Menschen mit schlecht eingestelltem Typ-2-Diabetes

Background

Approximately 15 % of patients with type 2 diabetes have permanently raised HbA1c levels. So far little is known about the psychosocial characteristics of this group. Some demographic and clinical characteristics seem to separate“poorly regulated” from“well regulated” patients but even here the results given in the literature are contradictory.

Aim

The aim of this study was to identify factors for the characterization of patients with type 2 diabetes mellitus from general practitioners and well versus poorly regulated metabolic control (according to HbA1c).

Material and methods

Interviews with 40 patients with type 2 diabetes and their general practitioners served as the basis for the development of 50 health psychological items in a questionnaire. These were distributed to 531 randomly selected type 2 diabetes patients with good or poor metabolic control.

Results

From the questionnaire four factors to describe these patients could be identified, among which the “perception of diabetes as a problem in daily life” was the strongest. Higher scores on this factor independently related to poor metabolic control. Among patients with good metabolic control there was a small cluster with a health psychological profile similar to patients with poor control.

Conclusion

The results suggest that for routine daily practice patients with poor metabolic control of type 2 diabetes should be interviewed about the perceived everyday problems with diabetes and to include this in shared goal setting of physicians and patients. This could foster the integration of diabetes into the patient’s daily routine in this problematic group.     

Coronary heart disease: acceptance of guideline recommendations irrelevant in Germany?

It is important to conduct research on how guidelines are acceptedand implemented among GPs and to look for barriers to theirimplementation. We believe, however, that a comparison betweencountries must be made with great care; we know that there aredifferences in the organization of primary care between differentEuropean countries. We also know there are differences in theprocess of implementing guidelines between     

Is COPD a rare disease? Prevalence and identification rates in smokers aged 40 years and over within general practice in Germany

Background. According to literature, COPD rates are high inspite of decreasing rates of main risk factors smoking and airpollution in developed countries. general practice is a goodplace to survey unbiased prevalence rates. Ten studies donein general practice over the last 20 years found prevalencerates among smokers between 13.1% and 92.1%. Objective. Prevalence and detection rates of COPD in smokersin German general practice. Methods. Twenty-eight of 34 invited and eligible GP surgeriesin/around Duesseldorf, Germany, took part in the non-announced2-day investigation of all smokers (40 years) who visited thesurgeries. Lung function test by hand-held spirometer, peakflow, sympton part of St George's Respiratory Questionnaire,and data on smoking habits were used. GOLD criteria for COPDwere employed. GPs had to give their diagnosis not knowing thetest results. Results. Of 3157 patients attending the 28 surgeries, 538 weresmokers. Four hundred and thirty-seven of these agreed to participate,5 had to be excluded for medical reasons/unacceptable spirometry.Three hundred and ninety-eight patients have not been previouslydiagnosed with COPD or asthma. Thirty patients were disgnosedwith COPD, making a prevalence of 6.9%, of which 15 patientswere already known as having COPD. Conclusion. Our result of low prevalence differs strongly fromall other studies in general practice. Considering our studydesign which avoids selection bias found in nearly all otherstudies (no pre-announcement, no self-selection of patientsor GPs, high participation rate and testing all patients), westrongly believe that our findings reflect the current situationof COPD in German general practice. Keywords. COPD, detection rate, general practice, prevalence, smoking, spirometry.     

Prävention in der Medizin

With the revival of “prevention” in Germany well-known problems from discussions in the 70s have gained new importance: prevention of behaviour vs prevention of conditions and orientation towards the individual vs society. On the one hand “curative” medicine in Germany never has allowed prevention to develop a role for itself, but on the other hand a preventive orientation has—unnoticed by medicine—revolutionized “curative medicine”. Not reflecting the structural differences between prevention and “curative medicine” has resulted in a number of serious misunderstandings of practical importance.     

Prophylaxis of constipation by wheat bran: a randomized study in hospitalized patients

To evaluate the efficacy of wheat bran in preventing constipation, 200 hospitalized patients were randomly allocated to groups receiving either a dietary supplement of 40 g bran daily or no dietary supplement at all. A quarter of the bran group patients refused to take their bran from the very beginning (refusers), one third stopped bran consumption during the study (dropouts), and only 42% of the patients continued on bran until discharge or death (participants). Independent of a previous history of constipation, neither the hospital incidence of constipation nor the average percentage of days on laxatives was significantly different between the bran group and the control group. Only the dropouts were significantly more constipated than the control patients, whereas no such difference could be demonstrated in the refusers or participants. It is concluded that the administration of bran as a prophylactic laxative confers no benefit in patients hospitalized for a relatively short time.     

How do general practitioners deal with patients they do not consider to be depressed but who are classified as such according the PHQ-9?

OBJECTIVES How GPs describe their patients who they did not identify as suffering from depression but who were classified as such by PHQ-9? What conclusions can be drawn with regard to how depression is dealt with and the illness model in use? METHOD GPs who took part in a screening study were asked in interviews to talk about some of their patients - not being informed that these were those not identified as depressive by them. This study comprises 21 narrative interviews from 18 GPs. Analysis by Framework method by Lewis and Ritchie. RESULTS The low identification rate of depression is not the result of failed recognition of "psychological problems" but of other factors centring on GPs' particular way of working and their concepts about mental illness: making a diagnosis only in a contextual way of interpreting symptoms; using the time passing as a help for diagnosing; emphasis on the impairment rather the diagnosis; considering the therapeutic consequences before making a diagnosis; a tolerance concerning "deviation" respectively wider view on "normality". CONCLUSION Understanding the different ways of conceptionalizing mental illness by psychiatrists and general practitioners is basic for their cooperation.     

Which patients with type 2 diabetes mellitus are perceived as ‘difficult’ by general practitioners?

AimsTo find factors that are associated with a general practitioner’s (GP’s) subjective impression of a patient being ‘difficult’ within a sample of patients with type 2 diabetes mellitus (T2DM).MethodsSecondary cross-sectional analysis of a cohort of GP patients with T2DM. GP questionnaire on clinical data and GPs’ subjective ratings of patient attributes (including ‘patient difficulty’). Patient questionnaire on sociodemographics and illness perceptions. Bivariate and multivariate analyses, adjusted for cluster-effect of GP practice.ResultsData from 314 patients from 49 GPs could be analysed. Independent associations with higher GP-rated difficulty were found for (odds ratio; 95% confidence interval): male patients from male GPs (1.27; 1.06–1.53), unmarried men (1.25; 1.04–1.51), men with non-German nationality (1.80; 1.24–2.61), patients perceiving more problems with diabetes (1.17; 1.04–1.30), patients with higher BMI (1.01; 1.00–1.02) and HbA1c values (1.06; 1.02–1.10), patients being perceived by the GP as less adherent (1.34; 1.22–1.46) and less health-literate (1.19; 1.04–1.35).ConclusionsThe impact of patients’ gender and illness perception yield new insights into GP-perceived complexity of care. Culturally and gender-sensitive communication techniques for adapting health care goals to patients’ problems (rather than norm values) may alleviate GPs’ work.