Schröder et al The German Society for Neurology then published the first national guideline for the treatment of Parkinson’s disease (status as of 11.06.2003)8 based on international standards.9–11 Germany was one of the first European countries to publish national guidelines as treatment standards for physicians in the area of Parkinson’s disease. At the same time, changes in health reforms within Germany that increased demand for higher quality and more cost-effective treatment regimes12 also had an impact on physicians’ prescribing behaviors and may have influenced whether or not they followed the new guideline. Germany was therefore chosen from a multinational survey to evaluate the awareness and knowledge of the German practice guideline for Parkinson’s disease among neurologists. The national guideline’s treatment recom- mendations were based on the following core principles that were aimed at delaying the onset of late-stage complications and reducing side effects: 1) patients less than 70 years old should be treated with dopamine agonists without L-dopa (L-dopa sparing approach); 2) if required for stable and adequate symptom control, more impaired patients less than 70 years old may use L-dopa in addition to dopamine agonist based treatment; 3) older patients and those with comorbid conditions should receive L-dopa, whilst the use of dop- amine agonists should be avoided until motor complications occur; 4) independent of age and treatment basis, monotherapy should be initiated and maintained for as long as possible until patients’ impairment requires more complex treatment. If this standard is followed, individualized pharmaco- therapy based on age, disease stage, and characteristics can result in an improved ongoing relief from symptoms and may delay the onset of long-term motor complications. Hence, guidelines issued by national professional societies are of particular practical relevance for treating physicians although, to date, little information is available on whether or not physicians adhere to these guidelines and implement them in their daily practice.13–16 The objective of this study was therefore to investigate whether neurologists in Germany implement the Parkinson’s disease national guideline in their daily practice, as exemplified by the actual use of dopamine agonists and L-dopa as recommended by the German Society for Neurology. Method Data collection Germany was chosen as part of a multinational, cross- sectional survey that was conducted amongst neurologists treating patients suffering from Parkinson’s disease (Adelphi 104 submit your manuscript | www.dovepress.com Dovepress Dovepress Group Products. Parkinson’s II Disease Specific Programmes: Real World Studies. Data on file. Macclesfield, UK. 2004).17 Data was collected during QII (April–June) 2004 from a total of 60 neurologists who were recruited in Germany. In order to cover all German regions equally, nationally representative samples of specialists who were responsible for decisions regarding drug therapy and management of outpatients with Parkinson’s disease were randomly screened using telephone interviews. Only those who expected to complete at least 10 patient records during a 2 week period were recruited; they were then asked to complete patient record forms for the next 10 Parkinson’s disease patients that visited their practice. The details recorded included demographics, symptoms and func- tionality, Hoehn and Yahr (H&Y) stage, consultation history, and drug therapy. The study was conducted in accordance with ESOMAR guidelines18 and ethical approval from the institutional review board was not required. The 60 neurologists provided data on 608 patients with Parkinsonism, of whom the 451 with a diagnosis of idiopathic Parkinson’s disease (according to the UK Brain Bank Criteria)19 were taken into consideration for further analyses. These figures are consistent with Parkinsonism and Parkinson’s disease diagnosis in a community based sample of participants.20 Patients were divided into five grades according to their level of functional impairment as rated by the physicians: patients without functional impair- ment (grade I), patients in H&Y stage I (grade II), patients in H&Y stage II–V without motor complications (grade III), patients with motor complications (grade IV), and patients in the palliative phase (grade V). Motor complications were defined as L-dopa-associated such as dyskinesia, dystonia, on-off fluctuations, and .10% off time per day. Explicit rules to test guideline adherence, however, could only be derived for patients receiving drug treatment who were without motor complications. This selection was manda- tory due to the complexity of treatment regimes in patients with L-dopa-associated motor complications, thus making the rules otherwise difficult to specify. Consequently, only the 320 patients in grade II (n = 82) and grade III (n = 238) were included in the final analyses. The patients were also divided into those aged ,70 years (n = 191) and those aged $70 years (n = 129). Assessment of guideline adherence Adherence to the national guideline was assessed using a number of methods Firstly, we defined four explicit parameters regarding the use of dopamine agonists and L-dopa that reflect the guideline’s Neuropsychiatric Disease and Treatment 2011:7