��?116b SGB?V in der rheumatologischen Versorgung

Background

The choice between outpatient and inpatient care is currently undergoing major changes within the German health care system with the amendment of §?116b SGB?V. This study investigates what proportion of hitherto inpatient rheumatologic care could potentially be given on an outpatient basis.

Methods

The analysis is based on administrative inpatient data from 2004 to 2008 covering approximately 23.6 million private health insurance insurants. The selection of patients with rheumatological diseases was based on diagnosis according to ICD-10 of §?116b SGB?V.

Results

From 2004 to 2008 the number of all rheumatologic cases increased by 13.9%, while the average length of hospital stay decreased from 9.46?days to 8.08?days and the number of attending hospitals declined by 3.1%. The number of rheumatologic cases with a short inpatient stay (??2?days) increased by 32.3%. We define the ambulatory potential as the proportion of patients with a short length of stay to the total of inpatient rheumatologic cases; this increased from 25.7% to 29.9%.

Discussion

Not all patients with a short inpatient stay can be transferred problem-free to ambulatory care. No channeling of patients to specialized centres has taken place thus far in Germany. Quality of care at the hospitals studied has not been considered. Further data are needed to link administrative data with quality care data.     

Rheumatologisches Medizinisches Versorgungszentrum an einer Akutklinik

Background

The chronic nature of most rheumatic diseases, the complexity of the course of the disease and types of therapy used necessitate a close interlocking of inpatient and outpatient treatment options. Some years ago in Germany the interdisciplinary outpatient and inpatient treatment was facilitated by statutory regulations. As the number of rheumatologists in private practice is not sufficient to provide adequate rheumatologic outpatient healthcare, the improvement of interface points between outpatient and inpatient care becomes more important. There are various ways for hospitals to take part in outpatient care, one of which is the foundation of an ambulatory healthcare center.

Methods

The introduction and integration of a medical healthcare center is described using an example.

Results

Against the background of insufficient rheumatology outpatient care in Cologne a city with 1 million inhabitants, the establishment of a rheumatology outpatient healthcare center at Porz am Rhein which is the only rheumatology clinic in this region is described.     

Versorgung von Patienten mit Non-CF-Bronchiektasen in der niedergelassenen Praxis

Background

Non-cystic fibrosis bronchiectasis (NCFB) is one of the most neglected diseases in respiratory medicine; however, it is of particular relevance in the ambulatory setting.

Objectives

There are many etiological causes of the disease; therefore, case findings as well as the diagnostic work-up are challenging in the German ambulatory setting.

Methods

The possibilities for a helpful approach to diagnostic and therapeutic procedures suitable for private practices according to the available literature are presented.

Results

The current literature points out that structural lung damage after infections (e.g. tuberculosis and pneumonia) has decreased in Germany during recent years. However, chronic obstructive pulmonary disease (COPD) as an etiology or comorbid condition has increased (up to 50?% in selected patients). As COPD is a frequent diagnosis in ambulatory care, the identification of NCFB patients remains a challenge. In up to 50?% of NCFB patients a causative etiology cannot be established (idiopatic bronchiectasis). However, a thorough diagnostic approach should be completed to identify treatable underlying conditions.

Conclusion

To provide a careful diagnostic work-up and therapeutic approach remains a challenge for community based physicians due to the lack of German guidelines for the management of NCFB. Therefore, modern therapeutic strategies, such as inhaled antibiotics and long-term treatment with azithromycin cannot be offered to all patients. The development of structures with an organizational level similar to those in cystic fibrosis is a future goal. This will help to explain the needs of this neglected patient group to healthcare providers and insurance companies.     

Geriatrische Versorgungsstrukturen in Deutschland

Background

To cover future needs of specialised geriatric patient-centred care, existing structures need to be developed further.

Materials and methods

Taking into account regional structures of providing care, the Federal Association of Geriatric Medicine in Germany developed the concept of Cross-Border Cooperation in Geriatric Medicine.

Results

This concept combines specific geriatric expertise provided by inpatient health care with specialised networking in ambulatory treatment of elderly with a typical geriatric profile. The objective is to provide geriatric patients with a holistic and specific care and case management that overcomes existing limitations.     

Der Abbau von Überversorgung als Teil der ärztlichen Berufsethik

Background

The topics of rationing and priority setting have been increasingly discussed over the past 5 years in Germany by physicians together with other health care stakeholders. The topic of overuse, however, has not been discussed with similar intensity and publicity.

Objectives

This analysis paper outlines the relationships and differences between efficiency, priority setting, and rationing. Furthermore, it argues why and how German physicians should address the topic of overuse with more transparency and intensity.

Discussion

Efforts of physicians to rationalize health care mainly comprise efforts to decrease overuse. The identification of important areas of overuse includes the prioritization of indications and medical interventions. Rationing health care can be unavoidable, for example, because other strategies such as rationalization, price regulation or disinvestments are not sufficient to avoid scarcity of financial resources. In such a case, rationing health care is unavoidable and, therefore, cannot be unethical per se. However, the debate on rationing becomes more legitimate if physicians demonstrate sufficient efforts to reduce overuse sufficiently. The Choosing Wisely initiative in the USA is outlined as one interesting option of how physicians could demonstrate and prove such efforts. Additional and more effective strategies to decrease overuse might be possible.

Conclusion

German physicians demand a more explicit communication within their communities and together with other stakeholders on the appropriateness of existing and potential future activities to decrease overuse. Such initiatives to avoid and decrease overuse should primarily be motivated through the ethical principle of beneficence, while the effect of cost containment should be considered as a welcomed side effect.     

Electronic Health Records and Ambulatory Quality of Care

CONTEXT

The US Federal Government is investing up to $29 billion in incentives for meaningful use of electronic health records (EHRs). However, the effect of EHRs on ambulatory quality is unclear, with several large studies finding no effect.

OBJECTIVE

To determine the effect of EHRs on ambulatory quality in a community-based setting.

DESIGN

Cross-sectional study, using data from 2008.

SETTING

Ambulatory practices in the Hudson Valley of New York, with a median practice size of four physicians.

PARTICIPANTS

We included all general internists, pediatricians and family medicine physicians who: were members of the Taconic Independent Practice Association, had patients in a data set of claims aggregated across five health plans, and had at least 30 patients per measure for at least one of nine quality measures selected by the health plans.

IINTERVENTION

Adoption of an EHR.

MAIN OUTCOME MEASURES

We compared physicians using EHRs to physicians using paper on performance for each of the nine quality measures, using t-tests. We also created a composite quality score by standardizing performance against a national benchmark and averaging standardized performance across measures. We used generalized estimation equations, adjusting for nine physician characteristics.

KEY RESULTS

We included 466 physicians and 74,618 unique patients. Of the physicians, 204 (44 %) had adopted EHRs and 262 (56 %) were using paper. Electronic health record use was associated with significantly higher quality of care for four of the measures: hemoglobin A1c testing in diabetes, breast cancer screening, chlamydia screening, and colorectal cancer screening. Effect sizes ranged from 3 to 13 percentage points per measure. When all nine measures were combined into a composite, EHR use was associated with higher quality of care (sd 0.4, p?=?0.008).

CONCLUSIONS

This is one of the first studies to find a positive association between EHRs and ambulatory quality in a community-based setting.     

Gesundheitsschutz bei Hitzewellen

Background

In the course of climate change periods of extreme heat will probably happen more frequently. The aim of heat health action plans is to prevent the health consequences of heat.

Objectives

The purpose of the present work is to develop a proposal for a heat health action plan for Hesse, Germany.

Materials and methods

In 34 interviews with experts the existing heat health warning system was evaluated. Heat health action plans of 8 European countries were analysed. On this basis a concept for a heat health action plan for Hesse was developed.

Results

In Hesse only nursing homes take preventative measures reliably, other health care sectors act along varying individual criteria. Heat health action plans include a heat health warning system and measures. They arrange competences and risk communication. Local authorities are responsible for implementation. Some plans include a surveillance system of mortality or morbidity. In a heat health action plan for Hesse measures should be specified and adapted to specific needs on the local level. Physicians in outpatient clinics are in a key position having contact with the vulnerable group of the elderly.

Conclusion

A heat health action plan offers opportunities for effective prevention if responsibilities are defined and evaluated, and monitoring of mortality and morbidity is integrated. In the structures of the German health care system efforts to prevent heat-related illness cannot succeed without reliable participation of the outpatient medical system.     

Bestandsaufnahme und Perspektiven der ambulanten rheumatologischen Versorgung in Deutschland

AIM: To gather information about current structures in rheumatologic ambulatory health care in Germany. Based on the results recommendations on future structures will be evaluated. METHODS: Data collection and statistical analysis via a structured 10-page questionnaire answered by members of the German Association of Rheumatologists. Questions in this second part of the study related to two topics: economic factors and a subjective assessment of the health care structures by the participants. RESULTS: Data from 197 ambulatory rheumatologists who participated in health care could be included in the analyses. Extensive and detailed data on economic issues surrounding ambulatory patient treatment and practice management from the perspective of ambulatory rheumatologists are presented (e.g., revenue, income, income differences between regions or practice size). In addition, perceptions of participating rheumatologists on future perspectives of patient treatment, health policy, and their own economical survival are reported. CONCLUSIONS: As in other specialties there is a significant difference not only between the eastern and western regions in Germany but also between the north and the south looking at e.g., revenue, income, with rheumatologists in the east treating significantly more patients. Reasons for those differences are not only related to regional remuneration schemes or the number of patients with a private but statutory health insurance, but are also driven by the number of different services provided (e.g., own laboratory). Physicians perceptions towards their own future in rheumatology are generally positive. Scepticism was reported for the individual economic survival in ambulatory treatment and future changes in health policy.     

Rheumatology outpatient nurse clinics: a valuable addition?

Objectives “Transmural rheumatology nurse clinics,” where nursing care is provided under the joint responsibility of a home care organization and a hospital, were recently introduced into Dutch health care. This article gives insight into outcomes of the transmural rheumatology nurse clinics.

Methods

Patients with rheumatologic conditions who attended a transmural nurse clinic, in addition to receiving regular care, were compared with patients with rheumatologic conditions who received regular care only. The main outcome measures were the need for rheumatology‐related information, the use of aids and adaptations, the use of health care services, and daily functioning.

Results

Attending a transmural nurse clinic does not influence patients' need for information, the application of practical aids and adaptations, or daily functioning. However, attending a transmural nurse clinic does result in more contacts with rheumatologists and occupational therapists.

Conclusions

Attending transmural nurse clinics does not result in major differences in outcomes compared with regular care. Further studies are needed to appreciate the long‐term effects of transmural nurse clinics.

     

Berliner TransitionsProgramm

Background

Transition is a crucial bridge between pediatric and adult rheumatology care and yet is often not a priority in either discipline. There is adequate evidence for the need of specific transition services. Various measures and transition programs have been proposed to support care during transition to adulthood; however, the implementation of youth-friendly services including transitional care has been frustratingly slow. Many structural and psychosocial barriers exist and prevent the widespread implementation of health transition support. Transition is resource consuming. It requires a reorganization of work flow to accommodate a clear, well-documented transitional pathway, including sufficiently long consultation times, age-appropriate communication, addressing of age-specific topics and a close cooperation between pediatric and adult rheumatologists.

Objectives

This article presents the Berlin transition program (BTP) and its development.

Results and perspectives

The BTP presented here is the first structured transition program financed by statutory health insurances in Germany. Since January 2013 it can be used for patients with rheumatic and musculoskeletal diseases in some regions of Germany. The BTP supports care at transfer; however, it cannot guarantee a successful transition. There is a need to make the BTP available nationwide and to evaluate its effectiveness. This could be a precondition to recognize transition services as part of regular healthcare.     

Ambulant betreute Wohngemeinschaften für Menschen mit Pflegebedarf

Background

Since the mid-1990s, supervised shared-housing arrangements (SHA; assisted living facilities) have developed as a specific type of small-scale living facility for elderly care-dependent persons with dementia in Germany, offering services different than those in residential care. Neither a uniform and binding definition of SHA nor reliable estimates concerning numbers currently exist. Since January 2013, SHA have been promoted nationwide in Germany by law.

Materials and methods

In a cross-sectional study funded by the National Association of Statutory Health Insurance Funds numbers as well as legal and financial frameworks of SHA in Germany were surveyed.

Results

As of February 2013, almost all German “Bundesländer” (federal states) have created special legal regulations for supervised SHA. The results of the present study show at least 1,420 SHA with 10,590 care places for adults in Germany. The regional distribution differs greatly.

Conclusion

Supervised SHA are increasingly an established care offer among the various long-term care offers in Germany. Different care and support offers help ensure individualized and high quality care for elderly care-dependent persons with dementia.     

A Randomized Trial of Treatments for High-Utilizing Somatizing Patients

BACKGROUND

Somatization and hypochondriacal health anxiety are common sources of distress, impairment, and costly medical utilization in primary care practice. A range of interventions is needed to improve the care of these patients.

OBJECTIVE

To determine the effectiveness of two cognitive behavioral interventions for high-utilizing, somatizing patients, using the resources found in a routine care setting.

DESIGN

Patients were randomly assigned to a two-step cognitive behavioral treatment program accompanied by a training seminar for their primary care physicians, or to relaxation training. Providers routinely working in these patients’ primary care practices delivered the cognitive behavior therapy and relaxation training. A follow-up assessment was completed immediately prior to treatment and 6 and 12 months later.

SUBJECTS

Eighty-nine medical outpatients with elevated levels of somatization, hypochondriacal health anxiety, and medical care utilization.

MEASUREMENTS

Somatization and hypochondriasis, overall psychiatric distress, and role impairment were assessed with well-validated, self-report questionnaires. Outpatient visits and medical care costs before and after the intervention were obtained from the encounter claims database.

RESULTS

At 6 month and 12 month follow-up, both intervention groups showed significant improvements in somatization (p?< 0.01), hypochondriacal symptoms (p?<?0.01), overall psychiatric distress (p?< 0.01), and role impairment (p?<?0.01). Outcomes did not differ significantly between the two groups. When both groups were combined, ambulatory visits declined from 10.3 to 8.8 (p?=?0.036), and mean ambulatory costs decreased from $3,574 to $2,991 (p?=?0.028) in the year preceding versus the year following the interventions. Psychiatric visits and costs were unchanged.

CONCLUSIONS

Two similar cognitive behavioral interventions, delivered with the resources available in routine primary care, improved somatization, hypochondriacal symptoms, overall psychiatric distress, and role function. They also reduced the ambulatory visits and costs of these high utilizing outpatients.     

Specialty,Political Affiliation,and Perceived Social Responsibility Are Associated with U.S. Physician Reactions to Health Care Reform Legislation

BACKGROUND

Little is known about how U.S. physicians’ political affiliations, specialties, or sense of social responsibility relate to their reactions to health care reform legislation.

OBJECTIVE

To assess U.S. physicians’ impressions about the direction of U.S. health care under the Affordable Care Act (ACA), whether that legislation will make reimbursement more or less fair, and examine how those judgments relate to political affiliation and perceived social responsibility.

DESIGN

A cross-sectional, mailed, self-reported survey.

PARTICIPANTS

Simple random sample of 3,897 U.S. physicians.

MAIN MEASURES

Views on the ACA in general, reimbursement under the ACA in particular, and perceived social responsibility.

KEY RESULTS

Among 2,556 physicians who responded (RR2: 65 %), approximately two out of five (41 %) believed that the ACA will turn U.S. health care in the right direction and make physician reimbursement less fair (44 %). Seventy-two percent of physicians endorsed a general professional obligation to address societal health policy issues, 65 % agreed that every physician is professionally obligated to care for the uninsured or underinsured, and half (55 %) were willing to accept limits on coverage for expensive drugs and procedures for the sake of expanding access to basic health care. In multivariable analyses, liberals and independents were both substantially more likely to endorse the ACA (OR 33.0 [95 % CI, 23.6–46.2]; OR 5.0 [95 % CI, 3.7–6.8], respectively), as were physicians reporting a salary (OR 1.7 [95 % CI, 1.2–2.5]) or salary plus bonus (OR 1.4 [95 % CI, 1.1–1.9) compensation type. In the same multivariate models, those who agreed that addressing societal health policy issues are within the scope of their professional obligations (OR 1.5 [95 % CI, 1.0–2.0]), who believe physicians are professionally obligated to care for the uninsured / under-insured (OR 1.7 [95 % CI, 1.3–2.4]), and who agreed with limiting coverage for expensive drugs and procedures to expand insurance coverage (OR 2.3 [95 % CI, 1.8–3.0]), were all significantly more likely to endorse the ACA. Surgeons and procedural specialists were less likely to endorse it (OR 0.5 [95 % CI, 0.4–0.7], OR 0.6 [95 % CI, 0.5–0.9], respectively).

CONCLUSIONS

Significant subsets of U.S. physicians express concerns about the direction of U.S. health care under recent health care reform legislation. Those opinions appear intertwined with political affiliation, type of medical specialty, as well as perceived social responsibility.     

Choosing Wisely

Background

In 2011 the American Board of Internal Medicine (ABIM) started the Choosing Wisely campaign.

Materials and methods

The goal was to establish top 5 lists by the medical societies to reduce diagnostic and therapeutic procedures which are not necessary or are potentially harmful, and thereby lower health care costs. The lists contributed by the American Geriatric Society and the American Medical Director Association in 2013 will be discussed.

Conclusion

At first glance, the idea seems simple, but numerous questions remain. Transferring this process to Germany appears theoretically possible, but various aspects of the health care system should be taken into consideration.     

Sind Mitglieder von Fibromyalgiesyndrom-Selbsthilfegruppen „anders“?

Background

No data were available on demographic and clinical characteristics of members of fibromyalgia syndrome (FMS) self-help groups in Germany.

Material and methods

The study was carried out from November 2010 to April 2011. A set of questionnaires was distributed by the German League Against Rheumatism and the German Fibromyalgia Association to members and to all consecutive FMS patients at nine clinical centres of different levels of care. The set included a self-developed questionnaire on demographic and medical data and on previously and currently used therapies, the patient health questionnaire (PHQ 4) and the fibromyalgia survey questionnaire.

Results

Members of FMS self-help groups (N?=?1,014) were older and reported a longer duration of chronic widespread pain, less anxiety and depression and a more frequent current use of aerobic exercise, relaxation training and complementary alternative medication than participants not affiliated with FMS self-help groups (N?=?630).

Conclusions

Membership in FMS self-help groups was associated with less psychological distress and a more frequent use of active self-management strategies.     

Mangelernährung und Demenz bei Bewohnern in Einrichtungen der stationären Altenpflege in Deutschland

Background and objective

Dementia is one of most challenging problems for the care of older people in Germany. Although malnutrition in nursing homes is also associated with dementia, few systematic studies have described health care structures in German nursing homes for people with dementia and their individual nutritional status. Therefore, the aim of this study was to determine dementia-specific differences concerning the nutrition situation for the elderly in German nursing homes.

Methods

A cross-sectional multicenter study was performed using a standardized multilevel instrument (observation, questionnaire) developed at the University of Maastricht. Variables are indicators for malnutrition and its risks, quality indicators, care dependency and types of interventions.

Results

In the 2008 and 2009 surveys, 53% of 4,777 participants (77.9% women, 22.1% men, mean age 82 years) were identified (based on care documentation) as having dementia. More than one third of this population (n?=?759, 85.1% women, 14.1% men, mean age 85 years) was probably malnourished; thus, the prevalence rate in the group of people with dementia was 10% higher compared to the group without dementia. People with dementia showed a higher risk in all relevant risk indicators (weight history, body mass index, and food intake) for malnutrition compared to those without dementia. Furthermore, people with dementia had higher care dependency rates and required more assistance for eating and drinking.

Conclusion

The study results confirm the relationship between malnutrition and dementia. The use of standardized nutrition screening tools is not common practice in German nursing homes yet. However, the results suggest that with an increasing risk for malnutrition combined with dementia the proportion of nursing interventions also increases, which means that nurses must react adequately. Nevertheless, the interventions concerning malnutrition should be improved especially with respect to preventive measurements.     

The Impact of Cost Displays on Primary Care Physician Laboratory Test Ordering

BACKGROUND

Physicians are under increased pressure to help control rising health care costs, though they lack information regarding cost implications of patient care decisions.

OBJECTIVE

To evaluate the impact of real-time display of laboratory costs on primary care physician ordering of common laboratory tests in the outpatient setting.

DESIGN

Interrupted time series analysis with a parallel control group.

PARTICIPANTS

Two hundred and fifteen primary care physicians (153 intervention and 62 control) using a common electronic health record between April 2010 and November 2011. The setting was an alliance of five multispecialty group practices in Massachusetts.

INTERVENTION

The average Medicare reimbursement rate for 27 laboratory tests was displayed within an electronic health record at the time of ordering, including 21 lower cost tests (< $40.00) and six higher cost tests (> $40.00).

MAIN MEASURES

We compared the change-in-slope of the monthly laboratory ordering rate between intervention and control physicians for 12 months pre-intervention and 6 months post-intervention. We surveyed all intervention and control physicians at 6 months post-intervention to assess attitudes regarding costs and cost displays.

KEY RESULTS

Among 27 laboratory tests, intervention physicians demonstrated a significant decrease in ordering rates compared to control physicians for five (19 %) tests. This included a significant relative decrease in ordering rates for four of 21 (19 %) lower cost laboratory tests and one of six (17 %) higher cost laboratory tests. A majority (81 %) of physicians reported that the intervention improved their knowledge of the relative costs of laboratory tests.

CONCLUSIONS

Real-time display of cost information in an electronic health record can lead to a modest reduction in ordering of laboratory tests, and is well received. Our study demonstrates that electronic health records can serve as a tool to promote cost transparency and reduce laboratory test use.