A theoretical framework for linking hospitals longitudinally: demonstrated using German Hospital Quality Reports 2016-2020.

BACKGROUND: In longitudinal health services research, hospital identification using an ID code, often supplemented with several additional variables, lacks clarity regarding representativeness and variable influence. This study presents an operational method for hospital identity delimitation and a novel longitudinal identification approach, demonstrated using a case study. METHODS: The conceptualisation considers hospitals as evolving entities, identifying "similar enough" pairs across two time points using an automated similarity matrix. This method comprises key variable selection, similarity scoring, and tolerance threshold definition, tailored to data source characteristics and clinical relevance. This linking method is tested by applying the identification of minimum caseload requirements-related German hospitals, utilizing German Hospital Quality Reports (GHQR) 2016-2020. RESULTS: The method achieved a success rate (min: 97.9% - max: 100%, mean: 99.9%) surpassing traditional hospital ID-code linkage (min: 91.5% - max: 98.8%, mean: 96.6%), with a remarkable 99% reduction in manual work through automation. CONCLUSIONS: This method, rooted in a comprehensive understanding of hospital identities, offers an operational, automated, and customisable process serving diverse clinical topics. This approach has the advantage of simultaneously considering multiple variables and systematically observing temporal changes in hospitals. It also enhances the precision and efficiency of longitudinal hospital identification in health services research.

Association between continuity of care and treatment outcomes in psychiatric patients in Germany: a prospective cohort study.

BACKGROUND: Continuity of care is considered an important treatment aspect of psychiatric disorders, as it often involves long-lasting or recurrent episodes with psychosocial treatment aspects. We investigated in two psychiatric hospitals in Germany whether the positive effects of relational continuity of care on symptom severity, social functioning, and quality of life, which have been demonstrated in different countries, can also be achieved in German psychiatric care. METHODS: Prospective cohort study with a 20-months observation period comparing 158 patients with higher and 165 Patients with lower degree of continuity of care of two psychiatric hospitals. Patients were surveyed at three points in time (10 and 20 months after baseline) using validated questionnaires (CGI Clinical Global Impression rating scales, GAF Global Assessment of Functioning scale, EQ-VAS Euro Quality of Life) and patient clinical record data. Statistical analyses with analyses of variance with repeated measurements of 162 patients for the association between the patient- (EQ-VAS) or observer-rated (CGI, GAF) outcome measures and continuity of care as between-subject factor controlling for age, sex, migration background, main psychiatric diagnosis group, duration of disease, and hospital as independent variables. RESULTS: Higher continuity of care reduced significantly the symptom severity with a medium effect size (p 0.036, eta 0.064) and increased significantly social functioning with a medium effect size (p 0.023, eta 0.076) and quality of life but not significantly and with only a small effect size (p 0.092, eta 0.022). The analyses of variance suggest a time-independent effect of continuity of care. The duration of psychiatric disease, a migration background, and the hospital affected the outcome measures independent of continuity of care. CONCLUSION: Our results support continuity of care as a favorable clinical aspect in psychiatric patient treatment and encourage mental health care services to consider health service delivery structures that increase continuity of care in the psychiatric patient treatment course. In psychiatric health care services research patients' motives as well as methodological reasons for non-participation remain considerable potential sources for bias. TRIAL REGISTRATION: This prospective cohort study was not registered as a clinical intervention study because no intervention was part of the study, neither on the patient level nor the system level.

[How do Surgical Patients Choose their Hospital? A Cross-sectional Study]. / Wie wählen chirurgische Patienten ihr Krankenhaus? Eine Querschnittstudie // How do surgical patients choose their hospital? A cross-sectional study.

BACKGROUND: Free hospital choice is promoted in health policy through public quality reporting. Previous studies on hospital choice mostly survey patients for specific elective procedures. This study examines all full inpatient surgical patients and compares them to those in other specialties. Research questions are: How many patients make their own decisions about the hospital? How much time do they have before admission? Where do they obtain information and what are their important decision criteria? MATERIALS AND METHODS: This study evaluates cross-sectional primary data on hospital choice collected by questionnaire from 1925 consecutively hospitalised patients from 11 medical specialties and 3 levels of care, including 438 surgical patients from 6 general surgery departments. RESULTS: Three quarters of surgical patients decide on the hospital themselves. Their own previous experience with the hospital is an important source of information and decision-making criterion for a good half of the patients, along with relatives and outpatient treatment providers as well as the hospital reputation. CONCLUSION: Many surgical patients decide in favour of a hospital because of the trust they have built up through previous treatment in the hospital, which they experience as satisfactory. The professional quality of treatment is thus the greatest impact factor on patients, their relatives and outpatient treatment providers. It is important to actively and specifically address and clarify possible dissatisfaction on the part of the patient before discharge.

[People with intellectual disabilities (ID) in outpatient medical care: barriers to access and treatment process]. / Menschen mit geistiger Behinderung (MmgB) in der ambulanten medizinischen Versorgung: Barrieren beim Zugang und im Untersuchungsablauf.

BACKGROUND AND AIM: People with intellectual disabilities (ID) show an increased morbidity. Their access to healthcare could be a contributing factor, but there is little data on this in Germany. This paper addresses the question of what barriers and facilitators exist in the use of medical outpatient healthcare for people with ID, considering their own perspective and the perspectives of their accompanying relatives and their general practitioners (GPs). METHODS: In this cross-sectional study, people with ID in three sheltered workshops, their relatives and their GPs were interviewed by means of questionnaires. The data were evaluated descriptively, and a statistical comparison of the perspectives of the people with ID and their relatives was performed. The content structure follows Cantrell's pathway model (identifying need, accessing services and interaction during a consultation). RESULTS: People with ID communicate complaints to their relatives, who usually accompany them to medical appointments. There are more organisational than spatial barriers. The treatment is sometimes impeded by fears, restlessness or not allowing examinations. It is difficult to find experienced health professionals, which is why a list of such practices and, structurally, medical centres for people with ID would be beneficial. The views of people with ID and their relatives show hardly any differences. GPs cite increased treatment effort, desire for further training and appropriate remuneration. CONCLUSIONS: Relatives play an important role in the medical care of people with ID. Difficulties in care can arise from the specific, more complex requirements in treating people with ID, which present as organisational difficulties but also require an active readiness for inclusion.

[Health Care Use by Intellectually Disabled People: A Cross-Sectional Study in three Sheltered Workshops]. / Inanspruchnahme der gesundheitlichen Versorgung von Menschen mit geistiger Behinderung, eine Querschnittstudie in 3 Werkstätten.

STUDY OBJECTIVE: People with intellectual disabilities have a lower life expectancy and more frequent comorbidities than the general population and have unmet health needs. Insufficient medical care is suspected to be one reason, for which little data is available in Germany. The study therefore focuses on the question of how people with intellectual disabilities make use of medical care, including screening and preventive measures. METHOD: In a cross-sectional study in 3 workshops for people with intellectual disabilities, the use of health care was surveyed by means of questionnaires from their relatives. The evaluation was carried out descriptively and by means of inferential statistics comparing participants with the general population as well as within the group of participants for socio-demographic differences. RESULTS: Almost all 181 participants (participation rate 19.3%) had a family doctor. In comparison to the general population, the participants made more frequent use of the services of general practitioners and the care provided by numerous other specialist areas. They made less frequent use of screening for colon, breast, cervix and prostate and more frequent use for skin cancer and general check-up. Dental check-ups and preventive measures showed no difference. Participants living in institutional settings made more use of the regular services than those living with relatives or alone. Participants with a migration background were less aware of care services. CONCLUSIONS: The results do not show any indications of a general undersupply of health care. Participation in cancer screening with more complex examinations should be encouraged, especially for people with mental disabilities living alone or with relatives. Those with a migration background and their families should be specifically informed.

[Effects of statutory quality assurance in acute inpatient care]. / Effekte der gesetzlichen Qualitätssicherung in der akutstationären Versorgung.

BACKGROUND: Statutory quality assurance (QA) serves to ensure and further develop the quality of service provision. Particularly prominent in Germany's acute inpatient care are mandatory quality reports (QRs) and participation in external quality assessments (eQAs). Their effects have not yet been comprehensively evaluated. OBJECTIVES: What are the effects of eQAs and QRs on the quality of care? MATERIALS AND METHODS: Based on a selective literature review, international evidence on the effects of QA was compiled. This was supplemented by analyses of the quality reports of the Federal Office for Quality Assurance (BQS), the Institute for Applied Quality Improvement and Research in Health Care (AQUA), and the Institute for Quality Assurance and Transparency in Healthcare (IQTIG), which have been responsible for eQAs since 2001. RESULTS: According to international literature, at most weak effects of these measures can be expected, especially on process quality. Studies from Germany mostly observe only uncontrolled temporal trends and partly show improved quality indicators. Only one controlled study each was able to show weak positive effects on outcome and process quality for eQAs and QRs, respectively. CONCLUSIONS: There are no convincing evaluation results for either the QRs or the eQAs. Deficiencies in the addressee-oriented design of the QRs and the reported indicator results in terms of their validity, risk adjustment, and temporal availability can be cited as potential causes. Statutory QA should be revised by paying more attention to the prerequisites for successful performance feedback and by again creating room for an intrinsically motivated assessment of one's own quality of care.

Impact of suspending minimum volume requirements for knee arthroplasty on hospitals in Germany: an uncontrolled before-after study.

BACKGROUND: In 2004, the Federal Joint Committee, supreme decision-making body in German healthcare, introduced minimum volume requirements (MVRQs) as a quality instrument. Since then, MVRQs were implemented for seven hospital procedures. This study evaluates the effect of a system-wide intermission of MVRQ for total knee arthroplasty (TKA), demanding 50 annual cases per hospital. METHODS: An uncontrolled before-after study based on federal-level data including the number of hospitals performing TKA, and TKA cases from the external hospital quality assurance programme in Germany (2004-2017). Bi- and multivariate analyses based on hospital-level secondary data of TKA cases and TKA quality indicators extracted from hospital quality reports in Germany (2006-2014). RESULTS: The number of TKAs performed in Germany decreased by 11% after suspending the TKA-MVRQ in 2011, and rose by 13% after its reintroduction in 2015. The number of hospitals with less than 50 cases rose from 10 to 25% and their case share from 2 to 5.5% during suspension. Change in hospital volume after the suspension of TKA-MVRQ was not associated with hospital size, ownership, or region. All four evaluable quality indicators increased significantly in the year after their first public reporting. Compared to hospitals meeting the TKA-MVRQ, three indicators show slight but statistically significant better quality in hospitals below the TKA-MVRQ. CONCLUSIONS: In Germany, TKA-MVRQs seem to induce in-hospital caseload adjustments rather than foster regional inter-hospital case transfers as intended.

[Falling Short of Minimum Volume Standards, Exemptions and Their Consequences from 2018 Onwards. Complex Procedures on Oesophagus and Pancreas in German Hospitals from 2006 to 2014]. / Mindestmengen unterschreiten, Ausnahmetatbestände und ihre Konsequenzen ab 2018. Komplexe Eingriffe am Ösophagus und Pankreas in deutschen Krankenhäusern im Zeitverlauf von 2006 bis 2014.

STUDY AIM: The minimum volume standards for hospitals in Germany, in force since 2004, provide four exemptions for non-complying hospitals. This study investigates the extent and importance of these exemptions for complex procedures on the oesophagus and pancreas for all non-complying hospitals and for the revised minimum volume regulations in force since the beginning of 2018. METHOD: Longitudinal, descriptive analyses of data on minimum volume standards and their exemptions for complex procedures on the oesophagus and pancreas, as presented by the hospital quality report cards of the reporting years from 2006 to 2014. RESULTS: For each year and both procedures, about 120 hospitals with some 500 cases report non-compliance with the minimum volume standards. Of these a third report no exemptions (with 180 procedures), a third state emergencies (110), and another third report exemptions due to internal hospital restructuring (210). Ensuring geographical access to care as an exemption is of no importance. After the three year exemption period for installation of a new service line, 20% of the hospitals with procedures on the oesophagus and 30% on the pancreas complied with the minimum volume standards. After the two-year period for staff realignment, the figures were 40 and 50%, respectively. CONCLUSION: Exemptions do not entirely explain all procedures performed by hospitals not complying with the minimum volume standards. The revised minimum volume regulations' restructuring of exemptions to "emergencies" and "new or renewed service lines" with a two year exemption period, are concordant with the empirical findings of this study.

Hospital choice in Germany from the patient's perspective: a cross-sectional study.

BACKGROUND: In many countries health policy encourages patients to choose their hospital, preferably by considering information of performance reports. Previous studies on hospital choice mainly have focused on patients undergoing elective surgery. This study examined a representative sample of hospital inpatients across disciplines and treatment interventions in Germany. Its research questions were: How many patients decide where to go for hospital treatment? How much time do patients have before admission? Which sources of information do they use, and which criteria are relevant to their decision? METHODS: Cross-sectional observational study covering 1925 inpatients of 46 departments at 17 hospitals in 2012. The stratified survey comprised 11 medical disciplines (internal medicine, gynaecology, obstetrics, paediatrics, psychiatry, orthopaedics, neurology, urology, ENT and geriatrics) on 3 hospital care levels representing 91.9% of all hospital admissions to inpatient care in Germany in 2012. The statistical analysis calculated the frequency distributions and 95% confidence intervals of characteristics related to the hospital choice. RESULTS: 63.0% [60.9-65.2] of patients in Germany chose the hospital themselves, but only 21.1% [19.3-22.9] had more than one week to decide prior to admission. Major sources of information were personal knowledge of hospitals, relatives, outpatient health professionals and the Internet. Main criteria for the decision were personal experience with a hospital, recommendations from relatives and providers of outpatient services, a hospital's reputation and distance from home. Specific quality information as provided by performance reports were of secondary importance. CONCLUSIONS: A majority of patients in the German health system choose their hospital freely. Providers of outpatient health care can have an important "agent" function in the quality-oriented hospital choice especially for patients with little time prior to admission and those who do not decide themselves. Hospitals have an impact on patients' future hospital choices by the treatment experience they provide to patients.

Patient satisfaction with ambulatory care in Germany: effects of patient- and medical practice-related factors.

OBJECTIVE: The study aimed to illustrate the effect of the patients' sex, age, self-rated health and medical practice specialization on patient satisfaction. DESIGN: Secondary analysis of patient survey data using multilevel analysis (generalized linear mixed model, medical practice as random effect) using a sequential modelling strategy. We examined the effects of the patients' sex, age, self-rated health and medical practice specialization on four patient satisfaction dimensions: medical practice organization, information, interaction, professional competence. SETTING: The study was performed in 92 German medical practices providing ambulatory care in general medicine, internal medicine or gynaecology. PARTICIPANTS: In total, 9888 adult patients participated in a patient survey using the validated 'questionnaire on satisfaction with ambulatory care-quality from the patient perspective [ZAP]'. MAIN OUTCOME MEASURE(S): We calculated four models for each satisfaction dimension, revealing regression coefficients with 95% confidence intervals (CIs) for all independent variables, and using Wald Chi-Square statistic for each modelling step (model validity) and LR-Tests to compare the models of each step with the previous model. RESULTS: The patients' sex and age had a weak effect (maximum regression coefficient 1.09, CI 0.39; 1.80), and the patients' self-rated health had the strongest positive effect (maximum regression coefficient 7.66, CI 6.69; 8.63) on satisfaction ratings. The effect of medical practice specialization was heterogeneous. CONCLUSIONS: All factors studied, specifically the patients' self-rated health, affected patient satisfaction. Adjustment should always be considered because it improves the comparability of patient satisfaction in medical practices with atypically varying patient populations and increases the acceptance of comparisons.

Minimum volume standards in German hospitals: do they get along with procedure centralization? A retrospective longitudinal data analysis.

BACKGROUND: Compliance with minimum volume standards for specific procedures serves as a criterion for high-quality patient care. International experiences report a centralization of the respective procedures. In Germany, minimum volume standards for hospitals were introduced in 2004 for 5 procedures (complex esophageal and pancreatic interventions; liver, kidney and stem cell transplantations), in 2006 total knee replacement was added. This study explores whether any centralization is discernible for these procedures in Germany. METHODS: A retrospective longitudinal analysis of secondary data serves to determine a possible centralization of procedures from the system perspective. Centralization means that over time, fewer hospitals perform the respective procedure, the case volume in high-volume hospitals increases together with their percentage of the annual total case volume, and the case volume in low-volume hospitals decreases together with their percentage of the annual total case volume. Using data from the mandatory hospital quality reports for the years 2006, 2008 and 2010 we performed Kruskal Wallis and chi-square tests to evaluate potential centralization effects. RESULTS: No centralization was found for any of the six types of interventions over the period from 2006 to 2010. The annual case volume and the number of hospitals performing interventions rose at differing rates over the 5-year period depending on the type of intervention. Seven percent of esophagectomies and 14% of pancreatectomies are still performed in hospitals with less than 10 interventions per year. CONCLUSIONS: For the purpose of further centralization of interventions it will be necessary to first analyze and then appropriately address the reasons for non-compliance from the hospital and patient perspective.

Mandatory quality reports in Germany from the hospitals' point of view: a cross-sectional observational study.

BACKGROUND: Public reporting of hospital quality is to enable providers, patients and the public to make comparisons regarding the quality of care and thus contribute to informed decisions. It stimulates quality improvement activities in hospitals and thus positively impacts treatment results. Hospitals often use publicly reported data for further internal or external purposes.As of 2005, German hospitals are obliged to publish structured quality reports (QR) every two years. This gives them the opportunity to demonstrate their performance by number, type and quality in a transparent way. However, it constitutes a major burden to hospitals to generate and publish data required, and it is yet unknown if hospitals feel adequately represented and at the same time consider the effort appropriate.This study assesses hospital leaders' judgement about the capability of QR to put legally defined aims effectively and efficiently into practice. It also explores the additional purposes hospitals use their QR for. METHODS: In a cross-sectional observational study, a representative random sample out of 2,064 German hospitals (N=748) was invited to assess QR via questionnaire; 333 hospitals participated. We recorded the suitability of QR for representing number, type and quality of services, the adequacy of cost and benefits (6-level Likert scales) and additional purposes QR are used for (free text question). For representation purposes, the net sample was weighted for hospital size and hospital ownership (direct standardization). Data was analyzed descriptively and using inferential statistics (chi-2 test) or for the purpose of generating hypotheses. RESULTS: German hospitals rated the QR as suitable to represent the number of services but less so for the type and quality of services. The cost-benefit ratio was seen as inadequate. There were no significant differences between hospitals of different size or ownership.Public hospitals additionally used their reports for mostly internal purposes (e.g. comparison with competitors, quality management) whereas private ones used them externally (e.g. communication, marketing) (p=0.024, chi-2 test, hypotheses-generating level). CONCLUSIONS: German hospitals consider the mandatory QR as only partially capable to put the legally defined aims effectively and efficiently into practice. In order for public reporting to achieve its potentially positive effects, the QR must be more closely aligned to the needs of hospitals.

[Patient safety in ambulatory care: Development and application of a CATI questionnaire (PSP-AMB) to capture patient safety problems from the perspective of patients aged 40 years and older]. / Patientensicherheit in der ambulanten Versorgung - Entwicklung und Anwendung eines CATI-Fragebogens (PSP-AMB) zur Erfassung patientensicherheitsrelevanter Probleme aus der Perspektive von Patient*innen ≥40 Jahre.

BACKGROUND: The epidemiology of patient safety problems (PSPs) in the German ambulatory care sector is largely unknown. So far, there has been a lack of appropriate survey instruments. OBJECTIVE: Development and application of a questionnaire (PSP-AMB), which records the epidemiology of PSP in the ambulatory care sector from the patient's perspective by using computer-assisted telephone interviews (CATI) on a population sample of ≥40-year-olds. METHODS: The questionnaire items were developed by means of a literature search and guided interviews with ambulatory care physicians (N=10) and patients (N=20). The conversion to CATI and its application in the field was carried out by a survey institute. Qualitative (N=20) and quantitative (N=110) pretests were conducted before going into the field. The sample was generated via randomly generated fixed and mobile telephone numbers. RESULTS: PSP-AMB collects 32 PSPs in seven areas of medical treatment, from medical history-taking to practice organisation, and surveys all PSPs from the last 12 months (PSP-one-year incidence), PSPs with harm since the age of 40 (PSP-40+-prevalence), as well as PSPs resulting in death or severe need for care via proxy survey of the participants' parents and children. Detailed questions record the consequences and handling of PSPs and participants' socio-demographic data. Between May and October 2018, a total of 10,037 citizens (participation rate: 12.4%) were interviewed. The drop-out rate was 8.3%. The sample represents the German population aged 40 years or older. DISCUSSION: PSP-AMB is suitable for systematically recording PSPs in the ambulatory care sector from the patient's perspective. Thus, PSP-AMB meets the international demand to actively involve patients as a valuable source of information to improve patient safety.

How do patients respond to safety problems in ambulatory care? Results of a retrospective cross-sectional telephone survey.

OBJECTIVES: Patients in German ambulatory care frequently report patient safety problems (PSP). It is unclear whether patients report PSP back to their general practitioner (GP) or specialist in charge. This study reports on how patients respond to experienced PSP. DESIGN: Retrospective cross-sectional study. SETTING: Computer-assisted telephone interviews (CATI) with randomly recruited citizens aged ≥40 years in Germany. PARTICIPANTS: 10 037 citizens ≥40 years. About 52% of the interviewees were female, 38% were between 60 and 79 years old and about 47% reported that they were chronically ill. A total of 2589 PSPs was reported. PRIMARY AND SECONDARY MEASURES/RESULTS: According to the respondents (n=1422, 77%, 95% CI: 74.7 to 79.1), 72% (95% CI: 70.2 to 73.7) of PSP were reported back to the GP in charge or to another GP/specialist. Further reactions were taken by 65% (95% CI: 62.5 to 67.5) of the interviewees: around 63% (95% CI: 62.5 to 66.2) of the reported PSP led to a loss of faith in the physician or to complaints. χ2 and binary logistic regression analyses show significant associations between the (a) reporting and (b) reaction behaviour and determinants like 'medical treatment area' ((a) χ2=17.13, p=0.009/(b) χ2=97.58, p=0.000), 'PSP with/without harm' ((a) χ2=111.84, p=0.000/(b) χ2=265.39, p=0.000) and sociodemographic characteristics when respondents are aged between 40 and 59 years ((a) OR 2.57/(b) OR 2.60) or have chronic illnesses ((a) OR 2.16/(b) OR 2.14). CONCLUSION: The data suggest that PSPs are frequently reported back to the GP or specialist in charge and have a significant serious impact on the physician-patient relationship. Much could be learnt from the patient reporting and reacting behaviour to prevent PSPs in ambulatory care.

[Implementation of Continuity of Care in Everyday Care - A Comparison Between two Psychiatric Hospitals]. / Umsetzung von Behandlungskontinuität im Versorgungsalltag ­ ein Vergleich zwischen zwei psychiatrischen Kliniken 1.

OBJECTIVE: The rigid separation of outpatient and inpatient care in the German health care system prevents continuity of care, although it has been shown to be of great importance for psychiatric patients. This study analyzes continuity of care of a model hospital with a global treatment budget according to §â€Š64b SGB V and constant treatment staff across all settings in comparison to a control hospital with regular financing without such a team. METHODS: In a prospective cohort study with a 20-month observation period, we collected data on continuity of care of 220 model and 215 control clinic patients. RESULTS: The model clinic achieved significant higher continuity of care than the control clinic, both during inpatient treatment at the time of recruitment and across all settings during the observation period. CONCLUSION: A global treatment budget can create the necessary conditions for more flexible psychiatric care and better implementation of continuity of care.

Differences in the diagnosis and management of type 2 diabetes in 3 countries (US, UK, and Germany): results from a factorial experiment.

OBJECTIVES: This article examines the diagnosis and management of type-2 diabetes when exactly the same "patient" is encountered by 192 randomly selected primary care doctors in 3 different health care systems--the United States, United Kingdom, and Germany. METHODS: We conducted a factorial experiment, employing 2 clinically authentic filmed scenarios, to examine country differences in the treatment of diabetes, while controlling the effects of selected characteristics of patients and physicians. The patient in the first scenario presented with (undiagnosed) signs and symptoms strongly suggestive of diabetes, while the second scenario presented an already diagnosed patient with an emerging foot neuropathy. Physicians were asked how they would diagnose and manage the patients after watching the video vignettes using a questionnaire with standardized and open-ended questions. RESULTS: Regarding the first (undiagnosed) case, US doctors would ask significantly more questions than physicians from the UK and Germany (P < 0.001). German physicians would give less advice but would want to see the patient again much sooner (P < 0.001). Regarding the diagnosed case with an emerging foot neuropathy, US physicians would be most active in terms of questioning, testing, prescribing, and advice giving. Again, physicians from Germany would be less active in terms of therapeutic strategies but they would like to see the patient again sooner (P = 0.005). CONCLUSIONS: Although physicians in the 3 countries encountered exactly the same patient, differences in diagnostic and management decisions were evident. The experimental design provides unconfounded estimates of health system differences while simultaneously controlling for the effects of selected patient attributes and physician characteristics.

Patient safety in ambulatory care from the patient's perspective: a retrospective, representative telephone survey.

OBJECTIVES: Data on patient safety problems (PSPs) in ambulatory care are scarce. The aim of the study was to record the frequency, type, severity and point of origin of PSPs in ambulatory care in Germany. DESIGN: Retrospective cross-sectional study. SETTING: Computer-assisted telephone interviews with randomly recruited citizens aged ≥40 years in Germany who were asked about their experiences with PSPs in ambulatory care. PARTICIPANTS: 10 037 citizens ≥40 years. MEASURES: A new questionnaire was developed to record patient experiences with PSPs in ambulatory care. The study reported here targets patient experiences in the last 12 months. The questionnaire focuses on PSPs in seven areas of medical treatment: anamnesis/diagnostic procedures; medication; vaccination, injection, infusion; aftercare; outpatient surgery; office administration; other areas. For each PSP reported, detailed questions were asked about the specialist group concerned, and, on the most serious harm, the severity of the harm and its consequences. The target parameters are presented as proportions with 95% CIs. RESULTS: 1422 of the respondents (14%) reported 2589 PSPs. The areas most frequently affected by PSPs were anamnesis/diagnostic procedures (61%) and medication (15%). General practitioners accounted for 44% of PSPs, orthopaedists for 15% and internists for 10%. 75% of PSPs were associated with harm, especially unnecessarily prolonged pain or deterioration of health; 35% of PSPs led to permanent harm. 804 PSPs (32%) prompted patients to see another doctor for additional treatment; 255 PSPs (10%) required inpatient treatment. CONCLUSION: PSPs experienced by patients are widespread in ambulatory care in Germany. The study reveals in which areas of medical treatment efforts to prevent PSPs could make the greatest contribution to improving patient safety. It also demonstrates the valuable contribution of patient reports to the analysis of PSPs.

Public reporting of hospital quality data: What do referring physicians want to know?

OBJECTIVE: To identify ambulatory care physicians' priorities for hospital quality criteria to support them in counselling patients what hospital to choose. METHODS: Three hundred non-hospital-based stratified randomly sampled physicians, representing the five main referring specialties in Germany participated in a cross-sectional survey. Physicians rated the importance of 80 hospital quality criteria to be used in their counselling of patients in need of hospital care. Criteria selection was based on a literature analysis and the content of Germany's mandatory hospital quality reports. We calculated the most important criteria and performed an ordinal regression analysis to examine whether the physicians' characteristics 'age', 'sex', 'specialty', 'practice type' and 'region' affected physicians' importance ratings. RESULTS: To counsel patients in need of a hospital referral, physicians preferred hospital quality criteria that reflect their own and their patients' experiences with a hospital. Additionally, hospitals' expertise and results of treatment were rated highly important. In contrast, hospitals' structural characteristics and compliance with external requirements were rated less important. Physicians' characteristics affected importance ratings only negligibly. CONCLUSIONS: To support referring physicians' counselling of patients regarding what hospital to choose in order to achieve optimal patient outcomes eventually, hospital report cards must be enriched by information on physicians' and their patients' experiences with hospitals. Hospitals' structural characteristics play a minor role in counselling of patients needing hospital care.

Evaluating compulsory minimum volume standards in Germany: how many hospitals were compliant in 2004?

BACKGROUND: Minimum hospital procedure volumes are discussed as an instrument for quality assurance. In 2004 Germany introduced such annual minimum volumes nationwide on five surgical procedures: kidney, liver, stem cell transplantation, complex oesophageal, and pancreatic interventions. The present investigation is the first part of a study evaluating the effects of these minimum volumes on health care provision. Research questions address how many hospitals and cases were affected by minimum volume regulations in 2004, how affected hospitals were distributed according to minimum volumes, and how many hospitals within the 16 German states complied with the standards set for 2004. METHODS: The evaluation is based on the mandatory hospital quality reports for 2004. In the reports, all hospitals are statutorily obliged to state the number of procedures performed for each minimum volume. The data were analyzed descriptively. RESULTS: In 2004, 485 out of 1710 German hospitals providing acute care and approximately 0.14% of all hospital cases were affected by minimum volume regulations. Liver, kidney, and stem cell transplantation affected from 23 to hospitals; complex oesophageal and pancreatic interventions affected from 297 to 455 hospitals. The inter-state comparison of the average hospital care area demonstrates large differences between city states and large area states and the eastern and western German states ranging from a minimum 51 km2 up to a maximum 23.200 km2, varying according to each procedure. A range of 9% - 16% of the transplantation hospitals did not comply with the standards affecting 1% - 2% of the patients whereas 29% and 18% of the hospitals treating complex oesophageal and pancreatic interventions failed the standards affecting 2% - 5% of the prevailing cases. CONCLUSION: In 2004, the newly introduced minimum volume regulations affected only up to a quarter of German acute care hospitals and few cases. However, excluding the hospitals not meeting the minimum volume standards from providing the respective procedures deserves considering two aspects: the hospital health care provision concepts by the German states as being responsible and from a patient perspective the geographically equal access to hospital care.

[Controversial study results in relation to minimum volume standards]. / Kontroverse Studienergebnisse zur Mindestmengenproblematik.

Multiple studies have demonstrated positive associations between volume and treatment outcome, especially in complex procedures. However, using these results in determining volume standards in Germany keeps being problematic: often, there is a lack of specific German data on the volume and outcome of healthcare providers making the modeling of potential effects almost impossible. In addition, recent publications focusing on the methods that are typically used in analyzing these associations indicate that the significance of positive volume-outcome associations is limited. The methodological quality of most studies is rather low, and there is a high heterogeneity among them concerning study populations, case mix, study designs and analytical methods. Results on the single-hospital level show a high variation of outcome parameters. There are both good hospitals with low volumes and bad hospitals with high volumes. Using the "best guideline-based current procedures" seems to be of high importance for the good outcomes of small and big hospitals. Furthermore, studies have demonstrated that data on historical outcomes are a better predictor for good outcomes than hospital procedural volumes. Furthermore in some studies negative outcomes were shown to be related to high volumes at facilities with a high case load per staff member. These results suggest that a more sophisticated consideration of the methods and results of volume-outcome studies is required. Therefore, volume standards should continue to be cautiously applied and obligatorily accompanied by health services research.