Antje Bergmann

Harmful alcohol consumption in Germany is a serious public health problem: About 7.7 million adults in Germany can be classified as risky alcohol consumers, about 74,000 deaths per year are related to alcohol consumption, and about 1.8 million adults in Germany (18–64 years) are classified as alcohol dependent. A treatment rate of 9% of all alcohol dependent patients in Germany implies a lack of supply and misuse of medical care. The aim of the study was to examine whether family practitioners (FPs) and psychiatrists have sufficient skills to diagnose and treat patients with alcohol problems. A total of 6324 FPs and psychiatrists in the states of Saxony and Rhineland-Palatinate in Germany were invited to participate in this survey. Nine hundred seventy-four participants (90.3%/FPs) could be included in the statistical analysis (response rate: 14.3%/FPs, 21.6%/psychiatrists). Data was analysed descriptively and logistical regressions were used to identify predictors for physicians’ ability to feel adequately trained to diagnose and treat patients with alcohol problems. In comparison to psychiatrists, less FPs reported feeling sufficiently trained to counsel patients with alcohol problems (81.5% vs. 44.8%). Regression analysis revealed that FPs who felt not adequately trained had less experience with patients with alcohol dependence (OR 7.4), had attended fewer hours on alcohol addiction in continuing medical education (OR 4.8), and were more likely to be female (OR 1.9). A minimum of 10 h of training was associated with improved self-assessed competence. Harmful drinking is a serious public health problem, and patients with alcohol dependence represent a large and demanding patient group in primary health care setting. Our study shows that the lack of training is a severe barrier in the work with this patient group in the primary care setting.

Medical students are at risk of contracting and transmitting infectious diseases such as pertussis. Complete vaccination status is important to protect own, patient and public health. Knowing own vaccination status is elementary for following current vaccination recommendations, including boosters. We aimed to assess pertussis vaccination status and vaccination acceptance among medical students of different nationalities. A cross-sectional multicenter health survey at German and Hungarian universities enclosed international medical students in the 1st, 3rd and 5th year of study. Self-reported data from 2655 students regarding pertussis vaccination status were analyzed. Subgroup analysis enclosed data of German (n = 1217), Hungarian (n = 960) and other nationality (n = 478) students (“other”). More Hungarians reported basic immunization (39.0% vs 15.8% Germans vs 24.3% others, p ≤ 0.05). Booster vaccination was reported more by Germans (60.5% vs 43.6% Hungarians vs 36.0% others, p ≤ 0.05). Germans were more likely to report being unvaccinated (3.7% vs 0.9% Hungarians, p ≤ 0.05). More medical students of other nationalities were unaware of their pertussis vaccination status (37.4% vs 20.0% Germans/ 16.5% Hungarians, p ≤ 0.05). 75.2% (n = 1931) rated pertussis vaccinations as absolutely necessary (86.2% Hungarians vs 69.8% Germans/ 66.1% others, p ≤ 0.05). Positive attitudes towards vaccinations were reported but a large group reported insufficient vaccination status and being not aware of their status, especially among international students. Hungarians possibly have a better vaccination status than reported, based on mandatory vaccinations in childhood. The low awareness of vaccination status has implications for future booster vaccinations. All students should be informed about current recommendations and receive vaccination offers in frames of low-threshold medical services.

In Germany, home visits account for a considerable workload for many family practitioners, substantial rural-urban disparities are assumable with regards to home visit frequency and duration. Considering the ongoing demographic change and a rural-urban migration a significant regional difference in the provision of care is assumable. There is a lack of reliable data on the current provision of home visits and how their organisational procedures can be ensured in the future. The aim of this study was to describe and assess the average workload of family practitioners during home visits and compare their rural-urban variations. A cross-sectional study over a period of 12 months was conducted in Saxony as part of the fifth project of the Saxon Epidemiologic Studies in General Practice (SESAM-5). Over a 1-week period, family practitioners documented every home visit and answered questionnaires about sociodemographic, organisational and clinical characteristics. According to common categorizations in empirical studies four regional groups (rural, semi-rural, semi-urban, urban) were analysed and compared by non-parametric tests: Kruskal-Wallis followed by Dunn’s, Jonckheere-Terpstra and Mann-Whitney-U. Multinomial logistic regression analyses were carried out using a collection of plausible predictors to assess influences for a high frequency and a long duration of home visits. The sample included 3673 home visits conducted by 253 family practitioners. On average, 14.5 home visits were carried out per week with an average duration of almost 28 min. After comparing regional areas, the number and total duration per home visit showed significant differences between the regions: 8.2 h (rural), 7 h (semi-rural), 6.6 h (semi-urban) and 5 h (urban). The regression analyses found that a high frequency of home visits was most likely accomplished in rural regions and a long duration was most likely performed in private homes. Workload of home visits is strongly associated with the regional location of the practice, leading to rural-urban disparities. Strategies to reduce regional disparities to ensure the future provision of care in the German and comparable health care systems should be discussed, e.g. by financial incentives (short-term), exploiting the potential of delegation (medium-term) and discussing the implementation of substitution (long-term).

Traumatic events like critical illness and intensive care are threats to life and bodily integrity and pose a risk factor for posttraumatic stress disorder (PTSD). PTSD affects the quality of life and morbidity and may increase health-care costs. Limited access to specialist care results in PTSD patients being treated in primary care settings. Narrative exposure therapy (NET) is based on the principles of cognitive behavioral therapy and has shown positive effects when delivered by health-care professionals other than psychologists. The primary aims of the PICTURE trial (from “PTSD after ICU survival”) are to investigate the effectiveness and applicability of NET adapted for primary care with case management in adults diagnosed with PTSD after intensive care. This is an investigator-initiated, multi-center, primary care-based, randomized controlled two-arm parallel group, observer-blinded superiority trial conducted throughout Germany. In total, 340 adult patients with a total score of at least 20 points on the posttraumatic diagnostic scale (PDS-5) 3 months after receiving intensive care treatment will be equally randomized to two groups: NET combined with case management and improved treatment as usual (iTAU). All primary care physicians (PCPs) involved will be instructed in the diagnosis and treatment of PTSD according to current German guidelines. PCPs in the iTAU group will deliver usual care during three consultations. In the experimental group, PCPs will additionally be trained to deliver an adapted version of NET (three sessions) supported by phone-based case management by a medical assistant. At 6 and 12 months after randomization, structured blinded telephone interviews will assess patient-reported outcomes. The primary composite endpoint is the absolute change from baseline at month 6 in PTSD symptom severity measured by the PDS-5 total score, which also incorporates the death of any study patients. Secondary outcomes cover the domains depression, anxiety, disability, health-related quality-of-life, and cost-effectiveness. The principal analysis is by intention to treat. If the superiority of the experimental intervention over usual care can be demonstrated, the combination of brief NET and case management could be a treatment option to relieve PTSD-related symptoms and to improve primary care after intensive care. ClinicalTrials.gov, NCT03315390 . Registered on 10 October 2017. German Clinical Trials Register, DRKS00012589 . Registered on 17 October 2017.

Tobacco use is the leading preventable cause of death worldwide. Besides cigarette smoking, waterpipe and e-cigarettes are gaining popularity among young adults. Medical students’ smoking behavior is of particular interest because of their impending role in health promotion as future physicians. Aim of our study is to examine the prevalence and predictors of cigarette, waterpipe and e-cigarette use and the association of tobacco use with self-reported health status in an international sample of medical students. In a multicenter cross-sectional study data on different aspects of health behavior were collected from medical students of 65 nationalities using a self-administered questionnaire in Germany (Dresden, Munich) and Hungary (Budapest, Pécs). The survey was conducted among 1st, 3rd and 5th year students. To explore associations between smoking behavior and socio-cultural factors Pearson’s chi2-tests and multivariate binary logistic regression analyses were performed. The largest subpopulations were formed by German (n = 1289), Hungarian (n = 1055) and Norwegian (n = 147) students. Mean age was 22.5 ± 3.3 years. Females represented 61.6% of the sample. In the whole sample prevalence of cigarette smoking was 18.0% (95% CI 16.6–19.4%), prevalence of waterpipe use was 4.8% (95% CI 4.0–5.7%), that of e-cigarette 0.9% (95% CI 0.5–1.2%). More males (22.0%) than females (15.5%) reported cigarette smoking. The lowest prevalence of cigarette smoking was found among Norwegian students (6.2%). Cigarette smokers were older, waterpipe users were younger than non-users. E-cigarette use was not associated with age of the students. Religious involvement was protective only against cigarette smoking. Financial situation showed no association with any kind of tobacco consumption. Cigarette smokers and e-cigarette users were less likely to report very good or excellent health status. Cigarette smoking is still the most popular way of consuming tobacco, although alternative tobacco use is also prevalent among medical students. To further health consciousness, medical schools should pay more attention to students’ health behavior, especially their smoking habits. Tobacco prevention and cessation programs for medical students should consider not only the health risks of cigarette smoking but the need to discourage other forms of tobacco use, such as waterpipe.

Based on changes in pharmacokinetics and –dynamics in elderly patients, there are potentially inappropriate medications (PIM) that should be avoided in patients aged ≥ 65 years. Current studies showed prescription rates of PIM between 22.5 and 28.4 % in the primary care setting. The evidence concerning reasons for PIM prescription by FPs is limited. This mixed method study consisted of three research parts: 1) semi-standardized content analysis of patients’ records, 2) qualitative interviews with FPs using a) open questions and b) selected patient-specific case vignettes and 3) qualitative interviews with FPs’ medical assistants. The integration of qualitative interviews was used to explain the quantitative results (triangulation design). PIM were identified according to the German PRISCUS list. Descriptive and multivariate statistical analysis was done using SPSS 22.0. Qualitative content analysis of interviews was used to classify the content of the interviews for indicating pertinent categories. All data were pseudonymously recorded and analyzed. Content analysis of 1846 patients’ records and interviews with 7 related FPs were conducted. Elderly patients [n = 1241, mean age: 76, females: 56.6 %] were characterized in average by 8.3 documented chronic diagnosis. 23.9 % of elderly patients received at least one PIM prescription. Sedatives/hypnotics were the most frequent prescribed PIM-drugs (13.7 %). Mental disorders, gender and number of long-term medication were detected as predictors for the probability of a PIM prescription. Common reported reasons for PIM prescription by FPs concerned limited knowledge regarding PIM, limited applicability of PIM lists in daily practice, lack of time, having no alternatives in medication, stronger patient-related factors than age that influence prescription, own bad experiences regarding changes of medication or refusal of following prescriptions of sedative/hypnotics. It is essential to see FPs in a complex decision making situation with several influencing factors on their prescribing, including: patient-oriented prioritization, FPs’ experiences in daily practice, FPs’ knowledge regarding existing recommendations and their trust in it and organizational characteristics of FPs’ daily medical practice. These pros and cons of PIM prescription in elderly patients should be considered in FPs’ advanced training.

Physical and mental health is important for coping with the high requirements of medical studies that are associated with a higher risk for severe stress, insomnia, smoking, harmful alcohol consumption and easier access to drugs. Health behaviors of medical students influence not just their own health but also the health of their future patients. We examined whether socio-cultural factors can explain differences in students’ health status and health-promoting behaviors. A multicenter cross-sectional survey in Germany (Dresden, Munich) and Hungary (Budapest, Pécs) enclosed international medical students in their 1st, 3rd and 5th academic years. The students were invited to voluntarily and anonymously complete a questionnaire on different aspects of health behavior during obligatory seminars and lectures in 2014. The response rate of the total sample was 56.2 % (n = 2935); the subgroup analysis enclosed data of German (n = 1289), Hungarian (n = 1057) and Norwegian (n = 148) students. A high number of Norwegian students (84.5 %) assessed their health status as very good/excellent. In comparison, only 60.3 % of the Hungarian and 70.7 % of the German participants reported a very good/excellent health status. The distributions were comparable between the study sites. Although gender, financial situation and nationality were significant health status predictors, they could explain only 8.2 % of the total variance of health status in the multivariable model. A comparably high number of Hungarian students (95.3 % vs. 67.4 % German and 56.7 % Norwegian) reported that they can currently do a lot/very much for their health. In contrast, a significant number of Norwegians (73.0 % vs. 63.7 % Hungarian and 51.5 % German) reported that they currently do a lot/very much for their health (chi2-test, p ≤ 0.001). Financial situation, study site and study year were the strongest predictors for health promotion activities (Nagelkerkes R2 = 0.06). Based on our study, gender and study year played only a minor role in the health status and health promotion beliefs and activities of medical students. Structural (study site) and somewhat socio-cultural factors (nationality, financial situation) mainly explained the differences regarding health promoting behaviors. Obligatory, free-of-charge courses for health promotion (activity and relaxation) should be included in study curriculums.

Home visits are part of general practice work in Germany. Within the context of an expanding elderly population and a decreasing number of general practitioner (GPs), open questions regarding the organisation and adequacy of GPs’ care in immobile patients remain. To answer these questions, we will conduct a representative primary data collection concerning contents and organisation of GPs’ home visits in 2014. Because this study will require considerable efforts for documentation and thus substantial involvement by participating GPs, we conducted a pilot study to see whether such a study design was feasible.

Multimorbidity is defined as suffering from coexistent chronic conditions. Multimorbid patients demand highly complex patient-centered care which often includes polypharmacy, taking an average of six different drugs per day. Adverse drug reactions, adverse drug events and medication errors are all potential consequences of polypharmacy. Our study aims to detect the status quo of the health care situation in Saxony’s general practices for multimorbid patients receiving multiple medications. We will identify the most common clinical profiles as well as documented adverse drug events and reactions that occur during the treatment of patients receiving multiple medications. We will focus on exploring the motives of general practitioners for the prescription of selected drugs in individual cases where there is evidence of potential drug-drug-interactions and potentially inappropriate medications in elderly patients. Furthermore, the study will explore general practitioners’ opinions on delegation of skills to other health professions to support medical care and monitoring of patients receiving multiple medications.