Agreement between self-reports and statutory health insurance claims data on healthcare utilization in patients with mental disorders.

BACKGROUND: Data on resource use are frequently required for healthcare assessments. Studies on healthcare utilization (HCU) in individuals with mental disorders have analyzed both self-reports and administrative data. Source of data may affect the quality of analysis and compromise the accuracy of results. We sought to ascertain the degree of agreement between self-reports and statutory health insurance (SHI) fund claims data from patients with mental disorders. METHODS: Claims data from six German SHI and self-reports were obtained along with a cost-effectiveness analysis performed as a part of a controlled prospective multicenter cohort study conducted in 18 psychiatric hospitals in Germany (PsychCare), including patients with pre-defined psychiatric disorders. Self-reports were collected using the German adaption of the Client Sociodemographic and Service Receipt Inventory (CSSRI) questionnaire with a 6-month recall period. Data linkage was performed using a unique pseudonymized identifier. Missing responses were coded as non-use for all analyses. HCU was calculated for inpatient and outpatient care, day-care services, home treatment, and pharmaceuticals. Concordance was measured using Cohen's Kappa (κ) and intraclass correlation coefficient (ICC). Regression approaches were used to investigate the effect of independent variables on the agreements. RESULTS: In total 274 participants (mean age 47.8 [SD = 14.2] years; 47.08% women) were included in the analysis. No significant differences were observed between the linked and unlinked patients in terms of baseline characteristics. Total agreements values were 63.9% (κ = 0.03; PABAK = 0.28) for outpatient contacts, 69.3% (κ = 0.25; PABAK = 0.39) for medication use, 81.0% (κ = 0.56; PABAK = 0.62) for inpatient days and 86.1% (κ = 0.67; PABAK = 0.72) for day-care services. There was varied quantitative agreement between data sources, with the poorest agreement for outpatient care (ICC [95% CI] = 0.22 [0.10-0.33]) and the best for psychiatric day-care services (ICC [95% CI] = 0.72 [0.66-0.78]). Marital status and time since first treatment positively affected the chance of agreement on utilization of outpatient services. CONCLUSIONS: Although there were high levels of absolute agreement, the measures of concordance between administrative records and self-reports were generally minimal to moderate. Healthcare investigations should consider using linked or at least different data sources to estimate HCU for specific utilization areas, where unbiased information can be expected. TRIAL REGISTRATION: This study was part of the multi-center controlled PsychCare trial (German Clinical Trials Register No. DRKS00022535; Date of registration: 2020-10-02).

Evaluation of a flexible and integrative psychiatric care model in a department of child and adolescent psychiatry in Tübingen, Germany: study protocol (EVA_TIBAS).

BACKGROUND: Model projects for flexible and integrated treatment (FIT) in Germany aim at advancing the quality of care for people with mental disorders. A new FIT model project was established in 2017 at the Department of child and adolescent psychiatry (KJP) of the University Hospital Tübingen (Universitätsklinikum Tübingen, UKT). The study design of EVA_TIBAS presented here describes the evaluation of the FIT model project at the KJP of the UKT. This evaluation aims at quantifying the anticipated FIT model project changes, which are to improve patients' cross-sectoral care at the same maximum cost as standard care. METHODS: EVA_TIBAS is a controlled cohort study using a mix of quantitative and qualitative methods. The FIT evaluation consists of three modules. In Module A, anonymized claims data of a statutory health insurance fund will be used to compare outcomes (duration of inpatient and day care psychiatric treatment, inpatient and day care psychiatric length of stay, outpatient psychiatric treatment in hospital, inpatient hospital readmission, emergency admission rate, direct medical costs) of patients treated in the model hospital with patients treated in structurally comparable control hospitals (estimated sample size = ca. 600 patients). In Module B, patient-reported outcomes (health related quality of life, symptom burden, return to psychosocial relationships (e.g. school, friends, hobbies), treatment satisfaction, societal costs) will be assessed quantitatively using validated questionnaires for the model and two control hospitals (estimated sample size = ca. 300 patients). A subsequent health economic evaluation will be based on cost-effectiveness analyses from both the insurance fund's and the societal perspective. In Module C, about 30 semi-structured interviews will examine the quality of offer, effects and benefits of the service offered by the social service of the AOK Baden-Württemberg (for stabilizing the overall situation of care in the family) in the model hospital. A focus group discussion will address the quality of cooperation between employees of the university hospital and the social services. DISCUSSION: The results of this evaluation will be used to inform policy makers whether this FIT model project or aspects of it should be implemented into standard care. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov PRS (ID: NCT04727359 , date: 27 January 2021).

[Utility Analysis of Oncological Centre Building in the Field of Colorectal Cancer]. / Nutzenanalyse onkologischer Zentrenbildung im Bereich der Behandlung des kolorektalen Karzinoms.

BACKGROUND: In the field of colorectal cancer and other cancer entities, there is an ongoing trend to establish multidisciplinary treatment in specialised cancer centres. Little is known by now about the outcomes of this centralised and quality-driven treatment approach. In light of the increasing cost-benefit discussions, assessments of their impact seem to be necessary. This paper discusses positive effects of cancer centres with a particular focus on the multidisciplinary approach and its potential impact on survival outcomes of colorectal cancer patients. The study applies a Markov approach to assess the epidemiological impact of the cancer centre establishment and associated life years gained, both at a regional level and over time. MATERIALS AND METHODS: We conducted a systematic literature review to evaluate effects of multidisciplinary treatment in specialised cancer centres in the field of colorectal cancer. Applying the PRISMA scheme, 602 articles were assessed by title, abstract and full text. Finally, 10 publications met the inclusion criteria and were included in a meta-analysis. Using the example of the "Krebszentrum Nord" at the University Hospital in the federal state of Schleswig-Holstein, we assessed the impact of changes in survival rates at the regional level by simulating expected incidence, mortality and prevalence rates in a Markov model including detailed population data of Schleswig-Holstein. RESULTS: The meta-analysis revealed that multidisciplinary treatment in a cancer centre was associated with a 4.5 % reduction of mortality rates in colorectal cancer patients. The greatest benefits were found for patients in advanced disease stages. At the regional level, 106 life years could be gained through the centre for colorectal cancer until 2020, according to the assumptions of the simulation. CONCLUSION: The establishment of colorectal cancer centres is associated with positive outcomes for patients. However, the scarce evidence base underpins the need for additional studies to further examine the impact of centre building in colorectal cancer care. Cancer registries are a solid foundation for further research. Future requirements for oncological care can be derived from the predicted epidemiological development.

Deprivation as a fundamental cause of morbidity and reduced life expectancy: an observational study using German statutory health insurance data.

Across all developed countries, there is a steep life expectancy gradient with respect to deprivation. This paper provides a theoretical underpinning for this gradient in line with the Grossman model, indicating that deprivation affects morbidity and, consequently, life expectancy in three ways: directly from deprivation to morbidity, and indirectly through lower income and a trade-off between investments in health and social status. Using rich German claims data covering 6.3 million insured people over four years, this paper illustrates that deprivation increases morbidity and reduces life expectancy. It was estimated that highly deprived individuals had approximately two more chronic diseases and a life expectancy reduced by 15 years compared to the least deprived individuals. This mechanism of deprivation is identified as fundamental, as deprived people remain trapped in their social status, and this status results in health investment decisions that affect long-term morbidity. However, in the German setting, the income and investment paths of the effects of deprivation were of minor relevance due to the broad national coverage of its SHI system. The most important aspects of deprivation were direct effects on morbidity, which accumulate over the lifespan. In this respect, personal aspects, such as social status, were found to be three times more important than spatial aspects, such as area deprivation.

Versorgung geriatrischer Krankheitsbilder unter ausgewählten ambulanten Facharztgruppen: Kombination von Befragungs- und GKV-Routinedaten zur Abbildung des Leistungsgeschehens.

BACKGROUND: In light of an aging population, the German health system faces the challenge of adapting regional health care structures to the changing care needs of geriatric patients. Since geriatric care is interprofessional, a structural analysis of the service providers involved is required. Therefore, the aim of this study is to determine the primary and joint care responsibilities for geriatric patients with specific characteristics, to estimate the associated effort for selected outpatient medical service providers and to identify resulting care concentrations. METHODS: The analysis includes six selected specialist disciplines in the outpatient sector and is based on two databases: 1) A representative survey among outpatient physicians related to geriatric care (n = 400) to examine both the primary geriatric care needs that professionals treat regularly and aggravating geriatric morbidity. 2) A claims data analysis determines services and efforts for approximately 300,000 geriatric patients for every year from 2014 to 2018. For the specialists included in the analysis, care concentration was determined by association analysis comparing the care efforts of outpatient physicians for patients with different geriatric characteristics. RESULTS: General practitioners, in particular, serve as primary care providers for all geriatric characteristics; there is no concentration of care on specific patient groups. Concentrations associated with care efforts and joint care responsibilities for patients with certain geriatric characteristics are found among the more specialized physician groups. Across all professions, the physicians surveyed believe that geriatric-specific immobility, depression, anxiety disorders and cognitive deficits make the provision of care more difficult. DISCUSSION: The results contribute to the understanding of primary and interdisciplinary care responsibilities of outpatient physicians related to the treatment of geriatric conditions and can thus represent an important basis for the structural planning of geriatric care. Nevertheless, it should be noted that within the scope of the analysis presented, only general practitioners and five specialist disciplines could be taken into account. Therefore, the considerations primarily allow initial conclusions about the care responsibility of outpatient physicians with regard to geriatric morbidity. To enable comprehensive structural planning, however, the analyses would have to be expanded to include all specialists involved in geriatric care. CONCLUSION: The joint care responsibility of outpatient physicians for specific geriatric patients underlines the relevance for interdisciplinary care models and the need for expansion of geriatric expertise in the outpatient sector. In view of the ageing population and an increase in morbidity, the planning of care structures should be based on the needs of geriatric patients and the associated expenses incurred by the various health care providers.

Health-related quality of life among patients with treated alcohol use disorders, schizophreniform disorders or affective disorders and the influence of flexible and integrative psychiatric care models in Germany (PsychCare).

Introduction: Flexible and integrated treatment options (FIT) have been established in German psychiatric hospitals to enhance continuous and patient-centered treatment for patients with mental disorders. We hypothesized that patients with experience in FIT treatment showed higher health-related quality of life (HRQoL) and comparable symptom severity compared with patients treated as usual (TAU). Further, we expected that some sub-dimensions of HRQoL determined HRQoL results clearer than others, while certain factors influenced HRQoL and symptom severity stronger in the FIT compared to the TAU group. In addition, we hypothesized that HRQoL is correlated with symptom severity. Methods: We undertook a controlled, prospective, multicenter cohort study (PsychCare) conducted in 18 psychiatric hospitals in Germany, using the questionnaires Quality of Well Being Self-Administered (QWB-SA) (HRQoL) and Symptom-Checklist-K-9 (SCL-K-9) (symptom severity) at recruitment (measurement I) and 15 months later (measurement II). We assessed overall HRQoL (measured in health utility weights (HUW) and symptom severity score for patients from FIT and TAU treatment. We investigated the QWB-SA dimensions and separated the results by diagnosis. We used beta regressions to estimate the effect of multiple co-variates on both outcomes. To investigate the correlation between HRQoL and symptom severity, we used Pearson correlation. Results: During measurement I, 1,150 patients were recruited; while 359 patients participated during measurement II. FIT patients reported higher HUWs at measurement I compared to TAU patients (0.530 vs. 0.481, p = 0.003) and comparable HUWs at measurement II (0.581 vs. 0.586, p = 0.584). Symptom severity was comparable between both groups (I: 21.4 vs. 21.1, p = 0.936; II: 18.8 vs. 19.8, p = 0.122). We found lowest HRQoL and highest symptom severity in participants with affective disorders. HRQoL increased and symptom severity decreased over time in both groups. The QWB-SA dimension acute and chronic symptoms was associated with highest detriments in HRQoL. We identified risk/protective factors that were associated with lower quality of life and higher symptom severity in both groups. We confirmed that HRQoL was negatively associated with symptom severity. Discussion: Health-related quality of life (during hospital treatment) was higher among patients treated in FIT hospitals compared to patients in routine care, while symptom severity was comparable between both groups.

Assessing patients' acceptable and realised distances to determine accessibility standards for the size of catchment areas in outpatient care.

Healthcare planning aims to ensure availability of care in a needs-based, evenly distributed and locally available manner. However, many planning mechanisms lack accessibility standards. To determine standards, catchment areas must be derived from health-related travel assessments and a population's distance acceptance for different medical specialisation levels. We estimated distance acceptance using representative cross-sectional survey data (n = 1.598). Moreover, we used utilization data covering 88% of the German population (2014/15) to calculate realised travel distances for six medical specialties (n = 676.255.605 cases). We specified a gravity-based distance decay function and estimated regression-based distance thresholds from both samples. Realised distances were mostly below 30 min (90% of cases) indicating appropriate mean accessibility. The 5% observed distance threshold was between 23.7 min for GPs and 47.6 min for dermatologists. Depending on medical speciality, distance acceptance was mainly determined by distance, age, activity level and town size for GP visits and by health and income for specialist care. 5% acceptance thresholds varied between 27.9 min to GPs for elderly patients and 51.6 min to orthopaedists for younger patients. Acceptable distances for 90% of the population were 6 (8) minutes to GPs (specialists). The variation of thresholds, which depended on socio-demographic and health variables and the population share that is fully accepting, illustrates that healthcare planners should move beyond averages to realise equal access for equal need.

Multiperspective and Multimethod Evaluation of Flexible and Integrative Psychiatric Care Models in Germany: Study Protocol of a Prospective, Controlled Multicenter Observational Study (PsychCare).

Background: New cross-sectoral mental health care models have been initiated in Germany to overcome the fragmentation of the German health care system. Starting in 2013, flexible and integrative psychiatric care model projects according to §64b SGB V German Social Law (FIT64b) have been implemented. The study "PsychCare" combines quantitative and qualitative primary data with routine health insurance data for the evaluation of these models. Effects, costs and cost-effectiveness from the perspectives of patients, relatives and care providers are compared with standard care. Additionally, quality indicators for a modern, flexible and integrated care are developed. This article describes the rationale, design and methods of the project. Methods: "PsychCare" is built on a multiperspective and multimethod design. A controlled prospective multicenter cohort study is conducted with three data collection points (baseline assessment, follow-up after 9 and 15 months). A total of 18 hospitals (10 FIT64b model and 8 matched control hospitals) have consecutively recruited in- and outpatients with pre-specified common and/or severe psychiatric disorders. Primary endpoints are differences in change of health-related quality of life and treatment satisfaction. Sociodemographic and service receipt data of the primary data collection are linked with routine health insurance data. A cost-effectiveness analysis, a mixed method, participatory process evaluation by means of qualitative surveys and the development of quality indicators are further elements of "PsychCare." Discussion and Practical Implications: The results based on data from different methodological approaches will provide essential conclusions for the improvement of hospital based mental health care in Germany. This should result in the identification of key FIT64b elements that can be efficiently implemented into standard care in Germany and re-structure the care strongly aligned to patient needs. Clinical Trial Registration: German Clinical Trial Register, identifier DRKS 00022535.

Economic impact of disease prevention in a morbidity-based financing system: does prevention pay off for a statutory health insurance fund in Germany?

Preventable chronic diseases account for the greatest burden in the German health system and statutory health insurance (SHI) funds play a crucial role in implementing and financing prevention strategies. On the contrary, the morbidity-based scheme to distribute financial resources from the Central Reallocation Pool among the different sickness funds may counteract efforts of effective prevention from an economic perspective. We assessed financial impacts of prevention from a sickness funds perspective in a retrospective controlled study. Claims data of 6,247,275 persons were analyzed and outcomes between two propensity-matched groups (n = 852,048) of prevention users and non-users were compared in a 4-year follow-up. Using a difference-in-differences approach, we analyzed healthcare expenditures, the development of morbidity, financial transfers from the Central Reallocation Pool, and contribution margins. The group of prevention users develops less morbidity (incidences and disease aggravations) compared to the control group. Healthcare expenditures increase in both groups within 4 years, whereas the increase is lower for prevention users compared to non-users (€568.04 vs. €640.60, p < 0.0001). Taking morbidity-based financial transfers into account, the decrease in contribution margins is stronger for prevention users (- €188.44 vs. - €138.73, p < 0.0001). This study demonstrates an economic disincentive from a sickness funds' perspective. In the semi-competitive SHI market, sickness funds will be discouraged from effective prevention strategies if investments are not worth it financially. Their efforts and knowledge are, however, crucial for joint action to foster prevention over cure in the health system.

Rural - urban differences in determinants of patient satisfaction with primary care.

In light of the rising regional inequalities in primary care provider supply, to ensure equitable access is a pressing issue in health policy. Most policy approaches fall short in considering the patient perspective when defining shortage areas. As a consequence, implementations of new service delivery models might fail to be responsive to patients' expectations. To explore regional differences in the relative importance of structure and process attributes as drivers of patient satisfaction with local primary care, we collected data from residents of three objectively well-supplied urban and six objectively worse-supplied rural areas in Germany and tested a multi-group structural equation model. The results suggest that the relative importance of care attributes is different among the regional conditions rural and urban. Regardless of regional constraints, the strongest determinants of satisfaction are not related to structural aspects but are concerned with the quality of the doctor-patient relationship. A lack of available choices and a higher tolerance in terms of distances provide possible explanations for the results. The high importance rural residents attribute to the interpersonal relation should not be neglected in the re-organization of traditional service delivery in rural areas.

German claims data analysis to assess impact of different intraocular lenses on posterior capsule opacification and related healthcare costs.

AIM: Cataract extraction is one of the most frequent surgeries in Germany. In most cases, the clouded natural lens is replaced by a hydrophobic or hydrophilic acrylic intraocular lens (IOL) implant. The most common long-term complication after cataract surgery is the development of a posterior capsule opacification (PCO). Although no precise real world data are available, published evidence suggests a lower risk for PCO development for hydrophobic acrylic IOLs compared to hydrophilic acrylic IOLs. Therefore, in the present study we assessed real world data on the impact of different IOL material types on the incidence of post-operative PCO treatment. SUBJECT AND METHODS: In this retrospective study, we included 3,025 patients who underwent cataract extraction and implantation of either an acrylic hydrophobic or hydrophilic IOL in 2010. We assessed clinical outcomes and direct costs in a 4-year follow-up period after cataract surgery from a statutory health insurance (SHI) perspective in Germany. RESULTS: PCO that required capsulotomies occurred significantly (p < 0.0001) less frequent in patients who had received a hydrophobic IOL (31.57% of 2,078 patients) compared to the group with hydrophilic IOL implants (56.6% of 947 patients) and costs per patient for postoperative treatment in a 4-year follow-up were 50.03 € vs. 87.81 € (i.e. 75% higher in the latter group, p < 0.0001). CONCLUSION: Considering the high prevalence of cataract, the economic burden associated with adverse effects of cataract extraction is of great relevance for the German SHI. Hydrophobic lenses seem to be superior regarding both medical and economic results.

Understanding shortages of sufficient health care in rural areas.

BACKGROUND AND PURPOSE: Despite efforts to provide comprehensive health care services and reduce inequalities, most developed countries face serious challenges in achieving comprehensive health care delivery in rural areas. The purpose of this study is to characterize health care shortages in the rural areas of developed countries and to comprehensively explore the underlying reasons for these shortages. METHODS AND SAMPLE: To answer the research questions, we conducted a systematic literature review. The content analysis included 176 papers on the topic of rural health care. The thematic-analysis approach revealed key aspects of health care shortages in rural areas and evidence regarding the reasons for these shortages. FINDINGS AND CONCLUSION: Shortages of sufficient health care in rural areas were clustered into the following five categories: provider shortages, maldistribution, quality deficiencies, access limitations and the inefficient utilization of health care services. The reasons for the occurrence of these shortage problems are manifold and are related to physical/infrastructural, professional, educational, social-cultural, economic and political issues. This paper contributes to a comprehensive understanding of the health care problems in rural areas by creating an integrated framework that examines several aspects of shortages in sufficient health care in rural areas as well as their underlying reasons. The results provide directions for future research and specific advice for policy makers.