Associations Of Statutory Health Insurance Physicians Research Articles

Effects of care of multimorbid patients in general practices by advanced practice nurses (FAMOUS): study protocol for a nonrandomized controlled trial

BackgroundMultimorbidity is a common phenomenon among patients treated in general practices. Key challenges within this group include functional difficulties, polypharmacy, treatment burden, fragmentation of care, reduced quality of life and increased health care utilization. These problems cannot be solved in the short consultation time of a general practitioner (GP) since there is an increasing shortage of GPs. In many countries, advanced practice nurses (APNs) are successfully integrated into primary health care for multimorbid patients.The objective of this study is to examine whether the integration of APNs in the primary care of multimorbid patients in Germany leads to optimized care of the target group and to a reduction in the workload of the GPs.MethodsThe intervention includes the integration of APNs into the care for multimorbid patients in general practice for twelve months. Qualifications for APNs include a master's level academic degree and 500 hours of project-specific training. Their tasks include in-depth assessment, preparation, implementation, monitoring and evaluation of a person-centred and evidence-based care plan.In this nonrandomized controlled trial, a prospective multicentre mixed methods study will be performed. The main inclusion criterion was the cooccurrence of three chronic diseases. For data collection in the intervention group (n = 817), routine data from health insurance companies and association of statutory health insurance physicians (ASHIP) will be used, as well as qualitative interviews. In addition, the intervention will be assessed through documentation of the care process and standardized questionnaires using a longitudinal design. The control group (n = 1634) will receive standard care. For the evaluation, routine data from health insurance companies are matched at a ratio of 1:2.Outcomes will be measured using emergency contacts and GP visits, treatment costs, health status of the patients and the satisfaction of parties involved.The statistical analyses will include Poisson regression to compare outcomes between the intervention and control groups. Descriptive and analytical statistical methods will be used in the longitudinal analysis of the intervention group data. Cost analysis will compare total costs and subgroup costs between the intervention and control groups. Qualitative data will be analysed using content analysis.DiscussionChallenges to this protocol could include the political and strategic environment as well as the planned number of participants.Trial registrationDRKS00026172 on DRKS.

Do decision-makers in the German healthcare system misjudge thesituation of a branch office? - Motivation of physicians to set up in a GP's practice in the area of the Association ofStatutory Health Insurance Physicians North-Rhine

The aim of the study was to illustrate motives for a GP's branch from the current point of view by branch (expectations fulfilled) and before branch (motivation). In addition, obstructive or beneficial factors of a branch should be identified. Using a mixed-methods approach (focus groups, individual interviews) with the target group were used in the qualitative part of experiences, opinions and motivations for the GP's branch and, after evaluation, a pre-tested questionnaire was used. A full survey of 675 identified GPs from the database of the Association of Statutory Health Insurance Physicians North Rhine was carried out. These had settled in the last 5 years before the survey period (09/2015). The questionnaire sent by post contained 17 questions on settlement motivation and 11 biographical aspects. The number of evaluable data records was 437 (64.7 %). The highest approval values, in the sense of conducive to settlement motivation, were "discontinuation of services in the hospital" (97.2 %) and "being one's own boss" (96.2 %). Rights and duties as a "panel physician" (8.5 %), and the "emergency service for panel physicians/on-call service" (22.7 %) were perceived as more of an obstacle. In terms of fulfilling expectations, the "discontinuation of services" (95.6 %) and the "diversity of age groups to be treated" (88.9 %) emerged. A total of 97 % would settle down again, regardless of the degree to which their wishes were fulfilled, and almost ¾ would only decided to work as family doctors after they had completed their studies. The fact that escaping from the stationary sector is the main driving force behind the settlement must be thought-provoking. Since this survey approach was not based on specialist groups or the level of training, but on a complete survey of established persons over a five-year period, it can be stated that the current incentive structures of a branch should be rethought due to the age structure of the interviewees.

From AGnES to PA - medical assistant professions in Germany: Who still keeps the track?

Demographic change will lead to a serious shortage of doctors in the inpatient and outpatient sectors in the next years. To ensure that medical care is provided in the future, various models of medical assistant professions have been created in the past, both at state and federal level. Due to the diversity of these training courses, advanced training courses and study paths, it is becoming increasingly difficult to keep track of fields of application, focal points of activities, etc. METHOD: An analysis of the currently existing models and professions of physician assistants was carried out. The models considered are VERAH, AgnESzwei, EVA, MoNi, MoPra, OTA/ATA, CTA, ANP and PA. VERAH, AgnESzwei, EVA, MoNi and MoPra carry out their activities in primary care. OTA/ATA, CTA, ANP and PA, on the other hand, are active in clinical inpatient care (PA also in outpatient care). All curricula show significant differences in entrance requirements, length of time and content. VERAH and AgnESzwei, EVA, MoNi and MoPra have the lowest entrance requirements and the shortest advanced training. VERAH and AgnESzwei focus on case management, while OTA/ATA or CTA training and ANP as well as PA studies focus on practical clinical use and the transfer of medical knowledge. While CTAs and OTAs/ATAs can work in the surgery field only and ANP mainly in the nursing field, PA can work both in the clinical and outpatient field. Due to the already existing doctors shortage, which will increase in the future, medical care can only be guaranteed by interprofessional team building. To this end, the professional associations and the associations of Statutory Health-Insurance physicians are called to develop appropriate models and remuneration.

ICD-Codierqualität ambulanter Krebsdiagnosen in GKV-Routinedaten

BackgroundDespite their importance for the morbidity-oriented risk structure compensation scheme, the ICD coding quality for outpatient diagnoses is often criticized. However, the coding quality for outpatient cancer diagnoses remains unclear. In this study, we examined the ICD-10 coding quality for outpatient breast, prostate and colorectal cancer diagnoses in statutory health insurance (SHI) claims data. MethodsThe cohort study comprised 34,756 members of the BARMER GEK statutory health insurance fund diagnosed with breast, prostate or colorectal cancer in 2012 and with no respective diagnosis in the previous 4 quarters. Using internal validation approaches, we examined the proportion of diagnoses confirmed by persistence (further diagnoses or death) and/or congruence (EBM, OPS and ATC codes). ResultsThe proportion of diagnoses confirmed by a further diagnosis or death within one quarter of follow-up was 69.8 % for breast cancer, 73.0 % for prostate cancer and 64.6 % for colorectal cancer, increasing to 71.8 %, 74.6 % and 68.0 %, respectively, when considering provision of care using EBM, OPS and ATC codes. By extending the diagnosis-free lead time to 16 quarters and the follow-up time to 4 quarters, the proportion rose to 83.9 %, 85.1 % and 75.8 %, respectively. Results varied by sex, age, the Associations of SHI Physicians and settlement pattern. ConclusionsBecause there were no further indications confirming the incident outpatient cancer diagnoses a proportion of diagnoses remain unconfirmed. When conducting studies based on SHI claims data, these limitations in the ICD coding quality for outpatient cancer diagnoses should be taken into account by using internal validation approaches.

Regionale Analyse der medikamentösen Behandlungsprävalenz und Arzneimitteltherapie von Diabetes mellitus in Deutschland

Diabetes mellitus is a widespread chronic disease. Diabetes prevalence was already analyzed in multiple complex studies. The goal of this analysis was the determination of the regional drug treatment prevalence and medication of diabetes mellitus in Germany. Simultaneously, we examined and validated the applicability of prescription data of the German statutory health insurance (SHI) as the basis for reliable and comparable prevalence estimations. For the analysis, we used anonymized data from a prescription database as well as the member statistics of the German federal Ministry of Health. By using defined prescription profiles with anti-diabetic medication, we determined the diabetic patients and treatment schemes per Association of SHI Physicians. Subsequently, we calculated and described the drug treatment prevalence and medication. A differentiation between type 1 and type 2 diabetes was not possible. The total prevalence of drug-treated patients in Germany was 7.77%. The regional values ranged from 6.40% in Schleswig-Holstein until 11.37% in Saxony-Anhalt. The highest numbers of drug treatment prevalence were found in the East of Germany. Insulin treatment was frequent in Hamburg, but rare in Bavaria. Insulin combined with oral anti-diabetic medication was mainly dispensed in Saxony-Anhalt and Brandenburg, least in Hamburg. A treatment with one or more oral anti-diabetics was most common in Bavaria and Bremen, lowest in Rhineland-Palatinate and Mecklenburg-West Pomerania. We developed an easy to use evaluation algorithm for prescription data to estimate the drug treatment prevalence of a chronic disease. The estimated prevalence confirms the increasing trend reported from other studies and appears to be plausible in comparison. More research is required to validate and enhance the method.

Herpes zoster in Germany: Quantifying the burden of disease

BackgroundHerpes zoster (HZ) is caused by a reactivation of the varicella-zoster-virus (VZV) and mainly affects individuals aged ≥ 50 years. Vaccines have been licensed or are under development that can protect against HZ and its main complication postherpetic neuralgia (PHN). In Germany, the burden of disease caused by HZ is not well known. To support the decision making process related to a potential vaccination recommendation, we estimated annual HZ disease burden in people aged ≥ 50 years in Germany by utilizing various data sources.MethodsWe assessed for 2007 and 2008 HZ-outpatient incidence (number of cases per 1,000 person-years, PY) by utilizing the Association of Statutory Health Insurance Physicians (ASHIP) database, which contains nationwide routine outpatient data. For the same time period annual number of HZ-inpatients and HZ-associated deaths were identified by using the Federal Health Monitoring System (FHM). PHN-incidence and loss of quality-adjusted life years (QALYs) caused by HZ were calculated by multiplying number of identified HZ-patients with upper and lower limit estimates for proportion of HZ-cases developing PHN and HZ-related QALY, respectively.ResultsFor the study period we identified an annual average of 306,511 HZ-outpatients aged 50+, resulting in a HZ-incidence of 9.6/1,000 PY. A total 14,249 HZ-associated inpatients and 66 deaths were reported in both years on average. HZ-incidence increased by age from 6.21 in people 50-54 years to 13.19 per 1,000 PY in people aged ≥ 90 years. Females were significantly more frequently affected than males in terms of outpatient HZ-incidence (11.12 vs. 7.8 per 1,000 PY), inpatient HZ-incidence (0.51 vs. 0.38 per 1,000 PY) and mortality (0.29 vs. 0.10 per 100,000 PY). PHN-incidence was estimated to range between 0.43 and 1.33 per 1,000 PY. Based on these figures, there were between 3,065 to 24,094 QALYs lost due to HZ in persons aged ≥ 50 years in Germany per annum.ConclusionOur study provides important baseline estimates for HZ-related disease burden in Germany. HZ poses a considerable burden on the health care system in Germany both in terms of outpatient and inpatient services. Follow-up assessments of HZ disease burden are needed to monitor the impact of VZV-vaccinations in Germany.

Varicella vaccination coverage of children under two years of age in Germany

BackgroundSince July 2004, routine varicella vaccination is recommended by the German Standing Vaccination Committee in Germany. Health Insurance Funds started to cover vaccination costs at different time points between 2004 and 2006 in the Federal States. Nationwide representative data on vaccination coverage against varicella of children under two years of age are not available. We aimed to determine varicella vaccination coverage in statutory health insured children under two years of age in twelve German Federal States using data from associations of statutory health insurance physicians (ASHIPs), in order to investigate the acceptance of the recommended routine varicella vaccination programme.MethodsWe analysed data on varicella vaccination from 13 of 17 ASHIPs of the years 2004 to 2007. The study population consisted of all statutory health insured children under two years of age born in 2004 (cohort 2004) or 2005 (cohort 2005) in one of the studied regions. Vaccination coverage was determined by the number of children vaccinated under 2 years of age within the study population.ResultsVaricella vaccination coverage of children under two years of age with either one dose of the monovalent varicella vaccine or two doses of the measles, mumps, rubella, and varicella vaccine increased from 34% (cohort 2004) to 51% (cohort 2005) in the studied regions (p < 0.001). More than half of the vaccinated children of cohort 2004 and two third of cohort 2005 were immunised at the recommended age 11 to 14 months. The level of vaccination coverage of cohort 2004 was significantly associated with the delay in introduction of cost coverage since the recommendation of varicella vaccination (p < 0.001).ConclusionsOur study shows increasing varicella vaccination coverage of young children, indicating a growing acceptance of the routine varicella vaccination programme by the parents and physicians. We recommend further monitoring of vaccination coverage using data from ASHIPs to investigate acceptance of the routine vaccination programmes over time.

Bestimmung von Impfquoten und Inzidenzen von Erkrankungen anhand von Daten der Kassenärztlichen Vereinigungen

The KV-Sentinel, established in 2004, is a joint project of the Robert Koch Institute and the 17 associations of statutory health insurance physicians (ASHIPs) in Germany. The ASHIPs provide anonymous physicians billing data to the Robert Koch Institute. The aim of this article is to describe methodological approaches for processing these routine data to determine vaccination coverage and incidence of vaccine preventable diseases. Furthermore, we discuss limitations in interpreting these data. The ASHIPs perform a data query of all vaccinations and of ICD-10 codes for pertussis, measles, mumps, varicella and herpes zoster and send anonymous data to the Robert Koch Institute. We perform routine tests to ensure data quality. Study population is the statutory health insured population (85.5% of the German population). Vaccination coverage is determined by the number of vaccinated persons and the number of statutory health insured persons. Incidence is calculated by the number of diseased persons per 100 000 statutory health insured persons. All 17 ASHIPs participate in the project. In total, 95 905 605 data records for vaccinations and 4 570 919 data records for pertussis, measles, mumps, varicella and herpes zoster were provided from 2004 to 2007. After performing routine tests with regard to structure and content of data, more than 99% of the data records can be analysed. In 2007, the majority of given vaccinations were monovalent vaccinations against influenza (39%) and tick-borne encephalitis (17%). In 2006 and 2007, 1 893 790 data records for diagnoses were provided. Of these, 75% were acute diagnoses and of these 70% were confirmed diagnoses. Most often, ICD-10 codes for herpes zoster (57%) and varicella (35%) were reported. Nationwide vaccination coverage of statutory health insured persons by age group can be determined by using billing data. It is possible to validate billing data of vaccinations with available data from other studies. Interpretation of billing data of acute vaccine preventable diseases remains challenging because it is difficult to assess potential under- or overestimation without the possibility of external validation. Therefore, further research is needed.

Stichproben in der ambulanten Qualitätssicherung am Beispiel der Koloskopie

Sampling inspections are an approved instrument for assuring and promoting the quality of healthcare. Individual documentations of medical services are requested from physicians and randomly selected for quality rating by experienced peer reviewers. For example, sampling inspections are stipulated by law for certain ambulatory services (e.g., colonoscopies) delivered by SHI-authorised physicians in order to maintain professional performance standards of colonoscopists. On behalf of the regional Association of Statutory Health Insurance Physicians (ASHIP) experienced colonoscopists regularly rate selected visual documentations (videotapes, photographs) of colonoscopies performed by SHI-authorised physicians in the ambulatory care sector. For anatomical reasons, however, a certain proportion of colonoscopies of inadequate quality will generally be tolerated. Whenever this value is exceeded, ASHIP may impose sanctions against the physician. The question is how sampling inspections have to be performed and dimensioned in order to ensure that the tests be sufficiently meaningful in terms of sensitivity and specificity. Relevant sampling test parameters such as the false-positive rate (physicians are wrongly accused of inadequate quality) and the false-negative rate (existing deficiencies are not identified) are calculated. The calculations are performed analytically or, in the case of complex sampling test scenarios, numerically by means of computer simulations. The calculations show that single-stage sampling tests usually do not result in acceptable values for the false-positive and the false-negative rates. For example, a sampling test which requires the documentation of 20 colonoscopies will -- assuming some reasonable tolerance of inadequately performed colonoscopies -- result in a false-positive rate of 6% and a false-negative rate of 47%. The false-positive-rate, which is particularly relevant from a legal point of view, can be reduced by providing a two-stage sampling test. A significant reduction of the false-negative-rate may be achieved by (multiple) repetition of the single-stage sampling test and consideration of cumulative probabilities. In principle, sampling inspections permit statements in terms of probabilities only. In sampling inspections of healthcare quality false-negative rates are usually considered, i.e., the probability that the test is unable to identify existing quality deficiencies. However, false-positive rates also need to be considered in cases where sanctions may be imposed against the physician on the basis of a positive sampling test. Numerical calculations of false-positive and false-negative rates for simple and complex sampling test scenarios should be performed in order to choose the optimum procedure and dimension of a sampling test.

Epidemiology and quality control of 245 000 outpatient colonoscopies.

Screening colonoscopy is an effective means for early detection of colorectal carcinoma. Any exhaustive evaluation of the method must take further factors into account: epidemiology of colorectal adenomas and carcinomas in the target population, acceptance by the patients, structure, process, and outcome quality, and health economics. The internet-based colonoscopy database of the Bavarian Association of Statutory Health Insurance Physicians (ASHIP) for the year 2006 includes data on 86.05% of all outpatient colonoscopies performed in Bavarian ASHIP patients, or a total of 245 263 documented examinations. The rate of participation in preventive colonoscopies was low (1.5%) and showed considerable geographical variation. The rate of detection of histologically confirmed colorectal neoplasia in symptom-free screened individuals was almost 26.0%. Some 1.3% of those screened had colorectal carcinoma. In 76.31% of the participants a completely clean gut was achieved. The incidence of bleeding, perforation, and cardiorespiratory complications was 0.22%, 0.03%, and 0.06%, respectively. The complication rate of outpatient colonoscopy is on the order of tenths of a percent, while the process quality is high. The rate of detection of colorectal adenoma and carcinoma is high and the projected benefits for public health are considerable, but the rate of participation is too low.

Quality circles in ambulatory care: state of development and future perspective in Germany.

To survey the quantitative development of quality circles (peer review groups; QC) and their moderators in ambulatory care in Germany, to describe approaches to documentation and evaluation, to establish what types of facilities and support is available and to assess opinions on the future importance of QC. Cross-sectional survey using a standardized questionnaire and supplementary telephone interviews. All 23 German regional Associations of Statutory Health Insurance Physicians (ASHIP) were surveyed. The total number of QC in ambulatory care in Germany increased rapidly from 16 in 1993 to 1633 in June 1996, with about 17% (range 1.0-52.1%) of all practicing physicians (112 158) currently involved. Throughout Germany, 2403 moderators were trained in 168 training courses by the qualifying date. Follow-up meetings were held or being planned in 20 ASHIP, with approximately 39% (23-95%) of the moderators participating. Systematic documentation of QC work was undertaken or planned in all 23 ASHIIP, and 10 ASHIP carried out comparative evaluation, with at least five others planning to start it. The ASHIP promoted the work of QC by providing organizational (22) or financial (20) support, materials (20) or mediation of resource persons (16). Eleven ASHIP received grants from drug companies. ASHIP rated the future importance of QC as increasing (18) or stable (four), but in no case as decreasing. The quantitative growth of QC in Germany is encouraging, but the extent of support and evaluation appears insufficient. Increased methodological support and facilitation, follow-up meetings on a more regular basis, improved documentation and evaluation of individual QC, and problem oriented evaluation of their impact on health care are essential for further successful development. Principles, problems and solutions discussed may be relevant for similar QI activities in other countries.