Family doctors' attitudes toward peer support programs for type 2 diabetes and/or coronary artery disease: an exploratory survey among German practitioners.

BACKGROUND: Type 2 diabetes (T2D) and coronary artery disease (CAD) are chronic illnesses where adherence to a healthy lifestyle is crucial. If organisational and cultural factors are well managed, Peer support programs (PSP) can improve self-management, quality of life, and health outcomes. In preparation for launching a PSP, we surveyed family doctors (FD) about their attitudes toward such a program and about potential barriers, and facilitators. METHODS: In March 2020 we surveyed 896 FDs from five university teaching practice networks in North-Rhine Westphalia, Germany, via an anonymous web-based survey. The questionnaire addressed details of PSPs, including suitable patients and FDs'role. Data were analysed using descriptive and inferential statistics; qualitative material underwent content analysis by two researchers. RESULTS: A total of 165 FDs responded (response rate: 18.4%), 97% were practice owners. Respondents viewed PSPs positively (T2D: 92.0%, CAD 89.9%), especially for patients with poor self-structuring (82.7%), low motivation (76.3%) and few social contacts (67.6%). On average, FDs were able to identify 4.0 ± 3.2 patients as potential group leaders. Major facilitators reported included motivation by peers (92.5%), exercise (79.1%), and social contacts (70.1%). Waning interest over time (73.1%) and poor motivation (70.9%) were considered barriers. The majority of FDs would recommend PSPs to their patients (89.5%). They considered such a program a valuable addition to current care (79.7%). The percentage of FDs' who expected long-term benefits for their workload was relatively low (37.6%). CONCLUSIONS: In an exploratory survey among German FDs on PSPs, respondents viewed PSPs as a valuable add-on for T2D and CAD patients, while not expecting a positive impact on their workload. Communication with FDs on PSPs may need to highlight anticipated implementation outcomes such as benefits of PSPs to the practice.

Unemployed individuals contact GPs more frequently but report lower satisfaction: results of the population-based DEGS1 and the GPCare-1 patient survey.

Unemployment is associated with a variety of adverse health-related outcomes, yet little data on primary care services for this risk group exist. Using data from two surveys, we analyzed the frequency of GP contacts and patients' experiences with GPs comparing unemployed with employed individuals. Data of the German Health Interview and Examination Survey for Adults (DEGS1), a nationwide cross-sectional study (n = 8151), were analyzed regarding associations between employment status and the number of GP visits. The General Practice Care-1 study (GPCare-1), a cross-sectional questionnaire survey (n = 813), evaluated patients' communication with their GP. Data were collected from June to August 2020 in 12 teaching practices affiliated with our university. The statistical analysis included individuals of working age (18-64 years old) (DEGS1 n = 5659, GPCare-1 n = 587). In both studies, working age subpopulations were analyzed (DEGS1: n = 5659 of 8151, GPCare-1: n = 587 of 813). In DEGS1, the prevalence of unemployment was 6.5% (n = 372). Unemployed individuals had more GP contacts in the last 12 months (4.50 vs. 2.86, p < 0.001). In the GPCare-1 study, unemployed individuals (6.6%, n = 39) were significantly less satisfied with GP communication: enough space in consultations (42.9% vs. 60.3%, p = 0.043), feeling comfortable to address sensitive topics (44.1% vs. 65.9%, p = 0.010), problems taken very seriously by GP (48.6% vs. 70.6%, p = 0.007). Yet, they were more willing to accept GPs' help for psychosocial burdens (67.6% vs. 47.6%, p = 0.024). GPs should be aware that patients with unemployment wish more support to cope with their burdening situation.

Attitudes of German GP trainees regarding add-on training programs differ if in office or hospital training phase.

BACKGROUND: Many residents are exposed to negative attitudes towards primary care during hospital training. Attractive add-on training programs exist, but it is unclear whether these need to be tailored to the location of training (hospital vs. office). We report differences in learner attitudes from a large German add-on training program. METHODS: Between 2017 and 2020, a regional network offered 31 quarterly seminars to primary care residents. The seminars addressed medical content, practice management and mentoring. We elicited participants' satisfaction, perceived topic relevance, preferences for future seminars, work situation and employer support for participation. A proportionate odds model was used to assess predictors of ratings; results were stratified by training location (hospital vs. office). RESULTS: Most respondents were female (380/575 = 70.0%), aged between 26 and 40 (80.8%), and had on average 3.54 ± 1.64 years of residency training. The majority (83.8%) was working in an office and full-time (63.0%). Overall evaluations were positive (very satisfactory 72.1%). Comparing residents in the hospital phase vs. the office phase, overall seminar ratings of the perceived impact on the motivation for primary care did not differ (p = 0.73 vs. 0.18, respectively). Hospital-based residents were less likely to rate the topics as relevant (39.4% vs. 55.7%, p = 0.02) and had different preferences for future seminar topics (top 3: palliative care, emergencies and chronic care vs. billing, disease management and practice finances for hospital and office phase, respectively). CONCLUSIONS: Keeping primary care residents motivated may require education tailored to training location. Our findings may be of interest to teachers, administrators and policymakers.

[Vaccine Refrigerator and Vaccine Management in General Practices: A Representative, Web-Based Survey among General Practitioners (Keep Cool I)]. / Impfkühlschrank- und Impfstoffmanagement in Hausarztpraxen: Eine repräsentative, Web-basierte Umfrage unter Hausärzten (Keep Cool I).

Aim: The purpose of this study was to analyse vaccine refrigerator and vaccine management in primary care and to identify physician- and practice-related influencing factors. Background: Adequate cooling of vaccines in a temperature range of 2-8°C is essential to assure vaccine effectiveness. Studies from various countries have demonstrated cooling chain problems. We surveyed general practitioners about the quality of their vaccine refrigerator and vaccine management and aimed at identifying physician- and practice-related influencing factors. Methods: A cross-sectional, web-based questionnaire survey was performed among 3 physician populations in primary care: a 10% random sample of general practitioners (n=954), all teaching physicians of the Universities Duisburg-Essen (n=221) and Halle-Wittenberg (n=92). Surveyed were items on the following 6 aspects: (1) responsibilities within practice teams, (2) vaccine ordering and storing, (3) criteria for the vaccine pre-selection, (4) stocking system inside the refrigerator, (5) wrapping, and use of stocking boxes, (6) refrigerator and temperature control. The quality indicator "comprehensive refrigerator management" was defined to include 4 aspects: (1) separate refrigerator, (2) written temperature documentation (temperature-logbook), (3) regular storage control (wrapping, temperature and expiration date), and (4) storage in original wrappings. Results: A total of 278 physicians participated in the survey (22%). Of these, 80% had a separate refrigerator, 52% reported written temperature documentation, 93% documented regular storage control addressing vaccine wrappings, temperature and expiration dates, and 95% reported vaccine storage in original card box wrappings. A "comprehensive refrigerator management" was realised by 42% of the practices. This indicator was reached more frequently by practices with 3 or more physicians (p=0.01) and those with an additional qualification in travel medicine (p=0.036). Conclusion: Our survey showed good results for most aspects of the refrigerator and vaccine management but room for improvement with regard to temperature documentation.

[How do you explain vaccine effects to patients? A representative, web-based survey among primary care physicians from North-Rhine Westphalia]. / Wie erklären Sie Ihren Patienten die Impfwirkung?

BACKGROUND: This study investigates how frequent general practitioners (GP) explain the immunological vaccine response to patients and which stylistic means they use. METHOD: Data from a cross-sectional, web-based survey were analyzed. The study population included a representative random sample of 10 % of GPs from North Rhine-Westphalia and all teaching physicians from two universities. The data was evaluated using a multi-method approach with a statistical analysis and a content analysis according to Mayring. RESULTS: The analysis included 187 GPs (69 % males, 56 % ≤50 years). 18.3 % of GPs routinely informed about the vaccine response. In a clinical vignette, 48.7 % used a layperson-oriented language, supported by figures of speech in 11.8 %. The key content categories were: protection against disease (63.6 %), antibody formation (64.2 %), vaccine concept (47.6 %), and potential adverse reactions (4.3 %). CONCLUSION: To improve patients' health literacy, physicians are asked to routinely explain the immunological effects of vaccines.

[Diagnostic screening for cancer and coronary heart disease with radiological and nuclear imaging techniques: early diagnosis at any price?]. / Check-up mit radiologischen und nuklearmedizinischen Verfahren: Früherkennung "um jeden Preis"?

Recently nuclear and radiological imaging techniques such as Glucose-PET, whole body MRI, coronary CT and various laboratory tests are used to screen asymptomatic patients for cancer and coronary heart disease. This review, based on the current relevant publications, including recent Japanese prospective studies, discusses issues arising from this screening approach. Although cases of early cancer are detected using such an approach, this preventive strategy has not been shown to improve quality of life and/or decrease mortality, but leads to additional radiation exposure and a high number of false-positive results with subsequent emotional and medical stress. Epidemiologic considerations and scientific data are discussed in order to suggest to doctors appropriate strategies when counselling patients about imaging screening options.

[Attitudes towards patient care at the end of life. A survey of directors of neurological departments]. / Einstellungen zur Patientenbetreuung in der letzten Lebensphase Eine Umfrage bei neurologischen Chefärzten.

In view of the increasing importance of palliative medicine and end-of-life care of neurological patients, a survey from the American Academy of Neurology was translated in a validated fashion and sent to all medical directors of neurological departments in Germany. The topics of the survey comprised-based on clinical scenarios-the withdrawal or withholding of life-sustaining measures, physician-assisted suicide (PAS) and euthanasia, advance directives and health care proxies, principles of palliative care, and ethical and legal questions in end-of-life care. Of 411 directors of departments, 152 participated in the survey. Almost all respondents support a patient's right to refuse life-sustaining treatment. Thirty-two percent think it is illegal to administer analgesics in doses that risk respiratory depression. Forty-five percent believe that treating terminal dyspnea with morphine is the same as euthanasia. Despite the fact that 88% of the respondents regard advance directives as helpful, only an average of 4% of their patients have completed one. About one third of the respondents have been confronted with a request by patients for PAS or euthanasia. Thirty-five percent believe that PAS should be made explicitly legal for terminally ill patients. Forty-six percent of the respondents believe that their training in end-of-life care was insufficient, and 91% express interest in education programs on palliative care.

[Difficulties in the transfer of drug therapy from inpatient to ambulatory treatment]. / Pharmakotherapeutische Transferproblematik von stationärer zu ambulanter Versorgung.

The prospective study compares prescribed drugs of 192 primarily cardiological patients at discharge and 7 weeks later in ambulatory care. The data were determined by discharge summaries and by standardized patient-questionnaires. The drug division was made with the ATC-classification according to the recommendations of the World Health Organisation for Drug Utilisation Studies. The intraindividual cost comparison was calculated by current pharmacy sale prices. The findings were changes in hospital discharge medications in ambulatory care in over 2/3 of the cases. The most frequent change was the additional prescribing of drug groups. The average daily tablet number increased in patients with the same or worsened subjective feeling after discharge. Additionally we found in a number of patients a change of drug therapy within the ATC-groups, or in fact, withdrawal of drug therapy all together. The frequency of changes increased with the number of patient/doctor contacts. The observation that the average daily therapeutical cost decreased just slightly could give an indication that cost saving was a minor part of the doctors decision for drug changing. However, the frequency of changes has shown to be dependent upon the specialities of the physician or pharmaceutical group.

A single question about prior stroke versus a stroke questionnaire to assess stroke prevalence in populations.

BACKGROUND: False-positive and false-negative answers to screening questions influence prevalence and incidence estimations for stroke in population studies. Despite frequent use in screening, only a few studies have examined causes and influence of incorrect self-reports. We compared the rates of false-positive and false-negative answers to a single question about prior stroke to those of the Stroke Symptom Questionnaire (SSQ), a newly developed instrument based on 6 symptom questions. Differences in stroke prevalence estimations and risk factors for incorrect reports are described. METHODS: The MEMO study (Memory and Morbidity in Augsburg Elderly) examines cognitive function and neurodegenerative diseases in an elderly population (n = 384) in southern Germany. All participants filled in the symptom questionnaire, received a neurological examination and a neuropsychological test battery. Medical records were obtained for event validation of subjects positive on screening and those negative on screening with symptoms suggesting a cerebrovascular event during examination. RESULTS: Prevalence of total stroke was 5. 3% using a single screening question and 6.8% using the questionnaire. The false-negative rate was higher for the single-question approach (34.2 versus 10.5%). It was strongly influenced by gender and cognitive function. The questionnaire had a higher false-positive rate than the single question. Based on the results, we established question combinations that best served three different research scenarios (frequency estimation, risk factor analysis, control selection), relevant to stroke research in population studies. CONCLUSIONS: A single screening question for stroke in the past with event validation by medical records underestimates stroke frequency in population studies by about 30%. Use of a number of questions for key symptoms combined with a general stroke question, as in the SSQ, improves the completeness of event ascertainment and allows the detection of stroke and transient ischemic attack at the same time.

Stroke knowledge among stroke support group members.

BACKGROUND AND PURPOSE: Community stroke education is needed to improve early stroke recognition and reduce delays in the referral of stroke patients. In some regions, stroke support groups are important promoters of regional stroke education. However, there are no data about the level of stroke knowledge among support group members that support this promotional role. METHODS: We performed a cross-sectional questionnaire survey among 11 German stroke support groups. The questionnaire asked for stroke knowledge and sociodemographic and medical data. Stroke knowledge was excellent if a participant knew (1) at least 2 stroke symptoms (good symptom knowledge) and (2) at least 2 stroke risk factors (good risk factor knowledge), as well as knowing (3) that immediate hospital admission or an emergency call is necessary in case of stroke (good action knowledge). RESULTS: A total of 133 members (96.2%) of 11 stroke support groups took part in the study. Mean age was 65.3 years (SD 11.2 years). Fifty-four percent of subjects were female, 72.8% were retired, and 69.8% were stroke patients. Of the participants, 80.3% had good symptom knowledge, 64.7% had good risk factor knowledge, and 79.7% had good action knowledge. Stroke knowledge was excellent in 44.0% of subjects. Logistic regression analysis showed that age <70 years and not having had a stroke were significant predictors for excellent stroke knowledge. CONCLUSIONS: Overall, members of stroke support groups are well informed about all aspects of modern stroke care. Because of their knowledge and personal experience, support groups should be viewed as important partners in community stroke education.

[Acute psychiatric symptoms as the initial manifestation of HIV-infection: differential diagnosis, therapy and medico-legal issues]. / Psychiatrische Akutsymptomatik als Erstmanifestation einer HIV-Infektion. Differentialdiagnostische, therapeutische und medizinrechtliche Probleme.

The prevalence of psychiatric symptoms and disorders in HIV-infected patients is high. The differential diagnosis includes psychoreactive disorders, acute psychiatric symptoms of an HIV-associated encephalopathy, and symptomatic psychotic illnesses due to secondary neurologic manifestations such as opportunistic central nervous infections and intracerebral lymphoma. Clinical aspects and psychopathological findings are not sufficient for differential diagnosis and identification of primarily psychiatric disorders. Secondary neurologic manifestations causing a symptomatic psychosis must be excluded as soon as possible by brain imaging (CT, MRI) and analysis of the cerebrospinal fluid. In emergency situations, however, German law imposes strict regulations, especially in the case of sectioned patients. These medical and medicolegal questions are illustrated by case reports and propositions for an effective strategy are made.

[Knowledge about stroke among the German population]. / Wissen über Schlaganfall in der deutschen Bevölkerung.

BACKGROUND AND OBJECTIVE: Modern stroke therapy requires patients to correctly identify stroke symptoms and seek immediate hospital admission. US studies showed that only 57% of the population knew at least one stroke symptom. This is the first study about stroke knowledge among German populations. METHODS: Using a cross-sectional questionnaire survey, 300 working-age participants of the PROCAM study, the Prospective Cardiovascular Münster Study, and 95 senior citizens of the Augsburg Study, a follow-up project of the MONICA survey 1989/90, were asked about stroke symptoms and what to do if they occur. Good knowledge about stroke was defined as knowing at least two stroke symptoms and calling the emergency medical system or seeking immediate hospital admission in case of symptoms. RESULTS: Participation rate in the PROCAM study was 90%, while all senior citizens took part. The mean age of the working population was 41.2 years, the mean age of the retired population was 72.8 years. 35% of the working and 24.5% of the retired participants knew at least two stroke symptoms. Urgent hospital admission was selected by 78.2% of the occupational but only 41.5% of the retired participants. Good stroke knowledge was demonstrated by nearly a third of the workers but less than 10% of the elderly. Among the occupational population, being a white-collar worker or knowing someone with a stroke was a significant predictor of good stroke knowledge. Among senior citizens higher age and current smoking status were significant predictors. CONCLUSION: Our study shows significant information deficits about stroke in our population: education needs to be geared especially towards the elderly.

[Supply of emergency physicians for patients with stroke in the Münster area. A cross-sectional study of the quality of regional health care]. / Notarzteinsätze für Schlaganfallpatienten im Raum Münster. Eine Querschnittsstudie der regionalen Versorgungsqualität.

BACKGROUND AND OBJECTIVE: Advances in understanding the pathophysiology and treatment of stroke have led to changed requirements, including the prehospital phase, for the care of patients with acute stroke. Rapid transport to a regional stroke centre is nowadays considered to be the standard for optimal quality of care. A retrospective cross-sectional analysis was undertaken in 1996 in the region of the town of Münster to test the quality of medical care provided by physicians on emergency call. PATIENTS AND METHODS: 250 of 3001 protocols (8.3%) filled in by emergency call physicians were selected in which the initial diagnosis of transitory ischaemic attack, stroke or cerebral haemorrhage had been made. Quality of patient care was assessed according to the following criteria; (1) complete medical treatment (blood sugar, blood pressure, cardiac rhythm and arterial oxygen saturation, including relevant treatment of any abnormality) (2) action time (arrival of emergency doctor within 12 min and arrival at hospital within 50 min); (3) type of the admission hospital (stroke centre defined as a hospital experienced in the treatment of stroke, with neurological and medical departments, as well as 24-hour cover for computed cranial tomography). A summated indicator of "optimal care" was used to determine whether the three stated criteria were met. RESULTS: Mean age of the stroke patients was 72.3 years. While the above mentioned quality criteria for the action time were met in 93.5% of patients, only 56.0% were admitted to a stroke centre, and this was significantly more often the final destination for patients under the age of 65 years than for older ones (p = 0.049). The quality indicator "complete medical treatment" was met for 27.2% of the transported patients. Measured according to present-day criteria, only 18.6% of patients received such optimal treatment. CONCLUSION: This analysis indicates that modern prehospital treatment of stroke patients does not reach adequate standards. In particular, it is not comprehensive. While the "action time" is usually adequate, there are deficiencies regarding the quality of medical care and the choice of the admission hospital. Further education for emergency physicians with respect to the management of stroke syndrome should be an integral part of any regional quality programme. The number of hospitals with adequate competence in the acute management of stroke cases is still insufficient.

[Cryptococcal meningoencephalitis in HIV infected immigrants. Diagnostic and therapeutic aspects with reference to evidence-based medicine"--an overview]. / Kryptokokkenmeningoenzephalitis von HIV-infizierten Immigranten. Diagnostische und therapeutische Aspekte unter Berücksichtigung der "evidence-based medicine"--Ein Uberblick.

Cryptococcal meningitis is one of the most frequent forms of meningoencephalitis in AIDS patients. Before the introduction of triazole antibiotics like difluconazole, the frequency of this meningitis among AIDS patients was 5-10%, yet declined during the last years. Clinically, nonspecific signs of a meningeal inflammation predominate while focal neurological signs are rare. Rapid institution of high-dose antimycotic therapy is the keystone to improve prognosis and decrease mortality. Antimycotics of choice are amphotericin B, fluconazole, and flucytosin. Diagnosis is established by detection of cryptococcal antigen in cerebrospinal fluid, microscopic demonstration of cryptococci using India-ink, and cryptococcal cultures. Recent developments aim to improve antimycotic therapies. During the last years, lifelong secondary prevention with difluconazole was established. Cryptococci which are resistant against fluconazole and amphotericin B are a special challenge, yet fortunately are rare. Longterm outcome of patients is determined by the progression of the underlying immunosuppression. Therefore, combination of secondary prophylaxis with modern antiviral substances is important. Clinical decision analysis in patients with suspected cryptococcal meningitis is presented using methods from evidence-based medicine.

Contrast transcranial Doppler ultrasound in the detection of right-to-left shunts: comparison of different procedures and different contrast agents.

BACKGROUND AND PURPOSE: Cardiac right-to-left shunts can be identified by transesophageal echocardiography (TEE) and by transcranial Doppler ultrasound (TCD) with the use of different contrast agents and different provocation procedures. Currently, data on an appropriate time window for the appearance of contrast bubbles in the TCD recording after the injection of the contrast medium and the comparison of different provocation maneuvers to increase right-to-left shunting are insufficient. METHODS: Forty-six patients were investigated by both TEE and bilateral TCD of the middle cerebral artery. The following protocol with 6 injection modes was applied in a randomized way: (1) injection of 10 mL of agitated saline without Valsalva maneuver, (2) injection of 10 mL of agitated saline with Valsalva maneuver, (3) injection of 10 mL of a commercial galactose-based contrast agent (Echovist) without Valsalva maneuver, (4) injection of 10 mL of Echovist with Valsalva maneuver, (5) injection of 10 mL of Echovist with standardized Valsalva maneuver, and (6) injection of 10 mL of Echovist with coughing. RESULTS: In 20 patients, a right-to-left shunt was demonstrated by TEE and contrast TCD (shunt-positive). Sixteen patients were negative in both investigations, no patient was positive on TEE and negative on TCD, and 10 patients were only positive on at least 1 TCD investigation but negative during TEE. The amount of microbubbles detected in the various tests decreased in the following order: Echovist and Valsalva maneuver, Echovist with coughing, Echovist and standardized Valsalva maneuver, saline with Valsalva maneuver, Echovist, and saline. With a time window of 20 to 25 seconds for the bubbles to appear in the TCD recording and with a sequence of first Echovist and Valsalva maneuver and then Echovist with coughing, all shunts were reliably identified with a specificity of 65% compared with TEE as the traditional gold standard. The time of first microbubble appearance was not helpful to distinguish between shunts detected on TEE and other shunts. CONCLUSIONS: TCD performed twice with 2 provocation maneuvers using Echovist is a sensitive method to identify cardiac right-to-left shunts also identified by TEE.

[The reliability of stroke scales. The german version of NIHSS, ESS and Rankin scales]. / Untersuchung zur Reliabilität von Schlanganfallskalen. Die deutschen Versionen von NIHSS, ESS und Rankin Scale.

Aim of the study was the translation of three frequently used stroke scales ("National Institutes of Health Stroke Scale" NIHSS, "European Stroke Scale" ESS and "Rankin Scale") into German and the analysis of the interrater reliability of the respective German versions. The translation process followed the protocol of the Medical Outcomes Trust (Boston) and included two independent forward, one backward translation and a consensus conference for the German versions. Interrater reliability was assessed using the weighted kappa statistic. For this study 43 patients with an ischemic stroke determined by computed tomography or magnetic resonance imaging were recruited from two university hospitals. Excluded were patients with an intracerebral hemorrhage or TIA. The interrater reliability of the three German versions was substantial to excellent. Mean Kappa for the NIHSS was 0.80, for the ESS 0.79 and 0.76 for the Rankin Scale using simple weights in the analysis. Additional analysis revealed the influence of preselected weights on the results of the kappa statistic. The use of German versions of frequently used stroke scales can reduce bias that is introduced by different levels of knowledge of the English language and thus improve the standardised assessment of neurological deficits in stroke.

Hypersensitivity pneumonitis: a sentinel event investigation in a wet building.

Hypersensitivity pneumonitis (HP) as a sentinel event implies a remediable exposure and an exposed cohort that require evaluation. A patient with HP convincingly related to her building led to a questionnaire survey in follow-up. Building coworkers demonstrated substantially higher symptom rates than did controls in five other buildings, although no further cases of disease were identified. It is likely that moisture sources in the building included an oversized cooling system and below-grade moisture, but the building met all applicable regulations and standards. Screening investigations for disease are not mandated by law and are often not conducted, in part because cost coverage is unclear. The absence of regulatory or professional standards that adequately address moisture in the built environment forces occupational health professionals to rely on disease documentation strategies to justify intervention.

[Prescribing practice for beta blockers at patient discharge to ambulatory care. A health care economic evaluation in a cardiology patient sample with special reference to drug budgeting]. / Verordnungspraxis von Betablockern an der Schnittstelle von stationärer zu ambulanter Versorgung. Eine gesundheitsökonomische Evaluation in einem kardiologischen Kollektiv under besonderer Berücksichtigung der Arzneimittelbudgetierung.

Beta blockers are known to reduce mortality from hypertension and coronary heart disease after myocardial infarction. Recent health care laws in Germany did impose a medication budget for ambulatory patients only. To evaluate the effects of this administrative instrument we studied prescribing practices of beta blockers in patients transferred from inpatient to ambulatory care. Specifically, we aimed of assessing the quality and cost effectiveness of beta blocker prescriptions. In a prospective cohort study of 142 patients discharged from a tertiary care center, the beta blocker medication was continued in 130 patients (91%). Adequate quality of the medication, defined as continuation of a beta blocker in sufficient dosage, was found in 77% of patients. Cost effective prescribing practices, defined as adequate quality at a lower cost than at discharge, were documented in 10% of the patients. However, inadequate dosage or even omitting of a beta blocker was found in 23% of patients. Overall, we found high-quality prescribing practices in more than two-thirds of our patients, but documented inadequate care in more than 20%. Our study did not document any consistent pattern between medication changes and cost-effective prescribing practices attributable to medication budgeting in Germany.