[Improving Postgraduate Medical Training In Germany: A Proposal]. / Ein Vorschlag zur Förderung der ärztlichen Weiterbildung im Kontext einer reformierten Krankenhausfinanzierung.

Postgraduate (vocational, residency) training in Germany is regulated by the Physicians' Chamber in each federal state. Although training requirements are specified in detail by regulatory documents, young doctors are left on their own to find training posts and suitable learning experiences. There are no programmes in place to support trainees nor to identify the need of the health care system regarding the composition of its medical workforce. Hospitals and practices pay salaries to physicians in training from funding obtained for services they provide. We propose a systematic and continuing process of identifying gaps in the workforce. Disciplines with a lack of qualified doctors will be supported by additional funds directed to practices and hospitals. Regional rotation schemes will coordinate and improve the quality of training. Apart from an administrative overhead, this system of regulation will not need additional resources because a limited part of current budgets will be explicitly channelled into salaries for trainees in specialties for which there is a higher need than into others.

[Interprofessional Care of Patients with Rheumatoid Arthritis from the Perspective of a General Practitioner Perspective: Results of a Cross-sectional Study]. / Interprofessionelle Versorgung von Patienten mit rheumatoider Arthritis aus hausärztlicher Sicht: Ergebnisse einer Querschnittserhebung.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Improving critical incident reporting in primary care through education and involvement.

BACKGROUND: Critical incident reporting systems (CIRS) can be an important tool for the identification of organisational safety needs and thus to improve patient safety. In German primary care, CIRS use is obligatory but remains rare. Studies on CIRS implementation in primary care are lacking, but those from secondary care recommend involving management personnel. OBJECTIVE: This project aimed to increase CIRS use in 69 practices belonging to a local practice network. METHODS: The intervention consisted of the provision of a web-based CIRS, accompanying measures to train practice teams in error management and CIRS, and the involvement of the network's management. Three measurements were used: (1) number of incident reports and user access rates to the web-based CIRS were recorded, (2) staff were given a questionnaire addressing incident reporting, error management and safety climate and (3) qualitative reflection conferences were held with network management. RESULTS: Over 20 months, 17 critical incidents were reported to the web-based CIRS. The number of staff intending to report the next incident online decreased from 42% to 20% of participants. In contrast, the number of practices using an offline CIRS (eg, incident book) increased from 23% to 49% of practices. Practices also began proactively approaching network management for help with incidents. After project completion, participants scored higher in the patient safety climate factor 'perception of causes of errors'. For many practices, the project provided the first contact with structured error management. CONCLUSION: Specific measures to improve the use of CIRS in primary care should focus on network management and practice owners. Practices need basic training on safety culture and error management. Continuing, practices should implement an offline CIRS, before they can profit from the exchange of reports via web-based CIRS. It is crucial that practices receive feedback on incidents, and trained network management personnel can provide such support.

Differences in the quality of oral anticoagulation therapy with vitamin K antagonists in German GP practices - results of the cluster-randomized PICANT trial (Primary Care Management for Optimized Antithrombotic Treatment).

BACKGROUND: In Germany, patients receiving oral anticoagulation (OAC) are often treated by general practitioners (GPs), and large proportions of patients receive vitamin K antagonists (VKAs). The quality of OAC in German GP practices, differences between various practices, and improvement potential through implementation of case management, have not yet been investigated satisfactorily. Based on results of a cluster-randomized controlled trial, we aimed to assess whether OAC quality can be improved, any variations between practices exist and determine practice- and patient-level factors. METHODS: The PICANT trial (2012-2015) was performed in 52 GP practices in Hesse, Germany. Adult patients with long-term indication for OAC received best practice case management in the intervention group. International normalized ratio (INR) values were recorded from anticoagulation passes. The Rosendaal method was used to calculate Time in Therapeutic Range (TTR) at patient level, and mean pooling to obtain center-specific TTR (cTTR) at practice level. The quality of OAC was assessed by TTR and cTTR. Linear model analyses were used to investigate associations between practice-/ patient-level factors and TTR. RESULTS: Inclusion of 736 patients (49.6% intervention and 50.4% control patients); 690 (93.8%) received phenprocoumon. Within 24 months, the TTR was 75.1% (SD 17.6) in the intervention versus 74.3% (SD 17.8) in the control group (p = 0.670). The cTTR averaged 75.1% (SD 6.5, range: 60.4 to 86.7%) in the intervention versus 74.3% (SD 7.2, range: 52.7 to 85.7%) in the control group (p = 0.668). At practice level, the TTR was significantly lower in practices with a male physician and certification in quality management. At patient level, the TTR was significantly higher in patients with moderate to high compliance, in men, and in patients that performed self-management. The TTR was significantly lower in patients with certain comorbidities, and who were hospitalized. CONCLUSIONS: The intervention did not effectively improve OAC quality compared to routine care. Quality of INR control was generally good, but considerable variation existed between GP practices. The variability indicates optimization potential in some practices. The demonstrated association between patient-level factors and TTR highlights the importance of considering patient characteristics that may impede achieving high quality therapeutic outcomes. TRIAL REGISTRATION: ISRCTN registry, ISRCTN41847489 , registered 27 February 2012.

Primary care management for patients receiving long-term antithrombotic treatment: A cluster-randomized controlled trial.

PURPOSE: To examine whether applying case management in general practices reduces thromboembolic events requiring hospitalization and major bleeding events (combined primary outcome). Secondary endpoints were mortality, frequency and duration of hospitalization, severe treatment interactions, adverse events, quality of anticoagulation, health-related quality of life and intervention costs, patients' assessment of chronic illness care, self-reported adherence to medication, GP and HCA knowledge, patient knowledge and satisfaction with shared decision-making. METHODS: Cluster-randomized controlled trial undertaken at 52 general practices in Germany with adult patients with a long-term indication for oral anticoagulation. The complex intervention included training for healthcare assistants, information and quality circles for general practitioners and 24 months of case management for patients. Assessment was after 12 and 24 months. The intention-to-treat population included all randomized practices and patients, while the per-protocol analysis included only those that received treatment without major protocol violations. RESULTS: The mean (SD) age of the 736 patients was 73.5 (9.4) years and 597 (81.1%) had atrial fibrillation. After 24 months, the primary endpoint had occurred in 40 (11.0%) intervention and 48 (12.9%) control patients (hazard ratio 0.83, 95% CI 0.55 to 1.25; P = .37). Patients' perceived quality of care, their knowledge, and HCAs' knowledge, had improved significantly at 24 months. The other secondary endpoints did not differ between groups. In the intervention group, hospital admissions were significantly reduced in patients that received treatment without major protocol deviations. CONCLUSIONS: Even though the main outcomes did not differ significantly, the intervention appears to have positively influenced several process parameters under 'real-world conditions'.

[Barriers to Digitalisation of Healthcare in Germany: A Survey of Experts]. / Hürden bei der Digitalisierung der Medizin in Deutschland ­ eine Expertenbefragung.

BACKGROUND: Digital health is a growing area in healthcare with a huge potential. Nevertheless, the degree of digitalization in German healthcare is low when compared internationally and with other German industries. Despite political efforts, certain barriers seem to strongly impede the process of digitalization process in healthcare. METHOD: We surveyed 18 representative healthcare experts from various sectors with semi-structured interviews on barriers and solutions for digital health. Thematic analysis by Braun and Clarke was used for interpretation. RESULTS: The interviewees identified barriers that were stakeholder-specific and across stakeholders. Self-regulatory bodies and the medical profession were found to lack willingness and organizational structure for digitalization. Lack of evidence and missing interoperability represented primary obstacles, while current legislation and financial regulations were rarely mentioned. In particular, infrastructure expansion and interoperability would require a coordinated, state intervention. Positive communication on possibilities and benefits of digital solutions was also considered important. CONCLUSION: A strong political will, an overarching strategy accompanied by a communication concept seems to be necessary in order for digital health to succeed. Regarding legislation, binding specifications, deadlines and sanctions may be needed for self-regulatory bodies, while also involving users in the development process at an early stage and creating positive incentives for using digital solutions.

Patient-perceived barriers and facilitators to the implementation of a medication review in primary care: a qualitative thematic analysis.

BACKGROUND: Although polypharmacy can cause adverse health outcomes, patients often know little about their medication. A regularly conducted medication review (MR) can help provide an overview of a patient's medication, and benefit patients by enhancing their knowledge of their drugs. As little is known about patient attitudes towards MRs in primary care, the objective of this study was to gain insight into patient-perceived barriers and facilitators to the implementation of an MR. METHODS: We conducted a qualitative study with a convenience sample of 31 patients (age ≥ 60 years, ≥3 chronic diseases, taking ≥5 drugs/d); in Hesse, Germany, in February 2016. We conducted two focus groups and, in order to ensure the participation of elderly patients with reduced mobility, 16 telephone interviews. Both relied on a semi-structured interview guide dealing with the following subjects: patients' experience of polypharmacy, general design of MRs, potential barriers and facilitators to implementation etc. Interviews were audio-recorded, transcribed verbatim, and analysed by two researchers using thematic analysis. RESULTS: Patients' average age was 74 years (range 62-88 years). We identified barriers and facilitators for four main topics regarding the implementation of MRs in primary care: patient participation, GP-led MRs, pharmacist-led MRs, and the involvement of healthcare assistants in MRs. Barriers to patient participation concerned patient autonomy, while facilitators involved patient awareness of medication-related problems. Barriers to GP-led MRs concerned GP's lack of resources while facilitators related to the trusting relationship between patient and GP. Pharmacist-led MRs might be hindered by a lack of patients' confidence in pharmacists' expertise, but facilitated by pharmacies' digital records of the patients' medications. Regarding the involvement of healthcare assistants in MRs, a potential barrier was patients' uncertainty regarding the extent of their training. Patients could, however, imagine GPs delegating some aspects of MRs to them. CONCLUSIONS: Our study suggests that patients regard MRs as beneficial and expect indications for their medicines to be checked, and possible interactions to be identified. To foster the implementation of MRs in primary care, it is important to consider barriers and facilitators to the four identified topics.