[Determinants for diagnostic and therapeutic co-operation between general practitioners]. / Determinanten diagnostischer und therapeutischer Kooperation von Hausärzten.

In the light of new opportunities for structural arrangements in Germany calling for higher co-operation between physicians in private practice, determinants for diagnostic and therapeutic co-operation need to be examined. In the present study, 130 general practitioners were asked in regard to four typical primary care indication groups whether they prefer to diagnose and treat the patients on their own or in co-operation with colleagues. This self-assessment was validated using the data from 2,069 physician-patient contacts: physicians preferring therapy in co-operation actually referred patients three times more often. Concerning both gastro-intestinal and rheumatic disorders, physicians' preferences for diagnostic and therapeutic co-operation are highly correlated (phi = 0.491 and 0.528 respectively); preferences for diagnostic and therapeutic co-operation across indications are not as strongly correlated (phi = 0.334 and 0.397 respectively). However, there is no general indication-independent attitude towards co-operation for individual physicians: Indication and type of services are two factors which--probably in addition to others--affect co-operation independently. We confirm earlier conclusions that the detailed analysis of provider and patient characteristics together with the actual patient management on a case by case basis is a powerful tool for health services research.

Sentinel practices in evaluating longer periods of care: quality of life and drug therapy of terminally ill persons in Lower Saxony (Germany).

STUDY OBJECTIVES: (1) To study the feasibility of using sentinel practice networks to evaluate longer periods of care. (2) To assess the quality of life and drug therapy of community dwelling terminally ill persons. DESIGN: Prospective longitudinal design with GPs in an existing sentinel practice network identifying "terminally ill" persons and recording the following data: age, sex, diagnoses, and ongoing drug therapy initially, time, place, duration, services, and drug changes for every contact, quality of life (HRCA-QL Index, Spitzer Index, uniscale), pain intensity and frequency on a weekly basis, and time and circumstances of death. SETTING: 26 GP practices in Lower Saxony, Germany. PATIENTS: 47 patients (age: mean 76 years, range 31 to 98; sex: 21 male, 26 female; diagnosis: 35 with cancer) with 582 contacts. Mean of recorded time before death was 70 days (median 50). MAIN RESULTS: Average number of physician-patient contacts increased from 0.7 a week three months before death to 2.4 in the final week. Quality of life decreased during that period (HRCA-QL Index: 5.1 to 0.8; Spitzer: 4.4 to 0.8; uniscale: 37 to 9). In the last week of life, no person was free of pain; analgetic therapy was "successful" in 57% of cases. CONCLUSIONS: (1) The sentinel practice approach is feasible for evaluating longer periods of care. The generalisibility, however, may be limited to certain subgroups. (2) The observed trends in quality of life, pain, and analgetic treatment should be compared with those in other settings and countries to identify the scope of care improvement.

[General practice management and therapy of terminally ill patients--a longitudinal study]. / Hausärztliche Betreuung und Therapie von Finalkranken--eine Längsschnittstudie.

Since most persons in Germany die outside a hospital, the aim of the study was to quantify GP and nursing services for persons in the ten weeks prior to death. GPs were asked to document patients they considered to be terminal, using a set of different documentation sheets: 1. age, sex, living situation, and diagnoses, 2. time, place, duration, services, and nursing intensity for every contact and 3. circumstances of death. GPs were told to expect three-month periods to be documented. Twenty-six practices participated, documenting 47 patients and 582 contacts. Mean age of the deceased was 76 years (31 to 98); 21 were male and 26 female. Patients were classified as "terminal" on average 70 days prior to death (median 50 days). Average number of doctor-patient contacts increased from 0.7/week to 1.6 in the third and second last week and 2.4 in the final week. Average number of hospital days were around 1.1/week for the whole period. Nursing hours by relatives increased to over 13 h/day in the final week. Professional home nursing services were available for 80% in the final week, but only for 3 h/day. Thirty-two patients (68%) died at home, 7 (15%) in a nursing home and 8 (17%) in hospital (after a mean of 6 days as in-patients). The results document the large amount of time needed by physicians, relatives and nurses in the last weeks of life for persons who die at home.

[The success of medical continuing education. Methods of evaluation--possibilities, limits and future developments]. / Der Erfolg ärztlicher Fortbildung. Evaluationsmethoden--Möglichkeiten, Grenzen und zukünftige Entwicklungen.

The question, whether evaluation of continuing medical education (CME) is necessary, is discussed in Germany for several years. It is frequently criticized that the effects of continuing education on the medical practice and the quality of the patient care are hardly concrete. Evaluation is too often understood as a tool of external control rather than an instrument of self control and feedback for the teachers and organizers of CME events. The evaluation methods in use have many methodological shortcomings, i.e., lack of objectivity, reproducibility, feed back to the students, nearness to practice, and are therefore reason for the missing acceptance of the evaluation by physicians. Evaluation methods make sense if they contribute to efficient learning. They are supposed to aid in correctly assessing both the need and success of learning. These demands are currently most completely fulfilled by the Canadian "Maintenance of Competence Program" (MOCOMP), the applicability of MOCOMP in Germany is now proofed by the German chamber of physicians.

[Family practice diagnosis of patients with venous diseases in relation to severity, diagnosis and practice facilities. Results of the ASAM study "Physician status and factor evaluation study of ambulatory patient management"]. / Hausärztliche Diagnostik bei Patienten mit Venenerkrankungen in Abhängigkeit von Schweregrad, Diagnose und Praxisausstattung. Ergebnisse aus der ASAM-Studie "Arztliche Standort- und Faktorbeurteilung und Untersuchung des ambulanten Patientenmanagements".

Although venous diseases are very common and represent frequent reasons for consultations in general practices, little is known about the actual ambulatory care for these patients. In a sentinel network consisting of general practitioners, 385 contacts with patients suffering from venous diseases (64% with varicose veins, 24% with phlebitis and 11% with ulcers) were documented. In 9% of the cases, the functional disability was "severe". The diagnostic procedures included laboratory tests in 23%, ECG in 11%, Doppler sonography in 8% and X-ray or angiography in 5%. The frequency of these diagnostic procedures correlated significantly with the degree of severity. The probability of a Doppler sonography in practices with ultrasound equipment compared to practices without it, was-stratified for the degree of severity, the unequal distribution of diseases and the level of acquaintance with the patient-between 2.2 and 2.6 (p always < 0.05), the probability of laboratory tests between 2.4 and 2.6 (p always < 0.001). This significant dependence of diagnostic procedures from the available equipment calls for the introduction of diagnostic standards as measures of quality assurance even for so-called trivial diseases.

[Professional development of media in general practice]. / Professionelle Entwicklung von Medien in der Praxis.

In the German state Niedersachsen, the practical advantage of computers as an information medium in the out-patient care was tested in the medical practice for two years. In a two year study, acceptance, suitability, and the didactic quality of new information software for practice computers were investigated in 20 medical practices. Under the supervision of the KVN, the support of a Multi-Medica Corporation and IBM as well as numerous university departments, the multimedia software was prepared and further developed during the trial in the medical practice. It became clear, that videos, pictures, and text as short information units were helpful for the information of patients. The quick access and the simple and clear presentation is crucial for their usage. Teaching software for patients and multimedia programs for the continuing education of physicians have to be looked at separately. For this, longer information units might be necessary.

[Prevalent disease characteristics in the ambulatory sector--need for social medicine competence with reference to hard-to-define and undefined disease pictures]. / Prävalente Erkrankungsformen im ambulanten Sektor--sozialmedizinischer Kompetenzbedarf unter Berücksichtigung schlecht und nicht definierter Krankheitsbilder.

Poorly defined or undefined disease patterns occur sporadically in the physician's daily routine. They appear as uncharacteristic, early and compensated stages of disease. Sociomedical competence can contribute to cope with illness, where physician and patient are unable to cope on the basis of diagnostic and clinical categories alone. It allows to understand the individual concept of illness as a construct, answering several purposes and dependent on the acting individuals and on the particular situation. The search for better solutions within the system opens many ways to redefine, reframe, behavioural change and structures beyond the limits of a clinical concept of disease. This requires theoretical knowledge about the complex effects an intervention may have. In medical training it is necessary to emphasise problem-orientated learning strategies to promote systemic understanding of the context of health and disease in the perspective of the individual and also from a social point of view.