BackgroundIn Germany, a decreasing number of general practitioners (GPs) face a growing number of patients with multimorbidity. Whilst care for patients with multimorbidity involves various healthcare providers, the coordination of this care is one of the many responsibilities of GPs. The aims of this study are to identify the barriers to the successful coordination of multimorbid patient care and these patients’ complex needs, and to explore the support needed by GPs in the care of multimorbid patients. Interviewees were asked for their opinion on concepts which involve the support by additional employees within the practice or, alternatively, external health care professionals, providing patient navigation.MethodsThirty-two semi-structured, qualitative interviews were conducted with 16 GPs and 16 medical practice assistants (MPAs) from 16 different practices in Berlin. A MPA is a qualified non-physician practice employee. He or she undergoes a three years vocational training which qualifies him or her to provide administrative and clinical support.The interviews were digitally recorded, transcribed and analysed using the framework analysis methodology.ResultsThe results of this paper predominantly focus on GPs’ perspectives of coordination within and external to general practice. Coordination in the context of care for multimorbid patients consists of a wide range of different tasks. Organisational and administrative obstacles under the regulatory framework of the German healthcare system, and insufficient communication with other healthcare providers constitute barriers described by the interviewed GPs and MPAs. In order to ensure optimal care for patients with multimorbidity, GPs may have to delegate responsibilities associated with coordinating tasks. GPs consider the deployment of an additional specifically qualified employee inside the general practice to take on coordinative and social and legal duties to be a viable option.ConclusionsThe cross-sectoral cooperation between all involved key players working within the healthcare system, as well as the coordination of the whole care process, is seemingly challenging for GPs within the complex care system of multimorbid patients. GPs are generally open to the assignment of a person to support them in coordination tasks, preferably situated within the practice team.

The increasing proportion of women in family medicine might favor task shifting in General Practice.

BackgroundPolicy efforts focus on a reorientation of health care systems towards primary prevention. To guide such efforts, we analyzed the role of primary prevention in general practice and general practitioners’ (GPs) attitudes toward primary prevention.MethodsMixed-method study including a cross-sectional survey of all community-based GPs and focus groups in a sample of GPs who collaborated with the Institute of General Practice in Berlin, Germany in 2011. Of 1168 GPs 474 returned the mail survey. Fifteen GPs participated in focus group discussions. Survey and interview guidelines were developed and tested to assess and discuss beliefs, attitudes, and practices regarding primary prevention.ResultsMost respondents considered primary prevention within their realm of responsibility (70%). Primary prevention, especially physical activity, healthy eating, and smoking cessation, was part of the GPs’ health care recommendations if they thought it was indicated. Still a quarter of survey respondents discussed reduction of alcohol consumption with their patients infrequently even when they thought it was indicated. Similarly 18% claimed that they discuss smoking cessation only sometimes. The focus groups revealed that GPs were concerned about the detrimental effects an uninvited health behavior suggestion could have on patients and were hesitant to take on the role of “health policing”. GPs saw primary prevention as the responsibility of multiple actors in a network of societal and municipal institutions.ConclusionsThe mixed-method study showed that primary prevention approaches such as lifestyle counseling is not well established in primary care. GPs used a selective approach to offer preventive advice based upon indication. GPs had a strong sense that a universal prevention approach carried the potential to destroy a good patient-physician relationship. Other approaches to public health may be warranted such as a multisectoral approach to population health. This type of restructuring of the health care sector may benefit patients who are unable to afford specific prevention programmes and who have competing demands that hinder their ability to focus on behavior change.

A specifically intended effect of these recommendations is to reduce the use of antibiotics to treat colds and acute bronchitis, for which they are not indicated. Further clinical trials of treatments for cough should be performed in order to extend the evidence base, which is now fragmentary.

Zusammenfassung Ziel Vor dem Hintergrund der demografischen Entwicklung werden zukünftig Versorgungsmodelle wichtig, die Hausärzte in der Versorgung von Patienten mit komplexem Bedarf unterstützen können. Die vorliegende Fragebogenstudie untersucht, welche Formen der Unterstützung sich Berliner Hausärzte wünschen. Methodik Alle niedergelassenen Hausärzte Berlins (n=2354) wurden im Zeitraum August bis September 2018 postalisch gebeten, einen für die Fragestellung entwickelten Fragebogen auszufüllen. Die Fragen adressierten den Unterstützungsbedarf sowie verschiedene Unterstützungsmodelle. Es wurde zwischen Unterstützungsmöglichkeiten innerhalb (Delegation, Substitution) und außerhalb (Sozialarbeiter, Versorgungslotsen, Pflegestützpunkt) von Hausarztpraxen differenziert. Die Auswertung erfolgte deskriptiv, sowie explorativ multivariat in Bezug auf Zusammenhänge zwischen der Zustimmung zu Unterstützungsmodellen und Praxis- bzw. Arztcharakteristika (Alter, Geschlecht der Ärzte, Lage der Praxis, Praxisform, Arbeitszeit). Ergebnisse 557 Fragebögen (Response Rate 23,7%) wurden ausgewertet. Unterstützungsbedarf wurde v. a. für administrative, koordinative und organisatorische Tätigkeiten gesehen sowie für soziale und sozialrechtliche Fragestellungen. Ein Großteil der teilnehmenden hausärztlichen Praxen steht sowohl der Delegation als auch der Substitution ärztlicher Leistungen positiv gegenüber. Darüber hinaus ist für Hausärzte auch Unterstützung außerhalb der eigenen Praxis durch Mitarbeiter eines ambulanten Pflegedienstes, eines Pflegestützpunktes, oder durch Sozialarbeiter und Versorgungslotsen vorstellbar. Insbesondere jüngere und weibliche Hausärzte sowie diejenigen, die bereits in kooperativen Praxis-Strukturen tätig sind, sind offen für kooperative Ansätze unter Einbeziehung weiterer Gesundheitsberufe. Schlussfolgerung Es bestehen noch unzureichend genutzte Potenziale der Delegation und der Kooperation mit bestehenden Strukturen. Die hier befragten Berliner Hausärzte zeigten ein hohes Maß an Zustimmung zu Delegation und Substitution. Aber auch Gesundheitsberufe und Institutionen außerhalb der eigenen Praxis könnten die Hausärzte stärker unterstützen. Insbesondere für administrative und koordinative Tätigkeiten sowie für soziale und sozialrechtliche Fragestellungen wird Unterstützungsbedarf gesehen. In weiteren Untersuchungen sollte die Akzeptanz unter der Ärzteschaft und die Machbarkeit unterschiedlicher Modelle weiter untersucht werden.