[The future is chronic].
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Education, Medical, Continuing↗
Biomedical subjects
Ferdinand M Gerlach
Publications and source records attributed to Ferdinand M Gerlach.
[New perspectives in the primary care of the chronically ill--against the "tyranny of the urgent". Part 1: chronic diseases as a challenge for primary care].
Chronic diseases and multimorbidity are becoming a fundamental challenge for primary care which already requires a very high input of resources. Due to their broad range and continuity, general practices play a major role, but are poorly prepared to succeed in the structured healthcare of chronically ill patients. The reality of care in everyday practice is primarily characterized by the 'tyranny of the urgent', and such a reaction to acute problems leads to noticeable deficits in permanent care. Part one of a two-part article series asks to what extent demographic changes and medical progress are responsible for this development. Meanwhile, a large quantity of empirical evidence indicates that results improve when case management is implemented for chronically ill patients. Though disease management programs are being increasingly established in Germany, many general practices are only poorly prepared for their tangible implementation in everyday routine. The comparison of two case studies shows how the primary care of chronically ill patients might look like in the future. On the basis of both scientific evidence and the globally acknowledged 'Chronic Care Model', part two of the article looks at sustainable strategies and special tools which allow for an adequate care of chronically ill patients in general practice.
Chronic Disease↗
[New perspectives in the primary care of the chronically ill--against the "tyranny of the urgent". Part 2: The chronic care model und case management as the basis of a forward-looking approach to primary care].
Family medicine remains strongly influenced by reactive medicine ('tyranny of the urgent') and the fragmentation of healthcare associated with it. In the first part of the present article the increasing practical and economic relevance of chronic diseases and multimorbidity were analyzed as a fundamental challenge for primary care and family medicine in particular. Part two describes a forward-looking approach to guidelines and special tools which are able to guide and support future healthcare tasks of general practice. Wagner's Chronic Care Model, which was developed on the basis of numerous controlled studies, integrates empirical results, theoretical ideas and real experience within a comprehensive concept for the treatment of chronic diseases. The model focuses on the'productive interaction' between an active patient and a proactive practice team. The various elements of the model help to better understand healthcare in general practices, for example by establishing reminder and recall systems by means of a structured reorganization, through patient registers, the implementation of consultation hours for chronically ill patients as well as patient training. 'Case management' is essential to the success of structured care. Taking care of patients with major depression as an example, it is demonstrated how case management through practice assistants in general practices enables the individual needs of chronically ill patients to be better taken into account. The professionalism of the practice team with new roles and task sharing as well as the implementation of modern strategies for the care of chronically ill patients provide a new chance and a sharpened profile for general practices of the future.
Case Management↗
[Effectiveness of German disease management programs--problems of clinical evaluation research in the light of a study protocol].
Since 2002 some of the world's largest disease management programs have been launched in Germany--initially for type II diabetes and coronary heart disease--with approximately 5 million eligible insured persons and (in 2005) 2.04 million registered participants. The programs were not piloted prior to their start, and the prescribed statutory evaluation cannot be expected to result in an effectiveness validation. The article describes the development of a study protocol for a randomized controlled trial. It also discusses methodological problems, in particular the definition of primary target criteria, the guarantee of a 'naturalistic' intensity of intervention, and the creation of a control group during nation-wide implementation. Due to lacking support from the stakeholders the proposed randomized trial could not be implemented. Its design, however, allows the required standards for the program evaluation to be specified.
Delivery of Health Care↗
[The future is chronic: German primary care and the Chronic Care Model--The comprehensive principles in the proactive treatment of the chronically ill].
BACKGROUND: In Germany, primary healthcare for patients with chronic diseases needs to be improved. Taking the example of depression, congestive heart failure, diabetes and diseases of the musculoskeletal system we analyzed to which extent the 'Chronic Care Model' allows for improvements. METHODS: Diagnosis-specific health assessment; adaptation of the 'Chronic Care Model' to the German healthcare system; peer reviewed discussions of the potentials for improving primary care of the chronically ill. RESULTS/DISCUSSION OF THE HEALTHCARE SITUATION: 1) Diagnosis and therapy of chronic diseases comply insufficiently with the evidence. 2) Patients are too passive and/or receive only little effective support. 3) Treatments are often uncoordinated and fragmented. 4) The follow-up of treatment results is often neglected. 5) Approaches to indicated diseases are promising. CONCLUSIONS: The'Chronic Care Model' could improve chronic care in Germany. Disease Management Programs (DMP) should amend multimorbidity and individual healthcare and/or facilitate implementation in general practice.
Chronic Disease↗
[The "Depression Monitoring list" (DeMoL) with integrated PHQ-D-Rationale and design of a tool for the case management for depression in primary care].
BACKGROUND: Structured and regular monitoring and/or case management support treatment continuity of patients with depression in primary care. Central tools are questionnaires with stratified operating instructions. Questions should be geared towards treatment relevance in primary care and identify clinical parameters in a reliable and valid manner and in due time. Stratified information transfer to the general practitioner should be objective to ensure patient-related communication in the practice team. METHOD: Development of a draft tool based on evidence-based guidelines, peer-reviewed pre-test, practice test among users. RESULT: The Depression Monitoring List (DeMoL) with integrated PHQ-D for interviews with depressive patients to be conducted by practice assistants assesses 1.)'clinical diagnosis' and 2.) 'patient adherence' and 3.) governs the information flow in the practice via a 'robot scheme'. Users (doctors and practice assistants) evaluated the tool as practicable and relevant for patient care in family practices. Experiences gained can also be used for the treatment of other chronic diseases.
Case Management↗
Testing a European set of indicators for the evaluation of the management of primary care practices.
BACKGROUND: Effective practice management is an important prerequisite for offering good clinical care. Internationally valid, reliable and feasible indicators and instruments are needed to describe and compare the management of primary care practices in Europe. OBJECTIVE: This paper describes development and evaluation of the European Practice Assessment instrument and indicators (Engels Y, Campbell S, Dautzenberg M et al. Developing a framework of, and quality indicators for, general practice management in Europe. Fam Pract 2005; 22(2): 215-22). METHODS: The study design was a validation and feasibility study set in 273 general practices in Austria, Belgium, France, Germany, Israel, The Netherlands, Slovenia, Switzerland and the UK. Use was made of a set of 62 valid quality indicators derived previously from an international Delphi procedure. The EPA instrument, based on this set of indicators, was used to collect data in the 273 practices. This instrument consists of self-completed questionnaires for doctors, staff managers and patients. In addition, there is an interview schedule for use by an outreach visitor, to be held with the lead GP or manager, and a visitor checklist. The instrument was analysed using expert review by the project partners, factor and reliability analyses, ANOVA analyses and by determining intraclass correlations. RESULTS: Fifty-seven indicators were found to be valid, feasible, reliable and discriminative in all participating countries. The instrument was able to determine differences in practice management within and between countries. All (but one) practices completed the assessment procedure. The data collection method appeared to be feasible, although some aspects can be improved. CONCLUSION: The EPA instrument provides feedback to practices that facilitates quality improvement and can compare primary care practices on a national and an international level.
Europe↗
Case management for the treatment of patients with major depression in general practices--rationale, design and conduct of a cluster randomized controlled trial--PRoMPT (PRimary care Monitoring for depressive Patient's Trial) [ISRCTN66386086]--study protocol.
BACKGROUND: Depression is a disorder with high prevalence in primary health care and a significant burden of illness. The delivery of health care for depression, as well as other chronic illnesses, has been criticized for several reasons and new strategies to address the needs of these illnesses have been advocated. Case management is a patient-centered approach which has shown efficacy in the treatment of depression in highly organized Health Maintenance Organization (HMO) settings and which might also be effective in other, less structured settings. METHODS/DESIGN: PRoMPT (PRimary care Monitoring for depressive Patients Trial) is a cluster randomised controlled trial with General Practice (GP) as the unit of randomisation. The aim of the study is to evaluate a GP applied case-management for patients with major depressive disorder. 70 GPs were randomised either to intervention group or to control group with the control group delivering usual care. Each GP will include 10 patients suffering from major depressive disorder according to the DSM-IV criteria. The intervention group will receive treatment based on standardized guidelines and monthly telephone monitoring from a trained practice nurse. The nurse investigates the patient's status concerning the MDD criteria, his adherence to GPs prescriptions, possible side effects of medication, and treatment goal attainment. The control group receives usual care--including recommended guidelines. Main outcome measure is the cumulative score of the section depressive disorders (PHQ-9) from the German version of the Prime MD Patient Health Questionnaire (PHQ-D). Secondary outcome measures are the Beck-Depression-Inventory, self-reported adherence (adapted from Moriskey) and the SF-36. In addition, data are collected about patients' satisfaction (EUROPEP-tool), medication, health care utilization, comorbidity, suicide attempts and days out of work. The study comprises three assessment times: baseline (T0) , follow-up after 6 months (T1) and follow-up after 12 months (T2). DISCUSSION: Depression is now recognized as a disorder with a high prevalence in primary care but with insufficient treatment response. Case management seems to be a promising intervention which has the potential to bridge the gap of the usually time-limited and fragmented provision of care. Case management has been proven to be effective in several studies but its application in the private general medical practice setting remains unclear.
Adult↗
[Signals for the initiation of structured diagnostic procedures for depression in primary health care. A practice-relevant evaluation of international guidelines].
BACKGROUND AND OBJECTIVES: Almost every tenth patient of a general practitioner (GP) suffers from depression. However, only 20-25% of these patients are correctly diagnosed during a GP consultation. How do international guidelines for depression in primary care initiate structured diagnostic procedures for depression? METHODS: We performed a systematic literature search on guidelines for the diagnosis of depression with focus on primary care. The quality of the guidelines was rated according to base of evidence, existence of pilot studies, data on implementation, presentation and specificity for primary care settings, and conflict of interest. We also screened whether and how the guidelines comment on the initiation of structured diagnostic procedures for depression. RESULTS: Of the 22 identified guidelines, only 15 address primary care. Only 3 of these were tested in pilot studies, 3 provided data on implementation, 9 were evidence-based. The best guideline (6 out of 6 criteria met) is available in Dutch and established for The Netherlands only. We ranked the guidelines from NHG, VHA and ICSI as very good in terms of methodological quality. They present 'red flags' that initiate structured diagnostic procedures by 'opportunistic screening'. This is followed by the application of a self-rating instrument and an ICD-10-based diagnostic checklist identifying up to 98% of all patients with depression in a given consultation time of 10 minutes on average. CONCLUSION: Based on these criteria a national diagnostic depression guideline should, from our point of view, explicitly include keys such as "red flags" for the initiation of structured diagnostic procedures.
Depressive Disorder↗
[Suspicion of COPD--development of an algorithm for stepwise diagnosis in primary care].
The implementation of the disease management programme (DMP) for asthma and COPD in the German health system in 2005 requires an optimal and evidence-based work-up of patients by general practitioners in routine daily practice. The German and international guidelines for COPD do not provide recommendations for a stepwise diagnostic work-up in primary care. Therefore, an evidence-based algorithm was developed for a stepwise diagnosis of COPD and its different stages in general practice, based on national and foreign guidelines that provide specific advice on diagnostic procedures.
Algorithms↗
[Case management for patients with congestive heart failure under ambulatory care--a critical review].
BACKGROUND: Congestive Heart Failure (CHF) is becoming the most serious cardiac health problem after coronary heart disease (CHD). But at present, service offered to CHF patients are flawed because of the fragmentation and discontinuity of care. Case management (CM) takes responsibility for following up patients, for assessing symptoms and taking action when patients do not adhere to guideline based treatment or fail to improve. This review analyses the evidence of primary care based CM for patients with CHF. METHODS: Searches in Medline using relevant MeSH terms and hand-searching were applied to identify relevant studies. We selected RCTs and pre-post studies focussing on patient-centred CM in ambulatory settings. A five-level score (simple to complex) was generated to describe interventions and compare results. RESULTS: 23 of 462 identified studies (16 RCT, 7 others) that fulfilled our selection and quality criteria were included. We classified 15 studies as "complex" CM, i.e. they contained more than three elements of intervention, were strongly integrated with the process of care, involved a specialised nurse, and offered individual patient education. All studies examined the length of hospital stay: costs were investigated in 17, quality of life in 10 and mortality in 7 studies. Studies examining a "complex" CM demonstrated positive effects on mortality and quality of life in the 3-6 months of follow up. Studies with a follow up period of 12 to 18 months showed a reduction of hospital days. CONCLUSION: Especially "complex" models of CM for patients with CHF can be effective in a primary care setting. CM can prevent the fragmentation and discontinuity of care by strengthening a close contact between patient and health care provider.
Ambulatory Care↗
[An assessment of patient education programmes for patients with type 1 and 2 diabetes, asthma and COPD, coronary heart disease, hypertension, congestive heart failure, and breast cancer in Germany].
BACKGROUND: Patient education programmes will be a mandatory part of the new legislation on disease management programmes for chronic diseases in Germany. Today, only little is known about the number, variety and effectiveness of implemented patient education programmes in Germany. METHODS: 176 potential providers of patient education programmes were identified by literature search, Internet search, and interviews with health education experts. We developed a semi-structured questionnaire. Assessment of content and quality was conducted in two steps by using defined criteria of the Co-ordinating Committee, the Head Association of the statutory health insurances and the respective Medical Associations: the first step was to check whether the programme had a structured teaching concept and whether all requirements for education with respect to a given disease had been taken into account. In the second step, we used balance sheets for reviewing the strengths and weaknesses of the programmes. RESULTS: 49 providers handed in 95 pa tient education programmes for assess ment. Due to formal mistakes only 91 programmes could be analysed. 49 programmes failed the criteria of the first assessment step. For the remaining 42 patient education programmes balance sheets were prepared. Areas of the most frequent deficiencies included: lack of scientific evaluation of the effectiveness of the programme, lack of transparency of cost data, and quality improvement activities. CONCLUSIONS: For the purpose of a nation-wide implementation of disease management programmes the existing patient education programmes in Germany need to be further improved. Single examples demonstrated that the accessible criteria of self-management are not sufficient for the evaluation of already established patient education programmes.
Asthma↗
[Suspected diagnosis of bronchial asthma--development of an algorithm for diagnosis of asthma in general practice].
In 2003, the German Ministry of Health will publish a legal document that will allow for the implementation of disease management programmes for asthma and COPD. Examination of German asthma guidelines reveals that they do not include recommendations for a stepwise diagnostic work-up of patients with relevant symptoms in general practice. Therefore an algorithm was developed for the diagnosis of asthma in general practice, based on both national and the most important foreign guidelines providing specific advice on diagnostic procedures.
Algorithms↗
[Evaluation of disease management programs--current deficits, demands and methods].
The evaluation of disease management programmes is necessary and has been made obligatory in Germany by the Fifth Book of Social Code. So far there has been extensive ambiguity as regards the precise definition of suitable strategies for the evaluation. Considering the scientific evaluation of the diabetes contract in North-Rhine current deficits of the evaluation of already existing programmes for chronically ill patients are exemplarily described. On the basis of international experience reasonable demands are discussed that ought to be accomplished when evaluating the effectiveness and benefit of the programmes. Taking the British Medical Research Council as an example, a four-step model will be suggested as a loophole in the methodological dilemma of varying suitable study designs, which allows for the adequate evaluation of even complex interventions.
Disease Management↗
[General practice in a modern health care system--consequences for medical research, education and practice].
This first of two articles describes the far-reaching changes to the practice and theory of general practice that are leading from the old-style general practitioner changing to the modern-day primary health care specialist. These already partly accomplished changes, whilst bringing into focus the future role of general practice in a modern health care system, are altering the self-awareness of the profession and the way it defines itself. Specifics of the theory and practice of decision-making in primary health care, within this context of vital importance but as yet barely taken into account, are explained on the basis of Bayes' theorem and with the aid of examples of empirical data on the rational diagnosis of thyroid dysfunction. Making use of examples of coronary heart disease diagnostics, the second part of this article illustrates important differences between health care-service levels and the consequences arising from these differences for medical research, education and practice.
Delivery of Health Care↗
[General practice in a modern health care system--consequences for medical records, education and practice (2)].
Exemplified by studies on the predictive value of standardised history taking of angina pectoris, part 2 of this contribution describes the different significance of medical diagnostics in dependency from different levels of the health care system (general practice, cardiologic drop-in clinic, university hospital). Because of different prevalences (pre-test probability) and in spite of exactly the same symptoms the probability of actual coronary heart disease is highly different. The specific post-test probability can be explained and calculated by Bayes' theorem. It becomes evident why general practitioners have to be cautious in adopting recommendations, if those recommendations are based on studies which were done with patients in specialised health care settings. As a consequence from the reflections and empirical findings presented, it becomes better comprehensible what general practice is not and which perspectives for research, education and practice are resulting.
Angina Pectoris↗