Influences on Physicians' Participation in Coordinated Ambulatory Cardiology Care: A Mixed-Methods Study.

INTRODUCTION: In 2009 a managed care programme for coordinated ambulatory cardiology care was established in Southern Germany. Designed as a voluntary contract between health insurers and ambulatory medical specialists, it aims for a guideline-oriented, efficient health care by general practitioners and medical specialists. In this study, we aimed to identify factors associated with physicians' participation and their relation to the aims of the programme. METHODS: A mixed-methods study was designed. We conducted semi-structured interviews with a sample of 21 specialists participating and 11 specialists not participating in the programme. Structured questionnaires were sent to all eligible medical specialists, of whom 75 specialists participating and 21 specialists not participating in the programme responded. Both the interview and questionnaire covered a range of questions on the participation and implementation of the program. RESULTS: Financial benefits were the most frequently named reason to participate. Other prevalent motives were the prospect of an alternative to regular health care, expected diagnostic possibilities and recommendations from peers. Reasons for not participating were mainly structural, such as technical modifications as well as economic investments and fear for one's professional autonomy. CONCLUSION: Physicians' participation in the programme was mainly financially driven and largely unrelated to its care-related aims. Still, it is unclear if these divergences between motivation to participate and aims of a managed care programme affect its eventual impact, hence further research is required.

Implementing coordinated ambulatory cardiology care in southern Germany: a mixed-methods study.

BACKGROUND: In 2009 health insurers AOK and Bosch BKK introduced the "FacharztProgramm Kardiologie" - a program for coordinated ambulatory cardiology care in the German state of Baden-Württemberg. It aims for efficient, medical guideline-oriented cardiology care to reduce avoidable hospitalizations as well as costs of care. A high number of cardiologists participate and the program has served as blueprint for programs in other medical fields. With many prerequisites and conditions involved, its implementation cannot be expected to be self-directed. Still, only little data on the actual implementation exists. We aimed to determine to what extent medical specialists and cooperating general practitioners implemented the program, which components they adapted, and which contextual factors they deemed relevant. METHODS: We collected data from primary care practices of medical specialists and general practitioners within Baden-Württemberg. Qualitative data was obtained through structured telephone interviews with participating and non-participating medical specialists as well as general practitioners cooperating with the program and general practitioners not cooperating. Interviews were analyzed through content-structuring qualitative content analyses via MAXQDA. Quantitative data was obtained using anonymous written questionnaires completed by participating and non-participating medical specialists as well as general practitioners cooperating with the program. Analyses were performed using SPSS Statistics, mainly with regard to differences within and between groups of physicians. RESULTS: Most components of the program regarding medical care were well implemented. However, access to medical care was not completely as intended due to high numbers of patients participating in the program and prioritization by physicians. Procedures for communication and cooperation between medical specialists and general practitioners were only partially adhered to and standardized communication was not implemented. A range of regional and practice-related contextual factors influenced implementation and outcomes. CONCLUSIONS: Implementation of this program was mixed. Contextual factors posed individual challenges to participating physicians which can't be captured by an encompassing program. Both control mechanisms and tailoring of the program to medical care seem needed. TRIAL REGISTRATION: Though not a clinical study, we deemed registration appropriate to ensure transparency. The study has been registered as a non-interventional observation study at the German Clinical Trials Register under ID: DRKS00013070.

Challenges in supporting lay carers of patients at the end of life: results from focus group discussions with primary healthcare providers.

BACKGROUND: Family caregivers (FCGs) of patients at the end of life (EoL) cared for at home receive support from professional and non-professional care providers. Healthcare providers in general practice play an important role as they coordinate care and establish contacts between the parties concerned. To identify potential intervention targets, this study deals with the challenges healthcare providers in general practice face in EoL care situations including patients, caregivers and networks. METHODS: Focus group discussions with general practice teams in Germany were conducted to identify barriers to and enablers of an optimal support for family caregivers. Focus group discussions were analysed using content analysis. RESULTS: Nineteen providers from 11 general practices took part in 4 focus group discussions. Participants identified challenges in communication with patients, caregivers and within the professional network. Communication with patients and caregivers focused on non-verbal messages, communicating at an appropriate time and perceiving patient and caregiver as a unit of care. Practice teams perceive themselves as an important part of the healthcare network, but also report difficulties in communication and cooperation with other healthcare providers. CONCLUSION: Healthcare providers in general practice identified relational challenges in daily primary palliative care with potential implications for EoL care. Communication and collaboration with patients, caregivers and among healthcare providers give opportunities for improving palliative care with a focus on the patient-caregiver dyad. It is insufficient to demand a (professional) support network; existing structures need to be recognized and included into the care.

Evaluating the quality of colorectal cancer care across the interface of healthcare sectors.

BACKGROUND: Colorectal cancer (CRC) has a high prevalence in western countries. Diagnosis and treatment of CRC is complex and requires multidisciplinary collaboration across the interface of health care sectors. In Germany, a new nationwide established program aims to provide quality information of healthcare delivery across different sectors. Within this context, this study describes the development of a set of quality indicators charting the whole pathway of CRC-care including data specifications that are necessary to operationalize these indicators before practice testing. METHODS: Indicators were developed following a systematic 10 step modified 'RAND/UCLA Appropriateness Method' which involved a multidisciplinary panel of thirteen participants. For each indicator in the final set, data specifications relating to sources of quality information, data collection procedures, analysis and feedback were described. RESULTS: The final indicator set included 52 indicators covering diagnostic procedures (11 indicators), therapeutic management (28 indicators) and follow-up (6 indicators). In addition, 7 indicators represented patient perspectives. Primary surgical tumor resection and pre-operative radiation (rectum carcinoma only) were perceived as most useful tracer procedures initiating quality data collection. To assess the quality of CRC care across sectors, various data sources were identified: medical records, administrative inpatient and outpatient data, sickness-funds billing code systems and patient survey. CONCLUSION: In Germany, a set of 52 quality indicators, covering necessary aspects across the interfaces and pathways relevant to CRC-care has been developed. Combining different sectors and sources of health care in quality assessment is an innovative and challenging approach but reflects better the reality of the patient pathway and experience of CRC-care.

[New ways in caring for patients with functional syndromes - interdisciplinary group intervention in the primary care setting: a qualitative study]. / Neue Wege in der Versorgung von Patienten mitfunktionellen Syndromen - Interdisziplinäre Gruppen-behandlung in der Hausarztpraxis: Eine qualitative Studie.

Interface problems between health care sectors hinder collaborative care in functional syndromes. The speciAL trial investigated a disorder-oriented group intervention conducted by the general practitioner (GP) and a psychosomatic specialist (PS) in the GP's office. To evaluate the GP-PS cooperation, our qualitative study analysed free text statements about collaborative group leading of all 18 intervention GPs. In the GPs' view, all sessions should structuredly be prepared and reviewed together for 20 min. Functions of the preparatory communication were gaining distance from daily business, attunement to the group and to each other, and preparing for the session topics. Functions of the communication after the sessions were professional exchange, reflection of the session and further treatment planning. The GPs saw the PS's role as a group leader and expert, their own role as a reference person for the patient, a link between all dimensions and a cotherapist. Crucial seemed a succeeding role splitting.

Video-assisted feedback in general practice internships using German general practitioner's guidelines.

INTRODUCTION: The planned modification of the Medical Licenses Act in Germany will strengthen the specialty of general practice. Therefore, medical students should get to know the daily routine of general practitioners during their academic studies. At least 10% of students should get the possibility to spend one quarter of the internship, in the last year of their academic studies, in a practice of family medicine. The demonstrated teaching method aims at giving feedback to the student based on video recordings of patient consultations (student-patient) with the help of a checklist. Video-feedback is already successful used in medical teaching in Germany and abroad. This feasibility study aims at assessing the practicability of video-assisted feedback as a teaching method during internship in general practice. TEACHING METHOD: First of all, the general practice chooses a guideline as the learning objective. Secondly, a subsequent patient - student - consultation is recorded on video. Afterwards, a video-assisted formative feedback is given by the physician. A checklist with learning objectives (communication, medical examination, a structured case report according to the guideline) is used to structure the feedback content. FEASIBILITY: The feasibility was assessed by a semi structured interview in order to gain insight into barriers and challenges for future implementation. The teaching method was performed in one general practice. Afterwards the teaching physician and the trainee intern were interviewed. The Following four main categories were identified: feasibility, performance, implementation in daily routine, challenges of the teaching concept.The results of the feasibility study show general practicability of this approach. Installing a video camera in one examination room may solve technical problems. The trainee intern mentioned theoretical and practical benefits using the guideline. The teaching physician noted the challenge to reflect on his daily routines in the light of evidence-based guidelines. CONCLUSION: This teaching method supports quality control and standardizing of learning objectives during the internship in general practice by using general practice guidelines. The use of a checklist enhances this method in general practice. We consider the presented teaching method in the context of the planned modification of the Medical Licenses Act is part of quality control and standardisation of medical teaching during general practice internships. In order to validate these presumptions, further, evaluation of this method concerning the learning objectives using the guidelines of general practice need to be carried out.

[Which criteria affect the cooperation between general practitioners and specialists in ambulatory care? A qualitative study about general practitioners' perception]. / Welche Kriterien beeinflussen Hausärzte bei der Überweisung zum Spezialisten in der ambulanten Versorgung? Eine qualitative Studie zur Sichtweise von Hausärzten.

BACKGROUND: Good cooperation between physicians is an essential requirement for quality health care. General practitioners (GPs) have a key role in coordinating the various levels of care and physician contacts. Within the scope of the "InteraKtion" study of the Competence Centre of General Practice Baden-Wuerttemberg GPs were interviewed about their experiences and opinions regarding their cooperation with specialists. The aim of this study was to identify criteria and barriers of the referral process. METHODS: 22 semi-structured interviews were conducted among GPs in Heidelberg, Tuebingen and Ulm. Data analysis was carried out using ATLAS.ti according to the qualitative content analysis by P. Mayring. RESULTS: From the GPs' point of view, the criteria for referral to specialists include: specialists' medical skills, good doctor-patient relationship and patient satisfaction. In addition, the willingness to arrange short-term appointments in urgent cases, timely diagnosis and adequate communication were mentioned. The following barriers were pointed out: long appointment wait times and the specialists' increased provision of Individual Healthcare Services. CONCLUSION: These results indicate that GPs have clear criteria for referral to specialists. These findings should find their way into future quantitative studies to explore the weighting of the criteria and barriers discussed here. Joint training activities or quality circles could improve the personal contact between GPs and specialists working in the same region.

[Barriers to evidence-based medicine encountered among GPs - an issue based on misunderstanding? A qualitative study in the general practice setting]. / Barrieren der Hausärzte gegen Evidenzbasierte Medizin - ein Verständnisproblem? Eine qualitative Studie mit Hausärzten.

The Chronic Care Model (CCM) is a framework for the structured care of patients with chronic conditions. It requires access of both physicians and patients to scientific evidence in order to facilitate shared treatment decision-making on the basis of the patient's individual needs and the best available external evidence. The aim of this study was to find out whether general practitioners (GP) actually make use of evidence-based information and guidelines and whether and how they communicate this information to their patients. We interviewed 14 general practitioners and conducted a content analysis. The majority of these GPs take a sceptical view towards evidence-based guidelines. Their main point of criticism is that guidelines disregard the individual patient's reality and life style. Instead, GPs emphasize the relevance of their own knowledge of the personal and medical history of and the continual care for their patients. Since GPs themselves often do not accept guidelines, they seldom impart their content to their patients. According to the GPs' experience there are contradictions between guideline-conformant therapy and individual treatment. The integrative character of evidence-based medicine is not recognized. The reason is that evidence-based medicine is equated with guidelines and trial results by the majority of the GPs interviewed. To facilitate guideline implementation in everyday practice GPs need to be provided with adequate access to scientific evidence and an understanding of the intentions of guidelines. If the doctors themselves do not accept guidelines, they will not share them with their patients. It must be made clear that guidelines are not intended as normative demands for a specific therapy for every patient, but are rather meant to assist the physician with his struggle for the best therapy for individual patients.

Diagnosing somatisation disorder (P75) in routine general practice using the International Classification of Primary Care.

OBJECTIVE: (i) To analyze general practitioners' diagnosis of somatisation disorder (P75) using the International Classification of Primary Care (ICPC)-2-E in routine general practice. (ii) To validate the distinctiveness of the ICD-10 to ICPC-2 conversion rule which maps ICD-10 dissociative/conversion disorder (F44) as well as half of the somatoform categories (F45.0-2) to P75 and codes the other half of these disorders (F45.3-9), including autonomic organ dysfunctions and pain syndromes, as symptom diagnoses plus a psychosocial code in a multiaxial manner. METHODS: Cross-sectional analysis of routine data from a German research database comprising the electronic patient records of 32 general practitioners from 22 practices. For each P75 patient, control subjects matched for age, gender, and practice were selected from the 2007 yearly contact group (YCG) without a P75 diagnosis using a propensity-score algorithm that resulted in eight controls per P75 patient. RESULTS: Of the 49,423 patients in the YCG, P75 was diagnosed in 0.6% (302) and F45.3-9 in 1.8% (883) of cases; overall, somatisation syndromes were diagnosed in 2.4% of patients. The P75 coding pattern coincided with typical characteristics of severe, persistent medically unexplained symptoms (MUS). F45.3-9 was found to indicate moderate MUS that otherwise showed little clinical difference from P75. Pain syndromes exhibited an unspecific coding pattern. Mild and moderate MUS were predominantly recorded as symptom diagnoses. Psychosocial codes were rarely documented. CONCLUSIONS: ICPC-2 P75 was mainly diagnosed in cases of severe MUS. Multiaxial coding appears to be too complicated for routine primary care. Instead of splitting P75 and F45.3-9 diagnoses, it is proposed that the whole MUS spectrum should be conceptualized as a continuum model comprising categorizations of uncomplicated (mild) and complicated (moderate and severe) courses. Psychosocial factors require more attention.

[Involvement of doctors' assistants in primary care for patients with long-term conditions. General practitioners' (GPs) perception of barriers and opportunities--a qualitative study]. / Einbeziehung nichtärztlicher Gesundheitsberufe in die Primärversorgung chronisch kranker Patienten: Chancen und Barrieren aus Sicht deutscher Hausärzte.

BACKGROUND AND PURPOSE: Care for patients with multiple and chronic diseases is an increasing challenge. The particular demands of chronically ill patients increase the complexity of primary care. Involvement of doctors' assistants is discussed as part of comprehensive frameworks for structured care like the Chronic Care Model (CCM). The aim of this qualitative study was to reveal perceived barriers and opportunities among German general practitioners (GPs) according to the involvement of their assistants in patient care. METHODS: 14 GPs were interviewed. The documents were evaluated analytically according to their content. RESULTS: Most GPs have a positive point of view with regard to the integration of their assistants. They claim a task-oriented training for the assistants as a precondition. Their working experience, an established patient-assistant relationship and the preparedness to take own responsibility in patient care are stated as supporting factors for the involvement of doctors' assistants in patient care. Main barrier seems to be a lack of time for additional work of their employees. CONCLUSION: There is a need for task-oriented training, in order to professionalize practice teams. Remarkably, this new approach to chronic care is already integrated into routine care. However, it seems to suit only for some distinct diseases, selected patients and a limited number of doctors' assistants. As part of further professionalization an evaluation of a new job profile for doctors' assistants should be discussed.