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

In recent years studies not falling under the German Pharmaceutical Law ("non-drug trials") have also been increasingly expected to be conducted according to Good Clinical Practice (GCP) in order to ensure that uniform standards are maintained for data quality and patient safety. However, simple transfer of the GCP criteria is not always possible and often not useful. Given the fact that research questions regarding non-drug interventions are common in primary care (e.g., general practice), the "Network for Clinical Studies in General Practice" has developed a manual for planning and conducting non-drug trials. This manual is based on the GCP guideline, taking account of the conditions and circumstances in primary care settings. Both structure and relevant content of the manual are presented in the article. (As supplied by the authors)., (Copyright © 2012. Published by Elsevier GmbH.)

Background: In Germany, clinical trials and comparative effectiveness studies in primary care are still very rare, while their usefulness has been recognised in many other countries. A network of researchers from German academic general practice has explored the reasons for this discrepancy., Methods: Based on a comprehensive literature review and expert group discussions, problem analyses as well as structural and procedural prerequisites for a better implementation of clinical trials in German primary care are presented., Results: In Germany, basic biomedical science and technology is more reputed than clinical or health services research. Clinical trials are funded by industry or a single national programme, which is highly competitive, specialist-dominated, exclusive of pilot studies, and usually favours innovation rather than comparative effectiveness studies. Academic general practice is still not fully implemented, and existing departments are small. Most general practitioners (GPs) work in a market-based, competitive setting of small private practices, with a high case load. They have no protected time or funding for research, and mostly no research training or experience. Good Clinical Practice (GCP) training is compulsory for participation in clinical trials. The group defined three work packages to be addressed regarding clinical trials in German general practice: (1) problem analysis, and definition of (2) structural prerequisites and (3) procedural prerequisites. Structural prerequisites comprise specific support facilities for general practice-based research networks that could provide practices with a point of contact. Procedural prerequisites consist, for example, of a summary of specific relevant key measures, for example on a web platform. The platform should contain standard operating procedures (SOPs), templates, checklists and other supporting materials for researchers., Conclusion: All in all, our problem analyses revealed that a substantial number of barriers contribute to the low implementation of clinical research in German general practice. Some issues are deeply rooted in Germany's market-based healthcare and academic systems and traditions. However, new developments may facilitate change: recent developments in the German research landscape are encouraging.

Background: Little or no longitudinal data have been available to date on the utilization of primary care physicians' services, particularly by chronically ill and multimorbid patients and by those who see their primary care physician often ("frequent attenders")., Methods: We collected anonymous data on 305 896 patients from 155 primary care practices over the period 1996-2006 and analyzed them with descriptive statistics, correlations, and multiple logistic regression., Results: Over the period of the study, patients visited their primary care physicians about 7 times per year on average. Frequent attendance, defined as 24 or more contacts per year, was not strongly associated with chronic illness or multimorbidity (r=0.19 and r=0.24, respectively) but was found to be linked to time-consuming medical services, such as detailed counseling (adjusted odds ratio [OR], 5.8) and house calls (OR, 3.5). Chronically ill patients utilized their primary care physicians' services less than we had expected. Chronic illness and multimorbidity were more common with increasing age; also correlated with age were the utilization of medical services, the number of visits to the primary care physician, and the number of visits to the primary care physician among frequent attenders., Discussion: Although in Germany visits to physicians of all types (both primary care physicians and specialists) in private practice became more frequent in total over the period of this study, visits to primary care physicians alone did not. Frequent attenders do not necessarily have chronic illness or multimorbidity but seem to constitute a particularly problematic group. Chronic illness is not a predictor for greater utilization of primary care physicians' services.

Background: Aim of this study was to evaluate the acceptance and use of a basic geriatric assessment (BGA), as it is covered by the German pay system, in primary care practices., Methods: We conducted qualitative interviews and collected quantitative data by an online questionnaire., Results: A total of 17 (10 men) general practitioners (GPs) agreed to be interviewed; 161 patients (134 men) completed the online questionnaire. GPs mainly performed BGA to substantiate the suspicion of cognitive impairment. Most of the German general practices accomplished not more than 5-10 BGA per quarter. Although those GPs who conducted BGA were convinced of its usefulness with regard to further patient care, concrete interventions were rarely named. The tests used within the BGA were not always in line with recommendations from the specific guidelines. The main reasons not to conduct BGA were the amount of time required and the lack of therapeutic consequences., Conclusion: Hitherto BGA is not an established tool in German primary care practices. The question, which single instruments are most suitable for older general practice patients, still needs clarification.

Introduction: Because hyperaldosteronism is the most common curable reason for secondary hypertension, screening is recommended. However, prevalence among general practice patients and feasibility of screening is still unclear. A design to assess prevalence in general practice and barriers against screening was created., Methods: This was an open, observational pilot study and focus group. In 2 general practices, all patients with arterial hypertension were included. Those with resistant hypertension (>140/90 mm Hg and taking ≥3 antihypertensive drugs) were eligible for screening. The design and feasibility of the study were discussed in a focus group of experienced general practitioners., Results: Of 3107 patients visiting the practices, 564 were diagnosed as having arterial hypertension. Seventy-nine fulfilled criteria for resistant hypertension. Aldosterone:renin ratio (ARR) could be measured in 63 of those patients. Withdrawal of ß-blocker was feasible in 34 of the 63 with measurable ARR. ARR was positive in 15, and in 3 of those 15 with positive ARR, it was caused by elevated aldosterone levels. Focus group discussion revealed barriers and concerns regarding organizational, financial, and practical aspects of a systematic screening., Conclusions: Screening for hyperaldosteronism in general practice seems possible in selected patients, but not in a systematic way. Barriers against systematic screening were a necessity for β-blocker cessation as well as structural prerequisites for patient identification.

Background and Aims: The hypothesis of increased cardiovascular risk contributing to chronic dizziness has been discussed controversially so far. We investigated older patients suffering from acute (<6 months), chronic (≥ 6 months) or no dizziness, in terms of their cardiovascular risk and other impairments., Methods: A cross-sectional three-group comparison of 257 patients (65+) presenting at family medicine surgeries in Germany was performed. Measures of cardiovascular risk, including overall scores, scores of quality of life (SF-12), activities of daily living (ADL), depression (GDS), dizziness handicap (DHI) and patients' needs (DiNA), as well as comorbidity and medication, were compared in univariate and multivariate logistic regression analysis., Results: In univariate analysis, systolic and diastolic blood pressure were significantly lower in the dizziness groups. The overall cardiovascular risk was not increased in dizzy patients. Anxiety was strongly associated with dizziness, whereas other associations were of marginal importance. In multivariate analysis, age (OR 1.10, 95% CI 1.03-1.17), female gender (OR 2.07, 95% CI 1.01-4.26) and anxiety (OR 2.50, 95% CI 1.03-6.05) were associated with acute dizziness, whereas only female gender was significant in chronic dizziness (OR 1.96, 95% CI 1.02- 3.75). Comparing all dizzy patients with the non-dizzy group, lower systolic blood pressure was also significantly associated with dizziness., Conclusions: Results from our sample suggest that low systolic blood pressure is more important for dizziness in older patients than increased cardiovascular risk. Acute-onset and long-term dizzy patients were comparable in many aspects, which makes this classification less clinically important.

Background: Dizziness is a common complaint of older patients in primary care, yet not much is known about the course of incident dizziness. The aim of the study was to follow-up symptoms, subjective impairments and needs of older patients (≥65) with incident dizziness and to determine predictors of chronic dizziness. Furthermore, we analysed general practitioners' (GPs') initial diagnoses, referrals and revised diagnoses after six months., Methods: An observational study was performed in 21 primary care practices in Germany, including a four-week and six-month follow-up. A questionnaire comprising characteristic matters of dizziness and a series of validated instruments was completed by 66 participants during enrollment and follow-up (after 1 month and 6 months). After six months, chart reviews and face-to-face interviews were also performed with the GPs., Results: Mean scores of dizziness handicap, depression and quality of life were not or only slightly affected, and did not deteriorate during follow-up; however, 24 patients (34.8%) showed a moderate or severe dizziness handicap, and 43 (62.3%) showed a certain disability in terms of quality of life at the time of enrollment. In multivariate analysis, n = 44 patients suffering from chronic dizziness (dependent variable, i.e. relapsing or persistent at six months) initially had a greater dizziness handicap (OR 1.42, 95%CI 1.05-1.47) than patients with transient dizziness. GPs referred 47.8% of the patients to specialists who detected two additional cases of benign paroxysmal positional vertigo (BPPV)., Conclusions: New-onset dizziness relapsed or persisted in a considerable number of patients within six months. This was difficult to predict due to the patients' heterogeneous complaints and characteristics. Symptom persistence does not seem to be associated with deterioration of the psychological status in older primary care patients. Management strategies should routinely consider BPPV as differential diagnosis.

The Research Agenda should be used as a key reference point to which new research should relate its usefulness and added value. Primary care evolves towards more interdisciplinary care, and research should focus more on the core competency of person-centred team care. There is an urgent need to develop clear definitions and appropriate research instruments for this domain. It will be a particular challenge to study comprehensive approaches in primary-care patients with multi-morbidity. The Research Agenda and the commentaries on it show future directions for primary care research. There are challenges related to a changing society, the shared responsibility and guidance of research by professionals and citizens (patients), and the need to fully integrate research as part of primary healthcare provision. There will be a need for a prioritization of spearheads to guide primary care research for the next decade: translational research, research on equity and health differences, on chronic disease and health systems research. This can not be realized without the development and maintenance of a solid research infrastructure: easily maintained and accessed observational databases, helpful information technology, strategies and techniques for patient involvement, advanced research training possibilities, and the development and validation of appropriate research instruments and outcome measures to capture the different challenges. Worldwide, primary care not only is a priority for health care policy, but it needs to become a research priority as well.

The recently published 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and highlights related needs and implications for future research and policy. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In three subsequent, articles the results for the six core competencies of the European Definition of GP/FM were presented. This article formulates the common aims for further research and appropriate research methodologies, based on the missing evidence and research gaps identified form the comprehensive literature review. In addition, implications of this research agenda for general practitioners/family doctors, researchers, research organizations, patients and policy makers are presented. The concept of six core competencies should be abandoned in favour of a model with four dimensions, including clinical, person related, community oriented and management aspects. Future research and policy should consider more the involvement and rights of patients; more attention should be given to how new treatments or technologies are effectively translated into routine patient care, in particular primary care. There is a need for a European ethics board. The promotion of GP/FM research demands a good infrastructure in each country, including access to literature and databases, appropriate funding and training possibilities.

Aim: To determine the prevalence of health problems uncovered by a Standardized Assessment for Elderly Patients in a Primary Care Setting (STEP), to explore how often STEP uncovered conditions new to general practitioners (GP) and ascertain how often STEP results led GPs to plan further interventions., Methods: This descriptive, interim analysis was based on the data of 189 elderly patients (median age, 78 years; interquartile range [IQ], 74-81) and their 20 GPs collected in Hannover region, Germany, between June 2008 and April 2009. Study nurses in the practice setting applied the 44-item STEP instrument, based mainly on self-reporting, as well as a standardized patient interview. Subsequently, GPs indicated whether the problems were new to them, and whether they planned further action or health interventions on the basis of the problems identified by STEP., Results: A median of 11 health problems (IQ, 8-14) were uncovered per patient, of which a median of 2 (IQ, 1-4) were new to the GP and interventions were planned for a median of 2 problems (IQ, 0-4). Many of the identified health problems are typical of old age. The following health problems uncovered by STEP were often new to the GPs (percentages differ to numbers due to missing GP ratings): cognitive impairment (33 of 64 affected by this problem, 73%), missing or unknown immunization status (84 of 160, 55%), and recent chest pain (19 of 37, 53%). Alcohol misuse was new in all 4 affected patients (100%) and recent falls were new in 5 of 7 patients (83%). Interventions for affected patients were frequently planned for problems of immunization (for 83 patients of 160 reporting the problem, 57%), current anxiety (4 of 9, 50%), and chest pain (14 of 37, 44%). Moreover, further management was frequently planned for depression (10 of 29, 39%) and cognitive impairment (16 of 64, 38%)., Conclusion: Using a geriatric assessment in primary care discloses relevant heath problems and treatment needs that GPs may otherwise overlook.

The 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. The previous articles presented background, objectives, and methodology, as well results on 'primary care management' and 'community orientation' and the person-related core competencies of GP/FM. This article reflects on the general practitioner's 'specific problem solving skills'. These include decision making on diagnosis and therapy of specific diseases, accounting for the properties of primary care, but also research questions related to quality management and resource use, shared decision making, or professional education and development. Clinical research covers most specific diseases, but often lacks pragmatism and primary care relevance. Quality management is a stronghold of GP/FM research. Educational interventions can be effective when well designed for a specific setting and situation. However, their message that 'usual care' by general practitioners is insufficient may be problematic. GP and their patients need more research into diagnostic reasoning with a step-wise approach to increase predictive values in a setting characterized by uncertainty and low prevalence of specific diseases. Pragmatic comparative effectiveness studies of new and established drugs or non-pharmaceutical therapy are needed. Multi-morbidity and complexity should be addressed. Studies on therapy, communication strategies and educational interventions should consider impact on health and sustainability of effects.

Background: The World Organization of Family Doctors (Wonca) defined core characteristics of general practice and general practitioners' competencies. It is unclear to which extent research has addressed these issues so far., Objective: To determine themes and research methods of general practice research as reflected by presentations at the European General Practice Research Network (EGPRN) meetings., Methods: Descriptive and retrospective study. All abstracts presented at each of the 14 EGPRN conferences between June 2001 and October 2007 were analysed for content and study design/methodology. Categories for content were developed inductively; a predefined hierarchical scheme was used for study designs., Results: A total of N=614 abstracts were classified. The main research topics were related to GP/health service issues (n=232), clinical (n=148) and patient-related themes (n=118). Original data (n=558) were mainly derived from cross-sectional designs (38.7%). Intervention studies (11.0%), longitudinal designs including case-control and cohort studies (13.3%) as well as instrumental research (2.2%) were less common. More than one-fourth of all original studies were qualitative studies (27.6%). Stratified analysis revealed that cross-sectional designs were less frequent in the second half of conferences. Analysis by country showed that, in contrast to different quantitative designs, the proportion of qualitative studies was comparable., Conclusions: To test effectiveness of diagnostic and therapeutic interventions under primary care conditions, a higher proportion of experimental studies would be preferable. This could increase the acceptance of general practitioners' specific approaches and provide clear guidance on approaches and procedures, especially in health care systems not predominantly based on primary care.

The recently published 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In a second article, the results for the two core competencies 'primary care management' and 'community orientation' were presented. This article reflects on the three core competencies, which deal with person related aspects of GP/FM, i.e. 'person centred care', 'comprehensive approach' and 'holistic approach'. Though there is an important body of opinion papers and (non-systematic) reviews, all person related aspects remain poorly defined and researched. Validated instruments to measure these competencies are lacking. Concerning patient-centredness, most research examined patient and doctor preferences and experiences. Studies on comprehensiveness mostly focus on prevention/care of specific diseases. For all domains, there has been limited research conducted on its implications or outcomes.

At the WONCA Europe conference 2009 the recently published 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' was presented. It is a background paper and reference manual, providing advocacy of general practice/family medicine (GP/FM) in Europe. The Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In this second article, the results for the core competencies 'primary care management' and 'community orientation' are presented. Though there is a large body of research on various aspects of 'primary care management', it represents a very scattered rather than a meta view. Many studies focus on care for specific diseases, the primary/secondary care interface, or the implications of electronic patient records. Cost efficiency or process indicators of quality are current outcomes. Current literature on community orientation is mainly descriptive, and focuses on either care for specific diseases, or specific patient populations, or on the uptake of preventive services. Most papers correspond poorly to the WONCA concept. For both core competencies, there is a lack of research with a longitudinal perspective and/or relevant health or quality of life outcomes as well as research on patients' preferences and education for organizational aspects of GP/FM.

Background: Integrating patients' priorities can improve the quality of care in general practice. Therefore, we aimed to learn more about patients' priorities in terms of their dizziness complaints., Methods: Patients were recruited by nine general practitioners. Inclusion criteria were an age of at least 65 years and dizziness due to any cause for any duration, assuring heterogeneity of included patients. Semi-structured interviews of 20 patients (12 women, mean age 79 years) were analysed by qualitative content analysis., Results: Patients were very much focused on finding causes for their dizziness, and some found their doctor had not taken the dizziness problem seriously yet. Each patient expressed own theories of aetiology that sometimes revealed apparent misconceptions of possible causes. Treatment aims were prioritised by patients in different ways (wish for recovery, relief or stabilisation). Some patients had not very well understood common therapy options, and interviewees frequently mentioned what they did on their own to face the dizziness (self-help measures). Remarkably, many patients were very much concerned about different aspects of mobility (fear of falling, loss of independence)., Conclusion: These patients' lack of understanding, their resources and concerns indicate the importance of a patient-centred communication about their dizziness complaints.

At the WONCA Europe conference 2009 the recently published 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' was presented. The Research Agenda is a background paper and reference manual for GPs/ family doctors, researchers and policy makers, providing advocacy of general practice/family medicine GP/FM in Europe. The Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of GP/FM, and its meaning for researchers and policy makers. Evidence gaps and research needs are pointed out to provide a basis for planning research for which there is a need and for action that may influence health and research policy, i.e. applying/lobbying for research funds. WONCA Europe and its associated networks and special interest groups could consider the agenda's research priorities when planning future conferences, courses, or projects, and for funding purposes. The European Journal of General Practice will publish a series of articles based on this document. In this first article, background, objectives, methodology and relevant literature are discussed. In subsequent articles, the results will be presented.

Background: Non-participation of general practitioners (GPs) is a serious source of bias for practice-based studies. Objective. To elucidate doctors' motives for non-participation in, and subjective barriers to, general practice research., Methods: German GPs that had opted out of a quality assessment project involving electronic patient records (EPRs) were mailed a questionnaire regarding their attitudes towards general practice research and their specific objections to the current project. A sub-sample of doctors was interviewed. Their statements were coded and classified with regard to the reasons given for non-participation and possible motivating factors., Results: The survey response rate was 37% (96/263); 21 GPs completed an additional qualitative interview. Nearly all respondents (88/96) considered general practice research to be important, but 58% had not previously participated in research projects and 56% would not do so in the future. Nearly half (47/96) were opposed to having data extracted from their EPRs. The qualitative analysis revealed deep concerns related to the collection of EPRs (e.g. potential misuse of data, being subject to control or resulting computer problems). Some GPs expressed concerns about recruiting their own patients for the study. Some doctors complained of not being sufficiently recognized as a partner or not having a voice in the research process., Conclusion: Doctors' negative attitudes, concerns and ambivalent feelings should be addressed in recruitment strategies, especially when the analysis of EPRs or direct patient contact is required. Some doctors do not participate in research out of principle and will be very difficult to convince.

Background: Older people consume an increasing amount of medication. Polypharmacy is associated with an elevated risk of adverse health outcomes resulting in hospitalizations and sometimes death., Objectives: To describe the prevalence of prescribed and over-the-counter (OTC) medications among older general practice patients living in the community. To determine predictors of polypharmacy (five or more prescribed drugs) from a variety of patient- and doctor-related factors., Methods: Sixty-seven randomly selected practices in two areas of Germany and 466 of their older patients (70+ years) were recruited for a geriatric assessment study. A cross-sectional analysis of health problems, GPs' awareness and their interventions was conducted. In this post hoc analysis, we assessed the medication use as reported by older patients and compared it with doctors' perceived medication regimens for their respective patients. The detailed assessment of patients' health and well-being enabled us to explore a variety of predictors of polypharmacy using logistic regression analysis with forward selection., Results: Study participants consumed an average of 3.7 prescribed medicines and an additional 1.4 OTC drugs. In all, 26.7% of patients used five and more chronically prescribed drugs. A set of five determinants predicted polypharmacy best: breathlessness, hypertension, dependency on instrumental activities of daily living, low subjective health and medication disagreement between doctors and patients., Conclusion: This older general practice population in Germany is among the top pharmaceutical user group of European study samples. Apart from disease-specific determinants, GPs should be aware that low subjective health and medication disagreement are independent predictors of polypharmacy.