Validität und Reliabilität von Entscheidungsregeln bei akuten Halsschmerzen

In dieser Arbeit werden vier Entscheidungsregeln zur Differenzierung zwischen Streptokokkeninfekt und anderen Racheninfekten auf ihre Validität in einer hausärztlichen Praxis überprüft und vergleichend beurteilt. (Validitätsstudie) Zudem wird untersucht, wie häufig zwei Untersucher am selben Patienten einen übereinstimmenden Befund erheben. (Reliabilitätsstudie

Decision making preferences in the medical encounter – a factorial survey design

<p>Abstract</p> <p>Background</p> <p>Up to now it has not been systematically investigated in which kind of clinical situations a consultation style based on shared decision making (SDM) is preferred by patients and physicians. We suggest the factorial survey design to address this problem.</p> <p>This method, which so far has hardly been used in health service research, allows to vary relevant factors describing clinical situations as variables systematically in an experimental random design and to investigate their importance in large samples.</p> <p>Methods/Design</p> <p>To identify situational factors for the survey we first performed a literature search which was followed by a qualitative interview study with patients, physicians and health care experts. As a result, 7 factors (e.g. "Reason for consultation" and "Number of therapeutic options") with 2 to 3 levels (e.g. "One therapeutic option" and "More than one therapeutic option") will be included in the study. For the survey the factor levels will be randomly combined to short stories describing different treatment situations.</p> <p>A randomized sample of all possible short stories will be given to at least 300 subjects (100 GPs, 100 patients and 100 members of self-help groups) who will be asked to rate how the decision should be made. Main outcome measure is the preference for participation in the decision making process in the given clinical situation.</p> <p>Data analysis will estimate the effects of the factors on the rating and also examine differences between groups.</p> <p>Discussion</p> <p>The results will reveal the effects of situational variations on participation preferences. Thus, our findings will contribute to the understanding of normative values in the medical decision making process and will improve future implementation of SDM and decision aids.</p

Pitfalls in the statistical examination and interpretation of the correspondence between physician and patient satisfaction ratings and their relevance for shared decision making research

BACKGROUND: The correspondence of satisfaction ratings between physicians and patients can be assessed on different dimensions. One may examine whether they differ between the two groups or focus on measures of association or agreement. The aim of our study was to evaluate methodological difficulties in calculating the correspondence between patient and physician satisfaction ratings and to show the relevance for shared decision making research. METHODS: We utilised a structured tool for cardiovascular prevention (arriba™) in a pragmatic cluster-randomised controlled trial. Correspondence between patient and physician satisfaction ratings after individual primary care consultations was assessed using the Patient Participation Scale (PPS). We used the Wilcoxon signed-rank test, the marginal homogeneity test, Kendall's tau-b, weighted kappa, percentage of agreement, and the Bland-Altman method to measure differences, associations, and agreement between physicians and patients. RESULTS: Statistical measures signal large differences between patient and physician satisfaction ratings with more favourable ratings provided by patients and a low correspondence regardless of group allocation. Closer examination of the raw data revealed a high ceiling effect of satisfaction ratings and only slight disagreement regarding the distributions of differences between physicians' and patients' ratings. CONCLUSIONS: Traditional statistical measures of association and agreement are not able to capture a clinically relevant appreciation of the physician-patient relationship by both parties in skewed satisfaction ratings. Only the Bland-Altman method for assessing agreement augmented by bar charts of differences was able to indicate this

Chest pain in primary care: is the localization of pain diagnostically helpful in the critical evaluation of patients? - A cross sectional study

BACKGROUND: Chest pain is a common complaint and reason for consultation in primary care. Traditional textbooks still assign pain localization a certain discriminative role in the differential diagnosis of chest pain. The aim of our study was to synthesize pain drawings from a large sample of chest pain patients and to examine whether pain localizations differ for different underlying etiologies. METHODS: We conducted a cross-sectional study including 1212 consecutive patients with chest pain recruited in 74 primary care offices in Germany. Primary care providers (PCPs) marked pain localization and radiation of each patient on a pictogram. After 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient, deciding on the etiology of chest pain at the time of patient recruitment. PCP drawings were entered in a specially designed computer program to produce merged pain charts for different etiologies. Dissimilarities between individual pain localizations and differences on the level of diagnostic groups were analyzed using the Hausdorff distance and the C-index. RESULTS: Pain location in patients with coronary heart disease (CHD) did not differ from the combined group of all other patients, including patients with chest wall syndrome (CWS), gastro-esophageal reflux disease (GERD) or psychogenic chest pain. There was also no difference in chest pain location between male and female CHD patients. CONCLUSIONS: Pain localization is not helpful in discriminating CHD from other common chest pain etiologies

The comprehensive diagnostic study is suggested as a design to model the diagnostic process

AbstractObjectivesThe classical diagnostic cross-sectional study has a focus on one disease only. Generalist clinicians, however, are confronted with a wide range of diagnoses. We propose the “comprehensive diagnostic study design” to evaluate diagnostic tests regarding more than one disease outcome.Study Design and SettingWe present the secondary analysis of a data set obtained from patients presenting with chest pain in primary care. Participating clinicians recorded 42 items of the history and physical examination. Diagnostic outcomes were reviewed by an independent panel after 6-month follow-up (n = 710 complete cases). We used Shannon entropy as a measure of uncertainty before and after testing. Four different analytical strategies modeling specific clinical ways of reasoning were evaluated.ResultsAlthough the “global entropy” strategy reduced entropy most, it is unlikely to be of clinical use because of its complexity. “Inductive” and “fixed-set” strategies turned out to be efficient requiring a small amount of data only. The “deductive” procedure resulted in the smallest reduction of entropy.ConclusionWe suggest that the comprehensive diagnostic study design is a feasible and valid option to improve our understanding of the diagnostic process. It is also promising as a justification for clinical recommendations

Educating physicians on strong opioids by descriptive versus simulated-experience formats: a randomized controlled trial

Background: Long-term prescriptions of strong opioids for chronic noncancer pain-which are not supported by scientific evidence-suggest miscalibrated risk perceptions among those who prescribe, dispense, and take opioids. Because risk perceptions and behaviors can differ depending on whether people learn about risks through description or experience, we investigated the effects of descriptive versus simulated-experience educative formats on physicians' risk perceptions of strong opioids and their prescription behavior for managing chronic noncancer pain. Methods: Three hundred general practitioners and 300 pain specialists in Germany-enrolled separately in two independent exploratory randomized controlled online trials-were randomly assigned to either a descriptive format (fact box) or a simulated-experience format (interactive simulation). Primary endpoints: Objective risk perception (numerical estimates of opioids' benefits and harms), actual prescriptions of seven therapy options for managing chronic pain. Secondary endpoint: Implementation of intended prescriptions of seven therapy options for managing chronic pain. Results: Both formats improved the proportion of correct numerical estimates of strong opioids' benefits and harms immediately after intervention, with no notable differences between formats. Compared to description, simulated experience led to significantly lower reported actual prescription rates for strong and/or weak opioids, and was more effective at increasing prescription rates for non-drug-based therapies (e.g., means of opioid reduction) from baseline to follow-up for both general practitioners and pain specialists. Simulated experience also resulted in a higher implementation of intended behavior for some drug-based and non-drug-based therapies. Conclusions: The two formats, which recruit different cognitive processes, may serve different risk-communication goals: If the goal is to improve exact risk perception, descriptive and simulated-experience formats are likely to be equally suitable. If, however, the goal is to boost less risky prescription habits, simulated experience may be the better choice

Use of guideline-recommended drug therapy in patients undergoing percutaneous coronary intervention for stable coronary heart disease in Germany: a multilevel analysis of nationwide routine data

Objectives: To determine the prescription of guideline recommended drug therapy in patients with stable coronary heart disease (sCHD) prior to percutaneous coronary intervention (PCI) in Germany and to examine the role of patient characteristics and features of regional healthcare supply in a multilevel model. Design Secondary data analysis of factors associated with the prescription of guideline recommended drug therapy using a multilevel model to analyse regional-level effects, over and above the effects of patient-level demographic and health status. Setting Office-based prescriptions in the year prior to the invasive procedure. Participants A linked nationwide dataset from Germany's three largest statutory health insurance funds of all patients receiving PCI in the year 2016. Main outcome measures Patients' odds of receiving optimal medical therapy and symptom-oriented therapy within 1 year prior to PCI. Results 68.6% of patients received at least one lipid-lowering drug and one symptom-oriented therapy prior to PCI. 43.6% received at least two agents to control their symptoms. Patients who received treatment in accordance with the recommendations had a greater number of diagnosed risk factors, a more severe history of cardiac disease and used a higher volume of ambulatory office-based physician services. The prescriptions prevalence for the symptom-oriented therapies differed significantly between eastern and western Germany, with a higher prevalence in the eastern districts. Conclusions: Guidelines can only provide decision-making corridors, and the applicability of recommendations must always be assessed on a case by case basis. Nevertheless, our analysis indicates that the prevalence of prescriptions in routine practice is subject to substantial variation and that conservative therapy options are not fully exhausted prior to PCI. This suggests that there might be room for improvement in the care of patients with sCHD

Evaluating an implementation strategy in cardiovascular prevention to improve prescribing of statins in Germany: an intention to treat analysis

BACKGROUND: The prescription of statins is an evidence-based treatment to reduce the risk of cardiovascular events in patients with elevated cardiovascular risk or with a cardiovascular disorder (CVD). In spite of this, many of these patients do not receive statins. METHODS: We evaluated the impact of a brief educational intervention in cardiovascular prevention in primary care physicians' prescribing behaviour regarding statins beyond their participation in a randomised controlled trial (RCT). For this, prescribing data of all patients >= 35 years who were counselled before and after the study period were analysed (each n > 75000). Outcome measure was prescription of Hydroxymethylglutaryl-CoA Reductase Inhibitors (statins) corresponding to patients' overall risk for CVD. Appropriateness of prescribing was examined according to different risk groups based on the Anatomical Therapeutic Chemical Classification System (ATC codes). RESULTS: There was no consistent association between group allocation and statin prescription controlling for risk status in each risk group before and after study participation. However, we found a change to more significant drug configurations predicting the prescription of statins in the intervention group, which can be regarded as a small intervention effect. CONCLUSION: Our results suggest that an active implementation of a brief evidence-based educational intervention does not lead to prescription modifications in everyday practice. Physician's prescribing behaviour is affected by an established health care system, which is not easy to change.Trial registration: ISRCTN71348772

Patients’ self‐reported physical and psychological effects of opioid use in chronic noncancer pain—A retrospective cross‐sectional analysis

Background: Strong opioids can have unintended effects. Clinical studies of strong opioids mainly report physical side effects, psychiatric or opioid use disorders. To date, too little attention has been paid to the psychological effects of opioids to treat patients with chronic noncancer pain (CNCP). This study aims to identify and measure (i) the nature and frequency of physical and psychological effects and (ii) the degree of physician counseling of patients with CNCP taking strong opioids. Methods: Within a cross-sectional survey-conducted as part of a randomised controlled online intervention trial (ERONA [Experiencing the risk of overusing opioids among patients with chronic non-cancer pain in ambulatory care])-300 German CNCP patients were surveyed via patient-reported outcome measures regarding on both the side effects from their use of strong opioids as well as their counselling experience. Results: Among the patients' reported effects, the psychological outcomes of the opioids in CNCP were: feeling relaxed (84%), fatigue (76%), dizziness (57%), listlessness (37%), difficulty with mental activities (23%), dulled emotions (17%) and poor memory (17%). Ninety-two per cent of the patients reported having received information about opioid effects, and 46% had discussed cessation of the opioid medication with their physicians before commencing the prescription. Conclusions: In addition to the well-known physical side effects, patients with CNCP taking strong opioids experience significant psychological effects. In view of these effects, discontinuation of opioid therapy should be discussed early to ensure their benefits do not outweigh their harm. Significance: In this study, patients with non-cancer pain notice that opioids they have taken do not only cause physical side effects but also may have an impact on their psyche and their emotions and, thus, may also affect quality of life substantially. Clinical trial number: DRKS00020358

Heartburn or angina? Differentiating gastrointestinal disease in primary care patients presenting with chest pain: a cross sectional diagnostic study

<p>Abstract</p> <p>Background</p> <p>Gastrointestinal (GI) disease is one of the leading aetiologies of chest pain in a primary care setting. The aims of the study are to describe clinical characteristics of GI disease causing chest pain and to provide criteria for clinical diagnosis.</p> <p>Methods</p> <p>We included 1212 consecutive patients with chest pain aged 35 years and older attending 74 general practitioners (GPs). GPs recorded symptoms and findings of each patient and provided follow up information. An independent interdisciplinary reference panel reviewed clinical data of each patient and decided about the aetiology of chest pain. Multivariable regression analysis was performed to identify clinical predictors that help to rule in or out the diagnosis of GI disease and Gastroesophageal Reflux Disease (GERD).</p> <p>Results</p> <p>GI disease was diagnosed in 5.8% and GERD in 3.5% of all patients. Most patients localised the pain retrosternal (71.8% for GI disease and 83.3% for GERD). Pain worse with food intake and retrosternal pain radiation were associated positively with both GI disease and GERD; retrosternal pain localisation, vomiting, burning pain, epigastric pain and an average pain episode < 1 hour were associated positively only with GI disease. Negative associations were found for localized muscle tension (GI disease and GERD) and pain getting worse on exercise, breathing, movement and pain location on left side (only GI disease).</p> <p>Conclusions</p> <p>This study broadens the knowledge about the diagnostic accuracy of selected signs and symptoms for GI disease and GERD and provides criteria for primary care practitioners in rational diagnosis.</p