Changes in drug therapy following hospital discharge for patients in a general practice: a German incident study

Objective: In primary care, clinically recommended drug medication is often modified after hospitalization. The aim of the study was to examine the frequency and factors associated with GPs changing the hospital drug treatment in a sample of patients discharged from the hospital. Methods: In a prospective study, the prehospital, hospital and posthospital diagnoses and drug treatment of 130 patients consecutively recruited from 15 general practices were recorded over a period of 12 months. The ICD-10 classification was used to compare the data from hospitals and general practices. GPs who changed the hospital drug treatment were interviewed in a semistructured way concerning their reasons for changing. Results: The most frequent diagnoses during and after hospitalization were listed in the ICD-10 chapters ‘Diseases of the cardiovascular system’ (34.3%) and ‘Endocrine, nutritional and metabolic diseases’ (18%). Accordingly, the most frequently prescribed drug medication was related to these chapters (47.5% and 15.9%, respectively). Hospitalization led to a significant increase in the number of drugs per patient [prehospital 5.4; hospital 6.6; posthospital 6.7; (p < 0.001)]. GPs changed the hospital drug recommendations of the discharge letters in 60.7% of the cases. They omitted drugs in 27.6%, replaced prehospital drug medication in 26.3%, changed to other manufacturers in 9.3%, added new drugs in 13.1% and changed the dosage in 4.2% of the cases. Changes in drug medication correlated significantly with the number of drugs and number of diagnoses (p < 0.001). The most frequently mentioned reason for drug changing by GPs was cost savings (30.3%). But more often they changed drug medication for patient-related reasons (42.4%): 'better individual drug effect' in 18.5%, 'no reasonable indication' in 17.1% and 'not related to adequate diagnosis' in 6.8% of the cases. Conclusion: After hospital discharge, GPs changed more than half of posthospital drug recommendations. Although they believed that economical aspects were the most important reason for their behavior, most drug changes were done for patient-related reasons

Correlation between patient quality of life in palliative care and burden of their family caregivers: a prospective observational cohort study

Background: Family caregivers play a key role in palliative care at home, and understanding the interdependencies in the constellation of patient, family caregivers and service providers is important. As few longitudinal studies have examined the influence of patient quality of life (QoL) in palliative care on burden of family caregivers, the aim of this study was to identify correlations between changing patient QoL and changing burden of family caregivers that need consideration in patient management. Methods: Palliative patients with cancer in primary care evaluated their QoL (Quality of Life Questionnaire Core 15 Palliative Care, QLQ-C15-PAL). They were assessed monthly for an interval of 6 months or until death of the patient. Family caregivers reported the burden they perceived while supporting the patient (Short form of the Burden Scale for Family Caregivers, BSFC). Longitudinal data were analysed for all patients with at least 3 available assessments, considering the most recent data for participants with more than 3 assessments. Changes in patient QoL were analysed using the Friedman test. In a stepwise regression analysis, influences of change in patient QoL on changing caregiver burden were investigated. Results: One hundred patients (63 men, 37 women; average age: 68 years) were enrolled in the study. The most common primary diagnoses were colon, lung or breast cancer. In 58 cases, assessments were available from both patients and caregivers. Patients reported overall quality of life increasing towards end of life, although reporting that physical functioning deteriorated. Symptoms of pain and fatigue bothered patients most. Caregiver burden was moderate and on average did not change over time. In a stepwise regression model, the difference in emotional functioning and the difference in dyspnoea showed an influence on the development of caregiver burden (explained variance of 19.3 %). Conclusions: Patients’ dyspnoea, feelings of depression and anxiety impacted on the perceived burden of family caregivers, but are manageable symptoms. Our results corroborate the need of regular assessment of patients’ needs taking into account caregiver burden. In this way, general practice teams can intervene early and may more likely meet patients’ needs in the end of life care process. Trial registration: Current Controlled Trials ISRCTN78021852, assigned on 04/04/200

Beurteilung des Therapieerfolgs – konventionelle versus neue Methoden

New ways of evaluating treatment success among thoracic tumour patients are increasingly being used alongside more conventional methods. These new approaches include tumour regression grading, CAD volumetry (computer-assisted volumetry), determination of the tumour density and tumour perfusion as well as the use of positron emission tomography (PET) using (18)F-FDG (fluorodeoxyglucose) or other tracers. Increasingly, endpoints that impact directly on the patient's quality of life and tumour-related symptoms are becoming more relevant factors together with the objectively measurable parameters used for assessing treatment response. This contribution describes the potential value of new methods and end-points from the point of view of a pathologist, radiologist, nuclear medicine specialist, radiotherapist, thoracic surgeon, medical and pneumology oncologist, and general practitioner

Erratum to: Out of hours care in Germany - High utilization by adult patients with minor ailments?

Background: Family practitioners (FPs) who work in Out-Of-Hours Care (OOHC) - especially in rural areas – complain about high workload related to low urgency and potentially unnecessary patient presentations with minor ailments. The aim of this study was to describe Reasons for Encounter (RFEs) in primary OOHC taken into account the doctor’s perspective in the context of high workload without knowing patients’ motives for visiting an OOHC-centre. Methods: Within this descriptive study, OOHC data from 2012 were evaluated from a German statutory health insurance company in the federal state of Baden-Wuerttemberg. 1.53 Million of the 10.5 Million inhabitants of Baden-Wuerttemberg were covered. The frequency of the ICD-10 diagnoses was determined at the three- and four-digit-level. The rate of hospitalizations was used to estimate the severity of the evaluated cases. Results: Taken as a whole, 163,711 reasons for encounter with 1,174 ICD-10 single diagnoses were documented, of these 62.2% were on weekends. Less than 5.0% of the examined patients were hospitalized. Low back pain-dorsalgia (M54) was the most common diagnosis in OOHC, with 10,843 cases. Injuries were found twelve times in the list of the 30 most frequent diagnoses. The most frequent infectious disease was acute upper respiratory infection of multiple and unspecified sites (J06). By analysing the ICD codes to four-digits and looking at the rate of hospitalizations, it can be assumed that many RFEs were of less urgency in terms of the prompt need for medical treatment. Conclusion: While it is acknowledged that it can be difficult to make an exact diagnosis in an OOHC setting, after analysing the ICD-10 diagnoses, the majority of reasons for encounter in OOHC were determined to be of low urgency, meaning that patients could have waited until regular consultation hours. In the OOHC setting, it is important to understand RFEs from both the patient perspective and the family practitioner perspective. Additionally, results like these can be used in staff education especially improving triage methods and medical recommendations and in developing specific guidelines for OOHC in Germany. Analysis of routine data, such as in this study, contributes to this understanding and contributes to resolving problems of coding

Train the Trainer for general practice trainer - a report of the pilot within the programme Verbundweiterbildungplus

Background: Since 2008 the Verbundweiterbildungplus programme of the Competence Centre General Practice Baden-Wuerttemberg offers continual improvement with regards to content and structure of general practice training. The programme uses the didactical concept of the CanMEDs competencies, which were developed in Canada, as a postgraduate medical training framework. Train the trainer (TTT)-programmes are an additional important element of these contentual optimisations of postgraduate training. Within this article we describe the conception and evaluation of the first TTT-workshop within the programme Verbundweiterbildungplus

The PAMINO-project: evaluating a primary care-based educational program to improve the quality of life of palliative patients

<p>Abstract</p> <p>Background</p> <p>The care of palliative patients challenges the health care system in both quantity and quality. Especially the role of primary care givers needs to be strengthened to provide them with the knowledge and the confidence of applying an appropriate end-of-life care to palliative patients. To improve health care services for palliative patients in primary care, interested physicians in and around Heidelberg, Germany, are enabled to participate in the community-based program 'Palliative Medical Initiative North Baden (PAMINO)' to improve their knowledge in dealing with palliative patients. The impact of this program on patients' health and quality of life remains to be evaluated.</p> <p>Methods/Design</p> <p>The evaluation of PAMINO is a non-randomized, controlled study. Out of the group of primary care physicians who took part in the PAMINO program, a sample of 45 physicians and their palliative patients will be compared to a sample of palliative patients of 45 physicians who did not take part in the program. Every four weeks for 6 months or until death, patients, physicians, and the patients' family caregivers in both groups answer questions to therapy strategies, quality of life (QLQ-C15-PAL, POS), pain (VAS), and burden for family caregivers (BSFC). The inclusion of physicians and patients in the study starts in March 2007.</p> <p>Discussion</p> <p>Although participating physicians value the increase in knowledge they receive from PAMINO, the effects on patients remain unclear. If the evaluation reveals a clear benefit for patients' quality of life, a larger-scale implementation of the program is considered. </p> <p><b>Trial registration</b>: The study was registered at ‘current controlled trials (CCT)’, registration number: ISRCTN78021852.</p

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