[Linkage of statutory health insurance data with those of a hospital information system: feasible, but also "useful"?]

AIM

Administrative data are increasingly being linked with other data sources for research purposes in the field of epidemiology and health services research abroad. In Germany, the direct linkage of routine data of statutory health insurance (SHI) providers with other data sources is complicated due to strict data protection requirements. The aim of this analysis was to evaluate an indirect linkage of SHI routine data with data of a hospital information system (HIS).

METHODS

The dataset comprised data from 2004 to 2010 from 2 sickness funds and one HIS. In both data sources, hospitalisations were restricted to admissions into one hospital with at least one diagnosis of heart failure. The 2 data sources were linked, in cases of the agreement of the admission and discharge dates, as well as the agreement of at least a certain percentage of diagnoses in HIS data when compared to SHI data (full coding depth). Based on the direct linkage using the pseudonymised insurance number as gold standard, the proposed linkage approach was evaluated by means of test statistics. Furthermore, the completeness of relevant information of the HIS was described.

RESULTS

The dataset contained 3 731 hospitalisations from the HIS and 8 172 hospitalisations from the SHI routine data. The sensitivity of the linkage approach was 86.7% in the case of an agreement of at least 30% of the diagnoses and decreased to 41.7% in the case of 100% agreement in the diagnoses. The specificity was almost 100% at all studied cut-offs of agreement. Anthropometric measures and diagnostic information were available only for a small fraction of cases in the data of the HIS, whereas information on the health status and on laboratory information was comparatively complete.

CONCLUSION

For the linkage of SHI routine data with complementary data sources, indirect linkage methods can be a valuable alternative in comparison to direct linkage, which is time-consuming with regard to planning and application. Since the proposed approach was used in a relatively small sample and a restricted patient population, a replication using nation-wide data without respective restrictions would require an extension of the algorithm. Furthermore, the large administrative effort seems questionable considering the comparatively high amount of missing values in interesting information in the HIS.

[Economic Evaluation of Integrated Care Systems - Scientific Standard Specifications, Challenges, Best Practice Model]

PURPOSE

 Transparency of economic performance of integrated care systems (IV) is a basic requirement for the acceptance and further development of integrated care. Diverse evaluation methods are used but are seldom openly discussed because of the proprietary nature of the different business models. The aim of this article is to develop a generic model for measuring economic performance of IV interventions.

METHODS

 A catalogue of five quality criteria is used to discuss different evaluation methods -(uncontrolled before-after-studies, control group-based approaches, regression models). On this -basis a best practice model is proposed.

RESULTS

 A regression model based on the German morbidity-based risk structure equalisation scheme (MorbiRSA) has some benefits in comparison to the other methods mentioned. In particular it requires less resources to be implemented and offers advantages concerning the relia-bility and the transparency of the method (=important for acceptance). Also validity is sound. Although RCTs and - also to a lesser -extent - complex difference-in-difference matching approaches can lead to a higher validity of the results, their feasibility in real life settings is limited due to economic and practical reasons. That is why central criticisms of a MorbiRSA-based model were addressed, adaptions proposed and incorporated in a best practice model: Population-oriented morbidity adjusted margin improvement model (P-DBV(MRSA)).

CONCLUSION

 The P-DBV(MRSA) approach may be used as a standardised best practice model for the economic evaluation of IV. Parallel to the proposed approach for measuring economic performance a balanced, quality-oriented performance measurement system should be introduced. This should prevent incentivising IV-players to undertake short-term cost cutting at the expense of quality.

[Life expectancy with and without need for care. Extent and development trends in Germany]

This article addresses the question if the number of life years men and women can expect to live in good health is increasing and secondly if the life years in long-term care decline to a shorter period before death (compression of morbidity) during the periods 1999-2003 to 2004-2008. The analyses is based on data of a health insurance company (Gmünder Ersatzkasse, GEK), which are calculated, using the prevalence-rate method of Sullivan. The results show that men and women at age 60 can expect to live longer (21.21 years instead of 20.04 years for men and 25.1 years instead of 23.96 years for women) and also live longer free of long-term care (19.89 instead of 18.89 years for men and 22.37 instead of 21.55 years for women). In addition to the prolonged life years, also the number of years a person can expect to live in long-term-care has increased (from 1.15 years to 1.32 years for men and from 2.41 years to 2.73 years for women). Therefore the data suggest that there is no compression of morbidity.

[Comments by the Working Group for Methods of Economic Evaluation in Health Care (AG MEG) to IQWiG's Draft Guidelines "Methods for Assessment of the Relation of Benefits to Costs in the German Statutory Health Care System"]

Since the coming into force of the GKV-Wettbewerbsstärkungsgesetz ("Act to strengthen competition in the statutory health insurance system") in April 2007, the Gemeinsame Bundesausschuss (G-BA "Federal Joint Committee") can commission the Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG--Institute for Quality and Efficiency in Health Care") with the assessment of costs and benefits of drugs. In January 2008, IQWiG published a working document for consultation describing the proposed methods for carrying out those evaluations. This commentary by the AG Methoden der Gesundheitsökonomischen Evaluation (AG MEG--"Working Group for methods of economic evaluation in health care") provides a critical appraisal and recommendations for the further development of IQWIG's draft guidelines. The core statements of the commentary are as follows: (1) The draft guidelines are unbalanced. Instead of providing comprehensive methodological guidance for health technology assessment, which is the actual task of IQWiG, they deal predominantly with the methods of technology appraisal which is in the responsibility of the decision-making bodies, i.e. of the G-BA and the Spitzenverband Bund der Krankenkassen ("Central Federal Association of Health Insurance Funds"). (2) IQWiG intends to compare the cost-effectiveness of alternative treatment options only within a given therapeutic area. The rationale for this restriction is not clear, as the decision-makers have to determine ceiling prices across therapeutic areas and diseases and effectively the overall volume of health care expenditure, as well. (3) IQWiG aims at carrying out an economic evaluation only if in a preceding benefit assessment a drug has been judged to be superior. Therefore, it has to be assured that the benefit assessment is performed in such a way that its results may be used for the economic assessment. This requires the application of summary scores for the joint measurement of multidimensional endpoints (as, e.g., QALYs), to evaluate community effectiveness instead of efficacy, and to choose a time horizon that is sufficiently long to reflect any differences in the health benefits between the technologies being compared. Furthermore, the comment hints at some additional problems embodied in the draft guidelines and a number of key methodological issues which are not discussed at all in the working document. In summary, the methods currently proposed by IQWiG are not up to the task of conducting economic evaluations. It is strongly recommended to perform a public consultation process for the revised draft guidelines anew.

[Need for care. The role of family care in long-term care]

In Germany, more than 2 million people are currently in need of care, and another 3 million need help below the threshold that entitles them to benefits by social legislation. Thus, the need of care, in contrast to the need of help, is a general risk recognised by legislation. Accordingly, the German long-term care insurance was introduced in 1994, where entitlement to benefits depends on the ability to perform activities of daily living; it neglects the requirements of care arising from gerontopsychiatric impairments. In this article, the concept of "need of care" will be critically discussed and the influence of demographic changes on the state of needing care will be explored. Against this background, future challenges of caregiving will be analysed. This analysis leads to a call for "mixed care arrangements", where family care can only be maintained by relying on professional relief and support of voluntary helpers, and where care institutions would have to define themselves as partners of families. This demand will have to be reflected in changed training concepts. Structurally, it is necessary to develop arrangements, which promote self-determined individual solutions, e.g. by implementing (personal) care budgets. Moreover, target group-orientated counselling offers and network structures will have to be established; in this respect, co-operative efforts between professional case management and voluntary work are exemplary approaches.

[Optimizing the nursing process by new management instruments. The Northern Germany Nursing Research Network]

The Northern Germany Nursing Research Network (Pflegeforschungsverbund Nord) has dedicated itself to developing management instruments intended to optimize the nursing process. It is coordinated by the administrative office of the Institute of Public Health and Nursing Research (Institut für Public Health und Pflegeforschung IPP, director: Prof. Dr. Stefan Görres), Department of "Interdisziplinäre Alterns- und Pflegeforschung", University of Bremen. Four partial projects are currently being worked on in two groups: Group A--"Deficient areas of nursing action": The projects belonging to this group are "Individual care-patterns of elderly people and their determinants" (University of Bremen) and "Mobility Restrictions in Nursing Homes-Multicentre Observational Study (MORIN)" (University of Hamburg). The purpose of these studies is to examine the relevance of quantitatively significant risk combinations from a nursing science perspective. Group B--"The generation and testing of nursing action management instruments": The projects in this area are "Nursing rounds as instruments of quality assurance in home-based care" (University of Applied Sciences, Bremen) and "Predicting the risk of falls, efficiency of standard scales in opposition to nursing assessment-Cluster-Randomised Controlled Trial (PROFESSION)" (University of Hamburg). These studies concentrate in a unique manner on the generation and testing of management/control instruments suitable for application to nursing action.

Der Wandel der Staatlichkeit im Gesundheitswesen von OECD-Ländern - Fragestellungen, Untersuchungsdesign und erste Ergebnisse

In the framework of the DFG-Research-Unit 597 "Transformation of the State" is Project C3 investigating the change of the role of the state in health care systems in OECD-countries between 1970 and 2000. The primary research hypothesis is, that a tendency of convergence exists regarding the role of the state for the three main dimensions of health care systems, namely service provision, financing and regulation. This is carried out firstly based on a quantitative oriented analysis for 23 OECD-countries, utilising the data set "OECD Health Data 2002", and secondly with qualitative oriented country-studies for England, Germany and the U.S. Findings for the qualitative country-studies give some hints of convergence regarding the "private-public-mix" between the health system types "social insurance" (Germany), "national health system" (England), and "market oriented health system" (USA). First quantitative results concerning the changing role of the state in relation to the health care systems in OECD-countries provide evidence for a convergence process between these states in the financing dimension. For the dependent variable "total health care costs in % of gross domestic product" a trend of convergence is observed for the members states of the European Union (n = 12), while in the remaining Non-EU countries (n = 11) a trend of divergence is identified. For the same parameter we found a convergence for OECD-countries of the type "national health system" (n = 14). For OECD-countries of the type "social insurance" (n = 8) this convergence process is observed only for the time period 1970 - 1980. Some results confirm the hypothesis of the "growth to limits" (Flora). But it appears to us that in future other significant factors like globalisation processes, the increasing potentials of the medical technology and demographic changes may play an important role for the overall health budget and specific needs of the population in the OECD-states.

Das National Institute for Clinical Excellence (NICE)

In discussions on the development of the institutional framework for decisions on the benefit package of social health insurance in Germany, the English National Institute for Clinical Excellence (NICE) is considered as either a good or a bad example for reform. According to this study, the procedures and criteria applied by NICE for making health care coverage decisions are legitimate. Procedures are transparent and interest groups are broadly represented. Decision criteria include cost effectiveness of services - albeit only if information on cost effectiveness is available and highly evident. Furthermore, cost effectiveness is not the only criteria for coverage decisions. NICE very rarely induces strong direct rationing, but rather leaves room for discretion. However, the trade-off between maximising allocative efficiency and avoiding distributional consequences becomes apparent.