Managing work-family conflict in the medical profession: working conditions and individual resources as related factors.

OBJECTIVES: This study developed and tested a research model that examined the effects of working conditions and individual resources on work-family conflict (WFC) using data collected from physicians working at German clinics. MATERIAL AND METHODS: This is a cross-sectional study of 727 physicians working in German hospitals. The work environment, WFC and individual resources were measured by the Copenhagen Psychosocial Questionnaire, the WFC Scale, the Brief Resilient Coping Scale and the Questionnaire for Self-efficacy, Optimism and Pessimism. Descriptive, correlation and linear regression analyses were applied. RESULTS: Clinical doctors working in German hospitals perceived high levels of WFC (mean=76). Sociodemographic differences were found for age, marital status and presence of children with regard to WFC. No significant gender differences were found. WFCs were positively related to high workloads and quantitative job demands. Job resources (eg, influence at work, social support) and personal resources (eg, resilient coping behaviour and self-efficacy) were negatively associated with physicians' WFCs. Interaction terms suggest that job and personal resources buffer the effects of job demands on WFC. CONCLUSIONS: In this study, WFC was prevalent among German clinicians. Factors of work organisation as well as factors of interpersonal relations at work were identified as significant predictors for WFC. Our results give a strong indication that both individual and organisational factors are related to WFC. Results may play an important role in optimising clinical care. Practical implications for physicians' career planning and recommendations for future research are discussed.

Exploring the impact of resilience, self-efficacy, optimism and organizational resources on work engagement.

BACKGROUND: The German health care system has undergone radical changes in the last decades. These days health care professionals have to face economic demands, high performance pressure as well as high expectations from patients. To ensure high quality medicine and care, highly intrinsic motivated and work engaged health care professionals are strongly needed. OBJECTIVE: The aim of this study was to examine relations between personal and organizational resources as essential predictors for work engagement of German health care professionals. METHODS: This investigation has a cross-sectional questionnaire study design. Participants were a sample of hospital doctors. Personal strengths, working conditions and work engagement were measured by using the SWOPE-K9, COPE Brief Questionnaire, Perceived Stress Questionnaire, COPSOQ and Utrecht Work Engagement Scale. RESULTS: Significant relations between physicians' personal strengths (e.g. resilience, optimism) and work engagement were evaluated. Work related factors showed to have a significant influence on work engagement. Differences in work engagement were also found with regard to socio-demographic variables. CONCLUSION: Results demonstrated important relationships between personal and organizational resources and work engagement. Health care management needs to use this information to maintain or develop work engaging job conditions in hospitals as one key factor to ensure quality health care service.

The trade-off between costs and quality of care in the treatment of psychosomatic patients with somatoform pain disorder.

BACKGROUND: The introduction of efficiency-oriented provider payment systems in inpatient mental healthcare in various Western countries may lead to the use of less healthcare resources in the treatment of patients. To avoid unintended effects on quality of care that may result from reductions in resource utilization, it is essential for decision and policy makers to know whether there is a trade-off between costs and quality of care. AIM OF THE STUDY: The aim of this study was to investigate and quantify the relationship between costs and outcomes in psychosomatic inpatients with somatoform pain disorder. METHODS: The inclusion criteria for patient selection (n = 101) were (i) a main diagnosis of somatoform pain disorder according to International Classification of Diseases-10 (ICD-10) [F45.4, F45.40, F45.41]; (ii) complete data on the mental component summary reflecting overall functioning of mental health (MCS-8) measured with the Short Form-8 Health Survey (SF-8) within 3 days of the admission and discharge dates; and (iii) treatment at Charité Universitaetsmedizin (Berlin, Germany) during the period January 2006-June 2010. The change in the MCS-8 score incurred over the treatment period was used as an indicator of quality of care. Treatment costs were calculated from the provider's perspective, mainly using bottom-up micro-costing. The year of valuation for cost calculation was 2008 (with no inflation adjustment); for costs provided by the accounting department for services consumed by the patient, the valuation year was based on the year of service provision. We hypothesized that the outcome 'change in MCS-8 score' was a function of the independent variable costs, patient characteristics, socio-demographic variables, pain-related variables, co-morbidities and subjective illness attribution, i.e. whether patients attributed the origin of pain mainly to a somatic cause or not. An interaction term between costs and illness attribution was included to control for the hypothesized differing effects of resource input or costs on the outcome variable conditional on patients' illness attribution. Hausman tests indicated that endogeneity was not present, thus, ordinary least squares regression (OLS) was conducted. We assessed whether the change in the MCS-8 score was clinically meaningful and perceptible by the patient, using the minimal clinical important difference (MCID). For Short Form Health Surveys, the MCID for changes in the mental component summary is typically around 3 points. RESULTS: We found a trade-off between costs and outcome for patients without or with only minor somatic illness attribution (77 % of the sample). This patient group improved 0.4 points in outcome after every 100 increase in total costs per case (F 1,77 = 13.836, t(77) = 3.72, p = 0.0004). For patients with mainly somatic illness beliefs (23 % of the sample), we did not find a trade-off between costs and outcome. CONCLUSION: For the majority of patients, we found a trade-off between costs and health outcome, thus, it seems advisable to carefully monitor outcome parameters when applying cost containment measures.

Introduction of DRG-based reimbursement in inpatient psychosomatics--an examination of cost homogeneity and cost predictors in the treatment of patients with eating disorders.

OBJECTIVE: Various western countries are focusing on the introduction of reimbursement based on diagnosis-related groups (DRG) in inpatient mental health. The aim of this study was to analyze if psychosomatic inpatients treated for eating disorders could be reimbursed by a common per diem rate. METHODS: Inclusion criteria for patient selection (n=256) were (1) a main diagnosis of anorexia nervosa (AN), bulimia nervosa (BN) or eating disorder-related obesity (OB), (2) minimum length of hospital stay of 2 days, (3) and treatment at Charité Universitaetsmedizin Berlin, Germany during the years 2006-2009. Cost calculation was executed from the hospital's perspective, mainly using micro-costing. Generalized linear models with Gamma error distribution and log link function were estimated with per diem costs as dependent variable, clinical and patient variables as well as treatment year as independent variables. RESULTS: Mean costs/case for AN amounted to 5,251€, 95% CI [4407-6095], for BN to 3,265€, 95% CI [2921-3610] and for OB to 3,722€, 95% CI [4407-6095]. Mean costs/day over all patients amounted to 208€, 95% CI [198-218]. The diagnosis AN predicted higher costs in comparison to OB (p=.0009). A co-morbid personality disorder (p=.0442), every one-unit increase in BMI in OB patients (p=.0256), every one-unit decrease in BMI in AN patients (p=.0002) and every additional life year in BN patients (p=.0455) predicted increased costs. CONCLUSION: We see a need for refinements to take into account considerable variations in treatment costs between patients with eating disorders due to diagnosis, BMI, co-morbid personality disorder and age.

Inpatient costs and predictors of costs in the psychosomatic treatment of anorexia nervosa.

OBJECTIVE: In German inpatient psychosomatics per diem lump sums will be introduced as reimbursement rates by 2013. It was the aim to calculate total inpatient costs per case for the psychosomatic treatment of patients with anorexia nervosa and to identify cost predictors. METHOD: The sample comprised of 127 inpatients. Cost calculation was executed from the hospital's perspective, mainly using microcosting. Medical records provided data on patient characteristics and individual resource use. Two generalized linear models with gamma distribution and log link function were estimated to determine cost predictors by means of demographic data, comorbidities, and body-mass-index at admission. RESULTS: Inpatient costs amounted to 4,647 €/6,831 US$ per case (standard deviation 3,714 €/5,460 US$).The admission BMI and "Disorders of Adult Personality and Behavior" were significant cost predictors (p < 0.05). DISCUSSION: The formation of patient groups within the diagnosis anorexia nervosa should be oriented towards the determined cost predictors.

[DRGs and daily rates of pay in psychosomatics: 2002-2005]. / DRGs und Pflegesätze in der Psychosomatik: 2002-2005.

OBJECTIVES: Over the last years the use of diagnosis-related groups (G-DRG) was introduced into most areas of the German health care system, which led to changed compensation for departments outside the G-DRG system as well. We evaluated the development of revenues in 17 different psychosomatic departments over the last three years. METHODS: Our analyses were based on official daily rates for each of the clinics included. If daily rates changed within one year, we used the average daily rate for that year. RESULTS: Together all departments provided 547 in-patient beds for the treatment of acute psychosomatic patients. With 85% occupancy all departments would achieve a revenue of 62.5 million euro in 2005, two million euro less than three years previously. Due to the introduction of the German DRG system their average income was reduced by approx. 3%. The loss was greater for psychosomatic departments at larger hospitals, which have a higher percentage of departments included in the G-DRG system. CONCLUSIONS: The introduction of the G-DRG system leads to reduced revenues for departments outside the G-DRG system, while performance was expected to remain at the same level and costs have increased. Thus, to ensure the spectrum of psychosomatic medicine as it is today, it has become increasingly important to demonstrate the real costs of treatment to political decision makers.

[Evaluation of the effectiveness of psychosomatic in-patient treatment on the basis of subjective and objective criteria]. / Evaluation stationärer psychosomatischer Behandlung anhand subjektiver und objektiver Kriterien.

OBJECTIVES: The effectiveness of psychosomatic in-patient treatment was evaluated using patients' subjective health ratings and objective data provided by health insurance companies. Associations between subjective and objective criteria were investigated. METHODS: 318 patients participated in the study. They completed questionnaires on physical complaints, moods and everyday functioning upon hospital admission, at discharge and at one-year follow-up. Insurance companies provided data for 140 of these patients (44 %). Sick leave and the utilization of in-patient treatment were assessed for a period of two years before and two years after psychosomatic treatment. RESULTS: As expected, subjective health status improved. The utilization of in-patient treatment decreased in both years after treatment compared to the year before. Sick leave increased in the first year after treatment but decreased significantly below the base level in the second year after treatment. Self-efficacy expectations and being employed were found to be predictors for long-term reduction in the length of in-patient treatment. Subjective and objective criteria were only slightly correlated. CONCLUSIONS: Sick leave and utilization of in-patient treatment were found to increase considerably in the year before psychosomatic treatment. Therefore, pre-post differences over the entire period were only marginal. The change in subjective criteria was more immediate, while changes in some objective parameters were delayed. Both subjective and objective criteria should be included in outcome studies.