German Health System Research Articles

The interplay of stress and work-related musculoskeletal disorders in dental practitioners.

Prevalence of work-related musculoskeletal disorders (WRMSDs) among general dental practitioners and orthodontists is approximated to range between 64% and 93%. Etiology of WRMSDs in the mentally and physically demanding occupation remains unclear, for which reason the aim of the study was to clarify the interplay of physical, psychological, and mental factors on WRMSDs. Of 94 orthodontists and 187 general dental practitioners (mean age = 35 years) questioned using an online survey, 84% reported persisting tension or pain in the back, neck, or shoulders. While 71% of females were employed (29% self-employed), only 39% of male participants were employed. Cluster analysis was used to characterize dental practitioners according to their movement profile and the moderating effect of stress on certain WRMSDs. Three movement profiles of general dental practitioners and orthodontists were significantly predictive of WRMSD. The minority could be characterized as healthy (n = 45), whereas twice as many reported nearly twice as much pain (n = 90). Stress proved to be a strong, significant moderator of WRMSDs in relation to sex, employment status, and body mass index. The prevalence of WRMSDs found was alarming. Given the feminization of dentistry, and that being female, stressed, and an employee (rather than self-employed) is a significant predictor of WRMSDs, this represents a danger to the German health system.

The role of national heritage in shaping Germany’s public health and data governance

Abstract Aim This paper aims to explain how political culture has influenced the scope of prevention measures, disease surveillance, and health data integration strategies in the German health system to date. Subject and methods Political culture is a major determinant of national health policies in countries, defining the means and scope of governmental authority for ensuring population health. This paper explains the role of political culture in shaping prevention and health promotion measures in the German health system, based on a public policy theory. Results During the post-war period, the structure of the German health system was (re-)designed to focus on curative medicine at the expense of public health. Current prevention and health promotion measures, often characterised as ‘too little, too late’, lead to medical treatments that are ‘too costly, too risky’. Linking data sources in Germany today is much more challenging than in other European countries, with health-relevant data often remaining in isolated silos that could be used for population health. Conclusion The analysis suggests that the national heritage shaping the political culture in Germany had a great influence on the limited role of government intervention, the interpretation of public health, and the state’s role in collecting and processing health data of citizens for research and policymaking.

FoPraNet-BW: An Infrastructure for Clinical Studies in Practice-Based Research Networks in the German Health System.

General practice-based research networks have become an integral tool to gain medical knowledge from primary care in many countries. For this purpose, a scalable IT-infrastructure is presented considering the limiting peculiarities in the German health system and enabling GPs to participate in clinical studies based on their patient population. The infrastructure consists of a central study management server and local clients for each practice. It adopts to the currently limited digital connectivity of GP practices, data protection regulations for clinical data and the needs of the medical staff to manage a clinical study. The infrastructure is in production at the four university hospitals in the state of Baden-Württemberg. Until now three clinical studies with over 70 GPs and 350 Participants are successfully conducted or have been finished. Further clinical studies are in the planning stages.

DESAM-ForNet Portal: A Novel Infrastructure to Integrate Distributed Information from Practice-Based Research Networks in the German Healthcare System.

Currently the German healthcare system does not have a generic structure to answer research questions in primary care through clinical studies. The DESAM-ForNet initiative was founded as an association of German Practice-Based Research Networks (PBRN), to propose an appropriate and feasible solution. Aim is the integration of distributed, consensual information from practices into a single point of contact. To this end, a consensus-based concept for a digital infrastructure was developed in cooperation with all partners involved. Based on a joint requirements analysis the new concept integrates the federal structure of the German health system and the existing research structures.

The use of the "group traumatic episode protocol (G-TEP) " in an outpatient randomized and hospital setting: Implementation and effects in heterogeneous patient samples.

The resource-based eye movement desensitization and reprocessing group intervention group traumatic episode protocol G-TEP showed promising results in reducing posttraumatic stress disorder, depression, and anxiety. Using a high structured G-TEP worksheet, the patients conduct self-bilateral stimulation while (re)processing their targets. We examined the effectiveness on multiple symptoms and practicability of G-TEP in an outpatient setting and its feasibility in hospital treatment. Study A: Forty-four patients suffering from different symptoms and diagnoses received four ambulatory G-TEP sessions within three eye movement desensitization and reprocessing-G-TEP sessions in a randomized delayed waitlist control group design. We investigate the improvements in symptoms and advantages of G-TEP as an upstream treatment. Study B: The targeted changes in symptom burden in 23 patients and the implementation process of G-TEP as an additional treatment option in a psychiatric hospital were examined. The measures used were Impact of Event Scale-Revised, Beck Depression Inventory-II, Brief Symptom Check List, and the Questionnaire on Dissociative Symptoms at pre- and posttreatment and follow-up. Both studies showed significant and long-lasting reductions in subjective distress and concomitant impairments. The distressing experiences became more "ego-syntonic," levels of avoidance decreased, abilities to manage negative emotions got strengthened, and they gained hope. All effects had a positive impact on subsequent treatment processes; some patients already went free of symptoms only with this short G-TEP treatment. G-TEP effectively alleviates symptoms caused by stressful experiences. G-TEP can be used as a stand-alone intervention in outpatients and can easily be integrated into the offer of multimodal therapy in a psychiatric ward. It can prevent the exacerbation of symptoms and chronification of disease and should be implemented into the (German) health system. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Die Bevölkerungsperspektive in der Bewertung der Leistungsfähigkeit des deutschen Gesundheitssystems: Ergebnisse einer Querschnittsbefragung GKV-Versicherter

IntroductionSince the World Health Report in 2000, Health System Performance Assessment (HSPA) has been established as a tool for the evaluation and evidence-informed governance of health systems. So far, the population perspective has not been integrated into HSPA in a systematic manner, although people's experiences and expectations are of great importance to improve health systems and especially to strengthen patient-centered care. Therefore, this study aims to conduct an HSPA of Germany's health system from the population's perspective covering all eight goals of WHO’s Health Systems Framework, and to identify strengths and needs for improvement. MethodsIn 2018, 32,000 people insured with the German sickness fund ‘AOK Nordost’ were invited by mail to participate in the survey. The questionnaire contained a total of 43 items covering the eight goals of WHO's Health Systems Framework (e.g., access, quality, safety) plus socioeconomics and other characteristics of the insured persons. The data on the health system goals were analyzed descriptively and by subgroups (age, sex, income, chronic conditions, health literacy). ResultsThe sample (n=1,481; response rate 4.6%) was 54.8% female and had a mean age of 59.1 years (±18.5). Altogether, the participants saw several needs for improvement within the German health system. For instance, 60.0% found quality differences between hospitals to be big, and between 3.9% and 8.5% reported mistakes related to their treatment or prescription medication in the previous two years. A big need for reform was especially seen regarding out-of-pocket payments (51.5%) and the coordination of ambulatory care physicians among each other (44.2%) and with hospitals (41.9%). In addition, big subgroup differences were seen, especially for income and health literacy. Of the participants in the lower income group, 37.2% reported a (very) strong financial burden due to out-of-pocket payments (vs. 20.7%). People with limited health literacy (52.1%) assessed the access to care generally as not being good, and they perceived greater quality differences and needs for reform, compared to their counterparts. For instance, 36.6% had experienced discrimination in the previous year (vs. 19.9%). DiscussionThe survey results provide a comprehensive picture of Germany's health system from the population perspective. In some areas, previous findings were confirmed (e.g., a lack of coordination between providers). Other results expand existing knowledge (e.g., the role of health literacy in health care provision) or raise new questions (e.g., the difference between the subjectively assessed burden from out-of-pocket payments and the objective measures currently used). The great differences between subgroups are a call to action on the level of both politics and practice to better consider the individual's needs in order to make health better for everyone. Further research could provide deeper insights in this regard. ConclusionStrengthening the population perspective in HSPA allows for a better understanding and evaluation of health systems and, in particular, helps to identify areas for improvement in patient-centered care.

Implementation of medication reviews in community pharmacy: reaching consensus on stakeholders’ recommendations for mechanisms of change using the nominal group technique

BackgroundSince 2022, patients with five or more medicines are eligible for a medication review (MR) in a community pharmacy remunerated by the German health system. However, implementation has been slow, with few pharmacies providing MRs. Stakeholders’ input is necessary to detail how implementation strategies can be executed effectively on a national level. Prior research identified “external facilitation” and “altering incentives” as crucial strategies to achieve implementation outcomes.AimTo gather stakeholders’ recommendations for, and obtain consensus on, mechanisms of change that allow implementation strategies to work in practice.MethodThe consensus method used was the nominal group technique (NGT) with NGT-discussions held separately with pharmacy owners and pharmacy chambers employees. Votes were summed and the relative importance (rI) calculated, defined as (score achieved for a mechanism)/(maximum possible score) × 100. Content analysis provided context for the highest ranked mechanisms and allowed linking to implementation outcomes.ResultsFour NGT-discussions were held in 2023 (n = 2 owners; n = 2 chamber employees) with a total of 17 participants. The overall highest ranked mechanisms were fit-for-purpose software (rI = 154.7) detailed process support (rI = 104.9) and an expert support line (rI = 77.7). These together with financial viability (rI = 40.0) were prioritised by both participant groups. Three mechanisms were favoured for both implementation strategies, namely software, process support and materials (rI = 34.3).ConclusionThis study identified stakeholders’ priorities for mechanisms of change to implement MRs in community pharmacies. Focusing efforts on the prioritised mechanisms is likely to significantly advance a national implementation plan for countries which are at an early implementation stage.

Listening to the Voices of Health Care Workers During the COVID-19 Pandemic: A Qualitative Study Providing In-Depth Insights Into Ethical and Individual Challenges.

In their daily practice, health care workers (HCWs) experience the effects of tensions between professional ethos and work realities, which can lead to ethical dilemmas. We aim to explore the ethical dilemmas that affected HCWs in Germany during the COVID-19 pandemic and to understand these in the context of the German health system. Between April and December 2022, we interviewed HCWs from various levels of care and key informants responsible for decisions related to HCWs in Germany. Three themes were identified in the data analyzed from 78 participants. The first highlighted the potency of pre-existing health system problems during the COVID-19 pandemic. The second captured the ethical dilemmas that were described as having arisen due to the tension between professional ethos and structural constraints. The third included factors related to increasing or diminishing the implications of ethical dilemmas. A lack of opportunities for HCWs to participate in political and managerial decisions was suggested to result in policies that do not meet the needs of HCWs and patients. Positive interpersonal interactions were described as helpful when coping with dilemmatic decision-making situations. In order to avoid negative consequences caused by unresolved ethical dilemmas, including moral distress, among HCWs, staff shortages and decision-making in the German health system urgently need to be addressed. HCWs' working conditions regularly evoke ethical dilemmas, particularly during public health emergencies. Together with HCWs, decision-makers must develop new models for working in health care settings that are in line with HCWs' professional ethos.

History of Eugenics in Otorhinolaryngology: Ernst Rüdin and the International Eugenics Network.

Introduction The early geneticist and psychiatrist Ernst Rüdin (1874-1952) became one of the key figures in the eugenics movement and in the German health system of the Nazi era. His connections in the international eugenics network have played an important role in the history of eugenics. Objective To discuss the connections between Ernst Rüdin's scientific group in Munich and Otmar von Verschuer's group in Frankfurt during the Nazi era. Methods Otorhinolaryngological materials from Ernst Rüdin's former private library are presented, and they show Rüdin's deep involvement in the international eugenics network. These materials provide insights into early medical genetics in otorhinolaryngology. Results One result of the present study is that eugenics groups from Munich, Frankfurt, and New York certainly influenced one another in the field of otorhinolaryngology. Karlheinz Idelberger and Josef Mengele were two scientists who performed hereditary research on orofacial clefts. Later, Mengele became deeply involved in Nazi medical crimes. His former work on orofacial clefts clearly had, to some extent, an influence on subsequent studies. Conclusion An international eugenics network already existed before 1933. However, it becomes clear that the weaknesses of many early genetic studies did not enable its authors to draw firm scientific conclusions, suggesting that scientists lacked an accurate concept of the genetic causes of most illnesses.

Developing digital competencies of nursing professionals in continuing education and training - a scoping review.

The German health and care system is transforming due to advancing digitalization. New technological applications in nursing, such as social and assistance robotics, artificial intelligence and legal framework conditions are increasingly focused in numerous research projects. However, the approaches to digitalization in nursing are very different. When integrating technologies such as robotics and artificial intelligence into nursing, it is particularly important to ensure that ethical and human aspects are taken into account. A structured classification of the development of digitalization in nursing care is currently hardly possible. In order to be able to adequately deal with this digital transformation, the acquisition of digital competences in nursing education programs is pivotal. These include the confident, critical and creative use of information and communication technologies in a private and professional context. This paper focuses on the question which specific training offers already exist at national and international level for nursing professions to acquire digital competences. A scoping review according to the PRISMA scheme was conducted in the PubMed and CINAHL databases. The search period for the scoping review extended from 2017 to 2024. The selection of the studies took place by inclusion and exclusion criteria and the content-related orientation of the publications. After reviewing the titles and abstracts, eight studies were included. Of these, four were published in German-speaking countries and another four in international English-language journals. The topic of digitization of the nursing professions and the question of how nurses can acquire digital competences is gaining international attention. Nevertheless, the research on explicit continuing education programs for nursing professions is still undifferentiated. No specific continuing education offer for the development of digital competences of nursing professionals was identified. Many authors remained at the meta-level when developing methodological concepts for the acquisition of digital competences. The systematic integration of digitalization into higher education and continuing vocational training is mentioned in the publications. The development of theory- and research-based educational frameworks, which can be used as a basis for curricula in nursing studies and continuing education, is highly recommendable.

Attempting a participatory action research (PAR) dissertation with refugee women during the COVID-19 pandemic or: How I learned to embrace messiness and failure

Conducting participatory action research (PAR) is an aspirational, dynamic, but notoriously unpredictable endeavour. In this article, I discuss challenges and lessons from my ongoing dissertation study, planned as a PAR approach to learning with refugee women in Germany about their conceptualisation of mental health in the post-resettlement context and their service and intervention needs and resources.It proved challenging to transfer central ideas around co-creation (e.g., through workshops and activities) – developed in the Anglo-Saxon/North American context – to an online context with German as a foreign language (for both the participants and me) amidst the COVID-19 pandemic. I, therefore, adapted the methodological approach to incorporate collaboration tools such as Padlet (for online meetings) and Ketso (for in-person meetings) and provide short briefings about scientific evidence and concepts focused specifically on issues raised during the discussions (e.g., racism, structural discrimination in German educational and health systems). Furthermore, to ensure the representation of multiple experiences, I incorporated a document analysis component for advocacy and information documents developed by migrant-led organisations in Germany. Situational analysis is proposed as a collaborative interpretation tool that can reduce the risk of epistemic and epistemological violence.Along the research process and amid the groundswell of challenges, a focus on ethics (of care, epistemological, and relational) provided a strong anchor for securing a way forward. These experiences and lessons learned can provide valuable insight into operationalising co-creation, relational ethics, and justice in health research with marginalised populations, especially through an interdisciplinary lens (public health and social science).

The Effects of Federalism, Corporatism and Legislative Power on Health System Transformation in Germany

ABSTRACT International comparisons show that although health services are becoming increasingly digital, interconnected, and person-centred in industrialised countries, Germany lags behind in utilising and linking health data to provide better healthcare. A detailed analysis focusing on structural factors is crucial for policy studies involving international comparisons and country rankings. In Germany, factors such as the constraints of federalism, a well-established bureaucracy and a fragmented political decision-making system contribute to a deeply rooted resistance to change across various public service sectors. In the same vein, this article outlines the current landscape of data-driven innovations in the German health system. It identifies federalism, corporatism, and legislative power as three structural reasons why the country has been lagging behind in this field, while also discussing potential future developments.

Dissemination of health-related technologies in Germany between 2020 and 2022

Abstract Background Health systems are facing major changes due to digitalization. ICTs offer the potential to improve healthcare, but the impact on health inequities is unclear. Therefore, the following research question will be addressed: How will health-related technologies be used in Germany between 2020 and 2022 and are there age- and gender-specific differences? Methods This analysis is based on three cross-sectional online surveys conducted in 2020 (N = 1570) and in 2022 (N = 1200; N = 1850). The sample is representative for age, gender, and federal state according to Eurostat. Participants indicated whether they used (yes/no) online booking for medical appointments (OB), video consultation (VC), and app-based transmission of health data to health insurers (DT). In 2020, participants were asked if they had used such technologies before and during the COVID-19 pandemic. For the stratified analysis, a Chi2-test was used. Results Before COVID-19, 34.5% of the participants used OB, 4.1% VC, and 18.8% DT. VC and DT differed by age, OB by gender only. In May 2020, there was a decrease in use of OB (21.6%) and DT (12.0%), but not VC (5.4%). Age-related differences existed for VC and DT. In March 2022, an increased usage was observed for all technologies (OB: 40.4%, DT: 22.3%, VC: 7.1%). Gender and age differences occurred for VC, but for age only for OB and DT. An increased use was also observed in autumn 2022 (OB: 57.6%, DT. 35.4%, VC: 11.1%). The usage of such technologies continued to vary by age and gender, with one exemption: no gender-specific differences appeared for VC. Conclusions With the exception of the onset of the COVID-19 pandemic, an increased diffusion of health-related technologies has been observed, accompanied by an elevated availability of such technologies after the pandemic. Although the diffusion of such technologies increased from 2020 to 2022, age- and gender-specific differences regarding their usage seem to emerge and tend to consolidate. Key messages • Between 2020 and 2022, an increased utilization of health technologies can be observed, which goes hand in hand with an expanded diffusion of such technologies in the German health system. • Not all population groups participate in digitization in the same way. Whether these differences will contribute to health inequities needs to be closely examined.

Community-centred yet little community health: The paradoxes of the German health system

Abstract Due to its history of development since the middle of the 19th century, the German health care system is almost exclusively dominated by pathogenesis and the resulting reactive treatment. Insiders dub it “repair medicine”. The situation of community health in Germany is very heterogeneous: On the one hand, the community is referred to as the ‘mother of all settings’. In health services research, it is also referred to as the third pillar of the health care system, alongside inpatient and outpatient care. On the other hand, it cannot and must not be ignored that public budget cuts hit public health structures very hard. Ultimately, the COVID-19 pandemic exposed the deficits caused by thirty years of consistent austerity policies. National surveys shows that the already weak public image of the community health structures has once again suffered a massive loss of confidence among the population during this period. The OECD points out that the health behaviour of the population in Germany deteriorated significantly more during the pandemic than was the case in countries which have had strong health promotion structures for decades. The municipality as the ‘mother of all settings’ could and should have intervened here - but did not. In the context of the ‘Public Health Service Pact’ the German government is currently implementing nationwide so-called ‘health stores’ with a focus on socio-economic hotspots in large cities. Concerned here are low-threshold offerings across the entire spectrum of health promotion and prevention. In this regard, we are also currently involved in an Erasmus KA 203 project with the title ‘Family Health Advisor’. From the German perspective, the project sustainability will depend on the extent to which we manage to transfer the project contents into community health structures, which the ‘Public Health Service Pact’ will bring with it in the next few years.

The Need of Evidence-Based Treatment of Early-Onset Feeding Tube Dependency: A Pico- Framework Based Analytic Review of Clinical Features and Treatment of Feeding Tube Dependency

Feeding Tube Dependency is a constant increasing perinatal mental health condition, with estimated 350 new cases per year in Germany.The early onset feeding tube dependency is the consequence of a generalized food aversion. To establish an evidence-based nationwide treatment plan, relevant research from the past twenty years were narratively reviewed. Feeding tube dependency is an international increasingmental health condition, with a high symptom persistence and a low spontaneous remission. The generalized food aversion would prevent the transition to oral feeding.The treatment protocols, supported by the German Health System, based on low-frequency individual treatment and intensive inpatient treatments are not supported by the most recent evidence. In treatment outcome research more promising and effective programs can be distinguished from ineffective programs. As a result, treatment which are designed as intensive treatment, home-based or inpatient and are psychodynamicbased are most effective. Day-clinic and behavioral modification programs are not or low in treatment effectiveness.The German Health System approach to assist families with feeding tube dependency is not evidence-based. A new structure of treatment is imperatively required.

Loop Excision for Precancers of the Uterine Cervix: Local or General Anaesthetic?

In Germany, treatment of HSIL or AIS of the uterine cervix by loop excision is performed almost exclusively under general anaesthesia (GA). International studies and guidelines show high acceptance of local anaesthesia (LA) due to hermeneutic, medical, and economic factors. We performed an observational comparative study aiming to prove advantages of local anaesthesia within the German health system. In a prospective observational study, patients diagnosed with HSIL or AIS of the uterine cervix were treated at the Institute for Cytology and Dysplasia, Berlin, by loop excision in 2021. We started with a feasibility study : 303 patients diagnosed with HSIL/AIS of the uterine cervix and her colposcopist answered an electronic questionnaire with respect to loop excision under LA. Since we found a high acceptance for LA in patients and colposcopists, we initiated a comparative study LA vs. GA: 322 patients underwent loop excision and selected their mode of anaesthesia: n=206 LA vs. n=116 GA. 114 patients of the feasibility study had to undergo loop excision and became part of the comparative study (n=79 for the LA group, n=35 for the GA group). All patients received a standardised questionnaire to document their pain score within 24h after treatment on a visual analogue scale, i.e. VAS, between 0 and 100. 178 patients of the LA group and 80 patients of the GA group completed and returned the questionnaire and form the cohort for our comparison of LA vs. GA. With 191 of these 258 patients, i.e. 74%, a telephone survey was performed to ask for patient satisfaction and the rates of recurrence after a mean interval of 1 year post surgery. We postulate that there will be no clinically relevant significant difference in satisfaction and postoperative pain between patients in the LA group and the GA group. In the feasibility study , 90% (272 of 303) of patients diagnosed with HSIL or AIS were considered eligible for LA by their colposcopists. 75% (227 of 303) of patients were open to loop excision under LA. In the comparative study , 63 of 206 women of the LA group were interviewed preoperatively: 89% would accept a pain score above 20 during the procedure, 33% a pain score above 50 and 11% of max. 20. Postoperatively, the median VAS pain score for loop excision under local anaesthesia was 13.1 in 178 patients, and pain during injection of local anaesthesia was 20.9 (p<0.001). The VAS pain score 20 minutes post surgery did not differ significantly between 178 patients after local anaesthesia versus 80 patients after general anaesthesia (p=0.09). The surgeons estimated the patient's pain significantly less than the patients themselves with an underestimate of -14.63 points on the VAS (p<0.001). Within 7 days following loop excision under LA, 95.5% of 178 patients would choose local anaesthesia as their preferred method for a potential repeat loop excision, 8.8% of which would like additional painkillers, and 4.5% would choose general anaesthesia.In a telephone follow-up survey of 133 women from the LA group after a mean of 12 months post surgery, 97% were "satisfied" or "very satisfied" with the treatment carried out. For patient satisfaction and postoperative pain, no clinically relevant significant difference was seen between the LA and the GA group.The rate of secondary bleeding (6.7% vs. 8.1%, p=0.72), recurrence of HSIL/AIS (3.6% vs. 5.2%, p=0.62), and the distribution of the histopathological R status (R0 89.5% vs. 81.1%, p=0.73; R1 5.3% vs.12.2%, p=0.57, Rx 4.1% vs. 5.4%, p=0.65) showed no significant difference when comparing the LA group versus the GA group. Following loop excision under local anaesthesia, more than 95% of patients would choose this method again for repeat surgery. One year post surgery, 97% of the patients were "satisfied" or "very satisfied" with the treatment under local anaesthesia. Offering local anaesthesia for loop excision to patients should be mandatory and included in current guidelines.

Multidrug-resistant isolates from Ukrainian patients in a German health facility: a genomic surveillance study focusing on antimicrobial resistance and bacterial relatedness

PurposeAntimicrobial resistance is a pressing issue in Ukraine, with healthcare-associated infections caused by multidrug-resistant organisms being a major concern. A recent prospective multicenter study revealed a staggering rate of 48.4% antimicrobial resistance to carbapenems among Enterobacterales causing a healthcare-associated infection. We conducted a systematic survey to investigate the incidence rate and incidence density of carbapenemase-producing Gram-negative bacteria (CPGN) among refugees and war-wounded Ukrainians in connection with the German health system.MethodsFrom the onset of the war until November 2022, seven Ukrainian patients were admitted to our hospital. Upon admission, screening samples and samples from the focus of suspected infection were taken from all seven patients. The incidence rate and the incidence density of CPGN were calculated as a result of the microbiological findings. We sequenced all CPGN using Illumina technology.ResultsThe incidence rate of CPGN at our hospital was 0.06 for 2021 and 0.18 for 2022. All seven Ukrainian patients were infected or colonized with at least one CPGN, including K. pneumoniae (14/25), P. aeruginosa (6/25), A. baumannii (1/25), Providencia stutartii (1/25), C. freundii (1/25), and E. coli (2/25). Genomic surveillance revealed that (i) most frequently detected carbapenemases among all sequenced isolates were blaNDM (17/25) and blaOXA-48 (6/25), (ii) most commonly observed plasmid replicons among the K. pneumoniae isolates recovered from Ukrainian patients were Col(pHAD28) (12/14), IncHI1B(pNDM-MAR) (9/14), IncFIB(pNDM-Mar) (12/14), and (iii) clonal relation between the pathogens of the Ukrainian isolates, but not for the isolates from our hospital surveillance system.ConclusionThe rising prevalence of community-acquired colonization and infection with CPGN is having a direct effect on the infection prevention measures, such as higher number of isolations, reprocessing of patient rooms, additional microbiological testing and overall organization within hospitals.

Versorgung geriatrischer Krankheitsbilder unter ausgewählten ambulanten Facharztgruppen: Kombination von Befragungs- und GKV-Routinedaten zur Abbildung des Leistungsgeschehens

BackgroundIn light of an aging population, the German health system faces the challenge of adapting regional health care structures to the changing care needs of geriatric patients. Since geriatric care is interprofessional, a structural analysis of the service providers involved is required. Therefore, the aim of this study is to determine the primary and joint care responsibilities for geriatric patients with specific characteristics, to estimate the associated effort for selected outpatient medical service providers and to identify resulting care concentrations. MethodsThe analysis includes six selected specialist disciplines in the outpatient sector and is based on two databases: 1) A representative survey among outpatient physicians related to geriatric care (n = 400) to examine both the primary geriatric care needs that professionals treat regularly and aggravating geriatric morbidity. 2) A claims data analysis determines services and efforts for approximately 300,000 geriatric patients for every year from 2014 to 2018. For the specialists included in the analysis, care concentration was determined by association analysis comparing the care efforts of outpatient physicians for patients with different geriatric characteristics. ResultsGeneral practitioners, in particular, serve as primary care providers for all geriatric characteristics; there is no concentration of care on specific patient groups. Concentrations associated with care efforts and joint care responsibilities for patients with certain geriatric characteristics are found among the more specialized physician groups. Across all professions, the physicians surveyed believe that geriatric-specific immobility, depression, anxiety disorders and cognitive deficits make the provision of care more difficult. DiscussionThe results contribute to the understanding of primary and interdisciplinary care responsibilities of outpatient physicians related to the treatment of geriatric conditions and can thus represent an important basis for the structural planning of geriatric care. Nevertheless, it should be noted that within the scope of the analysis presented, only general practitioners and five specialist disciplines could be taken into account. Therefore, the considerations primarily allow initial conclusions about the care responsibility of outpatient physicians with regard to geriatric morbidity. To enable comprehensive structural planning, however, the analyses would have to be expanded to include all specialists involved in geriatric care. ConclusionThe joint care responsibility of outpatient physicians for specific geriatric patients underlines the relevance for interdisciplinary care models and the need for expansion of geriatric expertise in the outpatient sector. In view of the ageing population and an increase in morbidity, the planning of care structures should be based on the needs of geriatric patients and the associated expenses incurred by the various health care providers.

Financing health promotion, prevention and innovation despite the rising healthcare costs: How can the new German government square the circle?

The German health system is under pressure due to increasing costs of healthcare provision and rising demand for health services. With the new coalition government, Germany has increased efforts to build a modern, innovative infrastructure for prevention and high-quality health services. The coalition agreement has a strong climate, innovation, and sustainability focus, reflecting at the same time the ambition of the new government to implement a preventive, inter-connected, and modern healthcare system in Germany. However, the agreement lacks detailed information on the achievement of the plans, especially concerning the question of how those measures should be funded in light of increasing expenditures for healthcare. Thus, the objectives of this study are to interpret the new government’s plans and answer the question of how Germany in the new legislative period can ensure and fund population-based prevention programmes, health-promoting measures and innovative solutions despite the rising healthcare costs. By analysing the relevant content of the coalition agreement and drawing on an expert workshop, this paper suggests the establishment of a prevention fund and flexible remuneration model for digitalised and innovative forms of care in the new legislative period. Our findings may help identify feasible approaches to sustainable financing of health promotion, prevention and innovation in the German healthcare system.

Immunodeficiency is prevalent in congenital heart disease and associated with increased risk of emergency admissions and death.

To provide population-based data on the prevalence and clinical significance of immune deficiency syndromes (IDS) associated with congenital heart disease (CHD). Utilizing administrative German Health System data the prevalence of increased susceptibility to infection (ISI) or confirmed IDS was assessed in CHD patients and compared with an age-matched non-congenital control group. Furthermore, the prognostic significance of IDS was assessed using all-cause mortality and freedom from emergency hospital admission. A total of 54 449 CHD patients were included. Of these 14 998 (27.5%) had ISI and 3034 (5.6%) had a documented IDS (compared with 2.9% of the age-matched general population). During an observation period of 394 289 patient-years, 3824 CHD patients died, and 31 017 patients experienced a combined event of all-cause mortality or emergency admission. On multivariable Cox proportional-hazard analysis, the presence of ISI [hazard ratio (HR): 2.14, P < 0.001] or documented IDS (HR: 1.77, P = 0.035) emerged as independent predictors of all-cause mortality. In addition, ISI and confirmed IDS were associated with a significantly higher risk of emergency hospital admission (P = 0.01 for both on competing risk analysis) during follow-up. Limited immune competence is common in CHD patients and associated with an increased risk of morbidity and mortality. This highlights the need for structured IDS screening and collaboration with immunology specialists as immunodeficiency may be amenable to specific therapy. Furthermore, studies are required to assess whether IDS patients might benefit from intensified antibiotic shielding or tailored prophylaxis.