The Digital Healthcare Act - a Turning Point in the German Digitisation Strategy?

Views of German mental health professionals on the use of digital mental health interventions for eating disorders: a qualitative interview study

INTRODUCTION

Digital mental health interventions (DMHIs) are getting increasingly important for mental health care. In the case of eating disorders (EDs), DMHIs are still in early stages. Few studies so far investigated the views of mental health professionals for EDs on the integration of DMHIs in routine care.

OBJECTIVE

To gain insights into the experiences, perspectives, and expectations of mental health professionals for EDs regarding DMHIs and to identify requirements for the future integration of DMHIs into routine care.

METHODS

Semi-structured qualitative telephone interviews with 24 German mental health professionals treating patients with EDs were conducted. A content analysis following a deductive-inductive approach asked for experiences, advantages and chances, disadvantages and boundaries, desired functions and properties, target groups, and general conditions and requirements for DMHIs for patients with EDs.

RESULTS

Only few professionals reported experiences with DMHIs besides video-based psychotherapy during the pandemic. From the therapists' point of view, DMHIs have the potential to deliver low-threshold access for patients with EDs. Useful functionalities were seen in digital meal records, skills training, and psychoeducation. However, a stable therapeutic alliance was reported as an important prerequisite for the successful integration into care. Therapists expressed concerns in case of severe anorexia nervosa or suicidality. The participants felt to be informed inadequately on recent developments and on the evidence base of DMHIs.

CONCLUSIONS

Mental health professionals for EDs show positive attitudes towards DMHIs, however many barriers to the integration in routine care were observed. The highest potential was seen for the use of DMHIs in addition to outpatient care and in aftercare. Specific requirements for DMHIs are related to different areas of the healthcare spectrum and for the different symptom profiles in anorexia nervosa, bulimia nervosa and binge eating disorder. Targeted DMHIs are needed and appropriate especially for concepts of blended care.

Orthopaedic and trauma surgeons' prioritisation of app quality principles based on their demographic background

BACKGROUND

Although apps are becoming increasingly relevant in healthcare, there is limited knowledge about how healthcare professionals perceive "quality" in this context and how quality principles that can aid them in assessing health-related apps may be prioritised. The objective was to investigate physicians' views of predefined (general) quality principles for health apps and to determine whether a ranking algorithm applied to the acquired data can provide stable results against various demographic influences and may thus be appropriate for prioritisation.

METHODS

Participants of an online survey of members of two German professional orthopaedics associations conducted between 02/12/2019 and 02/01/2020 were asked about their perception of a set of quality principles for health apps (i.e., "practicality," "risk adequacy," "ethical soundness," "legal conformity," "content validity," "technical adequacy," "usability," "resource efficiency," and "transparency"). Structured as a Kano survey, for each principle, there were questions about its perceived relevance and opinions regarding the presence or absence of corresponding characteristics. The available data were evaluated descriptively, and a newly developed method for prioritisation of the principles was applied overall and to different demographic strata (for validation).

RESULTS

Three hundred eighty-two datasets from 9503 participants were evaluated. Legal conformity, content validity, and risk adequacy filled ranks one to three, followed by practicability, ethical soundness, and usability (ranks 4 to 6). Technical adequacy, transparency, and resource efficiency ranked last (ranks 7 to 9). The ranking based on the proposed method was relatively stable, irrespective of demographic factors. The principles were seen as essential, with one exception ("resource efficiency"). Only those with little to no interest in digitisation (22/382, 5.8%) rated the nine principles indifferently.

CONCLUSIONS

The specified quality principles and their prioritisation can lay a foundation for future assessments of apps in the medical field. Professional societies build upon this to highlight opportunities for digital transformations in medicine and encourage their members to participate.

Socio-economic burden of disease: Survivorship costs for renal cell carcinoma

OBJECTIVE

The objective of this study is to assess the risk-stratified 10-year socio-economic burden of renal cell carcinoma (RCC) follow-up costs after initial treatment in Germany from 2000 to 2020.

METHODS

A micro-costing method considering direct and indirect medical expenditure associated with follow-up procedures was employed to calculate survivorship costs per patient. The frequencies of physician-patient visits, examinations and diagnostic tests were extracted from guidelines, whilst expenses were sourced from literature and official scales of tariffs. Societal costs were calculated based on three perspectives: patients, providers and insurers.

RESULTS

Mean societal 10-year follow-up costs per patient amounted to EUR 3,377 (95%CI: 2,969-3,791) for low-risk, EUR 3,367 (95%CI: 3,003-3,692) for medium-risk and EUR 4,299 (95%CI: 3,807-4,755) for high-risk RCC in 2020. Spending increased by +32% from 2000 to 2020 for low-risk RCC, whilst medium-and high-risk RCC expenditure was cut by -39% and -22%, respectively. Patients shouldered 27%, providers 43% and insurers 35% of costs in 2020. Resources were consumed by medical imaging (52%), physician-patient consultations (31%), travel expenses (17%) and blood tests (1%).

CONCLUSION

Results highlight the economic burden cancer survivorship poses for society. Cancer survivors require individualised, evidence-based and insurance-covered follow-up schedules to permit the early detection of side-effects, metastasis and secondary malignancies.

Prioritization of Quality Principles for Health Apps Using the Kano Model: Survey Study

Background

Health apps are often used without adequately taking aspects related to their quality under consideration. This may partially be due to inadequate awareness about necessary criteria and how to prioritize them when evaluating an app.

Objective

The aim of this study was to introduce a method for prioritizing quality attributes in the mobile health context. To this end, physicians were asked about their assessment of nine app quality principles relevant in health contexts and their responses were used as a basis for designing a method for app prioritization. Ultimately, the goal was to aid in making better use of limited resources (eg, time) by assisting with the decision as to the specific quality principles that deserve priority in everyday medical practice and those that can be given lower priority, even in cases where the overall principles are rated similarly.

Methods

A total of 9503 members of two German professional societies in the field of orthopedics were invited by email to participate in an anonymous online survey over a 1-month period. Participants were asked to rate a set of nine app quality principles using a Kano survey with functional and dysfunctional (ie, positively and negatively worded) questions. The evaluation was based on the work of Kano (baseline), supplemented by a self-designed approach.

Results

Among the 9503 invited members, 382 completed relevant parts of the survey (return rate of 4.02%). These participants were equally and randomly assigned to two groups (test group and validation group, n=191 each). Demographic characteristics did not significantly differ between groups (all P>.05). Participants were predominantly male (328/382, 85.9%) and older than 40 years (290/382, 75.9%). Given similar ratings, common evaluation strategies for Kano surveys did not allow for conclusive prioritization of the principles, and the same was true when using the more elaborate approach of satisfaction and dissatisfaction indices following the work of Timko. Therefore, an extended, so-called “in-line-of-sight” method was developed and applied for this evaluation. Modified from the Timko method, this approach is based on a “point of view” (POV) metric, which generates a ranking coefficient. Although the principles were previously almost exclusively rated as must-be (with the exception of resource efficiency), which was not conducive to their prioritization, the new method applied from the must-be POV resulted in identical rankings for the test and validation groups: (1) legal conformity, (2) content validity, (3) risk adequacy, (4) practicality, (5) ethical soundness, (6) usability, (7) transparency, (8) technical adequacy, and (9) resource efficiency.

Conclusions

Established survey methodologies based on the work of Kano predominantly seek to categorize the attributes to be evaluated. The methodology presented here is an interesting option for prioritization, and enables focusing on the most important criteria, thus saving valuable time when reviewing apps for use in the medical field, even with otherwise largely similar categorization results. The extent to which this approach is applicable beyond the scenario presented herein requires further investigation.

User experience and acceptance of patients and healthy adults testing a personalized self-management app for depression: A non-randomized mixed-methods feasibility study

Objective

Previous studies have shown positive treatment outcomes of e-mental health applications targeting depression. However, few applications provide personalized features. The aim of the present study is to ask for the user experience and acceptance of patients with depression and healthy adults, who tested the self-management app Self-administered Psycho Therapy SystemS over a period of 5 days. The results serve as a source for evidence-based recommendations for developers and clinicians.

Methods

A total of 110 participants (41 patients and 69 healthy controls) tested the app Self-administered Psycho Therapy SystemS over a period of 5 days and completed evaluation sheets developed for the purpose of this study. Quantitative measures were asked with 5-point Likert-scaled items (range: −2 to + 2) for the perceived quality of the programme and its components, its practicality (both referred to as user experience) and its acceptance. Student’s t-tests and Pearson correlations were calculated for group comparisons and associations, respectively. Open text fields were analysed by applying a qualitative structuring content analysis.

Results

The perceived quality of the total programme was rated with M = 0.96 (SD = 0.82), the practicality was M = 0.84 (SD = 0.08) and the acceptance was M = 0.25 (SD = 1.04). Patients rated perceived quality of the total programme and acceptance higher than healthy adults, while there was no difference in practicality. Acceptance was associated with increased depression scores (r = 0.33, p = .01), higher scores of perceived quality of the total programme (r = 0.48, p< .001) and of practicality (r = 0.45, p < .001). Feedback of both groups regarding usability, therapeutic content and personalization revealed a strong wish for guidance and insights into mood progress, opportunities for choice of interventions and features of customization for individualized treatment.

Conclusions

Patients with depression accepted the app Self-administered Psycho Therapy SystemS more than healthy adults and gave higher ratings in quality. User experience of all users shows a need for features of guidance, choice and personalization that clinicians and developers of future apps should pay attention to.

Testicular cancer follow-up costs in Germany from 2000 to 2015

Purpose

Advances in testicular cancer screening and therapy increased 10-year survival to 97% despite a rising incidence; eventually expanding the population of survivors requiring follow-up. We analyzed 10-year follow-up costs after testicular cancer treatment in Germany during 2000, 2008, and 2015.

Methods

Testicular cancer follow-up guidelines were extracted from the European Association of Urology. Per patient costs were estimated with a micro-costing approach considering direct and indirect medical expenses derived from expert interviews, literature research, and official scales of tariffs. Three perspectives covering costs for patients, providers, and insurers were included to estimate societal costs. Cost progression was compared across cancer histology, stage, stakeholders, resource use, and follow-up years.

Results

Mean 10-year follow-up costs per patient for stage I seminomatous germ-cell tumors (SGCT) on surveillance declined from EUR 11,995 in 2000 to EUR 4,430 in 2015 (p < 0.001). Advanced SGCT spending shrank from EUR 13,866 to EUR 9,724 (p < 0.001). In contrast, expenditure for stage II SGCT increased from EUR 7,159 to EUR 9,724 (p < 0.001). While insurers covered 32% of costs in 2000, only 13% of costs were reimbursed in 2015 (p < 0.001). 70% of SGCT follow-up resources were consumed by medical imaging (x-ray, CT, ultrasound, FDG-PET). Spending was unevenly distributed across follow-up years (years 1–2: 50%, years 3–5: 39%, years 5–10: 11%).

Conclusions

The increasing prevalence of testicular cancer survivors caused German statutory insurers to cut per patient cost by up to 80% by budgeting services and decreasing reimbursement rates. The economic burden was gradually redistributed to patients and providers.

Prostate cancer follow-up costs in Germany from 2000 to 2015

Purpose

The main objective of this study is to estimate and evaluate 10-year follow-up costs after prostate cancer treatment with curative (surgery, radiotherapy) and non-curative intent (hormone, androgen deprivation) per patient in Germany in 2000, 2008, and 2015.

Methods

Prostate cancer follow-up recommendations were extracted from the European Association of Urology guidelines from 2000 to 2015. Per patient costs were calculated with a detailed micro-costing approach considering direct and indirect medical expenses. Input parameters were derived from expert interviews, literature research, and official scales of tariffs. Costs for insurers, providers, and payers were included to estimate societal costs.

Results

Mean 10-year follow-up costs per patient after treatment with curative intent amounted to EUR 4415 in 2000, EUR 4224 in 2008 (p < 0.001), and EUR 5159 in 2015 (p < 0.001). Costs after hormone therapy with metastasis cumulated to EUR 10,846 in 2000, EUR 9818 in 2008 (p < 0.001), and EUR 11,978 in 2015 (p < 0.001). While insurers covered 37% of costs in 2000 (EUR 1664), only 23% of costs were reimbursed in 2015 (EUR 1195; p < 0.001). Cost sources mainly included consultations (55%), transportation (18%), and imaging (27%).

Conclusion

Early detection and advances in prostate cancer treatment increased 10-year survival rates beyond 80% in Germany, ultimately expanding the number of survivors requiring follow-up. Statutory insurers reacted by decreasing the reimbursement rates to reduce per patient cost by up to 46%. Consequently, the economic burden was mainly shifted to payers and providers.

Implications for Cancer Survivors

Equitable and effective follow-up schedules covered by insurance funds are necessary to care for prostate cancer patients.

Smartphone and App Usage in Orthopedics and Trauma Surgery: Survey Study of Physicians Regarding Acceptance, Risks, and Future Prospects in Germany

BACKGROUND

In the course of digitization, smartphones are affecting an increasing number of areas of users' lives, giving them almost ubiquitous access to the internet and other web applications. Mobile health (mHealth) has become an integral part of some areas of patient care. In contrast to other disciplines, routine integration of mobile devices in orthopedics and trauma surgery in Germany is still in its infancy.

OBJECTIVE

This study aimed to investigate physicians' current state of opinion regarding acceptance, future prospects, and risks of medical apps in the field of orthopedics and trauma surgery in Germany.

METHODS

A web-based survey among orthopedics and trauma surgeons in German university hospitals on the use of medical apps in everyday clinical practice was conducted between September 2018 and February 2019. The survey consisted of 13 open- and closed-ended or multiple-choice questions. A logistic regression analysis was performed to ascertain the effects of interindividual characteristics on the likelihood of participants' app and smartphone usage behavior.

RESULTS

A total of 206 physicians participated in the survey. All of the participants (206/206, 100%) owned a smartphone, and 79.1% (159/201) used the device, while 64.7% (130/201) used apps regularly in everyday clinical practice. Medical apps were perceived as beneficial, given their substantial future promise, by 90.1% (181/201) of the participants. However, 62.5% (120/192) of the participants were not satisfied with the current supply of medical apps in app stores. Desired specifications for future apps were "intuitive usability" (167/201, 83.1%), "no advertising" (145/201, 72.1%), and "free apps" (92/201, 45.8%). The attributes "transparent app development and app sponsoring" (75/201, 37.3%) and the existence of an "easy-to-understand privacy statement" (50/201, 24.9%) were of minor relevance. The majority of the participants (162/194, 83.5%) considered that future apps in the field of "medical research" would provide the greatest benefit. The greatest predicted risks were "data misuse" (147/189, 77.8%), "usage of untrustworthy apps" (135/189, 71.4%), and "alienation from patients" (51/189, 27.0%). Increasing age was significantly associated with a reduction in the likelihood of regular smartphone (odds ratio [OR] 0.91, 95% CI 0.86-0.97; P=.002) and app (OR 0.90, 95% CI 0.85-0.96; P=.001) usage, while the medical profession grade had no significant impact on the usage behavior.

CONCLUSIONS

The study demonstrates that young German doctors in orthopedics and trauma surgery already use smartphones and apps in everyday clinical practice. Medical apps are considered to play an important role in the future. However, a significant discrepancy exists between the supply and demand of mHealth applications, which creates a legal and ethical vacuum with regard to data protection.