Comparing the quality of care in physician networks to usual care for elderly patients in three German regions: a quasi-experimental cohort study.

OBJECTIVES: Patients in Germany have free choice of physicians in the ambulatory care sector and can consult them as often as they wish without a referral. This can lead to inefficiencies in treatment pathways. In response, some physicians have formed networks to improve the coordination and quality of care. This study aims to investigate whether the care provided by these networks results in better health and process outcomes than usual care. STUDY DESIGN: This was a quasi-experimental cohort study. METHODS: We analysed claims data from 2017 to 2018 in Bavaria, Brandenburg, and Westphalia-Lippe. Our study population includes patients aged 65 years or older with heart failure (n = 267,256), back pain (n = 931,672), or depression (n = 483,068). We compared condition-specific and generic quality indicators between patients treated in physician networks and usual care. Ambulatory care-sensitive emergency department cases were used as a primary outcome measure. Imbalances between the groups were minimized using propensity score matching. RESULTS: Rates of ambulatory care-sensitive emergency department cases yielded insignificant differences between networks and usual care in the depression and heart failure subgroups. For back pain patients, rates were 0.17 percentage points higher (P < 0.01) in network patients compared with usual care. Among network patients, generic indicators for prevention and coordination showed significantly better performance. For instance, the rate of completed vaccination against influenza is 3.03 percentage points higher (P < 0.01), and the rate of specialist visits after referral is 1.6 percentage points higher (P < 0.01) in heart failure patients, who are treated in physician networks. This is accompanied by higher rates of polypharmacy. Furthermore, the results for condition-specific indicators suggest that for most indicators, a greater proportion of the care provided by physician networks adhered to national treatment guidelines. CONCLUSIONS: Our findings suggest that physician networks in Germany do not reduce rates of ambulatory care-sensitive emergency department cases but perform better than usual care in terms of care coordination and prevention. Further research is needed to confirm our findings and explore the implications of the potentially higher rates of polypharmacy seen in physician networks.

[Mortality Related to Alcohol and Tobacco Consumption - A Benchmarking of Regional Trends and Levels]. / Mit Tabak- und Alkoholkonsum assoziierte Mortalität - Ein Benchmarking regionaler Trends und Niveaus.

STUDY AIM: Regional characteristics are being increasingly taken into account in studies on the determinants of health and health-care. A systematic observation and inclusion of regional particularities has, however, been absent from strategic planning and financing decisions to date. Furthermore, regional-level changes over time have, for the most part, not been considered in the existing studies. Accordingly, this article seeks to depict both the levels and trends in potentially avoidable mortality on the district level and to establish a benchmark that shows the theoretical goals for the reduction in avoidable deaths in each district. METHOD: Gender-specific and age-standardised potentially avoidable deaths were determined for each of the 413 German districts in the period from 2000 to 2008 on the basis of cause of death statistics provided by statistical agencies of the German federal states. Deaths due to lung cancer and alcohol-related diseases were taken into account as these are considered to be avoidable through primary prevention. The district-specific benchmark values were ascertained using 2 linear hierarchic nested models and tested for significance using an F-test. RESULTS: Overall, the lung cancer mortality was found to have declined amongst men and gradually increased amongst women during the time period under consideration. The benchmark for deaths from lung cancer in women shows that the increase in mortality is principally observed in West German and urban districts. In relation to the alcohol-related deaths we also see an east-west divide, with higher rates in eastern Germany. Shrinking districts in eastern Germany were able, however, to record a big reduction in rates in recent years. An unfortunate development in the trend of alcohol-related mortality in women was notably observed in regional areas of Bavaria. CONCLUSION: The analysis offers decision makers the possibility of pinpointing regions with high intervention need. Increasing lung cancer mortality rates in women living in cities points to, for example, a heightened need for anti-smoking campaigns in urban areas. In relation to alcohol-related diseases, a heightened need for target group-specific prevention was identified in East German districts as well as some districts in Bavaria.

[Ambulatory care-sensitive conditions: an international overview with conclusions for a German catalogue]. / Ambulant-sensitive Krankenhausfälle: Eine inter-nationale Übersicht mit Schlussfolgerungen für einen deutschen Katalog.

OBJECTIVE: Ambulatory care-sensitive conditions (ACSC) foster to quality measurement in the ambulatory sector. The objective of this review is to provide an overview of existing catalogues of ACSC and to derive insights that support the plan-ned development of an ACSC catalogue for Germany. METHODS: This article attempts to systemise the discussion on ACSC by delimiting the term from the related concepts of avoidable hospitalisations and avoidable diseases. Based on that, this article develops a definition of ACSC that is valid for the German context, makes a suggestion for the compilation of adequate diagnoses, and proposes how to apply an ACSC catalogue that is specific to Germany. An overview of nine central -articles describing the elaboration of ACSC catalogues in other countries and a first view of the diagnoses they comprise serve as a guidance. RESULTS AND CONCLUSION: The composition of an ACSC catalogue, that is adapted to the German context, is required to account for the local specifics of the German health-care system in order to ensure validity of the quality indicator. Such an outcome indicator for the ambulatory sector may mean a step towards a more outcome-oriented provision of care and may help ensure the quality of the German health-care system.

[Ambulatory care-sensitive conditions in Germany: a small area analysis (2006-2009)]. / Ambulant-sensitive Krankenhausfälle in Deutschland: Eine Analyse auf Kreisebene für die Jahre 2006-2009.

PURPOSE: The paper aims (1) to identify and depict cartographically ambulatory care-sensitive conditions in Germany (based on data for the years 2006-2009) and (2) to discuss the implications. METHOD: The selection of ambulatory care-sensitive conditions (ACSC) was based on a literature review by Purdy et al. (2009) because a German catalogue of ACSC does not yet exist. Five of these indications were excluded due to limited data -access or a low number of cases. Additionally, 2 -diagnoses that are potentially relevant for Germany were included. Subsequently, diagnosis-specific hospitalisation rates were calculated for each of the 412 counties (Stadtkreise and Landkreise). The spatial distribution of 6 selected diag-noses (heart failure, diabetes, dehydration and gastroenteritis, ENT infections, influenza and pneumonia as well as schizophrenia) was depicted and discussed. Furthermore, an overall analysis of diagnoses analysis was performed. RESULTS: Based on the overall analysis, counties with high hospitalisation rates were identified in Mecklenburg-Western Pomerania, Saxony-Anhalt and Thuringia as well as to a lesser degree in Brandenburg, Saarland, Rhineland Palatinate and North Rhine-Westphalia (for men and women). Low hospitalisation rates were often present in counties in Baden-Wuerttemberg. Based on the diagnosis-specific analysis, some regional clusters could be identified. Thus, high hospitalisa-tion rates for heart failure, diabetes, ENT infections were especially present in Eastern Germany. In contrast, there were no distribution patterns for high hospitalisation rates due to influenza and pneumonia. However, differences could be also identified between rural and urban regions: while hospitalisations due to dehydration and gastroenteritis were more often in rural -districts, hospitalisations due to schizophrenia occurred more frequently in urban regions. CONCLUSION: Knowledge of the spatial distribution of ACSC -rates serves as an important indicator for the identification of districts where health-care quality and access (structural--related) can be optimised. The analysis of hospitalisation rates for 6 selected indications showed that for some indications there were clear regional differences in the distribution of ACSCs in -Germany.

[Statistical methods for research on regional health-care services]. / Statistische Methoden der kleinräumigen Versorgungsforschung.

Accurate modeling of spatial dependencies between observations is a significant challenge in research on regional health-care services. This article provides insight into current methods of modeling relationships in regional health-care service research, with consideration of spatial dependencies. Spatial dependencies may be triggered by spillover effects between neighboring regions and spatially distributed differences in - e.g., morbidity - which are not observable. If not considered in the model, the results of the analyses may be biased. Spatial dependencies can be added to the regression model as a spatial lag or a spatial error term. Using an example study, we illustrate that failing to consider spatial autocorrelation may lead to biased coefficients and/or standard errors. Research on regional health-care services should, therefore, if possible, test for spatial autocorrelation in the data and adjust the model accordingly.

[Is the needs-based planning mechanism effectively needs-based? An analysis of the regional distribution of outpatient care providers]. / Wie "bedarfsgerecht" ist die Bedarfsplanung? Eine Analyse der regionalen Verteilung der vertragsärztlichen Versorgung.

AIMS: Since the 1990s licenses for opening a medical practice in Germany are granted based on a needs-based planning system which regulates the regional allocation of physicians in primary care. This study aims at an analysis of the distribution of physicians (and hence the effects of the planning system) with regard to the overarching objective of primary care supply: the safeguarding of "needs-based and evenly distributed health care provision" (Section 70 para 1 German Social Code V). METHODS: The need for health care provision of each German district (or region) and the actual number of physicians in the respective area are compared using a concentration analysis. For this purpose, the local health-care need was approximated in a model based on the morbidity predictors age and sex and by combining data on the local population structure with the age- and sex-specific frequency of physician consultations (according to data of the GEK sickness fund). The concentration index then measures the degree of regional inequity in the distribution of outpatient care. RESULTS: The results of the analysis demonstrate an inequitable regional distribution between medical needs of the local population and the existing outpatient health care provider capacities. These regional disparities in needs-adjusted supply densities are particularly large for -outpatient secondary care physicians and psychotherapists, even when taking into account the care provision of urban physicians for peri-urban areas as well as the adequacy of longer travel times to specialists. One major reason for these inequities is the design of today's physician planning mechanism which mainly conserves a suboptimal status quo of the past. CONCLUSION: The initiated reforms of the planning mechanism should progress and be further deepened. Especially today's quota-based allocation of practice licenses requires fundamental changes taking into account the relevant factors approximating local health care needs, re-assessing the adequate spatial planning level and expanding opportunities for introducing innovative and more flexible health care services models.

[Amenable mortality in Germany: spatial distribution and regional concentrations]. / Vermeidbare Sterbefälle in Deutschland: Räumliche Verteilung und regionale Konzentrationen.

AIM: The aim of this study is to identify small areas in Germany burdened by exceptionally high rates of amenable mortality using the 439 counties as unit of analysis. METHODS: To overcome shortcomings of conventional mortality measures, we construct an indicator for amenable mortality (AM) which captures deaths that should not occur given current medical knowledge and technology. We age-standardize individual-level data on mortality for the years 2000-2004 and plot the distribution of disease-specific AM on country maps. We consider deaths following ischaemic heart disease, cerebrovascular diseases, hypertension, diseases of the liver, traffic accidents, several cancer types and 24 other diseases that are classified as amenable to health care. The data is taken from the causes-of-death statistics (provided by Destatis). RESULTS: AM significantly differs between small areas within and between German federal states (Bundeslaender). Breast cancer and lung cancer in men are the most common AM-causes in Germany. The often discussed mortality-gap between East and West Germany is predominantly driven by differences in amenable deaths following cardiovascular diseases. However, the maps of most carcinogenic deaths show a north-south gradient rather than an east-west difference.

[Regional differences in life expectancy in Germany at county levels and their possible determinants]. / Regionale Unterschiede der Lebenserwartung in Deutschland auf Ebene der Kreise und kreisfreien Städte und deren möglichen Determinanten.

The aim of this study is to show health differences at a county level in Germany and to identify possible reasons for these differences. The study calculates life expectancy as being representative for the health status. The analytical part of the study uses a wide database with socioeconomic, environmental, educational and health-care data. In a first step, the set of variables is reduced by a factor analysis and three factors are generated (socioeconomic conditions, environment, health-care). Secondly, a cluster analysis is used to show the regional distribution of the gained factors and thirdly a regression analysis is used to show the influence of the three factors on life expectancy. The results of the regression analysis show that socioeconomic conditions have the greatest influence on health status. Because of this, preventive health-care measures should integrate an improvement of socioeconomic conditions.

Mapping the evidence regarding school-to-work/university transition and health inequalities among young adults: a scoping review protocol.

INTRODUCTION: School-to-work/university transition is a sensitive period that can have a substantial impact on health and health behaviour over the life course. There is some indication that health and health behaviour is socially patterned in the age span of individuals in this transition (16-24 years) and that there are differences by socioeconomic position (SEP). However, evidence regarding this phenomenon has not been systematically mapped. In addition, little is known about the role of institutional characteristics (eg, of universities, workplaces) in the development of health and possible inequalities in health during this transition. Hence, the first objective of this scoping review is to systematically map the existing evidence regarding health and health behaviours (and possible health inequalities, for example, differences by SEP) in the age group of 16-24 years and during school-to-work transition noted in Germany and abroad. The second objective is to summarise the evidence on the potential effects of contextual and compositional characteristics of specific institutions entered during this life stage on health and health behaviours. Third, indicators and measures of these characteristics will be summarised. METHODS AND ANALYSIS: We will systematically map the evidence on health inequalities during school-to-work-transitions among young adults (aged 16-24 years), following the methodological framework proposed by Arksey and O'Malley. The literature search is performed in Ovid MEDLINE, Web of Science, International Labour Organization and National Institute for Occupational Safety and Health, using a predetermined search strategy. Articles published between January 2000 and February 2020 in English or German are considered for the review. The selection process follows a two-step approach: (1) screening of titles and abstracts, and (2) screening of full texts, both steps by two independent reviewers. Any discrepancies in the selection process are resolved by a third researcher. Data extraction will be performed using a customised data extraction sheet. The results will be presented in tabular and narrative form. ETHICS AND DISSEMINATION: Ethical approval is not required for this scoping review. The results will be published in a peer-reviewed scientific journal and presented at international conferences and project workshops.

Exploring the role of hospitals and office-based physicians in timely provision of statins following acute myocardial infarction: a secondary analysis of a nationwide cohort using cross-classified multilevel models.

OBJECTIVES: To examine the role of hospitals and office-based physicians in empirical networks that deliver care to the same population with regard to the timely provision of appropriate care after hospital discharge. DESIGN: Secondary data analysis of a nationwide cohort using cross-classified multilevel models. SETTING: Transition from hospital to ambulatory care. PARTICIPANTS: All patients discharged for acute myocardial infarction (AMI) from Germany's largest statutory health insurance fund group in 2011. MAIN OUTCOME MEASURE: Patients' odds of receiving a statin prescription within 30 days after hospital discharge. RESULTS: We found significant variation in 30-day statin prescribing between hospitals (median OR (MOR) 1.40; 95% credible interval (CrI) 1.36 to 1.45), hospital-physician pairs caring for the same patients (MOR 1.32; 95% CrI 1.26 to 1.38) and to a lesser extent between physicians (MOR 1.14; 95% CrI 1.11 to 1.19). About 67% of the variance between hospital-physician pairs and about 45% of the variance between hospitals was explained by hospital characteristics including a rural location, teaching status and the number of beds, the number of patients shared between a hospital and an office-based physician as well as 16 patient characteristics, including multimorbidity and dementia. We found no impact of physician characteristics. CONCLUSIONS: Timely prescription of appropriate secondary prevention pharmacotherapy after AMI is subject to considerable practice variation which is not consistent with clinical guidelines. Hospitals contribute more to the observed variation than physicians, and most of the variation lies at the patient level. To ensure care continuity for patients, it is important to strengthen hospital capacity for discharge management and coordination between hospitals and office-based physicians.