[The use of benzodiazepines and Z-drugs for patients with sleeping problems - A survey among hospital doctors and nurses]. / Benzodiazepine und Z-Substanzen als Schlaf- und Beruhigungsmittel in einem Krankenhaus.

Aim | Benzodiazepines and Z-drugs are frequently prescribed sleep medications in spite of their poor risk-benefit ratio when used over a longer period of time. The aim of the study was to find out how the medical and nursing staff in a general hospital estimated the frequency of use for these drugs, and the risk-benefit ratio for elderly patients as well as the factors which positively influence the perceived use of these drugs. Methods | All members of the medical and nursing staff of a hospital received a questionnaire about their use of, and attitudes towards, benzodiazepines and Z-drugs. Absolute and relative frequencies were calculated to estimate the perceived frequency of use and the risk-benefit ratio. Multiple logistic regressions were used to analyze which factors are associated with a perceived high use of benzodiazepines or Z-drugs for insomnia. Results | More nurses than hospital doctors believed that they dispensed benzodiazepines often or always (57 % vs. 29 %) to patients with insomnia; this was also the case for Z-drugs (66 % vs. 29 %). Nearly half of the hospital doctors and 29 % of the nurses perceived more harms than benefits for benzodiazepines in the elderly. The following factors were associated with a high perceived usage of Z-drugs: working as a nurse (OR: 13,95; 95%-CI: 3,87-50,28), working in a non-surgical department (5,41; 2,00-14,61), having < 5 years of professional experience (4,90; 1,43-16,81) and feeling that the benefits of Z-drugs outweigh the risks for elderly patients (5,07; 1,48-17,35). For benzodiazepines, only the perceived positive risk-benefit ratio had an influence on the perceived use (3,35; 1,28-8.79). Conclusion | The medical and nursing staff perceived the frequency of prescription of benzodiazepines and Z-drugs and the risk-benefit ratio in different ways. Other aspects, such as working in a non-surgical department or having a smaller amount of working experience may also influence the decision to use Z-drugs.

[What it means for patients to have their illness experiences published in the Internet]. / Wie erleben Patienten die Veröffentlichung ihrer Krankheitserfahrungen im Internet?

Aim of the study was to explore meaning and consequences for patients for having their illness experiences published in the internet. Patients who participated in the establishment of a research-based internet website on illness experiences were interviewed about their experiences of taking part in the project. 14 patients with diabetes and 29 patients with chronic pain participated in the follow-up. They were interviewed with an open narrative and semi-structured approach about their motives and experiences of taking part in the project and the impact of the publication on them. Interview transcripts were coded and aggregated in a computer-assisted thematic analysis. Patients unanimously evaluated their participation positively. Many of them reported that it had been an intense and relevant experience, which equalled an intervention. They conveyed that the special effort of the researchers to establish a trustful and caring relationship had proven of value and led to a high identification of the participants with the aims of the website.

Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care.

Background: Inappropriate prescriptions of proton pump inhibitors (PPI) in hospital and primary care have been widely reported. Recommendations from hospital have been implicated as one reason for inappropriate prescriptions of PPI in primary care. Objective: To quantify the amount of appropriate PPI recommendations in hospital discharge letters and the influence of these recommendations on general practitioners' (GPs') PPI-prescriptions. Materials and Methods: This is an observational study in 31 primary care practices. We identified patients discharged from hospital with PPI recommendation between 2006 and 2007 and assessed practice records and PPI prescription six months prior and after hospital admission. Hospital recommendation for continuous PPI-treatment and continuation by GPs was classified as appropriate, inappropriate or uncertain. Logistic regression analysis was used to calculate factors associated with indicated and non-indicated PPI continuation. Results: In 263 (58%) out of 506 patients discharged from 35 hospitals with a PPI recommendation no indication could be found. Non-indicated PPIs were continued by GPs in 58% for at least 1 month. Indicated PPIs were discontinued in 33%. Two thirds of non-indicated PPIs were initiated in hospital. The strongest factor associated with non-indicated continuation was a PPI-prescription prior to hospital admission [OR: 3.0; 95% confidence interval (CI): 1.7-5.4]. This was also the strongest factor for continuation of an indicated PPI medication (OR: 3.2; 95% CI: 1.4-7.5). Conclusions: We found a strong influence of hospital recommendations and previous prescriptions on PPI prescriptions after discharge. Hospitals should critically review their practice of recommending PPI and document indications. GPs should carefully assess hospital recommendations and their medication prior to admission to avoid over- and under-prescribing.

[Relation between defined daily doses (DDD) and prescribed daily doses: a 3-month analysis of outpatient data from a statutory health insurance company]. / Inwieweit bilden definierte Tagesdosen (DDD) die tatsächlich verordneten Tagesdosen ab? Eine Analyse ambulanter Verordnungsdaten.

AIM: Defined daily doses (DDD) are used to analyse drug utilisation. For frequently prescribed drug groups, we studied to what extent the DDD correspond to the average prescribed daily doses (PDD). METHODS: We analysed all drugs prescribed for more than three months to insured of a large health insurance fund in Mecklenburg-Vorpommern, one federal state in Germany. PDD for plain ACE inhibitors, selective beta-antagonists and some antidiabetics (sulfonylurea compounds) were calculated and compared with their DDD. RESULTS: During the study period, about 38 500 patients received continuous prescriptions of each ACE inhibitors or selective beta-antagonists, and about 9 000 of sulfonylurea compounds. PDD differed from DDD in varying degrees. For ACE inhibitors, PDD ranged between 1.5 DDD (for captopril) and 3.5 (for ramipril). The PDD for beta antagonists were on average 0.9 DDD, similar for bisoprolol (0.8 DDD) and metoprolol (0.9 DDD). As for oral antidiabetics, doctors prescribed 1.0 DDD glibenclamid per day and patient and 2.0 DDD glimepirid. Depending on differences between DDD and PDD, real daily costs for drug therapy differed from the theoretical costs per DDD, for example in the case of ramipril they were 0.24 euros compared to 0.07 euros. CONCLUSION: The PDD were much higher than the DDD for several frequently prescribed drugs. Consequently, the daily drug costs exceeded the drug costs based on DDD. Evaluations of drug costs on the basis for DDD require careful interpretation. Moreover, the number of DDD alone is not a valid measurement for the appropriateness of drug therapy and can only give a rough estimate of the number of patients treated, at least for the drug groups in this study.

[What questions do headache patients pose in the internet? Content analysis of an internet expert forum]. / Mit welchen Fragen gehen Kopfschmerzpatienten ins Internet? Inhaltsanalyse eines Web-Expertenrates.

BACKGROUND: Most episodes of headache are not presented to doctors but are treated by self-management. Especially in these cases, the Internet has become an increasingly important source of health-care information. The aim of this study was to investigate the questions and needs of persons who sought help for their headache in an internet expert forum. METHODS: Using a content analysis approach, we analysed all questions sent to an internet expert forum for migraine and headache ( www.lifeline.de ). RESULTS: We analysed a total of 835 questions sent from April 2002 until April 2006. The majority of questions (85%) came from women. Most often the visitors asked questions about symptoms (32.2%, n=269), drugs or therapies (32.0%) and psychosocial problems (20%). Few visitors (45/835) complained about their doctors. Some of these were dissatisfied with their therapy and/or the effect and possible side effects of their prescribed drugs. In 19 questions we detected communication problems in former consultations with their doctors. CONCLUSION: Visitors of an expert forum for migraine and headache had questions about symptoms and their interpretation as well as drugs and therapies. Dissatisfaction with current treatment motivated only few patients to turn to the Internet. For most visitors the expert forum is obviously not an alternative but a supplement to professional care.

[Health-related quality of life in asthma patients from general practice]. / Gesundheitsbezogene Lebensqualität bei Asthmapatienten in der Hausarztpraxis.

OBJECTIVE: This study investigates health-related quality of life in asthma patients from general practices in comparison with a general population sample. It further examines the association between health-related quality of life, socio-demographic characteristics and smoking behaviour. PATIENTS AND METHODS: 838 asthma patients with a mean age of 47.8 +/- 16.3 years AND 66 % female participants from 83 general practices in the region of Göttingen and Freiburg/Germany completed the St. George's Respiratory Questionnaire (SGRQ), an instrument to assess health-related quality of life, and they completed questions on socio-demographic variables and smoking behaviour. SGRQ values were compared with estimates for the general population generated in Spain. The association between SGRQ and socio-demographic characteristics and smoking behaviour was analysed by multivariate linear regression models. RESULTS: The SGRQ total values for asthma patients were three times higher than in the general population sample corresponding to a higher level of restrictions in quality of life. Both in the general population sample and in asthma patients non-smokers had a better health-related quality of life than smokers, especially with respect to respiratory symptoms. In the multivariate analysis, socio-demographic characteristics and smoking behaviour were differently related to health-related quality of life. In smokers, the level of impairment by asthma symptoms was the higher the more they had smoked. Impairment in daily activities increased with increasing age and decreasing professional status. Increasing psycho-social restrictions were associated with higher age and lower educational level. CONCLUSION: Assessing health-related quality of life in its different dimensions enables the general practitioner to conclude on the individual impairment caused by the disease. This facilitates targeted therapeutic interventions. Results from this study underline once more that quality of life should be integrated as an additional clinical parameter in population-based analyses of health care use.

[Communication and exchange of clinical findings for low back pain between general practitioners and orthopaedic surgeons: a retrospective observational study]. / Kommunikation und Befundaustausch zwischen Hausärzten und Orthopäden bei Rückenschmerzen: Eine retrospektive Beobachtungsstudie.

INTRODUCTION: Low back pain is a frequent reason for consultation in general practice. Many patients are treated in cooperation with an orthopaedic surgeon which requires an effective exchange of information. The aim of this study was to investigate the level of communication between general practitioners (GPs) and orthopaedic surgeons. MATERIAL AND METHODS: In this retrospective observational study referrals from GPs and corresponding response letters from orthopaedic surgeons were analyzed. GPs were asked to provide reasons for referral and to rate the quality of the response letters. RESULTS: A total of 12 out of 82 GPs from the teaching network of the Medical School of Göttingen participated in the study. Of 911 referrals to ambulatory orthopaedic surgeons within 3 months, 34% (n=312) were referred for low back pain. GPs provided little information beyond a diagnosis on the referral contrary to their self-perception. Most referrals (61%) were initiated by patients and most of them were considered at risk for chronification (72%) by the referring GP. Despite a formal obligation to report back, GPs received a response letter for only one-third (114/312) of the patients. GPs rated most of them as satisfactory, however, 59% were unsatisfied with the treatment recommendations. Only 10% of the letters contained psychosocial details. The information provided in the orthopaedic response letters was heterogeneous and only partly fulfilled the criteria set by the Interdisciplinary Society for Orthopaedic Pain Management. CONCLUSION: Incomplete and scant information on referral forms from GPs and a high non-response rate from orthopaedic surgeons suggest that current health care system and referral forms do not promote effective communication about the patient. This might explain the satisfaction of GPs with the orthopaedic response letters despite the lack of information. The GPs dissatisfaction with the treatment recommendations reflects the limited treatment options for chronic low back pain in ambulatory care.

Preconception sex selection: a survey of visitors to an internet-based health forum.

The aim of this survey was to explore the attitudes towards gender selection, focusing on people who were affected by infertility and also familiar with advanced technologies such as the internet. A questionnaire was posted on a German internet site targeting infertile people with a wish for a first or another child. Nearly all respondents (736/742) were female. Most respondents (82.7%) were firmly against sex selection if the techniques used would require several treatment cycles and corresponding costs for the couple. Even if, hypothetically, sex selection could be achieved by simply taking a 'pink' or 'blue' pill before intercourse, only 19% would take this option. More respondents had some interest, if any, in conceiving a girl as first child or next child (27% girl versus 11% boy). A positive attitude towards sex selection was more likely if the respondents had a preference for either a boy or a girl (odds ratio [OR] = 12.8, P < 0.01) and, or had an unbalanced family (OR = 1.8, P = 0.03). Although this survey is based almost exclusively on answers from women, it seems reasonable to conclude that a widely available service for preconception sex selection for non-medical reasons would not cause a severe gender imbalance in Germany.

[How well do primary care patients assess the time needed for a consultation in general medical practice?]. / Wie gut schätzen Hausarzt-Patienten den Zeitbedarf einer Konsultation ein?

OBJECTIVE: This study explored the association between the anticipated and the actual amount of time spent in consultation in a general medical practice and the possible consequences for patient satisfaction. PATIENTS AND METHODS: A total of 95 patients (mean age: 42.4; 55.8 % females) from one general practice were asked before their consultation how much time they anticipated spending with the (53-year-old) doctor. Answers were categorized as "overestimate", "accurate" or "underestimate". At the end of the consultation, patient satisfaction was documented by the patient filling in a standardized questionnaire. Associations between the actual duration of the consultation and the accuracy of the patients' estimate of the time of consultation, patient satisfaction and recorded possible explanatory variables (e.g., sex, age, psychosomatic problems) were analysed by multiple logistic regression. RESULTS: Half of the patients (48/95) estimated that the consultation would last longer than it actually did. In contrast, significantly more patients with psychosomatic problems underestimated consultation length (38% vs. 10%; adjusted odds ratio = 6.9; 95% confidence interval = 1.9 to 24.3). The actual length of the consultation and patient satisfaction moderately correlated (Spearmans's rho correlation = 0.24 [p = 0.02]). If the length of consultation was shorter than expected, patients were somewhat more dissatisfied. CONCLUSION: Only about one-third of patients could accurately gauge ahead of time how long the consultation was going to take. Patients with psychosomatic or severe psychosocial problems took up the largest proportion of the doctor's time, but they significantly underestimated the time the doctor would actually spend with them. Both the predicted estimates of the duration and the actual time spent in consultation seem to influence to some extent patient satisfaction regarding the time spent with the doctor.

German primary care doctors' awareness of osteoporosis and knowledge of national guidelines.

AIMS: With the aging of populations in industrialized countries, managing osteoporosis in the primary care setting becomes increasingly important. General practitioners (GPs) are in an ideal position to identify and manage patients who are at an increased risk of osteoporosis and fracture. In a cross-sectional survey we studied whether German GPs (1) are aware of osteoporosis as an urgent health problem, (2) felt competent to manage patients with osteoporosis, (3) knew and used the national guideline for osteoporosis treatment and if not, (4) which barriers prevented them from doing so. PARTICIPANTS AND METHODS: A representative random sample of German GPs were sent a 30-item standardized questionnaire by mail. Chi-square statistics and multiple logistic regression were used to detect associations between knowledge of guidelines and explanatory variables. RESULTS: Of 2,194 doctors addressed, 892 (41.1%) answered the questionnaire. The majority of doctors (82.7%) felt competent in osteoporosis management (95% confidence interval: 80.2 - 85.2) and only 11.2% (8.2 - 13.1) did not consider osteoporosis an important problem in their practice. About half (459/892) reported knowing the national osteoporosis guideline well (51.7%; 48.4 - 55.0), whereas 22.6% (19.9 - 25.4) admitted to not being familiar with it at all. Knowledge of the guideline was positively associated with being a female doctor (OR=1.36; 1.01-1.85), having Internet access (OR=1.40, 1.06 - 1.85), seeing institutionalized patients (OR=1.67; 1.03 -2.69), and caring for patients with osteoporosis at a higher frequency (OR=2.60; 1.93 - 3.50). Nearly 43% (39.7 - 46.2) used the guideline in their practice without problems. In free-text fields, GPs reported most frequently that budgetary restrictions preventing the prescription of appropriate medication represented a severe problem for osteoporosis management. CONCLUSION: Although most GPs are aware of osteoporosis as an important health problem and felt competent in the management of this disease, only half of the respondents knew and used the national guideline. This may explain deficits in diagnosis and therapy of osteoporosis in Germany. Since guideline knowledge and frequency of consultations for osteoporosis strongly correlate, proper dissemination of the guideline may further enhance awareness of, and evidence-based treatment for, osteoporosis.

[Health services research in general practice. A new approach]. / Medizinische Versorgung in der hausärztlichen Praxis. Ein neuer Forschungsansatz.

Competence networks in medicine, involving departments of general practice (www.kompetenznetze-medizin.de), as well as a large research support program "General Practice" funded by the German Federal Ministry of Education and Research (www.gesundheitsforschung-bmbf.de/de/439.php) mirror the increasing importance of academic general practice for health services research. The use and benefit of computerized medical records is exemplified by the classification of therapeutic measures and prevalence estimates of diseases. Computerized medical records from 134 practices could be extracted via the BDT (BehandlungsDatenTräger) interface. Using SQL (structured query language) queries, we identified patients with urinary tract infection (UTI), airway obstruction and chronic heart failure and the therapeutic management for these illnesses. Age and sex of the patients were nearly completely documented in the BDT data. Patients with UTI (6,239 consultations) received most often cotrimoxazole (69%) and fluoroquinolone (15%), less often trimethoprim (9%) and herbal UTI drugs (4%). About half of the 2,714 patients with asthma received inhaled steroids, to a somewhat lesser degree than patients suffering from chronic obstructive pulmonary disease (50 vs 53%). In a subsample of practices (n=44), we identified 4,120 patients with a diagnosis of chronic heart failure. Using refined analysis tools, computerized medical records from general practices may be helpful to answer relevant questions of health services research and contribute to quality assurance in ambulatory patient care.

What do primary care patients think about generic drugs?

OBJECTIVE: To examine the attitude of patients towards generic drugs and prescriptions containing generic drugs as an alternative to brand-name products, with a special focus on information on patients attitude to generic drugs provided by their general practitioners (GPs). METHODS: A total of 804 patients in 31 general practices were surveyed using a self-questionnaire. The influence of age, sex, education, disease, knowledge of generic drugs, experience with generic substitution and information provided by the GP on patient attitudes towards generic drugs and substitutions were examined. RESULTS: Nearly two thirds of the patients (509/804) stated that they knew of the difference between brand-name drugs and generics; of these, one third were not satisfied with the information given by their GPs and 37% of patients expressed general skepticism towards generic drugs because of their lower price. This attitude was more frequent among those who felt that generic prescribing was "invented" to solve the financial crisis in the German health insurance system at their expense (odds ratio (OR): 6.2; 95% confidence interval: 4.0 - 9.8) and those who had not been confronted personally with a generic substitution (OR: 1.8; 1.3 3.0). Patients who had been skeptical when first confronted with a generic substitution were more frequently among those who considered inexpensive drugs to be inferior (OR: 4.5; 2.0 10.4) and they were frequently not satisfied with the information on substitution provided by their GP (OR: 2.7; 1.2 - 5.9). CONCLUSION: GPs are in an ideal position to inform their patients adequately about the equivalence of brand-name and generic drugs. However, the patient view that inexpensive drugs must be inferior may be difficult to rectify in the short term.

[Reproductive medicine in Germany--peculiarities and dilemmas]. / Reproduktionsmedizin in Deutschland -- Besonderheiten und Dilemmata.

BACKGROUND: Technological progress, as well as increasing success, of reproductive medicine may lower the threshold for childless couples to initiate infertility therapy. However this development may aggravate unsolved problems (e. g. multiple births) and may not increase the pregnancy rate, due to the present unsatisfactory legal situation in Germany (e. g. ban on selective blastocyst culture). METHODS: Based on a systematic review of the literature, we studied actual problems of German reproductive medicine under three public health-related topics: (1) the decline in population in Germany, (2) criteria for success in reproductive medicine and (3) new treatment options in the light of legal and ethical aspects. RESULTS: In Germany (and other industrial nations), reproductive medicine has emerged parallel to an ever-increasing rate of childlessness. Today, 2 % of all births result from treatments using the techniques of reproductive medicine. Nevertheless, the actual extent of involuntary childlessness is lower (below 8 %) than commonly suggested (between 10 and 15 %). Frequently, the success of treatment depends upon a series of treatment cycles and is, especially in Germany, accompanied by a high rate of multiple births (more than 30 %). Hence, a more adequate success rate may be the healthy, i. e., term, singleton baby. The use of selective blastocyst culture, currently not permitted in Germany, could further improve therapy or, at least, reduce patient stress and discomfort. CONCLUSION: Reproductive medicine, as seen from a public health perspective, needs to pursue patient-oriented requirements more in-depth. An open discussion of new technologies which could improve reproductive health but are at present not permitted, would be imperative.

[Pharmacogenetics in future medical care -- implications for patients and physicians]. / Pharmakogenetische Tests in der zukünftigen medizinischen Versorgung: Implikationen für Patienten und Arzte.

PURPOSE: Since public acceptance of pharmacogenetic testing will largely influence their implementation in routine medical care, common implications of pharmacogenetic testing from patients', physicians' and scientists' perspective are reviewed. METHODS: Broad literature review (MEDLINE; MeSH terms: Pharmacogenetics, Delivery of Health Care, Ethics, Attitude, Patient Acceptance of Health Care) of empirical and theoretical studies describing psychological, family-related, social, and ethical consequences of pharmacogenetic testing to describe relevant aspects for further empirical studies. RESULTS: Apart from anticipated benefit, acceptance of pharmacogenetic testing might be influenced by the following: Expectation of negative psychosocial consequences, fear of discrimination or violation of privacy. Due to its great complexity, understanding of test results and explanation of their impact pose new challenges for physician-patient relations. Since most studies are conceptual, empirical studies exploring attitudes of patients/physicians and determining medical as well as economic value of pharmacogenetic testing are imperative.

[Modular training in practical medicine: electronic evaluation of student education in general practice]. / Blockpraktikum Allgemeinmedizin: Elektronische Evaluation des studentischen Unterrichts in Allgemeinpraxen.

Effective from spring 2004, new regulations for undergraduate medical education in Germany require a two-week practical training in general practice. Similar to other forms of medical education, this practical training should be regularly evaluated by students. With regard to special conditions of the training, we preferred a web based evaluation. Since adequate models were not available, we designed, implemented and tested an electronic way of evaluation. The following aspects turned out to be of special importance: teamwork, time, data protection and cost. Meanwhile, the evaluation is established and still accessible as demo-version for visitors of the home page. This electronic evaluation of medical training in general practice is highly appropriate for a timely evaluation allowing us to obtain a comparison between students' expectations and actual experience as well as a continuous supervision and to provide feedback to the participating practices. This is an important step for quality assurance of medical education in practices inside and outside the university.

Drug changes at the interface between primary and secondary care.

OBJECTIVE: To analyze the frequency and factors associated with drug change in a sample of patients referred to hospital by their general practitioner. METHODS: This observational study is based on a chart review of 100 consecutively recruited patients with a chronic disease who were referred to the general internal medicine wards in each of 3 district general hospitals in Germany (total 300 patients). The frequency of drug cancellation, replacement, dosage alteration, change in manufacturer and of commencing treatment with a new drug were recorded. RESULTS: Half of the drugs used in chronic treatment (644/1,330) and prescribed by general practitioners were continued during hospitalization. The fraction canceled was 36%. In the rest of the drugs in this group, there were some minor changes carried out by the hospital. On the day of the drug survey, a total of 1,572 drugs were being taken by the patients and 724 of these drugs were newly prescribed by hospital. Only 13 patients experienced no change to their drug regimen during their stay in hospital. In more than 60% of patients (184/300), there were 3 or more changes made in their drug regimen. The rate of drug cancellation for antihypertensive and cardiac drugs in patients referred to hospital for cardiovascular and non-cardiovascular problems did not differ. CONCLUSION: During hospitalization, nearly every patient is confronted with some form of drug change. Of major concern is the high rate of drug change affecting drugs being taken for diseases other than that associated with the hospitalization. Hospital drug policy should encourage clinicians to continue drug regimens in newly admitted patients whenever medically appropriate and caution clinicians against making unnecessary changes to drug regimens prescribed by general practitioners.

Sexual problems of male patients in family practice.

OBJECTIVES: Little is known about men's expectations of their family physicians regarding sexual disorders. Our goal was to evaluate the frequency of sexual problems among male patients in family practice and to assess their need for help. STUDY DESIGN: We performed a cross-sectional survey based on structured questionnaires answered by patients and physicians in German family practices. POPULATION: We approached 43 family physicians; 20 (43%) participated. On a single day all men 18 years and older visiting the participating practices were approached, and 307 (84%) took part in the survey. OUTCOMES MEASURED: Patients were asked about their frequency and type of sexual problems, their need for help, and their expectations of their physicians. The physicians described their perceptions and management of sexual problems in family practice. RESULTS: Nearly all patients (93%) reported at least 1 sexual problem from which they suffered seldom or more often. The most common problems were low sexual desire (73%) and premature ejaculation (66%). Occupational stress was considered causative by more than half of the men (107/201). Forty-eight percent considered it important to talk with their physicians about sexual concerns. However, most physicians initiated a discussion about sexual concerns only seldom or occasionally. There was a nonsignificant correlation between the physicians' assumed knowledge and the patients' wish to contact them in case of sexual problems (rho=0.26). CONCLUSIONS: The high frequency of self-reported sexual disorders and the hesitancy of family physicians to deal with this topic signals a neglected area in primary health care. Certain conditions, such as occupational stress, which may be associated with sexual concerns, should encourage the physician to initiate discussions about sexuality.

[Subject health concepts and health-related quality of life--is there a correlation?]. / Subjektive Gesundheitskonzepte und gesundheitsbezogene Lebensqualität--Gibt es einen Zusammenhang?

OBJECTIVES: The aim of this study was to explore associations between lay concepts of health, quality of life and the health-related evaluation of daily activities. METHODS: A total of 221 persons (patients from general practice and adult as well as young members of sporting clubs) participated in the study (response rate: 84%). RESULTS: Health was often defined as "highest value of life"; "normal functioning of body and soul" and "complete well-being". Many persons considered sports, sleeping and leisure time being highly important for their health. The single dimensions of quality of life were associated with some health-related evaluations of daily activities, e.g., bodily functioning and health-related evaluation of television. Dividing the sample into persons who did or did not consider a certain concept of health (e.g., well-being) to be highly important had the following consequences: The quality of life was associated with different evaluations of daily activities in different strata; this association was sometimes negative, sometimes positive in different strata; more variance was explained by dividing the sample into different strata. CONCLUSIONS: The often contradictory associations between evaluation of everyday activities, lay concepts of health and quality of life should warn us not to think of health concepts and health actions in form of linear relations. Rather, health promotion should be more stronger oriented towards the individual's life conditions and his or her attitude to health.

The predictive value of asthma medications to identify individuals with asthma--a study in German general practices.

BACKGROUND: The assessment of prescribing performance by aggregated measures mainly developed from automated databases is often helpful for general practitioners. For asthma treatment, the frequently applied ratio of anti-inflammatory to bronchodilator drugs may, however, be misleading if the specificity of a drug for the treatment of asthma, compared with other diseases, is unknown. AIM: To test the association of specific drugs with the diagnosis of asthma compared with other diagnoses. DESIGN OF STUDY: Cross-sectional study analysing prescription data from a retrospective chart review. SETTING: Eight general practices and one community respiratory practice in a town in Northern Germany. METHOD: All patients in the participating practices who received at least one of the 50 asthma drugs most frequently prescribed in Germany within the past 12 weeks were identified. Odds ratios (ORs) with 95% confidence intervals (ClI) were calculated to reveal any association between a specific drug and the diagnosis of asthma. The unit of analysis was the item prescribed. RESULTS: Topical betamimetics (e.g salbutamol, fenoterol) were the most often prescribed asthma drugs in the general practices (52.1 ) and in the respiratory practice (57.6%). Inhaled steroids accounted for 15% and 13%; systemic steroids accounted for 10% and 13%, respectively. In the general practices, inhaled betamimetics had a moderate marker function for asthma (OR = 2.0; 95% CI = 1.14-3.58). A fixed oral combination drug of clenbuterol plus ambroxol was a marker drug against asthma (OR = 0.35; 95% CI = 0.20-0.61). In the respiratory practice, the diagnosis of asthma was strongly marked by fixed combinations of cromoglycate plus betamimetics (OR = 29.0; 95% CI = 6.86-122.24) and moderately by inhaled betamimetics (OR = 2.6; 95% CI = 1.28-5.14). In contrast, systemic steroids (OR = 0.24; 95% CI 0.10-0.57) and even inhaled steroids (OR = 0.46; 95% ClI= 0.22-0.96) proved to contradict the diagnosis of asthma. CONCLUSION: Only betamimetics were markers for asthma patients in both types of practices; inhaled steroids, however, were not. Combinations of cromoglycate were markers in the respiratory practice only. Limited specificity of drugs for a disease (e.g asthma) should be taken into account when analysing prescribing data that are not diagnosis linked.

Will German patients accept their family physician as a gatekeeper?

OBJECTIVE: Looking to the experience in the United States with managed care and the possible introduction of gatekeeping in the near future in Germany, we performed a population-based survey to examine preferences for future gatekeeping arrangements. DESIGN: Cross-sectional telephone survey. SETTING: Four health districts in Thuringia (formerly East Germany) and Lower Saxony (formerly West Germany). PARTICIPANTS: Out of a random sample of 644 adults in the 4 districts, 415 persons (64.4%) took part in the survey. MEASUREMENTS AND MAIN RESULTS: Using multiple logistic regression, we analyzed associations between preferences for gatekeeping arrangements and patient satisfaction, insurance status, and sociodemographic characteristics. Seventy-four percent of respondents valued first-contact care, especially older people (odds ratio [OR], 4.3; 95% confidence interval [95% CI], 2.0 to 9.3), people who were very satisfied with the relationship with their family physician (OR, 2.7; 95% CI, 1.6 to 4.8) and members of sickness funds in contrast to privately insured persons (OR, 2.4; 95% CI, 1.2 to 5.2). The family physician's influence in coordinating the use of specialist services was appreciated by 86%, more often by members of sickness funds (OR, 5.9; 95% CI, 2.4 to 14. 3), people who were very satisfied with their doctor's professional competence (OR, 3.2; 95% CI, 1.6 to 6.3) and older persons (OR, 2.9; 95% CI, 1.1 to 7.7). CONCLUSIONS: A vast majority of the German population would accept their family physician as entry point and as coordinator of all other health services. Since patient satisfaction, among other reasons, strongly influenced preferences for gatekeeper arrangements, family physicians themselves may be able to promote primary care health services.