Bestandsaufnahme der ambulanten rheumatologischen Versorgung in Deutschland

Aim

To gather information on current organizational structures in rheumatologic ambulatory health care in Germany. Based on the results recommendations on future structures will be discussed.

Methods

This study involved data collection and statistical analysis via a structured 10-page questionnaire among the members of the German Association of Rheumatologists. The questions concerned a variety of topics including information on office structures, patient structure, structure of services offered, co-operation with colleagues and hospitals, quality assurance measures, economic factors, and a subjective assessment of the health care structures in rheumatology by the participants.

Results

Data obtained from 197 rheumatologists who participate in health care were analyzed. In this paper results concerning the organizational as well as the medical ambulatory health care structure will be presented. Data on economic factors will be presented in part 2 of this study.

Conclusions

The organization of ambulatory treatment regarding processes and treatment differences between office-based physicians and rheumatologic outpatient departments in hospitals was very homogeneous. However, physicians in the eastern regions treated significantly more patients compared with the western parts of Germany. This difference was also observed between the north and south. Differences in patient groups (e.g. underlying diseases) were reported between different sub-groups of rheumatologists (e.g. internal specialists vs. GP vs. orthopedic rheumatologists). Integrated health care, as promoted by German social law, did not play a major role. Overall there was a high level of self-initiated training of physicians and participation in education of patients and other physicians.     

Ambulante rheumatologische Versorgung in Deutschland

Outpatient rheumatologic treatment in Germany is managed by rheumatologists in private practice (n?=?557), by authorized rheumatism outpatient centers (n?=?116), by rheumatism centers according to §116b (n?=?43) and by university outpatient departments. A total number of 975 rheumatologists were registered by the end of 2012 of whom approximately 830 were active in outpatient care. With this number of rheumatologists Germany is in the middle range in comparison to eight industrial nations including the USA. This number is not sufficient to provide adequate medical care and the consequences are too long waiting times for an appointment with a rheumatologist. Statistical data of the Kassenärztliche Bundesvereinigung (KBV, National Association of Statutory Health Insurance Physicians) showed 688,000 general insurance patients with rheumatoid arthritis (RA). As some 68.9?% of the population are in this insurance scheme there are some 770,000 RA patients in Germany (almost 1?% of the population). One way to improve rheumatology care in spite of the lack of rheumatologists could be special agreements with the general health insurance providers to improve cooperation and division of responsibilities between rheumatologists and general practitioners, to implement patient education, tighter control and treat to target in rheumatology care. Another way could be a new treatment level called “ambulant specialist care”, with no budget for medical care and no budget for the number of patients treated and therefore the chance for rheumatologists to treat more patients and have a better income. To achieve that more young doctors receive approval as a specialist in rheumatology, more chairs of rheumatology at universities and a nationwide stipendium for training assistants are needed.     

Clinical academic rheumatology: getting more than you pay for

OBJECTIVE: Rheumatology is among the least compensated specialties in medicine today. This is a significant problem for clinical rheumatologists in academic medicine who are often expected to earn their salaries through clinical practice alone. Additionally, academic rheumatologists usually cannot generate revenue through office laboratory monitoring, radiographs, or bone densitometry to supplement their income (i.e., downstream income). The purpose of our study was to examine revenue generated from downstream income to a university by a clinical-academic rheumatologist. METHODS: Consecutive outpatients (n = 127) seen predominantly by one academic rheumatologist over one month of clinic were followed for 18 months. The total physician compensation for patient visits was calculated and compared with the revenue generated from laboratory tests, radiologic studies, consultations, and specific rheumatologic treatments and procedures performed or ordered. Medicare reimbursement rates for 2003 were used as compensation standards for all charges. RESULTS: Physician office visit billing generated 36,297 US dollars from 730 office visits. The total amount of downstream income from these office visits was 363,813 US dollars (47,386 US dollars from laboratory tests, 35,582 US dollars from radiologic studies, 8,159 US dollars from rheumatologic procedures, 261,584 from rheumatologic infusions, and 11,101 US dollars from initial consultations). Therefore, 10.02 US dollars of downstream revenue was generated for every 1.00 of office visit compensation applied to the academic rheumatologist's salary. CONCLUSION: Although academic rheumatologists struggle to bill their salaries through seeing more patients, they are clearly a bargain for a university hospital because they generate >10.00 US dollars for every 1.00 US dollars they receive for an office visit.     

Versorgungsforschung im Kompetenznetz Rheuma – Was leistet sie für die Verbesserung der Versorgung?

One of the areas of research in the Rheumatology Competence Network deals with health services research. It evaluates the structures and outcomes of rheumatological care. The paper presents selected results from the projects in the field of health services research. Data for rheumatoid arthritis are presented according to the criteria for the inclusion of diseases in new health care programs ("Disease Management"). The national database of the German Collaborative Arthritis Centers and cohort studies show the high individual and economic burden of disease in rheumatoid arthritis. Treatment by rheumatologists and non-rheumatologists differs greatly and leads to different outcomes. There is great potential for improvement. Data on practice variation within the rheumatologic subspecialty are used for quality management. The involvement of rheumatology into new concepts of care offers the chance to show the effectiveness of rheumatologic care and to enhance existing forms of cooperation.     

Comparative National Policies on Care and Support of Older Persons

Abstract. This symposium focused on four developed nations: the US, Australia, Canada and Germany. Activities in each country were analysed along the following lines: What is the official policy with regard to income guarantees (national pension programs), medical care and/or medical insurance, long-term care and housing? How well are the policy goals expressed in legislation being met? What is the extent of variation in services across the country? What factors are associated with high and low levels of service? To what extent are these services viewed as universal entitlements vs. linked to welfare status? How are economic and demographic forecasts affecting discussions about the future of these programs?     

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.     

Using ecological frameworks to advance a field of research, practice, and policy on aging-in-place initiatives

Initiatives to promote aging in place have emerged rapidly in the United States across various health care settings (e.g., acute care hospitals, skilled nursing facilities) and broader community settings (e.g., public social service agencies). Moreover, recent federal policies include a growing number of provisions for local efforts to promote aging in place. Despite emerging bodies of research that have described singular initiatives in their own right, there has been very little scholarship that forges conceptual linkages across this increasingly vast domain of research, practice, and policy. Integrative theory development is critical to ensure that aging-in-place initiatives do not become fragmented from each other. This article uses insights from ecological frameworks-specifically Urie Bronfenbrenner's bioecological systems theory and M. Powell Lawton's general ecological model of aging-to conceptualize a range of programs as aging-in-place initiatives and for describing their similarities and differences, particularly in terms of the features through which they intend to promote aging in place. Theoretically derived dimensions along which to characterize aging-in-place initiatives include environment-focused aspects (e.g., the types of social systems and structures that the initiatives target for change) and person-focused aspects (e.g., the extent to which the initiatives target particular subgroups of older adults). The article concludes with a discussion on how these theoretically derived dimensions can be used to advance and integrate research, practice, and policy to systematically develop and expand aging-in-place initiatives.     

Epidemiologie der Hypertonie in Deutschland und weltweit

Hypertension represents a major risk factor for myocardial infarction and the most important risk factor for stroke. Two thirds of strokes and half of myocardial infarctions arise from a systolic blood pressure > 115 mmHg. The relationship between blood pressure and cardiovascular diseases is log linear. Hypertension is the leading risk factor of preventable deaths worldwide. High blood pressure accounts for 26% of the total mortality in Germany. The prevalence of hypertension in Germany (55%) is twice the rate in Canada and the USA. Health care indicators such as hypertension awareness, treatment and control in Germany trail behind when compared internationally. Hypertension treatment and control in Germany amount to 26% and 8%, respectively. Concepts for the improvement of health care in patients with high blood pressure are, e.g., improvement of guideline awareness among physicians as well as quality-oriented payment for health care.     

Strukturen der akutstationären rheumatologischen Versorgung

Severe rheumatological systemic diseases demand high levels of diagnostic and therapeutic measures and differentiated and complex methods of care. In Germany, specialised rheumatologists and, if hospitalisation is indicated, specialised rheumatology hospitals or departments are responsible for the treatment of these patients. Early rehabilitation procedures, provided by a multidisciplinary therapeutic team, are an important component of the treatment concept in these facilities. Early rehabilitation is integrated into the patients acute medical treatment plan, with careful consideration of the patients current health problems and functional capabilities (body functions and structures, activities and participation as outlined in the ICF), thereby providing a comprehensive, integrated therapy strategy which has long been acknowledged as necessary for the successful treatment of rheumatoid patients. This article presents an analysis concerning the development, organisation, facilities and processes of the acute medical in-patient care for patients with rheumatological disorders in Germany. In total there are 4188 beds in 88 acute hospitals exclusively available for rheumatological in-patients in Germany at present. There is at least one facility specialised in rheumatology in every German federal state. The density of care in the German federal states varies between 131.8 beds per 1 million inhabitants in Bremen and 9 beds per 1 million inhabitants in Saxony. In most regions of Germany the acute in-patient care for patients with rheumatological disorders is provided by hospitals specialised in rheumatology. Rheumatological patients are treated in a variety of hospital departments. In the year 2000 only 47% of the inpatients with rheumatoid arthritis, 56% of those with ankylosing spondylitis and 28% of those with systemic lupus erythematosus were treated in a ward specialising in rheumatology. Rheumatoid arthritis, with a total share of nearly 30%, was the most frequently treated rheumatic disease in wards specialising in rheumatology, followed by soft tissue disorders (e.g. fibromyalgia), diseases with systemic involvement of connective tissue and inflammatory spinal disorders such as ankylosing spondylitis.     

Health care utilization among older adults with arthritis

OBJECTIVE: To evaluate the effect of arthritis on subsequent 2-year use of health care services and out-of-pocket costs among older adults and determine if comorbidities or economic resources mitigate that effect. METHODS: Data were analyzed from 6230 participants interviewed in 1993 and 1995 in the Asset and Health Dynamic Survey Among the Oldest Old (AHEAD), a national probability sample of community-dwelling adults. Baseline arthritis status was ascertained from the report of an arthritis-related physician's visit or a joint replacement not associated with a hip fracture. The effect of baseline arthritis on the odds of subsequent 2-year health care utilization and high out-of-pocket expenses were estimated from multiple logistic regression controlling for demographic factors, comorbidity, and economic resources. RESULTS: Older adults with arthritis are significantly more likely to have a physician visit (odds ratio [OR] 3.0), hospital admission (OR 1.6), outpatient surgery (OR 1.3), receive home health care (OR 1.6), and have out-of-pocket cost >5000 US dollars (OR 1.6) compared with contemporaries having similar demographics (age, sex, racial/ethnic group, marital status), comorbid conditions, and economic resources (education, income, wealth, health insurance), but not reporting arthritis. CONCLUSIONS: Older adults with symptomatic arthritis reported greater medical utilization and cost compared with people not reporting arthritis. These disparities persisted after accounting for differences in demographics, comorbidities, and economic factors. These findings document greater economic burdens on a personal and societal level among people with arthritis. As individuals, older adults with arthritis spend more out-of-pocket dollars for health care than their contemporaries without arthritis. On a societal level, these findings of greater health care utilization among people with arthritis point to increasing future demands on the US health care system due to demographic increases in the numbers of older adults with arthritis and support policies aimed at improving arthritis prevention and treatment as well as reducing the economic disparities between those with and without arthritis.     

Ambulatory models of care for obstructive sleep apnoea: Diagnosis and management

The high prevalence of obstructive sleep apnoea (OSA) and increasing awareness of its potential health consequences has placed significant pressure on laboratory‐based sleep services leading to growing waiting lists and delays in diagnosis and treatment. Consequently, there has been increasing interest in the use of simplified, ambulatory models of care involving clinical prediction tools, portable sleep monitoring and home autotitrating continuous positive airway pressure. Researchers are also exploring the potential role for a wider range of health‐care providers, including trained nurses and general practitioners, in the primary management of OSA. Recent randomized, controlled studies evaluating the clinical effectiveness of ambulatory management strategies versus traditional laboratory‐based care for patients with OSA have consistently demonstrated that comparable patient outcomes can be achieved. The cost‐effectiveness of these strategies is currently being debated, and further research examining the long‐term economic implications of ambulatory models of care is needed.     

The Abrupt Expansion of Ambulatory Telemedicine: Implications for Patient Safety

The exponential growth of telemedicine in ambulatory care triggered by the COVID-19 public health emergency has undoubtedly impacted the quality of care and patient safety. In particular, the increased adoption of remote care has impacted communication, care teams, and patient engagement, which are key factors that impact patient safety in ambulatory care. In this perspective, we draw on a scoping review of the literature, our own clinical experiences, and conversations with patient safety experts to describe how changes in communication, care teams, and patient engagement have impacted two high priority areas in ambulatory safety: diagnostic errors and medication safety. We then provide recommendations for research funders, researchers, healthcare systems, policy makers, and healthcare payors for how to improve patient safety in telemedicine based on what is currently known as well as next steps for how to advance understanding of the safety implications of telemedicine utilization.KEY WORDS: Ambulatory care, Patient safety, Telemedicine, Diagnostic errors, Medication errors

COVID-19 spurred significant growth in telemedicine use in American ambulatory healthcare. Previously, telemedicine (which we define as synchronous, scheduled video or telephone visits between clinicians and patients) had been limited primarily to specific clinical scenarios (e.g., specialty consultations in rural areas, low acuity concerns) or large health systems. The pandemic expanded telemedicine to additional contexts and populations. Moving forward, telemedicine use will remain more prevalent compared to pre-pandemic. This rapid shift requires attention to unintended consequences. Chief among these is the implications for patient safety, particularly in low-income populations and communities of color who are disproportionately cared for by under-resourced systems that may have adopted telemedicine rapidly but incompletely thereby increasing the potential for safety vulnerabilities. By identifying factors that heighten safety risk in telemedicine care, we can mitigate them. In this paper, we focus on the safety risks of telemedicine only and do not include consideration of other telehealth modalities (e.g., remote patient monitoring, secure messaging).Ambulatory patient safety incidents are frequent, with an estimated 2–3 adverse events in every 100 primary care visits.¹In an AHRQ (Agency for Healthcare Research and Quality)-commissioned technical brief on ambulatory safety, key informants identified six domains of ambulatory safety (medication management, diagnostic errors, care transitions, referrals, culture, and testing) and six strategies used to address these vulnerabilities (communication, health technology, teams, patient engagement, organizational approaches, and measurement).² We use this framework to identify the strategies most altered by telemedicine and how those changes impact specific ambulatory safety domains.     

Ambulatory medical care in Mexico: the cost for users

OBJECTIVE: To analyze the results of the National Health Survey (ENSA-II) as to the costs generated by the search and obtainment of ambulatory medical attention in various institutions of the private and public health sector. MATERIAL AND METHODS: Information was raised from the health care cost indicators reported by the study population of the ENSA-II. The dependent variable was the direct expense for the consumer and the independent variables, the condition of being insured and the income. Variation significance levels were identified using the test by Duncan. RESULTS: The costs at national level in US dollar were: transport $2.20, medical visit $7.90, drugs $9.60, diagnostic studies $13.6; average total cost for ambulatory attention was $22.70. Empirical finding suggest a new direct and indirect cost-for-consumer analysis for the health care users. These costs represent an important burden on the family income, which worsens when users are not insured. CONCLUSIONS: Incorporation of the economic perspective to the analysis of public health issues should not be limited to the analysis of the health provider's expenses, particularly if the problems of equity and accessibility must be solved, which are at present characteristic of health care services in Mexico.     

Social integrations related to institutionalized and noninstitutionalized forms of care of elderly people

This is a report about a research project analyzing costs and effectiveness of institutionalized and ambulatory care of older people. For this analysis economic factors as well as social factors are considered. On the sociological part multiple objective conditions (e.g. state health, financial situation and family relations) were correlated with subjective factors as feelings of well-being and various personal attitudes. To this purpose approximately 900 elderly persons (3 samples: 1. inhabitants of homes of the aged, 2. ambulant served (meals on wheels, home help and community nurses), 3. random sample of persons living at their own home. The 3 samples were taken in an urban, semiurban and rural area. Some remarkable differences between the 3 samples could be shown referring to the general physical and mental status and rate of impairment, in the state of care, familiar situation, social integration and subjective attitude (e.g. demonstrating that the inhabitants of homes for the aged were less socially integrated and less satisfied.     

Expanding the Caring Lens: Nursing and Medical Students Reflecting on Images of Older People

In changing higher education environments, health profession’s educators have been increasingly challenged to prepare future health professionals to care for aging populations. This article reports on an exploratory, mixed-method research study that used an innovative photo-elicitation technique and interprofessional small-group work in the classroom to enhance the reflective learning experience of medical and nursing students. Data were collected from pre- and postquestionnaires and focus groups to explore shifts in perceptions toward older persons following the reflective learning session. The qualitative data revealed how using visual images of older persons provides a valuable learning space for reflection. Students found meaning in their own learning by creating shared storylines that challenged their perceptions of older people and themselves as future health professionals. These data support the use of visual methodologies to enhance engagement, reflection, and challenge students to explore and deepen their understanding in gerontology.     

Stationäre rheumatologische Versorgung in Deutschland

Acute inpatient treatment plays an important role in the care of patients with rheumatic diseases in Germany. Inpatient facilities are usually departments in general hospitals or highly specialized clinics. The introduction of the diagnosis-related groups (DRG) system has led to a change in form which is most obviously characterized by more homogeneous structures and shorter hospital stays. Many rheumatic patients are, however, treated in general hospitals due to a lack of specialized clinics. The presence of a department of rheumatology in medical schools is deficient which therefore leads to only a small number of specialists in rheumatology. The rheumatologists in inpatient facilities are also involved in the care of outpatients, whereby the number of licensed internal medical rheumatologists is declining. Further possibilities in outpatient treatment in hospitals were created with new governmental regulations (§116b). Changes are expected with the implementation of the new outpatient specialist medical care (ASV).     

Caregiver objective burden and assessments of patient-centered, family-focused care for frail elderly veterans

PURPOSE: There is a growing consensus that quality of care for frail elders should include family and be evaluated in terms of patient-centered, family-focused care (PCFFC). Family caregivers are in a unique and sometimes sole position to evaluate such care. In the context of caring for physically frail elders, this study examined the extent to which objective burden was associated with caregiver perceptions of PCFFC and the extent to which it mediated the influence of other variables on perceptions of PCFFC. DESIGN AND METHODS: In a study of frail elderly veterans receiving care in U.S. Department of Veterans Affairs ambulatory primary care clinics, informal caregivers assessed quality of care with 13 questions. Factor analysis of these items revealed an eight-item scale that specifically assessed PCFFC (alpha =.90). Regression analysis identified variables associated with caregiver (N = 210) assessments of PCFFC and the potential mediating effect of objective burden. RESULTS: Caregiver assessments of PCFFC were positively associated with care recipient instrumental activity of daily living limitations (p =.04) and perspectives on the quality of their own patient care (p <.001). Greater objective burden was negatively associated with caregiver assessments of PCFFC (p <.001) and mediated (i.e., reduced) the relationship between care recipient perceptions of the quality of their own patient care and caregiver assessments of PCFFC (DeltaR(2) =.06). IMPLICATIONS: These findings support recommendations for conducting caregiver assessments as part of routine care and highlight the importance of measuring objective burden and expectations for PCFFC in assisting physically frail elders. Primary care providers will require additional training in order to effectively implement and translate such caregiver assessments into clinical practice improvement.     

Male patient perceptions of HIV stigma in health care contexts

Individuals living with HIV may have a heightened sensitivity to the behaviors of others that may signal bias or discrimination. Identifying and avoiding these potentially problematic behaviors may be especially important for service providers, such as health care personnel, who regularly interact with HIV-positive clientele. This study examines the experiences of 50 male American military veterans living with HIV and their perceptions of HIV stigma within health care contexts. Participants described a variety of behaviors performed by health care personnel that they perceived to be indicative of HIV stigma, ranging from ambiguous nonverbal cues (e.g., minimal eye contact) to blatant discrimination (e.g., physical abuse of HIV-positive patients). These findings extend previous research on HIV stigma in health care settings by (1) focusing on health care personnel's actual behaviors rather than their attitudes and beliefs about HIV-positive patients, (2) including patients' perceptions regarding the behaviors of both clinical and nonclinical health care personnel, and (3) identifying behaviors patients perceive as stigmatizing that are unique to health care contexts. Combined, these findings provide health care personnel a tangible list of behaviors that should either be avoided or further explained to HIV-positive patients, as they may be interpreted as stigmatizing.     

2009年深圳市宝安区33例地中海贫血患儿规范治疗及家庭负担情况调查

目的 了解深圳市宝安区登记在册的地中海贫血(简称地贫)患儿规范治疗及家庭经济负担情况,为政府制订卫生政策提供依据.方法 2009年,以电话访谈的方式对登记在册的39例地贫患儿家庭进行初步调查,预约并入户问卷调查收集33例患儿治疗及家庭经济状况.结果 33例地贫患儿中,21例(63.7%)中重度贫血;5例(15.1%)需要照顾或特殊照顾;25例(75.8%)勉强或无法维持规范治疗.家庭月均收入为(4060±2002)元,月均支出为(4926±2991)元,月均治疗支出为(2665±1872)元;家庭平均借债总额为(64 600±53 940)元.当家庭收入不足时(25例),15例(60.0%)患儿家庭会减少患儿输血或排铁次数.结论 地贫患儿家庭经济负担沉重,造成患儿规范治疗不足或中断,影响其生存和生活质量,应给予足够的重视和社会关怀.

Abstract：

Objective To investigate the standardized treatment of 33 children with thalassemia and their family financial burden registered in Bao'an district, Shenzhen city, and to provide basic information for formulating health policy for the government. Methods In 2009, preliminary investigations on 39 registered families with thalassemia children were conducted by telephone, and a household survey was made to collect treatment and economic status by questionnaire on 33 children. Results Among 33 cases of thalassemia children, 21 cases(63.7%) were severe anemia, 5 cases( 15.1%) in need of care or special care, and 25 cases(75.8%) were difficult or unable to maintain standardized treatment. The average family monthly income and expenditure was (4060 ± 2002) and (4926 ± 2991) yuan, respectively. The average monthly treatment costs were (2665 ± 1872) yuan, and the average debt amounted to (64 600 ± 53 940) yuan. Fifteen families[60.0%(15/25)] would reduce the times of blood transfusions or iron transpirations when they encountered revenue deficiency. Conclusions The heavy economic burdens on families with children thalassemia result in inadequate or interrupted treatment on sick children and affect their survival and quality of life, which should be taken more attention and social care.