[Transparency as a prerequisite of innovation in health services research: deficits in the reporting of model projects concerning managed care]. / Transparenz als Voraussetzung für Innovation in der Versorgungsforschung: Defizite am Beispiel der Evaluation von Managed-Care-Modellvorhaben.

AIM: Currently, elements of managed care are being implemented in the German health-care system. The legal basis for these innovations are § 140, § 73, § 137, and §§ 63 et seq. of the German Social Code - Part 5 (SGB V). For the model projects according to §§ 63 et seq. of the German Social Code a scientific evaluation and publication of the evaluation results is mandatory. The present study examines the status of evaluation of German model projects. METHODS: The present study has a mixed method design: A mail and telephone survey with the German Federal Social Insurance Authority, the health insurance funds, and the regional Associations of Statutory Health Insurance Physicians has been conducted. Furthermore, an internet research on "Medpilot" and "Google" has been accomplished to search for model projects and their evaluation reports. RESULTS: 34 model projects met the inclusion criteria. 13 of these projects had been terminated up to 30/9/2008. 6 of them have published an evaluation report. 4 model projects have published substantial documents. One model project in progress has published a meaningful interim report. 12 model projects failed to give information concerning the evaluator or the duration of the model projects. IMPLICATIONS: The results show a significant deficit in the mandatory reporting of the evaluation of model projects in Germany. There is a need for action for the legislator and the health insurance funds in terms of promoting the evaluation and the publication of the results. The institutions evaluating the model projects should obligate themselves to publish the evaluation results. The publication is an essential precondition for the development of managed care structures in the health-care system and in the development of scientific evaluation methods.

[Methods for organisational health services research]. / Methoden für die organisationsbezogene Versorgungsforschung.

On 1 July 2009, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned below and published in this journal (Gesundheitswesen 2009; 71: 505-510). The focus of this part of the Memorandum III "Methods for health services research" is on the questions and methods of organisational health services research. In a first step, we describe the central questions which are at the core of organisational health services research. In a second step, we describe the methodological standards and requirements with regard to a) sampling, b) measurement and c) research design. We present a phase model for complex intervention trials. This model allows to conduct high quality organisational health services research, to integrate different methods of social research and to show in which phase they are of special importance.

Determinants and implications of cancer patients' psychosocial needs.

GOALS OF WORK: Cancer patients often experience distress. However, the majority of newly diagnosed patients gradually adapt to the crisis. When symptoms of distress and anxiety persist over months, patients require psychosocial support. The aim of the present study was to determine the proportion of cancer patients who indicate the need for psychosocial support and to identify sociodemographic, psychological and illness-related factors predicting the need for psychosocial support in a German sample. MATERIALS AND METHODS: The cross-sectional retrospective study was administered to 710 cancer patients who had been inpatients at the University Hospital of Cologne. The response rate was 49.5%. Patients suffering from bronchial, oesophageal, colorectal, breast, prostate and skin cancer participated in the study. The severity of depressive symptoms was assessed using the German version of the Major Depression Inventory. The level of anxiety was assessed with the state subscale of the German version of the State-Trait Anxiety Inventory. To measure the functional aspects of health-related quality of life, the scales "physical functioning", "role functioning", "emotional functioning", "cognitive functioning" and "role functioning" of the European Organisation for Research and Treatment of Cancer QLQ-C30 Questionnaire (EORTC QLQ-C30) were used. MAIN RESULTS: Of the cancer patients, 18.9% indicate an unmet need for psychosocial support and 9.5% are actually using psychosocial services. In a multiple logistic regression, significant indicators of the need for psychosocial support are gender [p = 0.014; standardised effect coefficient (sc) = 1.615] and emotional functioning (p < 0.001; sc = 1.533). The estimated model has a specificity of 92.2% and a sensitivity of 54.0%. CONCLUSION: Almost a third of the cancer patient population indicates an unmet need for psychosocial support or is actually using psychosocial services. Emotional functioning is a central predictor of the requirement for psychosocial support. Women are emotionally more affected than men and need more psychosocial support. The prognostic validity of the severity of depression and anxiety is limited.

[Medication after hospitalization for acute coronary syndrome: Determinants of individual drug changes]. / Medikamentöse Versorgung bei akutem Koronarsyndrom nach Krankenhausentlassung. Determinanten individueller Medikationswechsel.

BACKGROUND AND OBJECTIVE: This study examines drug changes from therapeutic medication given during hospitalization to that in further out-of-hospital treatment prescribed by medical practitioners of patients with acute coronary syndrome. The main focus of this trial was to demonstrate any change in such medication after hospital discharge. PATIENTS AND METHODS: During a six-month period a "health diary" covering health status and medication was filled in weekly by 104 patients who had been hospitalized for acute coronary syndrome in the Cologne area of Germany. The mean age of the patients was 62 years and 76 (73%) of them were men. Changes in medication between hospital discharge and further treatment were recorded. Prescribed daily doses and guideline-recommended daily doses were compared for each drug class. RESULTS: Changes in medication were not observed in a population-based approach but occurred on an individual patient's level in 40% of them when only those drugs recommended in therapeutic guidelines were analysed. A fifth more lipid-lowering drugs and over a third more beta-blockers had been prescribed than recommended in the appropriate guidelines. For other groups of drugs no significant deviations from guideline recommendations were noted. DISCUSSION: No obvious interface problem between hospital and further-treatment medication was observed in a population-based approach. However, variations in medication were found when drug prescriptions of individual patients were compared But despite these variations in individual patient the overall prescribing practice by physicians out of hospital showed good implementation of the therapeutic guidelines.

[The "tendency to excuse" of inpatients. The relevance of the "tendency to excuse" in the interpretation of patient surveys]. / Die "Entschuldigungstendenz" bei Krankenhauspatienten. Die Bedeutung der "Entschuldigungstendenz" bei der Interpretation der Ergebnisse von Patientenbefragungen

OBJECTIVES: The primary purpose of this study was to analyse the extent to which inpatients excuse the errors and inconveniences that take place during their hospital stay and how this "tendency to excuse" affects their assessment of the hospital services. METHODS: The data, which provided the basis for this study, were obtained from a postal survey that was sent to 1 548 patients who had been treated in one of three hospitals in Germany. The survey itself was conducted within the scope of the research project entitled "Organizational Governance Using Biopsychosocial Indicators" (U-BIKE-Study) and contained various modules of the Cologne Patient Questionnaire (CPQ). For the purpose of the analyses, the "tendency to excuse" was subdivided into "excuser,""medium excuser" and "non-excuser". RESULTS: A total of 855 patients completed and returned the questionnaire (55.2% response rate). Descriptive analyses showed that nearly half of the patients surveyed were willing to excuse many of the hospital's errors and inconveniences. Each of the "tendency-to-excuse" types assessed the hospital services differently. The "excuser" almost always provides the most positive of assessments and the "medium excuser" almost always provides the most negative. CONCLUSIONS: The analyses revealed that fewer patients than initially expected on the basis of the traditional concept of the patient role excuse hospital errors and inconveniences. This can be seen as an indication that many inpatients do not take on the assumed patient role. While interpreting patient surveys, the "tendency-to-excuse" types can shed light on possible means of optimising hospital services. The "tendency to excuse" patients therefore aid in providing more valid measurements when conducting patient surveys.

Health services research in surgery--definitions, approaches and methods.

BACKGROUND AND AIMS: Health services research (HSR) investigates the translation of clinical studies into the practice of health care in relation to quality and efficiency from the individual and socioeconomic perspective. Given the fact that HSR has become increasingly popular during the last decade, this article aims at providing an overview of the significance and benefit of HSR in general and especially in the field of surgery. RESULTS: The first part of the overview provides various definitions that apply to the field, gives a brief historical overview of the development in Germany in contrast to the USA and Great Britain, and describes relevant theoretical frameworks and methods. In the second part it deals with gaps in patient care, patient-related outcomes, registry research, the integration of clinical and ambulatory surgery, and research on implementation of guidelines into practice. CONCLUSIONS: This overview shows that HSR is by now regarded as an essential field, at least in developed countries, and that we are just at the beginning to understand why demonstrated effective strategies in the clinical context do not or rarely translate into routine patient's care.

How to improve satisfaction with hospital stay of severely injured patients.

BACKGROUND: In the context of medical quality assurance, patient satisfaction with medical and organisational aspects of health care service is considered to be a relevant outcome of patient surveys after a stay in hospital. Within quality research, it is assumed that assessments of patient satisfaction represent a direct measure of the quality of health care received. Furthermore, there is evidence that satisfied patients demonstrate higher levels of compliance for the course of their treatment and that the probability of successful treatment completion thus considerably increases. The present analysis aims to identify determinants of satisfaction of seriously injured patients with regard to their acute hospitalisation. MATERIALS AND METHODS: One hundred twenty-one seriously injured survivors of work-related or traffic-related accidents treated in two hospitals in Cologne during the years 1996 to 2001 were sent a survey questionnaire. In addition to socio-demographic details, the survey covered the subjective evaluation of organisational and structural aspects of the acute hospitalisation and the psychosocial care provided by the medical staff. RESULTS: Employing the "tailored design method", a response rate of 74.4% (n = 90) was obtained. Three highly significant factors influencing the satisfaction of seriously injured patients were identified by means of logistic regression: (1) patients' perception of being involved in treatment, (2) patients' feeling of being neglected by physicians and (3) patients' perception of trust in physicians. CONCLUSIONS: In the present study, the perceived quality of psychosocial care proved to have a significant effect on patients' satisfaction with their hospital stay. Results of the current analysis thus indicate that psychosocial aspects of physician-patient interaction are of considerable importance in the medical care of seriously injured patients. Although this study is mainly based on subjective patient reported outcome, there is evidence that the subjective view of a patient is relevant in many aspects of medical treatment and outcome. These results already gave the motivation to develop a prospective interventional study with a training programme of communication skills to improve subjective and objective outcome parameters of severely injured patients.

[Determinants of severely injured patients' trust in their hospital physicians]. / Einflussfaktoren auf das Vertrauen schwerverletzter Patienten in den Krankenhausarzt.

BACKGROUND: Several studies have shown negative effects of insufficient physician-patient interaction leading to a lack of compliance, worse subjective and objective evaluation of treatment outcome, increased consumption of pain medication, and decreased patient satisfaction. The aim of the present study was to identify patient-, physician-, and/or hospital-specific determinants which have a significant influence on the trust of severely injured patients in their physicians. METHODS: A written questionnaire was sent to 121 severely injured patients hurt predominantly in traffic accidents and treated between July 1996 and July 2001 in two departments of surgery in the German state of Northrhine-Westfalia. Applying the Total Design Method, a response rate of 74.4% (n=90) could be achieved. RESULTS: Using univariate analysis as a preselection tool, we developed a logistic regression model which identified four significant predictors of patients' trust in their physicians: (1) patient evaluation of information, (2) patient evaluation of their physician's decision policy, (3) patient evaluation of treatment success, and (4) patient age. CONCLUSIONS: Besides age of patient and subjective evaluation of treatment success, it is psychosocial aspects of interaction which influence trust in a physician. The results of this analysis confirm the importance of physician-patient communication for medical education, also for surgeons.

[Patient- and hospital-related determinants of satisfaction with hospital stay of severely injured patients]. / Patienten- und krankenhausspezifische Einflussfaktoren auf die Zufriedenheit mit dem Krankenhausaufenthalt schwerverletzter Patienten.

BACKGROUND: General political and legal changes in the German health care system will increase the importance of patient surveys. Patient satisfaction with medical and organizational care during their stay in a hospital is a relevant outcome of quality assurance. Satisfied patients also show a higher compliance with treatment and therefore increase the probability of a successful outcome. The objective of this analysis was to identify determinants of satisfaction with hospital stay of severely injured patients. METHODS: A written questionnaire was sent to 121 severely injured patients, who were predominantly hurt by traffic or work-related accidents and were treated between 1996 and 2001 in two hospitals in Cologne (response rate=74.4%, n=90). The questionnaire used in this study contained questions about psychosocial care of physicians and nurses in and organizational and structural characteristics of the hospital. RESULTS: Logistic regressions identified two significant predictors for satisfaction with hospital stay: (1) subjective evaluation of psychosocial quality of care by physicians and (2) patients' perception of active integration in treatment decisions. CONCLUSION: The results of this analysis confirm the importance of soft science in medical education also for surgeons. Medical education should integrate knowledge about psychosocial aspects of medicine. The quality of psychosocial care of physicians seems to be a predictor of patient satisfaction. The probability of dissatisfaction increases with deficits in communication, information, and time as well as no active integration in treatment. The results of this analysis confirm the vital importance of psychosocial aspects in physician-patient interactions with severely injured patients for satisfaction with stay in hospital.