BackgroundMedical overuse is a topic of growing interest in health care systems and especially in primary care. It comprises both over investigation and overtreatment. Quaternary prevention strategies aim at protecting patients from unnecessary or harmful medicine. The objective of this study was to gain a deeper understanding of relevant aspects of medical overuse in primary care from the perspective of German general practitioners (GPs). We focused on the scope, consequences and drivers of medical overuse and strategies to reduce it (=quaternary prevention).MethodsWe used the qualitative Grounded Theory approach. Theoretical sampling was carried out to recruit GPs in Bavaria, Germany. We accessed the field of research through GPs with academic affiliation, recommendations by interview partners and personal contacts. They differed in terms of primary care experience, gender, region, work experience abroad, academic affiliation, type of specialist training, practice organisation and position. Qualitative in-depth face-to-face interviews with a semi-structured interview guide were conducted (n = 13). The interviews were audiotaped and transcribed verbatim. Data analysis was carried out using open and axial coding.ResultsGPs defined medical overuse as unnecessary investigations and treatment that lack patient benefit or bear the potential to cause harm. They observed that medical overuse takes place in all three German reimbursement categories: statutory health insurance, private insurance and individual health services (direct payment). GPs criticised the poor acceptance of gate-keeping in German primary care. They referred to a low-threshold referral policy and direct patient access to outpatient secondary care, leading to specialist treatment without clear medical indication. The GPs described various direct drivers of medical overuse within their direct area of influence. They also emphasised indirect drivers related to system or societal processes. The proposed strategies for reducing medical overuse included a well-founded wait-and-see approach, medical education, a trustful doctor-patient relationship, the improvement of primary/health care structures and the involvement of patients and society.ConclusionsGPs are frequently located at the starting point of the diagnostic and treatment process. They have the potential to play a vital role in quaternary prevention. This requires a debate going beyond the medical profession and involving society as a whole.Electronic supplementary materialThe online version of this article (10.1186/s12875-017-0667-4) contains supplementary material, which is available to authorized users.

There is an ongoing debate whether visual object representations can be formed outside the focus of voluntary attention. Recently, implicit behavioral measures suggested that grouping processes can occur for task-irrelevant visual stimuli, thus supporting theories of preattentive object formation (e.g., Lamy, D., Segal, H., & Ruderman, L. Grouping does not require attention. Perception and Psychophysics, 68, 17-31, 2006; Russell, C., & Driver, J. New indirect measures of "inattentive" visual grouping in a change-detection task. Perception and Psychophysics, 67, 606-623, 2005). We developed an ERP paradigm that allows testing for visual grouping when neither the objects nor its constituents are related to the participant's task. Our paradigm is based on the visual mismatch negativity ERP component, which is elicited by stimuli deviating from a regular stimulus sequence even when the stimuli are ignored. Our stimuli consisted of four pairs of colored discs that served as objects. These objects were presented isochronously while participants were engaged in a task related to the continuously presented fixation cross. Occasionally, two color deviances occurred simultaneously either within the same object or across two different objects. We found significant ERP differences for same- versus different-object deviances, supporting the notion that forming visual object representations by grouping can occur outside the focus of voluntary attention. Also our behavioral experiment, in which participants responded to color deviances--thus, this time the discs but, again, not the objects were task relevant--showed that the object status matters. Our results stress the importance of early grouping processes for structuring the perceptual world.

BackgroundPatients with chronic depression (persisting symptoms for ≥2 years) are a clinically relevant group with extensive (co)morbidity, high functional impairment and associated costs in primary care. The General Practitioner (GP) is the main health professional attending to these patients. The aim of this study was to examine the GPs’ perception on managing patients with chronic depression.MethodsWe performed an explorative cross-sectional study with a systematic sample of GPs in central Germany. Source of data was a written questionnaire (46 items). Descriptive analysis was carried out.ResultsTwo hundred twenty (out of 1000; 22%) GPs participated. 93% of the GPs distinguish between care for patients with chronic depression and acute depressive episode. 92% would recommend psychotherapeutic co-treatment to the chronically depressed patient. 52% of GPs would favour a general restraint on antidepressants (ADs) in older chronically depressed patients (≥ 75 years) whereas 40% suggest long-term pharmacotherapy. If severe physical comorbidity is present GPs would be restrictive in prescribing ADs (65%) or would urgently refer to specialist psychiatric services (40%). In case of a comorbid anxiety disorder 66% of the GPs would suggest a combined psycho- und pharmacotherapy. If a substance use disorder coexists 84% would prefer urgent referrals to specialist services.ConclusionsParticipating GPs report awareness towards chronic depression in their patients. Physical and mental comorbidity seem to play an important role in GPs’ treatment decisions.

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