Health impact of borders: general reflections and a case study from the Polish-German border.

BACKGROUND AND OBJECTIVE: Political, economic, communicative and cultural borders still limit the accessibility of acute healthcare services for patients so that they frequently have to accept longer distances to travel to the next provider within their own country. In this paper, we analyze the impact of borders and opening of borders on acute medical care in hospitals and on patients in border regions. METHODS: We develop a conceptual framework model of cross-border healthcare and apply it to the Polish-German border area. The model combines the distance decay effect, a catchment area analysis, economies of scale and the learning curve. RESULTS: Borders have a major impact on acute medical care in hospitals and on patients. Setting of new borders will reduce the accessibility of health facilities for patients or require the establishment of new hospitals. Reopening borders might induce a vicious circle leading to the insolvency of a hospital which might result in poorer health for some patients. CONCLUSION: Strong effort should be invested to overcome political and cultural borders to improve the health of the population in border regions. Similarly, increased cross-border acute healthcare must be seen in the context of rural health and the special situation of small rural hospitals in rural peripheral areas.

[Is a tele-emergency physician system a sensible addition in rural German regions?-An analysis from a medical and economic perspective]. / Ist das Telenotarzt-System eine sinnvolle Ergänzung im ländlichen Raum? ­ Eine Analyse aus medizinischer und ökonomischer Perspektive.

BACKGROUND AND OBJECTIVES: In 2017, a tele-emergency-physician system was implemented in the county of Vorpommern-Greifswald (Germany) to optimise the prehospital emergency medical service and to counteract current challenges. It was evaluated from a medical and economic perspective whether a tele-emergency physician system is a useful addition to the existing prehospital emergency system, especially in rural regions. MATERIALS AND METHODS: Approximately 250,000 emergency medical service data from the years 2015 to 2020 (before and after the implementation of the telemedical system) were analysed in a pre-post comparison. A total of 3611 tele-emergency physician cases were analysed regarding medical indication and time-related factors. Additionally, total costs of the tele-emergency physician system as well as a cost analysis regarding prehospital and hospital medical costs of selected diseases were performed. RESULTS: The tele-emergency physician treated patients of all age groups with a wide spectrum of diseases. Of the cases, 48.2% were moderate to severe but not life-threatening disorders. Patients as well as emergency medical service personnel embraced the new system. According to the data, ambulances that were equipped with the telemedical system had the number of missions requiring an emergency physician on scene reduced significantly by 20%. The yearly costs of this telemedical system amount to €1.7 million. CONCLUSIONS: The tele-emergency physician system proved to be a telemedical innovation that is medically advisable, functional and cost-efficient. Therefore, the tele-emergency physician system continued to operate after the end of the research project and is ready to be implemented across Germany.

Telemedical emergency services: central or decentral coordination?

BACKGROUND AND OBJECTIVE: Teleemergency doctors support ambulance cars at the emergency site by means of telemedicine. Currently, each district has its own teleemergency doctor office (decentralized solution). This paper analyses the advantages and disadvantages of a centralized solution where several teleemergency doctors work in parallel in one office to support the ambulances in more districts. METHODS: The service of incoming calls from ambulances to the teleemergency doctor office can be modelled as a queuing system. Based on the data of the district of Vorpommern-Greifswald in the Northeast of Germany, we assume that arrivals and services are Markov chains. The model has parallel channels proportionate to the number of teleemergency doctors working simultaneously and the number of calls which one doctor can handle in parallel. We develop a cost function with variable, fixed and step-fixed costs. RESULTS: For the district of Greifswald, the likelihood that an incoming call has to be put on hold because the teleemergency doctor is already fully occupied is negligible. Centralization of several districts with a higher number of ambulances in one teleemergency doctor office will increase the likelihood of overburdening and require more doctors working simultaneously. The cost of the teleemergency doctor office per ambulance serviced strongly declines with the number of districts cooperating. DISCUSSION: The calculations indicate that centralization is feasible and cost-effective. Other advantages (e.g. improved quality, higher flexibility) and disadvantages (lack of knowledge of the location and infrastructure) of centralization are discussed. CONCLUSIONS: We recommend centralization of telemedical emergency services. However, the number of districts cooperating in one teleemergency doctor office should not be too high and the distance between the ambulance station and the telemedical station should not be too large.

[The Tele-Emergency Physician System as an Innovation in the Emergency Medical Service: Evaluation of Potentials by Employees of German Ambulance Control Centres]. / Das Telenotarzt-System als Innovation im Rettungsdienst: Potenzialbewertung durch Mitarbeiter deutscher Einsatzleitstellen.

BACKGROUND: One of the health policy challenges lies in guaranteeing comprehensive emergency care in Germany. Telemedical applications are assumed to be a potential solution to current problems. One of these innovations is the tele-emergency physician system, which changes the workflows of the various actors in prehospital emergency medicine. The aim of the study was to determine how the potentials of the tele-emergency physician system were evaluated by employees of the ambulance control centres in Germany. METHOD: In the cross-sectional study, employees of ambulance control centres throughout Germany were interviewed using an online-based questionnaire. The results are illustrated in a sub-group analysis according to the state of knowledge on innovation, either (very) low or (very) high. Correlation analyses were carried out to determine significant differences between the subgroups. Data analysis was performed using Microsoft Excel 2013 and IBM SPSS Version 25. RESULTS: The response rate was 69.04%. Of those surveyed, 76.23% expected that the tele-emergency physician system would save them a relevant amount of time. 57.38% believed that patients would be transported faster and 51.64% of the respondents did not see any chance of cost savings in the health care system. Significant evaluation differences resulted in expected time saving (p=0.004), shorter time to transport (p=0.009) and cost saving (p=0.0004). 64.71% thought that there would be a risk of increased documentation effort. 56.41% did not believe that patients would be sufficiently informed about the legal provisions on data protection during their tele-emergency physician treatment. The increase in documentation effort (p=0.02) and patients being sufficiently informed about data protection regulations (p=0.015) were evaluated significantly differently. 90.98% of the respondents rated the tele-emergency physician system as meaningful. The rural region was considered by 47.62% of the respondents as the primary region where the use of system would be necessary. 36.29% of the participants stated that a tele-emergency physician system should be implemented in their own area. CONCLUSION: All in all, the tele-emergency physician system is considered useful in prehospital emergency medical service by the staff of the emergency control centres. However, the majority of participants do not assume that there is potential for implementation of this system in their own region.

Evaluation of a Rural Emergency Medical Service Project in Germany: Protocol for a Multimethod and Multiperspective Longitudinal Analysis.

BACKGROUND: German emergency medical services are a 2-tiered system with paramedic-staffed ambulances as the primary response, supported by prehospital emergency doctors for life-threatening conditions. As in all European health care systems, German medical practitioners are in short supply, whereas the demand for timely emergency medical care is constantly growing. In rural areas, this has led to critical delays in the provision of emergency medical care. In particular, in cases of cardiac arrest, time is of the essence because, with each passing minute, the chance of survival with good neurological outcome decreases. OBJECTIVE: The project has 4 main objectives: (1) reduce the therapy-free interval through widespread reinforcement of resuscitation skills and motivating the public to provide help (ie, bystander cardiopulmonary resuscitation), (2) provide faster professional first aid in addition to rescue services through alerting trained first aiders by mobile phone, (3) make more emergency physicians available more quickly through introducing the tele-emergency physician system, and (4) enhance emergency care through improving the cooperation between statutory health insurance on-call medical services (German: Kassenärztlicher Bereitschaftsdienst) and emergency medical services. METHODS: We will evaluate project implementation in a tripartite prospective and intervention study. First, in medical evaluation, we will assess the influences of various project measures on quality of care using multiple methods. Second, the economic evaluation will mainly focus on the valuation of inputs and outcomes of the different measures while considering various relevant indicators. Third, as part of the work and organizational analysis, we will assess important work- and occupational-related parameters, as well as network and regional indexes. RESULTS: We started the project in 2017 and will complete enrollment in 2020. We finished the preanalysis phase in September 2018. CONCLUSIONS: Overall, implementation of the project will entail realigning emergency medicine in rural areas and enhancing the quality of medical emergency care in the long term. We expect the project to lead to a measurable increase in medical laypersons' individual motivation to provide resuscitation, to strengthen resuscitation skills, and to result in medical laypersons providing first aid much more frequently. Furthermore, we intend the project to decrease the therapy-free interval in cases of cardiac arrest by dispatching first aiders via mobile phones. Previous projects in urban regions have shown that the tele-emergency physician system can provide a higher availability and quality of emergency call-outs in regular health care. We expect a closer interrelation of emergency practices of statutory health insurance physicians with the rescue service to lead to better coordination of rescue and on-call services. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/14358.