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Background: The PRiVENT project aims to improve the care of invasively ventilated patients and to reduce the number of out-of-hospital long-term ventilated patients. PRiVENT offers intensive care units the opportunity to exchange information with experts from specialized weaning centers in interprofessional weaning boards and weaning consults and to exploit the full weaning potential of the patients. In the context of the accompanying process evaluation, the PRiVENT intervention components will be examined for sustainability, scalability and effectiveness, and the interprofessional collaboration between intensive care units and the responsible weaning centers will be investigated in order to identify potentials for the care of invasively managed patients., Methods: In a qualitative cross-sectional study, semistructured, problem-oriented interviews were conducted with care providers of participating ICUs. The data were digitally recorded, pseudonymized and verbatim transcribed. Data analysis was based on Brown and Clarke's Thematic Analysis and the Consolidated Framework for Implementation Research. MAXQDA 2020 software was used to organize the data., Results: Fourteen interviews were conducted with ICU care providers. The early transfer of patients to a weaning center and the integration of pulmonary expertise into routine care were identified as positively perceived potentials of the weaning boards and weaning consults. Especially in critically ill, multimorbid patients suffering from COVID-19, the expertise of the weaning centers was considered helpful. Due to heavy workloads, nurses were unable to participate in weaning boards and weaning consults., Conclusion: Interprofessional collaboration between weaning centers and ICUs in weaning boards and weaning consults can improve the care of invasively ventilated patients. Strategies to promote the involvement of nurses should be discussed and developed., Competing Interests: Joachim Szecsenyi ist Gründer des aQUA Institutes. Franziska Trudzinski gibt folgende Interessenkonfilkte an: 1. Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events: Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Grifols, Novartis, CSL Behring, Streamed up RG Gesellschaft für Information und Organisation mbH. 2. Participation on a Data Safety Monitoring Board or Advisory Board: CSL Behring, GlaxoSmithKline., (Thieme. All rights reserved.)

Background: The concept of Care Assistant in General Practice (VERAH) was developed in order to integrate non-medical staff more strongly into primary care and thus to meet the increasing demand for care and the simultaneous shortage of medical staff. VERAHs are increasingly responsible for software-supported case management and are thus confronted with new tasks. The aim of this study was therefore to explore the role of the VERAH in primary care practices., Methods: The present study is a qualitative secondary data analysis; the data collection took place within the projects VESPEERA and TelePraCMan. Twenty individual interviews and two focus group meetings were conducted with a total of 30 physicians, VERAHs and medical assistants from primary care. The data were analysed qualitatively according to Emerson. Contextual and socio-demographic data were collected with an accompanying questionnaire., Results: The VERAHs of all primary care practices from which interview partners participated performed tasks within software-supported case management. Concerning the role of the VERAH, three themes were identified in the interviews: a) concrete tasks of the VERAH in software-supported case management within the practice team, b) relevance of software-supported case management within the activities of the VERAHS and c) relationship between VERAHs and patients., Conclusion: Taking over tasks in software-supported case management can contribute to strengthening and expanding the role of the VERAH. In the future, more attention should be paid to a clear description of the new role, and the conditions of the VERAHs' task fulfilment should be considered., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Objective: The VISION intervention is a manualized short-term treatment for people with somatic symptom disorder, integrated into the primary care and delivered by psychotherapists via video consultations. As an innovative technology-based approach, the intervention was most recently piloted in a randomized feasibility trial. During the qualitative accompanying study presented here, the intervention was evaluated and optimised from the user perspective of patients who participated in the feasibility study., Methods: We interviewed a total of N=10 patients included in the intervention group in three semi structured focus group discussions focusing on how they (1) assess the intervention in terms of acceptance and individual benefit and (2) which adjustments are necessary from the user perspective for further optimization of the intervention. We performed a qualitative content analysis using MAXQDA Plus 2022., Results: Respondents reported initial reservations on their part regarding care via video consultation. After a brief period of habituation, the intervention was universally accepted. Main suggestions for improvement included a stronger focus on supporting patients find follow-up psychotherapy (if indicated) more flexible settings (e. g., location of video consultation), and a stronger integration of treatment into primary care., Discussion and Conclusion: The study provides systematically elaborated comprehensive findings on participants' practical experiences with the intervention. The model is appropriate for treating people with somatic symptom disorder. Before implementation, important suggestions for improvement should be thoroughly considered with continued patient and public involvement., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objectives: The aim of this study was to give an early snapshot of primary care strategies that were implemented to cope with the early period of the COVID-19 pandemic in Baden-Wuerttemberg (Germany)., Methods: In June 2020, all 271 outpatient SARS-CoV-2 contact points, established by the National Association of Statutory Health Insurance Physicians (16 centers for testing, 204 specialized family practices, 51 Outpatients Corona Centers), and a randomly generated sample of 400 primary care practices of Baden-Wuerttemberg were invited to take part in a paper-based questionnaire. The data were gathered anonymously and analysed descriptively., Results: Out of those invited, n=63 (15.8%) primary care practices and n=92 (33.9%) SARS-CoV-2 contact points participated; 78.7% of the primary care practices cooperated with SARS-CoV-2 contact points (n=48). In all, 92.1% had implemented a compulsory registration by phone for patients with (suspected) COVID-19 (n=58) and 81% offered consultation exclusively by phone or video in case of a mild courses (n=51). The new outpatient SARS-CoV-2 contact points were established in collaboration with several stakeholders, mainly led by primary care physicians (n=76, 82.6%) and almost 50% of these were established in March 2020 (n=42, 48.3%). The most commonly reported method of registration was regulated mainly by primary care practices (n=88, 95.7%) and public health departments (n=74, 80.4%). In 92.4% (n=85) of cases, it was possible to register by phone. The consultation response was most commonly given in the form of oral information to the patient (n=65, 77.4%). Less then 50% of the SARS-CoV-2 contact points used standardized sheets for registration, documentation and consultation. The assessment of future primary care structures for (suspected) COVID-19 patients were heterogeneous., Conclusions: Effort, improvisation and collaboration were required for a successful and rapid implementation of measures for primary care during the initial period of the COVID-19 pandemic. Impulses for ongoing development of primary care strategies during a pandemic can be derived out of these results., Competing Interests: AB, SM, FPK, CR, SSc und MW geben keine Interessenskonflikte an. NBG und SSt haben im März/April je eine Fieberambulanz aufgebaut. NBG erhielt Dienstpauschalen, SSt eine Aufwandsentschädigung für den Aufbau von der KVBW., (Thieme. All rights reserved.)

Mental health conditions represent a significant burden to the individual as well as the society. Within the health care system, the general practitioner is the first and, in most cases, the only provider. Timely referral of patients to specialized care is often difficult due to several barriers, particularly in rural areas. These barriers comprise long waiting times, the rising prevalence of psychosomatic and somatopsychic comorbidity, immobility in the elderly and stigmatisation related to mental health conditions. Following the Integrated Health Care approach, diagnosis and therapy of mental health conditions by psychotherapists directly within the general practice constitute an effective care model. We present a care model that is based on a telemental treatment approach for depression and anxiety disorders. Central is the piloting of psychotherapeutic video consultations in the general practice. The following article provides an overview of the care model and provides results concerning the intent to adopt the model in office-based psychotherapists., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Since October 2016, German patients are entitled to get a medication list if using at least 3 drugs. The patient's individual attitude to a medication list is supposed to be relevant for its use und acceptance., Study Aim: Because there is little known about those attitudes, this study examined which potential benefits patients see in possessing a medication list, and why certain patients might not use it., Method: In a qualitative survey, 375 citizens of the Rhein-Neckar region were interviewed by using a semi-standardized guide. A content analysis of the interviews was done., Results: Most citizens described medication lists as having private and economic benefits such as for health care or safe drug use. But often, they combine potential benefits with requirements such as age, number of prescribed drugs, or health status. Unsatisfied individual needs, excessive demands or an attitude of rejection are possible reasons for non-use., Conclusion: For successful implementation of the medication list, the individual attitude of patients should be assessed to be able to provide tailored information and assistance. The views of citizens about a medication list agree with the aims of the so-called German E-Health Act, but differ particularly with regard to named requirements and prioritisation., Competing Interests: WEH ist Gesellschafter der Dosing GmbH Heidelberg, die elektronische AMTS-Werkzeuge (inkl. Medikationspläne) zur Qualitätssicherung der Arzneimitteltherapie herstellt und vertreibt. HS ist (unbezahltes) Mitglied des wissenschaftlichen Beirats dieses Unternehmens. Alle anderen Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: General practice offers basic medical care to patients. Therefore, general practitioners (GPs) perform a variety of medical procedures. In order to estimate GPs array of services from the perspective of health services research, it is indispensable to know the procedures that are carried out by GPs and identify relevant influencing factors., Methods: Based on the results of a selective literature search, the Medical Association's regulations on specialty training and experiences gained so far in developing the competence-based curriculum for general practice, a questionnaire covering 89 procedures was developed and sent to 1 576 general practitioners all over Germany., Results: The response rate was 42%; 42 of 89 procedures were carried out by at least 50% of the participants. These procedures include the anatomical areas skin, eyes, ears, nose, gastrointestinal tract, urological tract and musculoskeletal system. Significant differences were shown in 25 of the most frequent procedures regarding practices in urban and rural areas, in 9 procedures with regard to the participant's length of occupation in general practice and in 19 procedures regarding male and female participants., Conclusion: This is the first survey that shows which procedures are performed by German GPs and how often they are performed. Factors such as practice location in either rural or urban area, physician's gender and years practiced as GP have been identified as important influences on the spectrum of services provided., Competing Interests: Interessenkonflikt:: Die Autoren geben an, dass kein Interessenkonflikt besteht. JS, JSz, ThL, SJ sind Fachärzte für Allgemeinmedizin., (© Georg Thieme Verlag KG Stuttgart · New York.)

2 334 patients from 29 dental practices took part in a written survey on their experiences with dental treatment in general as well as treatment of periodontal disease (response rate 80.8%). 72.6% of all participating patients fully agreed that they could recommend their dentist to their friends. 63.6% of patients undergoing treatment of periodontitis (N=328) rated this treatment as "excellent". However, for important aspects (prevention, patient information, treatment) potentials for improvement became obvious. 43.7% of patients treated for periodontitis were not completely satisfied with information on how this disease develops; 40.7% saw potentials for better information on preventive care (dental-hygiene, nutrition). An even higher percentage of patients actually not treated for periodontitis was interested in more information on prevention (51.4%). The results of the survey show that dentists should offer information and exercise on how to prevent periodontal desease more actively. There is a lack of research on the present state of affairs and potentials for improvement concerning treatment and prevention of periodontitis including the patients' perspective., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Within the next 8 years about 2 000 general practitioners (GPs) will be seeking a successor in the federal state of Baden-Württemberg, Germany. Both the small number of newly qualified GPs and the wish to work as an employee or in a group practice will lead to a situation in which about 500 practices will likely not find a successor. Using a single administrative district, the aim of this analysis was to develop a projection of the demand for GP health care at the community level., Methods: Using the administrative district of Rottweil with its 21 communities, a community-based demographic forecast on the basis of current birth and death probabilities was performed. From the projected population structure, the demand for GP care in the year 2023 was derived under the assumption of unchanged age- and gender-specific numbers of GP visits. The anticipated deficit or, respectively, overrun of GPs at the community level was calculated as the difference between expected demand and number of GPs not retiring for age-related reasons., Results: Until the year 2023 the demographic change will cause a shrinking population. However, with unchanged age- and gender-specific numbers of GP visits, a slightly higher demand of 0.6 GPs will occur as a result of population-aging. The expected age-related retirement of physicians will have a stronger impact on primary care demand than demography. Up to 32 (37%) GPs might need a successor. In addition to 4 communities today, this would result in another 5 communities not having a GP in 10 years., Conclusion: Communities that are at higher risk of GP shortage based on demographic changes and age of practicing GPs, can be identified by the approach described and applied here in order to implement targeted comprehensive community models of care., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The ageing of physicians working in ambulatory care make regional health planning a challenging task. This study examines the current supply of general practitioners (GP) within the communities from the perspective of mayors. The information gained on a community level can be used when discussing over- and undersupply as well as future health care planning., Methods: A questionnaire was sent to all 1101 mayors of the Federal state of Baden-Württemberg (BW) in May 2011. For the evaluation of the location of the communities, subjective ratings by the mayors were compared with official criteria, provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBSR)., Results: The participation rate was 63% (n=698). According to the mayors about 70% (n=468) were located in a rural area, according to BBSR criteria were about 26% (n=177) of answers given by rural communities. Of the participating mayors about 54% (n=355) stated that their community is cared for merely by GPs. From this information there was a locally experienced undersupply of GPs calculated for 13.5% (n=86) of the communities. This affected rural as well as non-rural communities. In communities up to 20 000 inhabitants, the ratio between GPs and other specialists seems to be 60:40 whereas in bigger cities the proportion of other specialists appears to be much higher., Conclusion: Half of the participating communities seem to not have a practicing specialised physician. An accumulation of specialised physicians in larger cities was reported. The GP shortage appears to mainly be experienced subjectively. Regarding the location (urban vs. rural) of the community, subjective views differ distinctly from the BBSR criteria. This discrepancy could influence a community's marketing strategy when competing for new physicians., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Little is known of the primary care characteristics in out of hours care centres (OOHC) as compared to regular care in Germany. Obviously the provision of patients in OOHC exhibits special characteristics concerning supply requirements, occupation and physician services, that require a first approximation., Methods: The data retrieval is managed within the CONTENT (CONTinous morbidity registration Epidemiologic NeTwork) research network. The used software allows for classifying reasons for encounter (RFE), health-problems (diagnoses) and processes of care (prescriptions, referrals, hospitalisations) with the International Classification of Primary Care (ICPC). Furthermore the software allows for pseudonymised data export. One OOHC Centre in South Hessen is part of the network. Therefore, this allows the comparison of this OOHC centre with the regular care of the included 5 physicians in 4 practices of the same region., Results: A 3-year period (01 April 2010-31 March 2013) with 192,827 patient contacts of 13,394 patients (58.1% female) in regular care and 14,354 patient contacts with 9,208 patients (64.1% female) in OOHC was described. Medium age of the patients of the regular provision was 59.6 vs. 45.7 years in the OOHC centre based on the contacts (p<0.0001). The most frequent RFE in the OOHC centre were fever and pain predominantly caused by acute infections, injuries or acute pain of the musculoskeletal system. In regular care there could be documented predominantly chronic health issues and vaccinations. The prevalent prescriptions in OOHC were therefore antibiotics and analgesics in regular care blood pressure medication and antidiabetic drugs. The rate of referrals was obviously lower than in regular care (7.1 vs. 22.7; p<0.0001), whereas the rate of hospitalisations was obviously higher in OOHC than in regular care (5.6 vs. 1.1; p<0.0001)., Conclusion: With the help of the data, requirements, occupation, resulting diagnoses and care processes in regular and out of hours care can be compared and described in detail. We could document major differences between the provision in OOHC and regular care. The results encourage initiating further studies to ensure the supply of primary care in OOHC., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: Patient perspective is crucial concerning health care and quality improvement. During episodes of care, patients come into contact with multidisciplinary health-care providers in inpatient and outpatient settings and are in a unique position to describe processes throughout the entire chain of care. The aim of this study was to identify patients’ experiences and preferences with fragmented cross-sectoral care to develop a patient-centred cross-sectoral quality-assessment instrument., Method: Patient perspective was analysed using qualitative focus-group methods. Patients were recruited from general practices if they had experienced cross-sectoral care. Focus group discussions were audiotaped, transcribed and analysed using ATLAS.ti software. Categories were extracted deductively according to a previously developed focus group guide and supplemented by inductive analyses., Results: Patients identified quality gaps mainly concerning communication and coordination of care mostly along the cross-sectoral interfaces. Referrals and hospitalisations were characterised by redundant examinations and deficits in forwarding clinical findings. Support and organisation of follow-up care was rated to be improvable mainly during inpatient care and discharge. Patients identified also quality deficits concerning inpatient hygiene factors and changes of medication. Lack of transparency and responsibility within the entire chain of care caused anxiety and unstableness of patients., Conclusion: Patients' experiences provide important information to identify quality gaps along the entire chain of care. Study results can be used to develop a cross-sectoral patient-centred quality assessment instrument., (© Georg Thieme Verlag KG Stuttgart · New York.)

Interface problems between health care sectors hinder collaborative care in functional syndromes. The speciAL trial investigated a disorder-oriented group intervention conducted by the general practitioner (GP) and a psychosomatic specialist (PS) in the GP's office. To evaluate the GP-PS cooperation, our qualitative study analysed free text statements about collaborative group leading of all 18 intervention GPs. In the GPs' view, all sessions should structuredly be prepared and reviewed together for 20 min. Functions of the preparatory communication were gaining distance from daily business, attunement to the group and to each other, and preparing for the session topics. Functions of the communication after the sessions were professional exchange, reflection of the session and further treatment planning. The GPs saw the PS's role as a group leader and expert, their own role as a reference person for the patient, a link between all dimensions and a cotherapist. Crucial seemed a succeeding role splitting., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Local governments have a crucial role in dealing with the primary care physicians shortage (PS). The aim of this study is to evaluate the perspectives and experiences of the local mayors on this issue., Methods: In May 2011, all 1101 mayors in the Federal State of Baden-Wuerttemberg (BW) were invited to participate in the study by filling out a survey developed by the authors. Data were analysed descriptively., Results: Of the contacted mayors in BW, 63% (n=698) responded. More than 90% of the participants consider it their duty to ensure future primary care. 16% experienced local practice closures due to PS. The infrastructure provided by the communities seems to be at a high level, whereas emergency practices exist in only 15% of the communities at present. Supportive actions to attract new GPs are evaluated as appropriate by almost half of the participants., Conclusions: The PS topic is of high relevance for communities in BW. In order to gain future physicians for their region, the majority of the communities are maintaining a high level of infrastructure and are willing to offer more actions. The young generation physicians need to be informed about these existing conditions. Innovative ideas should be implemented in individual communities as pilot projects., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Hospital referrals cause high costs in the health-care system. Information on hospital referrals from general practices in Germany is sparse. As a starting point for further research we describe the characteristics of hospital referrals and referred patients., Methods: In the CONTENT project (CONTinuous morbidity registration Epidemiologic NeTwork) the data sets of the patients of 23 general practices were gathered with the help of a modified electronic patient record system. The data of 49,423 patients (yearly contact group 2007) were analysed., Results: Approximately 4% of the patients were referred to a hospital. Most frequent diagnoses (International Classification of Primary Care) were: D75 "malignant neoplasm colon/rectum", K74 "ischaemic heart disease with angina" and L90 "osteoarthrosis of knee". Patients referred to hospital had a higher comorbidity (p<0.0001), higher contact frequencies (p<0.0001), higher prescribing rates (p<0.0001) and were older (p<0.0001) than patients not referred to hospitals. Variations of the referral rates over the year and the week were dependent on parallel variations of the contact frequencies between doctors and patients., Conclusion: Patients referred to hospital from general practice are older and have a higher morbidity than patients not referred. Hospital referrals to rule out diseases with a potentially dangerous course as a means of managing uncertainty seem to be the most effective field under control of general practitioners to reduce hospital referrals., (© Georg Thieme Verlag KG Stuttgart · New York.)

The vaccination status of German adults needs improvement. Low participation is also known in health screening programmes like the "Check up 35" which is offered every two years for adults aged 35 or above. However, the number of participants in health screening increases with age whereas vaccination status decreases. Within a study about patients' attitudes towards prevention in primary care, we investigated the knowledge about the vaccination status. Therefore, an anonymous survey was conducted among 333 patients from five general practices in 2007. 76% of the potential participants in health screening declared that they utilise it at least infrequently. In contrast to those who participate frequently in health screening (67%), those who participate infrequently (38%) or never (33%) but declare that their vaccination status is complete are significantly rare. Due to the results of our study it has to be discussed whether the health screening "Check up 35" should be regularly accompanied with vaccination counselling., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Various study approaches can be considered for the investigation of the efficiency of enrollment models, like GP-centred health-care contract or disease management programmes. As an active and independent enrollment into care models is effected by the insured (self-selection), a randomisation cannot be applied. The matched pairs design - in which for every insured a control insured with comparable morbidity is selected - presents an alternative investigation method. A precondition is a model that describes appropriately the morbidity on the basis of available routine data., Target: The aim of this study was to develop a procedure that selects comparable insured persons on the basis of routine data of the statutory health-care funds., Methods: Apart from age, gender, care status, insured status, days of disability, region, health insurance and belonging to an enrollment model, also ambulant as well as stationary performance data for the year 2005 following the PCG/DCG procedure for morbidity-oriented matching design developed by Lamers and Vliet (2003) were applied. Thereby the consumption of certain medications prescribed is determining for the allocation of patients to pharmaceutical cost groups (PCG). Additionally a classification into diagnosis cost groups (DCG) according to stationary diagnoses was conducted., Results: Within the scope of the enrollment models the formation of matched pairs following the PCG/DCG procedure represents an appropriate study design for the creation of a control group. In the first year of enrollment the insured of the interventional and those of the control group show a comparable morbidity. When applying 9 matching criteria a control insured person can be found for 87% of the enrolled individuals., Discussion/conclusions: There are various and complex possibilities to define morbidity. Variable parameters within the presented matched pairs design are the number of used matching criteria as well as minimum drug consumption limit relevant for the classification in PCGs. Alternative models are possible for morbidity definition considering, apart from the stationary diagnosis, also the ambulant diagnosis. When taking into account a higher number of morbidity criteria, the matched pairs design is confronted with dimensionality issues. The propensity score matching is discussed as approach to solve this problem., (Georg Thieme Verlag KG Stuttgart * New York.)

1,317 patients from 18 dentists took part in a written survey on patient evaluation of dental care. General satisfaction was high, but patients were critical concerning some aspects of dental care. On average, the aspects rated most often with "excellent" were hygiene in the practice, the possibility to get through to the practice on the telephone and quick service in case of urgent health problems. Most critical evaluations (on average) were given for waiting times, costs of the dental treatment for the patient and the range of magazines and written information in the waiting room. The highest statistical correlation to overall satisfaction (willingness to recommend this doctor to friends) showed the patients' assessments concerning the questions whether the doctor was listening to them and took enough time, as well as the result of the dental treatment from the patients' point of view. Differences of the survey results between practices were high. On average, patients of female dentists were more satisfied than patients of their male colleagues. Patients younger than 50 years and male patients were less satisfied than older patients and female patients. The patient surveys give important clues for quality management in the participating dental practices. The results of a patient survey should be evaluated against the background of the individual situation of the practice.

Objective: Disease management programmes (DMP) are supposed to improve the care of patients with type 2 diabetes or other chronic conditions. One stated aim is the improvement of the health-related quality of life. Within the ELSID study (controlled study for the evaluation of the DMP for patients with type 2 diabetes) there has been a survey of insurants of the general regional health funds (AOK) by means of the SF-36. The aim of this survey is a comparison of patients participating in the Diabetes DMP with those who are not participating in the program with regard to their quality of life., Methods: A random sample of 3,546 patients with type 2 diabetes out of the total sample of the ELSID study (20,625) was asked to complete the SF-36., Results: 1,532 questionnaires were returned (response rate 43.2%). 1,399 were analysed. Within all scales of the SF-36, men achieved higher scores than women. Differentiated in participants and non-participants in the DMP, in men there were lower scores for the participants than for the non-participants. In women this proportion was reversed., Conclusions: This cross-sectional-study provides first indications for gender-specific differences within the quality of life of patients with diabetes participating in the DMP compared to patients who are not participating. These differences should be considered more intensely within further research of DMP evaluation and the configuration of the programmes in the future.

Billing data for individual patients from General Practice surgeries can be used to analyse primary care utilisation. Making these data available for research and controlling purposes of the German health care system is vital for health services research. Due to the predominant billing purposes, German routine data are unlikely to yield a realistic and differentiated picture of primary care. The General Practice morbidity research network CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork) was established as part of the primary care research grant of the German Federal Ministry of Research and Education. As opposed to other available German routine health care data, the project is designed around episodes of care as the ordering principle of primary care. An episode-based registration integrates the elements reason for encounter, result of the encounter and medical procedure across the quarterly billing timeframe. The use of the International Classification of Primary Care (ICPC) in the CONTENT project supports a specific adaptation to documentation in primary care. As opposed to the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD), ICPC was especially developed for primary care purposes. An episode-based registration and an appropriate classification are prerequisites for a realistic and detailed picture of morbidity and services provided in primary care. An existing electronic medical record (EMR) was extended with domain-specific modules in order to meet the requirements of episode-based registration. The resulting database has already yielded analyses that were impossible to achieve from German routine health care data. Further analyses will subsequently be based on the continuously expanding database and have the potential to shed light on complex epidemiological and health economics research questions. First results point in the direction that the new mode of data collection, in contrast to routinely entered data, features the potential for a more detailed assessment concerning utilisation of medical services, morbidity, course of illness and outcomes in the context of primary care.

Objectives: To analyze the necessity and potential usefulness of a computerized physician order entry (CPOE) system in supporting the writing of pharmacotherapeutic recommendations in discharge letters., Methods: Systematic analysis of drug recommendations in discharge letters of a hospital providing tertiary care, structured interviews with in-hospital prescribers, and focus groups with general practitioners who admit patients to this hospital., Results: We analyzed 1800 randomly selected discharge letters, 1205 of which contained pharmacotherapeutic recommendations. The frequencies, structure, and quality of these recommendations varied considerably between departments. Nearly 16% of the recommendations contained both proprietary (brand) and non-proprietary names (active ingredient). Interviewed clinicians expressed interest in CPOE systems that check for contraindications and interactions between drugs, suggest cheaper products, and automatically insert active ingredients when omitted. The focus group sessions confirmed that the pharmacotherapeutic recommendations in current discharge letters do not effectively support daily clinical practice., Conclusions: Documenting active ingredients as well as brand names in drug therapy recommendations is currently not part of clinical practice. Computerized decision support can help to optimise the structure and communication of therapeutic information across interfaces and can be a quality factor with considerable influence on process quality, outcome quality, and costs of cooperative patient care.

Background: In Heidelberg, the clinical curriculum of medical education was fundamentally changed in 2001 due to co-operation with the Harvard Medical School. The pre-clinical curriculum has also already been undergoing reform since 1995: the benefits of two new lectures with early patient contact and special tasks in the subject of family medicine were to be assessed., Methods: In the first year, the students therefore had to assess the seminars, tutorials, and the internships in GP by means of a standardised questionnaire. In addition, reports had to be produced on teaching practice. The teachers were also questioned following agreement with and introduction of quality assurance measures., Results: 66-89% of students assigned good marks to the internships in GP, 40-58% for the accompanying seminars, and 70% for the tutors. The results of a general external evaluation which was carried out slightly differently were not quite so good. 87-89% of teachers agreed upon the elaborated criteria for the quality of teaching practice., Conclusions: The results show that GP-based education is already well accepted in the first year of training, and that early patient contact in primary care is highly appreciated by the students. On their part, the teaching GPs assess the quality promotion sessions as instruments towards continuous quality support in pre-clinical training as meaningful and necessary, especially with regard to licensing for teaching in General practice.

Using the German data of the European referral study from primary to secondary care this paper attempts to answer the following questions: which are the specialties GPs refer to, and which referrals were initiated by the patients. According to the study's methodology the gatekeeper function of the GPs or the patient initiative should be described by distinguishing between direct and indirect referrals. A direct referral is defined by a face to face encounter between patient and GP, while an indirect referral requires no such contact. For direct referral the GPs recorded the influence of the patient on their referral decision. In 71 practices (only the western part of the Federal Republic of Germany) 2077 direct and 1665 indirect referrals were documented. Every second direct referral was influenced by the patients. Women had a greater influence than men. An analysis by specialty showed that most of the direct referrals were directed to orthopaedics (14%), surgery (12%) and internal medicine (10%) and most of the indirect referrals to ophthalmology (25%), gynaecology (20%) and dermatology (8%) (64% of all indirect referrals were given to women). These results could be taken as an example how patients take over the responsibility of managing their complaints and illnesses by themselves in a health system with free access to specialist care. The role of the German GP as a gatekeeper and co-ordinator in the health care system turned out to be very limited. In consequence this might result in future problems such as a lack of co-operation, deficiencies in the continuity of medical treatment, over-medication unnecessary parallel investigations and additional costs.

Evaluation by Participants: For a project aimed at improving the prescribing performance of general practitioners (GPs) in Northern Hessia, 53 GPs who exceeded average prescribing costs by more than 20% were approached. 32 agreed to participate in 10 peer-review group meetings and to discuss an analysis of their own prescriptions issued during a three-months period. These 32 GPs in three quality circles as an intervention group were compared with a group of 15 GPs as a "gold standard" who had been working for two years already on other items than rational prescribing and who had not had any problems with prescribing costs. Apart from positive effects in changing actual prescribing behaviour, discussed elsewhere, an evaluation of the group work by participants in structured questionnaires and open discussions revealed differences between the intervention and the "gold standard" groups. Members of the intervention group had to overcome feelings of being controlled by the authorities in the first session, and felt less satisfied with the effect of the group work on their daily work in practice. This article discusses matters of working in groups, and points out the importance of volunteer participation.

The large inter-doctor variation in referrals to specialists known from previous research can only partly be explained by differences in presented morbidity, in practice setting or in general practitioners' (GPs') attitudes to their own work. The objective of this study was to analyse GPs' attitudes towards their own work and their influence on referral behaviour. This work is a follow up of the European study of referrals from primary to specialist care carried out in nine countries. We present an analysis of the West German part involving the same sample as in the European referral study. To 75 GPs a questionnaire with 26 items was sent, which validity and reliability was measured in studies before. 71 GPs took part in the study (response rate 95%). GPs with a high referral rate perform some technical procedures less frequently than GPs with a low referral rate. Many GPs consider their clinical responsibilities to be greater than their actual performance would suggest. In general, GPs tended to minimize risks. Significant correlations between attitudes and referral rates were found for 7 items only. GPs attitudinal consensus had no firm association to their referral behaviour (as measured by the instruments used). To explain this finding structural and financial aspects of the health care system should be taken into account. Further investigations about the referral process including a qualitative approach are necessary.

General practitioners play an important role in counselling for HIV-Tests. There is little known yet about the background of the decision process which results in doing the HIV-test. The EUROSENTINEL-study on requests for HIV-testing started in 1990 and is in the meanwhile carried out in 7 sentinel-networks in six european countries. In the beginning of 1991 the german part started in 36 practices in the north of Hessia. In the first year of the study these 36 practices recorded 327 consultations about HIV-testing. The initiative to counsel was taken in 64.2% by the patient and in 35.8% by the doctor. In male patients the main reasons for the consultation were heterosexual contacts and administrative or legal reasons. In female patients it were fear of HIV-infection without any risk and professional exposure. In 86.2% of patients the consultation was followed by a HIV-test. Seven Tests (2.5%) were positive. All HIV-positive patients belonged to the classical risk groups. The results are discussed in comparison to those of other european networks. It can be concluded that general practitioners play an important role in primary prevention of HIV-infection and in counselling people who are worried by the AIDS epidemic.

In countries with fee for service billing and direct access to specialist care the general practitioner does not know key figures of the population he serves. As the role of general practice in health-service-research, quality assurance activities and the construction of sentinel-networks is becoming more important, valid methods to determine the denominator are needed. Results from five practices suggest that yearly contact groups should be used as a common denominator for general practice in our health care system. For certain groups of patients (e. g. the elderly > 60 yrs.) even quarterly contact groups can give sufficient information to forecast the yearly contact group.