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Biomedical subjects

M M Kochen

Publications and source records attributed to M M Kochen.

At least 19 recordsLinked to original sources
PubMed2006

[Pragmatic and effective treatment of painful neck].

Management of a patient with atraumatic neck pain is a complex task that necessitates a careful differentiation between harmless and risky but preventable courses (red flags), with account having to be taken of psychosocial and somatic factors. At the same time diagnostic measures need to be limited to the truly necessary, and the development of chronicity must be avoided. The very fact that the clinical significance of neck pain clearly takes second place to its psychosocial and health-economic aspects points up the need to explicitly draw attention to the rare dangerous courses.

Chronic Disease↗
PubMed2006

[Transformation of general measures by patients in heart failure].

BACKGROUND AND OBJECTIVE: Non-pharmacological treatment (NPT) and immunization with influenzal and pneumococcal vaccines are an integral part in the management of heart failure (HF). However, few data are available about the implementation of NPT in real life. The aim of this study was to analyse long-term changes in behavior and the use of self-care strategies by patients with HF. PATIENTS AND METHODS: 91 of 151 patients in HF (77 men, 14 women; mean age 68) at the Göttingen University Hospital were recruited to the study. Implementation of NPT was assessed during the hospital stay and one year after discharge by standardized interviews. Additionally, patients were also asked about their preferred sources of information about HF. RESULTS: Compared with the baseline data, NPT were more frequently named after one year (significant increase for "See the doctor in case of weight gain" [24.3% vs. 57.1%; p<0.001] and "Dietary salt restriction" [41.4% vs. 70.0%; p<0.001]. Patients who had been readmitted reported NPT more frequently than those who had not previously been admitted to hospital (3.6 vs. 3.1, n.s). The majority of patients considered general practitioners to be the most important source for information on HF. CONCLUSIONS: One year after discharge more patients had become aware of NPT. On the whole lifestyle modification is still relatively uncommon. General practitioners are seen as the most important informants on the management of HF and could use this trust to promote greater implementation of NPT by their patients.

Aged↗
PubMed2006

[Health services research in general practice. A new approach].

Competence networks in medicine, involving departments of general practice (www.kompetenznetze-medizin.de), as well as a large research support program "General Practice" funded by the German Federal Ministry of Education and Research (www.gesundheitsforschung-bmbf.de/de/439.php) mirror the increasing importance of academic general practice for health services research. The use and benefit of computerized medical records is exemplified by the classification of therapeutic measures and prevalence estimates of diseases. Computerized medical records from 134 practices could be extracted via the BDT (BehandlungsDatenTräger) interface. Using SQL (structured query language) queries, we identified patients with urinary tract infection (UTI), airway obstruction and chronic heart failure and the therapeutic management for these illnesses. Age and sex of the patients were nearly completely documented in the BDT data. Patients with UTI (6,239 consultations) received most often cotrimoxazole (69%) and fluoroquinolone (15%), less often trimethoprim (9%) and herbal UTI drugs (4%). About half of the 2,714 patients with asthma received inhaled steroids, to a somewhat lesser degree than patients suffering from chronic obstructive pulmonary disease (50 vs 53%). In a subsample of practices (n=44), we identified 4,120 patients with a diagnosis of chronic heart failure. Using refined analysis tools, computerized medical records from general practices may be helpful to answer relevant questions of health services research and contribute to quality assurance in ambulatory patient care.

Airway Obstruction↗
PubMed2005

What do primary care patients think about generic drugs?

OBJECTIVE: To examine the attitude of patients towards generic drugs and prescriptions containing generic drugs as an alternative to brand-name products, with a special focus on information on patients attitude to generic drugs provided by their general practitioners (GPs). METHODS: A total of 804 patients in 31 general practices were surveyed using a self-questionnaire. The influence of age, sex, education, disease, knowledge of generic drugs, experience with generic substitution and information provided by the GP on patient attitudes towards generic drugs and substitutions were examined. RESULTS: Nearly two thirds of the patients (509/804) stated that they knew of the difference between brand-name drugs and generics; of these, one third were not satisfied with the information given by their GPs and 37% of patients expressed general skepticism towards generic drugs because of their lower price. This attitude was more frequent among those who felt that generic prescribing was "invented" to solve the financial crisis in the German health insurance system at their expense (odds ratio (OR): 6.2; 95% confidence interval: 4.0 - 9.8) and those who had not been confronted personally with a generic substitution (OR: 1.8; 1.3 3.0). Patients who had been skeptical when first confronted with a generic substitution were more frequently among those who considered inexpensive drugs to be inferior (OR: 4.5; 2.0 10.4) and they were frequently not satisfied with the information on substitution provided by their GP (OR: 2.7; 1.2 - 5.9). CONCLUSION: GPs are in an ideal position to inform their patients adequately about the equivalence of brand-name and generic drugs. However, the patient view that inexpensive drugs must be inferior may be difficult to rectify in the short term.

Drugs, Generic↗
PubMed2004

Antibiotics for community acquired pneumonia in adult outpatients.

BACKGROUND: Community-acquired pneumonia (CAP) is a common condition representing a significant disease burden for the community, particularly for the elderly. Because antibiotics are helpful in treating CAP, they are the standard treatment and CAP thus contributes significantly to antibiotic use, which is associated with the development of bacterial resistance and side-effects. Although several studies have been published concerning CAP and its treatment, the available data arises mainly from studies conducted in hospitalized patients and outpatients. There is no concise summary of the available evidence that can help clinicians in choosing the most appropriate antibiotic. OBJECTIVES: Our goal was to summarize the evidence currently available from randomized controlled trials (RCTs) concerning the efficacy of alternative antibiotic treatments for CAP in ambulatory patients above 12 years of age. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2003) which contains the Cochrane Acute Respiratory Infections Group's trial register; MEDLINE (January 1966 to September week 3, 2003), and EMBASE (January 1974 to March 2003). Studies were also identified by checking the bibliographies of studies and review articles retrieved as well as by perusing medical journals. To identify any additional published or unpublished studies, we contacted the following antibiotics manufacturers: Abbott, AstraZeneca, Aventis, Boehringer-Ingelheim, Bristol-Myers-Squibb, GlaxoSmithKline, Hoffmann-LaRoche, Lilly, Merck, Merck Sharp & Dohme, Novartis, Pfizer, Pharmacia, Sanofi, and Yamanouchi. No language restrictions were applied in any of the search strategies. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) in which one or more antibiotics were tested for the treatment of CAP in ambulatory adolescent or adult patients. Studies testing one or more antibiotic and reporting the diagnostic criteria used in selecting patients as well as the clinical outcomes achieved were included. No language restrictions were applied. DATA COLLECTION AND ANALYSIS: Data were extracted and study reports assessed by two independent reviewers (LMB and TJMV). Authors of studies were contacted as needed to resolve any ambiguities in the study reports. The data were analyzed using the Cochrane Collaboration's RevMan 4.2.2 Software. Differences between reviewers were resolved by discussion and consensus. MAIN RESULTS: Three randomized controlled trials involving a total of 622 patients aged 12 years and older diagnosed with community acquired pneumonia were included. The quality of the studies and of the reporting was variable. A variety of clinical, radiological and bacteriological diagnostic criteria and outcomes were reported. Overall there was no significant difference in the efficacy of the various antibiotics under study. REVIEWERS' CONCLUSIONS: Currently available evidence from RCTs is insufficient to make evidence-based recommendations for the choice of antibiotic to be used for the treatment of community acquired pneumonia in ambulatory patients. Pooling of study data was limited by the very low number of studies. Individual study results do not reveal significant differences in efficacy between various antibiotics and antibiotic groups. Multi-drug comparisons using similar administration schedules are needed to provide the evidence necessary for practice recommendations.

Adult↗
PubMed2004

Drug changes at the interface between primary and secondary care.

OBJECTIVE: To analyze the frequency and factors associated with drug change in a sample of patients referred to hospital by their general practitioner. METHODS: This observational study is based on a chart review of 100 consecutively recruited patients with a chronic disease who were referred to the general internal medicine wards in each of 3 district general hospitals in Germany (total 300 patients). The frequency of drug cancellation, replacement, dosage alteration, change in manufacturer and of commencing treatment with a new drug were recorded. RESULTS: Half of the drugs used in chronic treatment (644/1,330) and prescribed by general practitioners were continued during hospitalization. The fraction canceled was 36%. In the rest of the drugs in this group, there were some minor changes carried out by the hospital. On the day of the drug survey, a total of 1,572 drugs were being taken by the patients and 724 of these drugs were newly prescribed by hospital. Only 13 patients experienced no change to their drug regimen during their stay in hospital. In more than 60% of patients (184/300), there were 3 or more changes made in their drug regimen. The rate of drug cancellation for antihypertensive and cardiac drugs in patients referred to hospital for cardiovascular and non-cardiovascular problems did not differ. CONCLUSION: During hospitalization, nearly every patient is confronted with some form of drug change. Of major concern is the high rate of drug change affecting drugs being taken for diseases other than that associated with the hospitalization. Hospital drug policy should encourage clinicians to continue drug regimens in newly admitted patients whenever medically appropriate and caution clinicians against making unnecessary changes to drug regimens prescribed by general practitioners.

Adult↗
PubMed2004

Urinary tract infection in men.

OBJECTIVE: To explore the prevalence and microbiology of urinary tract infection (UTI) in symptomatic men in a primary care setting and to determine the appropriateness of patient management of these conditions by the general practitioners. METHODS: A cross-sectional survey was carried out matching documentation of symptoms and management with urine culture and results of susceptibility tests. All patients presenting with symptoms typical for a UTI in 36 teaching general practices in the area of Göttingen, Germany, were eligible for enrolment in the study. 15% (n = 90) of all patients were adult men. General practitioners (GPs) were instructed to manage patients as usual. Patient characteristics, dipstick tests and treatment were matched with results of urine cultures and susceptibility testing. RESULTS: Men presenting with symptoms indicative of UTI were predominantly elderly (median age 61 years) and 41% had additional risk factors. Antibiotics were prescribed for 36%, but these were not well-targeted. Urine culture revealed UTI in 60%, of which half had low colony counts (23% of all patients) or multiple bacterial growth (7%); 40% had sterile urine. Dipstick tests proved unhelpful: leukocytes and nitrite had sensitivities of 54% and 38%, specificities of 55% and 84%, positive predictive values of 65% and 78% and negative predictive values of 44% and 46%, respectively. Resistance levels were 53% for amoxicillin and cefaclor, 28% for cefixim, 22% for ciprofloxacin, 34% for both trimethoprim as individual substance and the combination with sulfamethoxazole (cotrimoxazole) and 25% for nitrofurantoin. CONCLUSION: Men with symptoms indicative of a UTI should not be treated empirically. A urine culture and antibiogram should be obtained before a treatment decision is made. A low-count UTI was common and should not be considered normal.

Adult↗
PubMed2003

[Medical care research based on family doctor routine data--are interface-communicated treatment data feasible?].

AIMS OF THE STUDY: As part of an ongoing project on the utilisation of generic drugs in general practice we aimed at determining whether the transfer of prescriptions and patient characteristics from doctors' computerized medical records via the BDT (Behandlungsdatenträger) interface was feasible, and whether these data are suitable for research in pharmacoepidemiology. METHODS: All 1,395 general practitioners from 6 regions in Germany were invited to participate in the 'generics project'; 232 (17 %) agreed. The 17 software companies whose systems were used by the participating practices were asked to grant access to the BDT interface. For a prescription survey, doctors were supposed to export BDT files from two 3-month periods each in 2000 and 2001. Data were anonymised and relevant information extracted with a special programme. RESULTS: So far, BDT data are available from 79 practices. They are suitable for practice- and patient-related prescribing analyses. By filter modifications, additional information (such as diagnoses, referrals, clinical findings or accounting codes) can be obtained. The procedure was well accepted if doctors and practice staff were assisted by computer experts. Some difficulties, however, were encountered in obtaining access to the BDT-interface from the software companies. Lack of standardisation of the BDT interface required additional conditioning of the data. CONCLUSION: The BDT interface offers an opportunity to export computerised patient records without the requirement of additional documentation. If routine data are more readily available for health services research, a standardised data structure and open access must be assured e. g. by centralised certification via the Federal statutory health organisation.

Data Collection↗
PubMed2003

[Asthma management at the interface of general practice and hospital care].

The aim of the study was to assess the management of patients hospitalised for asthma with regard to the recommendations of the German Airway League, and the communication between hospital doctors and general practitioners (GPs). All records of patients discharged with asthma or COPD (ICD9) between 1/1996 and 6/1998 were retrieved (n = 169) in one general hospital. All patients whose asthma had been known in admission and was given as a reason for hospitalisation in the discharge letter were selected (n = 93). Treatment prescribed by the patients' GPs before hospitalisation as well as diagnostic procedures and treatment in hospital and the recommendations in the discharge letter were reviewed. Additionally the GPs were questioned with case vignettes. Before hospitalisation, most patients had been treated with theophyllin (66 %) and inhaled betamimetics (62 %), only 44 % had received topical and 29 % oral steroids by their GP. In hospital, lung function assessment was performed in only 8 % of the patients and there was no monitoring of the peak flow. The most commonly prescribed drugs were theophyllin (94 %), mucolytics (94 %) and antibiotics (82 %). Half of the patients (47 %) were discharged without adequate anti-inflammatory baseline treatment. The discharge letters did not contain detailed recommendations on future asthma management. There seems to be room for improvement with regard to the implementation of the German Airway League's recommendations both in hospital and in general practice: Few patients received systemic or inhaled steroids, whereas theophyllin and antibiotics were prescribed routinely. In hospital, airway obstruction was neither measured initially nor monitored. Communication between hospital doctors and GPs seems to be insufficient.

Adult↗
PubMed2001

Sexual problems of male patients in family practice.

OBJECTIVES: Little is known about men's expectations of their family physicians regarding sexual disorders. Our goal was to evaluate the frequency of sexual problems among male patients in family practice and to assess their need for help. STUDY DESIGN: We performed a cross-sectional survey based on structured questionnaires answered by patients and physicians in German family practices. POPULATION: We approached 43 family physicians; 20 (43%) participated. On a single day all men 18 years and older visiting the participating practices were approached, and 307 (84%) took part in the survey. OUTCOMES MEASURED: Patients were asked about their frequency and type of sexual problems, their need for help, and their expectations of their physicians. The physicians described their perceptions and management of sexual problems in family practice. RESULTS: Nearly all patients (93%) reported at least 1 sexual problem from which they suffered seldom or more often. The most common problems were low sexual desire (73%) and premature ejaculation (66%). Occupational stress was considered causative by more than half of the men (107/201). Forty-eight percent considered it important to talk with their physicians about sexual concerns. However, most physicians initiated a discussion about sexual concerns only seldom or occasionally. There was a nonsignificant correlation between the physicians' assumed knowledge and the patients' wish to contact them in case of sexual problems (rho=0.26). CONCLUSIONS: The high frequency of self-reported sexual disorders and the hesitancy of family physicians to deal with this topic signals a neglected area in primary health care. Certain conditions, such as occupational stress, which may be associated with sexual concerns, should encourage the physician to initiate discussions about sexuality.

Adult↗
PubMed2001

The predictive value of asthma medications to identify individuals with asthma--a study in German general practices.

BACKGROUND: The assessment of prescribing performance by aggregated measures mainly developed from automated databases is often helpful for general practitioners. For asthma treatment, the frequently applied ratio of anti-inflammatory to bronchodilator drugs may, however, be misleading if the specificity of a drug for the treatment of asthma, compared with other diseases, is unknown. AIM: To test the association of specific drugs with the diagnosis of asthma compared with other diagnoses. DESIGN OF STUDY: Cross-sectional study analysing prescription data from a retrospective chart review. SETTING: Eight general practices and one community respiratory practice in a town in Northern Germany. METHOD: All patients in the participating practices who received at least one of the 50 asthma drugs most frequently prescribed in Germany within the past 12 weeks were identified. Odds ratios (ORs) with 95% confidence intervals (ClI) were calculated to reveal any association between a specific drug and the diagnosis of asthma. The unit of analysis was the item prescribed. RESULTS: Topical betamimetics (e.g salbutamol, fenoterol) were the most often prescribed asthma drugs in the general practices (52.1 ) and in the respiratory practice (57.6%). Inhaled steroids accounted for 15% and 13%; systemic steroids accounted for 10% and 13%, respectively. In the general practices, inhaled betamimetics had a moderate marker function for asthma (OR = 2.0; 95% CI = 1.14-3.58). A fixed oral combination drug of clenbuterol plus ambroxol was a marker drug against asthma (OR = 0.35; 95% CI = 0.20-0.61). In the respiratory practice, the diagnosis of asthma was strongly marked by fixed combinations of cromoglycate plus betamimetics (OR = 29.0; 95% CI = 6.86-122.24) and moderately by inhaled betamimetics (OR = 2.6; 95% CI = 1.28-5.14). In contrast, systemic steroids (OR = 0.24; 95% CI 0.10-0.57) and even inhaled steroids (OR = 0.46; 95% ClI= 0.22-0.96) proved to contradict the diagnosis of asthma. CONCLUSION: Only betamimetics were markers for asthma patients in both types of practices; inhaled steroids, however, were not. Combinations of cromoglycate were markers in the respiratory practice only. Limited specificity of drugs for a disease (e.g asthma) should be taken into account when analysing prescribing data that are not diagnosis linked.

Adult↗
PubMed2000

Will German patients accept their family physician as a gatekeeper?

OBJECTIVE: Looking to the experience in the United States with managed care and the possible introduction of gatekeeping in the near future in Germany, we performed a population-based survey to examine preferences for future gatekeeping arrangements. DESIGN: Cross-sectional telephone survey. SETTING: Four health districts in Thuringia (formerly East Germany) and Lower Saxony (formerly West Germany). PARTICIPANTS: Out of a random sample of 644 adults in the 4 districts, 415 persons (64.4%) took part in the survey. MEASUREMENTS AND MAIN RESULTS: Using multiple logistic regression, we analyzed associations between preferences for gatekeeping arrangements and patient satisfaction, insurance status, and sociodemographic characteristics. Seventy-four percent of respondents valued first-contact care, especially older people (odds ratio [OR], 4.3; 95% confidence interval [95% CI], 2.0 to 9.3), people who were very satisfied with the relationship with their family physician (OR, 2.7; 95% CI, 1.6 to 4.8) and members of sickness funds in contrast to privately insured persons (OR, 2.4; 95% CI, 1.2 to 5.2). The family physician's influence in coordinating the use of specialist services was appreciated by 86%, more often by members of sickness funds (OR, 5.9; 95% CI, 2.4 to 14. 3), people who were very satisfied with their doctor's professional competence (OR, 3.2; 95% CI, 1.6 to 6.3) and older persons (OR, 2.9; 95% CI, 1.1 to 7.7). CONCLUSIONS: A vast majority of the German population would accept their family physician as entry point and as coordinator of all other health services. Since patient satisfaction, among other reasons, strongly influenced preferences for gatekeeper arrangements, family physicians themselves may be able to promote primary care health services.

Adult↗
PubMed2000

German family physicians' attitudes toward care of involuntarily childless patients.

BACKGROUND AND OBJECTIVES: Many family physicians regard fertility counseling out of their scope of practice, although key elements in the care of involuntarily childless couples fall within the theoretical framework of family practice. This study analyzed the doctors' value system concerning the care of infertile patients and whether a personal interview leads to a greater sensitivity toward fertility issues. METHODS: We conducted 57 baseline and 51 follow-up interviews with family physicians in the area of Göttingen, Germany. We performed quantitative and qualitative analyses. RESULTS: During the baseline interview, all family physicians placed involuntary childlessness within the domain of fertility specialists or regarded it as patients' private matter. Fourteen family physicians (27%) considered fertility counseling more important at the follow-up interview than at the time of the baseline interview. Judgmental views of infertile couples could be detected in both interviews. More than one third of the family physicians assumed a connection between the patients' childlessness and their personal behavior or way of living. Although the majority (73%) of the family physicians regarded involuntary childlessness as a disease and considered assisted conception techniques as legitimate, a recommendation for fee reimbursement for fertility services was rejected by more than half of the physicians. CONCLUSIONS: Most German family physicians do not consider that care of involuntarily childless couples is within or appropriate to their scope of practice.

Attitude of Health Personnel↗
PubMed2000

[Bronchial asthma--expectations and concepts of general practitioners].

Discrepancies between asthma management in general practice and national as well as international guidelines and recommendations are currently not fully explained. Subjective conceptions, ideas and beliefs are likely to be as important as factual knowledge when physicians decide how to treat their patients. Our study is part of the European Drug Education Project, an international project promoting rational pharmacotherapy in 5 European countries. Interviews on asthma and its treatment were conducted with 20 general practitioners in Germany, emphasizing beliefs and ideas on the disease and its origins as well as treatment goals and options rather than factual knowledge. Qualitative analysis was performed using a phenomenographic approach. Phenomenography aims at describing "subjective" reality, as it is conceived by people to understand learning and reflection processes. Even though most physicians know the treatment recommendations for asthma, adherence is variable. Reasons can be found in the variability of disease conceptions, often emphasizing psychosomatic or patient-centered aspects. The importance of individual treatment goals and experience of the doctor-patient relationship in a general practice setting is highlighted. Uneasiness concerning specialist recommendations on disease management and pharmacotherapy are commonly expressed. There are considerable variations in the physicians' conceptions on asthma and its management. Understanding these attitudes can provide a rational basis for the development of guidelines and implementation strategies corresponding to the needs of primary care physicians.

Asthma↗
PubMed1999

The many facets of involuntary childlessness in general practice.

OBJECTIVE: To obtain a vivid picture of involuntary childlessness in general practice so that the doctor becomes aware of the frequency and the forms of childlessness. DESIGN: Analysis of in-depth interviews. SETTING: General practices in the area of Göttingen, Germany. SUBJECTS: 35 patients (27 females) who described themselves as involuntarily childless. MAIN OUTCOME MEASURES: Family status, reason for childlessness as seen from the patient's perspective, treatment status, and expectations towards the general practitioner (GP). RESULTS: Eleven patients had one or more children resulting, either from the present partnership or from a previous partnership. A deficient hormone status (7 patients) and tubal disorders (7) were most frequently reported by the patients. Some patients reported several reasons. In four cases, childlessness was directly or indirectly caused by problems within the partnership. Only eight interviewees or their partners were receiving active treatment at the current time. An additional eight couples had been previously treated. Medical information and emotional support were most often expected from the GP, but not always received--because of lack of time, lack of trust or lack of initiative on the doctor's part. CONCLUSIONS: Since social reasons, problems with the partnership or anxieties may cause childlessness or may be associated with somatic causes, the GP should consider infertility in the broader context of family medicine. Although not all childless patients do expect immediate diagnosis, referral and treatment for their condition, they are often waiting for the GP's initiative to talk about their problems.

Adult↗