Selective enrollment in Disease Management Programs for coronary heart disease in Germany - An analysis based on cross-sectional survey and administrative claims data.

BACKGROUND: In 2002, Disease Management Programs (DMPs) were introduced within the German healthcare system with the aim to increase the quality of chronic disease care. Due to the enrollment procedures, it can be assumed a) that only certain patients actively decide to enroll in a DMP and/or b) that only certain patients get the recommendation for DMP enrollment from their physician. How strong this assumed effect of self- and/or professional selection is, is still unclear. METHODS: We used data from a cross-sectional postal-survey linked on individual level with administrative claims data from a German sickness fund. The sample consisted of individuals suffering from coronary heart disease (CHD) who i) were either enrolled in the respective DMP or ii) fulfilled the disease related criteria for enrollment but were not enrolled. We applied multivariate logistic regression analyses to assess factors on patient level associated with DMP enrollment. RESULTS: We included 7070 individuals in our analyses. Male sex, higher age and receiving old age pension, a higher Charlson Score and a diagnosis of type 2 diabetes increased the odds for DMP-CHD enrollment significantly. Individuals with a diagnosed myocardial infarction (MI) were also more likely to be enrolled in the DMP-CHD. We found a significant interaction effect for MI and sex, indicating that the association between MI and DMP enrollment is stronger for women than for men. CONCLUSION: DMP-enrollees and non-enrollees differ in various factors. Studies analyzing the effectiveness of DMP-CHD should carefully take into account these group differences. Furthermore, the results suggest that the DMP-CHD assessed reaches men better than women.

Comparison of hospital costs and length of stay associated with open-mesh, totally extraperitoneal inguinal hernia repair, and transabdominal preperitoneal inguinal hernia repair: an analysis of observational data using propensity score matching.

BACKGROUND: Laparoscopic inguinal hernia surgery is increasingly seen as the superior technique in hernia repair. Compared to open-mesh hernia repair, laparoscopic approaches are often reported to be more cost-effective but incur higher costs for the provider. The objective of this study was to analyze the effect of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair of nonincarcerated inguinal hernias in men on hospital costs and length of stay (LoS). METHODS: We used routine administrative, highly standardized, patient-level cost data from 15 German hospitals participating in the national cost data study. We compared TEP, TAPP, and open-mesh repair. We conducted propensity score matching to account for baseline differences between treatment groups and subsequently estimated the treatment effect on costs and LoS. RESULTS: Total costs for both TEP and TAPP surgery were significantly lower than those for open-mesh repair (p < 0.0001 and p < 0.05, respectively). TEP repair also had a slight but nonsignificant advantage in total costs compared to TAPP repair, while TAPP surgery was associated with a significantly shorter LoS than TEP (p < 0.001). CONCLUSION: Results suggest that laparoscopic approaches in hernia repair are not necessarily associated with higher hospital resource consumption than open-mesh repair.

Health and Care Data: Approaches to data linkage for evidence-informed policy.

An indispensable prerequisite for answering research questions in health services research is the availability and accessibility of comprehensive, high-quality data. It can be assumed that health services research in the coming years will be increasingly based on data linkage, i.e., the linking, or connecting, of several data sources based on suitable common key variables. A range of approaches to data collection, storage, linkage and availability exists across countries, particularly for secondary research purposes (i.e., the use of data initially collected for other purposes), such as health systems research. The main goal of this review is to develop an overview of, and gain insights into, current approaches to linking data sources in the context of health services research, with the view to inform policy, based on existing practices in high-income countries in Europe and beyond. In doing so, another objective is to provide lessons for countries looking for possible or alternative approaches to data linkage. Thirteen country case studies of data linkage approaches were selected and analysed. Rather than being comprehensive, this review aimed to identify varied and potentially useful case studies to showcase different approaches to data linkage worldwide. A conceptual framework was developed to guide the selection and description of case studies. Information was first identified and collected from publicly available sources and a profile was then created for each country and each case study; these profiles were forwarded to appropriate country experts for validation and completion. The report presents an overview of the included countries and their case studies (Chapter 2), with key data per country and case study in the appendices. This is followed by a closer look at the possibilities of using routine data (Chapter 3); the different approaches to linkage (Chapter 4); the different access routes for researchers (Chapter 5); the use of data for research from electronic patient or health records (Chapter 6); foundational considerations related to data safety, privacy and governance (Chapter 7); recent developments in cross-border data sharing and the European Health Data Space (Chapter 8); and considerations of changes and responses catalysed by the COVID-19 pandemic as related to the generation and secondary use of data (Chapter 9). The review ends with overall conclusions on the necessary characteristics of data to inform research relevant for policy and highlights some insights to inspire possible future solutions - less or more disruptive - for countries looking to expand their use of data (Chapter 10). It emphasises that investing in data linkage for secondary use will not only contribute to the strengthening of national health systems, but also promote international cooperation and contribute to the international visibility of scientific excellence.

Patient-level hospital costs and length of stay after conventional versus minimally invasive total hip replacement: a propensity-matched analysis.

OBJECTIVES: A current trend in total hip replacement (THR) is the use of minimally invasive surgery. Little is known, however, about the impact of minimally invasive THR on resource use and length of stay. This study analyzed the effect of minimally invasive surgery on hospital costs and length of stay in German hospitals compared with conventional treatment in THR. METHODS: We used patient-level administrative hospital data from three German hospitals participating in the national cost data study. We conducted a propensity score matching to account for baseline differences between minimally invasively and conventionally treated patients. Subsequently, we estimated the treatment effect on costs and length of stay by conducting group comparisons, via paired t tests and Wilcoxon signed-rank tests, and regression analyses. RESULTS: The three hospitals provided data from 2886 THR patients. The propensity score matching led to 812 matched pairs. Length of stay was significantly higher for conventionally treated patients (11.49 days vs. 10.90 days; P < 0.05), but total costs did not differ significantly (€6018 vs. €5986; P = 0.67). We found a difference in the allocation of costs, with significantly higher implant costs for minimally invasively treated patients (€1514 vs. €1375; P < 0.001) in contrast to significantly higher staff and overhead costs for conventionally treated patients. CONCLUSIONS: Minimally invasive surgery was compared with conventional THR and was found to be associated with a reduced length of stay. Total hospital costs, however, did not differ between the two treatment groups, because of higher implant costs for minimally invasively treated patients.

The relationship between transformational leadership and social capital in hospitals--a survey of medical directors of all German hospitals.

CONTEXT: The German hospital market has been undergoing major changes in recent years. Success in this new market is determined by a multitude of factors. One is the quality of the social relationships between staff and the presence of shared values and rules. This factor can be considered an organization's "social capital." OBJECTIVE: This study investigates the relationship between social capital and leadership style in German hospitals using a written survey of medical directors. DESIGN AND SETTING: In 2008, a cross-sectional representative study was conducted with 1224 medical directors from every hospital in Germany with at least 1 internal medicine unit and 1 surgery unit. Among the scales included in the standardized questionnaire were scales used to assess the medical directors' evaluation of social capital and transformational leadership in the hospital. We used a multiple linear regression model to examine the relationship between social capital and internal coordination. We controlled for hospital ownership, teaching status, and number of beds. PARTICIPANTS: In total, we received questionnaires from 551 medical directors, resulting in a response rate of 45.2%. The participating hospitals had an average of 345 beds. The sample included public (41.3%), not-for-profit (46.9%), and for-profit (11.7%) hospitals. RESULTS: The data, which exclusively represent the perceptions of the medical directors, indicate a significant correlation between a transformational leadership style of the executive management and the social capital as perceived by medical directors. A transformational leadership style of the executive management accounted for 36% of variance of the perceived social capital. CONCLUSION: The perceived social capital in German hospitals is closely related to the leadership style of the executive management. A transformational leadership style of the executive management appears to successfully strengthen the hospital's social capital.

Integrating the Population Perspective into Health System Performance Assessment (IPHA): Study Protocol for a Cross-Sectional Study in Germany Linking Survey and Claims Data of Statutorily and Privately Insured.

BACKGROUND: Health system performance assessment (HSPA) is a major tool for evidence-based governance in health systems and patient/population-orientation is increasingly considered as an important aspect. The IPHA study aims (1) to undertake a comprehensive performance assessment of the German health system from a population perspective based on the intermediate and final dimensions defined by the World Health Organization (WHO) and (2) to identify differences in HSPA between (a) common user characteristics and (b) user types, which differ in their interactions and patterns of action within the health system. METHODS AND ANALYSIS: A cross-sectional survey was conducted between October and December 2018 with statutorily and privately health insured to assess the German health system from a population perspective related to the past 12 months. The random sample consists of 32 000 persons insured by AOK Nordost and 20 000 persons insured by Debeka. Data from the survey will subsequently be linked with health insurance claims data at the individual level for each respondent who has given consent for data linkage. Claims data covers the time period January 1, 2017 to June 30, 2018. The combination of the 2 data sources allows to identify associations between insured patient characteristics and differences in the assessment of health system performance. The survey consists of 71 items measuring all final and intermediate health system goals defined by the WHO and user characteristics like health literacy, self-efficacy, the attention an individual pays to his or her health or disease, the personal network, autonomy, compliance and sociodemographics. The claims data contains information on morbidity, care delivery, service utilization, (co)payments and sociodemography. DISCUSSION: The study represents a promising attempt to perform a holistic HSPA using a population perspective. For this purpose, a questionnaire was designed that contains both validated and new items in order to collect data on all relevant health system dimensions. In particular, linking survey data on HSPA with claims data is of high potential for assessing and analysing determinants of health system performance from the population perspective.

Patients' perceptions of health system responsiveness in ambulatory care in Germany.

OBJECTIVE: To identify overall levels of health system responsiveness and the associations with social determinants for ambulatory health care in Germany from a user perspective. METHODS: This analysis drew on a 2016 health survey sample of 6113 adults in Germany. Responsiveness was measured for general practitioners (GPs) and specialists (SPs) along the domains trust, dignity, confidentiality, autonomy and communication. Bivariate and multivariate logistic regression techniques were applied. RESULTS: Over 90% of all patients assessed their last GP and SP visit as good regarding trust, dignity, autonomy and communication, but only half for confidentiality in the doctor office (GP visits: 50.3%; SP visits: 52.4%). For GP visits, patients' young age of 18-34 years showed most associations with poor assessment of the domains, for SP visits a current health problem as the reason for the last consultation. CONCLUSION: While overall responsiveness levels for ambulatory care are high, ratings of confidentiality are distressing. Particularly patients' young age and bad health are associated with a poor assessment of responsiveness. PRACTICE IMPLICATIONS: Measures to improve doctor office infrastructure and to enhance responsiveness towards patients under the age of 35 years and those with health problems are vital to increase responsiveness.

Health system responsiveness and chronic disease care - What is the role of disease management programs? An analysis based on cross-sectional survey and administrative claims data.

Health system responsiveness is an important aspect of health systems performance. The concept of responsiveness relates to the interpersonal and contextual aspects of health care. While disease management programs (DMPs) aim to improve the quality of health care (e.g. by improving the coordination of care), it has not been analyzed yet whether these programs improve the perceived health system responsiveness. Our study aims to close this gap by analyzing the differences in the perceived health system responsiveness between DMP-participants and non-participants. We used linked survey- and administrative claims data from 7037 patients with coronary heart disease in Germany. Of those, 5082 were enrolled and 1955 were not enrolled in the DMP. Responsiveness was assessed with an adapted version of the WHO responsiveness questionnaire in a postal survey in 2013. The survey covered 9 dimensions of responsiveness and included 17 items for each, GP and specialist care. Each item had five answer categories (very good - very bad). We handled missing values in the covariates by multiple imputation and applied propensity score matching (PSM) to control for differences between the two groups (DMP/non-DMP). We used Wilcoxon-signed-rank and McNemar test to analyze differences regarding the reported responsiveness. The PSM led to a matched and well balanced sample of 1921 pairs. Overall, DMP-participants rated the responsiveness of care more positive. The main difference was found for the coordination of care at the GP, with 62.0% of 1703 non-participants reporting a "good" or "very good" experience, compared to 69.1% of 1703 participants (p < 0.001). The results of our study indicate an overall high responsiveness for CHD-care, as well for DMP-participants as for non-participants. Yet, the results also clearly indicate that there is still a need to improve the coordination of care.

Forgone care among chronically ill patients in Germany-Results from a cross-sectional survey with 15,565 individuals.

The decision not to seek health care although one feels that care is needed (forgone care), is influenced by various factors. Within the study "Responsiveness in ambulatory care" 15,565 chronically ill (coronary heart disease and/or type 2 diabetes) patients in Germany were surveyed in 2013. The survey included questions on forgone care, perceived discrimination when seeking care, net-income, subjective health status and subjective socioeconomic status (subSES). Survey data were linked on patient-level with administrative claims data by a German sickness fund. We applied multivariate binomial logistic regression analyses to assess the association between age, sex, comorbidities, living area, subjective health status, subSES, experienced discrimination, net-equivalent income and reported forgone care. The majority in the sample are men (71.4%), the average age is 69.4 (SD: 10.2) years and 14.1% reported forgone care. In the multivariate model, we find that younger age, female gender, perceived discrimination, depression, and a poor subjective health status increase the odds of reporting forgone care. Overall, our results suggest that a negative experience with the health care system, i.e. perceived discrimination/unfair treatment, are strong predictors of forgone care among the chronically ill.

Informed consumer or unlucky visitor? A profile of German patients who received dental services abroad.

OBJECTIVES: A common characteristic of sending countries in cross-border dental care is that of high costs and/or high copayments for dental services. This study aims to provide an insight into the characteristics of German patients receiving planned and emergency (unplanned) dental care abroad and their satisfaction with received services. METHODS: The Europabefragung is a postal survey carried out by Techniker Krankenkasse for patients who are treated in EU/EEA countries. This study uses data from the Europabefragung 2012. The survey was sent to 45 189 individuals; descriptive statistics for the subset of respondents who received emergency (unplanned) or planned dental treatment are presented. RESULTS: There were 18 339 responses to the questionnaire, out of which 17 543 were deemed valid; 1416 respondents had received emergency (unplanned) (78%) or planned (22%) dental care and were included in the analysis. There were clear differences between unplanned and planned treatments regarding country and type of treatment as well as satisfaction with different aspects of treatment and the need for follow-up care. Overall, satisfaction with treatment was high for both groups; individuals who had received planned treatment were more satisfied on all aspects of care and reported a need for follow-up care less frequently. CONCLUSIONS: While German patients who received both emergency (unplanned) and planned services abroad are mostly satisfied with their experience, some concerns arise with regard to continuity of care. Types of information provided to patients seeking care abroad and dissemination modalities should be carefully planned.

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.

BACKGROUND: 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. METHODS AND ANALYSIS: 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. DISCUSSION: 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.

Assessing the responsiveness of chronic disease care - is the World Health Organization's concept of health system responsiveness applicable?

The concept of health system responsiveness is an important dimension of health system performance assessment. Further efforts have been made in recent years to improve the analysis of responsiveness measurements, yet few studies have applied the responsiveness concept to the evaluation of specific health care delivery structures. The objective of this study was to test the World Health Organization's (WHO's) responsiveness concept for an application in the evaluation of chronic disease care. In September and October 2012 we conducted four focus groups of chronically ill people (n = 38) in Germany, in which participants discussed their experiences and expectations regarding health care. The data was analyzed deductively (on the basis of the WHO responsiveness concept) and inductively using directed content analysis. Ten themes related to health system responsiveness and one theme (finances) not directly related to health system responsiveness, but of high importance to the focus group participants, could be identified. Eight of the ten responsiveness themes are consistent with the WHO concept. Additionally, two new themes were identified: trust (consultation and treatment are not led by any motive other than the patients' wellbeing) and coordination (treatment involving different providers is coordinated and different actors communicate with each other). These findings indicate the suitability of the WHO responsiveness concept for the evaluation of chronic disease care. However, some amendments, in particular an extension of the concept to include the two domains trust and coordination, are necessary for a thorough assessment of the responsiveness of chronic disease care.