European Healthcare Systems Research Articles

Drivers and recent trends of hospitalisation costs related to acute pulmonary embolism.

The socio-economic burden imposed by acute pulmonary embolism (PE) on European healthcare systems is largely unknown. We sought to determine temporal trends and identify cost drivers of hospitalisation for PE in Germany. We analysed the totality of reimbursed hospitalisation costs in Germany (G-DRG system) in the years 2016-2020. Overall, 484 884 PE hospitalisations were coded in this period. Direct hospital costs amounted to a median of 3572 (IQR, 2804 to 5869) euros, resulting in average total reimbursements of 710 million euros annually. Age, PE severity, comorbidities and in-hospital (particularly bleeding) complications were identified by multivariable logistic regression as significant cost drivers. Use of catheter-directed therapy (CDT) constantly increased (annual change in the absolute proportion of hospitalisations with CDT + 0.40% [95% CI + 0.32% to + 0.47%]; P < 0.001), and it more than doubled in the group of patients with severe PE (28% of the entire population) over time. Although CDT use was overall associated with increased hospitalisation costs, this association was no longer present (adjusted OR 1.02 [0.80-1.31]) in patients with severe PE and shock; this was related, at least in part, to a reduction in the median length of hospital stay (for 14.0 to 8.0days). We identified current and emerging cost drivers of hospitalisation for PE, focusing on severe disease and intermediate/high risk of an adverse early outcome. The present study may inform reimbursement decisions by policymakers and help to guide future health economic analysis of advanced treatment options for patients with PE.

Healthcare support for ukrainian refugees in the Czech Republic: a literature review

The article focuses on the analysis of "most common methods providing health care to migrants and refugees and on the other hand on the analysis of "most common health problems" of refugees and migrants especially in Europe after the outbreak of war in Ukraine. Stemming from the conflict since 2014, it has triggered the most significant wave of refugees in contemporary history. The method of analysis is a "literature review" created from available sources in Medline, Scopus, PubMed, and Web of Science, focusing on data systematization within the GAJU 101/2022/S project funded by the South Bohemian University in České Budějovice, Czech Republic. The search strategy included keywords such as "Ukrainian migrants," "refugees," "health data," "central registry," "healthcare crisis," and "aid provision," employing logical operators. We examined 41 literary sources from both Czech and international publications, as well as official institution websites. The study identifies the complex interplay between migration and health, revealing diverse needs among migrants and refugees. It emphasizes the necessity of developing effective healthcare policies, particularly in crisis situations. Understanding the implementation of legal provisions for healthcare access is crucial for adapting healthcare systems in Europe. Upholding the principles of the Universal Declaration of Human Rights during information gathering ensures equal access to medical assistance regardless of individuals' status or financial standing. Therefore, further research in this direction should not only deepen our understanding of the migration-health relationship but also translate knowledge into policies for improving healthcare conditions for migrants and refugees in Europe.

Global assessment of the knowledge and confidence in managing allergic disorders among primary care pediatricians across Europe: An EAACI task force report.

Pediatricians are often the first point of contact for children in Primary Care (PC), but still perceive gaps in their allergy knowledge. We investigated self-perceived knowledge gaps and educational needs in pediatricians across healthcare systems in Europe so that future educational initiatives may better support the delivery of allergy services in PC. A multinational survey was circulated to pediatricians who care for children and adolescents with allergy problems in PC by the EAACI Allergy Educational Needs in Primary Care Pediatricians Task Force from February to March 2023. A 5-point Likert scale was used to assess the level of agreement with questionnaire statements. Thirty surveys per country were the cut-off for inclusion and statistical analysis. In this study, 1991 respondents were obtained from 56 countries across Europe and 210 responses were from countries with a cut-off below 30 participants per country. Primary care pediatricians (PCPs) comprised 74.4% of the respondents. The majority (65.3%) were contracted to state or district health services. 61.7% had awareness of guidelines for onward allergy referral in their countries but only 22.3% were aware of the EAACI competencies document for allied health professionals for allergy. Total sample respondents versus PCPs showed 52% and 47% of them have access to allergy investigations in their PC facility (mainly specific IgE and skin prick tests); 67.6% and 58.9% have access to immunotherapy, respectively. The main barrier to referral to a specialist was a consideration that the patient's condition could be diagnosed and treated in this PC facility, (57.8% and 63.6% respectively). The main reasons for referral were the need for hospital assessment, and partial response to first-line treatment (55.4% and 59.2%, 47% and 50.7%, respectively). Learning and assessment methods preference was fairly equally divided between Traditional methods (45.7% and 50.1% respectively) and e-learning 45.5% and 44.9%, respectively. Generalist physicians (GPs) have the poorest access to allergy investigations (32.7%, p = .000). The majority of the total sample (91.9%) assess patients with allergic pathology. 868 (43.6%) and 1117 (46.1%), received allergy training as undergraduates and postgraduates respectively [these proportions in PCPs were higher (45% and 59%), respectively]. PCPs with a special interest in allergology experienced greater exposure to allergy teaching as postgraduates. GPs received the largest amount of allergy teaching as undergraduates. Identifying allergic disease based on clinical presentation, respondents felt most confident in the management of eczema/atopic dermatitis (87.4%) and rhinitis/asthma (86.2%), and least confident in allergen immunotherapy (36.9%) and latex allergy (30.8%). This study exploring the confidence of PCPs to diagnose, manage, and refer patients with allergies, demonstrated knowledge gaps and educational needs for allergy clinical practice. It detects areas in need of urgent improvement especially in latex and allergen immunotherapy. It is important to ensure the dissemination of allergy guidelines and supporting EAACI documents since the majority of PCPs lack awareness of them. This survey has enabled us to identify what the educational priorities of PCPs are and how they would like to have them met.

Cost-effectiveness of remote haemodynamic monitoring by an implantable pulmonary artery pressure monitoring sensor (CardioMEMS-HF system) in chronic heart failure in the Netherlands.

Remote haemodynamic monitoring with an implantable pulmonary artery (PA) sensor has been shown to reduce heart failure (HF) hospitalizations and improve quality of life. Cost-effectiveness analyses studying the value of remote haemodynamic monitoring in a European healthcare system with a contemporary standard care group are lacking. A Markov model was developed to estimate the cost-effectiveness of PA-guided therapy compared to the standard of care based upon patient-level data of the MONITOR-HF trial performed in the Netherlands in patients with chronic HF (New York Heart Association class III and at least one previous HF hospitalization). Cost-effectiveness was measured as the incremental cost per quality-adjusted life year (QALY) gained from the Dutch societal perspective with a lifetime horizon which encompasses a wide variety of costs including costs of hospitalizations, monitoring time, telephone contacts, laboratory assessments, and drug changes in both treatment groups. In the base-case analysis, PA-guided therapy increased costs compared to standard of care by €12 121. The QALYs per patient for PA-guided therapy and standard of care was 4.07 and 3.481, respectively, reflecting a gain of 0.58 QALYs. The resulting incremental cost-effectiveness ratio was €20 753 per QALY, which is below the Dutch willingness-to-pay threshold of €50 000 per QALY gained for HF. The current cost-effectiveness study suggests that remote haemodynamic monitoring with PA-guided therapy on top of standard care is likely to be cost-effective for patients with symptomatic moderate-to-severe HF in the Netherlands.

EU Health Policy and the Healthcare Labour Market in Latvia: The Out-Migration of Healthcare Practitioners

Healthcare systems in Europe are facing increasingly complex challenges that demand innovative solutions. Furthermore, public health is increasingly recognised as a productive factor which impacts the healthcare sector’s contribution to national economies. The out-migration of healthcare practitioners from Latvia is one of the most pressing problems in the health sector, which, in turn, negatively impacts the country’s economy. The outflow of healthcare practitioners to other EU countries has increased since 2004, the year which saw Latvia’s accession to the EU. This trend is a consequence of labour accumulation efficiency in the single market, and this article aims at conducting analyses of the main push factors governing healthcare practitioners’ emigration from Latvia and the impact of these factors on the healthcare sector. The complexity of this migration determines the use of an interdisciplinary as a methodological approach in the analysis of the main trends in the healthcare labour market. This approach can assist one in carrying out an assessment of the healthcare system’s losses as a result of the out-migration which has occurred thus far. Particular attention is paid to the training of resident doctors as a perspective trend in keeping healthcare professionals in the country. The legal mechanism for recovering public funding dedicated to residency programs has also been assessed. In conclusion, the article states that the mass emigration of healthcare practitioners from Latvia may jeopardise the efficient functioning of the country’s healthcare system.

Modelling costs of interventional pulmonary embolism treatment: implications of US trends for a European healthcare system.

Catheter-directed treatment (CDT) of acute pulmonary embolism (PE) is entering a growth phase in Europe following a steady increase in the USA in the past decade, but the potential economic impact on European healthcare systems remains unknown. We built two statistical models for the monthly trend of proportion of CDT among patients with severe (intermediate- or high-risk) PE in the USA. The conservative model was based on admission data from the National Inpatient Sample (NIS) 2016-20 and the model reflecting increasing access to advanced treatment from the PERT™ national quality assurance database registry 2018-21. By applying these models to the forecast of annual PE-related hospitalizations in Germany, we calculated the annual number of severe PE cases and the expected increase in CDT use for the period 2025-30. The NIS-based model yielded a slow increase, reaching 3.1% (95% confidence interval 3.0-3.2%) among all hospitalizations with PE in 2030; in the PERT-based model, increase would be steeper, reaching 8.7% (8.3-9.2%). Based on current reimbursement rates, we estimated an increase of annual costs for PE-related hospitalizations in Germany ranging from 15.3 to 49.8 million euros by 2030. This calculation does not account for potential cost savings, including those from reduced length of hospital stay. Our approach and results, which may be adapted to other European healthcare systems, provide a benchmark for healthcare costs expected to result from CDT. Data from ongoing trials on clinical benefits and cost savings are needed to determine cost-effectiveness and inform reimbursement decisions.

Nursing students’ Health Literacy skills: a scoping review protocol for driving research

IntroductionThe healthcare systems in Europe are changing rapidly due to the increased complexity of healthcare needs, specifically for the ageing population with chronic diseases. Nurses play a key role in...

The Economic Costs of Informal Care: Estimates from a National Cross-Sectional Survey in The Netherlands.

Faced with an unprecedented demand for long-term care, European health care systems are moving towards mixed care models, where the welfare state and informal caregivers share care responsibilities. While informal care is often viewed as a means of alleviating pressure on public care, it comes with significant economic costs for caregivers, their employers, and society at large. This study uses nationally representative data to estimate the total direct (informal care time and out-of-pocket costs) and indirect (productivity) economic costs of informal care in the Netherlands in 2019. Informal care time costs are estimated using the opportunity cost and the proxy good methods. Indirect costs are estimated using the human capital and friction cost approaches. Our results reveal the considerable annual societal cost of informal care in the Netherlands, ranging between €17.5 billion and €30.1 billion, depending on the valuation approach. These costs are equivalent to 2.15% and 3.71% of Dutch GDP in 2019, comparable to the public expenditure on long-term care in that year. Female caregivers account for slightly more than half (53%-57%) of the total costs. Around 57%-88% of these costs are in the form of informal care time. The main driver of indirect costs is the temporary cessation of work, which comprises 12%-17% of the total costs. Findings corroborate that substantial resources, yet thus far largely disregarded, are spent on informal care even in a country with a relatively generous public long-term care system.

Cancer-associated financial burden in German head and neck cancer patients.

The financial toxicity of cancer causes higher morbidity and mortality. As the financial burden due to head and neck cancer (HNC) in European healthcare systems with legally established compulsory health insurance is still poorly understood, we set up an investigation to assess the financial impact of HNC. Between August 2022 and March 2023, HNC consecutive patients (n = 209) attending the cancer aftercare program of a university hospital in an outpatient setting were surveyed utilizing self-administered questionnaires about their socioeconomic situation, income loss, and out-of-pocket payments (OOPPs). The majority of HNC patients (n = 119, 59.5%) reported significant financial burden as a consequence of OOPP (n = 100, 50.0%) and/or income loss (n = 51, 25.5%). HNC patients reporting financial burden due to OOPP had on average 1,716 € per year costs related to their disease, whereas patients reporting an income loss had a mean monthly income loss of 620.53 €. Advanced UICC (7th edition, 2017) stage, T3 or T4 category, and larynx/hypopharynx cancer are significant predictors of financial burden. HNC survivors suffer from significant financial burden after HNC treatment, even in Germany with a healthcare system with statutory health insurance. The findings from this study offer valuable insights for healthcare professionals and policymakers, helping them acknowledge the economic impact of HNC.

Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

Complete revascularization by non-infarct-related artery (IRA) percutaneous coronary intervention (PCI) in patients with acute myocardial infarction is standard practice to improve patient prognosis. However, it is unclear whether a fractional flow reserve (FFR)-guided or angiography-guided treatment strategy for non-IRA PCI would be more cost-effective. To evaluate the cost-effectiveness of FFR-guided compared with angiography-guided PCI in patients with acute myocardial infarction and multivessel disease. In this prespecified cost-effectiveness analysis of the FRAME-AMI randomized clinical trial, patients were randomly allocated to either FFR-guided or angiography-guided PCI for non-IRA lesions between August 19, 2016, and December 24, 2020. Patients were aged 19 years or older, had ST-segment elevation myocardial infarction (STEMI) or non-STEMI and underwent successful primary or urgent PCI, and had at least 1 non-IRA lesion (diameter stenosis >50% in a major epicardial coronary artery or major side branch with a vessel diameter of ≥2.0 mm). Data analysis was performed on August 27, 2023. Fractional flow reserve-guided vs angiography-guided PCI for non-IRA lesions. The model simulated death, myocardial infarction, and repeat revascularization. Future medical costs and benefits were discounted by 4.5% per year. The main outcomes were quality-adjusted life-years (QALYs), direct medical costs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INB) of FFR-guided PCI compared with angiography-guided PCI. State-transition Markov models were applied to the Korean, US, and European health care systems using medical cost (presented in US dollars), utilities data, and transition probabilities from meta-analysis of previous trials. The FRAME-AMI trial randomized 562 patients, with a mean (SD) age of 63.3 (11.4) years. Most patients were men (474 [84.3%]). Fractional flow reserve-guided PCI increased QALYs by 0.06 compared with angiography-guided PCI. The total cumulative cost per patient was estimated as $1208 less for FFR-guided compared with angiography-guided PCI. The ICER was -$19 484 and the INB was $3378, indicating that FFR-guided PCI was more cost-effective for patients with acute myocardial infarction and multivessel disease. Probabilistic sensitivity analysis showed consistent results and the likelihood iteration of cost-effectiveness in FFR-guided PCI was 97%. When transition probabilities from the pairwise meta-analysis of the FLOWER-MI and FRAME-AMI trials were used, FFR-guided PCI was more cost-effective than angiography-guided PCI in the Korean, US, and European health care systems, with an INB of $3910, $8557, and $2210, respectively. In probabilistic sensitivity analysis, the likelihood iteration of cost-effectiveness with FFR-guided PCI was 85%, 82%, and 31% for the Korean, US, and European health care systems, respectively. This cost-effectiveness analysis suggests that FFR-guided PCI for non-IRA lesions saved medical costs and increased quality of life better than angiography-guided PCI for patients with acute myocardial infarction and multivessel disease. Fractional flow reserve-guided PCI should be considered in determining the treatment strategy for non-IRA stenoses in these patients. ClinicalTrials.gov Identifier: NCT02715518.

NEMECYS: Addressing Challenges to Building Security Into Connected Medical Devices

The European health care system is moving toward personalised, distributed, and home-based services. This is made possible via new and improved connected medical devices (CMDs), and will benefit health care providers in terms of reduced cost and improved service. Patients will see improved quality of life in terms of reduced travel time and reduced stress via treatment at home or where they want it. However, for these benefits to be fully realised, the cybersecurity of CMDs needs to be ensured. This paper presents a brief survey of challenges to building security into CMDs, and introduces NEMECYS, an EU-funded project which will help practitioners to (a) comply with Medical Device (MD) regulations; (b) be able to apply proportionate MD cybersecurity, and (c) build in cybersecurity by design for both MDs and the connected scenarios they operate in.

Critical success factors for creating sustainable digital health applications: A systematic review of the German case.

The Covid-19 pandemic has accelerated the adoption of digital technologies to address social needs, leading to increased investments in digital healthcare applications. Germany implemented a special law called the "Digitales Versorgungsgesetz" (DVG-Digital Supply Act) in 2019, which enables the reimbursement of digital health applications, including digital therapeutics (DTx), through a fast-track process. The Federal Institute for Drugs and Medical Devices (BfArM), the German federal authority responsible for overseeing digital health applications, has implemented legislative adjustments since the law's introduction, which have increased requirements for these applications and potentially led to the removal of some from the directory as well as a slowdown in the addition of new ones. To counteract this trend, this work aimed to identify key success factors for digital health applications (DiGAs). This research identifies critical success factors through a structured literature review for developing sustainable digital health applications within the European healthcare systems, specifically DiGAs. The study aims to support the ongoing digital transformation in healthcare. The identified success factors that significantly impact the sustainability of DiGAs include patient-centered design, application effectiveness, user-friendliness, and adherence to data protection and information security regulations using standardized approaches. These factors are crucial in preventing the failure of DiGA manufacturers in European countries. By considering and implementing these critical success factors, DiGA manufacturers can enhance their chances of long-term success and contribute to the digital transformation of the healthcare system in Europe.

Economic Burden of Clostridioides difficile Infection in European Countries.

Clostridioides difficile infection (CDI) remains a considerable challenge to healthcare systems worldwide. Although CDI represents a significant burden on healthcare systems in Europe, few studies have attempted to estimate the consumption of resources associated with CDI in Europe. The reported extra costs attributable to CDI vary widely according to the definitions, design, and methodologies used, making comparisons difficult to perform. In this chapter, the economic burden of healthcare facility-associated CDI in Europe will be assessed, as will other less explored areas such as the economic burden of recurrent CDI, community-acquired CDI, pediatric CDI, and CDI in outbreaks.

Explorative cost-effectiveness analysis of colorectal cancer recurrence detection with next-generation sequencing liquid biopsy in Spain, France, and Germany.

Next-generation sequencing liquid biopsy (NGS-LB) for colorectal cancer (CRC) detection and surveillance remains an expensive technology as economies of scale have not yet been realized. Nevertheless, the cost of sequencing has decreased while sensitivity has increased, raising the question of whether cost-effectiveness (CE) has already been achieved from the perspective of European healthcare systems. This health economic (HE) modeling study explores the CE of NGS-LB for CRC based on direct treatment costs compared to standard care without liquid biopsy in Spain, France, and Germany. A structured literature search was used to collect evidence from 2009 to 2020 on the stage-dependent quality of life (quality-adjusted life-years, QALY), efficacy, and total direct treatment costs (TDC) of NGS-LB. A decision-analytic Markov model was developed. Over the remaining lifetime, cumulative life expectancy (LE), TDC, and QALYs were calculated for 60-year-old men and women in CRC stage III with different assumed effects of NGS-LB of 1% or 3% on improved survival and reduced stage progression, respectively. The use of NGS-LB increases LE by 0.19 years in Spanish men (France: 0.19 years, Germany: 0.13 years) and by 0.21 years in Spanish women (France: 0.21 years, Germany: 0.14 years), respectively. The 3% discounted cost per QALY gained was 35,571.95 € for Spanish men (France: 31,705.15 €, Germany: 37,537.68 €) and 35,435.71 € for Spanish women (France: 31,295.57 €, Germany: 38,137.08 €) in the scenario with 3% improved survival and reduced disease progression. Compared to the other two countries, Germany has by far the highest TDC, which can amount to >80k euros in the last treatment year. In this explorative HE modeling study, NGS-LB achieves generally accepted CE levels in CRC treatment from the health system perspective in three major European economies under assumptions of small improvements in cancer recurrence and survival. Confirmation of these findings through clinical trials is encouraged.

EU NAVIGATE: Developing a European navigation intervention for older people with cancer and their family caregivers

Background: Most people who have cancer are older people, and this affects millions of Europeans yearly. Integrating high-quality, equitable, and cost-effective care across the continuum of supportive, palliative, end-of-life, and survivorship care for both patients and family caregivers is highly relevant from a healthcare, prevention, and economic perspective.&#x0D; Aims: EU NAVIGATE is an interdisciplinary, cross-country, and intersectoral project funded by the European Union and aiming to evaluate the effectiveness and cost-effectiveness of a patient and family navigation intervention (NavCare-EU) for older people with cancer and their family caregivers in different healthcare systems in Europe. It focuses on reaching underserved individuals, supporting and empowering them to access their own networks and available resources within their community. As the first step, the existing and promising Canadian Nav-Care intervention from will be adapted, contextualized, standardized and pilot-tested across six European countries.&#x0D; Concept and methods and anticipated results: NavCare-EU is a person- and family-centered non-pharmacological intervention in which volunteer navigators collaborate with patients and families to facilitate timely and equitable access to health and social care services and resources as needed. The Nav-CARE intervention involves a navigation model, including international blended training, and various tools to support navigators. We will share the model, different roles involved and training packages. Following the ADAPT guidance, the Nav-Care intervention will be translated and adapted in close collaboration with Local Adaptation Teams diverse users, and other stakeholders (according to principles of Patient and Public Involvement). To contextualize the original intervention, we follow the extended Normalization Process Theory. An International Oversight Group will safeguard the original intervention’s integrity and key components using the Model for Adaptation Design and Impact (MADI) to guide decision-making around the design of adaptations. The feasibility of the Nav-CARE intervention within local settings will be reviewed across countries in a pilot study to understand the practicalities of implementation, maximize feasibility, and troubleshoot issues that arise during implementation. Effectiveness and cost-effectiveness will be evaluated through an international pragmatic randomized controlled trial.&#x0D; Impact: The EU NAVIGATE will shift the state of the art of cancer care in Europe by providing an innovative solution to the complex care needs experienced by older cancer patients and their families. we pay particular attention to local healthcare contexts to ensure optimal implementation. We will present the final program ready for testing at the conference.

Acute care bundles should be used for patients with intracerebral haemorrhage: An expert consensus statement.

Intracerebral haemorrhage (ICH) is the most devastating form of stroke and a major cause of disability. Clinical trials of individual therapies have failed to definitively establish a specific beneficial treatment. However, clinical trials of introducing care bundles, with multiple therapies provided in parallel, appear to clearly reduce morbidity and mortality. Currently, not enough patients receive these interventions in the acute phase. We convened an expert group to discuss best practices in ICH and to develop recommendations for bundled care that can be delivered in all settings that treat acute ICH, with a focus on European healthcare systems. In this consensus paper, we argue for widespread implementation of formalised care bundles in ICH, including specific metrics for time to treatment and criteria for the consideration of neurosurgical therapy. There is an extraordinary opportunity to improve clinical care and clinical outcomes in this devastating disease. Substantial evidence already exists for a range of therapies that can and should be implemented now.

Implementation of pre-emptive testing of a pharmacogenomic panel in clinical practice: Where do we stand?

Adverse drug reactions (ADRs) account for a large proportion of hospitalizations among adults and are more common in multimorbid patients, worsening clinical outcomes and burdening healthcare resources. Over the past decade, pharmacogenomics has been developed as a practical tool for optimizing treatment outcomes by mitigating the risk of ADRs. Some single-gene reactive tests are already used in clinical practice, including the DPYD test for fluoropyrimidines, which demonstrates how integrating pharmacogenomic data into routine care can improve patient safety in a cost-effective manner. The evolution from reactive single-gene testing to comprehensive pre-emptive genotyping panels holds great potential for refining drug prescribing practices. Several implementation projects have been conducted to test the feasibility of applying different genetic panels in clinical practice. Recently, the results of a large prospective randomized trial in Europe (the PREPARE study by Ubiquitous Pharmacogenomics consortium) have provided the first evidence that prospective application of a pre-emptive pharmacogenomic test panel in clinical practice, in seven European healthcare systems, is feasible and yielded a 30% reduction in the risk of developing clinically relevant toxicities. Nevertheless, some important questions remain unanswered and will hopefully be addressed by future dedicated studies. These issues include the cost-effectiveness of applying a pre-emptive genotyping panel, the role of multiple co-medications, the transferability of currently tested pharmacogenetic guidelines among patients of non-European origin and the impact of rare pharmacogenetic variants that are not detected by currently used genotyping approaches.

Digital public health in Germany

Abstract The German healthcare system is complex, with different levels of government and stakeholders involved. Therefore, implementing a consistent and cohesive digitalisation strategy nationwide is challenging. Unsurprisingly the system seems to operate according to the mantra: “From the cradle to the grave: forms, forms”. It is still one of the most paper-based healthcare systems in Europe. Until 2021, there were no electronic health records. Electronic prescriptions are delayed until 2024. The systems structures appear stuck and inflexible. The COVID-19 pandemic displayed the weaknesses of the German healthcare system: A lack of digital infrastructure, limited access to teleconsultations and telemedicine, healthcare professionals lacking training in digital health tools, etc. However, instead of giving up, there was a push from the industry and legislators toward applying more digital tools in the healthcare routine. Germany was among the first countries to develop one of the safest contract tracing apps worldwide (Corona-Warn-App). It further lifted its restrictions on telemedical consultations and was the first country to introduce medical and care apps on prescription (DiGA and DiPA). Additionally, the first national health portal was introduced in 2020 to provide the general population with information on health- and disease-related topics and an overview of currently implemented and planned digital health services. Now, it is discussed setting up a national Health Data Lab to empower public health research through secondary data based on health insurance claims data. Nevertheless, the question remains where the German legislative sees the role of health promotion and primary prevention. While public health associations push for recognising these crucial aspects of public health, all national projects currently focus on diagnostics and treatment. The question remains if and when Germany will realise the potential of digital public health in primary health promotion.

The Future of HSR Program Evaluation: A European Perspective

Abstract There is a long tradition of program evaluation in public health, due to the influence of medical approaches and the development of evidence-based medicine. Health services research have thus provided substantial evidence and built itself partially on the evaluation of organizational innovations over time in various international healthcare settings. What is new here? What is the future of HSR from an evaluation perspective? Since the turn of the century, two main shifts in the resources and methods available to public health researchers could provide a significant leap for HSR research in Europe, and in France especially. First, more data are being produced and made available to researchers. Most healthcare systems in Europe have implemented DRGs and for doing so, information systems have been developed incidentally. This led to the routine production of data initially used for payment schemes, that are now increasingly being used for research. Although this is similar to what happened in the US, the main difference with European healthcare systems lies in the generalized approach of the welfare system to the whole population. Second, evaluation methods recently evolved towards the framework of what is known as “realist evaluation” based on the causal analysis of programs or public policies while incorporating contextual effects and a theoretical perspective to explain rather than merely measure the effect - or lack thereof. To conclude, we shall argue that the future of HSR program evaluation may bring together researchers, health professionals and policymakers to discuss, explore, experiment and implement innovative actions in healthcare to address the challenges to come.

20 years of declining hospital length-of-stay in different European healthcare models and systems

Abstract Background Hospital length of stay (LOS) is an important indicator of healthcare systems’ performance. Several factors are closely related to LOS, which is characterized by high heterogeneity among countries. This study aims to investigate the 20-year time-trends of LOS and their association with different healthcare systems’ and reimbursement models among 25 European countries. Methods We conducted a 20-year time-trend analysis (2000-2019) using a Weighted Least Squares model for panel data to investigate the association between LOS, healthcare systems’ models (National Health Service, NHS, National Health Insurance, NHI, Social Health Insurance, SHI, and Etatist Social Health Insurance, ESH), reimbursement schemes (Prospective Global Budget, PGB, Diagnosis Related Groups, DRG, and Procedure Service Payment, PSP), and several control variables. Data were extracted from the Eurostat and GBD study databases. Results The analysis showed a generalized reduction of LOS across the 25 countries, ranging from 9.20 days in 2000 to 7.24 in 2019. SHI was associated with a lower LOS compared to the reference category (NHS) (b=−0.6327, p &amp;lt; 0.05). Both DRG (b = 1.2399, p &amp;lt; 0.05) and PSP (b = 1.1677, p &amp;lt; 0.05) reimbursement models were positively associated with LOS when compared to PGB. Conclusions Our results confirmed the downward trend of LOS in the last 20 years among European countries, highlighting the strong influence of the healthcare system model. The results of this study offer insight into the factors influencing healthcare utilization and can inform the design of more efficient and sustainable healthcare systems. Key messages • This study investigated the relationship between HS models, financing, regulation, service provision, reimbursement schemes, and LOS, across 25 European countries in the last 20 years. • This study found a dominant influence of the HS models on LOS. SHI models were associated with shorter LOS compared to National Health Systems, after accounting for several factors.