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Die Krebsvorsorge für Gebärmutterhalskrebs ist trotz wesentlicher Reduktion der Inzidenz und Mort... more Die Krebsvorsorge für Gebärmutterhalskrebs ist trotz wesentlicher Reduktion der Inzidenz und Mortalität verbesserungswürdig. Das zytologische Screening kann durch den molekularbiologischen HPV-DNA-Nachweis in seiner Wirksamkeit verbessert werden, was durch die Dünnschichtzytologie nicht gelingt. Für die Abklärung von Frauen mit abnormalem zytologischem Ergebnis oder positivem Nachweis von High-Risk-HPV ist die Kolposkopie die Methode der Wahl. Wird durch kolposkopisch gezielte Knipsbiopsie eine schwergradige Präkanzerose diagnostiziert, muss diese möglichst schonend behandelt werden. Bezüglich der Einschätzung des Progressionspotenzials von HPV-Infektionen oder cervikalen Präkanzerosen stehen eine Reihe von HPV-assoziierten und HPV-unabhängigen Biomarkern zur Verfügung, deren Wertigkeit für die klinische Praxis noch gezeigt werden muss.
Journal of Clinical Epidemiology, 2014
Objectives: To develop a framework to identify and classify interactions within and among treatme... more Objectives: To develop a framework to identify and classify interactions within and among treatments and conditions and to test this framework with guidelines on chronic heart failure (CHF) and its frequent comorbidity.
BMC Medicine, 2014
Multimorbidity is a health issue mostly dealt with in primary care practice. As a result of their... more Multimorbidity is a health issue mostly dealt with in primary care practice. As a result of their generalist and patientcentered approach, long-lasting relationships with patients, and responsibility for continuity and coordination of care, family physicians are particularly well placed to manage patients with multimorbidity. However, conflicts arising from the application of multiple disease oriented guidelines and the burden of diseases and treatments often make consultations challenging. To provide orientation in decision making in multimorbidity during primary care consultations, we developed guiding principles and named them after the Greek mythological figure Ariadne. For this purpose, we convened a two-day expert workshop accompanied by an international symposium in October 2012 in Frankfurt, Germany. Against the background of the current state of knowledge presented and discussed at the symposium, 19 experts from North America, Europe, and Australia identified the key issues of concern in the management of multimorbidity in primary care in panel and small group sessions and agreed upon making use of formal and informal consensus methods. The proposed preliminary principles were refined during a multistage feedback process and discussed using a case example. The sharing of realistic treatment goals by physicians and patients is at the core of the Ariadne principles. These result from i) a thorough interaction assessment of the patient's conditions, treatments, constitution, and context; ii) the prioritization of health problems that take into account the patient's preferenceshis or her most and least desired outcomes; and iii) individualized management realizes the best options of care in diagnostics, treatment, and prevention to achieve the goals. Goal attainment is followed-up in accordance with a re-assessment in planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context may trigger the (re-)start of the process. Further work is needed on the implementation of the formulated principles, but they were recognized and appreciated as important by family physicians and primary care researchers.
PLoS ONE, 2014
Introduction: Multimorbidity is a major concern in primary care. Nevertheless, evidence of preval... more Introduction: Multimorbidity is a major concern in primary care. Nevertheless, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. The aim of this study is to systematically review studies of the prevalence, patterns and determinants of multimorbidity in primary care.
European Journal of General Practice, 2014
Older patients, suffering from numerous diseases and taking multiple medications are the rule rat... more Older patients, suffering from numerous diseases and taking multiple medications are the rule rather than the exception in primary care. A manifold of medical conditions are often associated with poor outcomes, and their multiple medications raise additional risks of polypharmacy. Such patients account for most healthcare expenditures. Effective approaches are needed to manage such complex patients in primary care. This paper describes the results of a scoping exercise, including a two-day workshop with 17 professionals from six countries, experienced in general practice and primary care research as well as epidemiology, clinical pharmacology, gerontology and methodology. This was followed by a consensus process investigating the challenges and core questions for multimorbidity research in primary care from a clinical perspective and presents examples of the best research practice. Current approaches in measuring and clustering multimorbidity inform policy-makers and researchers, but research is needed to provide support in clinical decision making. Multimorbidity presents a complexity of conditions leading to individual patient's needs and demanding complex processes in clinical decision making. The identification of patterns presupposes the development of strategies on how to manage multimorbidity and polypharmacy. Interventions have to be complex and multifaceted, and their evaluation poses numerous methodological challenges in study design, outcome measurement and analysis. Overall, it can be seen that complexity is a main underlying theme. Moreover, flexible study designs, outcome parameters and evaluation strategies are needed to account for this complexity.
BMC Public …, 2005
Rationale, design and conduct of a comprehensive evaluation of a primary care based intervention ... more Rationale, design and conduct of a comprehensive evaluation of a primary care based intervention to improve the quality of life of osteoarthritis patients. The PraxArt-project: a cluster randomized controlled trial [ISRCTN87252339] Abstract Background: Osteoarthritis (OA) has a high prevalence in primary care. Conservative, guideline orientated approaches aiming at improving pain treatment and increasing physical activity, have been proven to be effective in several contexts outside the primary care setting, as for instance the Arthritis Self management Programs (ASMPs). But it remains unclear if these comprehensive evidence based approaches can improve patients' quality of life if they are provided in a primary care setting.
BMC Cardiovascular Disorders, 2007
Background: Chronic congestive heart failure (CHF) is a complex disease with rising prevalence, c... more Background: Chronic congestive heart failure (CHF) is a complex disease with rising prevalence, compromised quality of life (QoL), unplanned hospital admissions, high mortality and therefore high burden of illness. The delivery of care for these patients has been criticized and new strategies addressing crucial domains of care have been shown to be effective on patients' health outcomes, although these trials were conducted in secondary care or in highly organised Health Maintenance Organisations. It remains unclear whether a comprehensive primary care-based case management for the treating general practitioner (GP) can improve patients' QoL.
Annals of Internal Medicine, 2009
Background: Case management by health care assistants in small primary care practices provides un... more Background: Case management by health care assistants in small primary care practices provides unclear benefit for improving depression symptoms.
British Journal of General Practice, 2015
There is limited evidence about the impact of treatment for subclinical hypothyroidism, especiall... more There is limited evidence about the impact of treatment for subclinical hypothyroidism, especially among older people. To investigate the variation in GP treatment strategies for older patients with subclinical hypothyroidism depending on country and patient characteristics. Case-based survey of GPs in the Netherlands, Germany, England, Ireland, Switzerland, and New Zealand. The treatment strategy of GPs (treatment yes/no, starting-dose thyroxine) was assessed for eight cases presenting a woman with subclinical hypothyroidism. The cases differed in the patient characteristics of age (70 versus 85 years), vitality status (vital versus vulnerable), and thyroid-stimulating hormone (TSH) concentration (6 versus 15 mU/L). A total of 526 GPs participated (the Netherlands n = 129, Germany n = 61, England n = 22, Ireland n = 21, Switzerland n = 262, New Zealand n = 31; overall response 19%). Across countries, differences in treatment strategy were observed. GPs from the Netherlands (mean treatment percentage 34%), England (40%), and New Zealand (39%) were less inclined to start treatment than GPs in Germany (73%), Ireland (62%), and Switzerland (52%) (P = 0.05). Overall, GPs were less inclined to start treatment in 85-year-old than in 70-year-old females (pooled odds ratio [OR] 0.74 [95% confidence interval [CI] = 0.63 to 0.87]). Females with a TSH of 15 mU/L were more likely to get treated than those with a TSH of 6 mU/L (pooled OR 9.49 [95% CI = 5.81 to 15.5]). GP treatment strategies of older people with subclinical hypothyroidism vary largely by country and patient characteristics. This variation underlines the need for a new generation of international guidelines based on the outcomes of randomised clinical trials set within primary care.
Die Krebsvorsorge für Gebärmutterhalskrebs ist trotz wesentlicher Reduktion der Inzidenz und Mort... more Die Krebsvorsorge für Gebärmutterhalskrebs ist trotz wesentlicher Reduktion der Inzidenz und Mortalität verbesserungswürdig. Das zytologische Screening kann durch den molekularbiologischen HPV-DNA-Nachweis in seiner Wirksamkeit verbessert werden, was durch die Dünnschichtzytologie nicht gelingt. Für die Abklärung von Frauen mit abnormalem zytologischem Ergebnis oder positivem Nachweis von High-Risk-HPV ist die Kolposkopie die Methode der Wahl. Wird durch kolposkopisch gezielte Knipsbiopsie eine schwergradige Präkanzerose diagnostiziert, muss diese möglichst schonend behandelt werden. Bezüglich der Einschätzung des Progressionspotenzials von HPV-Infektionen oder cervikalen Präkanzerosen stehen eine Reihe von HPV-assoziierten und HPV-unabhängigen Biomarkern zur Verfügung, deren Wertigkeit für die klinische Praxis noch gezeigt werden muss.
Journal of Clinical Epidemiology, 2014
Objectives: To develop a framework to identify and classify interactions within and among treatme... more Objectives: To develop a framework to identify and classify interactions within and among treatments and conditions and to test this framework with guidelines on chronic heart failure (CHF) and its frequent comorbidity.
BMC Medicine, 2014
Multimorbidity is a health issue mostly dealt with in primary care practice. As a result of their... more Multimorbidity is a health issue mostly dealt with in primary care practice. As a result of their generalist and patientcentered approach, long-lasting relationships with patients, and responsibility for continuity and coordination of care, family physicians are particularly well placed to manage patients with multimorbidity. However, conflicts arising from the application of multiple disease oriented guidelines and the burden of diseases and treatments often make consultations challenging. To provide orientation in decision making in multimorbidity during primary care consultations, we developed guiding principles and named them after the Greek mythological figure Ariadne. For this purpose, we convened a two-day expert workshop accompanied by an international symposium in October 2012 in Frankfurt, Germany. Against the background of the current state of knowledge presented and discussed at the symposium, 19 experts from North America, Europe, and Australia identified the key issues of concern in the management of multimorbidity in primary care in panel and small group sessions and agreed upon making use of formal and informal consensus methods. The proposed preliminary principles were refined during a multistage feedback process and discussed using a case example. The sharing of realistic treatment goals by physicians and patients is at the core of the Ariadne principles. These result from i) a thorough interaction assessment of the patient's conditions, treatments, constitution, and context; ii) the prioritization of health problems that take into account the patient's preferenceshis or her most and least desired outcomes; and iii) individualized management realizes the best options of care in diagnostics, treatment, and prevention to achieve the goals. Goal attainment is followed-up in accordance with a re-assessment in planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context may trigger the (re-)start of the process. Further work is needed on the implementation of the formulated principles, but they were recognized and appreciated as important by family physicians and primary care researchers.
PLoS ONE, 2014
Introduction: Multimorbidity is a major concern in primary care. Nevertheless, evidence of preval... more Introduction: Multimorbidity is a major concern in primary care. Nevertheless, evidence of prevalence and patterns of multimorbidity, and their determinants, are scarce. The aim of this study is to systematically review studies of the prevalence, patterns and determinants of multimorbidity in primary care.
European Journal of General Practice, 2014
Older patients, suffering from numerous diseases and taking multiple medications are the rule rat... more Older patients, suffering from numerous diseases and taking multiple medications are the rule rather than the exception in primary care. A manifold of medical conditions are often associated with poor outcomes, and their multiple medications raise additional risks of polypharmacy. Such patients account for most healthcare expenditures. Effective approaches are needed to manage such complex patients in primary care. This paper describes the results of a scoping exercise, including a two-day workshop with 17 professionals from six countries, experienced in general practice and primary care research as well as epidemiology, clinical pharmacology, gerontology and methodology. This was followed by a consensus process investigating the challenges and core questions for multimorbidity research in primary care from a clinical perspective and presents examples of the best research practice. Current approaches in measuring and clustering multimorbidity inform policy-makers and researchers, but research is needed to provide support in clinical decision making. Multimorbidity presents a complexity of conditions leading to individual patient's needs and demanding complex processes in clinical decision making. The identification of patterns presupposes the development of strategies on how to manage multimorbidity and polypharmacy. Interventions have to be complex and multifaceted, and their evaluation poses numerous methodological challenges in study design, outcome measurement and analysis. Overall, it can be seen that complexity is a main underlying theme. Moreover, flexible study designs, outcome parameters and evaluation strategies are needed to account for this complexity.
BMC Public …, 2005
Rationale, design and conduct of a comprehensive evaluation of a primary care based intervention ... more Rationale, design and conduct of a comprehensive evaluation of a primary care based intervention to improve the quality of life of osteoarthritis patients. The PraxArt-project: a cluster randomized controlled trial [ISRCTN87252339] Abstract Background: Osteoarthritis (OA) has a high prevalence in primary care. Conservative, guideline orientated approaches aiming at improving pain treatment and increasing physical activity, have been proven to be effective in several contexts outside the primary care setting, as for instance the Arthritis Self management Programs (ASMPs). But it remains unclear if these comprehensive evidence based approaches can improve patients' quality of life if they are provided in a primary care setting.
BMC Cardiovascular Disorders, 2007
Background: Chronic congestive heart failure (CHF) is a complex disease with rising prevalence, c... more Background: Chronic congestive heart failure (CHF) is a complex disease with rising prevalence, compromised quality of life (QoL), unplanned hospital admissions, high mortality and therefore high burden of illness. The delivery of care for these patients has been criticized and new strategies addressing crucial domains of care have been shown to be effective on patients' health outcomes, although these trials were conducted in secondary care or in highly organised Health Maintenance Organisations. It remains unclear whether a comprehensive primary care-based case management for the treating general practitioner (GP) can improve patients' QoL.
Annals of Internal Medicine, 2009
Background: Case management by health care assistants in small primary care practices provides un... more Background: Case management by health care assistants in small primary care practices provides unclear benefit for improving depression symptoms.
British Journal of General Practice, 2015
There is limited evidence about the impact of treatment for subclinical hypothyroidism, especiall... more There is limited evidence about the impact of treatment for subclinical hypothyroidism, especially among older people. To investigate the variation in GP treatment strategies for older patients with subclinical hypothyroidism depending on country and patient characteristics. Case-based survey of GPs in the Netherlands, Germany, England, Ireland, Switzerland, and New Zealand. The treatment strategy of GPs (treatment yes/no, starting-dose thyroxine) was assessed for eight cases presenting a woman with subclinical hypothyroidism. The cases differed in the patient characteristics of age (70 versus 85 years), vitality status (vital versus vulnerable), and thyroid-stimulating hormone (TSH) concentration (6 versus 15 mU/L). A total of 526 GPs participated (the Netherlands n = 129, Germany n = 61, England n = 22, Ireland n = 21, Switzerland n = 262, New Zealand n = 31; overall response 19%). Across countries, differences in treatment strategy were observed. GPs from the Netherlands (mean treatment percentage 34%), England (40%), and New Zealand (39%) were less inclined to start treatment than GPs in Germany (73%), Ireland (62%), and Switzerland (52%) (P = 0.05). Overall, GPs were less inclined to start treatment in 85-year-old than in 70-year-old females (pooled odds ratio [OR] 0.74 [95% confidence interval [CI] = 0.63 to 0.87]). Females with a TSH of 15 mU/L were more likely to get treated than those with a TSH of 6 mU/L (pooled OR 9.49 [95% CI = 5.81 to 15.5]). GP treatment strategies of older people with subclinical hypothyroidism vary largely by country and patient characteristics. This variation underlines the need for a new generation of international guidelines based on the outcomes of randomised clinical trials set within primary care.