Norbert Donner-Banzhoff

Background: Uncertainty is part of everyday medical practice, especially in family medicine. Former studies have focused on how clinicians manage uncertainty, but its emotional experience has received less attention. This study looks at irritation as a distinct affective entry point through which family medicine residents first perceive disruptions in clinical, interactional or organisational issues. Methods: Between 2019 and 2021, we spoke with 15 residents in Hesse, Germany. In semi‐structured interviews, they described situations where they felt uncertain, including the context, their emotions, and what they did next. We transcribed, pseudonymised and analysed the interviews using Kuckartz's qualitative content analysis. Results: In many cases irritation was the first emotional reaction when something in the consultation didn't feel right. We identified three common triggers: (1) a mismatch between intuition and medical findings, (2) irritation during patient interactions and (3) irritation caused by structural issues. The last two were our main focus, as they disrupt usual ways of working rather than pointing to hidden diagnoses. These moments of irritation could be confusing at first, but in some cases, they led residents to dig deeper into what shaped the patient's perspective, to ask colleagues for advice or pay more attention to systemic and organisational issues. Conclusion: Irritation acts as a harbinger of uncertainty by embodying those small breaks in routines and expectations from which uncertainty first arises. At first, it might throw residents off balance, but if they take the time to reflect on it, irritation can help them see things differently, stay attentive and improve their clinical skills. Residency programmes should give residents room to talk about these experiences, helping them handle uncertainty more effectively in their daily work.

Background: Polypharmacy and potentially inappropriate medications are highly prevalent in primary care and are associated with adverse drug events, reduced adherence, and diminished quality of life. Deprescribing is a key strategy to address these challenges, but its implementation is complex, particularly when long-term preventive medications are involved and decisions are preference-sensitive. Digital tools may support shared decision making in deprescribing, yet many existing tools lack clear implementation orientation. This study describes the iterative refinement of arribaMediQuit, a digital deprescribing tool for primary care, with the aim of improving usability, ethical robustness, and implementation potential. Methods: The refinement followed an iterative, participatory development process informed by the Medical Research Council framework for complex interventions and the International Patient Decision Aid Standards. Multiple stakeholder groups were involved, including general practitioners, researchers in health services and pharmacology, members of a patient advisory board, experts in medical ethics, and the original developers of the tool. Regular expert meetings were used to review content, terminology, visual design, decision logic, and deprescribing strategies. Feedback was continuously integrated into successive versions of the tool. The study focused on qualitative refinement rather than outcome evaluation. Results: Key refinements included the development of a dynamic medication database and a structured categorization of medications into three categories (symptomatic, intermediate, and preventive medications) with tailored decision processes. A new linear decision model was introduced for preventive medications to better reflect value-sensitive trade-offs under uncertainty. Terminology and visual elements were revised to align with everyday clinical language and to enhance patient comprehensibility. Ethical considerations, including the communication of benefits, harms, and withdrawal symptoms, were explicitly addressed. Stakeholders also identified potential future uses of the tool, such as educational applications and integration with other deprescribing or medication review tools. Conclusions: The iterative, theory-informed refinement of arribaMediQuit illustrates how shared decision making principles can be operationalized in a deprescribing tool designed for routine primary care. By integrating technical guidance with value-sensitive deliberation and implementation considerations, the tool shows promise for supporting ethically grounded and feasible deprescribing. Future studies will evaluate feasibility, acceptability, and use in routine practice.

Symptom checkers (SCs) are mobile healthcare applications for the general population. Based on symptoms entered by the user, SCs provide a list of likely diagnoses and/or triage advice. Studies conducted so far show limited accuracy of current SCs with designs carrying a high risk of bias. In this narrative review we discuss three major methodological shortcomings of previous studies: 1) wrong study setting, 2) inappropriate reference standards, and 3) too small samples. To reflect the home setting, participants of an accuracy study must be prospectively recruited to document symptomatic episodes and health care used. Studies based on vignettes or samples drawn from healthcare facilities are not sufficient. A panel reviewing follow-up data must determine diagnoses for each episode and appropriate (non-)utilization of healthcare (delayed-type reference standard). Even when outcomes are collapsed into four groups, the sample size requirements for investigating triage appropriateness are considerable (n=62,000). The severity and treatability of rare conditions must be accommodated. Because of the defensive tendency of available SCs (with sensitivity maximized), the specificity will necessarily be limited to 20 to 30% at most, irrespective of the findings of an empirical study. We discuss the prospects for technological improvements, such as Large Language Models. For investigations of their accuracy, the same design requirements apply as for established models. Accuracy evaluation should be guided by the function of the intervention under consideration independently of the technology used. Given the limitations of our knowledge regarding SCs’ accuracy, their place in the health care system is far from clear.

Menschen suchen eine ärztliche Praxis auf, damit ihre Unsicherheit (Was ist mit mir los? Was wird aus mir? Was hilft mir?) in Sicherheit verwandelt wird. In den Medien haben sie erfahren, dass die Medizin immer mehr weiß und kann. Die Erwartungen sind also hoch. Wie aber können wir den Spagat zwischen Überdiagnostik und unsicherer Diagnosestellung schaffen? Der Beitrag erklärt die Problematik und zeigt Lösungswege auf. Article published online: 25 November 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Background: The rising costs of drugs are putting health care systems under pressure. We report on the Bavarian Drug Agreement, which employs prescribing targets for preferred and generic drugs in ambulatory care. Under this agreement, providers are regularly profiled with individual feedback but also possible sanctions. We investigated the degree to which targets were being met (or not) and why failure occurred. Methods: We analysed prescribing data aggregated by practice for the quarter 1/2018. We chose eight specialisation groups and analysed their drug targets with a high prescribing volume, widely missed drug targets (<90%), and drugs preventing drug target achievement. Characterisation of drug targets and preventing drugs was undertaken. Results: Drug targets with a high prescribing volume are mostly achieved, while highly missed drug targets mostly do not affect the main indication area of the specialisation groups considered. Generic drug targets seem to be more easily achieved than recommended drug targets. Paediatrics accounts for the largest number of missed drug targets. Conclusions: The Bavarian tool implemented uses the prescribing volume (DDD) and price components to evaluate the prescription behaviour of physicians. Well-established drugs with demonstrated effectiveness, safety, and lower costs are preferred. Nevertheless, me-too drugs, combination drugs, costly innovations with unclear value, and drugs with application methods of variable convenience challenge the drug prescribers and are reasons for missed drug targets.

Background and objective: The German treatment guideline “chronic ischemic/coronary heart disease (IHD)” recommends that general practitioners (GPs) deliver advice on physical activity (PA) to IHD patients. However, the provision of PA advice seems to be inadequately implemented in general practice. One reason is the lack of medical training in providing PA advice effectively and efficiently. International guidelines recommend such training for health professionals. This study aims to explore experiences, perceptions and attitudes, including barriers and facilitators of GPs towards the routine delivery of PA advice to IHD patients. Methods: Between March and June 2023, 12 face-to-face problem centred interviews and six focus group discussions (n=37) with GPs were conducted. Interview and discussion guides were developed and pilot tested by the multi-professional study team. We used a purposive sampling strategy, and data were collected in an iterative process. Audio-recorded data were transcribed verbatim and analysed using a content structuring procedure (deductive and inductive approach). GPs were involved throughout the entire research process, e.g., in multi-professional analysis groups. Results: Whereas GPs are mostly aware of the health benefits of PA for patients with IHD, PA advice is not routinely provided. Conversations on PA tend to be rather unstructured and advice is often addressed more generally than customised to the patients’ needs and preferences. Priority is given to other lifestyle issues, such as smoking. PA advice is perceived as time consuming and rather ineffective with regard to the target behaviour. GPs frequently mention frustration in this context. Routine processes and structure-creating tools are mentioned as facilitating factors to provide advice on PA. GPs express a lack of and simultaneously a need for communication strategies (structure and tools) that can be integrated into everyday GP practice to motivate patients to PA. Conclusion: The results provide relevant insights into the everyday practice of GPs with regard to their attitudes on, experiences with, and requirements for the provision of PA advice to IHD patients. These results are helpful to inform a customised development of an appropriate GP training in the provision of very brief PA advice to IHD patients.

Zusammenfassung: In Deutschland werden die Anforderungen an die gebietsärztliche Qualifikation von den Landesärztekammern festgelegt. Deren Erfüllung ist jedoch den Ärztinnen in Weiterbildung überlassen. Es fehlt eine Abschätzung des Bedarfs an Gebietsqualifikationen, ebenso eine entsprechende Steuerung. Allerdings werden Fehlentwicklungen immer wieder beklagt, so z. B. das Missverhältnis von Haus- und Fachärztinnen im ambulanten Sektor. Wir schlagen eine systematische und kontinuierliche Bedarfsschätzung der einzelnen Fachgebiete vor. In solchen, wo eine Unterversorgung droht, würde die Weiterbildung durch Zuschüsse analog der aktuellen Förderung der Weiterbildung in der Allgemeinmedizin nach § 75a SGB V inzentiviert. Regionale fachspezifische Weiterbildungsverbünde würden für eine Allokation der Mittel an Institutionen mit evaluierter Qualität der Weiterbildung sorgen. Das Verfahren lässt sich kostenneutral gestalten, wenn ein Teil der Mittel aus den aktuellen Behandlungsentgelten, die implizit auch der Weiterbildung dienen, künftig explizit für eine Steuerung, Koordination und Verbesserung der Weiterbildung genutzt werden. Diese Möglichkeit besteht unabhängig vom Mechanismus der Entgelte für stationäre oder ambulante Leistungen.

Background: Chronic ischemic heart disease (IHD) is one of the leading causes of morbidity and mortality. Physical activity (PA) is an effective secondary preventive strategy in IHD management. The German IHD treatment guideline recommends that general practitioners (GPs) should deliver advice on PA to patients with IHD. However, this recommendation seems inadequately implemented, often due to GP’s insufficient specific training. International guidelines therefore recommend training GPs in how to deliver such advice effectively and efficiently. Currently, evidence is lacking on whether such training can enhance the frequency and quality of PA advice in routine care. The OptiCor project aims to develop and evaluate a training for GPs in the delivery of very brief PA advice to optimise the treatment of people with IHD in German general practice. Methods: OptiCor comprises three study phases over five years according to the Medical Research Council framework recommendations for developing and evaluating complex interventions. Phase 1 (needs analysis): A nationwide representative household survey will be conducted to collect data on receipt and type of GP-delivered PA advice in people with IHD. Focus group discussions and qualitative interviews with GPs and people with IHD will be conducted to explore, e.g. attitudes, motivation towards, experiences with, and barriers and facilitators of PA advice implementation or reception, respectively. The findings will inform the training development. Phase 2 (pilot): A pragmatic cluster randomised controlled trial (cRCT) on the effectiveness of the developed training on proportions of GP-delivered PA advice during routine care of IHD patients will be piloted. Phase 3 (evaluation): A full cRCT will be conducted with the patient-reported proportions of GP-delivered PA advice as primary endpoint. Health economic and process-related data will be collected to facilitate a potential future broad implementation and health economic evaluation of the training. Discussion: If the developed training successfully improves proportions and quality of GP delivered PA advice to patients with IHD, it could serve as a low-threshold and sustainable strategy for implementing PA recommendations in the secondary prevention of IHD in routine GP practice. This training could also potentially be transferred and applied to other chronic diseases or other health care settings. Trial registration: Most work packages (WPs) of this study build on each other over a period of five years. First WPs will inform the final design and methodology of the planned trials (pilot study (WP5) and main study (WP6)). WP5 and WP6 will therefore be prospectively registered with the German Register of Clinical Trials (DRKS) during the course of the project. The ongoing cross-sectional population survey (WP1) has been prospectively registered at DRKS (DRKS00031304, 19/06/2023).

Background: The concept of care pathways is widely used to provide efficient, timely, and evidence-based medical care. Recently, the investigation of actual empirical patient pathways has gained attention. We demonstrate the usability of State Sequence Analysis (SSA), a data mining approach based on sequence clustering techniques, on comprehensive insurance claims data from Germany to identify empirical ambulatory care sequences. We investigate patients with coronary artery disease before invasive coronary angiography (CA) and compare identified patterns with guideline recommendations. This patient group is of particular interest due to high and regionally varying CA rates. Methods: Events relevant for the care of coronary artery disease patients, namely physician consultations and medication prescriptions, are identified based on medical guidelines and combined to define states. State sequences are determined for 1.5 years before CA. Sequence similarity is defined for clustering, using optimal matching with theory-informed substitution costs. We visualize clusters, present descriptive statistics, and apply logistic regression to investigate the association of cluster membership with subsequent undesired care events. Results: Five clusters are identified, the included patients differing with respect to morbidity, urbanity of residential area, and health care utilization. Clusters exhibit significant differences in the timing, structure, and extent of care before CA. When compared with guideline recommendations, 3 clusters show signs of care deficits. Conclusions: Our analyses demonstrate the potential of SSA for exploratory health care research. We show how SSA can be used on insurance claims data to identify, visualize, and investigate care patterns and their deviations from guideline recommendations.