BackgroundThe majority of studies investigating stress in primary care have focused either on general practitioners (GPs) or practice assistants (PAs), but did not measure stress on a practice level. We analyzed the prevalence of chronic stress for both professional groups and on a practice level and investigated personal, practice, and regional characteristics.MethodsChronic stress was measured in GPs and PAs from 136 German practices using the standardized, self-administered TICS-SSCS questionnaire (12 items). Based on a sum-score, participants per professional group were categorized as having low or high strain due to chronic stress (≤ 25th and ≥ 75th percentile of the study population´s distribution, respectively). For a cluster-level analysis, the mean of all practice means was used to categorize low- and high-stress practices. The intra-class correlation coefficient (ICC) was calculated using ANOVA. Prevalence Ratios (PR) were used to compare low versus high strain due to stress, stratified for personal, practice and regional characteristics.ResultsThe response rate was 74.1% (n = 137/185). Data from 214 GPs (34.1% female), 500 PAs (99.4% female), and 50 PAs in training (98.0% female) were analyzed. Chronic stress was highest in female GPs (median 19, IQR (interquartile range) 11.5), followed by PAs (16, IQR 12.25) and male GPs (15, IQR 10). On a practice level, 26.3% of the practice personnel reported a high stress level. We observed an overall ICC of 0.25, with higher ICCs when stratifying by professional group (PAs: ICC 0.36, GPs in group practices: ICC 0.51). High chronic stress was observed as the number of working hours per week increased (GPs: PR 2.03, 95% CI 1.16–3.56; PAs: PR 2.02, 95% CI 1.22–3.35). There were no differences for practice type (solo/group) and the various regional characteristics.ConclusionPersonal and practice characteristics were associated with chronic stress in GPs, PAs, and on a practice level. The high ICCs indicate a need for stress-reduction strategies geared at both professions on a practice level.

Background Perceived high chronic stress is twice as prevalent among German general practitioners (GPs) and non-physician medical staff compared to the general population. The reasons are multi-factorial and include patient, practice, healthcare system and societal factors, such as multi-morbidity, the diversity of populations and innovations in medical care. Also, practice-related factors, like stressful patient-staff interactions, poor process management of waiting times and lack of leadership, play a role. This publicly funded study evaluates the effectiveness of the newly developed participatory, interdisciplinary, and multimodal IMPROVEjob intervention on improving job satisfaction among general practice personnel. The intervention aims at structural stress prevention with regard to working conditions and behavioural stress prevention for leaders and other practice personnel. Methods In this cluster-randomised controlled trial, a total of 56 general practices will be assigned to either (1) participation in the IMPROVEjob intervention or (2) the waiting-list control group. The IMPROVEjob intervention consists of the following elements: three workshops, a toolbox with supplemental material and an implementation period with regular contact to so-called IMPROVEjob facilitators. The first workshop, addressing leadership issues, is designed for physicians with leadership responsibilities only. The two subsequent workshops target all GP and non-physician personnel; they address issues of communication (with patients and within the team), self-care and team-care and practice organisation. During the 9-month implementation period, practices will be contacted by IMPROVEjob facilitators to enhance motivation. Additionally, the practices will have access to the toolbox materials online. All participants will complete questionnaires at baseline and follow up. The primary outcome is the change in job satisfaction as measured by the respective scale of the validated German version of the Copenhagen Psychosocial Questionnaire (COPSOQ, version 2018). Secondary outcomes obtained by questionnaires and - qualitatively - by facilitators comprise psychosocial working conditions including leadership aspects, expectations and experiences of the workshops, team and individual efforts and organisational changes. Discussion It is hypothesised that participation in the IMPROVEjob intervention will improve job satisfaction and thus constitute a structural and behavioural prevention strategy for the promotion of psychological wellbeing of personnel in general practices and prospectively in other small and medium sized enterprises. Trial registration German Clinical Trials Register: DRKS00012677. Registered on 16 October 2019. Retrospectively, https://www.drks.de/drks_web/navigate.do?navigationId=trial. HTML&TRIAL_ID = DRKS00012677.

BackgroundImmunization programs are among the most effective public health strategies worldwide. Adequate vaccine storage is a prerequisite to assure the vaccines’ effectiveness and safety. In a questionnaire survey among a random sample of German primary care physicians, we discovered vaccine storage deficits: 16 % of physicians had experience with cold chain breaches either as an error or near error, 49 % did not keep a temperature log, and 21 % did not use a separate refrigerator for vaccine storage. In a recent feasibility study of 21 practice refrigerators, we showed that these were outside the target range 10.2 % of the total time with some single refrigerators being outside the target range as much as 66.3 % of the time. These cooling-chain deficits are consistent with the international medical literature, yet an effective, easy to disseminate, practice-centered intervention to improve storage conditions is lacking.Methods/designThis randomized intervention trial will be conducted in a random sample of primary care practices. Based on continuous temperature recordings over 7 days, all practices with readings outside the target range for vaccine storage (+2 °C to +8 °C) will be randomly allocated to a web-based education program or a waiting list control group. The practice physicians and their teams constitute the target population. Participants will be educated about best practices in vaccine storage and will receive a manual including storage checklists and templates for temperature documentation. In all practices, temperatures of the vaccine refrigerators will be monitored continuously using a data logger with a glycol probe as a surrogate for vaccine vial temperature. The effectiveness of the web-based education program will be determined after 6 months in terms of the proportion of refrigerators with vaccine vial temperatures within the target range (+2 °C to +8 °C) during 7-day temperature logging. Secondary outcome parameters include temperature monitoring, no critically low temperatures (≤ -0.5 °C), compliance with storage recommendations, knowledge of good vaccine storage conditions, and assignment of personnel as vaccine storage manager and backup.DiscussionKeep Cool will develop and evaluate a web-based education program to improve vaccine storage conditions in primary care and thereby ensure immunization safety and effectiveness.Trial registrationDRKS00006561 (date of registration: 20 February 2015)

BackgroundThe prevalence of chronic stress among German general practitioners (GPs) was shown to be twice as high as in the general population. Because chronic stress negatively influences well-being and poor physician well-being is associated with poor patient outcomes, targeted strategies are needed. This analysis focuses on work-related factors associated with high chronic stress in GPs.MethodsThis cross-sectional study measured chronic stress among German GPs using the validated and standardized Trier Inventory for the Assessment of Chronic Stress (TICS-SSCS). Based on the TICS, GPs were categorized as either having low strain (≤ 25th percentile) or high strain (≥ 75th percentile) due to chronic stress. Questions on work-related challenges assessed the frequency and the subjectively perceived strain of single challenges. For exploratory analyses, these items were combined to dichotomous variables reflecting challenges that are common and that cause high strain. Variables significant in bivariate analyses were included in a multivariate logistic regression model analyzing their association with high chronic stress.ResultsData of 109 GPs categorized as having low strain (n = 53) or high strain (n = 56) due to chronic stress were analyzed. Based on bivariate analyses, challenges regarding personnel matters, practice software, complexity of patients, difficult patients, care facilities, scheduling of appointments, keeping medical records up-to-date, fee structures, and expectations versus reality of care were included in the regression model. Keeping medical records up-to-date had the strongest association with high chronic stress (odds ratio 4.95, 95% confidence interval 1.29–19.06). A non-significant trend showed that medicolegal investigations were more common among GPs with high chronic stress.ConclusionsThis exploratory research shows that chronic stress is predominantly associated with administrative challenges. Treatment documentation, which represents a legal safeguard and is closely linked to existential concerns, has the strongest influence.

IntroductionProtecting vaccines from freeze damage is considered one of the most poorly addressed problems in vaccine management. Freezing may impair the potency especially of adsorbed vaccines. The Keep Cool study aims at ensuring optimal vaccine storage conditions in general practices. This publication analyses the baseline data using standardised temperature recordings.MethodsThis prospective study in German general practices analysed 7-day temperature recordings of refrigerators used for vaccine storage. Temperatures were recorded continuously using a standardised data logger with an accuracy of ±0.4 °C. The prevalence rates of refrigerators within the target range (2 to 8 °C) and of those reaching critically low temperatures (≤0 °C) were calculated. In addition, the cumulative time and the duration of single episodes beyond the target range were computed. To assess for structural deficits, the prevalence of refrigerators with a cycling of >5 °C was determined. Generalised linear mixed models were applied to analyse correlating factors between the dependent variables ‘within temperature range’ and ‘reaching critically low temperatures’ with practice characteristics.ResultsThe study included 64 of 168 practices (38.1% response rate) with 75 refrigerators. The prevalence of refrigerators with temperatures within the target range was 32.0% (n = 24), and 14.7% (n = 11) reached critically low temperatures <0 °C. 44.0% of refrigerators (n = 33) showed temperatures >8 °C and 28.0% (n = 21) <2 °C. Of the 168 hours recorded per refrigerator, the average cumulative time >8 °C was 49 hours, <2 °C 75 hours and ≤0 °C 74 hours. The longest consecutive period of critically low temperatures was 168 hours (mean: 39±53). The prevalence of refrigerators with a cycling range of >5 °C was 29.3%.ConclusionGiven the importance of immunisation, the results of our study call for action, as two-thirds of the refrigerators exhibited cold chain breaches and 15% reached critically low temperatures threatening vaccine potency.

BackgroundEffective immunizations require a thorough, multi-step process, yet few studies comprehensively addressed issues around vaccination management.ObjectivesTo assess variations in vaccination management and vaccination errors in primary care.MethodsA cross sectional, web-based questionnaire survey was performed among 1157 primary physicians from North Rhine-Westphalia, Germany: a representative 10% random sample of general practitioners (n = 946) and all teaching physicians from the University Duisburg-Essen (n = 211). Four quality aspects with three items each were included: patient-related quality (patient information, patient consent, strategies to increase immunization rates), vaccine-related quality (practice vaccine spectrum, vaccine pre-selection, vaccination documentation), personnel-related quality (recommendation of vaccinations, vaccine application, personnel qualification) and storage-related quality (storage device, temperature log, vaccine storage control). For each of the four quality aspects, “good quality” was reached if all three criteria per quality aspect were fulfilled. Good vaccination management was defined as fulfilling all twelve items. Additionally, physicians’ experiences with errors and nearby-errors in vaccination management were obtained.ResultsMore than 20% of the physicians participated in the survey. Good vaccination management was reached by 19% of the practices. Patient-related quality was good in 69% of the practices, vaccine-related quality in 73%, personnel-related quality in 59% and storage-related quality in 41% of the practices. No predictors for error reporting and good vaccination management were identified.ConclusionsWe identified good results for vaccine- and patient-related quality but need to improve issues that revolve around vaccine storage.

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Background. Patients use self-care to relieve symptoms of common colds, yet little is known about the prevalence and patterns across Europe. Methods/Design. In a cross-sectional study 27 primary care practices from 14 countries distributed 120 questionnaires to consecutive patients (≥18 years, any reason for consultation). A 27-item questionnaire asked for patients' self-care for their last common cold. Results. 3,074 patients from 27 European sites participated. Their mean age was 46.7 years, and 62.5% were females. 99% of the participants used ≥1 self-care practice. In total, 527 different practices were reported; the age-standardized mean was 11.5 (±SD 6.0) per participant. The most frequent self-care categories were foodstuffs (95%), extras at home (81%), preparations for intestinal absorption (81%), and intranasal applications (53%). Patterns were similar across all sites, while the number of practices varied between and within countries. The most frequent single practices were water (43%), honey (42%), paracetamol (38%), oranges/orange juice (38%), and staying in bed (38%). Participants used 9 times more nonpharmaceutical items than pharmaceutical items. The majority (69%) combined self-care with and without proof of evidence, while ≤1% used only evidence-based items. Discussion. This first cross-national study on self-care for common colds showed a similar pattern across sites but quantitative differences.