[Health Promotion and Prevention of Non-Communicable Diseases by Public Health Departments in Baden-Württemberg during the COVID-19 Pandemic: Results of an Online Survey]. / Gesundheitsförderung und Prävention nicht-übertragbarer Erkrankungen durch Gesundheitsämter in Baden-Württemberg während der COVID-19-Pandemie ­ Ergebnisse einer Onlinebefragung.

OBJECTIVES: Disease prevention and health promotion are among the core tasks of German public health services (Öffentlicher Gesundheitsdienst - ÖGD), particularly local public health departments (Gesundheitsämter). Little is known about the extent to which the departments were able to continue activities in the field of health promotion and prevention of non-communicable diseases (HPP-NCDs) during the COVID-19 pandemic. Using the example of public health departments in Baden-Württemberg (BW), we therefore investigated how much staff was available to the departments for HPP-NCDs services, how much staff was actually dedicated to HPP-NCDs during the COVID-19 pandemic, which HPP-NCDs activities were carried out during the pandemic, which were cancelled, and which should be resumed as a priority, according to the public health departments. METHODS: We developed a largely standardized online questionnaire for the survey of the 38 public health departments in BW. Per department one questionnaire was to be completed. The survey took place from 9/1/2022 to 11/4/2022. The data of this explorative cross-sectional study were analyzed in a descriptive-statistical manner using SPSS, version 28. RESULTS: Of the 38 departments, 34 participated in the survey (89%). Departments had a mean of 2.44 full HPP-NCDs staff as planned (median 2.00; SD 1.41; range 0.20-5.00). Under pandemic conditions, a mean of 1.23 full HPP-NCDs staff were deployed (median 0.95; SD 1.24; range 0.00-4.50). Respondents gave examples of 61 HPP-NCDs activities that were conducted under pandemic conditions, and they described 69 HPP-NCDs activities that had to be cancelled. Of the latter, respondents felt that 40 should be resumed as a matter of highest priority. Analysis of the priority activities to be resumed reveals characteristic differences: e. g., resumption of structural prevention activities was viewed more frequently as a matter of hightest priority than resumption of behavioral prevention activities. CONCLUSIONS: During the pandemic, local public health departments in BW deployed, on average, actually only half of their full staff allocated as planned to HPP-NCDs. Comparing different categories of HPP-NCDs activities (cancelled during the pandemic) in terms of the relative frequency with which their resumption is viewed as matter of highest priority, characteristic differences can be observed. It remains an open question which conclusions can be drawn from such differences.

[Information on health promotion and prevention on the websites of Baden-Württemberg's public health services-a first approach]. / Informationen zu Gesundheitsförderung und Prävention auf den Webseiten baden-württembergischer Gesundheitsämter ­ eine erste Annäherung.

BACKGROUND: Health promotion and prevention are core tasks of German public health services (Öffentlicher Gesundheitsdienst). Health communication is, among other things, central to their effectiveness. As the Internet has become an important source of health information and public health services are increasingly in the public eye, their websites are gaining more focus. We therefore investigated how public health services present topics on health promotion and prevention of non-communicable diseases (HPP-NCDs) on their websites. METHODS: The websites of the 38 public health service departments in Baden-Wuerttemberg were examined using qualitative content analysis from June to October 2022. The presentation of the HPP-NCDs topic on the websites as well as the relevant measures were documented. For each measure/activity the addressed target group, the topic, and the type of intervention was collected. RESULTS: The HPP-NCDs topic is addressed on all websites (n = 38); however, the presentation style is heterogeneous. A total of 243 HPP-NCDs measures/activities were identified across the 38 websites. There was a broad spectrum of topics, target groups, and types of intervention used in the measures/activities presented. DISCUSSION: The study shows an extensive but heterogeneous presentation of HPP-NCDs on the websites of public health services. In doing so, they are caught between the requirements of public relations and health information. The use of synergy effects through the joint promotion of nationally relevant informational materials and measures could be beneficial for public health services.

Assessing the effect of a regional integrated care model over ten years using quality indicators based on claims data - the basic statistical methodology of the INTEGRAL project.

BACKGROUND: The regional integrated health care model "Healthy Kinzigtal" started in 2006 with the goal of optimizing health care and economic efficiency. The INTEGRAL project aimed at evaluating the effect of this model on the quality of care over the first 10 years. METHODS: This methodological protocol supplements the study protocol and the main publication of the project. Comparing quality indicators based on claims data between the intervention region and 13 structurally similar control regions constitutes the basic scientific approach. Methodological key issues in performing such a comparison are identified and solutions are presented. RESULTS: A key step in the analysis is the assessment of a potential trend in prevalence for a single quality indicator over time in the intervention region compared to the corresponding trends in the control regions. This step has to take into account that there may be a common - not necessarily linear - trend in the indicator over time and that trends can also appear by chance. Conceptual and statistical approaches were developed to handle this key step and to assess in addition the overall evidence for an intervention effect across all indicators. The methodology can be extended in several directions of interest. CONCLUSIONS: We believe that our approach can handle the major statistical challenges: population differences are addressed by standardization; we offer transparency with respect to the derivation of the key figures; global time trends and structural changes do not invalidate the analyses; the regional variation in time trends is taken into account. Overall, the project demanded substantial efforts to ensure adequateness, validity and transparency.

[Operationalization of Quality Indicators with Routine Data Using the Example of the Evaluation of "Integrated Care Healthy Kinzigtal"]. / Operationalisierung von Qualitätsindikatoren mittels Routinedaten am Beispiel der Evaluation der "Integrierten Versorgung Gesundes Kinzigtal".

AIM: As part of the 10-year evaluation of Gesundes Kinzigtal Integrated Care (IVGK, Innovation Fund Project 01VSF16002), a multidisciplinary group of experts agreed on 101 quality indicators (QI) to evaluate the quality of regionally integrated care with its focus on health and prevention programs. One criterion was that the selected QI should in principle be suitable for mapping using routine data. The aim of the study was to investigate how many and in what way the QI developed can actually be mapped in Germany with routine data and for what reasons operationalization was restricted or not possible. MATERIAL AND METHODS: The operationalization of the QIs was performed using pseudonymized billing data of the AOK Baden-Württemberg from 2006 to 2015, which the Scientific Institute of the AOK (WIdO) provided to the evaluation team. All operationalized indicators were binary coded (criterion fulfilled yes/no). The diagnoses, procedures, or drugs named in the numerator and denominator definitions were operationalized using ICD-10 codes (inclusion and exclusion diagnoses), EBM codes, OPS codes, ATC codes. Indicator prevalences were examined over time to check for abnormalities as an indication of possible misscoding. RESULTS: Ninety of the 101 indicators were operationalizable with routine data. Fourteen of the 90 indicators could only be operationalized with restrictions, as corresponding service codes were only introduced or existing codes were changed during the observation period. Seventy-six of 90 indicators could be operationalized without restrictions. In this context, 15 of these 76 indicators required pre- and follow-up periods, which meant that they could not be presented for all years. Eleven of 101 QIs could not be operationalized because EBM codes were only introduced after 2015 or were not recorded as individual services for all physician groups (e. g., spirometry and long-term ECG). Striking trends in indicator prevalences could be explained. CONCLUSION: Routine data enable resource-saving quality monitoring. A change in the data basis during the observation period, for example through the introduction or deletion of billing codes, makes the longitudinal, routine data-based quality assessment more difficult, but enables further or new indicators to be operationalized for later periods.

[DNVF Memorandum Health Literacy (Part 1) - Background, Relevance, Research Topics and Questions in Health Services Research]. / DNVF Memorandum Gesundheitskompetenz (Teil 1) ­ Hintergrund, Relevanz, Gegenstand und Fragestellungen in der Versorgungsforschung.

More than half of the German population has difficulties in dealing with health information. It is an important task of health services research to examine how healthcare professionals and health care organizations can meet this challenge. The DNVF Memorandum Health Literacy (Part 1) defines the terms of individual and organizational health literacy, presents the national and international state of research and ethical aspects of health literacy research in health care settings. The relevance of health literacy research is worked out in different phases of life, for different target groups and in different healthcare contexts. Central research topics and future research desiderata are derived.

[DNVF Memorandum Health Literacy (Part 1) - Background, Relevance, Research Topics and Questions in Health Services Research: Short Version]. / DNVF Memorandum Gesundheitskompetenz (Teil 1) ­ Hintergrund, Relevanz, Gegenstand und Fragestellungen in der Versorgungsforschung: Kurzfassung.

More than half of the German population has difficulties in dealing with health information. It is an important task of health services research to examine how healthcare professionals and health care organizations can meet this challenge. This short version of the DNVF Memorandum Health Literacy (Part 1) defines the terms of individual and organizational health literacy, presents the national and international state of research and ethical aspects of health literacy research in health care settings. Central research topics and future research desiderata are derived.

[Pursuing the triple aim: evaluation of the integrated care system Gesundes Kinzigtal: population health, patient experience and cost-effectiveness]. / Triple Aim - Evaluation in der Integrierten Versorgung Gesundes Kinzigtal - Gesundheitszustand, Versorgungserleben und Wirtschaftlichkeit.

BACKGROUND: The integrated care system Gesundes Kinzigtal (ICSGK), one of the most comprehensive population-based ICS in Germany, started its work nearly 9 years ago. The ICSGK is pursuing the Triple Aim: improving the health of the population, improving the individual's experience of care, and at the same time reducing the per capita costs of care. OBJECTIVES: To evaluate the impact of the ICSGK on the Triple Aim. MATERIALS AND METHODS: The ICSGK is being evaluated externally and internally via a mix of diverse quantitative and qualitative methods. This paper presents selected results for each Triple Aim dimension. RESULTS AND CONCLUSIONS: Regarding population health, most of the quality indicators examined by the external scientific evaluation show positive development. For example, the prevalence of patients with fractures among all insurants with osteoporosis is presented. In 2011, this prevalence was approximately 26 % in the "Kinzigtal" population (aged ≥ 20 years old) in comparison to 33 % in the control group. As far as patient experience is concerned, to the question "Would you recommend becoming a member of Gesundes Kinzigtal to your friends or relatives?" 92.1 % of those questioned answered "Yes, for sure" or "Yes, probably." Twenty-four percent of those questioned further stated that they would now live "more healthy" than before enrolment in the ICSGK. In the subgroup of questioned insurants who had objective agreements with their doctors 45.4 % answered in this way. On the subject of cost-effectiveness, for both participating socil health insurance schemes, cost savings relative to the costs normally expected for the ICSGK population concerned are observed every year. In the seventh intervention year (2012) the total is 4.56 million Euros for the AOK Baden-Württemberg (BW), which is a contribution margin of 146 Euros per insurant for the 31.156 insurants concerned (LKK BW = 322 Euros per insurant relative to cost savings). The results presented in this paper indicate positive effects in all three Triple Aim dimensions. Further longitudinal studies are recommended to validate those first results together with a detailed analysis to obtain in-depth insights into the specific influence of subcomponents of the total intervention.

Correction: Siegel et al. PEN-13: A New Generic 13-Item Questionnaire for Measuring Patient Enablement (German Version). Int. J. Environ. Res. Public Health 2019, 16, 4867.

In the original publication [...].

The Predominance of the Health-Promoting Patterns of Work Behavior and Experience in General Practice Teams-Results of the IMPROVEjob Study.

This study aims to identify the distribution of the "Work-related behavior and experience patterns" (Arbeitsbezogenes Verhaltens-und Erlebnismuster, AVEM) in general practitioners and their teams by using baseline data of the IMPROVEjob study. Members of 60 general practices with 84 physicians in a leadership position, 28 employed physicians, and 254 practice assistants participated in a survey in 2019 and 2020. In this analysis, we focused on AVEM variables. Age, practice years, work experience, and working time were used as control variables in the Spearman Rho correlations and analysis of variance. The majority of the participants (72.1%) revealed a health-promoting pattern (G or S). Three of eleven AVEM dimensions were above the norm for the professional group "employed physicians". The AVEM dimensions "striving for perfection" (p < 0.001), "experience of success at work" (p < 0.001), "satisfaction with life" (p = 0.003), and "experience of social support" (p = 0.019) differed significantly between the groups' practice owners and practice assistants, with the practice owners achieving the higher values, except for experience of social support. Practice affiliation had no effect on almost all AVEM dimensions. We found a high prevalence of AVEM health-promoting patterns in our sample. Nearly half of the participants in all professional groups showed an unambitious pattern (S). Adapted interventions for the represented AVEM patterns are possible and should be utilized for maintaining mental health among general practice teams.

Shared decision-making in antihypertensive therapy: a cluster randomised controlled trial.

BACKGROUND: Hypertension is one of the key factors causing cardiovascular diseases. A substantial proportion of treated hypertensive patients do not reach recommended target blood pressure values. Shared decision making (SDM) is to enhance the active role of patients. As until now there exists little information on the effects of SDM training in antihypertensive therapy, we tested the effect of an SDM training programme for general practitioners (GPs). Our hypotheses are that this SDM training (1) enhances the participation of patients and (2) leads to an enhanced decrease in blood pressure (BP) values, compared to patients receiving usual care without prior SDM training for GPs. METHODS: The study was conducted as a cluster randomised controlled trial (cRCT) with GP practices in Southwest Germany. Each GP practice included patients with treated but uncontrolled hypertension and/or with relevant comorbidity. After baseline assessment (T0) GP practices were randomly allocated into an intervention and a control arm. GPs of the intervention group took part in the SDM training. GPs of the control group treated their patients as usual. The intervention was blinded to the patients. Primary endpoints on patient level were (1) change of patients' perceived participation (SDM-Q-9) and (2) change of systolic BP (24h-mean). Secondary endpoints were changes of (1) diastolic BP (24h-mean), (2) patients' knowledge about hypertension, (3) adherence (MARS-D), and (4) cardiovascular risk score (CVR). RESULTS: In total 1357 patients from 36 general practices were screened for blood pressure control by ambulatory blood pressure monitoring (ABPM). Thereof 1120 patients remained in the study because of uncontrolled (but treated) hypertension and/or a relevant comorbidity. At T0 the intervention group involved 17 GP practices with 552 patients and the control group 19 GP practices with 568 patients. The effectiveness analysis could not demonstrate a significant or relevant effect of the SDM training on any of the endpoints. CONCLUSION: The study hypothesis that the SDM training enhanced patients' perceived participation and lowered their BP could not be confirmed. Further research is needed to examine the impact of patient participation on the treatment of hypertension in primary care. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00000125.

Implementation of shared decision making by physician training to optimise hypertension treatment. Study protocol of a cluster-RCT.

BACKGROUND: Hypertension is one of the key factors causing cardiovascular diseases which make up the most frequent cause of death in industrialised nations. However about 60% of hypertensive patients in Germany treated with antihypertensives do not reach the recommended target blood pressure. The involvement of patients in medical decision making fulfils not only an ethical imperative but, furthermore, has the potential of higher treatment success. One concept to enhance the active role of patients is shared decision making. Until now there exists little information on the effects of shared decision making trainings for general practitioners on patient participation and on lowering blood pressure in hypertensive patients. METHODS/DESIGN: In a cluster-randomised controlled trial 1800 patients receiving antihypertensives will be screened with 24 h ambulatory blood pressure monitoring in their general practitioners' practices. Only patients who have not reached their blood pressure target (approximately 1200) will remain in the study (T1 - T3). General practitioners of the intervention group will take part in a shared decision making-training after baseline assessment (T0). General practitioners of the control group will treat their patients as usual. Primary endpoints are change of systolic blood pressure and change of patients' perceived participation. Secondary endpoints are changes of diastolic blood pressure, knowledge, medical adherence and cardiovascular risk. Data analysis will be performed with mixed effects models. DISCUSSION: The hypothesis underlying this study is that shared decision making, realised by a shared decision making training for general practitioners, activates patients, facilitates patients' empowerment and contributes to a better hypertension control. This study is the first one that tests this hypothesis with a (cluster-) randomised trial and a large sample size.

Converting habits of antibiotic prescribing for respiratory tract infections in German primary care--the cluster-randomized controlled CHANGE-2 trial.

BACKGROUND: With an average prescription rate of 50%, in German primary care antibiotics are still too frequently prescribed for respiratory tract infections. The over-prescription of antibiotics is often explained by perceived patient pressure and fears of a complicated disease progression. The CHANGE-2 trial will test the effectiveness of two interventions to reduce the rate of inappropriate antibiotic prescriptions for adults and children suffering from respiratory tract infections in German primary care. METHODS/DESIGN: The study is a three-arm cluster-randomized controlled trial that measures antibiotic prescription rates over three successive winter periods and reverts to administrative data of the German statutory health insurance company AOK. More than 30,000 patients in two regions of Germany, who visit their general practitioner or pediatrician for respiratory tract infections will be included. Interventions are: A) communication training for general practitioners and pediatricians and B) intervention A plus point-of-care testing. Both interventions are tested against usual care. Outcome measure is the physicians' antibiotic prescription rate for respiratory tract infections derived from data of the health insurance company AOK. Secondary outcomes include reconsultation rate, complications, and hospital admissions. DISCUSSION: Major aim of the study is to improve the process of decision-making and to ensure that patients who are likely to benefit from antibiotics are treated accordingly. Our approach is simple to implement and might be used rapidly among general practitioners and pediatricians. We expect the results of this trial to have major impact on antibiotic prescription strategies and practices in Germany, both among general practitioners and pediatricians. TRIAL REGISTRATION: The study is registered at the Current Controlled Trials Ltd (ISRCTN01559032).

Social Determinants of Remaining Life Expectancy at Age 60: A District-Level Analysis in Germany.

Remaining life expectancy at age 60 (in short: RLE) is an important indicator of the health status of a population's elders. Until now, RLE has not been thoroughly investigated at the district level in Germany. In this study we analyzed, based on recent publicly available data (2015-2017), and for men and women separately, how large the RLE differences were in Germany across the 401 districts. Furthermore, we examined a wide range of potential social determinants in terms of their bivariate and multivariate (i.e., partial) impact on men's and women's RLE. Men's district-level RLE ranged between 19.89 and 24.32 years, women's district-level RLE between 23.67 and 27.16 years. The best single predictor both for men's and women's RLE at district level was 'proportion of employees with academic degree' with standardized partial regression coefficients of 0.42 (men) and 0.51 (women). Second and third in rank were classic economic predictors, such as 'household income' (men), 'proportion of elder with financial elder support' (women), and 'unemployment' (men and women). Indicators expressing the availability of medical services and staffing levels of nursing homes and services had at best a marginal partial impact. This study contributes to the growing body of evidence that a population's educational level is a decisive determinant of population health resp. life expectancy in contemporary industrialized societies.

Leadership program with skills training for general practitioners was highly accepted without improving job satisfaction: the cluster randomized IMPROVEjob study.

Leadership has become an increasingly important issue in medicine as leadership skills, job satisfaction and patient outcomes correlate positively. Various leadership training and physician psychological well-being programmes have been developed internationally, yet no standard is established in primary care. The IMPROVEjob leadership program was developed to improve job satisfaction among German general practitioners and practice personnel. Its acceptance and effectiveness were evaluated. The IMPROVEjob intervention is a participatory, interdisciplinary and multimodal leadership intervention that targets leadership, workflows and communication in general practices using three elements: (1) two leadership workshops with skills training; (2) a toolbox with printed and online material, and (3) a 9-month implementation phase supported by facilitators. A cluster-randomised trial with a waiting-list control evaluated the effectiveness on the primary outcome job satisfaction assessed by the Copenhagen Psychosocial Questionnaire (range 0-100). A mixed-methods approach with questionnaires and participant interviews evaluated the acceptance of the intervention and factors influencing the implementation of intervention content. Statistical analyses respected the clustered data structure. The COVID-19 pandemic necessitated intervention adjustments: online instead of on-site workshops, online material instead of facilitator practice visits. Overall, 52 of 60 practices completed the study, with altogether 70 practice leaders, 16 employed physicians, and 182 practice assistants. According to an intention-to-treat analysis, job satisfaction decreased between baseline and follow-up (not significantly) in the total study population and in both study arms, while the subgroup of practice leaders showed a non-significant increase. A mixed multilevel regression model showed no effect of the intervention on job satisfaction (b = - 0.36, p > 0.86), which was influenced significantly by a greater sense of community (b = 0.14, p < 0.05). The acceptance of the IMPROVEjob workshops was high, especially among practice leaders compared to assistants (1 = best to 5 = worst): skills training 1.78 vs. 2.46, discussions within the practice team 1.87 vs. 2.28, group discussions 1.96 vs. 2.21. The process evaluation revealed that the COVID-19 pandemic complicated change processes and delayed the implementation of intervention content in practice routines. The workshops within the participatory IMPROVEjob intervention were rated very positively but the multimodal intervention did not improve job satisfaction 9 months into the pandemic. Qualitative data showed an impairment of implementation processes by the unforeseeable COVID pandemic.Trial registration Registration number: DRKS00012677 on 16/10/2019.

Work-Related Health Literacy: A Scoping Review to Clarify the Concept.

The overall aim of this scoping review is to outline the current state of research on health literacy (HL) in the workplace: the primary objective is to clarify the concept of individual work-related HL; the secondary aims are to report on interventions that promote individual work-related HL and to present respective measurement instruments validated to date. A high level of work-related HL could support work ability and in the longer run employability. These topics are becoming increasingly important in current circumstances and in view of ongoing developments (e.g., digitalization and "new" work). A basic understanding and measurement of HL as an individual competence in the context of working life is necessary to develop future interventions to promote HL among people of working age. According to the participants, concept, and context (PCC) framework, we included articles on health literacy (concept) in the target group of people of working age in the workplace (population and context). Key information sources were the databases PubMed, CINAHL, PsycInfo, and PSYNDEX. A total of 30 articles were included. There are several terms for "health literacy in the workplace" (including individual work-related or occupational HL). The conceptualizations of the individual employee's competence covered all aspects of HL ("access", "understand", "appraise", and "apply" health information). The conceptualizations differed, among others, in the covered time horizon (referring either only to employees' current work situation or additionally to their employability in the lifespan) or whether they referred also to the viability of the respective company. Published interventions attempting to promote individual work-related HL seem mostly to be targeted at the promotion of mental HL. A variety of outcomes have been measured in intervention studies, while specific measurement instruments for individual work-related HL seem to be scarce. We recommend the development of country-specific instruments for the assessment of individual work-related health literacy and to measure mental and physical work-related health literacy.

Addressing future work ability of employees in GP consultations: results of a cross-sectional study.

OBJECTIVES: In this study we examined to what extent members of a best-practice integrated healthcare model in Germany discussed their subjective future work ability with their general practitioner (GP); furthermore, we examined independent variables which explain whether future work ability is discussed. METHODS: In a cross-sectional survey, 1168 (out of 3218 invited) integrated healthcare members responded to a standardized questionnaire. This study includes n = 475 employed respondents who were at most 65 years old. We determined the (relative) frequency of employed members up to 65 years who had already discussed their subjective future work ability with their GP. By means of logistic regression analysis, explanatory variables were identified which statistically explained the discussion of future work ability with their GP. RESULTS: N = 80 (16.8%) respondents stated they had discussed their future work ability with their GP. A multiple logistic regression analysis showed the following results: The odds ratio for discussing future work ability is increased the more satisfied respondents are with their general practitioner, the worse they assess their current work ability in relation to the physical demands of the job, and when respondents suffer from one or more chronic diseases (Nagelkerke's pseudo-R2 = 0.13). CONCLUSIONS: Even in this healthcare setting, employees up to the age of 65 rarely discussed their subjective future work ability with their GP. This suggests that the issue 'future work ability' is even less commonly discussed in other community-based care settings in Germany. It seems that health care providers involved in acute care only sporadically take this issue into consideration - despite the great importance of maintaining work ability.

Attitudes of Company Executives toward a Comprehensive Workplace Health Management-Results of an Exploratory Cross-Sectional Study in Germany.

Workplace health management (WHM) in Germany aims at maintaining and increasing the health and well-being of employees. Little is known about company executives' attitudes toward WHM. To gain more insight, we conducted a large-scale survey in companies in the German county of Reutlingen in 2017. We sent a standardized questionnaire to 906 companies, containing inter alia 26 self-constructed declarative statements depicting company executives' opinions on various WHM aspects; 222 questionnaires could be evaluated. By exploratory factor analysis we assigned the 26 items to six factors reflecting different attitudes toward WHM. Factor values were standardized to a scale from 0 to 10. The attitude 'positive view of general health services in the company', for example, achieved by far the lowest mean agreement (3.3 points). For the attitude 'general skepticism toward WHM', agreement and disagreement were balanced (5.0 points). Using multiple regression analyses, we searched for variables that could partially explain respondents' agreement with attitudes. In conclusion, a general WHM skepticism was widespread, but not dominant. The idea that general health services should be offered in companies was predominantly rejected. Older respondents and respondents from smaller companies and craft enterprises were more skeptical than average about WHM and its possible extensions.

Ten-Year Evaluation of the Population-Based Integrated Health Care System "Gesundes Kinzigtal".

BACKGROUND: The population-based integrated health care system called "Gesundes Kinzigtal" (Integrierte Versorgung Gesundes Kinzigtal, IVGK) was initiated more than 10 years ago in the Kinzig River Valley region, which is located in the Black Forest in the German state of Baden-Württemberg. IVGK is intended to optimize health care while maximizing cost-effectiveness. It consists of programs for promoting health and for enabling cooperation among service providers, as well as of a shared-savings contract that has enabled resources to be saved every year. The goal of the present study was to investigate trends in the quality of care provided by IVGK over the past ten years in comparison to conventional care. METHODS: This is a non-randomized observational study with a control-group design (Kinzig River Valley versus 13 structurally comparable control regions), employing data collected by AOK, a large statutory health-insurance provider in Germany, over the period 2006-2015. Quality assessment was conducted with the aid of a set of indicators, developed by the authors, that was based exclusively on claims data. The statistical analysis of the trends in these indicators over time was conducted with preset criteria for the relevance of any observed changes, as well as preset mechanisms of controlling for confounding factors. RESULTS: For 88 of the 101 evaluable indicators, no relevant difference was seen between the trend over time in the region of the intervention and the average trend in the control regions. Relevant differences in favor of the IVGK were observed for six indicators, and negatively divergent trends compared to the controls were observed for seven indicators. In the main summarizing statistical analysis, no positive or negative difference was found between the Kinzig River Valley and the other regions with respect to trends in the health-care indicators over time. CONCLUSION: An evaluation based on 101 indicators derived from health-insurance data did not reveal any improvement of the quality of care by IVGK and the totality of the programs that were implemented under it. However, under the conditions of the shared-savings contract, no relevant diminution in the quality of care was observed over a period of 10 years either, compared with structurally similar control regions without an integrated care model.