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Abstract Background There has been a marked increase in the use of complementary and alternative medicine (CAM) in recent years worldwide. In Germany, apart from 'Heilpraktiker' (= state-licensed, non-medical CAM practitioners), some general practitioners (GPs) provide CAM in their practices. This paper aims to explore the attitudes of GPs about the role of CAM in Germany, in relation to the healthcare system, quality of care, medical education and research. Furthermore, experiences of GPs integrating CAM in their daily practice were explored. Methods Using a qualitative methodological approach 3 focus groups with a convenience sample of 17 GPs were conducted. The discussions were transcribed verbatim and analysed using qualitative content analysis. Results The majority of the participating GPs had integrated one or more CAM therapies into their every-day practice. Four key themes were identified based on the topics covered in the focus groups: the role of CAM within the German healthcare system, quality of care, education and research. Within the theme 'role of CAM within the healthcare system' there were five categories: integration of CAM, CAM in the Statutory Health Insurance, modernisation of the Statutory Health Insurance Act, individual healthcare services and 'Heilpraktiker'. Regarding quality of care there were two broad groups of GPs: those who thought patients would benefit from standardizing CAM and those who feared that quality control would interfere with the individual approach of CAM. The main issues identified relating to research and education were the need for the development of alternative research strategies and the low quality of existing CAM education respectively. Conclusion The majority of the participating GPs considered CAM as a reasonable complementary approach within primary care. The study increased our understanding of GPs attitudes about the role of CAM within the German healthcare system and the use of 'Heilpraktiker' as a competing CAM-provider. It seems to be a need for increased funding for research, better education and remuneration by the Statutory Health Insurance in order to improve access to 'Integrative medicine' in Germany.

Abstract Background To assess factors associated with visits to GPs, orthopaedists, and non-physician practitioners of complementary medicine (alternative practitioners) by primary care patients with osteoarthritis (OA). Methods Cross-sectional survey among 1250 consecutively addressed patients from 75 primary care practices in Germany. All patients suffered from OA of the knee or hip according to ACR criteria. They received questionnaires collecting sociodemographic data, data about health service utilisation, prescriptions, comorbidities. They also included established instruments as the Arthritis Impact Measurement Scale (AIMS2-SF) to assess disease-specific quality of life and the Patient Health Questionnaire (PHQ-9) to assess depression. Hierarchical stepwise multiple linear regression models were used to reveal significant factors influencing health service utilization. Results 1021 of 1250 (81.6%) questionnaires were returned. Nonrespondents did not differ from participants. Factors associated with health service use (HSU) varied between providers of care. Not being in a partnership, achieving a high score on the PHQ-9, increased pain severity reflected in the “symptom” scale of the AIMS2-SF, and an increased number of drug prescriptions predicted a high frequency of GP visits. The PHQ-9 score was also a predictor for visits to orthopaedists, as were previous GP contacts, a high score in the "symptom" scale as well as a high score in the "lower limb scale" of the AIMS2-SF. Regarding visits to alternative practitioners, a high score in the AIMS -"social" scale was a positive predictor as older people were less likely to visit them. Conclusion Our results emphasize the need for awareness of psychological factors contributing to the use of health care providers. Addressing the revealed factors associated with HSU appropriately may lead to decreased health care utilization. But further research is needed to assess how this can be done successfully.

Background: There has been a marked increase in the use of complementary and alternative medicine (CAM) in recent years worldwide. In Germany, apart from 'Heilpraktiker' (= state-licensed, non-medical CAM practitioners), some general practitioners (GPs) provide CAM in their practices. This paper aims to explore the attitudes of GPs about the role of CAM in Germany, in relation to the healthcare system, quality of care, medical education and research. Furthermore, experiences of GPs integrating CAM in their daily practice were explored.Methods: Using a qualitative methodological approach 3 focus groups with a convenience sample of 17 GPs were conducted. The discussions were transcribed verbatim and analysed using qualitative content analysis.Results: The majority of the participating GPs had integrated one or more CAM therapies into their every-day practice. Four key themes were identified based on the topics covered in the focus groups: the role of CAM within the German healthcare system, quality of care, education and research. Within the theme 'role of CAM within the healthcare system' there were five categories: integration of CAM, CAM in the Statutory Health Insurance, modernisation of the Statutory Health Insurance Act, individual healthcare services and 'Heilpraktiker'. Regarding quality of care there were two broad groups of GPs: those who thought patients would benefit from standardizing CAM and those who feared that quality control would interfere with the individual approach of CAM. The main issues identified relating to research and education were the need for the development of alternative research strategies and the low quality of existing CAM education respectively.Conclusion: The majority of the participating GPs considered CAM as a reasonable complementary approach within primary care. The study increased our understanding of GPs attitudes about the role of CAM within the German healthcare system and the use of 'Heilpraktiker' as a competing CAM-provider. It seems to be a need for increased funding for research, better education and remuneration by the Statutory Health Insurance in order to improve access to 'Integrative medicine' in Germany. [ABSTRACT FROM AUTHOR]

Background: Adequate health care in correctional facilities is often limited by staff shortage, which entails time-consuming consultations with physicians outside of these facilities. Video consultations (VC) have been implemented in many different health care settings and may also be useful in correctional facilities. As part of a pilot project, synchronous VC were implemented in five correctional facilities in Germany in June 2018. The aim of this study was to describe the implementation process from the providers' perspective and to identify factors promoting or inhibiting the implementation process of VC with a focus on interprofessional collaboration between nursing staff and telemedicine physicians., Methods: As part of the mixed-methods evaluation of the pilot project, site visits to the five correctional facilities were carried out. Nursing staff from the five correctional facilities (n=49) and telemedicine physicians (n=10) were asked to participate in interviews and a questionnaire survey. Interviews were analyzed using qualitative content analysis and questionnaires were evaluated using descriptive statistical methods. The results from both data sources were integrated and discussed in the framework of Normalization Process Theory., Results: Interviews were conducted with 24.5% (n=12) of nursing staff and 20.0% (n=2) of telemedicine physicians, while questionnaires were returned by 22.5% (n=11) of nursing staff and 33.3% (n=3) of telemedicine physicians. VC with general practitioners and psychiatrists were perceived as an additional support during times when physicians were absent from the correctional facilities. Allocating telemedicine physicians to specific correctional facilities might further improve interprofessional collaboration with nursing staff during VC. Inhibiting factors comprised the lack of integrating nursing staff into the implementation process, increased workload, insufficient training and the implementation of VC at an inconvenient time., Conclusions: To summarize, VC are a promising supplement to face-to-face health care in correctional facilities despite several limitations. These might be compensated by improving interprofessional cooperation and by integrating telemedicine physicians into local health care teams., (© 2023. The Author(s).)

Background: Sweden has a largely tax-funded health care system that aims at providing equal access for everyone. However, the individual's perception and experience of the health care system remains a relevant topic for researchers. The aim of this study is to learn the patient's perspective on how patients and professionals negotiate in the social context of the Swedish health care system., Methods: Eight essays that had spontaneously been contributed to a medical writing contest were analyzed using narrative methods. Narratives were defined as a sequence of clauses that correspond to an order of events in the narrator's biography. The analysis comprised a three-step process. First, the essays were read and narratives were extracted. Second, an agency analysis was performed. Third, an analysis of social positioning was employed., Results: The Swedish health care system provides the social context and background for negotiations between patients and professionals. The narrators position the protagonists of the illness narratives as either patients or guardians of underage patients. The protagonists meet health care representatives in negotiation situations. Due to the lack of emotional connection between the negotiating parties, impossible situations arise. False promises are made which ultimately result in the patients' suffering. Thus, all negotiations failed from the narrators' perspective., Conclusion: The narrators invited their audience to solve negotiation situations differently. This study discusses some actions that may help navigate negotiation situations: Health care providers should acknowledge the patient's or guardian's social position and dilemma, allow emotions, involve all parties in the decision-making process and manage expectations. Writing competitions may provide a tool for experience-based assessment of health care systems.

Background: The STarT-Back-Approach (STarT: Subgroups for Targeted Treatment) was developed in the UK and has demonstrated clinical and cost effectiveness. Based on the results of a brief questionnaire, patients with low back pain are stratified into three treatment groups. Since the organisation of physiotherapy differs between Germany and the UK, the aim of this study is to explore German physiotherapists' views and perceptions about implementing the STarT-Back-Approach., Methods: Three two-hour think-tank workshops with physiotherapists were conducted. Focus groups, using a semi-structured interview guideline, followed a presentation of the STarT-Back-Approach, with discussions audio recorded, transcribed and qualitatively analysed using content analysis., Results: Nineteen physiotherapists participated (15 female, mean age 41.2 (SD 8.6) years). Three main themes emerged, each with multiple subthemes: 1) the intervention (15 subthemes), 2) the healthcare context (26 subthemes) and 3) individual characteristics (8 subthemes). Therapists' perceptions of the extent to which the STarT-Back intervention would require changes to their normal clinical practice varied considerably. They felt that within their current healthcare context, there were significant financial disincentives that would discourage German physiotherapists from providing the STarT-Back treatment pathways, such as the early discharge of low-risk patients with supported self-management materials. They also discussed the need for appropriate standardised graduate and post-graduate skills training for German physiotherapists to treat high-risk patients with a combined physical and psychological approach (e.g., communication skills)., Conclusions: Whilst many German physiotherapists are positive about the STarT-Back-Approach, there are a number of substantial barriers to implementing the matched treatment pathways in Germany. These include financial disincentives within the healthcare system to early discharge of low-risk patients. Therapists also highlighted the need for solutions in respect of scalable physiotherapy training to gain skills in combined physical and psychological approaches.

Background: Research on inequities in access to health care among asylum-seekers has focused on disparities between asylum-seekers and resident populations, but little attention has been paid to potential inequities in access to care within the group of asylum-seekers. We aimed to analyse the principles of horizontal equity (i.e., equal access for equal need irrespective of socioeconomic status, SES) and vertical equity (higher allocation of resources to those with higher need) among asylum-seekers in Germany., Methods: We performed a secondary exploratory analysis on cross-sectional data obtained from a population-based questionnaire survey among all asylum-seekers (aged 18 or above) registered in three administrative districts in Germany during the three-month study period (N = 1017). Data were collected on health care access (health care utilisation of four types of services and unmet medical need), health care need (approximated by sex, age and self-rated health status), and SES (highest educational attainment and subjective social status, SSS). We calculated odds ratios and 95% confidence intervals (CI) in multiple logistic regression models to analyse associations between SES indicators and access to health care under control of need., Results: We contacted 60.4% (614) of the total asylum-seekers population, of which 25.4% (N = 156) participated in the study. Educational attainment showed no significant effect on health care access in crude models, but was positively associated with utilisation of psychotherapists and hospital admissions in adjusted models. Higher SSS was positively associated with health care utilisation of all types of services. The odds of hospitals admissions for asylum-seekers in the medium and highest SSS category were 3.18 times [1.06, 9.59] and 1.6 times [0.49, 5.23] the odds of those in the lowest SSS category. After controlling for need variables none of the SES indicators were significantly associated with measures of access to care, but a positive association remained, indicating higher utilisation of health care among asylum-seekers with higher SES. Age, sex or general health status were the only significant predictors of health care utilisation in fully adjusted models. The adjusted odds of reporting unmet medical needs among asylum-seekers with "fair/bad/very bad" health status were 2.16 times [0.84, 5.59] the odds of those with "good/very good" health status., Conclusion: Our findings revealed that utilisation of health services among asylum-seekers is associated with higher need (vertical equity met). Horizontal equity was met with respect to educational attainment for most outcomes, but a social gradient in health care utilisation was observed across SSS. Further confirmatory research is needed, especially on potential inequities in unmet medical need and on measurements of SES among asylum-seekers.

Background: 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., Methods: 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., Results: 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)., Conclusion: 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.

Background: To assess factors associated with visits to GPs, orthopaedists, and non-physician practitioners of complementary medicine (alternative practitioners) by primary care patients with osteoarthritis (OA)., Methods: Cross-sectional survey among 1250 consecutively addressed patients from 75 primary care practices in Germany. All patients suffered from OA of the knee or hip according to ACR criteria. They received questionnaires collecting sociodemographic data, data about health service utilisation, prescriptions, comorbidities. They also included established instruments as the Arthritis Impact Measurement Scale (AIMS2-SF) to assess disease-specific quality of life and the Patient Health Questionnaire (PHQ-9) to assess depression. Hierarchical stepwise multiple linear regression models were used to reveal significant factors influencing health service utilization., Results: 1021 of 1250 (81.6%) questionnaires were returned. Nonrespondents did not differ from participants. Factors associated with health service use (HSU) varied between providers of care. Not being in a partnership, achieving a high score on the PHQ-9, increased pain severity reflected in the "symptom" scale of the AIMS2-SF, and an increased number of drug prescriptions predicted a high frequency of GP visits. The PHQ-9 score was also a predictor for visits to orthopaedists, as were previous GP contacts, a high score in the "symptom" scale as well as a high score in the "lower limb scale" of the AIMS2-SF. Regarding visits to alternative practitioners, a high score in the AIMS -"social" scale was a positive predictor as older people were less likely to visit them., Conclusion: Our results emphasize the need for awareness of psychological factors contributing to the use of health care providers. Addressing the revealed factors associated with HSU appropriately may lead to decreased health care utilization. But further research is needed to assess how this can be done successfully.