Physicians’ Perspectives on the Implementation of the Second Opinion Directive in Germany—An Exploratory Sequential Mixed-Methods Study

Abstract

A new Second Opinion Directive (SOD) was introduced in Germany in December 2018 for hysterectomy, tonsillotomy, and tonsillectomy to support shared decision making and to avoid unnecessary surgeries. Owing to its recent implementation, evidence and insights regarding outcomes and challenges encountered with the SOD are lacking, notably from the physicians’ perspective. To assess this, we undertook an exploratory sequential mixed-methods design with an initial qualitative phase followed by a quantitative evaluation. A qualitative analysis of 22 interviews with specialists in gynecology and otorhinolaryngology was followed by a statistical analysis of a survey of 136 physicians in those disciplines. The specialists expressed a generally positive opinion of the new SOD, emphasizing the aspects of patient orientation, support in decision making, and patient safety. However, they also highlighted the following structural problems regarding the SOD implementation: In addition to an increased organisational effort, the specialists criticised the SOD with regard to its implementation in rural regions with a low availability of specialists for referral. Barriers that impede the implementation of the current directive, such as the adaptation of the qualifying requirements for authorized second opinion physicians, as well as the inclusion of relevant indications, need focused consideration to obtain better alignment with everyday practice.

Does the Second Opinion Directive in Germany reach the patient? A parallel-convergent mixed- methods study

“…Interestingly, we found some contradictory results in a previous study among physicians [12]. They stated more frequently that they informed about where to nd an SO physician and that the medical records could be taken along.…”

“…The main nding is that the SOD does not reach the health care system because physicians do not provide information as intended in the SOD. While physicians are generally positive about the concept of SOs, a previous study demonstrated that the implementation of SOD is associated with a lack of acceptance and challenges in everyday practice [12]. Insu cient implementation could be explained, on the one hand, by the fact that physicians tend to have a negative attitude towards the SOD.…”

“…We have already learned about physicians' negative attitude towards the SOD, so it seems that the SOD needs to be adjusted in certain respects to be better accepted. For example the criterion "postdoctoral lecture quali cation or advanced trainer for physicians" needed for authorization of SO physicians was heavily criticized as well as the fact that there are not enough SO physicians in rural areas [12]. Since patients with the SOD-assigned indications cannot be identi ed simply like that, there are again two options.…”

“…In the group tonsillectomy/tonsillotomy, 19 parents or legal guardians replied to the questionnaire, the median age of the children was 8 (IQR 6-11), and females constituted 47.4% (9/19) of respondents. In the groups hysterectomy and tonsillectomy/tonsillotomy, HLS was 14 in median (IQR [11][12][13][14][15], and the DCS resulted in 12.5 (IQR 4.2-31.3). Those three questions were not part of the short form for shoulder arthroscopy.…”

“…The present study is part of the ZWEIT project [8], which examines the characteristics and use of SO programs in Germany and considers the resulting needs and wishes from the perspectives of physicians [12,13] and of (potential) patients [14,15]. Figure 1 combines the elements of the SOD investigated in this study and the research questions.…”