Inklusive Leidenschaft

INKLUSIVE LEIDENSCHAFT Inklusive Leidenschaft / Wollny, Anja (Rights reserved) ( -

How do general practitioners implement decision-making regarding COPD patients with exacerbations? An international focus group study

Purpose: To explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations. Methods: Thematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong. Results: Four main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients’ perspective: the GPs considered patients’ experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients’ perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of “wrong decisions” and concerning the negotiation of responsibilities. Conclusion: Fear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs’ management decisions. GPs consider a holistic understanding of illness and the patients’ own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs’ decisions depend on the availability and reliability of other formal and informal carers, and the health care systems’ organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients’ social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations

Why do physicians lack engagement with smoking cessation treatment in their COPD patients? A multinational qualitative study

Smoking cessation is the only effective intervention to slow down the accelerated decline in lung function in smokers with chronic obstructive pulmonary disease. Nevertheless, physicians often do not routinely provide evidence-based smoking cessation treatment to their patients. To understand underlying reasons, we explored how physicians engage in smoking cessation treatment in their chronic obstructive pulmonary disease patients. In total, 21 focus group discussions were held with general practitioners and pulmonologists in seven different countries in Europe and Asia. We generated three themes, whereby some of the issues concerned smokers in general: first, ‘physicians’ frustration with chronic obstructive pulmonary disease patients who smoke’. These frustrations interfered with the provision of evidence-based treatment and could result in this group of patients being treated unequally. Second: ‘physicians’ limited knowledge of, and negative beliefs about, smoking cessation treatment’. This hindered treating smokers effectively. Third: ‘healthcare organisational factors that influence the use of smoking cessation treatments’. Money and time issues, as well as the failure to regard smoking as a disease, influenced how physicians engaged in smoking cessation treatment. Our results indicate that there is a number of barriers to the provision of effective smoking cessation treatment in patients with chronic obstructive pulmonary disease and smokers in general. Introducing an informative smoking cessation programme, including communication skills and ethical issues, in the vocational and postgraduate medical training may help to address these barriers. This is important in order to increase engagement with smoking cessation treatment and to improve quality of chronic obstructive pulmonary disease care

Reducing unnecessary prescriptions of antibiotics for acute cough: Adaptation of a leaflet aimed at Turkish immigrants in Germany

<p>Abstract</p> <p>Background</p> <p>The reduction in the number of unnecessary prescriptions of antibiotics has become one of the most important objectives for primary health care. German GPs report that they are under "pressure to prescribe" antibiotics particularly in consultations with Turkish immigrants. And so a qualitative approach was used to learn more about the socio-medical context of Turkish patients in regard to acute coughs. A German leaflet designed to improve the doctor-patient communication has been positively tested and then adapted for Turkish patients.</p> <p>Methods</p> <p>The original leaflet was first translated into Turkish. Then 57 patients belonging to 8 different GPs were interviewed about the leaflet using a semi-standardised script. The material was audio recorded, fully transcribed, and analysed by three independent researchers. As a first step a comprehensive content analysis was performed. Secondly, elements crucial to any Turkish version of the leaflet were identified.</p> <p>Results</p> <p>The interviews showed that the leaflets' messages were clearly understood by all patients irrespective of age, gender, and educational background. We identified no major problems in the perception of the translated leaflet but identified several minor points which could be improved. We found that patients were starting to reconsider their attitudes after reading the leaflet.</p> <p>Conclusion</p> <p>The leaflet successfully imparted relevant and new information to the target patients. A qualitative approach is a feasible way to prove general acceptance and provides additional information for its adaptation to medico-cultural factors.</p

Converting habits of antibiotic use for respiratory tract infections in German primary care – study protocol of the cluster-randomized controlled CHANGE-3 trial

Background: The overuse of antibiotics is a major cause for the worldwide rise of antibiotic resistance. Although it is well known that acute respiratory tract infections (ARTI) are mainly caused by viruses and are often self limiting, antibiotics are too frequently prescribed in primary care. CHANGE-3 examines whether a complex intervention focusing on improving communication and provision of prescribing feedback reduces antibiotic use in patients suffering from ARTI. Methods/design: The CHANGE-3 trial is a cluster-randomized controlled trial nested within a web-based public campaign conducted in two regions in Germany. A total of 114 medical practices will be included. Practices randomized to the intervention will receive a practice-specific antibiotic-prescription feedback and an educational outreach visit. During the visit the whole practice team will receive an introduction to e-learning modules addressing patient-centered communication on antibiotics. Furthermore, the practices will receive tablet PCs with information on antibiotics and the treatment of ARTI to be presented to patients. Practices randomized to the control will provide care as usual. The primary outcome measure is the antibiotic prescribing rate for patients with a history of ARTI. Data collected before the intervention, during the intervention and after the intervention will be compared. The use of narrow- vs. broad-spectrum antibiotics will be analyzed as a secondary outcome. A process evaluation is also part of the trial. Discussion: This study should contribute to the growing body of research on reducing antibiotic prescription. Trial registration: ISRCTN, ISRCTN15061174. Registered retrospectively on 13 July 2018

Diversity in der Verwaltung

DIVERSITY IN DER VERWALTUNG Diversity in der Verwaltung / Wollny, Anja [Hrsg.] (Rights reserved) ( -

¿Médicos generales atrapados en la "trampa de una relación"? Resultados de un estudio cualitativo acerca de los conceptos que poseen los médicos acerca de la enfermedad y de sus estrategias de tratamiento de la úlcera venosa

In der Hausarztpraxis spielen Krankheitskonzepte von Patient(inn)en und Ärzt(inn)en in der Arzt-Patienten-Interaktion, insbesondere im Aushandlungs- und Entscheidungsprozess über Diagnose- und Therapieverfahren, eine wichtige Rolle. Im Gegensatz zu den Krankheitskonzepten der Patientinnen und Patienten sind die der Hausärztinnen und Hausärzte empirisch nur wenig erforscht. In einer eigenen Untersuchung wurden am Beispiel der Krankheitsbilder Kopfschmerzen, akuter Husten, Ulcus cruris venosum, Schizophrenie und Aortenaneurysma (KAUSA) die Krankheitskonzepte von Hausärztinnen und Hausärzten analysiert. Offene narrative und leitfadengestützte Interviews mit Ärztinnen und Ärzten zum Krankheitsbild Ulcus cruris venosum (UCV) wurden in diesem Teil der Studie einer Sekundäranalyse mittels textanalytischer Verfahren unterzogen. In der Absicht, theoriebildend zu arbeiten, folgte das Forschungsprojekt KAUSA der Methodologie der Grounded Theory. In dem Beitrag werden Lesarten und Strukturhypothesen zu den einzelnen Fällen und fallvergleichende sowie fallübergreifende Aussagen zu den nicht offen liegenden Krankheitskonzepten von Hausärzten bei UCV entwickelt und diskutiert. Die aus den mündlichen Präsentationen im Interview empirisch rekonstruierten ärztlichen Krankheitskonzepte weisen neben kognitiven Elementen, die in der wissenschaftlichen Diskussion noch am ehesten thematisiert werden, kaum erforschte emotionale und handlungsbezogene Dimensionen auf. So wird beispielsweise ein offenes Bein von den Ärztinnen und Ärzten als vertrautes und gut behandelbares "Arbeitsgebiet" wahrgenommen, die Patientin oder der Patient selbst dagegen eher als Störfaktor erlebt. Irritationen und Unsicherheiten treten auf der Seite der Ärztinnen und Ärzte dabei weniger in Bezug auf vermeintliches medizinisches Wissen auf, als im Sprechen über die Interaktionssituationen mit den Patientinnen und Patienten, möglicherweise auch in der Interaktion selbst. Damit rücken Wahrnehmungs-, Interpretations- und Verstehensprozesse, also die Kommunikation und Interaktion mit Patientinnen und Patienten als soziale Phänomene und nicht allgemeinärztliches Wissen bei der Behandlung von Patient(inn)en mit einem UVC in den Vordergrund. URN: urn:nbn:de:0114-fqs0801420In general practice, how patients and doctors conceptualize disease plays an important part in decision making and in the patient-doctor relationship. Although the concepts of disease held by patients have been extensively investigated there is little empirical research about doctors’ concepts of disease. To explore more closely doctors' concepts of disease we investigated general practitioners' (GP) conceptualization of venous ulcer as an example. For this purpose we performed a secondary analysis of narrative interviews in which general practitioners were interviewed by fellow doctors or senior medical students about their patients with venous ulcers. Text analytic and interpretative techniques were used, leaning partly on the methodology of Grounded Theory. Interpretations and structural hypotheses about the hidden concepts of disease found within single cases or the comparison of all cases will be discussed in this article. Surprisingly, doctors' concepts of disease in relation to venous ulcer are not based primarily on medical knowledge. In addition to cognitive aspects, the concepts of disease reveal dimensions of emotionality and interaction, which have rarely been investigated. For example venous ulcers are looked upon as a familiar and easily treatable; whereas the patients themselves are seen as an unpleasant factor of interference. The doctors seem to feel more irritated while speaking about the interaction with the patient than the medical knowledge itself. Our research about general practitioners' concepts of disease in relation to venous ulcers reveals that social phenomena such as processes of perception, interpretation, and understanding are more important than medical knowledge of the disease. URN: urn:nbn:de:0114-fqs0801420En la medicina general, la forma en que pacientes y médicos conceptualizan la enfermedad desempeña un papel importante en la toma de decisiones y en la relación médico-paciente. Aunque los conceptos que de la enfermedad tienen los pacientes han sido investigados exhaustivamente, hay poca investigación empírica sobre los conceptos de la enfermedad en los médicos. Para estudiar más de cerca los conceptos que de la enfermedad tienen los médicos, investigamos la conceptualización de la úlcera venosa entre médicos generales, como un ejemplo. Para tal fin, se realizó un análisis secundario de entrevistas narrativas realizadas por doctores o estudiantes de niveles superiores a médicos generales, acerca de sus pacientes con úlceras venosas. Se utilizaron técnicas interpretativas y analíticas de texto, apoyándose parcialmente en la metodología de teoría fundamentada. Se discuten en el artículo tanto las interpretaciones e hipótesis estructurales sobre los hallazgos de conceptos ocultos de la enfermedad en casos aislados, como la comparación de todos los casos. Sorprendentemente, los conceptos de los médicos en relación a la enfermedad de la úlcera venosa no se basan principalmente en los conocimientos médicos. Además de los aspectos cognitivos, los conceptos de la enfermedad revelan dimensiones de la emotividad y la interacción, que rara vez han sido investigados. Por ejemplo, se considera a las úlceras venosas como algo familiar y de tratamiento fácil, mientras que los propios pacientes son vistos como un desagradable factor de interferencia. Los médicos parecen sentirse más irritados al hablar acerca de la interacción con el paciente que al hablar sobre el conocimiento médico en sí. Nuestra investigación acerca de los conceptos de los médicos generales con relación a la enfermedad de úlceras venosas revela que fenómenos sociales tales como los procesos de percepción, interpretación y comprensión son más importantes que el conocimiento médico de la enfermedad. URN: urn:nbn:de:0114-fqs080142

Hausärzte in der "Beziehungsfalle"? Ergebnisse einer qualitativen Studie zu ärztlichen Krankheitskonzepten und Behandlungsstrategien bei Ulcus cruris venosum

In der Hausarztpraxis spielen Krankheitskonzepte von Patient(inn)en und Ärzt(inn)en in der Arzt-Patienten-Interaktion, insbesondere im Aushandlungs- und Entscheidungsprozess über Diagnose- und Therapieverfahren, eine wichtige Rolle. Im Gegensatz zu den Krankheitskonzepten der Patientinnen und Patienten sind die der Hausärztinnen und Hausärzte empirisch nur wenig erforscht. In einer eigenen Untersuchung wurden am Beispiel der Krankheitsbilder Kopfschmerzen, akuter Husten, Ulcus cruris venosum, Schizophrenie und Aortenaneurysma (KAUSA) die Krankheitskonzepte von Hausärztinnen und Hausärzten analysiert. Offene narrative und leitfadengestützte Interviews mit Ärztinnen und Ärzten zum Krankheitsbild Ulcus cruris venosum (UCV) wurden in diesem Teil der Studie einer Sekundäranalyse mittels textanalytischer Verfahren unterzogen. In der Absicht, theoriebildend zu arbeiten, folgte das Forschungsprojekt KAUSA der Methodologie der Grounded Theory. In dem Beitrag werden Lesarten und Strukturhypothesen zu den einzelnen Fällen und fallvergleichende sowie fallübergreifende Aussagen zu den nicht offen liegenden Krankheitskonzepten von Hausärzten bei UCV entwickelt und diskutiert. Die aus den mündlichen Präsentationen im Interview empirisch rekonstruierten ärztlichen Krankheitskonzepte weisen neben kognitiven Elementen, die in der wissenschaftlichen Diskussion noch am ehesten thematisiert werden, kaum erforschte emotionale und handlungsbezogene Dimensionen auf. So wird beispielsweise ein offenes Bein von den Ärztinnen und Ärzten als vertrautes und gut behandelbares "Arbeitsgebiet" wahrgenommen, die Patientin oder der Patient selbst dagegen eher als Störfaktor erlebt. Irritationen und Unsicherheiten treten auf der Seite der Ärztinnen und Ärzte dabei weniger in Bezug auf vermeintliches medizinisches Wissen auf, als im Sprechen über die Interaktionssituationen mit den Patientinnen und Patienten, möglicherweise auch in der Interaktion selbst. Damit rücken Wahrnehmungs-, Interpretations- und Verstehensprozesse, also die Kommunikation und Interaktion mit Patientinnen und Patienten als soziale Phänomene und nicht allgemeinärztliches Wissen bei der Behandlung von Patient(inn)en mit einem UVC in den Vordergrund.In general practice, how patients and doctors conceptualize disease plays an important part in decision making and in the patient-doctor relationship. Although the concepts of disease held by patients have been extensively investigated there is little empirical research about doctors’ concepts of disease. To explore more closely doctors' concepts of disease we investigated general practitioners' (GP) conceptualization of venous ulcer as an example. For this purpose we performed a secondary analysis of narrative interviews in which general practitioners were interviewed by fellow doctors or senior medical students about their patients with venous ulcers. Text analytic and interpretative techniques were used, leaning partly on the methodology of Grounded Theory. Interpretations and structural hypotheses about the hidden concepts of disease found within single cases or the comparison of all cases will be discussed in this article. Surprisingly, doctors' concepts of disease in relation to venous ulcer are not based primarily on medical knowledge. In addition to cognitive aspects, the concepts of disease reveal dimensions of emotionality and interaction, which have rarely been investigated. For example venous ulcers are looked upon as a familiar and easily treatable; whereas the patients themselves are seen as an unpleasant factor of interference. The doctors seem to feel more irritated while speaking about the interaction with the patient than the medical knowledge itself. Our research about general practitioners' concepts of disease in relation to venous ulcers reveals that social phenomena such as processes of perception, interpretation, and understanding are more important than medical knowledge of the disease.En la medicina general, la forma en que pacientes y médicos conceptualizan la enfermedad desempeña un papel importante en la toma de decisiones y en la relación médico-paciente. Aunque los conceptos que de la enfermedad tienen los pacientes han sido investigados exhaustivamente, hay poca investigación empírica sobre los conceptos de la enfermedad en los médicos. Para estudiar más de cerca los conceptos que de la enfermedad tienen los médicos, investigamos la conceptualización de la úlcera venosa entre médicos generales, como un ejemplo. Para tal fin, se realizó un análisis secundario de entrevistas narrativas realizadas por doctores o estudiantes de niveles superiores a médicos generales, acerca de sus pacientes con úlceras venosas. Se utilizaron técnicas interpretativas y analíticas de texto, apoyándose parcialmente en la metodología de teoría fundamentada. Se discuten en el artículo tanto las interpretaciones e hipótesis estructurales sobre los hallazgos de conceptos ocultos de la enfermedad en casos aislados, como la comparación de todos los casos. Sorprendentemente, los conceptos de los médicos en relación a la enfermedad de la úlcera venosa no se basan principalmente en los conocimientos médicos. Además de los aspectos cognitivos, los conceptos de la enfermedad revelan dimensiones de la emotividad y la interacción, que rara vez han sido investigados. Por ejemplo, se considera a las úlceras venosas como algo familiar y de tratamiento fácil, mientras que los propios pacientes son vistos como un desagradable factor de interferencia. Los médicos parecen sentirse más irritados al hablar acerca de la interacción con el paciente que al hablar sobre el conocimiento médico en sí. Nuestra investigación acerca de los conceptos de los médicos generales con relación a la enfermedad de úlceras venosas revela que fenómenos sociales tales como los procesos de percepción, interpretación y comprensión son más importantes que el conocimiento médico de la enfermedad