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      Regional variation of patient behaviour and reasons for consultation in the general practice of Northern Germany: protocol for an observational study

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          Abstract

          Introduction

          Inappropriate supply and an increasing demand on the healthcare system have been of concern for health policy in Germany for at least 15 years. In the primary care setting, this especially relates to an undersupply of general practitioners (GPs) in the countryside. In addition, there seem to be other regional differences, for example, a difference in accessing primary and secondary care between rural and urban areas. Despite these findings, regional differences in health services have not been studied extensively in Germany. Therefore, this study aims to explore regional variations of patient populations and reasons for accessing primary medical care.

          Methods and analysis

          We will conduct a cross-sectional observational study based on standardised interviews with 240 GPs and ∼1200 patients. Data collection started on 10 June 2015 and will probably be completed by 31 October 2016. We will include all districts and cities within 100 km from Hamburg and assign them according to the type of regions: rural, urban and environs. All eligible GPs will be invited to participate. Each practice will recruit up to 15 patients, aged 18 years or older. Questionnaires are based on a preliminary qualitative study and were pretested. Data will be analysed with descriptive statistics and regression modelling strategies adjusted for confounders and the GP-induced cluster structure.

          Ethics and dissemination

          Our study was approved by the Ethics Committee of the Medical Association of Hamburg and is conducted in accordance with the Declaration of Helsinki. Study participants give written informed consent before data collection and data is pseudonymised. Survey data and person identifiers are stored separately in locked cabinets and have restricted availability. The results of our study will be presented at conferences and published in peer-reviewed journals.

          Trial registration number

          NCT02558322; Pre-results.

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          Most cited references12

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          Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population.

          The aim of this study was to assess the validity of the Patient Health Questionnaire depression module (PHQ-9). It has been subject to studies in medical settings, but its validity as a screening for depression in the general population is unknown. A representative population sample (2,066 subjects, 14-93 years) filled in the PHQ-9 for diagnosis [major depressive disorder, other depressive disorder, depression screen-positive (DS+) and depression screen-negative (DS-)] and other measures for distress (GHQ-12), depression (Brief-BDI) and subjective health perception (EuroQOL; SF-36). A prevalence rate of 9.2% of a current PHQ depressive disorder (major depression 3.8%, subthreshold other depressive disorder 5.4%) was identified. The two depression groups had higher Brief-BDI and GHQ-12 scores, and reported lower health status (EuroQOL) and health-related quality of life (SF-36) than did the DS- group (P's < .001). Strong associations between PHQ-9 depression severity and convergent variables were found (with BDI r = .73, with GHQ-12 r = .59). The results support the construct validity of the PHQ depression scale, which seems to be a useful tool to recognize not only major depression but also subthreshold depressive disorder in the general population.
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            [Structural differences between health insurance funds and their impact on health services research: results from the Bertelsmann Health-Care Monitor].

            Claims data of health insurance companies are an important database for health services research. We investigated if there are differences in baseline characteristics and prevalence of chronic diseases between members of several health insurance funds in Germany, and if so, whether adjusting for age and sex could explain these differences. 10 representative surveys (conducted between 2004 and 2008) of the 'Bertelsmann Health-Care Monitor' comprising 15 089 participants aged 18 to 79 years were analysed. Our main independent variable was membership in one of 8 health insurance funds. The prevalence of self-reported hypertension, diabetes, atopic diseases, coronary heart disease and heart failure was studied. We first estimated the crude prevalence of chronic diseases stratified by these funds. We further fitted logistic regression models and adjusted for age and sex as well as for further comorbidities and health related factors. Most respondents were insured in the BKK (Betriebskrankenkassen; 20.1%), the AOK (Allgemeinen Ortskrankenkassen; 19.2%) and private health insurances (15.3%). Substantial differences were found according to age, sex, educational level and prevalences of chronic diseases. Stratified by health insurance funds, prevalences ranged between 17.1-29.6% for hypertension, between 3.9-11.4% for diabetes, between 4.3-6.7% for atopic diseases, between 3.4-6.7% for coronary heart disease and between 2.6-5.7% for heart failure. When adjusting for sex and age, estimates for all 5 diseases were significant higher in AOK members compared to privately insured persons (3 diseases within the BAMER and the DAK, accordingly). In total, this was the case for 17 out of 35 comparisons. Even after adjusting for further comorbidities and health related factors 6 out of 35 comparisons showed significant increased estimates compared to privately insured persons. We found considerable differences in the prevalence of chronic diseases between German health insurance funds that remained after controlling for age and sex, and even after adjustment for further health-related variables. Further methodological studies are urgently needed to assess strengths and weaknesses of German claim data. © Georg Thieme Verlag KG Stuttgart · New York.
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              The career expectations of medical students: findings of a nationwide survey in Germany.

              Demographic change, technical progress, and changing patterns of service use influence the future demand for physicians in the German health care system. The attitudes of medical students towards their later work in the health system is important for current health care planning. For that reason a nationwide survey aimed to identify major trends in preferred specialty, workplace characteristics (regional location, hospital) and perceived hindrances for clinical work. A questionnaire consisting of 34 closed questions was developed at the University of Mainz in 2009 and administered over the Internet in June and July 2010 to all medical students in Germany. The questions addressed the students' intentions regarding specialty training, location of practice, workload, and regional preference, as well as potential reasons why they might choose not to practice clinical medicine in the future. 12 518 web-based questionnaires were filled in (approx. 15.7% of all medical students in Germany in 2010). The mean age was 24.9 years, with 64% female and 36% male. Favored specialties were internal medicine (42.6%), family medicine (29.6%), pediatrics (27.0%) and surgery (26.8%). Nearly all respondents (96%) stated that they attached importance to compatibility of work and family life. Working in a salaried position (92.2%) was preferred to working in private practice (77.7%). General practice, in particular in rural locations, was significantly less favored than work as a specialist in cities. Although the coming generation of physicians anticipate working in clincial settings in the future, shortfalls in the areas of primary care and in rural locations are likely if medical students adhere to their preferences stated in the questionnaire.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2016
                29 June 2016
                : 6
                : 6
                : e010738
                Affiliations
                Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf , Hamburg, Germany
                Author notes
                [Correspondence to ] Dr Ingmar Schäfer; in.schaefer@ 123456uke.de
                Article
                bmjopen-2015-010738
                10.1136/bmjopen-2015-010738
                4932249
                27357194
                27cc5417-ca4a-4896-8b3b-bdd4f77adcbf
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 1 December 2015
                : 5 February 2016
                : 28 February 2016
                Categories
                Epidemiology
                Protocol
                1506
                1692
                1696

                Medicine
                primary care,regional variation,reasons for consultation,patient types,urban area,rural area
                Medicine
                primary care, regional variation, reasons for consultation, patient types, urban area, rural area

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