[Polypharmacy after Discharge from Hospital: An Analysis Using Data of the Statutory Health Insurance (AOK) of Saxony-Anhalt]. / Polypharmazie in der nachstationären Versorgung: Eine Analyse mit Daten der AOK Sachsen-Anhalt.

INTRODUCTION AND AIM: The growing number of people suffering from chronic diseases and multimorbidity is associated with an increased risk of polypharmacy. The aims of the study are to estimate the prevalence of polypharmacy and to analyse its determinants in the transition from in- to outpatient care. Furthermore, we estimate the risk of a potential inappropriate medication (PIM) and its determinants. METHODS: The analyses are based on the data of a German statutory health insurance (AOK Saxony-Anhalt) of the third quarter of 2009. The analyses include all insured persons aged 60 years and older who were discharged from hospital within the study period and had filled at least one prescription at the pharmacy (n=21 041). After the analysis of prevalence rates of polypharmacy within 30 days after discharge from hospital, we used binary logistic regression models to estimate the effect of determinants of polypharmacy and PIM. In addition, interaction effects between the number of diseases and the number of practitioners involved in the therapy were calculated. RESULTS: Our analyses show a significant effect of the number of diseases and the number of practitioners on the risk of polypharmacy. Furthermore, patients who are treated with 5 or more drugs have a significantly higher risk of a PIM prescription. The interaction model illustrates a disproportional rise of polypharmacy risk in women with multiple chronic conditions with an increase in the number of doctors treating them. CONCLUSION: The results suggest that polypharmacy is not a result of increasing morbidity alone. Furthermore, the remarkable effect of the number of physicians treating a patient points to an unsolved problem in communication and coordination in outpatient pharmacotherapy and shows the need for centralized medication monitoring.

Linking primary study data with administrative and claims data in a German cohort study on work, age, health and work participation: is there a consent bias?

OBJECTIVES: We analysed the degree and impact of consent bias in the prospective study 'leben in der Arbeit (lidA)' after linking primary interview data with claims data from German statutory health insurance funds as well as with administrative data provided by the German Federal Employment Agency. STUDY DESIGN: Prospective cohort study. METHODS: Within two study waves (2011, 2014) primary data were collected based on computer-assisted personal interviews. During interview informed consent to data linkage was obtained. We used binary logistic regression analyses with participants' consent for record linkage as the dependent variable calculating odds ratios (ORs) and 95% confidence intervals (95% CIs) for independent variables. Several sociodemographic, socio-economic and work-related factors were modelled as potential determinants of consent. RESULTS: A total of 4244 participants took part in both waves. After excluding invalid consent, 4178 participants were included in the analysis. About 3918 (93.8%) of these participants gave their consent to link their primary data with data from at least one source. Within regression analyses only moderate bias was found due to region of residence, apprenticeship, professional affiliations, income and number of diseases. Participants from former West Germany were less likely to have their study data linked with both data sources (OR 0.63 [95% CI 0.42-0.96]) than those from the former East Germany. Participants with no information on income were more likely to refuse consent to both data sources compared to the reference group (net income: under EUR 1000; OR 0.15 [95% CI 0.08-0.30]). Respondents with two (OR 1.37 [95% CI 1.06-1.77]) or three and more diseases (OR 1.30 [95% CI 1.02-1.66]) diagnosed by a doctor agreed more frequently to linking both data sources than participants without disease. There is just a small proportion of variance in consenting explained by the models (R2: 0.063-0.085). Also, only small changes of factors' prevalence were observed in consenters. CONCLUSIONS: For the first time in Germany, the lidA-study links primary survey data with health claims and administrative employment data. We conclude that there is only a minor relation between the analysed factors and consent behaviour of the participants. A linked data set may be used in further analyses without substantial biases.

[Social Security Needs Social Medicine: Self-image of Physicians Practicing Social Medicine in Statutory Health Insurances and Social Security Systems]. / Soziale Sicherheit braucht Sozialmedizin Selbstverständnis von Ärztinnen und Ärzten in der sozialmedizinischen Begutachtung und Beratung.

OBJECTIVE: In January, 2014, the division "Social Medicine in Practice and Rehabilitation" of the German Society for Social Medicine and Prevention established a working group on the self-image of the physicians active in the field of social medicine (medical expertise and counseling). METHODS: The result of this work is the contribution presented here after consensus was achieved by specialists of social medicine from different fields and institutions (social security etc.) and in good cooperation with Prof. Dr. Gostomzyk and Prof. Dr. Robra. RESULTS: Based on the importance of an up to date social medicine for claimants and recipients of benefits on the one hand and the social security system on the other, and also on a description of the subjects, objectives and methods the following aspects are presented: · The perspective of social medicine. · Qualification in social medicine, concerning specialist training and continuing medical education. · The fields of duty of experts in social medicine. · The proceedings in social medicine. The working group identified challenges for the specialists in social medicine by a narrowed perception of social medicine by physicians in hospitals and practice, accompanied by an enlarged importance of expertise in social medicine, by the demand for more "patient orientation" and gain of transparency, and concerning the scientific foundation of social medicine. CONCLUSIONS: The working group postulates: · The perspective of social medicine should be spread more widely.. · Confidence in experts of social medicine and their independency should be strengthened.. · The not case-related consulting of the staff and executives should be expanded.. · Social medicine in practice needs support by politics and society, and especially by research and teaching.. · Good cooperation and transfer of experiences of the different branches of social security are essential for the impact of social medicine..

[Memorandum on sustainable reinforcement of prevention and health promotion: challenges at the federal, state and local level]. / Memorandum--Prävention und Gesundheitsförderung nachhaltig stärken: Herausforderungen auf Bundes-, Landes- und kommunaler Ebene.

Research-based evidence and practice-based experience are core requirements for the effective implementation of preventive interventions. The knowledge gained in the Prevention Research Funding Initiative of the German Federal Ministry of Education and Research (2004-2013) was therefore amalgamated, reflected and consolidated in the Cooperation for Sustainable Prevention Research (KNP) meta-project. In annual strategy meetings, researchers and practitioners from the field and other experts developed 3 memoranda providing recommendations for the further development of research and practice in the field of prevention and health promotion. Memorandum III is primarily aimed at decision-makers in politics and administration at the federal, state and local level, in civil society and in the workplace. Its recommendations show that structuring efforts are urgently needed to achieve sustainable policy, particularly in the fields of health, education, employment and social affairs. Memorandum III brings together the knowledge extracted and problems identified in research projects. More so than its 2 predecessors, Memorandum III abstracts knowledge from the individual projects and attempts to derive guidance for action and decision-making, as shown by the 7 recommendations that appear to useful for consensus-building in practice and research. Value judgments are inevitable. Prevention and health promotion are an investment in the future: of social health, social capital and social peace. Improvement of the framework conditions is needed to achieve the harmonized awareness and the sustained effectiveness of these structure-building efforts in different policy areas, spheres of life, fields of action, and groups of actors. This includes the implementation of an overall national strategy as well as the expansion of sources of funding, extension of the legal framework, overarching coordination, and the establishment of a National Center of Excellence to develop and safeguard prevention and health promotion. The memorandum is intended to stimulate a discourse resulting in structure-building and stabilizing measures designed to ensure the sustainability of prevention and health promotion.

[GP medication prioritisation in older patients with multiple comorbidities recently discharged from hospital: a case-based bottom-up approach]. / Hausärztliche Arzneimittelpriorisierung bei stationär entlassenen, multimorbiden, älteren Patienten--Ein Vignetten-Ansatz aus der Hausarzt-Perspektive.

INTRODUCTION: After the hospital discharge of older patients with multiple morbidities, GPs are often faced with the task of prioritising the patients' drug regimens so as to reduce the risk of overmedication. AIM: How do GPs prioritise such medications in multimorbid elderly patients at the transition between inpatient and home care? The experience by the GPs is documented in typical case vignettes. METHOD: 44 GPs in Sachsen-Anhalt were recruited--they were engaged in focus group discussions and interviewed using semi-standardised questionnaires. Typical case vignettes were developed, relevant to the everyday care that elderly patients would typically receive from their GPs with respect to their drug optimisation. RESULTS: According to the results of the focus groups, the following issues affect GPs' decisions: drug and patient safety, their own competence in the health system, patient health literacy, evidence base, communication between secondary and primary care (and their respective influences on each other). When considering individual cases, patient safety, patient wishes, and quality of life were central. This is demonstrated by the drug dispositions of one exemplary case vignette. CONCLUSIONS: GPs do prioritise drug regimens with rational criteria. Initial problem delineation, process documentation and the design of a transferable product are interlinking steps in the development of case vignettes. Care issues of drug therapy in elderly patients with multiple morbidities should be investigated further with larger representative samples in order to clarify whether the criteria used here are applied contextually or consistently. Embedding case vignettes into further education concepts is also likely to be useful.

[Children and Adolescents--Preventive Activities are Effective]. / Kinder und Jugendliche--Präventive Maßnahmen wirken.

Health-related attitudes and behaviour are working already in the first years of life. Approaches of prevention for children and adolescents exist from structured programmes to promote healthy behaviour and to strengthen life skills through the support of parents to the qualification of professionals for the promotion of childhood resources. An essential starting point is the design of living conditions in which children and young people spend a lot of their time. An important goal of the BMBF-Förderschwerpunkt "Prevention Research" was the knowledge about which programmes, policies and approaches are effective and justify a transfer into practice. On looking back on the projects, some factors for the effectiveness of the measures could be identified: the presence of a reason, context reference, programme offerings and activation of all actors. The research projects also provide evidence of an increase in knowledge of effective evaluation since supply onset, although a binding standard of evaluation, the understanding of relevant outcome measures and other aspects are still lacking.

[Stability of long-term professional objectives of young physicians during postgraduate training. Results of a multicenter cohort study]. / Stabilität der beruflichen Endziele im Verlauf der fachärztlichen Weiterbildung. Ergebnisse einer multizentrischen Kohortenstudie mit zweijährigem Intervall.

INTRODUCTION: We investigated persistences and changes of career preferences of medical residents in Germany after two years of postgraduate training with regard to future working place and position. The results are compared with those forwarded at graduation from medical school in a gender comparative perspective. METHODS: The study is based on a standardized postal survey among the participants in the "KarMed" study, originally based on 1012 graduates of the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg in 2009. 2107 persons were contacted. The return rate at baseline was 48 %, and the two surveys after the baseline reached return rates of 87 % and 89 % respectively. In all samples 2/3 were women as in actual medical undergraduate education. Descriptive statistics and regression analysis were performed. RESULTS: After 2 years of residency, residents after 2 years of postgraduate training still preferred the hospital over private practice as their final workplace after postgraduate training. The attractiveness of leading positions in the hospital declined among men, whereas it was already low for women at graduation. A large proportion of those physicians preferring the ambulatory sector, especially women, wishes to work as employee instead of private practice. At the personal level, almost 60 % forwarded the same preferences as those at graduation. Gender, parenthood and region of study (East vs. West Germany) did not influence stability or change of preferences. CONCLUSION: The results demonstrate the persistence of professional preferences regarding future sector and position of medical work during postgraduate training. These preferences do neither match with principles of gender equality nor with future workforce needs (e. g. in primary care).

[John E. Wennberg, pioneer of regional health services research: what does he teach us in Germany?]. / John E. Wennberg, Pionier der regionalen Versorgungsforschung : Was kann eine deutsche Versorgungswissenschaft von ihm lernen?

Using claims data, Wennberg demonstrated regional health-care variation that was not due to differentials in morbidity nor was it preference-based, but was partly supply-sensitive. The structure, processes, and outcomes of care are imperfectly coupled, and more services are not necessarily associated with better outcomes. Feeding data back to the responsible providers, restraining capacities, and fostering patient autonomy are seen as important in reducing unwarranted variation in health-care service delivery. In Germany, regional analyses of claims data and disease registries confirm the heterogeneity of processes and outcomes. A reduction in regional variation is in the interest of patient safety and likely to improve the effectiveness and efficiency of medical care. More health-care delivery science-both analytic and experimental-is needed.

[The professional and private situation of male and female physicians entering postgraduate medical education in Germany]. / Die berufliche und private Situation von Ärztinnen und Ärzten zu Beginn der fachärztlichen Weiterbildung.

AIM: This study investigated the professional and the private situation of medical interns at the onset of their postgraduate training in Germany. We analysed the contractual situation and the working hours in the hospital, the professional situation of the partner and the number of hours invested in private life with special reference to gender and children. METHOD: A standardised postal survey was conducted among all last year medical students in the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg after entering postgraduate training. 1 009 were contacted for a first follow-up one year later and 87% responded. Descriptive statistics and regression analysis were performed. RESULTS: The analysis shows that female physicians are disadvantaged compared to males with regard to various professional and private conditions relevant for career development, especially when children are present. We found a large number of hints pointing towards a persistence of traditional role patterns within the couple relationship. These conditions differed substantially between the regions of former German Federal and former German Democratic Republic. CONCLUSIONS: A growing number of children in the study population in the course of the longitudinal analysis will show if these gender-related differences persist in the course of the training period and which influences on career development can be observed.

[Memorandum prevention research - research areas and methods]. / Memorandum zur Präventionsforschung - Themenfelder und Methoden (Langfassung).

From 2004 to 2012, the German Ministry of Education and Research (BMBF) established its first funding programme for the promotion of prevention research. 60 projects on primary prevention and health promotion and the meta-project entitled "Cooperation for Sustainable Prevention Research" (KNP) received BMBF grants under this programme during this period. The experience and knowledge gained and recommendations arising from the research funded under this programme are compiled in memorandum format. The "Memorandum on Prevention Research - Research Areas and Methods" highlights 5 research areas that are considered to be especially relevant from the perspective of the involved scientists and practice partners.The promotion of structural development and sustainability enhancement in disease prevention and health promotion are central areas that should branch out from existing nuclei of crystallization. Improving the health competence of the population and of specific subpopulations is another major area. Research in these areas should contribute to the development of theoretical concepts and to the empirical testing of these concepts. The transfer of knowledge for effective use of developed disease prevention and health promotion programmes and measures is still a scarcely researched area. Among other things, studies of the transfer of programmes from one context to another, analyses of the coop-eration between politics and science, and the continued theoretical and conceptual development of transfer research are needed. Long-term data on the effects of intervention studies are also needed for proper evaluation of sustainability. The latter dem-onstrates the importance of method development in disease prevention and health promotion research as an area that should receive separate funding and support. This research should include, in particular, studies of the efficacy of complex interventions, health economic analyses, and participative health research.

[Memorandum - research funding of prevention]. / Memorandum - Forschungsförderung Prävention.

The memorandum of the research funding of prevention has been devised within the framework of the Prevention Research Funding Programme of the Federal Ministry of Education and Research. It consists not only of the obtained findings of the research-practice co-operation but also of recommendations for the implementation of prospective, innovational, effective, practice-oriented and sustainable research. The respective knowledge has been acquired from quantitative surveys on the experiences of scientists and practice partners within the prevention research funding project as well as from extensive qualitative methods of structured group evaluation. A participatory co-operation between research and practice based on mutual respect, trust and recognition is seen as mandatory for the further development of both prevention and health promotion research. Research and practice partners are required to engage in an ab initio collaboration starting from the conception phase, whereby it is advisable to encourage and fortify the communication between research, practice and funding partners by systematic surveillance in form of a meta-project. In addition, the inclusion of the target population from the outset and on a collaborative basis is considered as beneficial in order to ensure the practical application of the research findings. Furthermore, innovatory research designs which are able to provide a framework for internal flexibility, continuous re-assessment and adjustment are fundamental for the implementation of practice-oriented research. Moreover, a dynamic co-operation between different groups of interest not only depends on sharing responsibility but also on sufficient funding for both research and practice, which is particularly important for the transfer and communication of the attained findings. With regard to the evaluation of both effectiveness and sustainability of interventions, a research funding project is required which makes long-term results possible through the utilization of regulated monitoring and guarantees quality and continuous effectiveness. Furthermore, in order to stimulate progress within the basic theories of prevention and health promotion, it is also essential for a funding project to focus on elementary concepts. Additionally, for the efficient and sustainable development of health within a population it is advisable to apply both self-contained research and the involvement of primary prevention and health promotion to research projects concerning health, social affairs, education, work and environment.

[Do female medical graduates have different views on professional work and workload compared to their male colleagues? Results of a multicenter postal survey in Germany]. / Haben Frauen am Ende des Medizinstudiums andere Vorstellungen über Berufstätigkeit und Arbeitszeit als ihre männlichen Kollegen? Ergebnisse einer multizentrischen postalischen Befragung.

BACKGROUND AND AIM: This study investigated the career preferences of medical graduates with regard to discipline, final position, preferred area of work, and work load after the completion of postgraduate according to gender in Germany. METHODS: Standardized postal survey among all last year medical students in the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg in 2009. 2017 persons were contacted and 1012 (48 %) participated. Descriptive statistics and regression analysis were performed. Qualitative interviews with graduates completed data collection. RESULTS: Overall, graduates prefer the hospital over private practice as their workplace after postgraduate training. However, 50 % of male graduates but only 29 % of female graduates aspire a leading position in the hospital. Male graduates often prefer careers in surgical disciplines, specialized internal medicine whereas female graduates orient themselves towards gynecology, pediatrics and smaller clinical disciplines like dermatology. 80 % of male but only 40 % of female graduates prefer a full-time position after completion of postgraduate training, whereas 16 % of female graduates aim at a part-time position only. CONCLUSION: The results demonstrate the persistence of traditional role models among medical graduates. Men aim at leading positions in the hospital whereas women prefer lower hospital positions or outpatient practices. Women look for part-time jobs, at least temporarily for child rearing whereas men continue to prefer full-time jobs.

[Quality evaluation in colorectal surgery in dependence on health-care categories of hospitals - minor differences in outcome with room for improvement in process quality]. / Qualität der Kolorektalchirurgie in Abhängigkeit von der Versorgungsstufe - geringe Unterschiede in der Ergebnisqualität bei Verbesserungspotenzial in der Prozessqualität leisten der Zertifizierung an deutschen Krankenhäusern Vorschub.

BACKGROUND: In the present study, different variables focusing on quality of colorectal surgery were investigated with respect to hospital categories: university hospital - U; hospital with maximum care responsibility (with a full spectrum of medical disciplines) - M; secondary care hospital with central regional responsibility (6-9 departments) - S; primary care hospital with local responsibility (2-5 departments) - G; The primary goal of this study was to analyse the current standard of care in patients with colorectal carcinoma in Germany. METHODS: From 2000-2004, data of 47 435 patients with colorectal cancer were evaluated, using data compiled in the German multi-centred observational study "Colon/Rectal Carcinoma". Analysis was performed for all variables with respect to hospital categories. Due to the remarkable number of patients, differences between the groups were to be regarded as significant if p<0.01. RESULTS: Preoperative colonoscopy (U: 70.1% M: 70.4% S: 67.9% G: 67.2) and preoperative determination of serum tumour markers (U: 83.8% M: 80.1% S: 81.9% G: 77.1) mainly indicate the quality of gastroenterological work-up before surgical intervention. In general, standards established by the "German Cancer Association" were not met and showed significantly lower rates for primary and secondary care hospitals. In contrast, variables indicating quality of perioperative course and outcome: rate of anastomotic leak (U: 2.1% M: 2.8% S: 2.1% G: 3.1%), rate of surgical intervention (U: 4.3% M: 3.1% S: 3.5% G: 3.1%) and mortality rate (U: 4.4% M: 2.2% S: 3.5% G: 4.1%) were in accordance with the requirements and did not differ significantly between all groups. However, an analysis of surgical and histopathological process quality (complete histology: U: 96.3% M: 93.6% S: 91.9% G: 90.9%) revealed significant differences with results being significantly lower for primary care hospitals. CONCLUSION: There is in principle no necessity to centre colorectal surgery in tertiary care hospitals as quality parameters focusing on results and outcome are comparable. However, in primary care hospitals, there are deficits with regards to process quality. Therefore, all measures aiming to enhance in particular process quality, i. e., hospital certification or participation with quality assurance studies, are highly desirable to further improve patient care.

[Unresolved problems of undocumented migrants in Germany: an analysis of medical consultations in Berlin, Cologne and Bonn]. / Problemlagen von versteckt lebenden Migranten in Deutschland: Analyse der medizinischen Beratungsanlässe in Berlin, Bonn und Köln.

INTRODUCTION: Little is known about health related problems of undocumented migrants in Germany. Patterns for medical consultations and socio-demographic characteristics are only available in isolated reports. This article identifies and compares empirical data from non-governmental organisations (NGOs) who provide medical care for unregistered migrants. METHODS: Annual reports of 2006 and 2007 of the Malteser Migranten Medizin (Berlin, Cologne) and the MediNetz Bonn were selected for this document analysis. RESULTS: We identified similarities and differences in the socio-demographic background and patterns of medical consultations between the explored regions. The number of documented migrants without medical insurance increased during the observed period. DISCUSSION: The patterns of health-care utilisation for undocumented immigrants changed in the observed period which might be caused by the EU enlargement to the East. The heterogeneous quality of the annual reports and the lack of information about the use of alternative health-care facilities limit the results of this analysis.

[Using claims data for small area analysis and controlling of hospital care]. / Die Nutzung der GKV-Daten für die kleinräumige Analyse und Steuerung der stationären Versorgung.

In Germany, only few data sources enable a small-area analysis of medical care. However, this is necessary for empirically based planning of future medical care. Here claims data of the statutory health insurance provide new insights into medical care by utilization analysis at district and postal zip code levels. Examples of small-area analysis of hospital care show manifold possibilities of using these data for purposes of health services research and planning. The most important result of these analyses is the considerable variation of hospital care utilization which is constant over time and regions. Claims data are updated regularly, complete, unbiased, and of high quality. They also have a clear reference to population and region. Limitations of using claims data arise from the absence of clinical information. For purposes of hospital planning the restriction to the hospital sector is more important. In the future this limitation will be overcome by using claims data from primary and hospital care together.

Risk factors for community-acquired pneumonia in German adults: the impact of children in the household.

The objective of this case-control study was to identify the main risk factors for community-acquired pneumonia (CAP) in a German adult population. A self-administered questionnaire was given to CAP cases provided by the German competence network CAPNETZ and population-based, randomly selected controls (sex- and age-matched). Multivariate analysis showed that in addition to known risk factors such as previous CAP [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.3-2.1], more than one respiratory infection during the previous year (OR 3.6, 95% CI 2.9-4.5), chronic pulmonary diseases (OR 2.3, 95% CI 1.7-3.0), number of comorbidities (OR 1.6, 95% CI 1.4-1.9), and number of children in the household (2 children: OR 2.2, 95% CI 1.5-3.4; > or = 3 children: OR 3.2, 95% CI 1.5-7.0) were independent risk factors for CAP. This was pronounced in particular in people aged < or = 65 years. The most likely explanation for this finding is higher exposure to infectious agents.

[Notes on the planned German health fund model]. / Anmerkungen zum geplanten Gesundheitsfondsmodell.

The aim of this paper is to evaluate the planned German health fund model, a special risk adjustment scheme, in terms of competition policy. Starting from the present model of risk adjustment, we have examined the consequences of introducing the fund model on competition in the health insurance market. On the one hand, the risk adjustment fund will, at best, decrease ineffective competition for "good risks". On the other hand, it will increase the pressure of competition inside the health insurance market by providing new incentives to the unemployed to change their sickness fund. Significant economies, however, can only be realised by increasing the competition for contracts between the health insurance companies and the suppliers of medical services. The new risk adjustment fund then will also offer only a limited potential for competition between individual sickness funds. Besides, it remains to be seen to what extent policy-makers are able to achieve an optimally designed risk adjustment fund and whether the sickness funds themselves do not misinterpret the reform as nationalization in disguise and consequently delegate their management responsibilities back to the policy-makers.

[Determinants of hospital admission--investigation by case vignettes]. / Determinanten der Krankenhausaufnahme--eine Untersuchung mit Fallvignetten.

Unexplained differences in the density of in-patient management in one federal state in Germany led to a regional survey of physicians in independent and hospital practice, which aimed to describe more precisely the determinants of referral and admission behaviour. Brief typical case descriptions (vignettes) were designed, as an instrument of data collection, dealing with two examples of management problems: upper and lower abdominal pain. The urgency of inpatient treatment was ranked using clinical scores and guidelines. Social characteristics for the patient (age, gender, social situation, preference for/against hospitalisation, day of the week on which the patient presented) were randomly assigned to the case vignettes. Each physician was asked by mail to decide on the management of 10 upper and 10 lower abdominal vignettes each. The physicians were also asked to provide additional information on the characteristics of their practice or hospital. The data were analysed using multivariate hierarchical models. A 28 % response rate meant that vignettes were available from 455 general practitioners and internal medicine specialists in independent practice, as well as 261 hospital surgeons and internal medicine specialists, together with responses from 31 physicians from the medical service of the German statutory health insurance (MDK). 7376 upper abdominal and 7335 lower abdominal vignettes were analysed. Admission rates reflected the graded severity of the symptoms built into the vignettes. Hospital physicians wanted to admit the vignette patients much more frequently than physicians in independent practice wished to refer them. Older patients, independent of symptoms, were more frequently referred or admitted than younger patients. In the case of acute symptoms it is the day of the week when the patient consulted the physician and in the case of elective surgery the patient's preference that are important for hospitalisation. The results show that medical decisions on case management are made using reasonable problem-specific preferences. The probability of actually instigating admission was, other things being equal, much higher in hospital physicians than in office-based physicians. As an instrument of comparative research into medical care, case vignettes have practical advantages in relation to medical audits and standardised patients. They can also be used for teaching, examining, documenting and quality assurance purposes.

[Preventive home visits to the elderly: systematic review of available evidence]. / Präventive Hausbesuche im Alter: eine systematische Bewertung der vorliegenden Evidenz.

The aim of preventive home visits to elderly persons is to reduce mortality, to avoid admissions to nursing homes and hospitals and to improve the functional status and general wellbeing of the elderly. Preventive home visits are rarely a standard service in national health care systems. For over 20 years, controlled randomized studies have been carried out to test their effectiveness. This systematic review evaluates the evidence available on preventive home visits for elderly persons in the context of considerations relating to the incorporation of such a service into the German health care system. Three current systematic reviews (two of them meta-analyses) were identified in a systematic literature survey. They consider a total of 26 studies, most of them RCTs. A further three original controlled studies were identified and evaluated. The original studies were very heterogeneous with respect to goals, target groups, intensity and duration of the home visit programme and with respect to the individuals performing the study (number, profession, qualifications and cooperation). This makes it more difficult to perform a pooled overall evaluation. It was possible to consider mortality, admissions to nursing homes, functional status and psychosocial status as relevant target parameters. The systematic reviews arrive at different assessments of effectiveness. A quantitative, across-studies evaluation demonstrated that preventive home visits to elderly persons were effective both in studies with selected and with unselected inclusion of participants. The second meta-analysis did not confirm this result. Effectiveness here was only demonstrated using stratified analyses which investigated a large number of home visits, the performance of a multidimensional assessment with follow-up visits and the average age and morbidity of participants as relevant influencing factors. However no factor exerted an influence over more than one of the investigated target parameters. The findings thus constitute very unspecific evidence of effectiveness with largely unclear determinants of success. Preventive home visit programmes have been tested in various health systems. Results from controlled (randomised) German studies have not been published to date. The results of studies from other countries have only limited applicability to the conditions in the German health care system because the opportunities for, and extent of, economical and effective improvement in the preventive care of the elderly depend on the standard of care existing in the individual country. The additional value of screening depends on the empirical level of care and not on a given standard. At present the introduction of home visits in Germany cannot be recommended beyond studies. However there appear to be sufficient reasons for controlled studies in Germany which should be carried out in a coordinated way with mutual agreement on concepts.