Self-help friendliness and cooperation with self-help groups among rehabilitation clinics in Germany (KoReS): a mixed-methods study protocol.

INTRODUCTION: Self-help is an important complement to medical rehabilitation for people with chronic diseases and disabilities. It contributes to stabilising rehabilitation success and further coping with disease and disability. Rehabilitation facilities are central in informing and referring patients to self-help groups. However, sustainable cooperation between rehabilitation and self-help, as can be achieved using the concept of self-help friendliness in healthcare, is rare, as is data on the cooperation situation. METHODS AND ANALYSIS: The KoReS study will examine self-help friendliness and cooperation between rehabilitation clinics and self-help associations in Germany, applying a sequential exploratory mixed-methods design. In the first qualitative phase, problem-centred interviews and focus groups are conducted with representatives of self-help-friendly rehabilitation clinics, members of their cooperating self-help groups and staff of self-help clearinghouses involved based on a purposeful sampling. Qualitative data collected will be analysed through content analysis using MAXQDA. The findings will serve to develop a questionnaire for a quantitative second phase. Cross-sectional online studies will survey staff responsible for self-help in rehabilitation clinics nationwide, representatives of self-help groups and staff of self-help clearinghouses. Quantitative data analysis with SPSS will include descriptive statistics, correlation, subgroup and multiple regression analyses. Additionally, a content analysis of rehabilitation clinics' websites will evaluate the visibility of self-help in their public relations. ETHICS AND DISSEMINATION: The University Medical Center Hamburg-Eppendorf Local Psychological Ethics Committee at the Center for Psychosocial Medicine granted ethical approval (reference number LPEK-0648; 10.07.2023). Informed consent will be obtained from all participants. Results dissemination will comprise various formats such as workshops, presentations, homepages and publications for the international scientific community, rehabilitation centres, self-help organisations and the general public in Germany. For relevant stakeholders, practical guides and recommendations to implement self-help friendliness will derive from the results to strengthen patient orientation and cooperation between rehabilitation and self-help to promote the sustainability of rehabilitation processes.

[Comparing Community Capacities by Local Actors and External Experts: An Audit of Health Promotion Activities in Lenzsiedlung, Hamburg]. / Evaluation von Gemeinde-Kapazitäten durch Quartiersakteur*innen und externe Expert*innen im Vergleich ­ Ergebnisse der Auditierung der Gesundheitsförderungsaktivitäten in der Hamburger Lenzsiedlung.

AIM: The questionnaire "Capacity building in Neighbourhoods (KEQ)" has five dimensions which are regarded as intermediary outcome results of community health promotion. The questionnaire was to be completed by local actors and thus has some features of self-evaluation. We wanted to find out whether external experts make similar or more critical assessments. METHODS: We conducted an audit of the health promotion activities in our intervention area (Hamburg neighbourhood Lenzsiedlung) in two steps. Five external health promotion experts functioned as auditors with experience in evaluating good practice projects of health promotion. The first part of the audit was a document-based evaluation, the second part a visit-based one during a two-day stay in the intervention area. RESULTS: In the comparison of local actors' assessments (KEQ questionnaire results) with those of external experts in the document-based audit, the judgements of external experts were more positive on all five dimensions of the questionnaire (deviations from +0.1 to +0.9 on a scale from 1 to 5). In the visit-based audit, there was convergence in the assessments of the local actors and the external experts. They were partly identical; only the dimension "local leadership" was viewed slightly more critically by the external experts. CONCLUSIONS: Based on our discussion of the four methodical problems of the comparison, we conclude that, on the whole, local actors do not tend to evaluate their activities too positively. However, if resources are available, one should try to confirm local views of outcomes by external assessments.

Self-help friendliness in cancer care: A cross-sectional study among self-help group leaders in Germany.

BACKGROUND: Peer support is increasingly recognized as crucial for improving health and psychosocial outcomes in oncological care. The integration of cancer self-help groups (SHGs) into cancer care facilities has gained importance in recent years. Yet, there is a lack of knowledge of the extent and quality of cooperation between cancer care facilities and SHGs and their integration into routine care. The concept of self-help friendliness (SHF) provides a feasible instrument for the measurement of cooperation and integration. METHODS: A cross-sectional study across Germany investigates the experiences of 266 leaders of cancer SHGs concerning their cooperation with cancer care facilities based on the criteria for SHF. The participatory study was developed and conducted with representatives of the House of Cancer Self-Help and the federal associations of cancer self-help. RESULTS: According to the SHG leaders, about 80% of their members primarily find their way to an SHG via other patients and only less than 50% more or less frequently via hospitals or rehabilitation clinics. The quality of cooperation with cancer centres, hospitals and rehabilitation clinics, however, is rated as good to very good by more than 70% of the respondents. Nine out of 10 quality criteria for SHF are fully or at least partially implemented, the values vary between 53% and 87%. Overall, 58% of the SHG leaders feel well to be very well integrated into care facilities. CONCLUSIONS: The results show a positive assessment of the involvement of SHGs in oncological care, but differences between inpatient and outpatient care and low referrals to SHGs are prominent. The concept of SHF is a feasible solution for a systematic and measurable involvement of SHGs. PATIENT OR PUBLIC CONTRIBUTION: The perspectives and insight of patient representatives obtained through qualitative interviews were directly incorporated into this study. Representatives of cancer self-help organizations were involved in the development of the questionnaire, reviewed it for content and comprehensibility, and further helped to recruit participants.

[Evidence-based health promotion: Where are we in education, training, and continuing training of relevant stakeholders? An exploratory overview]. / Evidenzbasiert Gesundheit fördern: Wo stehen wir in Aus­, Fort- und Weiterbildung der relevanten Akteure? Eine explorative Übersicht.

BACKGROUND: Health promotion interventions are not yet evidence-based to a desirable extent. A comparatively unnoticed explanatory factor could be that in the education and training of practitioners in health promotion and prevention, evidence-based approaches are still not sufficiently taken into account. OBJECTIVES: To what extent is the topic of evidence-based practice found in basic documents such as competency frameworks, module manuals of degree programs, and the education trainings offered by central training providers for practitioners in prevention and health promotion? MATERIALS AND METHODS: Selective Internet research and document analysis of two subject-specific qualifications frameworks, 31 degree programs, and three major training providers with respect to explicitly mentioned evidence topics. RESULTS: Clear consideration of evidence in both qualification frameworks and in 17 of the 31 degree programs; no explicit mention in any qualification program of the three training providers in the last five years. CONCLUSIONS: Limitations of the methodological approach are that not the entire field was analyzed, that only explicit consideration of evidence topics was sought, and that planning papers are an uncertain indicator of actual practice in education, training, and continuing education. Nonetheless, the exploratory study points to a need for action. It is suggested to approach universities and training providers with the aim of anchoring evidence topics more strongly in their offers, e.g., on the basis of the memorandum of the Bundeszentrale für gesundheitliche Aufklärung (Federal Centre for Health Education; BZgA) "Evidence-based Prevention and Health Promotion."

[Integrated Urban Development and Health Integrated Urban Development and Health Programme and Reality in Hamburg. A Documentary Analysis]. / Integrierte Stadtentwicklung und Gesundheit: Programmatik und Realität am Beispiel Hamburgs. Eine Dokumentenanalyse.

BACKGROUND: Legal regulations and funding programmes of (integrated) urban development, both at the federal and Hamburg level, require socio-spatial collaboration with health promotion. RESEARCH QUESTION: To what degree can the programmatic integration of health promotion into urban development be found in implementation documents? MATERIAL AND METHODS: An internet search was conducted in the "Transparency Portal" of Hamburg, containing more than 100,000 official documents, using three approaches: 1.) search with 7 central concepts of urban development and the appearance of health themes within them; 2.) finding the "Integrated Development Concepts" (planning papers) of 10 model projects of the funding programme "Social City" and identification of health themes within them; 3.) search of the internet pages of the two most important institutions for health promotion after identifying documents indicating their cooperation with bodies of urban development (Hamburg Authority for Health and Consumer Protection; Hamburg Working Group for Health Promotion). RESULTS: Health aspects in areas with special needs have not been taken into consideration as much as the programmes would require. However, there are some positive examples. Current details of collaboration can be seen on the internet pages of the Hamburg Working Group for Health Promotion. DISCUSSION AND CONCLUSIONS: The (pilot) study has the problem that references to health in official documents can lead to both over- and under-estimations of the activities in reality. However, it could be shown that there are models of good practice which should be more widely used in order to reduce the gap between programmes and reality. Some recommendations for this purpose are presented for further discussion.

[Integrated health reporting at the communal and federal state level-policy initiatives and approaches of the last 20 years]. / Integrierte Gesundheitsberichterstattung auf Landes- und kommunaler Ebene: Initiativen und Ansätze der letzten 20 Jahre.

The Ottawa Charter produced a new paradigm of health promotion, putting forward concepts such as intersectoral policies, determinants of health, and mediating. In this framework, the demand was made that health reports should be conceptualized as integrative, containing data from all sectors where health determinants can be found. The research question is: Can we identify explicit concepts and a publicly communicated practice of integrated health reporting in the German-speaking countries? In order to answer this question, a web search was carried out and supplemented by emailed inquiries to key project personnel.Eight projects were identified: four projects/initiatives represented local or regional integrated health reporting; in North Rhine-Westphalia there were two initiatives started by the federal state but relating to local reporting; in Berlin (Germany) and Burgenland (Austria) we found reports for the federal states. The projects are presented in compressed form. Limitations of this explorative research are its restriction to reports explicitly labeled as "integrative" and the narrowly defined search terms.Positive findings were good indicator concepts, some legal frameworks, and other promotive factors, such as scholarly support. However, there are shortcomings in putting integrative reporting into practice. Barriers might be the complexity of programs, missing financial, personal, and professional resources, organizational and methodical problems, as well as anxieties and prejudices. Some examples show that the barriers can be overcome. The guideline "Good Practice Health Reporting" supports the call for integrated reporting explicitly, however too much is hidden in the document.

[Sustainable urban health: conceptual foundations and current initiatives]. / Nachhaltige StadtGesundheit: konzeptionelle Grundlagen und aktuelle Initiativen.

The interactions between cities/settlements and health have been an issue of discussion since antiquity. Since the late 1970s, there has been renewed interest in the role of nonmedical determinants of health. This paper aims to retrace the development of relevant new concepts during the last 40 years, clarify their mutual relationships, and from this background present the concept of sustainable urban health. For this purpose, a secondary analysis is conducted and relevant documents and literature are being interpreted.After an introduction using illustrative examples of urban health, the paper describes how the WHO has provided crucial input to a renewed debate on public health since the 1970s, based on concepts such as "multi-/intersectoral action," "healthy public policy," and "health in all policies." Sustainable urban health, tying in with this tradition, is characterized as a program of expanding the horizon and of building bridges between disciplines and societal sectors. This is exemplified by a local initiative in the city of Hamburg.Rather than being substantially different, the WHO concepts may be seen as representing various shades of emphasis. Health in all policies (HiAPs) are in line with the UN Declaration of Human Rights and the UN Sustainable Development Goals; the concept succeeded in being integrated into both WHO and EU policy making. Additional work is required for the sustainable urban health goal to synchronously promote health and sustainability in urban societies.

[Self-help friendliness in ambulatory care, hospital care and rehabilitation services : Is collaboration with self-help structures being recognised in quality management systems?] / Selbsthilfefreundlichkeit in ambulanter, stationärer und rehabilitativer Versorgung : Wird die Kooperation mit der Selbsthilfe in Qualitätsmanagementsystemen berücksichtigt?

BACKGROUND: The "self-help friendliness" concept means the sustainably institutionalised collaboration of health services with self-help groups, led by criteria defining good collaboration. It aims to improve patient-centeredness. Therefore self-help friendliness should be taken into account in quality management systems (QMSs). OBJECTIVE: The objective is an analysis of whether and to what degree criteria of good collaboration have been introduced into the most widespread quality management systems in Germany. MATERIAL AND METHODS: Overall, 17 QMSs were analysed: hospital care (3), outpatient care (8), rehabilitation (6, the quantitatively most important ones). METHODS: analysis of websites, supplemented by a qualitative email survey with five to seven short questions building on our knowledge from websites and a previous survey. RESULTS: Criteria for good collaboration are well represented within QMSs for inpatient care and within the most widespread ones for doctors in ambulatory care (seven of seven relevant sector-specific QMSs). This is not the case in the quality management system based on DIN EN ISO 9001-2000 and three lesser used ones in ambulatory care. All six researched QMSs for rehabilitation services contain some (between one and four) tips for collaboration with self-help groups, however they are not very visible. DISCUSSION: The German network "Self-help friendliness and patient-centeredness in health services" tries to improve the overall unsatisfactory situation through closer collaboration with QMSs. The recently started discussion on quality premiums for good healthcare services may be favourable for future development, if patient-centeredness is recognised as a crucial quality goal.

[Complex health promotion community interventions with children : Evaluation using examples from a rural (Ortenaukreis) and an urban region (Lenzviertel Hamburg)]. / Komplexe gemeindeorientierte Interventionen zur Gesundheitsförderung bei Kindern : Evaluation am Beispiel einer ländlichen (Ortenaukreis) und einer städtischen Region (Lenzviertel Hamburg).

This article focuses the challenges of evaluating complex health promotion interventions in community settings. On the basis of two examples - the Präventionsnetzwerk Ortenaukreis (prevention network Ortenau, southwest Germany) and the project "Lenzgesund" (health promotion in the Lenz quarter of Hamburg, Germany) - empirical approaches and solutions are described. Across projects five central principles could be extracted: 1) a detailed description of the intervention and its objectives, 2) the connection of concept, structure, process, and outcome evaluation, 3) a multimodal and multimethodic approach, 4) participation, and 5) the analysis of summative evaluation data and implementation factors. These principles enable the description of effects beyond RCT designs.

[Responsibilities and concepts for undergraduate and postgraduate medical education in Germany : A plea for a reorientation]. / Zuständigkeiten und Konzepte zur ärztlichen Ausbildung und Weiterbildung : Ein Plädoyer für eine Neuorientierung.

BACKGROUND: Undergraduate medical education in Germany takes place in the medical faculties of universities, whereas postgraduate medical education takes place in nearly all hospitals under the aegis of medical associations. Both phases of the medical qualification process live on their own; the communication between the two responsible bodies is negligible. Previous reforms have always tackled undergraduate education only, whereas postgraduate education takes place without public attention. OBJECTIVE: This position paper discusses the origins and consequences of the complete separation between undergraduate and postgraduate medical education in Germany with regard to responsible bodies, learning objectives, and didactical concepts. On the basis of this critical analysis, proposals are presented to narrow the gap between the two phases. MATERIALS AND METHODS: This paper is based on several sources: data from historical documents, information retrieved from the internet on educational concepts in other OECD countries as well as intensive discussions among the authors. RESULTS AND DISCUSSION: The dissociation between under- and postgraduate education has historical reasons. Over a longer period of time the German Federal States reduced their responsibility for postgraduate education in favor of medical associations. The authors propose steps towards a better integration of both sequences, towards seeing the educational process as a continuum. In such a concept, medical associations would have a greater influence on undergraduate education and - vice versa - medical faculties on the postgraduate phase.

Involving self-help groups in health-care institutions: the patients' contribution to and their view of 'self-help friendliness' as an approach to implement quality criteria of sustainable co-operation.

BACKGROUND: The importance of patient participation and involvement is now widely acknowledged; in the past, few systematic health-care institution policies existed to establish sustainable co-operation. In 2004, in Germany, the initiative 'Self-Help Friendliness (SHF) and Patient-Centeredness in Health Care' was launched to establish and implement quality criteria related to collaboration with patient groups. OBJECTIVES: The objective of this study was to describe (i) how patients were involved in the development of SHF by summarizing a number of studies and (ii) a new survey on the importance and feasibility of SHF. SETTING AND PARTICIPANTS: In a series of participative studies, SHF was shaped, tested and implemented in 40 health-care institutions in Germany. Representatives from 157 self-help groups (SHGs), 50 self-help organizations and 17 self-help clearing houses were actively involved. The second objective was reached through a survey of 74 of the 115 member associations of the biggest self-help umbrella organization at federal level (response rate: 64 %). RESULTS: Patient involvement included the following: identification of the needs and wishes of SHGs regarding co-operation, their involvement in the definition of quality criteria of co-operation, having a crucial role during the implementation of SHF and accrediting health-care institutions as self-help friendly. The ten criteria in total were positively valued and perceived as moderately practicable. CONCLUSIONS: Through the intensive involvement of self-help representatives, it was feasible to develop SHF as a systematic approach to closer collaboration of professionals and SHGs. Some challenges have to be taken into account involving patients and the limitations of our empirical study.

Implementing 'self-help friendliness' in German hospitals: a longitudinal study.

In Germany, the term 'self-help friendliness' (SHF) describes a strategy to institutionalize co-operation of healthcare institutions with mutual aid or self-help groups of chronically ill patients. After a short explanation of the SHF concept and its development, we will present findings from a longitudinal study on the implementation of SHF in three German hospitals. Specifically, we wanted to know (i) to what degree SHF had been put into practice after the initial development phase in the pilot hospitals, (ii) whether it was possible to maintain the level of implementation of SHF in the course of at least 1 year and (iii) which opinions exist about the inclusion of SHF criteria in quality management systems. With only minor restrictions, the findings provide support for the usefulness, practicability, sustainability and transferability of SHF. Limitations of our empirical study are the small number of hospitals, the above average motivation of their staff, the small response rate in the staff-survey and the inability to get enough data from members of self-help groups. The research instrument for measuring SHF was adequate and fulfils the most important scientific quality criteria in a German context. We conclude that the implementation of SHF leads to more patient-centredness in healthcare institutions and thus improves satisfaction, self-management, coping and health literacy of patients. SHF is considered as an adequate approach for reorienting healthcare institutions in the sense of the Ottawa Charta, and particularly suitable for health promoting hospitals.

Self-help friendliness: A German approach for strengthening the cooperation between self-help groups and health care professionals.

Public and patient involvement in social and health care has proceeded in many civil societies. Depending on the legislations on national and community levels, citizens and patients have a greater say in shaping social and health care. In Germany, the patient involvement by self-help organizations at the macro level (national level and level of federal states) has significantly developed over the last ten years. At the meso level, however, the patient involvement is neither such far nor such systematically developed. The concept of self-help friendliness (SHF) in health care is a patient centred model that allows the development and implementation of patient participation in different health care institutions: hospitals, ambulatory medical care, public health institutions, rehabilitation facilities etc. In a series of projects on SHF we have (1) analysed the needs and wishes of self-help groups for cooperation with health care professionals as well as their experience, (2) gathered facilitators and barriers concerning the cooperation between self-help groups and hospitals, (3) developed a framework concept for SHF in hospitals including eight quality criteria for measuring SHF, and (4) implemented the framework of SHF in about 40 health care institutions (www.selbsthilfefreundlichkeit.de). Further projects followed: development of an instrument for measuring SHF in hospitals, integration of SHF-criteria in quality management systems in inpatient care as well as in out-patient care, and transferring SHF to a) medical ambulatory care, b) public health departments, and c) rehabilitation facilities. Considering advantages and shortcomings of the approach, we can summarize that implementing SHF is feasible, transferable and a helpful measure for promoting patient centeredness in health care.

Increasing patient centredness in outpatient care through closer collaboration with patient groups?: an exploratory study on the views of health care professionals working in quality management for office-based physicians in Germany.

OBJECTIVES: In Germany, "self-help friendliness" is an upcoming popular concept for the promotion of patient centredness through closer cooperation of health care services with self-help groups of chronically ill and/or disabled patients and their relatives. The study aimed at gathering information from physicians with special expertise in quality management on opportunities for and barriers against introducing more collaboration between physicians and self-help groups in outpatient care. METHODS: A cross-sectional explorative survey was conducted with quality circle moderators (group leaders) from four German federal states in 2008 and 2010 (n=624 or 32.1% respondents out of 1943). Main outcome measure was the moderators' assessment of their peers, measured with 18 items. Statistical analyses were mainly descriptive, supplemented by subgroup analyses by federal state and characteristics of the respondents. RESULTS: Moderators see a large willingness of outpatient physicians to integrate self-help activities, and many opportunities for better cooperation with patient groups. Nevertheless, most types of cooperation need activation and motivation. To enhance the cooperation, additional fees by health insurance funds, CME credit points and the decrease of doctors' work load are most likely to be effective. CONCLUSIONS: Given the willingness of office-based physicians to cooperate with patient groups, increased patient centredness through cooperation seems to be an achievable quality target in medical practices in Germany. Self-help-friendliness in medical practices is considered as an important partnership approach; however, the implementation is still in the early stages and has to overcome diverse barriers, mainly based on unfavourable opinions, negative attitudes and lack of incentives.

A comparison of conventional and retrospective measures of change in symptoms after elective surgery.

BACKGROUND: Measuring change is fundamental to evaluations, health services research and quality management. To date, the Gold-Standard is the prospective assessment of pre- to postoperative change. However, this is not always possible (e.g. in emergencies). Instead a retrospective approach to the measurement of change is one alternative of potential validity. In this study, the Gold-Standard 'conventional' method was compared with two variations of the retrospective approach: a perceived-change design (model A) and a design that featured observed follow-up minus baseline recall (model B). METHODS: In a prospective longitudinal observational study of 185 hernia patients and 130 laparoscopic cholecystectomy patients (T0: 7-8 days pre-operative; T1: 14 days post-operative and T2: 6 months post-operative) changes in symptoms (Hernia: 9 Items, Cholecystectomy: 8 Items) were assessed at the three time points by patients and the conventional method was compared to the two alternatives. Comparisons were made regarding the percentage of missing values per questionnaire item, correlation between conventional and retrospective measurements, and the degree to which retrospective measures either over- or underestimated changes and time-dependent effects. RESULTS: Single item missing values in model A were more frequent than in model B (e.g. Hernia repair at T1: model A: 23.5%, model B: 7.9%. In all items and at both postoperative points of measurement, correlation of change between the conventional method and model B was higher than between the conventional method and model A. For both models A and B, correlation with the change calculated with the conventional method was higher at T1 than at T2. Compared to the conventional model both models A and B also overestimated symptom-change (i.e. improvement) with similar frequency, but the overestimation was higher in model A than in model B. In both models, overestimation was lower at T1 than at T2 and lower after hernia repair than after cholecystectomy. CONCLUSIONS: The retrospective method of measuring change was associated with a larger improvement in symptoms than was the conventional method. Retrospective assessment of change results in a more optimistic evaluation of improvement by patients than does the conventional method (at least for hernia repair and laparoscopic cholecystectomy).

Evaluating the implementation of the WHO Healthy Cities Programme across Germany (1999-2002).

The WHO Healthy Cities Project (1988) is a well-known example of the setting-based approach to health promotion. Developed as a framework for translating the key principles of the Ottawa Charter for Health Promotion (1986) into practice, it is best characterized as a process for successfully encouraging healthy public policy. In 2001, the German Healthy Cities Network (HCN) commissioned a survey of the 52 local Healthy Cities programme Coordinators (HCC) to monitor progress and identify strengths and weaknesses associated with its implementation. Most (90%; 47/52) HCC participated in the survey. Several positive aspects of the Health Cities Programmes (HCP) in Germany were identified: during the first 5 years, it expanded rapidly; project coordinators felt highly engaged, despite limited resources; a combination of traditional and innovative approaches was adopted and applauded; and almost 75% of HCC felt that their efforts had been beneficial. Nonetheless, the following shortcomings were identified: increased resources required; greater clarification of concepts and strategies at the local level; stronger commitment to the Nine-Point Programme of Action; greater integration within the national HCN and the local political administrative system (PAS); better programme documentation and evaluation. In conclusion, the HCN in Germany has expanded and developed since its inception 20 years ago. German HCP will only improve if professionalism and quality of local work are improved, particularly in terms of strengthening their influence on the local PAS and on public policies.

Assessing patient-reported outcomes of cholecystectomy in short-stay surgery.

BACKGROUND: The project aimed at testing the feasibility of a quality improvement system based on patient-reported outcomes in short-stay surgery for cholecystectomy. METHODS: In two centers for short-stay surgery, patients referred for laparoscopic cholecystectomy were surveyed between Aug 1999 and Jan 2002. Patients reported on health-related quality of life (SF-36), symptoms (gallstone symptom checklist, GSCL) and other indicators preoperatively (T0), 14 days (T1) and 6 months postoperatively (T2). The SF-36 subscales physical functioning, bodily pain, and role physical as well as the GSCL and treatment satisfaction at T2 were considered as main outcomes. The main outcomes were analyzed by generalized linear models with regard to predictors. RESULTS: At T0 a total of 205 patients were included. The response rate at T2 was 63.4% (74.6% females, 53.6 years of age). The GSCL score at T0 (29.4% preoperatively) fell slightly to 27.9% at T1 and decreased to 14.8% at T2 (T0-T2: p < 0.001). The SF-36 subscales showed a different course over time (decrease of health-related quality of life at T1 and large increase at T2). The level of satisfaction with the outcome of cholecystectomy was 82.3%. The patient-reported outcomes were mainly influenced by the preoperative level, age and self-reported postoperative complaints. CONCLUSION: The low response rate was mainly due to nondelivery of questionnaires at T1 during the regular postoperative visit by the operating physician. Though nonresponse occurs under conditions of routine care, meaningful information was gained, which should be used for quality improvement activities. Because the preoperative level is a major determinant of the postoperative health outcomes, the prospective pre-post measurement should be preferred if institutional comparisons are intended.