Infrastructure- and workforce capacity for the provision of health care to people with invasive home mechanical ventilation: A scoping review of indicators and norms.

INTRODUCTION: Both the availability and adequacy of infrastructure- and workforce capacity are critical to provide integrated and continuing care, especially to people with complex care needs such as those with invasive home mechanical ventilation (HMV). This review aims to synthesise indicators and norms that are available for assessing this infrastructure- and workforce capacity. METHODS: A scoping review was conducted by searching PubMed, Livivo, the grey literature, specific registries, and the websites of relevant professional societies for international publications on specific infrastructure- and workforce capacity indicators or norms on HMV from January 2000 up to and including March 2021. Exclusion criteria comprised missing indicator/norm information, differing populations/care settings, and secondary literature. Indicators and norms were extracted, clustered, and analysed by applying the WHO Monitoring and Evaluation Framework and qualitative content analysis. RESULTS: Fifteen publications met the inclusion criteria. Forty-five indicators and 44 norms on HMV-related infrastructure- and workforce capacity were synthesised. The synthesis revealed a heterogeneous set of indicators and norms (mainly from cross-sectional surveys and guidelines). The methodological information on their definition, rationales, disaggregation, and evidence is scarce. CONCLUSION: To enable integrated care in HMV and comparable populations with complex care needs, the identified limitations in assessing infrastructure- and workforce capacity should be addressed.

[General practitioners' palliative care activities in Westphalia-Lippe compared to other federal states - Secondary analysis of a survey]. / Hausärztliche Palliativversorgung in Westfalen-Lippe im Vergleich mit anderen Bundesländern ­ sekundäre Auswertung einer Befragungsstudie.

INTRODUCTION: In palliative home care frictional loss at the interface between primary palliative care (PPC) and specialised palliative home care (SPHC) is repeatedly pointed out. PPC and SPHC appear to be insufficiently interlinked. The model implemented in Westphalia-Lippe differs from others in Germany: it relies on close cooperation between general practitioners (GPs) and palliative consultancy services (PCS), an early start of the palliative care process and comprehensive/widespread collaboration. We hypothesize that the framework conditions applying in Westphalia-Lippe have positive effects on the uptake of palliative care activities by GPs. The objective of this study therefore is to compare GPs' attitudes and their willingness to provide palliative care between GPs in Westphalia-Lippe and GPs in other federal states/Associations of Statutory Health Insurance Physicians (ASHIPs) in order to empirically test our hypothesis. METHODS: Secondary evaluation of a nationwide paper-based survey from 2018 for national data acquisition of GPs' palliative care activities at the interface of SPHC. Answers of the participating GPs from Westphalia-Lippe (n=119) are contrasted with the answers of the GPs from seven other federal states (n=1,025). RESULTS: GPs from Westphalia-Lippe have a consistently higher self-perception of being responsible for palliative care of their patients, more often take responsibility for palliative care activities and feel more confident in carrying them out. GPs from Westphalia-Lippe are more likely to know other palliative care facilities/actors and they find them to be more likely available for GPs. They rate the quality of the overall palliative infrastructure higher. For GPs from Westphalia-Lippe the involvement of PCS/SPHC providers is less important than for GPs from other regional ASHIPs. If they are involved in the palliative treatment of a patient, GPs from Westphalia-Lippe feel more frequently involved in the course of treatment. DISCUSSION: Our study indicates that the special framework conditions for palliative care provided by GPs in Westphalia-Lippe have positive effects on their uptake of palliative care activities. An essential factor could be the PPC- and SPHC-integrated approach to palliative care in Westphalia-Lippe. CONCLUSION: Westphalia-Lippe may provide orientation for other regions regarding the involvement of GPs at the interface to specialized palliative care. Whether the type of palliative home care in Westphalia-Lippe also produces advantages in terms of quality and costs of care compared to the rest of Germany is something that needs to be investigated in the future.

[High-cost patients in Germany: General description of utilization and costs]. / Hochkostenversicherte in Deutschland: Leistungs- und Kostenprofile.

BACKGROUND: Studies from different countries have shown that a small number of insured persons (high-cost patients) are responsible for a large portion of health care spending. At the same time, it is assumed that some of these costs could be saved by a better management of this group of people. The aim of this article is to analyze the performance and cost profiles of high-cost patients, to put them in an international comparison, and to derive a better management approach. METHODS: Retrospective observation study based on statutory health insurance data from two statutory health insurances for the year 2013. STUDY POPULATION: top 5 %, as well as top 1 % of the most expensive insured persons. Identification of characteristics of high-cost patients and international comparison with the Netherlands, the USA, Canada, Spain, England and Japan. RESULTS: 5 % of insured persons account for almost half of the total costs and the most expensive 1 % of 22 %. These high-cost patients in Germany are, on average, 20 years older than the general population. Almost every person of the high-cost population was prescribed at least one medication during the study period (99.2 %), and 85.8 % had at least one hospital stay. Hospital care accounts for the biggest part of total costs: 75 % together with drugs. The average per capita costs caused by one of the 5 % most expensive insured persons in the year under review are 20 times higher than that of the other 95 % of insured persons. High-cost patients are generally more multimorbid and have higher mortality rates. The most common diagnoses of these patients are hypertension, lipoprotein metabolism disorder and back pain. CONCLUSION: Similar to other developed countries, Germany faces the challenge to develop and implement adequate intervention approaches addressing the special requirements of high-cost insured persons. This paper provides a first basis. The analogies of high-cost patients in Germany and other countries illustrate the need for transnational research and intervention approaches on this specific issue. More in-depth work is needed to investigate the potentials of Predictive Modelling and integrated care approaches to the management of this group of insured persons.

[Development of an indicator set for the evaluation of the population-based integrated healthcare model 'Gesundes Kinzigtal' (Healthy Kinzigtal)]. / Entwicklung eines Indikatorensets zur Evaluation der Integrierten Versorgung Gesundes Kinzigtal.

INTRODUCTION: The project "INTEGRAL-10-year evaluation of the population-based integrated health care model 'Gesundes Kinzigtal' (Healthy Kinzigtal)" (ICM-GK) is funded by the Innovation Committee of the Federal Joint Committee (G-BA) (grant no. 01VSF16002). The evaluation is to be based on a set of indicators that can be captured in routine data. On the one hand, they can be used to assess ICM-GK programs that are program-specific and geared towards prevention and disease management. On the other hand, possible negative side effects of the ICM-GK, which is designed as a "shared savings contract", are to be examined by also observing care needs not covered by the ICM-GK contract. Since an indicator set for the evaluation of regional integrated care (IC) programs in Germany is not yet available, a suitable indicator set should be developed. METHODS: RESULTS: The methodological framework links the OECD concept for quality assessment of health systems with Kessner's tracer methodology. Disease groups with a high prevalence ("common diseases"), prevention potential and potential for improvement through IC were selected as tracers. The literature search resulted in 239 QIs and the QI database search in 293 QIs, which were supplemented by 21 QIs from the focus groups. Out of a total of 553 QIs, 251 QIs remained after removal of duplicates and comparison with the data basis. This preliminary QI set was reduced to 101 QIs by consensus. In addition, 48 health reporting indicators were supplemented which serve to classify regional quality results. The final QI set maps the following 19 disease categories/tracers: heart failure (16 QIs), myocardial infarction (4 QIs), CHD (10 QIs), stroke (6 QIs), metabolic syndrome (7 QIs of which 5 were diabetes-related), COPD (6 QIs), asthma (3 QIs), chronic pain (5 QIs), back pain (3 QIs), geriatrics (7 QIs), dementia (8 QIs), osteoporosis (3 QIs), rheumatism (3 QIs), multiple sclerosis (2 QIs), depression (4 QIs), antibiotic therapy (3 QIs), drug safety (1 QI), child care (5 QIs), early detection/prevention (5 QIs). 33 of these QIs are dedicated to five tracers that are not explicitly ICM-GK programs. Most QIs assess aspects of the effectiveness of care for the chronically ill and measure process quality. DISCUSSION: The set of indicators initially enables the quality assessment of regional, cross-indication care quality in the population-based integrated health care model 'Gesundes Kinzigtal' on the basis of routine data. Although the QI set focuses on effectiveness and process quality, it also includes QIs for preventive and acute care, coordination of care, patient orientation and safety, and outcomes. In contrast to other QI sets, both primary care and specialist health care and integrated, cross-sectoral and cross-professional care aspects have been considered. The benefits of the QI set for comparisons of regional quality and the evaluation of different IC programs remain to be tested. CONCLUSION: On the basis of a broadly based research and participatory development process, a set of indicators has been developed that enables comprehensive evaluation of the regional quality of care of cross-indication, integrated care models focusing on common diseases. In order to be able to increasingly evaluate aspects of care coordination and patient orientation, health promotion as well as nursing, palliative and emergency care in the future, it would be helpful if routine data were collected or made accessible in these areas as well.

[Individual patient satisfaction in 'Gesundes Kinzigtal': Interim results of a trend study]. / Individueller Patientennutzen im "Gesunden Kinzigtal" ­ Zwischenergebnisse einer Trendstudie.

INTRODUCTION: The integrated health care pilot model "Gesundes Kinzigtal" (GK) is recognized as a reference model for integrated healthcare in Germany. The aim of GK is to improve the health of the insured persons and, at the same time, to decrease their healthcare costs compared to usual care. The evaluation of GK has so far shown that GK might reach this aim. However, there are still no evaluation studies on GK focusing on patient-reported outcomes. This gap needs to be closed by a trend study, which is the main topic of this paper: We present interim results of this study, focusing on patient satisfaction with GK, insured persons' self-reported change of health behavior, their knowledge on health maintenance, and health-related quality of life. METHOD: The baseline survey of the trend study was conducted in 2013: 3,034 members of GK were invited to complete a standardized questionnaire (by mail). In the first follow-up survey in 2015, 3,471 members were invited. Health-related quality of life was measured by EQ-5D and EQ-VAS; the other above-mentioned indicators were developed by our work group. Conducting variance analysis and logistic regression analysis using SPSS, it was analyzed to what extent the above-mentioned indicators changed between the first and the second survey. RESULTS: The response rate was 23.4 % and 24.9 %, respectively. Overall patient satisfaction with GK and the mean EQ-5D value remained stable; the remaining indicators improved more or less over the course of time. Among these, the proportion of participants who indicated that they "now lead an overall healthier life" than before their enrolment into GK significantly increased from 25.6 % to 30.7 % (p=0.020). DISCUSSION AND CONCLUSION: The significant increase in the proportion of respondents who "now lead an overall healthier life" might be attributed to the fact that patient activation and empowerment was (and is) a top priority of the GK management strategy. Caution is advised, though, with this interpretation because of the limitations inherent to trend studies without an appropriate control group.

[Evaluation of the population-based 'Integrated Health Care System Gesundes Kinzigtal' (IHGK). Findings on health care quality based on administrative data]. / Evaluation der populationsbezogenen 'Integrierten Versorgung Gesundes Kinzigtal' (IVGK). Ergebnisse zur Versorgungsqualität auf der Basis von Routinedaten.

BACKGROUND AND OBJECTIVES: The management company "Gesundes Kinzigtal GmbH" signed an agreement on integrated healthcare with the statutory health insurer AOK Baden-Württemberg, effective as of November 1, 2005. The aim of the evaluation was to check whether the extent of overuse and underuse of healthcare services in the area of intervention declined or increased compared with usual care. METHODS: Longitudinal study with non-randomised control group based on health insurers' claims data from the years 2004-2011. Intervention group: residents of the Kinzigtal region insured by AOK. CONTROL GROUP: persons insured with the AOK in other regions of Baden-Württemberg. Healthcare quality indicators were derived from other studies and guidelines. Fifteen out of the 18 indicators related to overuse or underuse; three related to an outcome, namely avoidable hospital stays, the appearance of fractures in patients with osteoporosis, and mortality. Trend and outcome analyses rely on Poisson and Cox regressions adjusted for age, sex, the Charlson Index, and multimorbidity. RESULTS: Two out of 5 indicators for overuse and 2 out of 10 for underuse showed significant improvement for the intervention population relative to the control group. The risk of a fracture in patients with osteoporosis (HR: 0.809; 95 % CI: 0.740 to 0.885; p<0.0001) and mortality (HR: 0.944; 95% CI; 0.899-0.991; p=0.0194) were significantly lower in the Kinzigtal population. No negative trends were found. CONCLUSIONS: Compared with the control group, which represents the secular trend, significant improvements of healthcare quality in the intervention group (6 out of 18 indicators) are considerably more frequent than significant changes for the worse (0 out of 18 indicators). To date, the effects are not very strong, as all insured persons from the Kinzigtal form the basis of the analysis irrespective of their participation in the integrated care program. Claims data are appIicable to indicator based evaluation, but it would be necessary to consider additional years to see whether observed positive trends could be enhanced.

[The influence of framework conditions for integrated care programs on their potential of evaluation]. / Wie beeinflussen die Rahmenbedingungen integrierter Versorgungsprogramme die Möglichkeiten der Evaluation?

AIM AND METHODS: A common justification of the failure to perform scientific evaluations of integrated care programs (in accordance with Sect. 140 SGB V) is the high level of expenditure which is strongly influenced by the conditions of the particular program. Two practical examples will be used to outline frameworks of integrated care programs that may create obstacles to evaluation. If possible, appropriate solutions that may help to avoid or at least reduce these obstacles will be presented. RESULTS: In many programs target groups and program objectives are inaccurately defined. Especially disease-specific programs bear the risk of having too small a sample size to exclude random effects. Only a few integrated care programs include evaluations that have been proactively planned from the outdet. CONCLUSION: In particular, early planning of evaluations plays an important role in avoiding distortions of results and additional expenses. It may also have a positive influence on all other frameworks.

[Being cared for and caring: living with multiple chronic diseases (Leila)-a qualitative study about APN contributions to integrated care]. / Umsorgt werden und umsorgen: Leben mit mehreren Langzeiterkrankungen (Leila) - Eine qualitative Studie zum Beitrag von APN in integrierter Versorgung.

BACKGROUND: Living with multiple chronic diseases is complex and leads to enhanced care needs. To foster integrated care a project called "Living with chronic disease" (Leila) was initiated. AIM: The aim was to develop an Advanced Practice Nursing (APN) service in collaboration with medical centers for persons who are living with multiple chronic diseases. The following research questions were addressed: 1. What are patients' experiences, referring physicians and APNs with the Leila-Service? 2. How are referral processes performed? 3. How do the involved groups experience collaboration and APN role development? METHODS: A qualitative approach according grounded theory of Corbin and Strauss was used to explore the experiences with the Leila project and the interaction of the persons involved. 38 interviews were conducted with patients who are living with multiple chronic diseases, their APN's and the referring physicians. RESULTS: The findings revealed "Being cared for and caring" as main category. The data demonstrated how patients responded to their involvement into care and that they were taken as serious partners in the care process. The category "organizing everyday life" describes how patients learned to cope with the consequences of living with multiple chronic diseases. "Using all resources" as another category demonstrates how capabilities and strengths were adopted. CONCLUSIONS: The results of the cooperation- and allocation processes showed that the APN recognition and APN role performance have to be negotiated. Prospective APN-services for this patient population should be integrated along with physician networks and other service providers including community health nursing.