[Experiences with Regional Medical Coordinators in Ambulatory Care in the Early COVID-19 Phase 2020 in Bavaria: Survey of Regional Ambulatory Coordinators and General Practitioners]. / Erfahrungen mit Versorgungsärzt*innen in der frühen COVID-19-Phase 2020 in Bayern ­ Befragung von Versorgungs- und Hausärzt*innen.

BACKGROUND: During the state of emergency in Bavaria in the early Corona phase 2020, some physicians in ambulatory care were appointed as regional medical coordinators (RMCs). The aim of the present study was to evaluate this newly introduced but temporary position. METHODS: In November 2020, a paper-based questionnaire was sent out to all 85 RMCs who could be identified through an internet research and to all 197 teaching practices of the Institute of General Practice and Health Services Research at the Technical University of Munich. The data analysis was descriptive and anonymised. RESULTS: Overall, 75 (88%) RMCs and 156 (79%) general practitioners (GPs) were included. 97% of the RMCs and 67% of the GPs assessed the introduction of RMCs in ambulatory care as reasonable, but also as an intervention concerning the self-administration of physicians (RMCs: 59% and GPs: 42%). 37% of the GPs stated that RMCs should be avoided as far as possible in future pandemic situations. Overall, GPs with more intensive contact to an RMC showed higher levels of agreement. Both groups rated the collaboration and communication strategies of politics, authorities and the Bavarian Association of Statutory Health Insurance Physicians as difficult and often contradictory. However, most of the RMCs assessed the cooperation with politics and authorities at the local level as positive. The lack of medical protective equipment at the beginning of the pandemic was judged critically by both groups of the respondents. CONCLUSIONS: The establishment of RMCs in the early Corona phase 2020 in Bavaria was considered sensible by almost all RMCs and the majority of the surveyed GPs. For the future, it seems necessary to involve primary care physicians more intensively and permanently in decision-making processes and to strengthen existing structures.

The "General practitioner learning stations"-development, implementation and optimization of an innovative format for sustainable teaching in general practice.

BACKGROUND: Teaching general practice in a university setting is still challenging. In our department we have developed a teaching format with content from a previous lecture-style-teaching into an interactive small group format taught by frontline general practitioners (GPs). The "GP learning stations" introduce students to the skills and attributes of a GP working in primary care in a university setting. Our main objective was to understand whether the teaching format had proven itself sustainable in a university setting over eight years. Furthermore, we wanted to better understand the role of the GP as a medical educator. METHODS: More than eight years of experience in organizational and staff expenses were collected and analyzed. In addition, the grade point average of the students' evaluation was calculated and their free text answers were categorized and evaluated descriptively. During two teach-the-teacher seminars attending GPs were asked why they teach and if they feel equipped to teach the format. RESULTS: The initially high organizational and staff expenses were significantly reduced. The recruitment of GPs, their didactic contribution, and their joint creation of content went smoothly throughout the whole period. A total of 495 students participated in the regular evaluation. The analysis yielded a grade point average of 1.9, on a scale from 1 = very good to 6 = insufficient. In the free text answers students praised the educators, the format and the practical relevance. The interactive transfer of the content, the didactic competence of the educators and the spatial environment were viewed critically. Reasons for GPs to teach were the joy to pass on knowledge and experience, and to make the work of GPs more attractive to students. Most GPs felt prepared to teach through their experience as a physician although some felt unprepared to teach through their lack of didactic knowledge. CONCLUSION: Despite reducing the costs of the format, a grade point average of 1.9 could be achieved in the long term. This supports the teaching concept of learning stations and its "mixture of discussion, scientific background and role play, combined with (…) experiences and exciting individual cases from (GPs) everyday life", hopefully making general practice more attractive to the students.

The diversity of opinion among general practitioners regarding the threat and measures against COVID-19 - Cross-sectional survey.

BACKGROUND: After the 'first wave' in spring 2020, opinions regarding the threat and measures against COVID-19 seemed to vary among German general practitioners (GPs). OBJECTIVES: To systematically investigate opinions and to identify subgroups of GPs sharing similar views. METHODS: A questionnaire was sent to all 210 practices accredited for undergraduate teaching of family medicine at the Medical Faculty of the Technical University of Munich. Questions addressed personal opinions regarding risks, dilemmas, restrictions and their relaxation associated with COVID-19, and personal fears, symptoms of depression and anxiety. Patterns of strong opinions ('archetypes') were identified using archetypal analysis, a statistical method seeking extremal points in the multidimensional data. RESULTS: One hundred and sixty-one GPs sent back a questionnaire (response rate 77%); 143 (68%) with complete data for all 38 relevant variables could be included in the analysis. We identified four archetypes with subgroups of GPs tending in the direction of these archetypes: a small group of 'Sceptics' (n = 12/8%) considering threats of COVID-19 as overrated and measures taken as exaggerated; 'Hardliners' (n = 34/24%) considering threats high and supporting strong measures; 'Balancers' (n = 77/54%) who also rated the threats high but were more critical about potentially impairing the quality of life of elderly people and children; and 'Anxious' GPs (n = 20/14%) tending to report more fear, depressive and anxiety symptoms. CONCLUSION: Among the participants in this survey, opinions regarding the threat and the measures taken against COVID-19 during the 'first wave' in Germany in spring 2020 varied greatly.

Health care assistants in primary care depression management: role perception, burdening factors, and disease conception.

PURPOSE: In primary care, the involvement of health care assistants (HCAs) in clinical depression management is an innovative approach. Little is known, however, about how HCAs experience their new tasks. We wanted to describe the perceptions and experiences of HCAs who provided case management to patients with depression in small primary care practices. METHODS: This qualitative study was nested in the Primary Care Monitoring for Depressive Patients Trial on case management in Germany. We used a semi-structured instrument to interview 26 HCAs and undertook content analysis. We focussed on 3 key aspects: role perception, burdening factors, and disease conception. RESULTS: Most HCAs said their new role provided them with personal and professional enrichment, and they were interested in improving patient-communication skills. They saw their major function as interacting with the patient and considered support for the family physician to be of less importance. Even so, some saw their role as a communication facilitator between family physician and patient. Burdening factors implementing the new tasks were the increased workload, the work environment, and difficulties interacting with depressed patients. HCAs' disease conception of depression was heterogeneous. After 1 year HCAs believed they were sufficiently familiar with their duties as case managers in depression management. CONCLUSION: HCAs were willing to extend their professional responsibilities from administrative work to more patient-centred work. Even if HCAs perform only monitoring tasks within the case management concept, the resulting workload is a limiting factor.

Case management for depression by health care assistants in small primary care practices: a cluster randomized trial.

BACKGROUND: Case management by health care assistants in small primary care practices provides unclear benefit for improving depression symptoms. OBJECTIVE: To determine whether case management provided by health care assistants in small primary care practices is more effective than usual care in improving depression symptoms and process of care for patients with major depression. DESIGN: Cluster randomized, controlled trial. A central automated system generated the randomization scheme, which was stratified by urban and rural practices; allocation sequence was concealed until groups were assigned. SETTING: 74 small primary care practices in Germany from April 2005 to September 2007. PATIENTS: 626 patients age 18 to 80 years with major depression. INTERVENTION: Structured telephone interview to monitor depression symptoms and support for adherence to medication, with feedback to the family physician. MEASUREMENTS: Depression symptoms at 12 months, as measured by the Patient Health Questionnaire-9 (PHQ-9); secondary outcomes were patient assessment of chronic illness care, adherence to medication, and quality of life. RESULTS: A total of 310 patients were randomly assigned to case management and 316 to usual care. At 12 months, 249 intervention recipients and 278 control patients were assessed; 555 patients were included in a modified intention-to-treat-analysis (267 intervention recipients vs. 288 control patients). Compared with control patients, intervention recipients had lower mean PHQ-9 values in depression symptoms (-1.41 [95% CI, -2.49 to -0.33]; P = 0.014), more favorable assessments of care (3.41 vs. 3.11; P = 0.011), and increased treatment adherence (2.70 vs. 2.53; P = 0.042). Quality-of-life scores did not differ between groups. LIMITATION: Patients, health care assistants, family physicians, and researchers were not blinded to group assignment, and 12-month follow-up of patients was incomplete. CONCLUSION: Case management provided by primary care practice-based health care assistants may reduce depression symptoms and improve process of care for patients with major depression more than usual care. PRIMARY FUNDING SOURCE: German Ministry of Education and Research.

[The "Depression Monitoring list" (DeMoL) with integrated PHQ-D-Rationale and design of a tool for the case management for depression in primary care]. / Die "Depressions-Monitoring-Liste (De MoL)" mit integriertem PHQ-D-Rationale und Entwicklung eines Instruments für das hausärztliche Case Management bei Depression.

BACKGROUND: Structured and regular monitoring and/or case management support treatment continuity of patients with depression in primary care. Central tools are questionnaires with stratified operating instructions. Questions should be geared towards treatment relevance in primary care and identify clinical parameters in a reliable and valid manner and in due time. Stratified information transfer to the general practitioner should be objective to ensure patient-related communication in the practice team. METHOD: Development of a draft tool based on evidence-based guidelines, peer-reviewed pre-test, practice test among users. RESULT: The Depression Monitoring List (DeMoL) with integrated PHQ-D for interviews with depressive patients to be conducted by practice assistants assesses 1.)'clinical diagnosis' and 2.) 'patient adherence' and 3.) governs the information flow in the practice via a 'robot scheme'. Users (doctors and practice assistants) evaluated the tool as practicable and relevant for patient care in family practices. Experiences gained can also be used for the treatment of other chronic diseases.

Case management for the treatment of patients with major depression in general practices--rationale, design and conduct of a cluster randomized controlled trial--PRoMPT (PRimary care Monitoring for depressive Patient's Trial) [ISRCTN66386086]--study protocol.

BACKGROUND: Depression is a disorder with high prevalence in primary health care and a significant burden of illness. The delivery of health care for depression, as well as other chronic illnesses, has been criticized for several reasons and new strategies to address the needs of these illnesses have been advocated. Case management is a patient-centered approach which has shown efficacy in the treatment of depression in highly organized Health Maintenance Organization (HMO) settings and which might also be effective in other, less structured settings. METHODS/DESIGN: PRoMPT (PRimary care Monitoring for depressive Patients Trial) is a cluster randomised controlled trial with General Practice (GP) as the unit of randomisation. The aim of the study is to evaluate a GP applied case-management for patients with major depressive disorder. 70 GPs were randomised either to intervention group or to control group with the control group delivering usual care. Each GP will include 10 patients suffering from major depressive disorder according to the DSM-IV criteria. The intervention group will receive treatment based on standardized guidelines and monthly telephone monitoring from a trained practice nurse. The nurse investigates the patient's status concerning the MDD criteria, his adherence to GPs prescriptions, possible side effects of medication, and treatment goal attainment. The control group receives usual care--including recommended guidelines. Main outcome measure is the cumulative score of the section depressive disorders (PHQ-9) from the German version of the Prime MD Patient Health Questionnaire (PHQ-D). Secondary outcome measures are the Beck-Depression-Inventory, self-reported adherence (adapted from Moriskey) and the SF-36. In addition, data are collected about patients' satisfaction (EUROPEP-tool), medication, health care utilization, comorbidity, suicide attempts and days out of work. The study comprises three assessment times: baseline (T0) , follow-up after 6 months (T1) and follow-up after 12 months (T2). DISCUSSION: Depression is now recognized as a disorder with a high prevalence in primary care but with insufficient treatment response. Case management seems to be a promising intervention which has the potential to bridge the gap of the usually time-limited and fragmented provision of care. Case management has been proven to be effective in several studies but its application in the private general medical practice setting remains unclear.