Evaluation der Leitlinien-Akzeptanz, Praktikabilität und Optimierung zum Thema Thoraxschmerz im Praxistest

The target group of this study are patients who seek consultation with their family physician due to chest pain. All types of pain (burning, piercing, etc.) which take place within the ventral thorax of the posterior axillary line are classified as chest pain. A differentiation is made between cardiac and non-cardiac conditions. The guideline chest pain was developed by employees of the Department of General Medicine, Preventive and Rehabilitative Medicine, as well as practicing or academically active general practitioners. The development concept is based on a 10-step plan by DEGAM. The subject matter of this dissertation is the acceptance, practicability and the feasibility of the guideline modules in family physician practices at this point in time. Furthermore, to which extent the collected patient data matches the guideline recommendations in terms of diagnosis and treatment will also be of interest in the analysis. This evaluation aims to provide information concerning possible modifications of the guideline and the according modules. Moreover, a comparison between the guideline cohort and the non-guideline cohort will be carried out while taking the following points into account: • the diagnosis accuracy • the diagnostic validity of the suspected diagnosis • the procedure differentiated by risk categories This study was carried out from October 26, 2009 till February 2, 2010 in 57 family physician practices in Hessia, Germany. In the twelve-week time period, 862 patients older than the age of 35 with newly occurring chest pain were included in the study for the validation of the Marbuger KHK Score. The practical test was embedded in the diagnostic cross-sectional study. 17 family physicians were recruited for the guideline evaluation. For logistical reasons, they represent the last tranche of the entire study. They were invited to an informational meeting, and were provided a preliminary final version of the guideline and the according modules. The collection of data was completed using standardized questionnaires for the evaluation of the entire guideline, the associated modules, and two focus group discussions. The result of the focus group discussion was multifaceted, and the statements of the family physicians were heterogeneous. In regards of the long version, the opinions of the participants ranged from completely simple to horrid, or too complex . In contrast, the shorter version and the Marburger KHK Score was evaluated positively, and was easy to integrate into the daily routine in a practice. Several family physicians agreed that their work could be structured better, and that the quality of medical provision could be improved by means of medical innovations. Others were unconvinced by the guidelines, because of their belief in the individuality of patients. The number of recruited patients per practice ranged from 2 to 60. Several family physicians only used the guideline in uncertain cases, but the majority shared the opinion that their behavior remained unchained by the utilization of the guideline. In contrast, others reported that they were more attentive during the study, and performed much more extensive anamneses than before. Using the collected data, it can be deduced that the guideline chest pain was accepted by the family physicians, and perceived as a stimulus. However, a proportion of the family physicians did not adhere to the suggestions made by the guideline authors due to other suspect diagnoses, and their own beliefs. In regards of diagnosis accuracy, diagnostic validity, and utilization of ECG tests, there proved to be no difference discernible between family physicians who received and were given an introduction to the guideline, and those who did not have such information at hand. The implementation of guidelines is obviously a complex process which requires long-term support. The results led to a revision of the guideline modules.