German Health System Research Articles

Attitudes of Germans towards distributive issues in the German health system

Social health care systems are inevitably confronted with the scarcity of resources and the resulting distributional challenges. Since prioritization implies distributional effects, decisions regarding respective rules should take citizens' preferences into account. In this study we concentrate on two distributive issues in the German health system: firstly, we analyze the acceptance of prioritizing decisions concerning the treatment of certain patient groups, in this case patients who all need a heart operation. We focus on the patient criteria smoking behavior, age and whether the patient has or does not have young children. Secondly, we investigate Germans' opinions towards income-dependent health services. The results reveal the strong effects of individuals' attitudes regarding general aspects of the health system on priorities, e.g. that individuals with an unhealthy lifestyle should not be prioritized. In addition, experience of limited access to health services is found to have a strong influence on citizens' attitudes, too. Finally, decisions on different prioritization criteria are found to be not independent.

Exploring Health System Responsiveness in Ambulatory Care and Disease Management and its Relation to Other Dimensions of Health System Performance (RAC) - Study Design and Methodology.

The responsiveness of a health system is considered to be an intrinsic goal of health systems and an essential aspect in performance assessment. Numerous studies have analysed health system responsiveness and related concepts, especially across different countries and health systems. However, fewer studies have applied the concept for the evaluation of specific healthcare delivery structures and thoroughly analysed its determinants within one country. The aims of this study are to assess the level of perceived health system responsiveness to patients with chronic diseases in ambulatory care in Germany and to analyse the determinants of health system responsiveness as well as its distribution across different population groups. The target population consists of chronically ill people in Germany, with a focus on patients suffering from type 2 diabetes and/or from coronary heart disease (CHD). Data comes from two different sources: (i) cross-sectional survey data from a postal survey and (ii) claims data from a German sickness fund. Data from both sources will be linked at an individual-level. The postal survey has the purpose of measuring perceived health system responsiveness, health related quality of life, experiences with disease management programmes (DMPs) and (subjective) socioeconomic background. The claims data consists of information on (co)morbidities, service utilization, enrolment within a DMP and sociodemographic characteristics, including the type of residential area. RAC is one of the first projects linking survey data on health system responsiveness at individual level with claims data. With this unique database, it will be possible to comprehensively analyse determinants of health system responsiveness and its relation to other aspects of health system performance assessment. The results of the project will allow German health system decision-makers to assess the performance of nonclinical aspects of healthcare delivery and their determinants in two important areas of health policy: in ambulatory and chronic disease care.

Presence of patient-relevant endpoints in trials of recently launched oncology drugs: What measuring stick do we use to measure value?

e17790 Background: The German health system assesses additional therapeutic benefit of drugs based on patient-relevant endpoints. With prices of cancer drugs under scrutiny in the US, a critical vi...

Positionspapier für eine Reform der medizinischen Notfallversorgung in deutschen Notaufnahmen

The hospital emergency departments play a central role for the in- and outpatient care of patients with medical emergencies in Germany. In this position paper we point out some general financial and organizational problems of German emergency departments and urge for a higher significance of emergency care in the German health system as an element of public services. The corresponding reform proposals include a change in hospital financing towards a more budget-based system for the emergency departments, an improved structural planning for regional and transregional emergency care, an intensified cooperation with the emergency services of the ambulatory care physicians, a better organizational representation of emergency care within the hospitals and an advancement of emergency medicine in postgraduate medical education.

Developing cross-sectoral quality assurance for cataract surgery in the statutory quality assurance program of the German health care system: Experiences and lessons learned

Since 2001, statutory external quality assurance (QA) for hospital care has been in place in the German health system. In 2009, the decision was taken to expand it to cross-sectoral procedures. This novel and unprecedented form of national QA aims at (1) making the quality procedures comparable that are provided both in inpatient and outpatient care, (2) following-up outcomes of hospital care after patients’ discharge and (3) measuring the quality of complex treatment chains across interfaces. As a pioneer procedure a QA procedure in cataract surgery QA was developed. Using this as an example, challenges of cross-sectoral QA are highlighted. These challenges relate, in particular, to three technical problems: triggering cases for documentation, following-up patients’ after hospital discharge, and the burden of documentation in outpatient care. These problems resulted finally in the haltering of the development of the QA procedure. However, the experiences gained with this first development of cross-sectoral QA inspired the reorientation and further development of the field in Germany. Future cross-sectoral QA will rigorously aim at keeping burden of documentation small. It will draw data for QA mainly at three sources: routine data, patient surveys and peer reviews using indicators. Policy implications of this reorientation are discussed.

Current capabilities of telemedicine in anaesthesiology

Because of an ageing population and a relative lack of professionals, the German health system is under great pressure. In rural regions in particular, anesthesiology is also affected - nursing staff, anesthetists, intensive care physicians, and emergency physicians often have to be supported by freelancers from other regions and from abroad - at least periodically. In addition to the increasing number of treatments, the potential quality of therapy is also increasing owing to progress in medical research. Against this background the need for resources is increasing to ensure the optimal quality of treatment. This applies to all clinical disciplines, including all sections of anesthesiology - especially in economically underdeveloped regions where highly qualified experts are lacking. In various cases it is not the physical attendance or manual skills of experts that is primarily requested on-site, but rather their medical expertise and experience. Therefore, telemedicine systems are suitable for closing these gaps very effectively and efficiently. In the various anesthesiological sub-sections the number of scientific papers published to date varies. For anesthesia and pain therapy only a few telemedical applications or concepts have been reported in the literature. However, in tele-intensive care medicine and tele-emergency medicine several national and international research projects have successfully been carried out, leading to established routine systems in some cases.

Trying to Improve the Recovery Attitudes of Service Providers

More and more the recovery orientation is becoming a quality marker of psychiatric services. At the Department of Psychiatry at Klinikum Bremerhaven we have tried to measure the effect of our efforts to improve the recovery attitudes of the staff. During the last two years nearly all staff members participated in three training courses each with 6 hours focusing on different aspects of recovery (top down approach). Furthermore we have included more peer providers as “recovery companions” (2012: n=3, 2014: n=7) in all areas of our department (bottom up approach). To measure the effect of these activities we have translated the Recovery Self Assessment (RSA) Questionnaire into German. The staff members were then asked to fill in our German version of the RSA in May 2012 (T1) and March 2014 (T2). 60 (T1) respectively 65 (T2) questionnaires could be evaluated. As presented in the table RSA total score and the scores of all five RSA factors improved. These results and some findings on the single item level that seem to be important against the background of the specific features of the German health system will be presented in detail. Our preliminary results point out that our bidirectional approach may be appropriate to improve the recovery orientation of psychiatric services. The implications for our future policy will be presented.

Evidence-based complementary and alternative medicine in inpatient care: take a look at Europe.

The aim of this report is to provide the reader an overview of the complex therapy currently used within the German health system. Complex therapies in inpatient care in Germany establish the basis for an integrative and interdisciplinary provision of services. They define minimal criteria for the organization of a hospital, enable the integration of different therapeutic approaches, and therefore, lead to an intensive and holistic treatment by a specially trained team. The German model can be viewed as a pilot program for the introduction of integrative patient-centered care in other hospitals around the world.

Attitudes of Germans Towards Distributive Issues in the German Health System

Social health care systems are inevitably confronted with the scarcity of resources and the resulting distributional challenges. Since prioritization implies distributional effects, decisions on respective rules should take citizens’ preferences into account. Thus, knowledge about citizens’ attitudes and preferences regarding different distributional issues implied by the type of financing health care is necessary to judge the public acceptance of a health system. In this study we concentrate on two distributive issues in the German health system: First, we analyse the acceptance of prioritizing decisions concerning the treatment of certain patient groups, in this case patients who all need a heart operation. Here we focus on the fact that a patient is strong smoker or a non-smoker, the criteria of age or the fact that a patient has or does not have young children. Second, we investigate Germans’ opinions towards income dependent health services. The results reveal strong effects of individuals’ attitudes regarding general aspects of the health system on priorities, e.g. that individuals behaving health demanding should not be preferred. In addition, experiences of limited access to health services are found to have a strong influence on citizens’ attitudes, too. Finally, decisions about different prioritization criteria are found to be not independent.

PCN38 - Budget Impact of Metastatic Castrate-Resistant Prostate Cancer (CRPC) to German Payers

The 2010 Urological Association Guidelines for Management of Castrate-Resistant Prostate Cancer (CRPC) recommend docetaxel plus prednisone for first-line chemotherapy for symptomatic metastatic CRPC patients who have progressed from hormone therapy. Since 2010, several CRPC agents with better tolerability and longer survival have launched. These improved therapies are causing a shift in practice. The aim of our analysis was to 1) quantify the 3-year mCRPC budget impact for the German health system based on the practice shift, and 2) estimate the cost per additional month of progression-free survival (PFS). A conceptual decision analytic model was developed for the German health system to estimate the impact on direct medical costs of a therapy shift in CRPC over three years. Guideline recommended regimens were represented in model with three lines of therapies: palliative, abiraterone, enzalutamide, docetaxel and cabazitaxel. Progression in therapy was measured as the duration of PFS. A targeted literature search identified US per-patient-per-month costs of docetaxel treated patients (hospitalization=€954, ambulatory=€765, ER=€32, MD=€318) and were adapted to the German health system by applying a published purchase price parity factor. Drug costs were based on Ex-factory pricing. Adverse event rates were used as a proxy to derive relative resource utilization of other treatments. Utilization of CRPC regimens was informed by interviews with EU opinion leaders. The shift in practice pattern is expected to increase the German health system’s 3-year budget by €23 million. The additional cost/month of PFS is estimated to decrease by €99/month from €4,659 for current treatment mix to €4,560 for future treatment mix by year 3. From the German health system’s perspective, a change in practice pattern will result in an increase in total budget of €23 million. The reduction in cost/month of PFS of €99/month indicates the shift in practice will use more efficient therapies.

Verlängerungen ambulanter Psychotherapien: Eine Studie zu Patienten-, Therapeuten-, Behandlungs- und Verlaufsmerkmalen

Due to the treatment costs, extensions of the standard therapy duration are a matter of critical examination. This study investigates which factors characterize patients with treatment extensions in the German health system and how effective these extensions are for a reduction of the patients' symptoms. We analysed a disorder heterogeneous sample of 810 patients. We found that therapy extensions are more common among with more severe mental disorders, when the therapeutic relationship is positive, and little therapy success has been achieved during the standard duration. Overall, the findings suggest that outpatient psychotherapy is mainly extended for patients with a low symptom reduction after the standard therapy duration and that therapy extension allows a symptom reduction that could not have been achieved otherwise.

Outsourcing and concession models as door opener for public-private partnerships in the European health sector?

Purpose – The purpose of this paper is to reduce the research gap in private sector participation in the Danish and German health systems, where empirical evidence is still very scarce compared with the impressive accumulation of similar literature in Anglo-Saxon countries. Design/methodology/approach – Based on the findings of two case studies – one Danish and the other, a German hospital – the paper assesses the future potential of different private sector participation strategies in health care. Findings – The assessment is that low-level private sector participation approaches such as outsourcing and concession models remain limited and specialised financing instruments for health care in Denmark and Germany due to legal restrictions and lesser importance being placed on operational financial savings and improved management than on achieving strategic goals. Furthermore, existing approaches do not necessarily prepare the ground for public-private partnerships. Research limitations/implications – To date, longitudinal studies of private sector participation in health care are almost non-existent for continental Europe, yet critical for the assessment of the outcomes of long-term projects of ten to 40 years' duration. In addition, there is still a need for more international comparisons, especially for studies comparing more than two countries. Originality/value – Case studies about private sector participation in health care with transnational European or international comparisons are very scarce. The paper, which compares two cases of a Danish and a German hospital, is therefore a contribution to reducing a relevant research gap. To date, private sector participation in the German health system, in particular, has rarely been discussed in international journal publications.

Counseling cancer patients on complementary and alternative medicine

Complementary and alternative medicine (CAM) is of high relevance in oncology. Only a minority of professionals feel competent in CAM. Our aim was to provide a strategy for establishing evidence-based counseling on CAM in oncology in the German health system. We performed a systematic search of the literature on patient counseling concerning CAM. Of 811articles identified in this search 51met our inclusion criteria. Data from these articles were analyzed and adapted to the needs of German patients by a group of experts of the DEGRO ("Deutschen Gesellschaft für Radioonkologie") and the German Cancer Society. In the next step a strategy about how to integrate evidence-based counseling on CAM at cancer centers and oncological institutions was developed. First, evidence-based recommendations on CAM counseling were derived. The core of our strategy combines two levels of information provision: level1 will be oncologists, radiotherapists and other specialists and level2 oncological CAM experts. The latter group will serve as trainers and backup for complicated or advanced questions and for individual counseling of patients with complex needs. Professionals in level1 will be offered special training. Evidence-based counseling on CAM is not only possible but also mandatory in order to meet patient information needs. Our proposal would allow for integrated counseling available at all oncological institutions and guarantee a high quality. Furthermore, provision of information on two different levels allows the effective use of resources (manpower and financing).

P5.056 Mission is Possible! The German STI-Society (DSTIG) as a Pacemaker For Sexual Health and STI-Research in Germany

BackgroundFor the last 111 years the “German STI Society - Society for the Promotion of Sexual Health” (DSTIG) has been the biggest medical and social society focusing on sexually transmitted...

Ist eine gesundheitsökonomische Zusatzqualifikation für HNO-ärztliche Leitungspositionen Voraussetzung?

The increasing medical-technical progress as well as the dramatic demographic changes cause problems with regard to rapid enlargement of medical service offers, allocation of resources and a financing shortfall in the German public health system. The economization in the German Health System can also be perceived in ENT departments. After performing an internet search about the rapidly growing market for qualifications measures in health economics, we hence conducted an anonymous survey for ENT senior doctors and directors of the 34 German University Departments to evaluate their attitude towards, as well as their expectation of such an add-on qualification. Since the German government finalized the health care reform in the year 2000 such qualification measures rapidly developed: amongst others, 26 postgraduate, extra-occupational master programs have been inaugurated. The anonymous survey was answered by 105 ENT doctors (63 senior doctors, 27 vice professors and 15 directors). 63% out of these 105 colleagues considered such an add-on qualification to be mandatory. 41% of the colleagues were already "add-on qualified" in that field, only 10 of them by means of a study program. 71 of 105 colleagues (68%) considered the add-on qualification to be advantageous for their future personal career. With regard to the designated contents of the study program, "Staff Management" was even prioritized to "Hospital Financing" and "Cost Accounting". Aspects of management and a (health-) economical basic knowledge became an integral part of the daily routine for "first-line management doctors" also in (University) ENT-departments.

S2K-Leitlinie zur Diagnostik und Therapie der idiopathischen Lungenfibrose

Idiopathic pulmonary fibrosis is a fatal lung disease with a variable and unpredictable natural history and limited treatment options. Since publication of the ATS-ERS statement on IPF in the year 2000 diagnostic standards have improved and a considerable number of randomized controlled treatment trials have been published necessitating a revision. In the years 2006 - 2010 an international panel of IPF experts produced an evidence-based guideline on diagnosis and treatment of IPF, which was published in 2011. In order to implement this evidence-based guideline into the German Health System a group of German IPF experts translated and commented the international guideline, also including new publications in the field. A consensus conference was held in Bochum on December 3rd 2011 under the protectorate of the "Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP)" and supervised by the "Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften" (AWMF). Most recommendations of the international guideline were found to be appropriate for the german situation. Based on recent clinical studies "weak negative" treatment recommendations for pirfenidone and anticoagulation were changed into "weak positive" for pirfenidone and "strong negative" for anticoagulation. Based on negative results from the PANTHER-trial the recommendation for the combination therapy of prednisone plus azathiorpine plus N-acetlycsteine was also changed into strong negative für patients with definite IPF. This document summarizes essential parts of the international IPF guideline and the comments and recommendations of the German IPF consensus conference.

Inzidenz und Prävalenz von Diabetes mellitus Typ 2 in Deutschland

Based on claims-data of 5.43 million members of a large German statutory health insurance fund in 2008 (Techniker Krankenkasse), the aim of this contribution is to update and more precisely quantify age- and gender-specific prevalence and incidence of type 2 diabetes mellitus (T2DM) in a German setting. A patient was classified as T2DM prevalent if he or she had received at least two outpatient diagnoses of T2DM in two different quarters of the year and/or had received at least one T2DM diagnosis during inpatient treatment between 01/01/2006 and 12/31/2008. A patient was considered to have had new onset T2DM in 2008 under one of three conditions: 1. no diagnosis of T2DM in 2006 and 2007, 2. no presripction of oral antidiabetics in 2006 and 2007, 3. either one inpatient or two outpatient diagnoses of T2DM conducted in two different quarters of 2008 or one outpatient T2DM diagnosis in 2006/07 when the second diagnosis was made in 2008. A total of 254,524 patients had T2DM. Compared to the total membership of the medical insurance fund, the prevalence of T2DM was 4.69 %. The average age was 64.8 years, and 66.37 % were male. The incidence of T2DM in our sample was 2.814 cases per 1,000 person-years in men and 1.690 cases in 1,000 person-years in women. Based on our sample and on official population data, 4,704,585 patients (5.75 %) in Germany would be T2DM prevalent in 2009. The number of incident T2DM cases would amount to 215,746 patients (0.264 %). T2DM is one of the most common chronic diseases in Germany. The expected demographic changes in Germany will increase the burden on the German health system caused by T2DM.

Zur Notwendigkeit gruppenanalytischer Kompetenz im therapeutischen Feld

Summary The Importance of Group-Analytic Competences for Psychotherapeutic Health Services The article deals with questions of the supply with psychotherapeutic treatments. Due to the good integration in the German health system psychotherapy is widely accepted as a means of treating psychic and psychosomatic disorders and of accompanying the treatment of somatic diseases. Although there is a growing attention for psychic disorders in our society it is difficult to define the real need for psychotherapeutic treatment; it is estimated that some 3 % of the population are in need for psychotherapeutic treatment and show a readiness to make use of psycho-therapeutic help. An appropriate supply with psychotherapy at that level has so far not been realized as can be seen by the waiting lists of most of the psychotherapists; however a substantial rise in the number of psychotherapists would have to over-come considerable economical and political obstacles. Methods of short-termpsychotherapy and group-psychotherapy will gain importance in the near future, since they promise to fill the still existing gaps in the health service and to offer an attractive perspective for the insurance companies who have to act under a considerable economical pressure.

Bypass Surgery with Psychological and Spiritual Support (the BY.PASS Study): Results of a Pragmatic Trial Based on Patients’ Preference

Background: Some general hospitals within the German health system provide supportive interventions, psychological as well as spiritual, to their patients. It remains to be proven if these interventions are effective when used in routine clinical practice. Aim: To evaluate the effectiveness of psychological and spiritual interventions on improving recovery following bypass surgery. Methods: The BY.PASS study is a pragmatic, patient preference trial (ISRCTN 07297983). Adult patients scheduled for elective coronary bypass surgery were enrolled. Patients were assigned to study conditions according to their personal preference: preference for psychological interventions, for spiritual interventions or for no intervention. Patients who were open for any kind of intervention were randomly assigned either to psychological or spiritual interventions. During a control period, patients were asked about their preference, but did not receive any interventions. Primary outcomes of the study were in-hospital morbidity and early mortality. Psychological measures served as secondary outcomes. Results: A total of 847 patients were enrolled. Patients of the control (n = 260) and the intervention group (n = 269) who explicitly wanted to have interventions were compared. No significant treatment effects either for morbidity (d = 0.08, 95% CI –0.09 to 0.25), or for mortality (OR = 1.81; 95% CI 0.50–6.57) could be found. A reduction of negative mood resulted from both interventions. Conclusions: Although the effects observed were small, the study can serve as a basis to discuss methodological as well as theoretical aspects of a pragmatic trial, based upon patients’ preferences.

The German Health System and Heilpraktiker: integration of TCM and natural therapies in Germany

The German Health System and Heilpraktiker: integration of TCM and natural therapies in Germany