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BACKGROUND: Several changes have led to general practitioners (GPs) working in a more differentiated setting today and being supported by other health professions. As practice changes, primary care specific continuing medical education (CME) may also need to adapt. By comparing different primary care specific CME approaches for GPs across Europe, we aim at identifying challenges and opportunities for future development. METHODS: Narrative review assessing, analysing and comparing CME programs for general practitioners across different north-western European countries (UK, Norway, the Netherlands, Belgium (Flanders), Germany, Switzerland, and France). Templates containing detailed items across seven dimensions of country-specific CME were developed and used. These dimensions are role of primary care within the health system, legal regulations regarding CME, published aims of CME, actual content of CME, operationalisation, funding and sponsorship, and evaluation. RESULTS: General practice specific CME in the countries under consideration are presented and comparatively analysed based on the dimensions defined in advance. This shows that each of the countries examined has different strengths and weaknesses. A clear pioneer cannot be identified. Nevertheless, numerous impulses for optimising future GP training systems can be derived from the examples presented. CONCLUSIONS: Independent of country specific CME programs several fields of potential action were identified: the development of curriculum objectives for GPs, the promotion of innovative teaching and learning formats, the use of synergies in specialist GP training and CME, the creation of accessible yet comprehensive learning platforms, the establishment of clear rules for sponsorship, the development of new financing models, the promotion of fair competition between CME providers, and scientifically based evaluation.
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Medicina Geral , Clínicos Gerais , Humanos , Educação Médica Continuada/métodos , Medicina Geral/educação , Medicina de Família e Comunidade/educação , Europa (Continente)RESUMO
AIM: At present, there are only a few reliable findings on the ever-increasing number of doctors employed in outpatient care. Therefore, some results of a nationwide quantitative survey of persons in this occupational group will be presented and discussed here. METHOD: The study is a standardized quantitative survey of physicians employed in the outpatient sector. The target population is represented by a disproportionately stratified sample from the databases of the Association of Statutory Health Insurance Physicians of the federal states. A total of 10,580 doctors were contacted and the response rate was 21.8%. The sample design not only allows descriptive analyses for small subpopulations to be carried out but also regional disparities to be taken into account. RESULTS: It can be shown that mainly young female doctors take up employment in the outpatient sector. 59% of doctors work part-time, the average weekly working time is 28.9 h. A medical office employs about 4 doctors and on average (median) about 30 people are treated per day. CONCLUSION: An important reason for the steady growth of this occupational group may be the flexibility of working hours and the possibility of part-time work, which in turn has a positive effect on the compatibility of family and career. Finally, yet importantly, this could be the reason why this occupational group seems to consist predominantly of young female doctors. Often, however, this kind of employment also represents a transitional model towards a private practice or - for former practice owners - into retirement. In general, however, being employed in outpatient care seems to be the desired "normal working model" for many doctors.
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Médicos , Assistência Ambulatorial , Emprego , Feminino , Alemanha , Humanos , AposentadoriaRESUMO
BACKGROUND: Increasing numbers of emergency cases, different stakeholders involved (physicians' practices vs. hospitals providing ambulatory and inpatient care) and changing patient utilization patterns lead to changes in health care needs. This study aimed at analyzing changes in patient characteristics as well as indications for in- and outpatient emergency care between 2009 and 2015 and their potential reasons. METHODS: Based on in- and outpatient routine data, we descriptively analyzed changes in emergency diagnosis, population-based emergency prevalence as well as regional differences and their changes over time. Using generalized linear models (GLM), we examined regional shifts in emergency cases being treated in ambulatory and inpatient settings. RESULTS: Between 2009 and 2014 the number of cross-sectoral ambulatory emergency cases increased by 4 % (in emergency departments an increase by 42% with the highest incidence rate ratio (IRR) in the 20-34-year-old age group). Inpatient emergency cases increased by 20% with older patients representing the largest group. The ICD chapter "Diseases of the circulatory system", responsible for most inpatient hospital cases, had the second highest probability of hospital addmissions (64.7%). There were larger variations in indications for outpatient care. Regression analysis showed that there was greater use of ambulatory emergency services by the healthier (IRR 1.15 [KI 95%: 1.13; 1.16]) and urban population (IRR 1.14 [KI 95%: 1.13; 1.15]). CONCLUSIONS: The first time cross-sector analysis of indication-specific emergencies based on nationwide inpatient and outpatient billing data from 2009-2015 provides insightsinto healthcare provision at the interface between the sectors. Indications that are treated in physician practices and emergency outpatient clinics and those that lead to hospital admissions point out the potential for managing patient care appropriately. Patient behaviors in healthcare utilization can be addressed by interventions for specific patient subgroups. However, a prerequisite for the development of such measures is the inclusion of a cross-sectoral perspective in the system of emergency care.
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Assistência Ambulatorial , Emergências , Serviços Médicos de Emergência , Adulto , Serviço Hospitalar de Emergência , Alemanha , Humanos , Adulto JovemRESUMO
Background: Patient-physician communication and textual health information are central to health care. Yet, how well patients understand their physicians and written materials is under-studied. Objectives: Focusing on outpatient health care in Germany, the aim of this research was to assess patients' levels of understanding oral and written health information and to identify associations with socioeconomic variables. Methods: This analysis drew on a 2017 health survey (n=6,105 adults 18 years of age and above). Measures for the quality of patient-physician communication were derived from the Ask Me 3 program questions for consultations with general practitioners (GPs) and specialists (SPs), and for textual health information via a question on the comprehensibility of written materials. Correlations with socioeconomic variables were explored using bivariate and multivariable logistic regression analyses. Results: Over 90% of all respondents reported that they had understood the GP's and SP's explanations. A lack of understanding was most notably correlated with patients' self-reported very poor health (odds ratio [OR]: 5.19; 95% confidence interval [CI]: 2.23-12.10), current health problem (OR: 6.54, CI: 1.70-25.12) and older age (65 years and above, OR: 2.97, CI: 1.10-8.00). Fewer patients reported that they understood written materials well (86.7% for last visit at GP, 89.7% for last visit at SP). Difficulties in understanding written materials were strongly correlated with basic education (OR: 4.20, CI: 2.76-6.39) and older age (65 years and above, OR: 2.66, CI: 1.43-4.96). Conclusions: In order to increase patients' understanding of health information and reduce inequalities among patient subgroups, meeting the communication needs of patients of older age, low educational status and with poor health is essential.
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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.
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Assistência Ambulatorial/normas , Satisfação do Paciente , Adolescente , Adulto , Idoso , Confidencialidade , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Autonomia Pessoal , Relações Médico-Paciente , Determinantes Sociais da Saúde , Inquéritos e Questionários , ConfiançaRESUMO
BACKGROUND: The aim of this paper is to identify systematic differences due to sociodemographic and health-related determinants in outpatient healthcare utilisation and access in Germany for the period from 2006 to 2016. The study focuses on frequent users and those reporting particularly long wait times for their physician appointments, and it contributes to assessing the level of health equity in Germany. METHODS: The investigation draws on nine population surveys conducted by the German National Association of Statutory Health Insurance Physicians (NASHIP), which interviewed 42,925 respondents aged 18 and above. "Frequent users" were operationalised as those respondents who reported more than ten consultations with outpatient general practitioners (GPs) and specialists (SPs) in the preceding twelve months. Respondents who experienced wait times of more than one month for their last doctor appointment were categorised as "very long wait times". Sociodemographic determinants included age, gender, educational and occupational status, population and region of place of residence, as well as type of health insurance of the respondents. Health-related factors were self-assessed health status and reason for last medical consultation. Statistical analyses were conducted using bivariate and multivariate techniques (logistic regression). RESULTS: Utilisation: Frequent users of GPs and SPs are predominantly respondents in poor health, retirees and younger persons (18 to 34 years of age). Furthermore, people with a lower educational background consult their GPs significantly more often than people with higher levels of education. Also, patients with statutory health insurance coverage visit GPs more frequently than those having private health insurance, whereas the opposite holds true for SP consultations. Access: Very long wait times for GP and SP appointments were most often experienced by respondents who consult GPs and SPs for preventive medical check-ups or health screenings, have statutory health insurance, live in eastern Germany and who are above 60 years of age. In addition, people with higher levels of education are significantly more likely to experience wait times for SP appointments of more than one month than people with a lower educational background. The proportion of frequent users as well as of those reporting very long wait times for SP appointments has increased in Germany over the period examined. CONCLUSION: This study reveals that a high frequency of GP and SP consultations is primarily associated with self-assessed poor health, indicating that prioritisation is based on clinical need. In order to ensure the same needs-based prioritisation in the access to outpatient healthcare, regulatory measures are required to decrease wait times of more than one month for SP appointments, with a special focus on people with statutory health insurance coverage, residents of eastern Germany and the elderly.
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Pesquisas sobre Atenção à Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Nível de Saúde , Medicina/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Adolescente , Adulto , Idoso , Doença Crônica/epidemiologia , Escolaridade , Feminino , Alemanha , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Socioeconômicos , Listas de Espera , Adulto JovemRESUMO
BACKGROUND: Demographic change, technical progress, and changing patterns of service use influence the future demand for physicians in the German health care system. The attitudes of medical students towards their later work in the health system is important for current health care planning. For that reason a nationwide survey aimed to identify major trends in preferred specialty, workplace characteristics (regional location, hospital) and perceived hindrances for clinical work. METHODS: A questionnaire consisting of 34 closed questions was developed at the University of Mainz in 2009 and administered over the Internet in June and July 2010 to all medical students in Germany. The questions addressed the students' intentions regarding specialty training, location of practice, workload, and regional preference, as well as potential reasons why they might choose not to practice clinical medicine in the future. RESULTS: 12 518 web-based questionnaires were filled in (approx. 15.7% of all medical students in Germany in 2010). The mean age was 24.9 years, with 64% female and 36% male. Favored specialties were internal medicine (42.6%), family medicine (29.6%), pediatrics (27.0%) and surgery (26.8%). Nearly all respondents (96%) stated that they attached importance to compatibility of work and family life. Working in a salaried position (92.2%) was preferred to working in private practice (77.7%). General practice, in particular in rural locations, was significantly less favored than work as a specialist in cities. CONCLUSION: Although the coming generation of physicians anticipate working in clincial settings in the future, shortfalls in the areas of primary care and in rural locations are likely if medical students adhere to their preferences stated in the questionnaire.
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Atitude do Pessoal de Saúde , Escolha da Profissão , Mobilidade Ocupacional , Coleta de Dados , Internato e Residência/estatística & dados numéricos , Estudantes de Medicina/estatística & dados numéricos , Feminino , Alemanha , Humanos , Masculino , Adulto JovemRESUMO
Due to governmental regulation in 2004 new options to establish ambulatory care facilities have become available and are widely used by healthcare providers. Medical service centres (Medizinische Versorgungszentren, MVZs) are characterised by the obligation for interdisciplinary teams of physicians, extended options for the employment of physicians and finally by flexible avenues of investment regarding the establishment of medical service centres. Medical service centres aim to improve ambulatory healthcare provision via an integrated service approach and offer opportunities for hospitals and third-party payers to set foot into the ambulatory healthcare sector. The rise of MVZs has therefore been closely and quite sceptically watched by the medical profession. The spread of MVZs is constant but limited to a modest growth rate. 250 MVZs are set up annually; in summer 2009 a total number of about 1300 had been reached, which is fairly small compared to 92,000 individual and group practices. The prominent specialities include general medicine, internal medicine, and surgery. The majority of MVZs are located in urban and suburban areas. Especially hospitals have, however, been using this approach to establish and operate ambulatory care centres with employed physicians. It remains to be seen whether and to what extent MVZs will improve service provision to the benefit of patients or mainly represent a new business model compromising existing structures. Continuous evaluation of trends is therefore essential for the further development of new ambulatory care structures.
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Instituições de Assistência Ambulatorial/organização & administração , Instituições de Assistência Ambulatorial/tendências , Serviços de Saúde/tendências , Previsões , Alemanha , Humanos , Corpo Clínico Hospitalar , Prática PrivadaRESUMO
OBJECTIVES: To provide an overview of the development of health technology assessment (HTA) in Germany since the 1990s. METHODS: Analysis of key documents (e.g. literature, laws, and other official documentation) and personal experiences. RESULTS: Health technology assessment (HTA) entered the political agenda in Germany only in the mid-1990s, basically as the result of a top-down approach toward more efficiency in health care, but with a strong impetus of an evidence-based medicine movement. Accordingly, HTA became part of several healthcare reform laws since 1997, which led to the establishment of the Federal Joint Committee (G-BA) and the Institute for Quality and Efficiency in Health Care (IQWiG) in 2004. This tandem construction aims at using evidence in decision-making processes for coverage and other decisions. CONCLUSIONS: These developments have led to a considerable impact of HTA in Germany. In addition, a broad spectrum of activities at universities and in other organizations, such as the German Institute for Medical Documentation and Information (DIMDI), can be observed that contribute to both teaching and research in HTA. German researchers in the field of HTA are actively involved in international projects, such as EUNetHTA, and contribute to scientific conferences and journals.
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Avaliação da Tecnologia Biomédica/história , Alemanha , História do Século XX , História do Século XXI , Desenvolvimento de Programas , Avaliação da Tecnologia Biomédica/legislação & jurisprudência , Avaliação da Tecnologia Biomédica/organização & administraçãoRESUMO
The motivation for quality management has now reached medical and psychotherapeutic practices. This is partly due to exogenous factors, including regulatory requirements such as Sect. 135a SGB V (German Book of Social Code) demanding the implementation and further development of internal quality management from both out-patient and in-patient healthcare providers. The National Association of SHI-Accredited Physicians in Germany (KBV), along with several regional associations, responded to these internal demands and external requirements by developing the quality management system "Quality and Development in Practices (QEP)". Assisted by an independent institute, 61 selected practices participated in the pilot study. The pilot phase included five interview rounds held between April and November 2004 with 60 practices taking part. The results describe practitioners' expectations for the current state of and the demand for internal quality management. Only one in five practices expects improvements from the implementation of quality management in the area of healthcare processes and management. The improvement of organizational processes, patients' safety and patient outcomes are considered more important. In a self-assessment procedure which included 73 targets with 236 verifications from the quality target catalogue a distinct potential for quality improvement has been revealed. The greatest need for improvement has been identified in cases where quality management defines specific requirements for the practices. These include: treatment pathways, patient information, risk management, case discussions and instruction, quality improvement, regulations and quality measurement. Even practices with advanced quality development activities were able to detect some potential for improvement with the application of the QEP catalogue. In order to attain 15 selected quality targets with 45 verifications, the practices were provided with tools like sample documents and suggestions for internal regulations to be used for quality improvement and requiring relatively small efforts. The effectiveness of implementing a quality management system cannot be adequately demonstrated by an accompanying evaluation. However, established instruments (such as the quality target catalogue and verifications), complemented with suitable outcome indicators, allow the effects of the implementation of internal quality management to be measured in a comparative, or, ideally in a randomized study.
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Epidemiologia/normas , Legislação Médica/normas , Alemanha , Humanos , Garantia da Qualidade dos Cuidados de SaúdeRESUMO
BACKGROUND: We sought to develop and validate a decision-analytic model for the natural history of cervical cancer for the German health care context and to apply it to cervical cancer screening. METHODS: We developed a Markov model for the natural history of cervical cancer and cervical cancer screening in the German health care context. The model reflects current German practice standards for screening, diagnostic follow-up and treatment regarding cervical cancer and its precursors. Data for disease progression and cervical cancer survival were obtained from the literature and German cancer registries. Accuracy of Papanicolaou (Pap) testing was based on meta-analyses. We performed internal and external model validation using observed epidemiological data for unscreened women from different German cancer registries. The model predicts life expectancy, incidence of detected cervical cancer cases, lifetime cervical cancer risks and mortality. RESULTS: The model predicted a lifetime cervical cancer risk of 3.0% and a lifetime cervical cancer mortality of 1.0%, with a peak cancer incidence of 84/100,000 at age 51 years. These results were similar to observed data from German cancer registries, German literature data and results from other international models. Based on our model, annual Pap screening could prevent 98.7% of diagnosed cancer cases and 99.6% of deaths due to cervical cancer in women completely adherent to screening and compliant to treatment. Extending the screening interval from 1 year to 2, 3 or 5 years resulted in reduced screening effectiveness. CONCLUSIONS: This model provides a tool for evaluating the long-term effectiveness of different cervical cancer screening tests and strategies.
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Técnicas de Apoio para a Decisão , Programas de Rastreamento , Neoplasias do Colo do Útero/diagnóstico , Adolescente , Adulto , Feminino , Alemanha , Humanos , Cadeias de Markov , Pessoa de Meia-Idade , Teste de Papanicolaou , Esfregaço Vaginal/estatística & dados numéricosRESUMO
Since the establishment of health technology assessment units in the latter 1980s, Canada has witnessed an unprecedented transformation of the governance, management and service delivery of its healthcare system. In Alberta, this transformation culminated in the establishment of regional health authorities that provide integrated healthcare to Albertans. With the shift of responsibility for healthcare delivery from the provincial to the regional level, the Alberta Heritage Foundation for Medical Research HTA unit recognized that for health technology assessment to continue to be relevant, it must follow this change. Four steps were taken to refocus the unit's scope: a thorough analysis of the healthcare environment; face-to-face interviews with the chief executive officers of the regions; the development of a framework for HTA in the regions; and the organization of a conference on evidence-based decision making. These steps were helpful in bringing HTA to the attention of regional decision makers. A formal, analytical assessment of the regional healthcare environment, provision of general information (through the framework and conference) and individual information (through face-to-face interviews) enabled a proactive engagement with regions. However, to meet the demands and needs of a population that expects comprehensive coverage that delivers "state of the art" diagnostics and treatments, the efficacy and effectiveness of interventions can sometimes be of subordinate importance.
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Programas Nacionais de Saúde/organização & administração , Regionalização da Saúde/organização & administração , Avaliação da Tecnologia Biomédica/organização & administração , Pessoal Administrativo , Alberta , Tomada de Decisões Gerenciais , Eficiência Organizacional , Medicina Baseada em Evidências , Necessidades e Demandas de Serviços de Saúde , Humanos , Entrevistas como Assunto , Liderança , Inovação Organizacional , Responsabilidade Social , Resultado do TratamentoRESUMO
Positron Emission Tomography (PET) has been regarded as a breakthrough technology that helps diagnoses various conditions. PET was developed in the United States during the 1960s, and has since diffused rather slowly into most modern health care systems. Germany is an exception, as here the diffusion of PET has been rapid, and more than 70 PET scanners have been installed. At present, PET scans are not included in the health care basket though they are often used and members of the statutory sickness fund frequently seek reimbursement for this technology. The Standing Committee therefore conducted a formal inquiry into the value of PET scanning in publicly funded (statutory) ambulatory health care. The Committee's decisions were based on a technology assessment of PET. This report found that PET has been approved by the German Federal Institute for Drugs and Medical Devices (BfArM) for five indications. The evidence for these five indications was compared to that for other diagnostic methods such as magnetic resonance imaging. The assessment found no convincing evidence to support the introduction of PET into statutory ambulatory health care in Germany. In April 2002 the Standing Committee consequently denied approval for the reimbursement of PET as a publicly funded diagnostic procedure.
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Assistência Ambulatorial , Testes Diagnósticos de Rotina , Tomografia Computadorizada de Emissão , Alemanha , Humanos , Programas Nacionais de SaúdeRESUMO
Health Technology Assessment (HTA) in social insurance-based, or so-called 'Bismarck' health care systems (Germany, Austria, and the Netherlands) has taken a different course than in either taxed-based (Sweden, Norway, United Kingdom, and Spain) or private health care systems (such as the United States). The culture of informed decisions supported by transparent and evidence-based evaluations of health interventions was hindered by the strong professional autonomy and sectoral interests in Germany and Austria for a long time. On the other hand, HTA has a long-standing tradition in the Netherlands. In all three countries sickness funds play an important role in implementing evaluations-as a policy tool-by linking reimbursement to explicit proof of effectiveness in both new and established interventions. This article focuses on the obstacles and opportunities for HTA in Germany, Austria and the Netherlands as countries with insurance-based health care systems.
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Política de Saúde , Pesquisa sobre Serviços de Saúde , Programas Nacionais de Saúde/organização & administração , Avaliação da Tecnologia Biomédica , Cobertura Universal do Seguro de Saúde/organização & administração , Áustria , Alemanha , Países Baixos , Cultura Organizacional , Formulação de Políticas , Autonomia ProfissionalAssuntos
Atenção à Saúde/organização & administração , Difusão de Inovações , União Europeia/organização & administração , Cooperação Internacional , Avaliação da Tecnologia Biomédica/organização & administração , Europa (Continente) , Medicina Baseada em Evidências , Política de Saúde , Humanos , Serviços de Informação , Metanálise como Assunto , Avaliação de Programas e Projetos de SaúdeRESUMO
The "Bundesausschuss der Aerzte und Krankenkassen" (hereafter referred to as the "Bundesausschuss") is one of Germany's self-governing bodies in ambulatory health care. This Federal Standing Committee of Physicians and Sickness Funds has the mandate, among others, to issue directives for the ambulatory health care provided by 110,000 physicians to the approximately 70 million citizens of Germany. The Bundesausschuss' directives are legally binding and must be followed by both the physicians who provide ambulatory medical services and the sickness funds who insure these services. Although elements of evidence-based medicine were first introduced in 1990, health technology assessment (HTA) was not systematically integrated into the decision making process of the working group for medical and surgical procedures until 1998. The HTA reports of the Bundesausschuss take account of the status of the technology in other health care systems (public systems in particular) and of statements by the scientific community and interested parties, such as patient groups, and review the evidence currently available (in primary studies, systematic reviews, other assessments, etc.). These reports are prepared by representatives of the physicians and the sickness funds, in close collaboration, whenever possible, with academic experts in health technology assessment. The reports serve as a basis for the decisions made by the Bundesausschuss, which ensures their impact, and are published on the Internet at http://www.kbv.de/hta. The Bundesausschuss reports also reflect the deliberation process for each technology, in the context of the legal environment. They also explain how a decision was reached. The shortcomings of HTA process are the time and financial resources required to conduct these assessment. The advantages include the increased transparency of the decision-making process, for both the German "social" court system and for the insured. Further developments will be directed by the future framing of the legal environment by the ministry of health. A similar decision-making body has recently been installed for the hospital sector and both committees will be co-ordinated by a board, which will organize the deliberation process. It will be important to further encourage and integrate the use of evidence in the decision-making processes of these statutory bodies.