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Introduction: The approaches to cope with the challenges of providing medical care to patients with symptoms of long COVID are multidisciplinary and involve primary care worldwide. The aim of this study was to explore the experiences and ideas for continued development of medical care of long COVID from the patients' (PAT) and primary care practitioners' (PCP) perspective., Methods: Between the third and fourth COVID-19 wave in Germany (July to September 2021), a mixed methods study was conducted by inviting patients and PCPs in two neighboring districts (urban and rural) in Baden-Wuerttemberg to a paper-based questionnaire with both closed and open questions. On the part of the PCPs a written, anonymized, complete survey was conducted, on the part of symptomatic COVID long-haulers an anonymized online survey with announcement of the study by multiple recruiting processes. Qualitative content analysis was applied to free text entries. The quantitative results were analyzed mainly descriptively., Results: The responses of n = 72 PCPs (response rate 12%) and n = 126 PAT showed a heterogeneous assessment regarding the satisfaction with medical care for long COVID as well as the perception of the attitude towards patients and their disease in both groups. Uncertainty and dealing with it played a relevant role in both groups as well. The professional medical knowledge was assessed by 3,1 (self-assessment PCPs) and 3,2 (PAT) on average using a five-point Likert scale (1 = not applicable; 5 = applicable). The request for a structured overall concept with competent contact points and coordination of medical care for long COVID patients emerged out of the statements of both groups., Conclusion: The results support an interdisciplinary, intersectoral and interprofessional stepped-care concept for long COVID in Germany with PCPs as the first contact persons, integration of specialized contact points and knowledge transfer. Therefore, it appears to be both reasonable and appropriate to establish regional networks with links between regional outpatient medical care structures and the university medical sector., (Copyright © 2022. Published by Elsevier GmbH.)

Introduction: Due to individual care needs, the provision of care to patients with two or more chronic diseases (multimorbidity) is described as complex. In addition, the number of chronically ill people is increasing, due in part to demographic changes which pose a challenge, especially for outpatient primary care. In order to fulfil patients' needs and to promote self-management as a central care element of chronically ill patients, the use of eHealth applications increases. TelePraCMan will be developed as one of these applications and includes a symptom-based electronic diary, which will be implemented in the established German disease management programme 'PraCMan'. This study is conducted as a part of the TelePraCMan project and aims to detect the needs of potential end users (physicians, medical assistants, patients)., Methods: In the TelePraCMan development phase, an explorative cross-sectional study was conducted with potential end users of the TelePraCMan app (patients, physicians and medical assistants). For this purpose, a written survey was conducted in Baden-Wurttemberg between April 2019 and March 2020. The survey covered smartphone usage behaviour, technology affinity using the standardised questionnaire TA-EG, support network for technical questions and sociodemographic data., Results: A total of n=202 patients (n=98), physicians (n=58) and medical assistants (n=43) participated in the survey. Concerning smartphone use, 78.2 % of the participants stated that the function used most frequently was writing short messages. Health apps were the least used function (9.6 %). Furthermore, patients (12.6 %) use health apps more often than medical assistants (10.3%) and doctors (4.4 %). Participants aged 50 and younger were found to have a higher affinity for technology (mean=3.20, SD=0.51) than participants over 50 years of age (mean=2.98, SD=0.67). Older, multimorbid respondents had a particularly low affinity for technology (mean=2.52, SD=0.69). 10.9 % of the over-fifties and 12.5 % of the multimorbid persons felt able to fix any technical problems on their own without help. Multimorbid participants over the age of 50 were observed to prefer personal support over internet-based support., Discussion: On average, multimorbid respondents in the age group over 50 have a lower affinity for technology than respondents aged under 50 without multimorbidity. The most frequent negative attitude towards electronic devices is also found among patients over 50 years of age, who are expected to be the main target group of the TelePraCMan app. These findings can be used to derive requirements for the design and development of functions of the app, as well as accompanying measures, such as intuitive and simple user interface, a telephone hotline to support users, close consultation with users on the planned functions, and more., Conclusion: Based on this survey, we were able to determine the needs of the future target group of the TelePraCMan app. This is seen as a starting point for the development of an implementation strategy and the pilot testing of the app in primary care., (Copyright © 2022. Published by Elsevier GmbH.)

Background: Germany is facing a shortage of primary care physicians (general practitioners, GPs). To improve post-graduate training in general practice, competency centres were established across Germany. The core of their work is a seminar programme. It was observed that some GP trainees constantly participate, while others are seldomly seen. The aim of this study was to explore what helps and what hinders constant participation., Methods: GP trainees of the Verbundweiterbildung plus Baden-Württemberg (2008 - 2017), predecessor of the KWBW Verbundweiterbildung plus© program (2017 - present), were included in the study. First, participation in the years 2014 and 2015 was analysed. We recruited the very active as well as the no-show participants for semi-structured telephone interviews. Content analysis was performed by three independent scientists., Results: Participation of n=353 trainees was analysed. N=30 trainees participated in the study (including n=13 no show). The average interview length was 25minutes (13-36minutes). Trainees felt motivated by practice-oriented, varying and learner-oriented subjects. They highlighted the professional and personal interaction and its networking effects. Participants favoured lecturing during working days, topics structuring daily training and supporting every day practice. The seminar moderators' treasure trove of experience and their teaching competencies were regarded as essential. The fact that employers do not regularly grant time away from work to attend the training programme was cited as a major inhibiting factor. Other reasons given for non-attendance included long travel distances, repeat topics or an imbalance between gain of knowledge and social interactions, and finally, a high individual level of work strain, given the dual burden on those trying to combine work and family life and taking on the main responsibility for children., Conclusions: The main enablers (motivators) of participation were practice- and learner-oriented topics and beneficial social interactions. During the seminars, participants experience group membership and the enthusiastic (learning) atmosphere boosts trainees to proceed with their training and follow their career paths in general practice. Continuous participation requires protected time. Competence centres for postgraduate medical education should take these findings into consideration for quality management and programme planning, and, if possible, should initiate and evaluate appropriate countermeasures., (Copyright © 2021. Published by Elsevier GmbH.)

Background: There are only limited possibilities for doctors in outpatient services to establish quality management that is based on data-driven feedback regarding the quality of health care. However, transparency about one's own activities is a prerequisite for refining this quality. The aim of this project was to make the quality of care for patients with coronary heart disease (CHD) more transparent, use this as a basis to initiate improvement processes, and explore the framework conditions and factors promoting or inhibiting the intended improvement of health care quality., Method: 48 general practitioners (GPs) in 32 GP practices from a Bavarian doctors' network (Qualität und Effizienz, QuE) participated in the project. On the basis of claims data from the AOK-Bayern (a statutory health insurance in Bavaria), data from disease management programs (DMP) and medically documented data, 11 quality indicators for patients with CHD were calculated. The indicator scores were individually presented in feedback reports for each doctor's practice. These were the basis for two quality circles. The indicators were measured again after 12 months, and changes against the baseline measurement were registered. GPs from Bavaria formed the control group. Focus groups with the quality circle moderators and two participant surveys were used to identify promoting and inhibiting factors., Results: The baseline values showed a good level of care. Potential for improvement became apparent for pharmacotherapy with beta blockers and statins. After conducting the quality circles four of the eleven indicators showed an increase as intended ("beta blockers for CHD and cardiac insufficiency", "beta blockers after myocardial infarction", "statins", "successful blood pressure control"). For three of these indicators the increase rates were higher than those in the Bavarian control group. One indicator ("statins") was striking because of the wide variation of practice values suggesting differences in care within the network. The majority of participating doctors regarded the database as valid. Quality circles were highly appreciated as an opportunity for professional exchange among colleagues. The data-based feedback reports helped to make deficits in health care transparent and to identify actions that need to be taken. Barriers to implementing quality improvement measures in clinical practice became apparent., Discussion: Reflecting quality indicators in quality circles can effectively trigger quality improvement processes. Barriers would appear to exist, in particular, to the implementation of measures into daily practice routine. Additional organizational support offered by higher-level quality management structures, IT solutions for patient-related data processing as well as a system of financial compensation, which rewards professional concern for quality, may help to overcome the existing barriers., (Copyright © 2018. Published by Elsevier GmbH.)

Aim of the Study: This study compares doctors' and patients' assessments of the severity of postoperative complications reported by patients. Within the context of quality assurance and patient safety, the study aims to contribute to developing instruments to include patients' views for measuring postoperative complications., Methods: In a questionnaire development study 474 patients who had undergone different kinds of surgery were given a questionnaire and asked whether postoperative complications occurred, and if so, to describe these complications in free text and assesses their severity as "slight, temporary" or "extensive". In an additional study, the patients' written descriptions of their complications were presented independently to two doctors (general practitioner [GP], orthopaedic surgeon) who were asked to assess the severity from their point of view. The physicians were not aware of the patients' or the other physician's assessments., Results: 23.5 % of the patients participating in the survey reported postoperative complications in the questionnaire. Feedback from 80 of these patients included sufficient information for data analysis concerning the study's aim, including the description of their complication in free text. 47 (58.7 %) of these patients assessed their postoperative complications as being "slight, temporary", 33 (41.3 %) as being "extensive". The doctors, on the other hand, assessed the severity of the complications described by the patients much less often as "extensive" (GP: 20.0 %, orthopaedic surgeon: 11.3 %). In only 4 (12.0 %) of the 33 cases where the patient chose "extensive" both doctors also chose the assessment item "extensive". In 10 cases (30.3 %), one doctor's "extensive" assessment matched the patient's assessment, and in 19 cases (57.6 %) the patients but none of the doctors assessed the complications as being "extensive". There was a higher correlation between the GP's and the patients' assessments than between the orthopaedic surgeon's and the patients' ratings. Examples of patients' descriptions of their postoperative complications in free text as well as the corresponding assessments of patients and doctors are presented., Conclusions: Patients' views and assessments of postoperative complications are different from doctors' views. Adequate instruments for measuring the occurrence and severity of postoperative complications should be developed bringing the patients' perspectives into the doctors' assessments. Also, it might be useful to include questions addressing information received pre- and postoperatively about the expected postoperative course as well as communication with patients in the case of complications., (Copyright © 2018. Published by Elsevier GmbH.)

Background: The indication for a mitral valve intervention is an important patient-relevant parameter for the assessment of process quality and the comparison of healthcare providers. In this article, we describe the development of a corresponding quality indicator for an external hospital quality assurance (QA) procedure in Germany., Methods: An expert panel was set up by the aQua Institute to assist with the development of a QA procedure for mitral valve interventions and the associated quality indicators. In a comprehensive, systematic literature and evidence research, the American and European guidelines were identified as the best evidence available. Especially the more current American guideline formed the basis on which a quality indicator dealing with the correct indication for a mitral valve intervention was developed., Results: The developed quality indicator assesses the proportion of patients for whom an indication for a mitral valve intervention was determined in compliance with guideline recommendations. The indicator differentiates between surgical and catheter-based procedures. To determine whether or not the indication was correct, different medical parameters are included, such as, for example, type of mitral valve defect, etiology of the disease, severity of symptoms, valve morphology (e. g., mitral valve area), valve hemodynamics and comorbidity, which healthcare providers have to document., Conclusion: The documentation for the developed quality indicator is considerable. Nonetheless, its relevance is undeniable because it allows the user to determine whether a surgical or catheter-based mitral valve intervention was necessary and performed according to guideline recommendations. In the first year of its implementation, this indicator should be evaluated for further improvement and simplification of assessment., (Copyright © 2017. Published by Elsevier GmbH.)

Purpose: This paper describes the development of quality indicators for an external statutory and cross-sectoral quality assurance (QA) procedure in the context of the German health care system for adult patients suffering from schizophrenia, schizotypal and delusional disorders (F20-F29)., Methods: Indicators were developed by a modified RAND/UCLA Appropriateness Method with 1) the compilation of an indicator register based on a systematic literature search and analyses of health care claims data, 2) the selection of indicators by an expert panel that rated them for relevance and for feasibility regarding implementation. Indicators rated positive for both relevance and feasibility formed the final indicator set., Results: 847 indicators were identified by different searches. Out of these, 56 were selected for the indicator register. During the formal consensus process the expert panel recommended another 45 indicators so that a total of 101 indicators needed to be considered by the panel. Of these, 27 indicators rated both relevant and feasible were included in the final set of indicators: this set included 4 indicators addressing structures, 19 indicators addressing processes and 4 indicators addressing outcomes. 17 indicators of the set will be reported by hospitals and 8 by psychiatric outpatient facilities. Two indicators considered to be cross-sectoral will be reported by both sectors., Discussion: F20-F29 and its treatment show some specific features which so far have not been addressed by any procedure within the statutory QA program of the German health care system. These features include: Schizophrenia and related disorders a) are potentially chronic conditions, b) are mainly treated in outpatient settings, c) require a multi-professional treatment approach and d) are treated regionally in catchment areas. These specific features in combination with the peculiarities of some legal, political and organizational characteristics of the German health care system and its statutory QA program have strongly influenced the development of indicators. The result was a seemingly "imbalanced" set of indicators with a greater number of indicators for inpatient than for outpatient care despite the fact that clinical reality is otherwise., Conclusions: The circumstances of the German health care system that restricted the development of this cross-sectoral QA procedure addressing care for F20-F29 are also most likely to emerge with the development of cross-sectoral QA procedures for other (potentially) chronic conditions that are mainly treated in the outpatient setting by multi-professional teams or by networks of different providers. In order to be able to develop a QA procedure that mirrors the reality of service provision for (potentially) chronic diseases such as F20-F29 we need to explore further current and new data sources, diminish sectoral borders, and implement health care responsibility on the level of catchment areas., (Copyright © 2017. Published by Elsevier GmbH.)

In 2015, more than 890,000 asylum seekers were registered in Germany. The provision of medical and psychosocial care for asylum seekers is facing numerous obstacles. Access to health care is mostly insufficient, particularly in initial reception centres. The present article describes the development and implementation of an interdisciplinary outpatient clinic for asylum seekers at the main registration authority in the state of Baden-Wuerttemberg operated by physicians of the University Hospital of Heidelberg and the local Medical Association in Heidelberg. A steering committee was appointed to plan and implement the interdisciplinary outpatient clinic. Semi-structured interviews with nine steering committee members were conducted to elucidate perceived barriers during the planning and implementation phase. The steering committee's strong personal commitment and the health authorities' impartial management were cited as the main contributing factors to the success of the implementation process. Significant barriers were seen in the funding of personnel, equipment, and language mediation as well as in legal liability and billing-related aspects. Results are discussed with a focus on financing, administrative and legal framework as well as language mediation, documentation and further matters that are essential to ensure high-quality care., (Copyright © 2017. Published by Elsevier GmbH.)

Background: The integration of information and communication technologies (ICT) is increasingly considered in the development of healthcare structures. This fact is also recognised in the e-Health Act. In this context, personal health records (PHR) have a specific meaning. The aim of this paper is to provide an overview on utilization, barriers and possible effects on the implementation of PHR., Methods: This analysis is based on a literature search in Web of Science (Core Collection) (01/2000 to 12/2014) using the following terms: "personal health record", "personal medical record", "personal electronic health record", "interpersonal health record", "personally controlled health record"., Results: In general, patients have positive attitudes towards the electronic exchange of personal health information (PHI) on a PHR. Even the sharing of PHI with physicians, health professionals, family and friends appears to be an option for many patients. Physicians also see the potential of a PHR on the internet, but they are more critical than patients. Barriers exist towards the use of complex and non-intuitive PHR concepts along with technical faults and the lack of functionality. From the physicians' perspective, prejudices concerning the use of PHR have not been confirmed and, other than previously expected, the workload has not increased so much. However, clinical outcomes have so far been rather moderate. Stronger effects may be achieved by embedding the PHR in a broader healthcare concept., Conclusion: In the context of chronic disease, a connected PHR (patient-controlled, cross-sectoral, and interoperable) can be a valuable tool for organizing healthcare for patients. To take full effect, the development of such systems should focus on patients and their families as well as on physicians and other healthcare professionals. Whether the e-Health Act is a step in the right direction will have to be established by future analysis., (Copyright © 2017. Published by Elsevier GmbH.)

Background: In 2011, the national German Medical Association (Bundesärztekammer) published guidelines for a slim-lined training program in general practice (Quereinstieg) for qualified medical specialists in other fields (e. g., surgeons, internists or anesthesiologists). This step is part of a strategy to prevent further shortages of general practitioners in Germany. In the state of Baden-Wuerttemberg, qualified medical specialists are allowed to complete their general practice training in approximately two years instead of five. The aim of this study was to understand the reasons of specialists for changing to a career in general practice., Methods: The postgraduate training program Verbundweiterbildung plus Baden-Württemberg had 597 trainees at the time of the study in December 2015. Previously qualified specialists in another medical discipline were identified and invited to participate in this study. Qualitative data was gathered using semi-structured interviews with content analysis of the interviews performed by three independent members of the research team., Results: In total, 36 out of 597 trainees were identified as previously qualified specialists in another medical discipline. All 36 were invited to take part and 15 agreed to participate in this study. Overall, 15 interviews were performed, with a mean time of 24.19minutes. Participants with a median age of 40 years (33-59 years) - mainly anesthesiologists (n=7), surgeons (n=3) and internists (n=3) - presented with an average of 6.5 years of professional experience in their specialty. First, the participants' motivation to switch career arose from the wish to intensify the quality of patient contacts with a holistic approach including family and social background and from the infinite variety of general practice. Another reason given for a career change was self-employment opportunities. Finally, feelings of frustration over poor working conditions in hospitals resulted in a job search elsewhere in medicine, taking account of the challenges of ageing and family life. A major finding was that without the slim-lined program, the majority of participants would not have changed their career., Discussion: The slim-lined training program in general practice attracts experienced medical doctors. Specialists decide to change career because of the particular ways of working in general practice and with the intention to improve their daily work as a physician, either to improve individual working conditions and/or to improve their individual curative work profile. In addition, specialists are attracted by the concept of self-employment in general practice. Therefore, appreciation of the specific ways of working in general practice as well as management skills are most important during the reduced 2-year training. Further studies should investigate if facilitating a career switch to general practice is a good way to improve the shortage of general practitioners., (Copyright © 2016. Published by Elsevier GmbH.)

Background: A Train-The-Trainer course (TTT course) for general practice trainers was developed as part of the program Verbundweiterbildung plus Baden-Württemberg. The course included aspects of training such as organizational and legal knowledge as well as didactic skills for trainers in 9.5 teaching units (45minutes each). The present article analyzes the evaluation of the course and considers possible future developments for TTT courses in Germany., Methods: An evaluation tool was used covering aspects such as information, relevance for daily work, opportunities for participant engagement in the seminars and working environment as well as didactic competencies among teachers. Within five years, 256 trainers participated in a TTT course and received an evaluation sheet. Data were analyzed descriptively., Results: 249 evaluation sheets were included (response rate 97 %). Overall, the participants were (very) satisfied with the course in general, its organization, the exchange with colleagues and the teaching units. The participants used the free text mode to give positive feedback; in particular, teaching units in organizational and legal regulations as well as practical feedback training to strengthen professionalism were evaluated positively. Suggestions for improvements included follow-up courses or a deepening of understanding of course contents., Conclusion: The participants gave a very positive overall rating and claimed to have benefited from the course contents. Future projects should address further qualifications of general practice trainers and facilitate the exchange with colleagues on an ongoing basis., (Copyright © 2016. Published by Elsevier GmbH.)

Background: Medical education is intended to enable students to become a physician who can practise the profession of medicine on his own authority, responsibility and accountability. In 2015, the competencies required to accomplish this have been described in the National Competency-based Catalogue of Learning Objectives Medicine. The aim of this study was to survey the extent to which the respective medical procedures were learned during medical school. Postgraduate trainees were asked to self-assess their level of proficiency in carrying out procedures commonly performed in family medicine., Methods: A questionnaire involving 17 procedures was distributed among 328 postgraduate trainees in family medicine attending training sessions in Baden-Wuerttemberg. Participants could assess the extent to which they were able to independently perform each procedure (ranging from "not able to do it", "able to do it under direct supervision", "able to do it if supervision is provided upon request" to "able to do it on my own", and "able to provide supervision to others" respectively). Respondents that were able to perform procedures without the need for supervision were asked to indicate when they acquired the competency. Data were analysed descriptively., Results: A total of 196 postgraduate trainees (59.8%) completed the questionnaire. The average age was 35 years, 71 % of the participants were female. For five out of 17 procedures at least half of the participants regarded themselves as being "able to do it on my own" or "able to provide supervision to others". The procedure that was most often (52.5 %) named as having been learned in medical school was "otoscopy", followed by "wound suturing" and "mask ventilation" (42%)., Conclusions: Following graduation, GP trainees are unable to independently perform the majority of common procedures in family medicine. This indicates that insufficient proficiency in procedural skills is provided in undergraduate medical education, revealing the need for structured, supervised specialty training following graduation., (Copyright © 2016. Published by Elsevier GmbH.)

The development of cross-sectoral quality assurance programs usually requires extensive topic identification. Illustrated by the complex processes of care for stroke and transient ischemic attacks (TIAs), a method for comprehensive topic identification is presented. The first step involves a thorough literature search in terms of systematic reviews, health technology assessments, guidelines, studies into healthcare delivery and the use of specific instruments. Routine data as well as epidemiologic studies are used to analyze the reality of service provision. In addition, experts are consulted to gain expertise concerning deficits of care, approaches to quality assurance and experience with existing quality assurance programs. Furthermore individual patient experiences are collected to add the patients' perceptions of care. Because of the limitation on the regulatory scope of Book V of the German Social Code, which, in this case, was necessary, another source of information was the legal framework and its impact on rescue chain, acute treatment and rehabilitation. Existent quality management systems, accreditations and quality assurance programs in prevention, acute treatment and rehabilitation have been searched in order to avoid any overlap with existing measures. After identifying a total of 71 quality targets according to deficits of care, recommendations for care and expert opinions in primary and secondary prevention, rescue chain, acute treatment, rehabilitation and supply of assistive equipment and therapies, respectively, the usability of instruments was tested. These instruments included case documentation, patient surveys and routine data. 14 quality targets proved to be reproducible by these instruments and were included in the recommendations for a cross-sectoral quality assurance program for stroke and TIA., (Copyright © 2016. Published by Elsevier GmbH.)

Background: The German Society of General Practice and Family Medicine (DEGAM) has defined educational seminars during post-graduate training as a core element to improve trainees' specific knowledge and competencies. Furthermore, these seminars facilitate networking among trainees and support the process of identity formation in family medicine. Since its implementation in 2009, the Verbundweiterbildung(plus) Baden-Württemberg (VWB(plus) Ba-Wü) has offered educational seminars. Aim of this article is to analyse the content of these educational seminars and to derive implications for other family medicine training programmes in Germany., Methods: From 2009 to 2015, the data from all educational seminars was descriptively analysed. Furthermore, two researchers categorised the seminar contents independently of each other and assigned them to the competence-based curriculum for family medicine training (Kompetenzbasiertes Curriculum Allgemeinmedizin, KCA)., Results: Until 2015, 600 trainees participated in a starter seminar of the VWB(plus) Ba-Wü. In total, 1,116 teaching units and 160 different seminars covered all relevant topics of the KCA. A restructuring of organisational processes and seminars was necessary to handle the increase in the number of participants, including the development of specific software for electronic support. Of all these seminars, 56% were held by specialists or trainees in family medicine. The participating trainees rated the educational seminars in general and the possibility for networking as (very) good., Conclusions: The contents of the educational seminars included in family medicine training programs will have to be specifically based on family medicine and cover all relevant aspects of the KCA - medical expertise, competencies and procedures. In order to ensure a common standard concerning didactic methods and qualifications of teachers, a didactic guideline is to be developed. The increasing demand of family medicine training programmes requires (further) development of the software eSchoolab, including integration of the KCA., (Copyright © 2016. Published by Elsevier GmbH.)

Introduction: Pre- and postgraduate education is meant to be competency-based. Over the last two decades various competency frameworks have been published. An important aspect of competency is professionalism, being discussed widely in the literature while a clear-cut definition is still lacking. The purpose of this study was to translate the Nijmegen Professionalism Scale into the German language, to adapt the scale to the German setting and to examine the psychometric properties, test-retest reliability and feasibility of the culturally adapted instrument designed to assess professionalism in general practice, in addition to the validity of the concept of professionalism and to testify the transfer across linguistic, cultural and societal differences., Method: After translating the Nijmegen Professional Scale into German, we conducted its cultural adaptation, the German Professionalism Scale (Pro-D). Its psychometric properties were assessed using Cronbach's α, descriptive statistics, and test-retest reliability. The validation of the construct was analysed by confirmatory factor analysis. Feasibility was confirmed in interviews with GP trainees and their trainers., Results: A total of 133 trainees completed the Pro-D. The Pro-D showed high internal consistency (Cronbach's α 0.93) and good test-retest reliability (Spearman's rank correlation and Wilcoxon's matched-pairs test) for the different domains. Confirmatory factor analysis was unable to establish construct validity. Change in sensitivity of the instrument was good. Statements of interviews confirmed the feasibility of the new instrument., Conclusions: We found good psychometric properties for the Pro-D. This might indicate transferability of the concept across linguistic, cultural and societal differences although the concept of professionalism was not replicated in a confirmatory factor analysis., (Copyright © 2016. Published by Elsevier GmbH.)

Objectives: To develop a model aiming to improve the quality of services for reproductive health care in rural Kenya and designed to measure the quality of reproductive health services in such a way that allows these services to identify measures for improving their performance., Methods: The Integrated Quality Management System (IQMS) was developed on the basis of a pre-existing and validated model for quality promotion, namely the European Practice Assessment (EPA). The methodology for quality assessment and feedback of assessment results to the service teams was adopted from the EPA model. Quality assessment methodology included data assessment through staff, patient surveys and service visitation. Quality is assessed by indicators, and so indicators had to be developed that were appropriate for assessing reproductive health care in rural Kenya. A search of the Kenyan and international literature was conducted to identify potential indicators. These were then rated for their relevance and clarity by a panel of Kenyan experts., Results: 260 indicators were rated as relevant and assigned to 29 quality dimensions and 5 domains. The implementation of IQMS in ten facilities showed that IQMS is a feasible model for assessing the quality of reproductive health services in rural Kenya. IQMS enables these services to identify quality improvement targets and necessary improvement measures. Both strengths and limitations of IQMS will be discussed., (Copyright © 2015. Published by Elsevier GmbH.)

Background: On the basis of the assumption that a significant proportion of hospitalisations for so-called ambulatory care sensitive conditions (ACSCs) are potentially avoidable by ambulatory care measures, hospitalisation rates for ACSCs are used internationally as population based indicators for access to and quality of ambulatory care. The German Council of Health Experts proposes hospitalisation rates for diabetes, asthma, hypertension and chronic heart failure as ACSC measures in Germany., Objectives: This article focuses on regional differences in ACSC rates, describes the longitudinal development and explores potential determinants., Material and Methods: Descriptive statistical analyses as well as spatial regression analyses were performed on the basis of Federal Statistical Office data. We included data from the hospital and physician statistics. Bayesian spatial regression techniques were used., Results: Whereas hospitalisation rates for asthma decreased between 2000 and 2010, hospitalisation rates for diabetes, hypertension and chronic heart failure increased. Comparing age-adjusted ACSC rates across all German federal states, the Eastern states as well as Saarland showed significantly higher ACSC rates over time. This observation can in part be explained by physician density and the number of hospital beds., Conclusion: Although not all ACSC hospitalisations can be avoided, these results display a potential for optimising care across healthcare sectors in Germany., (Copyright © 2014. Published by Elsevier GmbH.)

Patients with chronic disease usually need to take multiple medications. Drug-related interactions, adverse events, suboptimal adherence, and self-medication are components that can affect medication safety and lead to serious consequences for the patient. At present, regular medication reviews to check what medicines have been prescribed and what medicines are actually taken by the patient or the structured evaluation of drug-related problems rarely take place in Germany. The process of "medication reconciliation" or "medication review" as developed in the USA and the UK aim at increasing medication safety and therefore represent an instrument of quality assurance. Within the HeiCare(®) project a structured medication management was developed for general practice, with medical assistants playing a major role in the implementation of the process. Both the structured medication management and the tools developed for the medication check and medication counselling will be outlined in this article; also, findings on feasibility and acceptance in various projects and experiences from a total of 200 general practices (56 HeiCare(®), 29 HiCMan,115 PraCMan) will be described. The results were obtained from questionnaires and focus group discussions. The implementation of a structured medication management intervention into daily routine was seen as a challenge. Due to the high relevance of medication reconciliation for daily clinical practice, however, the checklists - once implemented successfully - have been applied even after the end of the project. They have led to the regular review and reconciliation of the physicians' documentation of the medicines prescribed (medication chart) with the medicines actually taken by the patient., (Copyright © 2013. Published by Elsevier GmbH.)

Introduction: Implementation research deals with the question of how to ensure that evidence-based knowledge is put into practice. One approach is the development of "tailored interventions (TI)". These are designed to address previously identified barriers and enablers. A common definition or methodological concept for TI has not yet been established. In this paper, a concept for TI is introduced. We describe the stepwise development of an implementation intervention for GP settings where recommendations based on current evidence are provided for the treatment of multimorbid patients receiving polypharmacy. Each step will be explained and illustrated by original data., Methods/results: A stepwise approach was used to develop a TI: problem analysis, identification and prioritisation of determinants, identification and prioritisation of strategies and the design of a complex intervention and its underlying logic model., Discussion: The stepwise exemplary description of this tailoring strategy may support other researchers in this field when designing a TI., (Copyright © 2013. Published by Elsevier GmbH.)

For several years, the use of administrative data in mandatory quality measurement has been requested by several stakeholders in Germany. Main advantages of using administrative data include the reduction of documentary expenditures and the possibility to perform longitudinal quality analyses across different healthcare units. After a short introduction, a brief overview of the current use of administrative data for mandatory quality assurance as well as current developments is given, which will then be further exemplified by decubital ulcer prophylaxis. By using administrative data coding expenditures in this clinical area could be reduced by nine million data fields. At the same time the population analysed was expanded resulting in a more than tenfold increase in potentially quality-relevant events. Finally, perspectives, further developments, possibilities as well as limits of quality measurement with administrative data are discussed., (Copyright © 2014. Published by Elsevier GmbH.)

Background and Research Question: Pursuant to Section 73b, volume V of the German Social Security Code (SGB V), the agreement on family doctor-centred care (HzV), which went into effect in Baden-Wuerttemberg on July 1, 2008, provides for spatially inclusive and comprehensive medical coverage. The most important elements of the agreement are: the voluntary registration of family practices and patients, the strengthening of the coordinative function of family practices, the fulfilment of certain training, quality and qualification requirements, the standardised remuneration system and the use of specified practice software for billing and the prescription of drugs. The aim of this complex intervention is to strengthen family medicine, improve health care, in particular for patients with chronic disease, and to limit primary health care costs while improving its quality wherever possible. This first controlled nationwide evaluation examines the question whether these objectives were met in the early phase (2008 to 2011) and, if so, to what extent., Method: Four work packages were defined: 1. differences in health care processes (utilisation, contact to specialists, hospitalisations, drug prescriptions); 2. developments in practice teams and of patient satisfaction; 3. deployment of specially trained health care assistants in family practices (VERAH); 4. implementation of the DEGAM (German Society of General Practice and Family Medicine) heart failure guideline. To the extent that it was possible to use the statutory health insurance company AOK Baden-Wuerttemberg's routine data, an adjusted comparison of the target variables was made for HzV- and non-HzV-insured patients between the first and second or between the third and fourth quarters of 2008, and between the first and second or third and fourth quarters of 2010., Results: HzV participants were older, had a higher disease burden (Charlson Index 1.45 vs. 1.19), and were attended to more intensively than patients receiving routine care (1.7 more contacts with the family doctor per half-year). The number of non-referred contacts to specialists fell by 12.5 %. An increase in the number of referrals and hospitalisations was not observed. Participation in structured treatment programmes was substantially higher, e.g. 15 % vs. 7.5 % (non-HzV) in DMP diabetes mellitus Type 2. In the HzV, the rise in medication costs due to family physician prescriptions (ignoring the effect of discount agreements) was lower by 2.5 %, and the me-too rate was significantly lower. Higher remuneration contributed to greater satisfaction among HzV physicians despite the perceived increase in the workload. In a survey of 2,535 patients HzV participants showed a high rate of patient satisfaction overall, and physical examinations and services aimed at preventing illness were regarded particularly favourably. A survey of 294 VERAH showed that they more often accepted patient-related tasks such as home visits, geriatric assessments, patient training, and vaccination and preventive management. Family physicians were prepared to delegate responsibilities and, as a result, felt disburdened. In accordance with the latest DEGAM guideline patients with heart failure enjoyed an improvement to an overall high level in their drug therapies with ACE inhibitors, AT1 antagonists and beta blockers. Further improvement resulting from medical quality circles and training was not observed., Discussion and Conclusions: The results confirm the findings of international studies: in particular, HzV benefits patients with chronic disease, and patients receive improved health care when they participate in the Baden-Wuerttemberg HzV. All four evaluation modules reveal that changes towards the intended direction are taking place. Family doctors assumed more responsibility for coordination. These findings reflect the early start-up phase and the development phase of HzV in Baden-Wuerttemberg. These effects, together with those of other prioritised topics, will be continuously monitored as part of an accompanying evaluation process., (Copyright © 2013. Published by Elsevier GmbH.)

Considering the demographic development models for primary care have to be focused on chronic illness care especially. The so called "Hausarztzentrierte Versorgung" (HzV) in Baden-Wuerttemberg constitutes such a model of an implementation of family doctor-centred health care. For evaluation purposes the perspective of patients is of particular interest. Therefore the aim of this study was to analyse how chronically ill patients assess their medical care. Altogether 53 primary care practices in Baden-Wuerttemberg took part in a patient survey. The quality of chronic illness care from the patients' perspective was assessed by means of the PACIC short form. Furthermore the general satisfaction with care as well as sociodemographic characteristics were determined. For analysis two different groups were regarded: HzV-doctor and HzV-patient with a chronic condition (group 1) and non-HzV-doctor and non-HzV-patient with a chronic condition (group 2). Altogether 2,535 patients were recruited for the survey (response rate 47.8%). Out of these, 836 patients could be assigned to group 1 and 319 patients could be assigned to group 2. Patients in both groups were very satisfied with their care. The patients in group 1 stated more frequently that they received a written treatment plan from their general practitioner and that they were asked about their state of health when leaving the practice. Overall satisfaction was positively associated with organisation of care (β= 0.484), support in difficult situations (β= 0.171) and information on the usefulness of consulting other doctors (β= 0.163) with an explained variation of R(2)=0.459. Irrespective of their group affiliation patients rate the medical care of their chronic condition very positively. Especially the assessment of the quality of care from the perspective of different patient groups (HzV participants and non-HzV participants) could contribute essentially as a feedback for physicians concerning the implementation of the main contents of the HzV for participating physicians., (Copyright © 2013. Published by Elsevier GmbH.)

A debate on the application of quality indicators (QIs) arose among the members of the German College of General Practitioners and Family Physicians (DEGAM) when two QI systems for ambulatory care (QISA and AQUIK) were published in a short time interval. A research question that emanated from this discussion was whether appropriate QI might be developed based on German general practice guidelines. In spring 2010, the DEGAM guideline committee (SLK) decided to conduct a project on guideline-based development of QIs using the DEGAM guidelines for dementia, neck pain and sore throat. All members of the SLK were invited to participate in the development process which comprised three face-to-face meetings and four paper-pencil ratings. Finally, 17 QIs for the three guidelines on dementia (n=8), neck pain (n=7) and sore throat (n=2) emerged. These QIs received different ratings in the dimensions relevance, practicability, and appropriateness for public reporting as well as for pay for performance. In this project, guideline authors themselves developed QIs based on German general practice guidelines for the first time ever. Not before practice administration systems facilitate the availability of data in the context of clinical documentation, the practicability of the new QIs can be proven in real every-day practice., (Copyright © 2012. Published by Elsevier GmbH.)

The agreement on family-doctor centred care (Hausarztzentrierte Versorgung, "HzV") pursuant to Sect. 73b, Volume V of the German Social Security Code became effective in Baden-Wuerttemberg, Germany, on July 1(st), 2008. This complex intervention, which is voluntary for both family doctors and patients, aims to strengthen the coordinative function of family practices. As a result, this intervention is believed to increase the quality of medical health care for persons insured - in the medium to long-term - and thereby, ideally, to additionally save expenses. Working package 1 was one out of a total of four working packages and focused on the evaluation of potential intervention effects of the HzV intervention based on the analyses of AOK routine data in Baden-Wuerttemberg. A total of 1.44 million insured persons were eligible for the present analyses. Insured adults voluntarily participating in the family doctor-centred health care intervention (HzV insured persons: n=580,924 in the intervention group) of the AOK were compared to those not participating in this intervention (non-HzV insured persons: n=862,237 in the control group). For both HzV and non-HzV insured persons, a comparison of each outcome of interest (encounters with family doctors, encounters with specialists, rate of hospitalisations, duration of hospitalisations, rate of re-hospitalisations, costs of pharmacotherapy, rate of polypharmacy, rate of Me-Too pharmaceuticals) was conducted for quarters 3 and 4 of 2008 as well as for quarters 3 and 4 in 2010. Both groups of insured persons differed in that they either participated in the HzV intervention between January 1, 2009 and June 30, 2011 or not. Before January 1, 2009 individuals in both groups did not participate in the HzV intervention. This design allowed for both longitudinal and cross-sectional comparisons. Moreover, the design implicitly controlled for potential seasonal bias. In order to adjust for relevant covariates (insured persons' age, gender, nationality, insurance state, morbidity), multivariate multilevel regression models were developed and applied. On average, HzV insured persons were about 3 years older (56.2 ± 27.3 vs. 53.1 ± 18.4 years) and had higher levels of comorbidity (Charlson Comorbidity Index: 1.45 ± 1.86 vs. 1.19 ± 1.71). No significant differences in terms of rate and duration of hospitalisations were observed. The same applied to the number of rehospitalisations within 30 days. After adjustment for covariates, however, an increase in visits to the respective family doctor of 38% was found in the intervention group. Moreover, a decrease of encounters to specialists with and without referrals from family doctors could be observed (-29.8 % and -12.5%, respectively). Interestingly, even costs of pharmacotherapy, polypharmacy and prescriptions of Me-Too drugs were statistically significantly lower or less frequent, respectively, in the group of HzV insured persons. In conclusion, besides the observed associations in terms of pharmacotherapy, the HzV intervention appears to have advantageous effects in terms of family doctor centred health care., (Copyright © 2013. Published by Elsevier GmbH.)

External quality assurance has three main aims: to make service provision in medicine and nursing comparable, to systematically identify deficits in service quality and to support the introduction of measures for quality improvement. This article reflects on three major developments in mandatory external quality assurance in the German healthcare system that took place during the last five years. These developments include the implementation of cross-sectoral quality assurance, the utilisation of new data sources and a new focus on quality deficits and practicability. The article highlights the challenges that come along with these developments., (Copyright © 2013. Published by Elsevier GmbH.)

Objectives: Health care systems in Germany and around the world are faced with demographic change and the need of providing health services in increasingly complex health care surroundings. A highly qualified workforce is needed to face the challenges ahead and to coordinate health care. In addition, there is evidence that interprofessional education strengthens interprofessional collaboration which can lead to improved health outcomes. The University of Heidelberg, Medical Faculty, decided to develop a bachelor programme integrating specific health professions and interprofessional qualifications into the curriculum. The manuscript describes the identification process of the outcome-focused competencies for this bachelor degree., Methods: The six-step curriculum model by Kern et al. was applied. An expert panel identified major tasks and health care fields for which the students should be qualified for. These results were transferred into a questionnaire and distributed among targeted learners as well as practitioners, experts and employers in different health care fields for relevance ratings. Also, individuals were interviewed to receive additional information and to generate further ideas., Results: Thirteen different practice fields, five tasks and thirteen topics common to all health care professions were collected. The subsequent survey comprising 66 items was completed by 139 targeted learners as well as 82 practitioners and experts. All identified practice fields were rated as relevant for future professional life. Top ratings were "supervising procedures" (targeted learners) and "interprofessional communication and coordination" (practitioners, experts and employers). The results were discussed and consented in the expert panel and learner outcomes/objectives were categorized according to the CanMED roles., Discussion: A thorough needs assessment was performed setting the foundation for the further development of the curriculum. The identified competencies are in line with the five core competencies defined by the WHO which are necessary for interprofessional collaboration: patient-centred care, partnering, quality improvement, information and communication technology, and public health perspective. The application of the CanMED framework proved to be suitable. It may be used as common terminology to help define interfaces with curricula of other health professions. The interprofessional development of the bachelor programme fostered a deeper understanding between health professionals and can therefore be regarded as a first step in improving interprofessional collaboration., (Copyright © 2012. Published by Elsevier GmbH.)

Background and Purpose: Due to the increasing lack of physicians, an ageing and thus multi-morbid society and a misdistribution of physicians in Germany primary care provided by general practitioners is at risk. Therefore, approaches to recruit more physicians for general practice are being sought. The aim of the present study was to explore individual motivations for choosing a career in general practice, vocational trainees' perspectives on the current situation of vocational training and to identify possible approaches to improve the situation with suggestions from vocational trainees in Germany., Methods: A qualitative study was conducted by interviewing 13 trainees. The interviews that were based on a predefined interview guideline were recorded and transcribed. The analysis was performed according to Mayring supported by the software Atlas.ti., Results: In general, the reasons given for choosing general practice include the holistic view towards patients, the opportunity to see the direct impact of therapies and self-employment. Furthermore, general practice was perceived as a job with a positive work-life balance. Barriers to vocational training are the lack of structure of individual rotations and the low salaries during the rotation in practice. Furthermore, the basic conditions for working as a self-employed general practitioner in Germany were described as being a disincentive. A general suggestion for improvement was to promote professional recognition of general practice at universities. A qualification of vocational trainers was requested. Specific suggestions were: better payment, better-structured rotations and a specific preparation for the self-employed general practitioner., Conclusion: The results of this study reveal that a single measure is insufficient for recruiting more young doctors for general practice. In fact, a package of measures is necessary to improve aspects of the vocational training but also general conditions for the profession., (Copyright © 2010. Published by Elsevier GmbH.)

The European Practice Assessment (EPA) is a comprehensive quality management which consists of 220 indicators covering 5 domains (infrastructure, people, information, finance, and quality and safety). The aim of the project presented was to evaluate EPA as an instrument for benchmarking in ambulatory care practices. A before-and-after design with a comparison group was chosen. One hundred and two practices conducted EPA at baseline (t1) and at the 3-year follow-up (t2). A further 209 practices began EPA at t2 (comparison group). Since both practice groups differed in several variables (age of GP, location and size of practice), a matched-pair design based on propensity scores was applied leading to a subgroup of 102 comparable practices (out of the 209 practices). Data analysis was carried out using Z scores of the EPA domains. The results showed significant improvements in all domains between t1 and t2 as well as between the comparison group and t2. Furthermore, the results demonstrate that the implementation of total quality management and the re-assessment of the EPA procedure can lead to significant improvements in almost all domains., (Copyright © 2011. Published by Elsevier GmbH.)

Background: In order to ensure the delivery of primary care part of the vocational medical training must take place in the general practice setting. In Germany, this requires the authorization to provide general practitioner (GP) training. While in many countries specific qualification programmes for GP trainers are obligatory, this does not yet apply in Germany. The aim of this survey was to explore perspectives and experiences of GP trainers focusing on their needs in view of a possible qualification course., Methods: A three-page questionnaire was developed and sent to all 1,780 GP trainers in the federal state of Baden-Wuerttemberg, Germany., Results: Of the 1,780 GP trainers 656 responded (response rate: 37%), 18% of them being female trainers. About a quarter of the respondents had a vocational trainee, while 36% were looking for one at the time of the survey. The reason most frequently given for not having a vocational trainee was "no applicants" (n=323). Motivational reasons for involvement as a GP trainer were most commonly "interpersonal co-operation" (83%) and "enthusiasm for education" (69%). Only 2% of the respondents reported a bad experience with vocational trainees. Special needs were expressed regarding both legal and fiscal issues with vocational trainees in general practice and the development of a curriculum., Conclusions: For the first time the perspectives and experiences of GP trainers have been explored in the present study. The results may provide a basis for the development of a qualification programme for GP trainers in Germany., (Copyright © 2010. Published by Elsevier GmbH.)

Patients with little knowledge of the German language have a special need for information. Due to language barriers they behave more passively in medical encounter, have a poorer knowledge about their disease and are generally less satisfied with their medical care. Foreign language patient information material could bridge the gap between medical consultation and the patients' self-responsibility and involve patients more actively in the treatment process. Based on extensive research in several areas (internet, clinic and practice leaflets, drug patient information leaflets) the present article illustrates that in all these areas foreign language patient information is very poorly available compared to German material. The reinforcement of the development of such material could lead to a higher involvement of immigrant patients' in the decision-making process, higher rates of patient safety and satisfaction and, overall, to a better quality of care for all patient groups in Germany., (Copyright © 2011. Published by Elsevier GmbH.)

Objective: The purpose of this cluster-randomised controlled trial was to evaluate the efficacy of quality circles (QCs) working either with general data-based feedback or with an open benchmark within the field of asthma care and drug-drug interactions., Methods: Twelve QCs, involving 96 general practitioners from 85 practices, were randomised. Six QCs worked with traditional anonymous feedback and six with an open benchmark. Two QC meetings supported with feedback reports were held covering the topics "drug-drug interactions" and "asthma"; in both cases discussions were guided by a trained moderator. Outcome measures included health-related quality of life and patient satisfaction with treatment, asthma severity and number of potentially inappropriate drug combinations as well as the general practitioners' satisfaction in relation to the performance of the QC., Results: A significant improvement in the treatment of asthma was observed in both trial arms. However, there was only a slight improvement regarding inappropriate drug combinations. There were no relevant differences between the group with open benchmark (B-QC) and traditional quality circles (T-QC). The physicians' satisfaction with the QC performance was significantly higher in the T-QCs., Conclusion: General practitioners seem to take a critical perspective about open benchmarking in quality circles. Caution should be used when implementing benchmarking in a quality circle as it did not improve healthcare when compared to the traditional procedure with anonymised comparisons., (Copyright © 2011. Published by Elsevier GmbH.)

Background: In Germany content-related vocational training mostly is the responsibility of the trainees themselves. The aim of this needs assessment is to explore the requirements of a longitudinal training course in vocational training., Methods: A combined quantitative-qualitative needs assessment was chosen. We used data of a continuous record keeping system in primary care to assess the occupational field, and the needs of vocational trainees were explored in a qualitative survey., Results: Data of more than 120,000 consulting problems in primary care were attributed to different medical expertises by frequency (orthopaedics 22.1%; internal medicine 17.2%; dermatology 12.2%; ear, nose, and throat medicine 11.9%). They revealed a high concordance between the needs derived from the consulting problems and the vocational trainees' needs identified in the qualitative survey (421 text units in the categories: medical expertise, competencies and skills and reflection on one's own performance)., Conclusion: The results of this needs assessment demonstrate the importance of vocational trainees' needs and the findings of health services research for improvement of content-related vocational training. Furthermore, the results form the basis for longitudinal training courses in vocational training, as shown in the approach of the training course within the training programme Verbundweiterbildung(plus)., (Copyright © 2010. Published by Elsevier GmbH.)

Background: Effective implementation of disease management programmes (DMPs) in primary care practices often requires changes in practice workflows and responsibilities and acceptance by the parties involved. Within the ELSID study (evaluation study of the DMP diabetes mellitus type 2) the physicians' attitudes toward DMPs were obtained and an optimised implementation of DMPs was developed by conducting a quality management cycle with primary care practice teams. The aim was to investigate which practice workflows will have to be changed and what kind of barriers to implement these changes are perceived., Methods: In 78 primary care practices of the two German federal states of Rheinland-Pfalz and Sachsen-Anhalt a quality management cycle was conducted using a structured analysis of the current state of DMP workflows and the need for improvement identified. Subsequently, an optimised workflow was developed and targets were agreed upon. After 6 months, the study team called to inquire about the current state of implementation and, if appropriate, actual barriers to change., Results: After 6 months, 71 practices had been interviewed by phone. 64 of them (90.1%) had agreed on at least one target (e.g., to purchase new instrumentation, to regularly discuss feedback reports, to set up a patient registry). On average three targets had been formulated, and 2 out of 3 had been implemented in the meantime. In most cases lack of time was given as the reason for non-implementation., Conclusions: The majority of surveyed practices perceived some need for improvement. But sufficient resources (time, staff and money) are required to ensure efficient implementation of DMPs in primary care practices and their integration with routine processes. A redefinition of responsibilities for DMPs will strengthen the role of medical assistants and promote high-quality implementation of these programmes., (Copyright © 2010. Published by Elsevier GmbH.)

Background: Patients with chronic heart failure have complex care needs which can be addressed by case management interventions. Monitoring lists for heart failure were developed and tested as part of a trial evaluating primary care-based case management of patients with heart failure (HICMan)., Method: Design and characteristics of the monitoring lists used during the HICMan trial are described in order to evaluate technical feasibility and time expenditure. In a secondary analysis of data from the HICMan trial descriptive statistics were used., Results: Two checklists were developed on the basis of evidence-based guidelines to regularly monitor heart failure patients by phone and home visits. These checklists contain questions about heart failure symptoms and signs (precursors) of clinical deterioration. Ninety-seven heart failure patients (64 NYHA class I/II, 33 NYHA class III) were monitored for 12 months. Eighteen critical incidents like acute angina pectoris or acute dyspnoea occurred during the study, two of them leading to immediate hospital admissions. Patients with NYHA class III had significantly more potentially clinically relevant incidents than patients with NYHA class I/II. Mean [SD, range] time expenditure for telephone monitoring was 10min [± 5min, 2 to 38min], for home visits 53min [± 13min, 18 to 90min]. Both monitoring lists appeared to be plausible and feasible tools for the primary care-based case management of heart failure patients., (Copyright © 2010. Published by Elsevier GmbH.)

Background: Quality circles (QC) are viewed as one of the most important tools of quality improvement and continuing education in ambulatory care. Yet, little is known about the quality of QC work., Methods: From 1995 to 2007, an external assessment of QC work took place at four regional Associations of Statutory Health Insurance (SHI) Physicians. After each meeting, QC leaders completed questionnaires. This basic documentation focused on important features of QC work--continuity, topics, methods, results and satisfaction., Results: 28,800 meetings in 1,640 quality circles were documented, and 27,255 documents from 1,241 groups analysed. Continuity was high over long periods, and medical topics were dealt with in more than 80% of the time. The use of appropriate methods, however, have room for improvement. Participants were very satisfied., Conclusions: For the first time the quality of QC structures, processes and results was assessed in Germany using a broad dataset. The working principles of QC appear to be well-established. Using the basic documentation practical recommendations are made to improve the quality of QC.

The discussion about the advantages of evidence-based guidelines in daily dental practice is a matter of current interest. In this report three high-quality S3 level pilot guidelines which have been developed in dental medicine were evaluated under practice conditions. Quality circles in the city of Hamburg readily accepted to join this survey. By means of a questionnaire before and after a 4-month field test in dental practices the participants of quality circles were interviewed about their attitude towards guidelines and to the application of the guidelines. In addition, the experience gained with the application of the guidelines was incorporated into a group discussion with moderators of quality circles. The inclusion of quantitative and qualitative methods enabled a recording of the complete range of differentiated opinions concerning the application of guidelines. The results show that the concerns expressed by participants can be reduced by integrating guidelines in their everyday clinical practice. A strength and weakness analysis demonstrates that the quality circle moderators' attitudes towards approved guidelines range from rather positive to ambivalent. Field testing by quality circles proves to be a sound method for evaluating the acceptance of guidelines in daily practice., (Copyright © 2009. Published by Elsevier GmbH.)

The Chronic Care Model (CCM) is a framework for the structured care of patients with chronic conditions. It requires access of both physicians and patients to scientific evidence in order to facilitate shared treatment decision-making on the basis of the patient's individual needs and the best available external evidence. The aim of this study was to find out whether general practitioners (GP) actually make use of evidence-based information and guidelines and whether and how they communicate this information to their patients. We interviewed 14 general practitioners and conducted a content analysis. The majority of these GPs take a sceptical view towards evidence-based guidelines. Their main point of criticism is that guidelines disregard the individual patient's reality and life style. Instead, GPs emphasize the relevance of their own knowledge of the personal and medical history of and the continual care for their patients. Since GPs themselves often do not accept guidelines, they seldom impart their content to their patients. According to the GPs' experience there are contradictions between guideline-conformant therapy and individual treatment. The integrative character of evidence-based medicine is not recognized. The reason is that evidence-based medicine is equated with guidelines and trial results by the majority of the GPs interviewed. To facilitate guideline implementation in everyday practice GPs need to be provided with adequate access to scientific evidence and an understanding of the intentions of guidelines. If the doctors themselves do not accept guidelines, they will not share them with their patients. It must be made clear that guidelines are not intended as normative demands for a specific therapy for every patient, but are rather meant to assist the physician with his struggle for the best therapy for individual patients., (Copyright © 2010. Published by Elsevier GmbH.)

Progress in medical research has led to an increased number of diagnostic tests. However, the diagnostic accuracy of these tests often lacks evaluation in the primary care setting. Ignorance of evidence-based diagnostic strategies may cause a distorted estimation of diagnostic certainty in general practice and may increase pointless application of diagnostic tests. This study investigates the attitudes of students towards diagnostic accuracy and evaluates whether a seminar about evidence-based diagnosis has an impact on these attitudes. 424 medical students were asked to complete a questionnaire before and after a 90-minute seminar. Before the seminar, 71% of the students thought that due to a lack of resources some diagnostic tests--although necessary--are not being reimbursed. At the end of the seminar, this proportion was reduced by 12% (p<0.001). The call for global reimbursement for all diagnostic tests was reduced by 25% (p<0.001). In contrast, there was no change in the proportion of students (21%) that incorrectly attributed diagnostic uncertainty to a lower competence of the general practitioner. Thus, it seems that after a single seminar there was a cognitive change concerning the application of diagnostic tests rather than a change in the personal attitudes of students towards diagnostic uncertainty in primary care. In this context, the continuous implementation of the principles of evidence-based medicine would be necessary to improve the students' decision-making skills on the basis of a critical attitude including the reasonable handling of uncertainties in medical care.

Since 2002 some of the world's largest disease management programs have been launched in Germany--initially for type II diabetes and coronary heart disease--with approximately 5 million eligible insured persons and (in 2005) 2.04 million registered participants. The programs were not piloted prior to their start, and the prescribed statutory evaluation cannot be expected to result in an effectiveness validation. The article describes the development of a study protocol for a randomized controlled trial. It also discusses methodological problems, in particular the definition of primary target criteria, the guarantee of a 'naturalistic' intensity of intervention, and the creation of a control group during nation-wide implementation. Due to lacking support from the stakeholders the proposed randomized trial could not be implemented. Its design, however, allows the required standards for the program evaluation to be specified.

The dependency of the predictive values of tests on the prevalence of diseases is an escrow issue of clinical diagnostics. The relation between pre-test probability and post-test probability is well explained by Bayes' theorem, and the relation between prevalence and false diagnoses can be described well by modifying this theorem. In cases of low prevalence the positive predictive value (PPV) is lower and the false-positive predictive value (FPPV) higher. These aspects mainly depend on the test specificity. But basically, in cases of low prevalence there is a higher negative predictive value (NPV) and a lower false negative predictive value (FNVP). Depending on the sensitivity and specificity, NPV and FNPV vary only slightly in low prevalence ranges. These statistical relations are able to explain the typical mode of operation of general practitioners with their unselected patients. In order to increase PPV and decrease FPPV in the diagnostic workup, the GP must use his clinical experience, time and stepwise diagnostic procedures. More diagnostic studies are necessary to improve the diagnostic workup in patient care.

The implementation of the disease management programme (DMP) for asthma and COPD in the German health system in 2005 requires an optimal and evidence-based work-up of patients by general practitioners in routine daily practice. The German and international guidelines for COPD do not provide recommendations for a stepwise diagnostic work-up in primary care. Therefore, an evidence-based algorithm was developed for a stepwise diagnosis of COPD and its different stages in general practice, based on national and foreign guidelines that provide specific advice on diagnostic procedures.

Background: Patient education programmes will be a mandatory part of the new legislation on disease management programmes for chronic diseases in Germany. Today, only little is known about the number, variety and effectiveness of implemented patient education programmes in Germany., Methods: 176 potential providers of patient education programmes were identified by literature search, Internet search, and interviews with health education experts. We developed a semi-structured questionnaire. Assessment of content and quality was conducted in two steps by using defined criteria of the Co-ordinating Committee, the Head Association of the statutory health insurances and the respective Medical Associations: the first step was to check whether the programme had a structured teaching concept and whether all requirements for education with respect to a given disease had been taken into account. In the second step, we used balance sheets for reviewing the strengths and weaknesses of the programmes., Results: 49 providers handed in 95 pa tient education programmes for assess ment. Due to formal mistakes only 91 programmes could be analysed. 49 programmes failed the criteria of the first assessment step. For the remaining 42 patient education programmes balance sheets were prepared. Areas of the most frequent deficiencies included: lack of scientific evaluation of the effectiveness of the programme, lack of transparency of cost data, and quality improvement activities., Conclusions: For the purpose of a nation-wide implementation of disease management programmes the existing patient education programmes in Germany need to be further improved. Single examples demonstrated that the accessible criteria of self-management are not sufficient for the evaluation of already established patient education programmes.

In 2003, the German Ministry of Health will publish a legal document that will allow for the implementation of disease management programmes for asthma and COPD. Examination of German asthma guidelines reveals that they do not include recommendations for a stepwise diagnostic work-up of patients with relevant symptoms in general practice. Therefore an algorithm was developed for the diagnosis of asthma in general practice, based on both national and the most important foreign guidelines providing specific advice on diagnostic procedures.

The evaluation of disease management programmes is necessary and has been made obligatory in Germany by the Fifth Book of Social Code. So far there has been extensive ambiguity as regards the precise definition of suitable strategies for the evaluation. Considering the scientific evaluation of the diabetes contract in North-Rhine current deficits of the evaluation of already existing programmes for chronically ill patients are exemplarily described. On the basis of international experience reasonable demands are discussed that ought to be accomplished when evaluating the effectiveness and benefit of the programmes. Taking the British Medical Research Council as an example, a four-step model will be suggested as a loophole in the methodological dilemma of varying suitable study designs, which allows for the adequate evaluation of even complex interventions.

In Germany, the change from the "traditional", experience-based general practitioner (GP) to the evidence-based practising co-ordinator may be accelerated by the introduction of disease management programmes. Here, we will discuss some tools that can help to meet this challenge. Also, a set of requirements will be defined that the health care system will have to provide in support of GPs. Maintaining the relationship between doctor and patient and also allowing for individual care on the basis of evidence-based medicine will remain a challenge.