seemed to mask a deep personal involvement)., Conclusions: By critical discourse analysis of the CCSVI discussion in a patient online forum, we reconstruct a lay discourse about the evidentiary value of knowledge. We detected evidence criteria in this lay discourse that are different from those in the expert discourse. But we should be cautious to interpret this dissociation as a sign of an intellectual incapability to understand scientific evidence or a naïve trust in experiential knowledge. Instead, it might be an indication of cognitive dissonance reduction to protect oneself against contradictory information.

Objective: The aim of this study was to analyse the psychometric properties of the short version of the Calgary Cambridge Guides and to decide whether it can be recommended for use in the assessment of communications skills in young undergraduate medical students., Methods: Using a translated version of the Guide, 30 members from the Department of General Practice rated 5 videotaped encounters between students and simulated patients twice. Item analysis should detect possible floor and/or ceiling effects. The construct validity was investigated using exploratory factor analysis. Intra-rater reliability was measured in an interval of 3 months, inter-rater reliability was assessed by the intraclass correlation coefficient., Results: The score distribution of the items showed no ceiling or floor effects. Four of the five factors extracted from the factor analysis represented important constructs of doctor-patient communication The ratings for the first and second round of assessing the videos correlated at 0.75 (p<0.0001). Intraclass correlation coefficients for each item ranged were moderate and ranged from 0.05 to 0.57., Conclusions: Reasonable score distributions of most items without ceiling or floor effects as well as a good test-retest reliability and construct validity recommend the C-CG as an instrument for assessing communication skills in undergraduate medical students. Some deficiencies in inter-rater reliability are a clear indication that raters need a thorough instruction before using the C-CG.

Objective: To evaluate the efficacy of video-assisted patient education to modify behavior., Methods: Fourteen databases were searched for articles published between January 1980 and October 2013, written in English or German. Behavioral change as main outcome had to be assessed by direct measurement, objective rating, or laboratory data., Results: Ten of the 20 reviewed studies reported successful behavioral modification in the treatment group. We discerned three different formats to present the information: didactic presentation (objective information given as verbal instruction with or without figures), practice presentation (real people filmed while engaged in a specific practice), narrative presentation (real people filmed while enacting scenes). Seven of the ten studies reporting a behavioral change applied a practice presentation or narrative presentation format., Conclusion: The effectiveness of video-assisted patient education is a matter of presentation format. Videos that only provide spoken or graphically presented health information are inappropriate tools to modify patient behavior. Videos showing real people doing something are more effective., Practice Implications: If researchers wish to improve a skill, a model patient enacting the behavior seems to be the best-suited presentation format. If researchers aim to modify a more complex behavior a narrative presentation format seems to be most promising., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Inappropriate prescriptions of Proton pump inhibitors (PPIs) initiated in hospitals are frequently continued in primary care. No research has explored why general practitioners (GPs) continue or discontinue inappropriate drug therapy., Objectives: This study aims to describe factors and motives associated with the continuation of inappropriate prescriptions of PPIs in primary care., Methods: Semi-structured qualitative interviews on basis of a purposive sampling of five GPs who often continued inappropriate prescriptions and five GPs who frequently discontinued inappropriate drug therapy with PPIs (10 GPs total, of which four were female and six male)., Results: Although all GPs enrolled in the study were enthusiastic about the effectiveness of PPIs, differences between the continuing and discontinuing GPs exists in three areas: The two groups varied ( 1 ) in awareness of indications and general attitudes towards prescribing ( 2 ) in perception of the hospital physicians' competence in prescribing and ( 3 ) appreciation of general prescribing conditions in hospitals., Conclusion: Differences between the continuing and discontinuing GPs were found in their level of knowledge and their perceptions of the hospital physicians' competence and the threshold to prescribing in hospitals. Financial pressure and possible adverse effects demand a more balanced and evidence-based prescribing of PPIs. Attempts to change behaviour should focus on the GPs' awareness of indications for PPIs, NSAID risks, and prescribing approaches in hospitals. Default prescribing in hospital demands critical examination.

Background: Lifestyle counselling is a pivotal aspect of diabetes care. But general practitioners (GPs) often have problems in finding their role in patients' weight management. The aims of this study were to investigate the experiences of type 2 diabetes patients with lifestyle counselling from their GPs and to explore how patients' preferences regarding counselling are embedded in the context of self-management and wider cultural aspects of nutrition., Methods: Narrative interviews were conducted with 35 people with type 2 diabetes aged between 35 and 77 years. The interviews were transcribed verbatim and analysed using the thematic framework method., Results: Many patients had a strong feeling of personal responsibility for weight reduction as integral to diabetes self-management but found it difficult to integrate the changes their disease requires into their self-management activities. They attached great importance to their GPs' advice on diet. While some patients appreciated direct communication, others regarded dramatic pictures as either unhelpful or offending. A serious problem was the incompatibility of the dietary recommendations with daily life resulting in a reluctance to adjust the whole diet to the needs of diabetes care., Conclusions: Ambivalence towards patient self-management and tensions between the necessary changes to patients' lifestyles and their culture, makes the GP's role difficult and full of conflict. Instead of focusing exclusively on the guidelines of diabetes management and provision of information, GPs should explore the patients' capabilities of self-management through open communication and accept their patients' wishes to protect nutrition as part of their culture.

Purpose: To study drug persistence for antihypertensive treatment considering typical patient behaviour including extended drug holidays or irregular repeat prescriptions., Methods: We used prescription data from a German statutory health insurance to follow up patients for 4 years. Medication persistence was defined as the continued use of a specific drug class, therapy persistence as the continued use of any antihypertensive drug. We applied 2 different interval criteria within which a repeat prescription had to be issued: 180 and 360 days., Results: A total of 9,513 patients started an antihypertensive therapy between 2006 and 2008. Applying the 180-day (360-day) interval criterion, 28 % (66 %) of the patients starting therapy with a beta-blocker were still medication-persistent after 4 years. The rates were similar for angiotensin-II receptor blockers (ARBs; 30 % and 69 % respectively) or angiotensin-converting enzyme (ACE) inhibitors (28 % and 61 % respectively). Looking at therapy persistence, these rates were 44 % (79 %) when an ACE inhibitor was the initial drug, 46 % (82 %) for ARBs. On average, even of those who were defined as therapeutically persistent with the 360 days criterion, half received a repeat prescription within 96 days, three quarters within 131 days-with a median supply of 1.2 units per day and 1.25 defined daily doses., Conclusion: By applying more patient-orientated criteria, we found that many patients were therapy-persistent and received a prescription at the appropriate time. Therapy persistence was nearly independent of the initial agent; thus, drug persistence may not be an argument in favour of choosing a certain drug as a first-line option.

Background: Increasing numbers of patients are raising their voice in online forums. This shift is welcome as an act of patient autonomy, reflected in the term "expert patient". At the same time, there is considerable concern that patients can be easily misguided by pseudoscientific research and debate. Little is known about the sources of information used in health-related online forums, how users apply this information, and how they behave in such forums., Objective: The intent of the study was to identify (1) the sources of information used in online health-related forums, and (2) the roles and behavior of active forum visitors in introducing and disseminating this information., Methods: This observational study used the largest German multiple sclerosis (MS) online forum as a database, analyzing the user debate about the recently proposed and controversial Chronic Cerebrospinal Venous Insufficiency (CCSVI) hypothesis. After extracting all posts and then filtering relevant CCSVI posts between 01 January 2008 and 17 August 2012, we first identified hyperlinks to scientific publications and other information sources used or referenced in the posts. Employing k-means clustering, we then analyzed the users' preference for sources of information and their general posting habits., Results: Of 139,912 posts from 11,997 threads, 8628 posts discussed or at least mentioned CCSVI. We detected hyperlinks pointing to CCSVI-related scientific publications in 31 posts. In contrast, 2829 different URLs were posted to the forum, most frequently referring to social media, such as YouTube or Facebook. We identified a total of 6 different roles of hyperlink posters including Social Media Fans, Organization Followers, and Balanced Source Users. Apart from the large and nonspecific residual category of the "average user", several specific behavior patterns were identified, such as the small but relevant groups of CCSVI-Focused Responders or CCSVI Activators., Conclusions: The bulk of the observed contributions were not based on scientific results, but on various social media sources. These sources seem to contain mostly opinions and personal experience. A small group of people with distinct behavioral patterns played a core role in fuelling the discussion about CCSVI., Competing Interests: Conflicts of Interest: None declared.

Background: Frequent attenders receive much attention in primary care research. Defining frequent attendance is crucial for an adequate view on this group of demanding patients. We aimed to develop a purely contact-based definition of "frequent attendance" and to apply it to real patients., Methods: From electronic records of 123 general practices in Germany, patients' inter-contact intervals (ICI) between two consecutive doctor-patient-contacts were calculated in this retrospective observational study. ICI less than 7 days were labelled "frequent attendance", patients with 60% or more of such intervals "frequent attenders (new view)". In contrast, patients having at least 24 contacts per calendar year were considered "frequent attenders (traditional view)". Both groups were analysed in their diseases and demands, using multiple logistic regression., Results: A total of 177,057 patients with at least 3 ICI in 1996 until 2006 yielded 4,408,033 ICI. One third were "short" ICI (less than 7 days), resulting in 19,759 (11.2%) frequent attenders (new). In contrast, 22,921 (12.9%) patients were frequent attenders (traditional). Compared to non-frequent attenders, frequent attenders (new) were more likely to have pneumonia (OR 1.66), stroke (OR 1.49), dementia (OR 1.46), or severe substance abuse (OR 1.44), also to need home visits or emergency attention. Frequent attenders (traditional) were more likely to have dementia (OR 2.76) or stroke (OR 2.06), and by far to need home visits (OR 5.43; all p < 0.001)., Conclusions: A new measure, the interval in days of two consecutive face-to-face contacts (ICI), widens our perspective on frequent attenders in general practice. In many cases, their consultation behaviour and need for medical services seem to follow "disease logic".

Aim of the study was to explore meaning and consequences for patients for having their illness experiences published in the internet. Patients who participated in the establishment of a research-based internet website on illness experiences were interviewed about their experiences of taking part in the project. 14 patients with diabetes and 29 patients with chronic pain participated in the follow-up. They were interviewed with an open narrative and semi-structured approach about their motives and experiences of taking part in the project and the impact of the publication on them. Interview transcripts were coded and aggregated in a computer-assisted thematic analysis. Patients unanimously evaluated their participation positively. Many of them reported that it had been an intense and relevant experience, which equalled an intervention. They conveyed that the special effort of the researchers to establish a trustful and caring relationship had proven of value and led to a high identification of the participants with the aims of the website., (© Georg Thieme Verlag KG Stuttgart · New York.)

For some time now, antibiotic-resistant bacterial strains have been found in the human population, in foods, in livestock and wild animals, as well as in surface waters. The entry of antibiotics and resistant bacterial strains into the environment plays an important role in the spread of antibiotic resistance. The goal of the present study was to monitor the entry of antibiotic resistances into the environment through the contamination of wastewater. To assess the extent of transmission of antibiotic resistances from human sources into the environment, the resistance patterns of Escherichia coli strains isolated from human patients have been compared to those found in strains isolated from sewage sludge. Our results may indicate if resistances to particular antibiotics are more prone than others to spread into the environment. To monitor the increase of specific resistances over time, samples taken in the years 2000 and 2009 were analysed. Our study shows that for some antibiotics a parallel development of resistance patterns has taken place in both patient and environmental samples over time. For other sets of antibiotics, independent developments have occurred in the samples. A clear increase of multi-resistant E. coli strains over time was observed in samples from both sources.

Background: Although it is taken for granted that history-taking and communication skills are learnable, this learning process should be confirmed by rigorous studies, such as randomized pre- and post-comparisons. The purpose of this paper is to analyse whether a communication course measurably improves the communicative competence of third-year medical students at a German medical school and whether technical or emotional aspects of communication changed differently., Method: A sample of 32 randomly selected students performed an interview with a simulated patient before the communication course (pre-intervention) and a second interview after the course (post-intervention), using the Calgary-Cambridge Observation Guide (CCOG) to assess history taking ability., Results: On average, the students improved in all of the 28 items of the CCOG. The 6 more technically-orientated communication items improved on average from 3.4 for the first interview to 2.6 in the second interview (p < 0.0001), the 6 emotional items from 2.7 to 2.3 (p = 0.023). The overall score for women improved from 3.2 to 2.5 (p = 0.0019); male students improved from 3.0 to 2.7 (n.s.). The mean interview time significantly increased from the first to the second interview, but the increase in the interview duration and the change of the overall score for the students' communication skills were not correlated (Pearson's r = 0.03; n.s.)., Conclusions: Our communication course measurably improved communication skills, especially for female students. These improvements did not depend predominantly on an extension of the interview time. Obviously, "technical" aspects of communication can be taught better than "emotional" communication skills.

Background:  Inappropriate prescriptions of proton pump inhibitors (PPI) in hospital and primary care have been widely reported. Recommendations from hospital have been implicated as one reason for inappropriate prescriptions of PPI in primary care. Objective:  To quantify the amount of appropriate PPI recommendations in hospital discharge letters and the influence of these recommendations on general practitioners' (GPs') PPI-prescriptions. Materials and Methods:  This is an observational study in 31 primary care practices. We identified patients discharged from hospital with PPI recommendation between 2006 and 2007 and assessed practice records and PPI prescription six months prior and after hospital admission. Hospital recommendation for continuous PPI-treatment and continuation by GPs was classified as appropriate, inappropriate or uncertain. Logistic regression analysis was used to calculate factors associated with indicated and non-indicated PPI continuation. Results:  In 263 (58%) out of 506 patients discharged from 35 hospitals with a PPI recommendation no indication could be found. Non-indicated PPIs were continued by GPs in 58% for at least 1 month. Indicated PPIs were discontinued in 33%. Two thirds of non-indicated PPIs were initiated in hospital. The strongest factor associated with non-indicated continuation was a PPI-prescription prior to hospital admission [OR: 3.0; 95% confidence interval (CI): 1.7-5.4]. This was also the strongest factor for continuation of an indicated PPI medication (OR: 3.2; 95% CI: 1.4-7.5). Conclusions:  We found a strong influence of hospital recommendations and previous prescriptions on PPI prescriptions after discharge. Hospitals should critically review their practice of recommending PPI and document indications. GPs should carefully assess hospital recommendations and their medication prior to admission to avoid over- and under-prescribing., (© 2012 Blackwell Publishing Ltd.)