Lohmann H, Kulessa F, Holling H, Johnen A, Reul S, Lueg G, Duning T
Klinik für Allgemeine Neurologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland.
Institut für Psychologie, Westfälische Wilhelms-Universität Münster, Münster, Deutschland.
Nervenarzt. 2017 Aug;88(8):895-904. doi: 10.1007/s00115-017-0325-z.
Published in 2009, the German S3 guidelines on dementia define a milestone in quality improvement of the diagnostics and treatment of dementia. In clinical practice patients suffering from dementia are primarily treated by physicians in private practice; therefore, this study examined how the guidelines are implemented in outpatient clinical settings. Furthermore, it aimed at the identification of behavioral determinants that govern the actual diagnostic and therapeutic approach in clinical practice.
Physicians involved in the primary care of dementia patients were asked to participate in a nationwide internet survey. The questionnaire covered aspects on the diagnostic and therapeutic care of dementia patients as recommended by the S3 guidelines. Behavioral determinants of the implementation of the guidelines (e. g. treatment decisions) were derived from an established psychological prediction model.
Out of a total of 2755 physicians contacted, the data of 225 participants could be used in this study. The diagnostic recommendations of the S3 guidelines were implemented in satisfactory measures (e.g. combined cognitive screening in at least 68%, cerebral neuroimaging in at least 93% and specific laboratory diagnostics in at least 27% of cases); however, only two thirds of the patients with indications for a guideline-conform therapy were treated in accordance with the S3 guidelines. There was a substantial prescription of non-recommended drugs and a notable long-term use of antipsychotic drugs (prescription by at least 14% of non-neurological medical specialists and by 8% of neurologists and psychiatrists). When considering the behavioral determinants in the implementation of the guidelines, normative assumptions ("my colleagues and patients expect me to comply with the guidelines") surprisingly had the highest impact, which was then followed by attitudes towards the behavior ("utilization of the guidelines improves diagnostics and therapy").
The German S3 guidelines on dementia were satisfactorily implemented in outpatient clinical practice; however, deficits existed in the frequency of the pharmaceutical treatment of patients with indications for therapy, the prescription of non-recommended drugs and the relatively common use of permanent neuroleptic medications. Interestingly, the motivation for implementation of the guidelines was not primarily influenced by the physicians' personal convictions but mainly stimulated by the expectations of others.
2009年发布的德国痴呆症S3指南是痴呆症诊断和治疗质量改进的一个里程碑。在临床实践中，痴呆症患者主要由私人执业医生治疗；因此，本研究考察了这些指南在门诊临床环境中的实施情况。此外，其目的是确定在临床实践中指导实际诊断和治疗方法的行为决定因素。
参与痴呆症患者初级护理的医生被邀请参加一项全国性的网络调查。问卷涵盖了S3指南推荐的痴呆症患者诊断和治疗护理方面的内容。指南实施的行为决定因素（如治疗决策）源自一个既定的心理预测模型。
在总共联系的2755名医生中，225名参与者的数据可用于本研究。S3指南的诊断建议得到了令人满意的实施（例如，至少68%的病例进行了联合认知筛查，至少93%的病例进行了脑神经成像，至少27%的病例进行了特定实验室诊断）；然而，只有三分之二有指南相符治疗指征的患者得到了符合S3指南的治疗。存在大量不推荐药物的处方以及抗精神病药物的显著长期使用情况（至少14%的非神经科医学专家以及8%的神经科医生和精神科医生开具了此类药物）。在考虑指南实施中的行为决定因素时，规范性假设（“我的同事和患者期望我遵守指南”）出人意料地产生了最大影响，其次是对行为的态度（“使用指南可改善诊断和治疗”）。
德国痴呆症S3指南在门诊临床实践中得到了令人满意的实施；然而，在有治疗指征患者的药物治疗频率、不推荐药物的处方以及永久性抗精神病药物的相对普遍使用方面存在不足。有趣的是，指南实施的动机并非主要受医生个人信念的影响，而是主要受他人期望的推动。
