[The impact of social and institutional characteristics on the appropriateness of invasive cardiologic procedures]. / Der Einfluss sozialer und struktureller Faktoren auf die Angemessenheit invasiver kardiologischer Prozeduren.

BACKGROUND AND PURPOSE: Germany has the highest per capita rate of invasive cardiologic procedures in Europe. An aim of the SULEIKA study was to present a clearer picture of this important area of health care. METHODS: Clinical data along with social characteristics of patients were acquired by means of questionnaires. An additional survey was established to collect data about the treating institution. Clinical information was used to define the appropriateness of coronary angiographies and percutaneous coronary interventions. A possible impact of social or institutional characteristics on the appropriateness was examined. RESULTS: 549 of 709 diagnostic coronary angiographies (77.4%) were rated "appropriate", 54 (7.6%) as "equivocal", and 106 (15%) as "inappropriate". 245 of 317 coronary interventions (77.3%) were rated "appropriate", 40 (12.6%) as "equivocal", and 32 (10.1%) as "inappropriate". Social and institutional impact were found for invasive diagnostics but not for PCI. CONCLUSION: Social characteristics of patients and institutional characteristics have only a marginal impact on the indication of invasive cardiologic procedures. A trend toward "overdiagnostics" within the group of younger patients has been noticed, even in the case of missing hard medical evidence. A serious deficit of health care research can be found. Consented criteria to assess the appropriateness of medical treatments are missing. More research has to be done in the field of concepts and processes controlling the distribution and movement of patients into different sections of the health care system. Validated, standardized and comprehensive data for an international comparison of decisions about medical treatments are needed.

Evaluation of a community-level health policy intervention.

In this article an evaluation approach towards an innovative community-level health policy intervention in Germany is presented. The aim of the intervention was basically to establish new structures of health planning and co-ordination at the community level in order to improve health monitoring and health care as well as health promotion. To realise this aim Round Tables, Working Groups and Project Offices were implemented in the communities. Based on the theory of change and using a developmental perspective the evaluation was focussed on the links between contexts, activities and outputs of the initiative. A mixed-method design with triangulation of quantitative and qualitative methods was applied. Results show that most of the communities succeeded in convening all major organisations and institutions of the local health care system within the Round Tables. Working climate was rated favourably by most of the involved actors. All communities succeeded in developing and enacting recommendations for action programmes, and about 40% of these programmes were implemented during the observation period of the project. Probability of programme implementation was high if measures remained within the scope of the communities' range of decision authority. Potential effects on population health produced by the action programmes could not be assessed both for logistic reasons and due to the short observation period. Finally, some major characteristics of health policy evaluation at the community level are discussed briefly.

Health promotion research: towards a new social epidemiology

Social factors affect health. Social epidemiologists have shown not only the harmful effects of stress and the helpful ones of social support but also the importance of the wider physical and social environment. This raises two questions for health promotion research. How can we better understand the social determinants of health and disease? How can healthy public policy transform present knowledge into action? This book gives some of the most recent, relevant and reliable answers to both. Twenty-one articles describe the state of the art and give examples of interventions and their results in five areas of health promotion research. The authors are experts from a number of European countries and the United States. The first part of the book focuses on healthy public policy: expanding health policy from a concern solely with illness and health care to multisectoral policies to create environments that promote health. The other four parts examine important issues in health promotion: social and behavioural factors, appropriate settings, special populations and community intervention. This book provides valuable reading for people working in health planning and service delivery, and for those working in health promotion or training others to do so. In helping to bridge the gap between knowledge of and action on social factors and health, this book makes an important contribution to health for all.