Integration of Complementary and Alternative Medicine into Family Practices in Germany: Results of a National Survey

More than two-thirds of patients in Germany use complementary and alternative medicine (CAM) provided either by physicians or non-medical practitioners (“Heilpraktiker”). There is little information about the number of family physicians (FPs) providing CAM. Given the widespread public interest in the use of CAM, this study aimed to ascertain the use of and attitude toward CAM among FPs in Germany. A postal questionnaire developed based on qualitatively derived data was sent to 3000 randomly selected FPs in Germany. A reminder letter including a postcard (containing a single question about CAM use in practice and reasons for non-particpation in the survey) was sent to all FPs who had not returned the questionnaire. Of the 3000 FPs, 1027 (34%) returned the questionnaire and 444 (15%) returned the postcard. Altogether, 886 of the 1471 responding FPs (60%) reported using CAM in their practice. A positive attitude toward CAM was indicated by 503 FPs (55%), a rather negative attitude by 127 FPs (14%). Chirotherapy, relaxation and neural therapy were rated as most beneficial CAM therapies by FPs, whereas neural therapy, phytotherapy and acupuncture were the most commonly used therapies in German family practices. This survey clearly demonstrates that CAM is highly valued by many FPs and is already making a substantial contribution to first-contact primary care in Germany. Therefore, education and research about CAM should be increased. Furthermore, with the provision of CAM by FPs, the role of non-medical CAM practitioners within the German healthcare system is to be questioned

Rationale, design and conduct of a comprehensive evaluation of a primary care based intervention to improve the quality of life of osteoarthritis patients. The PraxArt-project: a cluster randomized controlled trial [ISRCTN87252339] ; study protocol

Background: Osteoarthritis (OA) has a high prevalence in primary care. Conservative, guideline orientated approaches aiming at improving pain treatment and increasing physical activity, have been proven to be effective in several contexts outside the primary care setting, as for instance the Arthritis Self management Programs (ASMPs). But it remains unclear if these comprehensive evidence based approaches can improve patients' quality of life if they are provided in a primary care setting. Methods/Design: PraxArt is a cluster randomised controlled trial with GPs as the unit of randomisation. The aim of the study is to evaluate the impact of a comprehensive evidence based medical education of GPs on individual care and patients' quality of life. 75 GPs were randomised either to intervention group I or II or to a control group. Each GP will include 15 patients suffering from osteoarthritis according to the criteria of ACR. In intervention group I GPs will receive medical education and patient education leaflets including a physical exercise program. In intervention group II the same is provided, but in addition a practice nurse will be trained to monitor via monthly telephone calls adherence to GPs prescriptions and advices and ask about increasing pain and possible side effects of medication. In the control group no intervention will be applied at all. Main outcome measurement for patients' QoL is the GERMAN-AIMS2-SF questionnaire. In addition data about patients' satisfaction (using a modified EUROPEP-tool), medication, health care utilization, comorbidity, physical activity and depression (using PHQ-9) will be retrieved. Measurements (pre data collection) will take place in months I-III, starting in June 2005. Post data collection will be performed after 6 months. Discussion: Despite the high prevalence and increasing incidence, comprehensive and evidence based treatment approaches for OA in a primary care setting are neither established nor evaluated in Germany. If the evaluation of the presented approach reveals a clear benefit it is planned to provide this GP-centred interventions on a much larger scale

Untersuchungen zur gentherapeutischen Behandlung der X-gebundenen juvenilen Retinoschisis

Bei der XLRS handelt es sich um eine X-chromosomal rezessive Netzhaut-degeneration. Sie wird verursacht durch Mutationen im RS1-Gen und ist eine der häufigsten Ursachen für eine frühe zentrale Netzhautdegeneration beim männlichen Geschlecht. Charakteristisch für die Erkrankung ist eine Aufspaltung der Netzhautschichten und eine Signalweiterleitungsstörung zwischen Photorezeptoren und den nachgeschalteten Bipolarzellen. Die überwiegende Mehrheit der bekannten RS1-Mutationen führt zu einem Funktionsverlust des kodierten Proteins, Retinoschisin. In früheren Versuchen verschiedener Arbeitsgruppen konnte bereits ein therapeutischer Erfolg eines RS1-Gentransfers im Mausmodell gezeigt werden. Da mehrere Studien den Vorteil einer möglichst physiologischen heterologen Genexpression bei gentherapeutischen Anwendungen zeigen, war es Ziel dieser Dissertation, ein gentherapeutisches Konstrukt zu testen, bei dem das RS1-Gen unter Kontrolle der bisher bekannten humanen regulatorischen Regionen von RS1 steht (pcDNA3_natives-RS1). In in vitro Studien an verschiedenen retinalen und nicht-retinalen Zelllinien konnte eine RS1-Expression ausgehend von diesem Konstrukt (pcDNA3_natives-RS1) nachgewiesen werden. Es wurde zudem gezeigt, dass die Expression, wie auch im endogenen RS1-Promotor, abhängig vom retinalen Expressionsfaktor CRX ist. Im zweiten Versuchsteil wurde das neue Gentherapiekonstrukt in explantierten murinen Rs1h-/Y-Netzhäuten getestet. Nach Elektroporation dieser Netzhäute und 8-tägiger Inkubation konnte jedoch keine RS1-Expression nachgewiesen werden. Möglicherweise weist dies auf eine physiologische Expression des RS1-Konstruktes hin, da zum Zeitpunkt der Entnahme des Gewebes (p0) natürlicherweise nur eine sehr schwache Expression im Mausauge detektierbar ist. Zuletzt wurden die Konstrukte in vivo nach Elektroporation in die Netzhäute von Rs1h -/Y-Mäusen getestet. Hier zeigte sich eine schwache, aber deutliche, RS1-Expression. Interessanterweise wurde jedoch auch bei verwendeten Kontrollkonstrukten, mit denen schon erfolgreich eine gentherapeutische Behandlung an Rs1h-/Y-Mäusen durchgeführt worden war, ein schädigender Einfluss auf die retinale Integrität gezeigt. Dies lässt eventuell darauf schließen, dass die Art des Konstrukttransfers mittels Elektroporation schädlich für die Netzhaut war. Insgesamt lässt sich sagen, dass die von Kraus et al. identifizierten humanen regulatorischen Elemente in vitro und im Mausmodell in vivo eine RS1-Expression ermöglichen. In weiterführenden Studien könnte ein möglicher Vorteil einer von diesem Konstrukt ausgehenden räumlich, zeitlich und quantitativ kontrollierten RS1-Expression gegenüber anderen gentherapeutischen Konstrukten, zum Beispiel durch die Verwendung von AAV als Vektorsystem im Mausmodell, deutlich werden

A brief patient-reported outcome instrument for primary care: German translation and validation of the Measure Yourself Medical Outcome Profile (MYMOP)

Background: Measure Yourself Medical Outcome Profile (MYMOP) is a patient-generated outcome instrument capable of measuring effects from a wide range of health care interventions. This paper reports the translation of this instrument into German (MYMOP-D) and the assessment of validity and sensitivity to change for the MYMOP-D. The instrument was piloted in a German primary care context. Methods: The translation process was conducted according to international guidelines. Recruited patients of both general practitioners and non-medical Complementary and Alternative Medicine (CAM) practitioners (“Heilpraktiker”) in the German state of Baden-Wuerttemberg completed a questionnaire comprised of the MYMOP-D and the EQ-5D. Responses were analysed to assess construct validity. For assessing the instrument’s sensitivity to change, patients received the MYMOP-D again after four weeks at which point they were also asked for their subjective views on change of symptoms. Correlation between MYMOP-D and EQ-5D and sensitivity to change as gradient in score change and as standardized response mean (SRM) were calculated. Results: 476 patients from general practices and 91 patients of CAM practitioners were included. Construct validity of the MYMOP-D was given with a correlation of r = .47 with the EQ-5D. Sensitivity to change for subjective change of symptoms could only be analysed for improvement or no change of symptoms, as only 12 patients reported deterioration of symptoms. Results showed the expected smooth gradient with 2.2, 1.3, and 0.5 points of change for large, little improvement and no change, respectively. SRM for MYMOP-D Profile Score was 0.88. Conclusions: The MYMOP-D shows excellent construct validity. It is able to detect changes when symptoms in patients improve or remain unchanged. Deterioration of symptoms could not be evaluated due to too few data. With its brevity and simplicity, it might be an important tool for enhancing patient-centred care in the German health care context

Manuelle Medizin aus Sicht der Anwender: eine qualitative Studie mit Ärzten

Hintergrund: Manuelle Medizin (MM) hat einen hohen Stellenwert in der ambulanten Versorgung von Beschwerden des Bewegungsapparats. Trotz Vorliegen zahlreicher randomisiert-kontrollierter Studien und Meta-Analysen im Bereich der MM ist die Bewertung aufgrund verschiedener Schulen und Techniken teilweise schwierig. Ziel der vorliegenden Studie war es, bei der großen Beliebtheit dieser Therapieform die Motivation und Erfahrungen von Ärzten bezüglich der Anwendung von MM in der täglichen Praxis zu ergründen. Methoden: Im Rahmen eines qualitativen Forschungsansatzes wurden 21 semi-strukturierte, telefonische Einzelinterviews mit Ärzten mit der Zusatzqualifikation für MM durchgeführt. Die Rekrutierung erfolgte über die Deutsche Gesellschaft für Manuelle Medizin sowie über einen Verteiler von Ärzten, die an Forschungsfragen zu MM interessiert sind. Die Interviews wurden aufgezeichnet, transkribiert und, unterstützt durch das Computerprogramm Atlas.ti, inhaltsanalytisch ausgewertet. Ergebnisse: Als Hauptmotivation für die Anwendung von MM wurde eine Stärkung der Arzt-Patienten-Beziehung durch einen unmittelbaren Zugang zum Patienten mit schnellen Behandlungserfolgen geschildert. Weitere beschriebene Aspekte sind die Einfachheit der Methode, die Unabhängigkeit von räumlichen oder apparativen Gegebenheiten und die damit verbundenen niedrigen Kosten. Positive, als direkt die Zufriedenheit mit MM beeinflussend beschriebene Faktoren sind die Möglichkeit, eigene Fähigkeiten zu nutzen, den Patienten zu einem gesunden Lebensstil zu motivieren und die Dankbarkeit des Patienten. Als Aspekte, welche die Zufriedenheit negativ beeinflussen, wurden die schlechte Vergütung der Therapie, die unklare Evidenzlage, die Anwendung bei oft selbstlimitierenden Krankheiten und das Risiko schwerwiegender Nebenwirkungen sowie die Gefahr einer iatrogenen Fixierung genannt. Schlussfolgerungen: Die Ergebnisse dieser Studie zeigen eine große Bandbreite von zumeist positiven Sichtweisen und Erfahrungen von Ärzten bei der Anwendung von MM. Dem Wunsch nach dem unmittelbar heilenden Handeln scheint durch MM begegnet zu werden. Die MM scheint als willkommene Abwechslung zur alltäglichen Berufsausübung zu dienen, die als distanziert wahrgenommen wird

A comparison of the workload of rural and urban primary care physicians in Germany: analysis of a questionnaire survey

<p>Abstract</p> <p>Background</p> <p>Many western countries are facing an existing or imminent shortage of primary care physicians especially in rural areas. In Germany, working in rural areas is often thought to be associated with more working hours, a higher number of patients and a lower income than working in urban areas. These perceptions might be key reasons for the shortage. The aim of this analysis was to explore if working time, number of treated patients per week or proportion of privately insured patients vary between rural and urban areas in Germany using two different definitions of rurality within a sample of primary care physicians including general practitioners, general internists and paediatricians.</p> <p>Methods</p> <p>This is a secondary analysis of pre-collected data raised by a questionnaire that was sent to a representative random sample of 1500 primary care physicians chosen by data of the National Association of Statutory Health Insurance Physicians from all federal states in Germany. We employed two different methods of defining rurality; firstly, level of rurality as rated by physicians themselves (urban area, small town, rural area); secondly, rurality defined according to the Organisation for Economic Co-operation and Development.</p> <p>Results</p> <p>This analysis was based upon questionnaire data from 715 physicians. Primary care physicians in single-handed practices in rural areas worked on average four hours more per week than their urban counterparts (p < 0.05). Physicians' gender, the number of patients treated per week and the type of practice (single/group handed) were significantly related to the number of working hours. Neither the proportion of privately insured patients nor the number of patients seen per week differed significantly between rural and urban areas when applying the self-rated classification of rurality.</p> <p>Conclusion</p> <p>Overall this analysis identified few differences between urban and rural primary care physician working conditions. To counter future misdistribution of primary care, students should receive practical experience in rural areas to get more practical knowledge on working conditions.</p

ELSID-diabetes study-evaluation of a large scale implementation of disease management programmes for patients with type 2 diabetes. Rationale, design and conduct : a study protocol

Background: Diabetes model projects in different regions of Germany including interventions such as quality circles, patient education and documentation of medical findings have shown improvements of HbA1c levels, blood pressure and occurrence of hypoglycaemia in before-after studies (without control group). In 2002 the German Ministry of Health defined legal regulations for the introduction of nationwide disease management programs (DMP) to improve the quality of care in chronically ill patients. In April 2003 the first DMP for patients with type 2 diabetes was accredited. The evaluation of the DMP is essential and has been made obligatory in Germany by the Fifth Book of Social Code. The aim of the study is to assess the effectiveness of DMP by example of type 2 diabetes in the primary care setting of two German federal states (Rheinland-Pfalz and Sachsen-Anhalt). Methods/Design: The study is three-armed: a prospective cluster-randomized comparison of two interventions (DMP 1 and DMP 2) against routine care without DMP as control group. In the DMP group 1 the patients are treated according to the current situation within the German-Diabetes-DMP. The DMP group 2 represents diabetic care within ideally implemented DMP providing additional interventions (e.g. quality circles, outreach visits). According to a sample size calculation a sample size of 200 GPs (each GP including 20 patients) will be required for the comparison of DMP 1 and DMP 2 considering possible drop-outs. For the comparison with routine care 4000 patients identified by diabetic tracer medication and age (> 50 years) will be analyzed. Discussion: This study will evaluate the effectiveness of the German Diabetes-DMP compared to a Diabetes-DMP providing additional interventions and routine care in the primary care setting of two different German federal states

Comparison of AIMS2-SF, WOMAC, x-ray and a global physician assessment in order to approach quality of life in patients suffering from osteoarthritis

BACKGROUND: Chronic diseases like osteoarthritis (OA) substantially affect different dimensions of quality of life (QoL). The aim of the study was to reveal possible factors which mainly influence general practitioners (GPs) assessment of patients' QoL. METHODS: 220 primary care patients with OA of the knee or the hip treated by their general practitioner for at least one year were included. All GPs were asked to assess patients' QoL based on the patients' history, actual examination and existing x-rays by means of a visual analog scale (VAS scale), resulting in values ranging from 0 to 10. Patients were asked to complete the McMaster Universities Osteoarthritis Index (WOMAC) and the Arthritis Impact Measurement Scale2 Short Form (AIMS2-SF) questionnaire. RESULTS: Significant correlations were revealed between "GP assessment" and the AIMS2-SF scales "physical" (rho = 0.495) and "symptom" (rho = 0.598) as well as to the "pain" scale of the WOMAC (rho = 0.557). A multivariate ordinal regression analysis revealed only the AIMS2-SF "symptom" scale (coefficient beta = 0.2588; p = 0.0267) and the x-ray grading according to Kellgren and Lawrence as significant influence variables (beta = 0.6395; p = 0.0004). CONCLUSION: The results of the present study suggest that physicians' assessment of patients' QoL is mainly dominated by physical factors, namely pain and severity of x-ray findings. Our results suggest that socioeconomic and psychosocial factors, which are known to have substantial impact on QoL, are underestimated or missed. Moreover, the overestimation of x-ray findings, which are known to be less correlated to QoL, may cause over-treatment while important and promising targets to increase patients' QoL are missed

The role of complementary and alternative medicine (CAM) in Germany – A focus group study of GPs

BACKGROUND: There has been a marked increase in the use of complementary and alternative medicine (CAM) in recent years worldwide. In Germany, apart from 'Heilpraktiker' (= state-licensed, non-medical CAM practitioners), some general practitioners (GPs) provide CAM in their practices. This paper aims to explore the attitudes of GPs about the role of CAM in Germany, in relation to the healthcare system, quality of care, medical education and research. Furthermore, experiences of GPs integrating CAM in their daily practice were explored. METHODS: Using a qualitative methodological approach 3 focus groups with a convenience sample of 17 GPs were conducted. The discussions were transcribed verbatim and analysed using qualitative content analysis. RESULTS: The majority of the participating GPs had integrated one or more CAM therapies into their every-day practice. Four key themes were identified based on the topics covered in the focus groups: the role of CAM within the German healthcare system, quality of care, education and research. Within the theme 'role of CAM within the healthcare system' there were five categories: integration of CAM, CAM in the Statutory Health Insurance, modernisation of the Statutory Health Insurance Act, individual healthcare services and 'Heilpraktiker'. Regarding quality of care there were two broad groups of GPs: those who thought patients would benefit from standardizing CAM and those who feared that quality control would interfere with the individual approach of CAM. The main issues identified relating to research and education were the need for the development of alternative research strategies and the low quality of existing CAM education respectively. CONCLUSION: The majority of the participating GPs considered CAM as a reasonable complementary approach within primary care. The study increased our understanding of GPs attitudes about the role of CAM within the German healthcare system and the use of 'Heilpraktiker' as a competing CAM-provider. It seems to be a need for increased funding for research, better education and remuneration by the Statutory Health Insurance in order to improve access to 'Integrative medicine' in Germany