Search

Background Recent reforms in Austria have focused on establishing team-based care within multiprofessional primary care units, to enhance amongst others, the work attractiveness of general practice. Nearly 75% of qualified general practitioners are not working as contracted physicians with the social health insurance. This study aims to explore the facilitators of and barriers to non-contracted general practitioners to work in a primary care unit. Methods We conducted twelve semi-structured, problem-centered interviews among purposively sampled non-contracted general practitioners. To extract categories of facilitators and barriers for working in a primary care unit, transcribed interviews were inductively coded using qualitative content analysis. Subcategories were grouped into factors (facilitators and barriers) of thematic criteria and mapped on the macro-, meso-, micro-, and individual levels. Results We identified 41 categories, including 21 facilitators and 20 barriers. Most facilitators were located at the micro-level, while most barriers were located at the macro-level. Teamwork and associated conditions made primary care units attractive as workplaces and corresponded with individual demands. In contrast, system factors tended to reduce the attractiveness of working as a general practitioner. Conclusions Multifaceted efforts are needed to address relevant factors at all of the levels mentioned above. These need to be carried out and consistently communicated by all stakeholders. Efforts to strengthen the holistic approach in primary care, like modern remuneration and patient steering mechanisms, are essential. Financial support, consulting services as well as training on entrepreneurship, management, leadership, and team-based care may help to reduce the risk and burden of founding and running a primary care unit.

Zusammenfassung Hintergrund/Ziel der Studie Evidenzbasierte Behandlungspfade konnen sich als nutzliches Tool zur Leitlinienimplementierung erweisen. Es scheint jedoch Hurden zu geben, die den Einsatz von Behandlungspfaden erschweren. Ziel der vorliegenden Fragebogenerhebung war es, die wahrgenommene Anwendbarkeit des Behandlungspfades „Ubergewicht/Adipositas bei Kindern und Jugendlichen auf Primarversorgungsebene“ zu erheben wie auch forderliche und hinderliche Faktoren im Einsatz des Behandlungspfades zu identifizieren. Methodik Im Janner 2020 wurde eine Online-Fragebogenerhebung an 3916 niedergelassene Allgemeinmedizinerinnen/Allgemeinmediziner und 470 Facharztinnen/Facharzte fur Kinder- und Jugendheilkunde in Osterreich ausgesandt. Die erhobenen Daten wurden deskriptiv ausgewertet. Ergebnisse Insgesamt nahmen 148 Personen an der Fragebogenerhebung teil (Rucklaufquote 3,7%). Der Grosteil der Befragten gab an, evidenzbasierte Behandlungspfade grundsatzlich als hilfreich wahrzunehmen (90%) und diese auch zu verwenden (57%). Wenige der Befragten (9%) fuhlten sich uber neue, in Osterreich entwickelte Behandlungspfade gut informiert. Die meisten Befragten betrachteten den Behandlungspfad „Ubergewicht/Adipositas bei Kindern und Jugendlichen auf Primarversorgungsebene“ als sinnvolle Unterstutzung (60%), als Nachschlagewerk (72%) oder als Erleichterung fur die Begrundung ihres Vorgehens gegenuber ihren Patientinnen und Patienten (68%). Ein groser Teil der Befragten gab jedoch an, dass der Behandlungspfad im medizinischen Alltag nicht gut anwendbar ist. Die haufigsten genannten hinderlichen Faktoren fur den Einsatz des Behandlungspfades waren fehlende zeitliche Ressourcen, fehlende Strukturen und fehlende finanzielle Anreize. Als Faktoren, die den Einsatz des Behandlungspfades fordern konnten, wurden am haufigsten andere Darstellungs- und Zugangsmoglichkeiten (z. B. Individualisierbarkeit, Einbindung in die Praxissoftware) genannt. Schlussfolgerung Obwohl die Befragten grostenteils positive Erwartungen an den Einsatz des Behandlungspfades „Ubergewicht/Adipositas bei Kindern und Jugendlichen auf Primarversorgungsebene“ hatten, bewerteten viele die Anwendbarkeit im medizinischen Alltag dennoch als schwierig. Eine okonomische, praktikable Gestaltung sowie eine leichte Verfugbarkeit von Behandlungspfaden und das Schaffen von Rahmenbedingungen, die einen Einsatz dieser in den medizinischen Alltag erleichtern, scheinen notwendige nachste Schritte fur einen vermehrten Einsatz von evidenzbasierten Behandlungspfaden zu sein.

Zusammenfassung Ziel der Studie Ziel der Studie ist es, mehr darüber zu erfahren, wie Migrantinnen den Zugang zu Versorgung von Depression erleben und welche Schwierigkeiten und Verbesserungswünsche sie haben. Methodik Inhaltsanalytische Auswertung von zwölf teilstrukturierten qualitativen Einzelinterviews mit Migrantinnen der ersten Einwanderergeneration, die aufgrund von Depression in Deutschland behandelt wurden. Ergebnisse Schwierigkeiten beim Zugang zu Versorgung sind fehlendes Wissen zu Depressionssymptomen und Behandlungsoptionen, der Umgang mit Stigmatisierung und Vorurteilen, mangelnde Behandlungskoordination und Beratung insbesondere beim Zugang zu ambulanter Psychotherapie, lange Wartezeiten sowie Verständigungsschwierigkeiten. Betroffene wünschen sich entstigmatisierende öffentliche Informationskampagnen zu Depression, bessere Informations- und Beratungsmöglichkeiten für Patienten sowie sprachliche Unterstützung insbesondere zu Beginn der Behandlung. Schlussfolgerung Beim Versorgungszugang von Migrantinnen mit Depression besteht Verbesserungsbedarf. Die beschriebenen Schwierigkeiten sollten bei der Planung von Versorgungsangeboten und bei der Behandlung von Patienten stärker berücksichtigt werden.

General practices are rooted in the local community and considered to be particularly well-positioned for engaging in preventive and health-promoting activities. The overall aim of the scoping review is to identify priorities and gaps in research published in the past 20 years on preventive and health-promoting activities provided by general practitioners or their teams in general practices in Germany. MEDLINE and Embase databases were systematically searched in November 2020. Papers were selected in dual-review mode and extracted in single-review mode. Data analysis was finished by May 2021. In total, 530 papers were included in the synthesis. Little research has been carried out into collaboration opportunities both within the general practice team and in communities as a whole, with specialists (18%), hospitals (9%), and health insurance companies (6%) being the most frequent cooperation partners of GPs. 15%-20% of papers each dealt with 'early detection', 'information provision' and 'cardiovascular prevention'. Secondary (53%) and tertiary prevention (43%) was more often the subject of research than primary (39%) and quaternary prevention (15%). Healthy subjects (26%) were less often studied than people with pre-existing conditions (42%) and risk factors (48%). Little information was available on preventive activities in terms of gender, young people, migration background, housing conditions or educational background. Personal counselling (15%) was the most frequently described approach to health promotion in general practices, along with printed information materials (10%). This scoping review provides information on which to base targeted interventions and future research that can contribute towards transforming general practices into promoters of health within the community.

Zusammenfassung Ziel der Studie Bei der Behandlung von Patienten mit rheumatoider Arthritis sind Haus- und Fachärzte, Pflegedienste, Ergo- und Physiotherapeuten sowie verschiedene andere Berufsgruppen beteiligt. Ziel dieser Studie ist eine Beschreibung dieser interprofessionellen Kooperationen in der alltäglichen Versorgungspraxis aus hausärztlicher Sicht. Methodik Mittels einer Querschnittserhebung wurden von Februar bis September 2017 die Kooperationen von Hausärzten (n=121 in 68 Praxen) in Hessen und Rheinland-Pfalz mit verschiedenen anderen Versorgern erfasst. Diese Querschnittserhebung war in die prospektive Kohortenstudie PANORA (Prävalenz von Anti-CCP-Antikörpern bei Patienten mit neuen Beschwerden am Bewegungsapparat) integriert. Der verwendete Fragebogen für Hausärzte enthielt geschlossene Fragen zu Soziodemografie, Häufigkeit, Gewichtung und Bewertung der bestehenden Kooperationen. Die erhobenen Daten wurden deskriptiv ausgewertet. Ergebnisse Bei Betrachtung der von Hausärzten übernommenen Aufgaben, gaben mehr als 70% der Ärzte an bei der Betreuung ihrer Patienten mit rheumatoider Arthritis „oft“ die Koordination der Medikamente, Gespräche über die Diagnose und Laborkontrollen durchzuführen. Die häufigste Kooperation mit der größten Wichtigkeit und einer geringen Zufriedenheit ergab sich mit den Rheumatologen. Als zweithäufigste Kooperation und hoher Wichtigkeit wurde die Kooperation mit den Physiotherapeuten bewertet. Die höchste Zufriedenheit wurde mit der Zusammenarbeit mit Pflegediensten beschrieben. Schlussfolgerung Die vorliegende Studie zeigt, dass Hausärzte bei der Versorgung von Patienten mit rheumatoider Arthritis in jedem Stadium der Versorgung verschiedene Versorgungsaufgaben übernehmen und dabei unterschiedlich häufig mit anderen Versorgern zusammenarbeiten. Insbesondere die Zusammenarbeit mit den Rheumatologen und den Physiotherapeuten ist den Hausärzten wichtig. Jedoch wurde die Kooperation mit Rheumatologen als unzureichend und verbesserungswürdig beurteilt.

Background General practitioner (GP) workforce shortages are a global threat to primary health care systems. In Austria, nearly 75 % of qualified GPs are not working as contracted GPs within the social health insurance system. This study aims to explore the facilitators and barriers for non-contracted GPs to work in a primary care unit (PCU). Methods We conducted twelve semi-structured, problem-focused interviews among purposively sampled non-contracted GPs. To extract categories of facilitators and barriers for working in a PCU, transcribed interviews were inductively coded using qualitative content analysis. These subcategories were then grouped into categories of thematic criteria and mapped on the macro-, meso-, micro-, and individual levels. Results We identified 36 factors, including 18 facilitators and 18 barriers. Most facilitators were located on the micro-level, while most barriers were located on the macro-level. Teamwork, which allows focus on professional medical work, shared responsibilities, flexibility in working time and work-life balance, mainly make PCUs attractive as workplaces and correspond with individual demands. By contrast, the absence of a clear vision for reform and insufficient implementation produce general ignorance and resistance. The conditions of contracts with social health insurance providers, including the remuneration system, requirements for PCUs and high workload with little time for individual patient care, are seen as inflexible and discouraging. Combined with insufficient vocational training and the low perceived status of GPs and PHC generally, GPs voiced concerns about being an entrepreneur and businessperson. Conclusions Targeted and proactive measures are necessary to attract non-contracted GPs to leave their current individual work-life arrangement and consider working in a PCU, especially considering the higher perceived risks. Multi-faceted efforts are needed to approach factors on all levels. Addressing system barriers should include a reform strategy with a clearly stated mission, defined PHC role, and tangible stakeholder commitment, as well as a modernized remuneration system and supportive measures to equip GPs with essential competences and skills. Proactive communication and exchange could promote the already existing attractive working conditions in PCUs and attract non-contracted GPs into the public sector.

ObjectivesWe explore the importance of SARS-CoV-2 sentinel surveillance testing in primary care during a regional COVID-19 outbreak in Austria.DesignProspective cohort study.SettingA single sentinel practice serving 22 829 people in the ski-resort of Schladming-Dachstein.ParticipantsAll 73 patients presenting with mild-to-moderate flu-like symptoms between 24 February and 03 April, 2020.InterventionNasopharyngeal sampling to detect SARS-CoV-2 using real-time reverse transcriptase-quantitative PCR (RT-qPCR).Outcome measuresWe compared RT-qPCR at presentation with confirmed antibody status. We split the outbreak in two parts, by halving the period from the first to the last case, to characterise three cohorts of patients with confirmed infection: early acute (RT-qPCR reactive) in the first half; and late acute (reactive) and late convalescent (non-reactive) in the second half. For each cohort, we report the number of cases detected, the accuracy of RT-qPCR, the duration and variety of symptoms, and the number of viral clades present.ResultsTwenty-two patients were diagnosed with COVID-19 (eight early acute, seven late acute and seven late convalescent), 44 patients tested SARS-CoV-2 negative and 7 were excluded. The sensitivity of RT-qPCR was 100% among all acute cases, dropping to 68.1% when including convalescent. Test specificity was 100%. Mean duration of symptoms for each group were 2 days (range 1–4) among early acute, 4.4 days (1–7) among late acute and 8 days (2–12) among late convalescent. Confirmed infection was associated with loss of taste. Acute infection was associated with loss of taste, nausea/vomiting, breathlessness, sore throat and myalgia; but not anosmia, fever or cough. Transmission clusters of three viral clades (G, GR and L) were identified.ConclusionsRT-qPCR testing in primary care can rapidly and accurately detect SARS-CoV-2 among people with flu-like illness in a heterogeneous viral outbreak. Targeted testing in primary care can support national sentinel surveillance of COVID-19.

Introduction and hypothesis We conducted a systematic review of the effectiveness of local preemptive analgesia for postoperative pain control in women undergoing vaginal hysterectomy. Methods MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews were searched systematically to identify eligible studies published through September 25, 2019. Only randomized controlled trials and systematic reviews addressing local preemptive analgesia compared to placebo at vaginal hysterectomy were considered. Data were extracted by two independent reviewers. Results were compared, and disagreement was resolved by discussion. Forty-seven studies met inclusion criteria for full-text review. Four RCTs, including a total of 197 patients, and two SRs were included in the review. Results Preemptive local analgesia reduced postoperative pain scores up to 6 h and postoperative opioid requirements in the first 24 h after surgery. Conclusion Preemptive local analgesia at vaginal hysterectomy results in less postoperative pain and less postoperative opioid consumption.

BackgroundMany countries are facing a shortage and misallocation of general practitioners (GPs). The development of a policy response may benefit from the knowledge of worldwide policies that have been adopted and recommended to counteract such a development.AimTo identify measures proposed or taken internationally to prevent GP shortages.Design and SettingA literature review followed by an expert assessment focussed on sources from OECD countries.MethodThe literature search identified international policy documents and literature reviews in bibliographical databases, and examined institutional websites and references of included publications. The internet search engine Google was also used. The resulting measures were then assessed for completeness by three experts.ResultsTen policy documents and 32 literature reviews provided information on 102 distinct measures aimed at preventing GP shortages. The measures attempt to influence GPs at all stages of their careers.ConclusionsThis catalogue of measures to prevent GP shortages is significantly more comprehensive than any of the policy documents it is based on. It may serve as a blueprint for effective reforms aimed at preventing GP shortages internationally.

Summary Overweight and obesity are increasing worldwide. In general practice, different approaches exist to treat people with weight problems. To provide the foundation for the development of a structured clinical pathway for overweight and obesity management in primary care, we performed a systematic overview of international evidence‐based guidelines. We searched in PubMed and major guideline databases for all guidelines published in World Health Organization (WHO) “Stratum A” nations that dealt with adults with overweight or obesity. Nineteen guidelines including 711 relevant recommendations were identified. Most of them concluded that a multidisciplinary team should treat overweight and obesity as a chronic disease. Body mass index (BMI) should be used as a routine measure for diagnosis, and weight‐related complications should be taken into account. A multifactorial, comprehensive lifestyle programme that includes reduced calorie intake, increased physical activity, and measures to support behavioural change for at least 6 to 12 months is recommended. After weight reduction, long‐term measures for weight maintenance are necessary. Bariatric surgery can be offered to people with a BMI greater than or equal to 35 kg/m2 when all non‐surgical interventions have failed. In conclusion, there was considerable agreement in international, evidence‐based guidelines on how multidisciplinary management of overweight and obesity in primary care should be performed.

Die osterreichische Vorsorgeuntersuchung (VU) wurde 1974 als Kassenleistung eingefuhrt und im Jahr 2005 zum letzten Mal neu gestaltet. Ziel dieser Arbeit war daher, die wissenschaftlichen Grundlagen der VU unter Verwendung des GRADE (Grading of Recommendations Assessment, Development and Evaluation) Ansatzes zu aktualisieren. Die wissenschaftliche Evidenz fur Untersuchungen und Beratungen, die derzeit Teil der VU sind, wurde aktualisiert und um weitere potentiell relevante Untersuchungen erweitert. Vertreter/innen der Bevolkerung diskutierten in drei Fokusgruppen ihre Erwartungen an die VU. In einem strukturierten Prozess wurden von einem Beratungsgremium evidenzbasierte Empfehlungen erarbeitet, welche Untersuchungen/Beratungen Teil der VU sein sollen. Das Beratungsgremium formulierte insgesamt 26 Empfehlungen zu 20 Zielerkrankungen oder Risikofaktoren. Es empfahl erstmals Screening auf abdominales Aortenaneurysma, osteoporotisches Frakturrisiko und chronische Nierenerkrankungen. Screening auf asymptomatische Bakteriurie, Screening auf Eisen‑/Vitamin B12-Mangelanamie und die Identifizierung von Personen mit erhohtem Risiko fur ein Glaukom sollen zukunftig auf Basis der Erkenntnisse nicht mehr in der VU enthalten sein.

The aim of the study was to find out how migrant women experience access to care for depression, what difficulties they have and what improvements they want.Content analysis of twelve partially structured qualitative individual interviews with first-generation migrant women who were treated for depression in Germany.Difficulties with accessing care included a lack of knowledge about symptoms of depression and treatment options, dealing with stigmatization and prejudices, lack of treatment coordination and professional advice, especially regarding outpatient psychotherapy, long waiting times and difficulties in communication. To improve access to care, patients suggested destigmatizing public information campaigns on depression, better information material, more and improved counseling options for patients as well as language support especially at the beginning of treatment.There is room for improvement regarding access to care for migrant women with depression. Their difficulties and wishes should be given more consideration when planning care services and treatment.Ziel der Studie ist es, mehr darüber zu erfahren, wie Migrantinnen den Zugang zu Versorgung von Depression erleben und welche Schwierigkeiten und Verbesserungswünsche sie haben.Inhaltsanalytische Auswertung von zwölf teilstrukturierten qualitativen Einzelinterviews mit Migrantinnen der ersten Einwanderergeneration, die aufgrund von Depression in Deutschland behandelt wurden.Schwierigkeiten beim Zugang zu Versorgung sind fehlendes Wissen zu Depressionssymptomen und Behandlungsoptionen, der Umgang mit Stigmatisierung und Vorurteilen, mangelnde Behandlungskoordination und Beratung insbesondere beim Zugang zu ambulanter Psychotherapie, lange Wartezeiten sowie Verständigungsschwierigkeiten. Betroffene wünschen sich entstigmatisierende öffentliche Informationskampagnen zu Depression, bessere Informations- und Beratungsmöglichkeiten für Patienten sowie sprachliche Unterstützung insbesondere zu Beginn der Behandlung.Beim Versorgungszugang von Migrantinnen mit Depression besteht Verbesserungsbedarf. Die beschriebenen Schwierigkeiten sollten bei der Planung von Versorgungsangeboten und bei der Behandlung von Patienten stärker berücksichtigt werden.

Evidence-based clinical pathways can be a useful tool for guideline implementation. However, there seem to be barriers to the use of clinical pathways. The aim of the present questionnaire survey was to assess the perceived usability of the clinical pathway "Overweight/obesity in children and adolescents at primary care level" and to identify factors promoting and hindering the use of the clinical pathway.In January 2020, an online questionnaire survey was sent out to 3,916 general practitioners and 470 pediatricians in Austria. The data collected were analysed descriptively.A total of 148 people took part in the questionnaire survey (response rate 3.7 %). The majority of respondents indicated that they, in general, perceive evidence-based clinical pathways as helpful (90 %) and also make use of them (57 %). Few respondents (9 %) felt well-informed about new clinical pathways developed in Austria. Most of the respondents considered the clinical pathway "Overweight/obesity in children and adolescents at primary care level" as a useful support (60 %), as a reference work (72 %) or as a facilitator for justifying their approach to their patients (68 %). However, a large proportion of the respondents stated that the clinical pathway is not easily applicable in everyday practice. The three most frequently cited barriers to using the clinical pathway were lack of time resources, lack of structures and lack of financial incentives. Other display and access options (e. g., individualisation, integration into practice software) were most frequently cited as factors that might promote the use of the pathway.Although the majority of the respondents had positive expectations regarding the use of the clinical pathway "Overweight/obesity in children and adolescents at primary care level", many of them still perceived its usability in everyday clinical practice as difficult. The necessary next steps to improve the use of evidence-based clinical pathways seem to be: an economic and practicable design, easy accessibility of clinical pathways and the creation of framework conditions that facilitate their use in everyday practice.

BACKGROUND: This is the third update of this review, first published in July 2009. All major guidelines on treatment of hypertension recommend weight loss; anti‐obesity drugs may be able to help in this respect. OBJECTIVES: Primary objectives: To assess the long‐term effects of pharmacologically‐induced reduction in body weight in adults with essential hypertension on all‐cause mortality, cardiovascular morbidity, and adverse events (including total serious adverse events, withdrawal due to adverse events, and total non‐serious adverse events).. Secondary objectives: To assess the long‐term effects of pharmacologically‐induced reduction in body weight in adults with essential hypertension on change from baseline in systolic and diastolic blood pressure, and on body weight reduction. SEARCH METHODS: For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to March 2020: the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. The searches had no language restrictions. We contacted authors of relevant papers about further published and unpublished work. SELECTION CRITERIA: Randomised controlled trials of at least 24 weeks' duration in adults with hypertension that compared approved long‐term weight‐loss medications to placebo. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed risks of bias, and extracted data. Where appropriate and in the absence of significant heterogeneity between studies (P > 0.1), we pooled studies using a fixed‐effect meta‐analysis. When heterogeneity was present, we used the random‐effects method and investigated the cause of the heterogeneity. MAIN RESULTS: This third update of the review added one new trial, investigating the combination of naltrexone/bupropion versus placebo. Two medications, which were included in the previous versions of this review (rimonabant and sibutramine) are no longer considered relevant for this update, since their marketing approval was withdrawn in 2010 and 2009, respectively. The number of included studies in this review update is therefore six (12,724 participants in total): four RCTs comparing orlistat to placebo, involving a total of 3132 participants with high blood pressure and a mean age of 46 to 55 years; one trial comparing phentermine/topiramate to placebo, involving 1305 participants with high blood pressure and a mean age of 53 years; and one trial comparing naltrexone/bupropion to placebo, involving 8283 participants with hypertension and a mean age of 62 years. We judged the risks of bias to be unclear for the trials investigating orlistat or naltrexone/bupropion. and low for the trial investigating phentermine/topiramate. Only the study of naltrexone/bupropion included cardiovascular mortality and morbidity as predefined outcomes. There were no differences in the rates of all‐cause or cardiovascular mortality, major cardiovascular events, or serious adverse events between naltrexone/bupropion and placebo. The incidence of overall adverse events was significantly higher in participants treated with naltrexone/bupropion. For orlistat, the incidence of gastrointestinal side effects was consistently higher compared to placebo. The most frequent side effects with phentermine/topiramate were dry mouth and paraesthesia. After six to 12 months, orlistat reduced systolic blood pressure compared to placebo by mean difference (MD) −2.6 mm Hg (95% confidence interval (CI) −3.8 to −1.4 mm Hg; 4 trials, 2058 participants) and diastolic blood pressure by MD −2.0 mm Hg (95% CI −2.7 to −1.2 mm Hg; 4 trials, 2058 participants). After 13 months of follow‐up, phentermine/topiramate decreased systolic blood pressure compared to placebo by −2.0 to −4.2 mm Hg (1 trial, 1030 participants) (depending on drug dosage), and diastolic blood pressure by −1.3 to −1.9 mm Hg (1 trial, 1030 participants) (depending on drug dosage). There was no difference in the change in systolic or diastolic blood pressure between naltrexone/bupropion and placebo (1 trial, 8283 participants). We identified no relevant studies investigating liraglutide or lorcaserin in people with hypertension. AUTHORS' CONCLUSIONS: In people with elevated blood pressure, orlistat, phentermine/topiramate and naltrexone/bupropion reduced body weight; the magnitude of the effect was greatest with phentermine/topiramate. In the same trials, orlistat and phentermine/topiramate, but not naltrexone/bupropion, reduced blood pressure. One RCT of naltrexone/bupropion versus placebo showed no differences in all‐cause mortality or cardiovascular mortality or morbidity after two years. The European Medicines Agency refused marketing authorisation for phentermine/topiramate due to safety concerns, while for lorcaserin the application for European marketing authorisation was withdrawn due to a negative overall benefit/risk balance. In 2020 lorcaserin was also withdrawn from the US market. Two other medications (rimonabant and sibutramine) had already been withdrawn from the market in 2009 and 2010, respectively.

Background Coronavirus disease 2019 (COVID-19) represents a significant challenge to health care systems around the world. A well-functioning primary care system is crucial in epidemic situations as it plays an important role in the development of a system-wide response. Methods 2,187 Austrian and German GPs answered an internet survey on preparedness, testing, staff protection, perception of risk, self-confidence, a decrease in the number of patient contacts, and efforts to control the spread of the virus in the practice during the early phase of the COVID-pandemic (3rd to 30th April). Results The completion rate of the questionnaire was high (90.9%). GPs gave low ratings to their preparedness for a pandemic, testing of suspected cases and efforts to protect staff. The provision of information to GPs and the perception of risk were rated as moderate. On the other hand, the participants rated their self-confidence, a decrease in patient contacts and their efforts to control the spread of the disease highly. Conclusion Primary care is an important resource for dealing with a pandemic like COVID-19. The workforce is confident and willing to take an active role, but needs to be provided with the appropriate surrounding conditions. This will require that certain conditions are met. Registration Trial registration at the German Clinical Trials Register: DRKS00021231.

Background A shortage of general practitioners (GPs) is common to many European countries. To counteract this, it is essential to understand the factors that encourage or discourage medical students from choosing to become a GP Objective To evaluate medical students’ attitudes towards general practice and to identify factors that discourage them from considering a career as a GP. Methods In this multinational cross-sectional online survey, 29 284 students from nine German, four Austrian and two Slovenian universities were invited to answer a questionnaire consisting of 146 closed and 13 open-ended items. Results Of the 4486 students that responded (response rate: 15.3%), 3.6% wanted to become a GP, 48.1% were undecided and 34.6% did not want to be a GP. Significant predictors for interest in becoming a GP were higher age [odds ratio (OR) = 1.06; 95% confidence interval (CI) = 1.02–1.10], positive evaluation of the content of a GP’s work (OR = 4.44; 95% CI = 3.26–6.06), organizational aspects (OR = 1.42; 95% CI = 1.13–1.78), practical experience of general practice (OR = 1.66; 95% CI = 1.08–2.56) and the country of the survey [Slovenian versus German students (Reference): OR = 2.19; 95% CI = 1.10–4.38; Austrian versus German students (Reference): OR = 0.50; 95% CI = 0.32–0.79]. Conclusion Strategies to convince undecided students to opt for a career as a GP should include a positive representation of a GP’s work and early and repeated experience of working in a general practice during medical school.

Background Evidence that antihyperglycaemic therapy is beneficial for people with type 2 diabetes mellitus is conflicting. While the United Kingdom Prospective Diabetes Study (UKPDS) found tighter glycaemic control to be positive, other studies, such as the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, found the effects of an intensive therapy to lower blood glucose to near normal levels to be more harmful than beneficial. Study results also showed different effects for different antihyperglycaemic drugs, regardless of the achieved blood glucose levels. In consequence, firm conclusions on the effect of interventions on patient-relevant outcomes cannot be drawn from the effect of these interventions on blood glucose concentration alone. In theory, the use of newer insulin analogues may result in fewer macrovascular and microvascular events. Objectives To compare the effects of long-term treatment with (ultra-)long-acting insulin analogues (insulin glargine U100 and U300, insulin detemir and insulin degludec) with NPH (neutral protamine Hagedorn) insulin (human isophane insulin) in adults with type 2 diabetes mellitus. Search methods For this Cochrane Review update, we searched CENTRAL, MEDLINE, Embase, ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was 5 November 2019, except Embase which was last searched 26 January 2017. We applied no language restrictions. Selection criteria We included randomised controlled trials (RCTs) comparing the effects of treatment with (ultra-)long-acting insulin analogues to NPH in adults with type 2 diabetes mellitus. Data collection and analysis Two review authors independently selected trials, assessed risk of bias, extracted data and evaluated the overall certainty of the evidence using GRADE. Trials were pooled using random-effects meta-analyses. Main results We identified 24 RCTs. Of these, 16 trials compared insulin glargine to NPH insulin and eight trials compared insulin detemir to NPH insulin. In these trials, 3419 people with type 2 diabetes mellitus were randomised to insulin glargine and 1321 people to insulin detemir. The duration of the included trials ranged from 24 weeks to five years. For studies, comparing insulin glargine to NPH insulin, target values ranged from 4.0 mmol/L to 7.8 mmol/L (72 mg/dL to 140 mg/dL) for fasting blood glucose (FBG), from 4.4 mmol/L to 6.6 mmol/L (80 mg/dL to 120 mg/dL) for nocturnal blood glucose and less than 10 mmol/L (180 mg/dL) for postprandial blood glucose, when applicable. Blood glucose and glycosylated haemoglobin A1c (HbA1c) target values for studies comparing insulin detemir to NPH insulin ranged from 4.0 mmol/L to 7.0 mmol/L (72 mg/dL to 126 mg/dL) for FBG, less than 6.7 mmol/L (120 mg/dL) to less than 10 mmol/L (180 mg/dL) for postprandial blood glucose, 4.0 mmol/L to 7.0 mmol/L (72 mg/dL to 126 mg/dL) for nocturnal blood glucose and 5.8% to less than 6.4% HbA1c, when applicable. All trials had an unclear or high risk of bias for several risk of bias domains. Overall, insulin glargine and insulin detemir resulted in fewer participants experiencing hypoglycaemia when compared with NPH insulin. Changes in HbA1c were comparable for long-acting insulin analogues and NPH insulin. Insulin glargine compared to NPH insulin had a risk ratio (RR) for severe hypoglycaemia of 0.68 (95% confidence interval (CI) 0.46 to 1.01; P = 0.06; absolute risk reduction (ARR) -1.2%, 95% CI -2.0 to 0; 14 trials, 6164 participants; very low-certainty evidence). The RR for serious hypoglycaemia was 0.75 (95% CI 0.52 to 1.09; P = 0.13; ARR -0.7%, 95% CI -1.3 to 0.2; 10 trials, 4685 participants; low-certainty evidence). Treatment with insulin glargine reduced the incidence of confirmed hypoglycaemia and confirmed nocturnal hypoglycaemia. Treatment with insulin detemir compared to NPH insulin found an RR for severe hypoglycaemia of 0.45 (95% CI 0.17 to 1.20; P = 0.11; ARR -0.9%, 95% CI -1.4 to 0.4; 5 trials, 1804 participants; very low-certainty evidence). The Peto odds ratio for serious hypoglycaemia was 0.16, 95% CI 0.04 to 0.61; P = 0.007; ARR -0.9%, 95% CI -1.1 to -0.4; 5 trials, 1777 participants; low-certainty evidence). Treatment with detemir also reduced the incidence of confirmed hypoglycaemia and confirmed nocturnal hypoglycaemia. Information on patient-relevant outcomes such as death from any cause, diabetes-related complications, health-related quality of life and socioeconomic effects was insufficient or lacking in almost all included trials. For those outcomes for which some data were available, there were no meaningful differences between treatment with glargine or detemir and treatment with NPH. There was no clear difference between insulin-analogues and NPH insulin in terms of weight gain. The incidence of adverse events was comparable for people treated with glargine or detemir, and people treated with NPH. We found no trials comparing ultra-long-acting insulin glargine U300 or insulin degludec with NPH insulin. Authors' conclusions While the effects on HbA1c were comparable, treatment with insulin glargine and insulin detemir resulted in fewer participants experiencing hypoglycaemia when compared with NPH insulin. Treatment with insulin detemir also reduced the incidence of serious hypoglycaemia. However, serious hypoglycaemic events were rare and the absolute risk reducing effect was low. Approximately one in 100 people treated with insulin detemir instead of NPH insulin benefited. In the studies, low blood glucose and HbA1c targets, corresponding to near normal or even non-diabetic blood glucose levels, were set. Therefore, results from the studies are only applicable to people in whom such low blood glucose concentrations are targeted. However, current guidelines recommend less-intensive blood glucose lowering for most people with type 2 diabetes in daily practice (e.g. people with cardiovascular diseases, a long history of type 2 diabetes, who are susceptible to hypoglycaemia or older people). Additionally, low-certainty evidence and trial designs that did not conform with current clinical practice meant it remains unclear if the same effects will be observed in daily clinical practice. Most trials did not report patient-relevant outcomes.

Introduction Health information is a prerequisite of informed decision-making. Criteria for development, content and presentation have recently been published in a corresponding guideline. Within a systematic search, 27 relevant checklists were identified, none of them, however, complying with the guideline or providing reasonably operationalised measurement items. Therefore, a draft of a checklist with 19 criteria was drafted. The current study aims at developing and validating this measure of quality. Methods and analysis The validation design consists of five single studies to be conducted at the University of Halle-Wittenberg/Germany and Graz/Austria. (1) Achieving content validity through expert reviews of the first draft, (2) achieving feasibility using ‘think aloud’ in piloting with untrained users, (3) pretesting the instrument applied to health information materials without use of secondary sources: determining inter-rater reliability and criterion validity, (4) determining construct validity using information on proceedings and methods in the development process provided by the developers and (5) determining divergent validity in comparison with the Ensuring Quality Information for Patients (EQUIP) (expanded) Scale. The substudies will use varying samples of experts, students and developers and will apply the instrument to materials of various domains. Sample sizes will be adjusted to the particular research designs and questions. Analyses will employ qualitative methods, such as content analyses and discourse within the expert panel, and correlation-based methods both for determining inter-rater reliability and validity. Ethics and dissemination The project is approved by the ethics committee of the Martin Luther University Halle-Wittenberg (approval number: 2019 115). Results will be published, and the instrument made accessible on public health platforms. It is meant to become a certification standard. MAPPinfo can be used as a screening instrument without training or secondary sources. Although developed in the German language, the instrument will be applicable also in other languages. Trial registration number AsPredected22546; date of registration: 24 July 2019. Protocol version July 2020.

Objectives To review systematically the past 10 years of research activity into the healthcare experiences (HCX) of patients with chronic heart failure (CHF) in Germany, in order to identify research foci and gaps and make recommendations for future research. Design In this scoping review, six databases and grey literature sources were systematically searched for articles reporting HCX of patients with CHF in Germany that were published between 2008 and 2018. Extracted results were summarised using quantitative and qualitative descriptive analysis. Results Of the 18 studies (100%) that met the inclusion criteria, most were observational studies (60%) that evaluated findings quantitatively (60%). HCX were often concerned with patient information, global satisfaction as well as relationships and communication between patients and providers and generally covered ambulatory care, hospital care and rehabilitation services. Overall, the considerable heterogeneity of the included studies’ outcomes only permitted relatively trivial levels of synthesis. Conclusion In Germany, research on HCX of patients with CHF is characterised by missing, inadequate and insufficient information. Future research would benefit from qualitative analyses, evidence syntheses, longitudinal analyses that investigate HCX throughout the disease trajectory, and better reporting of sociodemographic data. Furthermore, research should include studies that are based on digital data, reports of experiences gained in under-investigated yet patient-relevant healthcare settings and include more female subjects.

BackgroundDelay in COVID-19 detection has led to a major pandemic. We report rapid early detection of SARS-CoV-2 by reverse transcriptase-polymerase chain reaction (RT-PCR), comparing it to the serostatus of convalescent infection, at an Austrian National Sentinel Surveillance Practice in an isolated ski-resort serving a population of 22,829 people.MethodsRetrospective dataset of all 73 patients presenting with mild to moderate flu-like symptoms to a sentinel practice in the ski-resort of Schladming-Dachstein, Austria, between 24 February and 03 April, 2020. We split the outbreak in two halves, by dividing the period from the first to the last case by two, to characterise the following three cohorts of patients with confirmed infection: people with reactive RT-PCR presenting during the first half (early acute infection) vs. those presenting in the second half (late acute), and people with non-reactive RT-PCR (late convalescent). For each cohort we report the number of cases detected, the accuracy of RT-PCR and the duration of symptoms. We also report multivariate regression of 15 clinical symptoms as covariates, comparing all people with convalescent infection to those with acute infection.FindingsAll 73 patients had SARS-CoV-2 RT-PCR testing. 22 patients were diagnosed with COVID-19, comprising: 8 patients presenting early acute, and 7 presenting late acute and 7 late convalescent respectively; 44 patients tested SARS-COV-2 negative, and 7 were excluded. RT-PCR sensitivity was high (100%) among acute presenters, but dropped to 50% in the second half of the outbreak; specificity was 100%. The mean duration of symptoms was 2 days (range 1-4) among early acute presenters, and 4.4 days (1-7) among late acute and 8 days (2-12) among late convalescent presenters respectively. Convalescent infection was only associated with loss of taste (ORs=6.02;p=0.047). Acute infection was associated with loss of taste (OR=571.72;p=0.029), nausea and vomiting (OR=370.11;p=0.018), breathlessness (OR=134.46;p=0.049), and myalgia (OR=121.82;p=0.032); but not loss of smell, fever or cough.InterpretationRT-PCR rapidly and reliably detects early COVID-19 among people presenting with viral illness and multiple symptoms in primary care, particularly during the early phase of an outbreak. RT-PCR testing in primary care should be prioritised for effective COVID-19 prevention and control.Research in ContextEvidence before this studyA comprehensive and effective test-trace-isolate (TTI) strategy is necessary to keep track of current and future COVID-19 infection in the UK and avoid a secondary wave later this year, as society reopens. As part of a wider TTI strategy, it is important to assess the feasibility of COVID-19 testing in primary care. We searched PubMed for implementation of SARS-CoV-2 testing in primary care using the following search terms: (“SARS-CoV-2” OR “COVID-19”) AND “testing” AND (“primary care” OR “general practice”). We did not find any studies that met these criteria.Added value of this studyTo our knowledge, our study provides first evidence that extension of a National Influenza Surveillance Programme to include SARS-CoV-2 RT-PCR testing in primary care leads to viral detection among patients presenting with mild to moderate flu-like illness during a local outbreak of COVID-19. We show that the sensitivity of reverse transcriptase-polymerase chain reaction (RT-PCR), the technique to detect viral RNA, is high (100%) in the initial phase of the outbreak and among patients who were acutely unwell. Acute infection was associated with multiply symptoms: loss of taste, nausea and vomiting, breathlessness, myalgia and sore throat; but not loss of smell, fever or cough. We also show high correlation between reactive RT-PCR and seropositivity.Implications of all available evidenceOur findings suggest that RT-PCR can rapidly and reliably detect early COVID-19 among people presenting with viral illness and multiple symptoms in primary care, particularly during the early phase of an outbreak. Furthermore RT-PCR testing in primary care can effectively detect new COVID-19 clusters in the community and should be included in any strategy for prevention and control of the disease.

General practitioners, specialists, occupational and physical therapists, nursing services and other professional groups are all involved in the treatment of patients with rheumatoid arthritis. This study aims to describe interprofessional cooperation in daily ambulatory care from the perspective of a general practitioner.The cross-sectional study investigated cooperation between general practitioners (n=121 in 68 medical practices) and several other health care providers in Hesse and Rhineland Palatinate, Germany, from February to September 2017. It was part of the prospective cohort study PANORA (Prevalence of anti-cyclic citrullinated peptide (anti-CCP) positivity in patients with new onset of non-specific musculoskeletal symptoms). The questionnaire that was used contained closed-ended questions on socio-demographics and frequency of contact, and asked physicians to assess and weigh existing collaboration. Descriptive statistics were used for data analysis.When caring for patients with rheumatoid arthritis, 70%, of the physicians often took responsibility for synchronizing medications, and discussing diagnoses and test results. The most frequent cooperation was with rheumatologists and was considered as highly important but the least satisfactory. The second most frequent cooperation was with physical therapists and this was also rated as very important. Physicians had highest level of satisfaction with their collaboration with the nursing services.This study shows that general practitioners perform several medical tasks when treating patients with rheumatoid arthritis. During the process, they work together with several health care providers to various degrees. Cooperation with rheumatologists and physical therapists is particularly important to general practitioners; cooperation with rheumatologists is considered inadequate and in need of improvement.Bei der Behandlung von Patienten mit rheumatoider Arthritis sind Haus- und Fachärzte, Pflegedienste, Ergo- und Physiotherapeuten sowie verschiedene andere Berufsgruppen beteiligt. Ziel dieser Studie ist eine Beschreibung dieser interprofessionellen Kooperationen in der alltäglichen Versorgungspraxis aus hausärztlicher Sicht.Mittels einer Querschnittserhebung wurden von Februar bis September 2017 die Kooperationen von Hausärzten (n=121 in 68 Praxen) in Hessen und Rheinland-Pfalz mit verschiedenen anderen Versorgern erfasst. Diese Querschnittserhebung war in die prospektive Kohortenstudie PANORA (Prävalenz von Anti-CCP-Antikörpern bei Patienten mit neuen Beschwerden am Bewegungsapparat) integriert. Der verwendete Fragebogen für Hausärzte enthielt geschlossene Fragen zu Soziodemografie, Häufigkeit, Gewichtung und Bewertung der bestehenden Kooperationen. Die erhobenen Daten wurden deskriptiv ausgewertet.Bei Betrachtung der von Hausärzten übernommenen Aufgaben, gaben mehr als 70% der Ärzte an bei der Betreuung ihrer Patienten mit rheumatoider Arthritis „oft“ die Koordination der Medikamente, Gespräche über die Diagnose und Laborkontrollen durchzuführen. Die häufigste Kooperation mit der größten Wichtigkeit und einer geringen Zufriedenheit ergab sich mit den Rheumatologen. Als zweithäufigste Kooperation und hoher Wichtigkeit wurde die Kooperation mit den Physiotherapeuten bewertet. Die höchste Zufriedenheit wurde mit der Zusammenarbeit mit Pflegediensten beschrieben.Die vorliegende Studie zeigt, dass Hausärzte bei der Versorgung von Patienten mit rheumatoider Arthritis in jedem Stadium der Versorgung verschiedene Versorgungsaufgaben übernehmen und dabei unterschiedlich häufig mit anderen Versorgern zusammenarbeiten. Insbesondere die Zusammenarbeit mit den Rheumatologen und den Physiotherapeuten ist den Hausärzten wichtig. Jedoch wurde die Kooperation mit Rheumatologen als unzureichend und verbesserungswürdig beurteilt.

Background: The health status, health awareness and health behavior of persons with a migration background often differ from the autochthonous population. Little is known about the proportion of patients with a migration background (PMB) that participate in primary care studies on oral antithrombotic treatment (OAT) in Germany, and whether the quality of their antithrombotic care differs from patients without a migration background. The aim of this paper was to use the results of a cluster-randomized controlled trial (PICANT) to determine the proportion of PMB at different stages of recruitment, and to compare the results in terms of sociodemographic characteristics and antithrombotic treatment. Methods: This study used screening and baseline data from the PICANT trial on oral anticoagulation management in GP practices. For this analysis, we determined the proportion of PMB during the recruitment period at stage 1 (screening of potentially eligible patients), stage 2 (eligible patients invited to participate in the trial), and stage 3 (assessment of baseline characteristics of patients participating in the PICANT trial). In addition, we compared patients in terms of sociodemographic characteristics and quality of anticoagulant treatment. Statistical analysis comprised descriptive and bivariate analyses. Results: The proportion of PMB at each recruitment stage declined from 9.1% at stage 1 to 7.9% at stage 2 and 7.3% at stage 3). A lack of German language skills led to the exclusion of half the otherwise eligible PMB. At stages 1 and 3, PMB were younger (stage 1: 70.7 vs. 75.0 years, p

Background Austria has recently been embroiled in the complex debate on the legalization of measures to end life prematurely. Empirical data on end-of-life decisions made by Austrian physicians barely exists. This study is the first in Austria aimed at finding out how physicians generally approach and make end-of-life therapy decisions. Methods The European end-of-life decisions (EURELD) questionnaire, translated and adapted by Schildmann et al., was used to conduct this cross-sectional postal survey. Questions on palliative care training, legal issues, and use of and satisfaction with palliative care were added. All Austrian specialists in hematology and oncology, a representative sample of doctors specialized in internal medicine, and a sample of general practitioners, were invited to participate in this anonymous postal survey. Results Five hundred forty-eight questionnaires (response rate: 10.4%) were evaluated. 88.3% of participants had treated a patient who had died in the previous 12 months. 23% of respondents had an additional qualification in palliative medicine. The cause of death in 53.1% of patients was cancer, and 44.8% died at home. In 86.3% of cases, pain relief and / or symptom relief had been intensified. Further treatment had been withheld by 60.0%, and an existing treatment discontinued by 49.1% of respondents. In 5 cases, the respondents had prescribed, provided or administered a drug which had resulted in death. 51.3% of physicians said they would never carry out physician-assisted suicide (PAS), while 30.3% could imagine doing so under certain conditions. 38.5% of respondents supported the current prohibition of PAS, 23.9% opposed it, and 33.2% were undecided. 52.4% of physicians felt the legal situation with respect to measures to end life prematurely was ambiguous. An additional qualification in palliative medicine had no influence on measures taken, or attitudes towards PAS. Conclusions The majority of doctors perform symptom control in terminally ill patients. PAS is frequently requested but rarely carried out. Attending physicians felt the legal situation was ambiguous. Physicians should therefore receive training in current legislation relating to end-of-life choices and medical decisions. The data collected in this survey will help political decision-makers provide the necessary legal framework for end-of-life medical care.

Throughout the world, the incidence and prevalence of patients with chronic kidney disease have been steadily rising. In 2016, the Styrian nephrology awareness program "niere.schutzen" ("Kidney Protection") was launched to early identify patients with renal insufficiency. The aim of this study was to search for existing international nephrological screening and support programs in order to identify possible evaluation parameters and concepts for niere.schutzen. A search in MEDLINE® revealed five relevant international programs from four countries. These differed from one another with respect to the population to be screened, the screening method and the support measures. All the programs involved the transparent documentation of patient data, and allowed for disease monitoring, as well as the impact of specific measures on assessed parameters and variables (laboratory data, participation rates) to be determined. Depending on the data sources employed and the availability and comprehensiveness of additional documentation, three evaluation methods of different informative value were developed. The first method requires no participant labelling, while the second and third methods require the participants to be assigned to a particular program. With the third method, the documentation also needs to be conducted in line with a disease management program. Considering that the speedy implementation of the niere.schutzen program is desired for political reasons, the only practical method is the first one as it does not entail patient documentation and only involves the evaluation of process parameters.