[Evaluation of Specialised Paediatric Palliative Home Care in Lower Saxony, Germany - A Qualitative Study on Parents' Perspectives]. / Evaluation der spezialisierten ambulanten pädiatrischen Palliativversorgung in Niedersachsen - Eine qualitative Studie zur Elternsicht.

BACKGROUND: In 2007 the children's right to specialised paediatric palliative home care became law in Germany. This claim should be met in Lower Saxony by the establishment of a comprehensive specialised paediatric home care (SPPHC). Since April 2010, a central office undertakes the coordination and administration throughout the federal state. Regional teams comprising nursing, medical and psychosocial specialists care for the children and adolescents suffering from complex conditions due to life-limiting conditions - subsidiary to regional health care providers. The aim of the study was to evaluate SPPHC in Lower Saxony. METHODOLOGY: From June 2012 to February 2013, semi-structured interviews were conducted with 20 parents of children aged from 3 to 18 years. The young patients fulfilled all criteria to be eligible for SPPHC. 13 of the families experienced SPPHC. 7 families did not utilise the specialised care, mostly because the palliative situation occurred before the implementation of specialised care. Data were analysed using content analysis (Mayring). Therefore, key aspects of paediatric palliative home care were summarised in main categories. The evaluation of parent's satisfaction with palliative home care was performed by an evaluation scheme developed for the main categories (very good - good - bad- very bad) and operated for every case. RESULTS: 6 dimensions of paediatric palliative home care were identified: (i) benefit of care, (ii) continuity of care, (iii) perception of care providers as a team, (iv) dealing with the issues death and dying/hospice and palliative, (v) care provider's communication/cooperation with parents, and (vi) parent's Information. As all parents clearly indicated a rating on the first 3 categories, these categories were selected for the evaluation of parent's satisfaction with the received home care. The evaluation revealed that parents experienced in SPPHC looked upon these 3 main categories more favourably than parents without the experience of SPPHC. As room for improvement, the respondents requested the extension of physician's presence and communication with the families as well as with each other, efforts to better meet the needs of psycho-social support of the families and to optimise follow up-care. CONCLUSION: The implementation of SAPPV was rated positively by the concerned families. In addition, options for improvement could be identified.

[How Steady are Hospitals in Complying with Minimum Volume Standards? A Retrospective Longitudinal Data Analysis of the Years 2006, 2008, and 2010]. / Wie konstant halten Krankenhäuser die Mindestmengenvorgaben ein? Eine retrospektive, längsschnittliche Datenanalyse der Jahre 2006, 2008 und 2010.

BACKGROUND: The outcome volume relationship has been analysed for more than 30 years and debated ever since. For German hospitals minimum volume standards (MVS) have been introduced for some procedures in 2004. Hospitals have to report procedure volumes in their quality reports. This study analyses for the first time how constant hospitals comply with minimum volume standards over time. MATERIALS AND METHODS: Data used are the reported volumes, which hospitals published in their quality reports in 2006, 2008, and 2010. The case volumes of complex oesophageal and pancreatic interventions, total knee replacements, and liver, kidney and stem cell transplantations (KTX, LTX, STX) are analysed in a retrospective, longitudinal study design. RESULTS: More than 80 % of hospitals conducting LTX, KTX, and total knee replacements are complying with MVS constantly, in STX 57 % of hospitals comply, and with complex pancreatic and oesophageal interventions compliance is 44 and 28 %, respectively. Twenty-seven to 36 % of hospitals conducting the three last mentioned procedures vary in complying with the MVS over time. 3.5 % (total knee replacements) up to 26 % (pancreatic interventions) and 37 % (oesophageal interventions) of all hospitals constantly fail to comply with MVS. Hospitals constantly over the MVS treat more than 80 % of all patients, except in complex oesophageal interventions. Hospitals with varying compliance in oesophageal and pancreatic interventions are mainly hospitals with 100 to 599 beds. Only very few hospitals of these two procedure types stop conducting the interventions after failing to comply with MVS earlier, the other some 120 hospitals for each intervention type treat 2 cases on average per year. CONCLUSION: The MVS on KTX, LTX, STX, and total knee replacement are almost constantly complied with. A considerable number of hospitals conducting oesophageal and pancreatic interventions never or rarely meet the MVS without discontinuing this type of intervention. At least for hospitals that never comply with MVS on oesophageal and pancreatic interventions, requirements and possibilities for a regional patient transfer should be studied in depth.

[Accessibility of organ cancer centres: is there already nation-wide coverage in Germany?]. / Erreichbarkeit von Organkrebszentren: Existiert bereits ein flächendeckendes Angebot in Deutschland?

INTRODUCTION: For several years, health care providers and health policy have been establishing certified cancer treatment centres. Although certification is not required by law, a comprehensive and close to home medical care in certified centres is required for all patients with cancer. We analysed whether Germany already provides a spatially inclusive and comprehensive supply with certified centres for the most common cancers for women and men. METHODS: Based on the central place concept "coverage" is defined as accessibility within 30 min by car for over 90% of the population. Using a software-supported route searching procedure we calculated 30- and 60-minutes-driving time zones around all breast and prostate cancre centers. We aggregated the population shares of all 5 digit postcode areas within the defined driving time zone and compared these areas to those outside the radius. The results are depicted as cartographic information. RESULTS: Nationwide 84% of the female populations over 18 years can reach the next breast centre within 30 min by car. In particular in the states of Mecklenburg-Western Pomerania and Brandenburg several areas do not provide sufficient access to breast centres. Using a travel time threshold of 60 min leads to an accessibility rate of 99%. 56% of the male population have access to a prostate cancer centre within half an hour by car. Again, the biggest coverage problems exist especially in eastern Germany. Within a radius of 60 min, the accessibility of prostate cancer centres increases to 94%. CONCLUSIONS: In Germany, some regions do not provide a spatially inclusive and comprehensive supply with organ cancer centers. However, it must be remembered that comprehensive access to care cannot be pursued as the only goal of health policy. Instead, the trade-off between justice, health and patients' interests and economic performance and adequate funding must be considered.

[Breast cancer centres in North Rhine-Westphalia - case volume trends 2004-2010]. / Brustkrebszentren in Nordrhein-Westfalen - Fallzahlentwicklung 2004-2010.

BACKGROUND: To improve quality of breast cancer care, in 2004 the state of North Rhine-Westphalia (NRW), Germany, began to appoint 51 breast cancer centres. These centres comprise 91 hospitals performing breast cancer surgery which have - amongst other things - to fulfill minimum volume standards. The aim of our study was to analyse if the intended regionalisation of care from 252 hospitals performing breast cancer surgery formerly to the appointed hospitals had taken place by the year 2010. METHODS: We used data for the years 2004-2010 from the agency for quality assurance in North Rhine-Westphalia concerning breast cancer care and analysed trends concerning the number of hospitals performing breast cancer surgery, case volumes, and achievement of minimum volume standards by performing descriptive and inferential statistics. RESULTS: Between 2004 and 2010 the number of breast cancer cases increased by 36.6% from 12 975 to 17 724 cases (p<0.001, Wilcoxon test). Simultaneously, the number of hospitals performing breast cancer surgery decreased from 252 to 208 whereby more than double the number of planned hospitals still performed breast cancer surgery. The case volumes of the 71 appointed hospitals for which we had individual data over the entire period of time increased by 49.4% from 8 103 cases in year 2004 to 12 105 cases in 2010. Assuming that case volume trends of those 20 appointed hospitals of which we did not have individual data developed uniformly to all other appointed hospitals, the proportion of cases that were operated in not appointed hospitals decreased from 20% in year 2004 to 12.5% in 2010 (p<0.001, χ2 test). Simultaneously, the proportion of cases that were operated in hospitals not achieving minimum volume standards decreased from 42.7% in year 2004 to 12.1% in 2010 (p<0.001, χ2 test). CONCLUSION: The establishment of breast cancer centres in NRW regionalised breast cancer surgery. In fact, in 2010 breast cancer surgery still took place in more than 100 not appointed hospitals. However, these hospitals were responsible for only a small proportion of breast cancer surgery.

[How do patients choose a hospital for elective surgery?]. / Wie wählen Patienten ein Krankenhaus für elektive operative Eingriffe?

BACKGROUND: Patients want to decide on health care providers. Published quality reports are supposed to help but are rarely used. How patients manage choosing a hospital for elective surgery in Germany and whether they use the hospital quality reports was explored for the Federal Joint Committee. METHOD: A cross-sectional survey asked 48 hospitalized patients from 5 specialties in 4 hospitals after elective surgery about their criteria and sources of information, and their use of the compulsory quality reports for choosing the hospital. Data were analyzed descriptively. RESULTS: To choose their hospital is very important for patients with elective surgery and they do so. Usually there is enough time to obtain information before admission. The three main criteria are own experience with a hospital, short distance from their homes, and the hospital's expertise. The main sources of information are relatives, contact with the hospital's outpatient departments, and patient's ambulatory health care provider. Written information is only used as supplementary information. The compulsory quality reports are not known and, hence, are not used.

[Medical decision making in symptoms of type 2 diabetes mellitus in general practice]. / Hausärztliche entscheidungen bei symptomen für diabetes mellitus typ 2.

BACKGROUND: Patient and physician attributes influence medical decisions as non-medical factors. The current study examines the influence of patient age and gender and physicians' gender and years of clinical experience on medical decision making in patients with undiagnosed diabetes type 2. METHOD: A factorial experiment was conducted to estimate the influence of patient and physician attributes. An identical physician patient encounter with a patient presenting with diabetes symptoms was videotaped with varying patient attributes. Professional actors played the "patients". A sample of 64 randomly chosen and stratified (gender and years of experience) primary care physicians was interviewed about the presented videos. RESULTS: Results show few significant differences in diagnostic decisions: Younger patients were asked more frequently about psychosocial problems while with older patients a cancer diagnosis was more often taken into consideration. Female physicians made an earlier second appointment date compared to male physicians. Physicians with more years of professional experience considered more often diabetes as the diagnosis than physicians with less experience. CONCLUSION: Medical decision making in patients with diabetes type 2 is only marginally influenced by patients' and physicians' characteristics under study.

[Distances to hospitals performing minimum volume relevant procedures in Germany 2004 to 2006]. / Distanzen zu Krankenhäusern mit Mindestmengen-relevanten Eingriffen 2004 bis 2006.

INTRODUCTION: In 2004, Germany introduced annual minimum volumes nationwide on five surgical procedures (kidney, liver, stem cell transplantation, complex oesophageal, and pancreatic interventions). In 2006, minimum volumes for total knee prosthesis were added and the five established minimum volumes were almost doubled. Since minimum volumes usually result in the regionalisation of procedures, especially patients from rural areas are impeded by geographical access problems. The aim of our study was to analyse regional and time-related differences in the distances patients travelled to hospitals performing minimum volume relevant procedures between 2004 and 2006 in Germany. METHODS: We performed a secondary analysis of data from the Institute for the Hospital Remuneration System (InEK). Using a geographical information system we analysed the distances that patients who underwent one of the six minimum volume procedures travelled to the hospital in the years 2004-2006. We performed t-tests to analyse differences between the 16 German Federal States and the years of observation while correcting for multiple testing. RESULTS: On average patients travelled between 28.6/28.0 km (2004/2006) for knee prosthesis and 78.9 km for stem cell transplantation (2004) and 97.4 km for liver transplantation (2006). In 2004, distances travelled differed up to a factor of 9.9 [comparing distances travelled to stem cell transplantation of patients of the states of Berlin (30.6 km) and Hamburg (303 km)]. In 2006, the maximum difference (factor 12.2) was observed for oesophageal interventions comparing distances travelled in the states of Bremen (7.2 km) and Saarland (88.8 km). For almost all comparisons there were significant differences of the minimum and maximum distances travelled in one of the Federal States compared to the federal average. Comparing distances travelled in 2004 and 2006 we found only small and inconsistent variations. DISCUSSION: We found that geographical access to inpatient care for minimum volume procedures in Germany differs sizably between the Federal States in 2004 and 2006. In spite of doubling the minimum volumes in 2006, the distances patients travelled to hospitals hardly change. This may be caused by an inert implementation of the minimum volume regulation leading to an unchanged number of hospitals providing the respective procedures.

[Public reporting--forms and effects]. / Public Reporting -Formen und Effekte öffentlicher Qualitätsberichterstattung.

Since 2004 hospitals in Germany publish structured report cards bi-yearly. Content and scope of these mandatory public reports are still under discussion. Therefore we provide an up to date overview on forms and effects of public reports. By enabling transparency, comparative reports on the quality of health care aim at supporting patients to choose better performing health care providers and motivating health care providers to enhance quality improvement activities. Internationally existing public reports range from reports on national health systems on the whole to reports on the quality of particular procedures of individual health care providers. Contrary to the multitude of public reports, the evidence on the effects of public reporting remains scant. The few existing studies show that hospitals react on the public reports by some quality improvements. However, regarding the selection of providers and the quality of care they only show inconsistent effects of public reporting. Moreover, unsolved methodical problems of pubic reporting and potentially unintended consequences have to be considered. Therefore the question remains whether the expected effects in terms of quality improvements outbalance the unintended consequences in the long run and if the investments in public reporting will be paid off.

[Guideline for the Early Detection of Breast Cancer in Germany 2008. Recommendations from the short version]. / Stufe-3-Leitlinie Brustkrebs-Früherkennung in Deutschland 2008 : Auszug aus der Kurzfassung: Handlungsempfehlungen.

The updated 2008 German Guideline for Early Detection of Breast Cancer provides evidence-based and consensus-based recommendations of the knowledge gained by the German Society for Surgery and the German Society of Plastic, Aesthetic, and Reconstructive Surgeons together with 29 professional societies, associations, and nonmedical organizations. The guideline is meant to assist physicians, healthy women, and patients in medical decisions with recommendations regarding the diagnostic chain in early detection of breast cancer. In addition to these recommendations, the guideline also includes descriptions of quality assurance for resources, procedures, outcomes, and evaluation using a set of quality indicators. It updates the previous version from 2003. The guideline's recommendations are presented. They are described in detail in the full publication (in German) Geburtsh Frauenh 2008; 68:251-261. The long version of the Guideline, methods report, and evidence report are available on the internet at www.awmf-leitlinien.de (reg. no. 077/001) with free access.

[Hospitals failing minimum volumes in 2004: reasons and consequences]. / Unterschreitungen der Mindestmengen 2004: Begründungen und Konsequenzen.

BACKGROUND: In 2004 Germany introduced annual minimum volumes nationwide on five surgical procedures: kidney, liver, stem cell transplantation, complex oesophageal, and pancreatic interventions. Hospitals that fail to reach the minimum volumes are no longer allowed to perform the respective procedures unless they raise one of eight legally accepted exceptions. The goal of our study was to investigate how many hospitals fell short of the minimum volumes in 2004, whether and how this was justified, and whether hospitals that failed the requirements experienced any consequences. METHOD: We analysed data on meeting the minimum volume requirements in 2004 that all German hospitals were obliged to publish as part of their biannual structured quality reports. We performed telephone interviews: a) with all hospitals not achieving the minimum volumes for complex oesophageal, and pancreatic interventions, and b) with the national umbrella organisations of all German sickness funds. RESULTS: In 2004, one quarter of all German acute care hospitals (N=485) performed 23,128 procedures where minimum volumes applied. 197 hospitals (41%) did not meet at least one of the minimum volumes. These hospitals performed N=715 procedures (3.1%) where the minimum volumes were not met. In 43% of these cases the hospitals raised legally accepted exceptions. In 33% of the cases the hospitals argued using reasons that were not legally acknowledged. 69% of those hospitals that failed to achieve the minimum volumes for complex oesophageal and pancreatic interventions did not experience any consequences from the sickness funds. However, one third of those hospitals reported that the sickness funds addressed the issue and partially announced consequences for the future. The sickness funds' umbrella organisations stated that there were only sparse activities related to the minimum volumes and that neither uniform registrations nor uniform proceedings in case of infringements of the standards had been agreed upon. DISCUSSION: In spite of the high number of hospitals that failed to achieve the minimum volumes in 2004, only few hospitals experienced consequences from the sickness funds. The reluctance of the payers may be explained, amongst others, by the small number of patients affected and the percentage of cases where legally accepted exceptions applied. In view of the partly unclear definitions of the exceptions and difficulties in the interpretation and execution of the minimum volumes in the hospitals and at the sickness fund level, it may be helpful to formulate more concrete instructions for the implementation of the standards.

[Influence of minimum volumes on the structure of inpatient care]. / Auswirkung der Mindestmengenvereinbarung auf die stationäre Versorgungsstruktur.

OBJECTIVE: In 2004 five minimum volumes were introduced for the first time into German hospitals. The structural effects of these minimum volumes are presented as the first part of a health service research to evaluate the minimum volume regulation. DESIGN/METHODOLOGY/METHODS: The investigation is based on the mandatory hospital quality reports for 2004. Data were extracted from 1710 quality reports, descriptively analysed and applied to the modified minimum volumes for 2006. RESULTS: In 2004, 485 out of 1710 German hospitals providing acute care and approximately 23,128 cases, i.e., 0.14% of all hospital cases, were affected by at least one minimum volume regulation. The number of affected hospitals varies considerably between the German Federal Sates with 16% in Bavaria and 75% in Bremen. In 2004 (and presumably 2006) the following hospital numbers will comply with the minimum volume regulation: liver transplantation 100% (63%), kidney transplantation 91% (84%), stem cell transplantation 84% (65%), complex oesophageal interventions 71% (40%), complex pancreatic interventions 82% (51%). On a case level, 4% of kidney transplantation cases and up to 22% of complex oesophageal interventions were to be redistributed. Viewing the hospital size by number of beds, smaller (100-300 beds) and medium size hospitals (300-600 beds) are affected in complex oesophageal and pancreatic interventions, whereas in transplantations medium and large hospitals (>600 beds) are affected. Considering the regional distribution on a district level, the number of districts with at least one hospital providing the respective service will decrease from 2004 to 2006, with the strongest reduction in complex oesophageal interventions from 172 to 82 districts (-53%). CONCLUSION: In 2004 the minimum volume regulation has moderate structural effects on the care setting. In 2006 these effects will be stronger due to the doubled number of interventions required for most of the minimum volumes. The effects on transplantations have to be differentiated from those on oesophageal and pancreatic interventions since the former are already highly centralised whereas the latter are mainly provided on a medium hospital care level and will be shifted on to the maximum hospital care level. This process should stimulate a debate on geographically equal access to care within and among the Federal Sates.

[Development of the quality of surgical gynaecological care in the State of Hesse, Germany under external quality assurance]. / Entwicklung der operativ-gynäkologischen Versorgungsqualität in Hessen unter externer Qualitätssicherung.

UNLABELLED: BACKGROUND AND RESEARCH GOAL: All German hospitals have to participate by law in comparative performance assessment, so called external quality assurance (QA). However, there is only limited research showing a positive impact of such state- and nationwide QA programmes. This article analyses whether the quality of surgical gynaecological care in Hessian hospitals changed after receiving regular feedback on the quality of care between 1998 to 2002. METHODS: Secondary data analysis of data from all hospitals with gynaecological services in Hesse (n = 84) was performed. The requirement of a constant caseload and continuous data supply reduced cases from 218,217 to 148,549. Considering twelve quality indicators we recalculated the performance of all Hessian hospitals for each quarter during 1998 and 2002. Changes over time were analysed by using rank correlation coefficients and considering multiple testing. RESULTS: Two indicators (antibiotic prophylaxis in breast surgeries and hysterectomies) showed a significant quality improvement over time. Six indicators (post-operative infections, inappropriate removals of cyst of ovaries, hormone receptor analysis and x-ray of tumour in breast cancer, ovary-preserving procedures for benign tumours and heparin prophylaxis) demonstrated a slight quality improvement and another four indicators (unplanned revision of operation, organ injuries, adjuvant therapy and breast-preserving surgery in breast cancer) tended towards reduced quality. CONCLUSION: During 1998-2002, we observed only marginal improvements in the quality of care. The expected significant improvement of all quality indicators, based on external QA and comparative performance reporting of all Hessian gynaecological hospitals did not eventuate.

[Health services research in surgery: the example of breast cancer surgery]. / Versorgungsforschung in der operativen Medizin am Beispiel der Mammakarzinomchirurgie.

The epidemiological relevance of breast cancer in Germany has led to a number of initiatives actually changing the processes and structures of care. The ultimate aim of health services research in surgery is to evaluate the impact of these initiatives on the effectiveness and efficiency of the respective health care services. Results of international studies show for instance breast-conserving therapy to be related to the patients' socioeconomic status. In addition, breast specialists tend to operate more in adherence to practice guidelines and to implement new procedures like sentinel lymph node biopsies earlier. Preliminary results from Germany also demonstrate a considerable practice variation in breast cancer surgery. Causes and effects of such variation still have to be explored. For that purpose, newly available data sources on health care services in relation to breast cancer surgery in Germany could be used. The inherent challenge is to combine data from tumour registries, statutory comparative quality assurance activities and inpatient remuneration via DRGs for health services research in surgery.

[Accessibility of doctors' surgeries in Essen, Germany]. / Barrierefreiheit von Arztpraxen am Beispiel Essen.

BACKGROUND: Constructional barriers often prevent persons who are only partially able, for example those requiring a wheel chair for pre-ambulation, from entering buildings where doctors practise. Even though many international and national resolutions have long been demanding free access to the environment for the partially able, this has not been specially prescribed in Germany. Hence, no one knows anything about outpatient health care facilities in this regard. The present study aimed at analysing accessibility to orthopaedic and neurological practices and surgeries for wheelchair patients. METHOD: We chose Essen, the sixth largest town in Germany, as an example of an urban area, where orthopaedists and neurologists are frequently accessed by wheelchair patients. We performed on-site investigations of the exterior and interior zones of all orthopaedic and neurological surgery buildings in Essen (each n = 29). Criteria for our descriptive analysis were parking lots for the handicapped, shunting areas, entrances at-grade, steps/stories, banisters, ramps, bells and openers of front, elevator and surgery doors, their opening and width. Following the criteria of the DIN 18 024 standard part 2 ("accessibility") the surgeries were divided into four groups 1) fully accessible; 2) slight barriers; 3) considerable barriers; 4) massive barriers. RESULTS: None of the 58 investigated surgeries was fully accessible, 21 of the 29 surgeries of each medical specialty had massive barriers, so that wheelchair patients could access these surgeries only with the help of at least two (strong) persons. Six of the 29 orthopaedic and three of the 29 neurological surgeries had slight barriers, whereas two orthopaedic and five neurological surgeries had distinct barriers. Main barriers were steps in the entrance area; front, elevator or surgery doors too narrow (width less than 80 cm), and elevators too small. DISCUSSION: For wheelchair patients in Germany, free choice of doctors seems to be massively reduced. Since 80 % of orthopaedic and 90 % of neurological surgeries in Essen do not fulfil the quality feature "constructional accessibility", measures that have been taken in the past to help partially able persons to participate in this respective aspect of social life have not been effective. New measures to improve the present situation should be agreed upon by all the institutions involved (politics, local authorities/construction supervision, sickness funds, doctors and associations of sickness fund physicians, and concerned persons). If voluntary measures do not lead to free choice of doctors for wheelchair patients, further legal regulations appear to be mandatory.

[Current research perspectives of health system research and health economics in Germany]. / Aktuelle Forschungsperspektiven von Gesundheitssystemforschung und Gesundheitsökonomie in Deutschland.

The German statutory health insurance scheme is confronted with a steadily rapid progress of medical sciences and increasing difficulties to mobilize the financial resources necessary for applying the new scientific knowledge in health care. Therefore it is absolutely imperative to intensify the efforts to improve the effectiveness and efficiency of health care. Health policies based on health targets, the development of patterns requiring integrated care, redefining the bunch of health insurance benefits, and a more regular use of methods of economic evaluation have been proposed as promising approaches towards optimizing resource allocation in health care. However, an analysis of these approaches demonstrates that a valid appraisal of their potential to improve the effectiveness and efficiency of health care requires further research. In addition, European integration may produce tendencies towards a convergence of the national health care systems; this makes it rather difficult to assess how the room for autonomous national health policies will develop in the future.

Germany's long-term-care insurance: putting a social insurance model into practice.

A growing population of elderly has intensified the demand for long-term care (LTC) services. In response to the mounting need, Germany put into effect a LTC Insurance Act in 1995 that introduced mandatory public or private LTC insurance for the entire population of 82 million. The program was based on the organizational principles that define the German social insurance system. Those individuals in the public system and their employers each pay contributions equal to 0.85 percent of each employee's gross wages or salary. Ten percent of the population with the highest incomes have chosen the option of purchasing private long term care insurance. Provisions were made for uniform eligibility criteria, benefits based on level of care needs, cost containment, and quality assurance. Over the first four years of its operation, the system has proved financially sound and has expanded access to organized LTC services. The German system thus may serve as an example for other countries that are planning to initiate social LTC insurance systems in other nations.

[Do we really want managed care?]. / Wollen wir wirklich Managed Care?

In spite of the mounting criticism levelled at Managed Care, it is still being discussed in Germany as a promising concept expected to improve both the quality as well as the cost effectiveness of health care. However, this discussion focuses largely on the theoretical advantages of Managed Care in comparison with the German health care system. To examine whether these advantages of Managed Care are actually realised once the concept is broadly implemented, we analysed the contemporary effects of managed care on patients and physicians in the US. This revealed that while Managed Care has for the time being slowed the rise in health services expenditures, major shortcomings of the concept are evident: Patients express a loss of trust in the health care system and complain about decreased choice, poor continuity of care, and persistent high personal health care cost. Physicians complain about increasing financial risks imposed on them, about curtailed therapeutic freedom, and generally the way they must now conduct their medical practice. Law-makers, in turn, react to the defects of the Managed Care industry by imposing increasing external controls and regulations. All in all, Managed Care as implemented by many of the US systems does not appear to fulfill the positive expectations of the two principal stakeholders--patients and physicians. Instead, a large number of side effects are in evidence that appear to make a transfer of the American concept to the German health care system far from desirable.

[Quality assurance measures in surgical gynecology. Program development and routine introduction in Hessia]. / Die Qualittssicherungsmassnahme in der operativen Gynäkologie. Programmentwicklung und Routine-Einführung in Hessen.

Frequently, quality assurance measures fail during application in routine practice despite showing very promising results in the developmental stage. Using the project 'Quality assurance in gynecological surgery' as an example which has made the leap into routine practice, we describe the development of a successful quality assurance measure. We name some of the elements which have proved to be crucial for the assumption of a new quality assurance measure. First of all, decisive was the development of the measure by renowned experts of the scientific medical society together with methodologists. All current professional and legal demands on medical quality assurance were included as were methodological knowledge for the optimal formation of such a measure. The evaluation of the measure on approximately 50,000 gynecological surgical procedures showed that the new quality assurance measure is suitable in gynecological surgery as an instrument both for making transparent the quality of health care delivery as well as for supporting comprehensive internal and external assessments of performance, outcomes, and processes of care and comparisons with the "best" care provider ("benchmarking"). Secondly, a favorable point in time--here the introduction of a diagnosis related payment system--and the early and close cooperation on the part of the program developers with political decision-makers helped to ensure that the newly developed quality assurance measure in gynecological surgery was accepted for routine practice.