Transformational nurse leadership attributes in German hospitals pursuing organization-wide change via Magnet® or Pathway® principles: results from a qualitative study

BACKGROUND

Budget constraints, staff shortages and high workloads pose challenges for German hospitals. Magnet® and Pathway® are concepts for implementing organization-wide change and redesigning work environments. There is limited research on the key elements that characterize nurse leaders driving the implementation of Magnet®/Pathway® principles outside the U.S. We explored the key attributes of nurse leaders driving organization-wide change through Magnet®/Pathway® principles in German hospitals.

METHODS

Using a qualitative study design, semi-structured interviews (n = 18) were conducted with nurse leaders, managers, and clinicians, in five German hospitals known as having started implementing Magnet® or Pathway® principles. The interviews were recorded and transcribed verbatim. Data were analyzed in Atlas.ti using content analysis. For the analysis, a category system was created using a deductive-inductive approach.

RESULTS

Five leadership attributes and eleven sub-attributes were identified as main themes and sub-themes: Visionary leaders who possess and communicate a strong vision and serve as role models to inspire change. Strategic leaders who focus on strategic planning and securing top management support. Supportive leaders who empower, emphasizing employee motivation, individualized support, and team collaboration. Stamina highlights courage, assertiveness, and resilience in the face of challenges. Finally, agility which addresses a leader's presence, accessibility, and rapid responsiveness, fostering adaptability.

CONCLUSIONS

The study demonstrates leadership attributes explicitly focusing on instigating and driving organization-wide change through Magnet®/Pathway® principles in five German hospitals. The findings suggest a need for comprehensive preparation and ongoing development of nurse leaders aimed at establishing and sustaining a positive hospital work environment.

Financial risk protection in private health insurance: empirical evidence on catastrophic and impoverishing spending from Germany's dual insurance system

Financial risk protection from high costs for care is a main goal of health systems. Health system characteristics typically associated with universal health coverage and financial risk protection, such as financial redistribution between insureds, are inherent to, e.g. social health insurance (SHI) but missing in private health insurance (PHI). This study provides evidence on financial protection in PHI for the case of Germany's dual insurance system of PHI and SHI, where PHI covers 11% of the population. Linked survey and claims data of PHI insureds (n = 3105) and population-wide household budget data (n = 42,226) are used to compute the prevalence of catastrophic health expenditures (CHE), i.e. the share of households whose out-of-pocket payments either exceed 40% of their capacity-to-pay or push them (further) into poverty. Despite comparatively high out-of-pocket payments, CHE is low in German PHI. It only affects the poor. Key to low financial burden seems to be the restriction of PHI to a small, overall wealthy group. Protection for the worse-off is provided through special mandatorily offered tariffs. In sum, Germany's dual health insurance system provides close-to-universal coverage. Future studies should further investigate the effect of premiums on financial burden, especially when linked to utilisation.

Recruiting and retaining bachelor qualified nurses in German hospitals (BSN4Hospital): protocol of a mixed-methods design

INTRODUCTION

Many countries in Europe are facing a shortage of nurses and seek effective recruitment and retention strategies. The nursing workforce is increasingly diverse in its educational background, ranging from 3-year vocational training (diploma) to bachelor and master educated nurses. This study analyses recruitment and retention strategies for academically educated nurses (minimum bachelor), including intention to leave, job satisfaction and work engagement compared with diploma nurses in innovative German hospitals; it explores recruitment and retention challenges and opportunities, and identifies lessons on recruitment and retention taking an international perspective.

METHODS AND ANALYSIS

The study will apply a convergent mixed-methods design, including qualitative and quantitative methods. The qualitative study will include semistructured interviews among hospital managers, nurses, students and stakeholders in Germany. In addition, expert interviews will be conducted internationally in countries with a higher proportion of bachelor/master nurses in hospitals. The quantitative, cross-sectional study will consist of a survey among professional nurses (bachelor/master, diploma nurses) in German hospitals. Study settings are hospitals with a higher-than-average proportion of bachelor nurses or relevant recruitment, work environment or retention strategies in place. Analyses will be conducted in several phases, first in parallel, then combined via triangulation: the parallel analysis technique will analyse the qualitative and quantitative data separately via content analyses (interviews) and descriptive, bivariate and multivariate analyses (survey). Subsequently, data sources will be collectively analysed via a triangulation matrix focusing on developing thematic exploratory clusters at three systemic levels: microlevel, mesolevel and macrolevel. The analyses will be relevant for generating lessons for clinical nursing, management and policy in Germany and internationally.

ETHICS AND DISSEMINATION

Ethics approval was obtained by the Charité Ethics Committee.Several dissemination channels will be used, including publications and presentations, for the scientific community, nursing management, clinical nurses and the wider public in Germany and internationally.

[Methodological Challenges and Lessons Learned in the Scientific Use of Data from a Private Health Insurance Company within the IPHA Project]

The 11% of people with private health insurance (PHI) in Germany have so far been underrepresented in health services research. The scientific use of PHI data is rare. The aim of this research was to examine the scientific usability of PHI data and to highlight challenges and lessons learned in the process of data preparation and analysis using a linked dataset (n=3,109) of survey and claims data of one PHI company. Challenges were identified in the terminology of the PHI insurance, in the processing and validity of the data, and regarding insured persons without submitted billing receipts. With thorough preparation of the data and presentation of the limitations, PHI data can be used for health services research.

Health Literacy of People with Substitutive Private Health Insurance in Germany and Their Assessment of the Health System Performance According to Health Literacy Levels: Results from a Survey

Health literacy (HL) is a competence to find, understand, appraise, and apply health information and is necessary to maneuver the health system successfully. People with low HL are, e.g., under the risk of poor quality and safety of care. Previous research has shown that low HL is more prevalent among, e.g., people with lower social status, lower educational level, and among the elderly. In Germany, people with substitutive private health insurance (PHI) account for 11% of the population and tend to have a higher level of education and social status, but in-detail assessments of their HL are missing so far. Therefore, this study aimed to investigate the HL of PHI insureds in Germany, and to analyze their assessment of the health system according to their HL level. In 2018, 20,000 PHI insureds were invited to participate in a survey, which contained the HLS-EU-Q16, and items covering patient characteristics and the World Health Organization health systems framework goals (e.g., access, quality, safety, responsiveness). Low HL was found for 46.2% of respondents and was more prevalent, e.g., among men and insureds with a low subjective social status. The health system performance was perceived poorer by respondents with low HL. Future initiatives to strengthen health systems should focus on promoting HL.

Drivers of patient perceptions of health system responsiveness in Germany

BACKGROUND

Health system responsiveness (HSR)-the ability of a health system to meet the non-medical legitimate expectations of patients-is a key to patient-centred health systems. Although responsiveness is essential to provide equitable and accountable health care, little is known about patient-side drivers of HSR. This study aims to narrow this gap.

METHODS

A survey among 20,000 Germans with substitutive private health insurance included questions on HSR and patient characteristics such as health literacy (HL), experienced discrimination, and sociodemographic information. Survey data were linked to patient-level claims data. Logistic regression was applied to assess the association between HSR and patient characteristics.

RESULTS

The sample (age 54.0 ± 16.1; 60.5% male) contains 2951 respondents with outpatient physician care in the past year. Of the nine HSR items, eight are rated as (very) good (74.4%-94.3%), except for coordination between providers (60.2%). Patient characteristics highly influence HSR: patients with high HL, for instance, are more likely to assess responsiveness as (very) good (e.g., clear explanations from physicians: OR 4.17). Poor assessment of responsiveness is seen among users who experienced discrimination.

CONCLUSION

This study revealed new associations between HSR and patient characteristics. Incorporating this knowledge in practice would help strengthen patient-centred health services by considering patient experiences and expectations. This highlights that HSR can be used as a tool to evaluate and promote patient-centred health services. Future research should investigate additional drivers of HSR, both on the patient and the provider sides.

[Patients, Partners, Professionals, Payers and Policy Makers Preferences for Integrated Care for Multimorbidity in Germany: A Discrete Choice Experiment]

AIM OF THE WORK

The aim of this study was to measure and compare the relative importance that patients with multimorbidity, partners and other informal caregivers, professionals, payers and policy makers attribute to different outcome measures of integrated care (IC) programmes in Germany.

METHODS

A DCE was conducted, asking respondents to choose between two IC programmes for persons with multimorbidity. Each IC programme was presented by means of attributes or outcomes reflecting the Triple Aim. They were divided into the outcomes health/ wellbeing, experience with care and costs with in total eight attributes and three levels of performance.

RESULTS

The results of n=676 questionnaires showed that the attributes "enjoyment of life" and "continuity of care" received the highest ratings across all stakeholder groups. The lowest relative scores remained for the attribute "total costs" for all stakeholders. The preferences of professionals and informal caregivers differed most distinctly from the patients' preferences. The differences mostly concerned "physical functioning", which was rated highest by patients, and "person centeredness" and "continuity of care", which received the highest ratings from professionals.

CONCLUSIONS

The preference heterogeneities identified in relation to the outcomes of IC programmes between different stakeholders highlight the importance of informing professionals and policy makers about the different perspectives in order to optimise the design of IC programmes. The results also support the relevance of joint decision-making and coordination processes between professionals, informal caregivers and patients.

Transformation-oriented leadership in German hospitals: beneficial attributes and competencies

Introduction

Due to a shortage of health professionals and economic pressure, many German hospitals are required to transform the clinical work environment to increase job satisfaction, but also to attract and retain health professionals. Leadership is a key factor for the successful implementation of organization-wide change. The aim of this study was to identify the attributes and competencies among leaders that are beneficial for implementing and managing hospital-wide transformations.

Methods

A qualitative study design. In 2020, 18 face-to-face, semi-structured interviews were conducted with chief nursing officers, ward managers, nurses and physicians in five German hospitals which have started implementing a hospital-wide transformation (e.g. Magnet® or Pathway®). Interviews were recorded and transcribed verbatim. Data were analyzed in Atlas.ti using the content analysis method according to Mayring.

Results

Results show five beneficial leadership elements to instigate and steer hospital-wide transformation: (1) Charismatic leaders are role models and idealists with well-communicated visions that are grounded in clinical practice and reflect the clinical practitioners. (2) Mentally strong leaders have courage, stamina, and are resilient. (3) Empowering leaders are highly supportive and increase the intrinsic motivation of employees. (4) Imparting interprofessional appreciation refers to leaders who cultivate a respectful relationship with persons from other professional groups and recognize their daily performance. (5) Agile leaders are well and quickly accessible for employees and respond situationally to changing demands in everyday work.

Conclusions

Interviewees described characteristics of hospital leaders as success factors for establishing and maintaining continuous change processes. Charismatic and supportive leaders are critical to transform the hospitals’ culture and values. In addition, equitable interprofessional collaboration is of utmost importance.

Key messages

• Charismatic, agile, empowering leaders can have a positive impact on system-wide change processes.

• The successful transformation of hospitals’ work environment needs interprofessional appreciation and the mutual acknowledgement of competences.

Implementation strategies to integrate academically qualified nurses in German innovator hospitals

Background

In Germany, the number of Bachelor and Master programs for nurses has increased significantly over the past 20 years but the recommended target of 10%-20% of academically qualified nurses has not yet been reached. In university hospitals, it was 3% in 2018. Major challenges for hospital managers are to attract and retain academically qualified nurses in clinical practice, with some hospitals doing better than others.

Methods

In 2020, semi-structured interviews (n = 18) were conducted with chief nursing officers, nurse managers, nurses, and physicians working in five innovator hospitals, characterised by a high willingness to change the work environment, improve quality of care, and increase the number of academically qualified nurses. The interviews were recorded, transcribed, and analysed using Atlas.ti. Mayring's qualitative content analysis method was applied.

Results

Recruiting, retaining, and integrating academically qualified nurses varied in the five hospitals studied but all provided time and/or financial support for nursing students. Those with a longer tradition of attracting academically qualified nurses were following a hospital-wide strategy. CNOs or other leaders motivated nurses to enrol in a degree program, provided close support for clinical projects (e.g., on the ward) and when starting a career (e.g., coaching), and fostered individual career planning. Specialised tasks for nurses with a master's degree were leadership roles or specialised patient care. Taking over additional clinical or scientific activities according to their qualification was seen as beneficial to integrate the nurses. Barriers were the limited acceptance of graduated nurses by nurses with a vocational training, low staffing levels, and limited political support.

Conclusions

Recruiting and retaining graduated nurses takes efforts by hospitals in the current situation of a nation-wide nursing shortage. A hospital-wide approach can be a way to overcome this challenge.

Speakers/Panelist

Inge Rinzema

V&VN VS, Dutch Association of Nurse Practitioners, Utrecht, Netherlands

Johanna Heikkilä

JAMK University, Jyväskylä, Finland

Sabine Valenta

Department of Nursing Science, University of Basel, Basel, Switzerland

Assessment of health system performance in Germany: Survey-based insights into the perspective of people with private health insurance

INTRODUCTION

The World Health Organization (WHO) defined intermediate and overall goals to assess the performance of health systems. As the population perspective becomes more important for improving health systems, the aim of this study was to gain insights into the perspective of people with private health insurance (PHI) in Germany along the predefined WHO goals.

METHODS

A cross-sectional survey was conducted in 2018 among people with PHI in Germany. The questionnaire included items on all intermediate (access, coverage, quality, and safety) and overall WHO goals (improved health, responsiveness, social and financial risk protection, and improved efficiency). Descriptive analyses were conducted for the total sample and subgroups (gender, age, income, and health status).

RESULTS

In total, 3601 respondents (age 58.5 ± 14.6; 64.7% male) assessed the German health system. For example, 3.3%-7.5% of the respondents with subjective needs reported forgone care in the past 12 months due to waiting time, distance, or financial reasons and 14.4% suspected medical errors in their care. During the last physician visit 94.2% experienced respectful treatment but only 60.6% perceived coordination of care as good. Unnecessary health services were perceived by 24.2%. For many items significant subgroup differences were found, particularly for age groups (18-64 vs. 65+).

CONCLUSION

Conducting a health system performance assessment from the population perspective gained new and unique insights into the perception of people with PHI in Germany. Areas to improve the health system were seen in, for example, coordination of care, financial risk protection, and quality of care, and inequalities between subgroups were identified.

A workplace organisational intervention to improve hospital nurses' and physicians' mental health: study protocol for the Magnet4Europe wait list cluster randomised controlled trial

INTRODUCTION

The increasing burden of mental distress reported by healthcare professionals is a matter of serious concern and there is a growing recognition of the role of the workplace in creating this problem. Magnet hospitals, a model shown to attract and retain staff in US research, creates positive work environments that aim to support the well-being of healthcare professionals.

METHODS AND ANALYSIS

Magnet4Europe is a cluster randomised controlled trial, with wait list controls, designed to evaluate the effects of organisational redesign, based on the Magnet model, on nurses' and physicians' well-being in general acute care hospitals, using a multicomponent implementation strategy. The study will be conducted in more than 60 general acute care hospitals in Belgium, England, Germany, Ireland, Norway and Sweden. The primary outcome is burnout among nurses and physicians, assessed in longitudinal surveys of nurses and physicians at participating hospitals. Additional data will be collected from them on perceived work environments, patient safety and patient quality of care and will be triangulated with data from medical records, including case mix-adjusted in-hospital mortality. The process of implementation will be evaluated using qualitative data from focus group and key informant interviews.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee Research UZ/KU Leuven, Belgium; additionally, ethics approval is obtained in all other participating countries either through a central or decentral authority. Findings will be disseminated at conferences, through peer-reviewed manuscripts and via social media.

TRIAL REGISTRATION NUMBER

ISRCTN10196901.

Health workforce response to Covid-19: What pandemic preparedness planning and action at the federal and state levels in Germany?: Germany's health workforce responses to Covid-19

Introduction

The Covid‐19 pandemic has required countries to prepare their health workforce for a rapid increase of patients. This research aims to analyse the planning and health workforce policies in Germany, a country with a largely decentralised workforce governance mechanism.

Methods

Systematic search between 18 and 31 May 2020 at federal and 16 states on health workforce action and planning (websites of ministries of health, public health authorities), including pandemic preparedness plans and policies. The search followed World Health Organisation (WHO) Europe's health workforce guidance on Covid‐19. Content analysis was performed, informed by the themes of WHO.

Results

The pandemic preparedness plans consisted of no or limited information on how to expand and prepare the health workforce during pandemics. The 16 states varied considerably regarding implementing strategies to expand health workforce capacities. Only one state adopted a policy on task‐shifting despite a federal law on task‐shifting during pandemics.

Conclusions

Planning on the health workforce, its capacity and skill‐mix during pandemics was limited in the pandemic response plans. Actions during the peak of the pandemic varied considerably across states, were implemented ad hoc and with limited planning. Future action should focus on integrated planning and evaluation of workforce policies.

Drivers of successful implementation of integrated care for multi-morbidity: Mechanisms identified in 17 case studies from 8 European countries

This paper provides a deeper understanding of the mechanisms underlying implementation strategies for integrated care. As part of the SELFIE project, 17 integrated care programmes addressing multi-morbidity from eight European countries were selected and studied. Data was extracted from 'thick descriptions' of the 17 programmes and analysed both inductively and deductively using implementation theory. The following ten mechanisms for successful implementation of integrated care were identified. With regards to service delivery, successful implementers (1) commonly adopted an incremental growth model rather than a disruptive innovation approach, and found (2) a balance between flexibility and formal structures of integration. For leadership & governance, they (3) applied collaborative governance by engaging all stakeholders, and (4) distributed leadership throughout all levels of the system. For the workforce, these implementers (5) were able to build a multidisciplinary team culture with mutual recognition of each other's roles, and (6) stimulated the development of new roles and competencies for integrated care. With respect to financing, (7) secured long-term funding and innovative payments were applied as means to overcome fragmented financing of health and social care. Implementers emphasised (8) the implementation of ICT that was specifically developed to support collaboration and communication rather than administrative procedures (technology & medical devices), and (9) created feedback loops and a continuous monitoring system (information & research). The overarching mechanism was that implementers (10) engaged in alignment work across the different components and levels of the health and social care system. These evidence-based mechanisms for implementation are applicable in different local, regional and national contexts.

Are persons with a limited health literacy less satisfied with the German health care system?

Background

Health literacy (HL) is the ability to find, understand, appraise and apply health information with the aim of using this information to make decisions affecting the own health. Previous studies showed limited HL in around 50% of the German population. The assessment of the German health care system from the perspective of persons with limited HL is subject of this study.

Methods

In 2018, a survey was conducted among 20,000 persons with private health insurance in Germany. Survey items were based on the intermediate and final goals of the WHO Health Systems Framework. Questions comprised, for example, satisfaction with the health care system, responsiveness (e.g. perceived discrimination), access (e.g. off-hour care), and safety (e.g. medical errors). HL was assessed with the HLS-EU-Q16 questionnaire. Descriptive statistics and Chi-square test were used to analyze the data and group differences.

Results

Overall, 3,601 participants (18.0%) completed the survey (58.6 years ± 14.6; 64.6% male). Limited HL was seen with 44.6% (8.5% inadequate & 36.1% problematic), whereas 55.4% did not report limited HL (43.4% sufficient & 12.0% excellent). Very satisfied with the German health care system were 6.5% of the persons with limited HL (vs. 14.3%). Perceived discrimination within the last 12 months was reported by 11.0% of the persons with limited HL (vs. 5.1%). To get medical care on weekends, holidays or evenings outside hospitals was rated as “very hard” by 34.6% of the persons with limited HL (vs. 23.6%). The feeling that they experienced medical errors was reported by 18.7% with limited HL (vs. 11.5%) and 5.9% were unsure (vs. 2.2%). All results were statistically significant (p < 0.001).

Conclusions

Persons with limited HL were less satisfied with the overall German health care system in comparison to persons with not limited HL and reported more often perceived discrimination. Strengthening HL could help to improve satisfaction with the health care system.

Key messages

Limited HL among persons with private health insurance in Germany was found in 44.6% of the survey’s participants. Persons with limited HL indicated to be less satisfied with the German health care system and perceived more often discrimination in their health care.

Financial risk protection of individuals with private health insurance

Background

Financial Protection is a key dimension of universal health coverage and health system performance assessment and is also monitored within the framework of the sustainable development goals. Analyses of financial hardship among people who have out-of-pocket (OOP) spending through the use of health services in Germany usually focus solely on households with statutory health insurance due to the peculiarities of private health insurance (PHI) data. This study aims to analyse financial protection among privately insured in Germany.

Methods

A cross-sectional survey was conducted in 2018 with 20,000 privately insured in Germany. The survey comprised questions on household net-income, OOP spending on health, unmet needs, perceived financial burden). Catastrophic expenditure was analysed and defined as share of households with OOP spending greater than 10% of household income. Further results on financial protection and access are based on descriptive analyses.

Results

A total of 3,601 participants (18.0%) completed the survey (58.6 years ± 14.6; 64.6% male). 82.2% of households reported OOP spending, mostly on OTC drugs, deductibles and medical aids. Median OOP spending was €300-499 per year. Average OOP spending as share of household income was 1.3% and 0.6% of households have catastrophic OOP spending. In total, 6.6% of respondents reported unmet needs due to financial barriers, of which 5.3% had no OOP spending. 11.2% of all respondents reported to feel strongly financially burdened by OOP spending with a gap between the lowest (26.2%) and highest income group (9.9%).

Conclusions

PHI insured have comparatively low OOP spending with less than 1% of households having catastrophic expenditures on health. However, 6.2% of respondents reported to forgo care due to financial reasons which supports the assumption that OOP payments can create a barrier to access. Unmet needs and financial burden are higher in lower income groups which raises concerns about equity.

Key messages

Financial protection is good among privately insured in Germany with only few households reporting catastrophic expenditures which indicates a broad and sufficient benefit coverage under PHI. Although out-of-pocket spending is low, privately insured perceive a strong financial burden (particularly in lower income groups) and face financial barriers to access care mirrored in forgone care.

Health system performance assessment from the private health insured persons’ perspective in Germany

Background

About 11% of the German population has full private health insurance (PHI) and mainly consists of self-employed persons, civil servants or persons with an income above a certain threshold (in 2020: 62,550 €/year) who choose to opt out from statutory health insurance. It can be assumed that these persons represent a distinct population group in Germany. Therefore, the assessment of the German health system performance from the perspective of persons with PHI was subject to this research (project IPHA “Integrating the Population Perspective in Health System Performance Assessment”).

Methods

A paper/online survey was conducted in 2018 among 20,000 persons with PHI in Germany. The items for this survey were based on the intermediate (access, coverage, quality and safety) and final goals (improved health, responsiveness, improved efficiency, and social and financial risk protection) of the WHO Health Systems Framework.

Results

The survey was completed by 3,601 participants (18.0%). Participants (age 58.6 years ± 14.6; 64.6% male) assessed the German health system very differently, exemplarily shown for the intermediate goal “access” and final goal “responsiveness”: Whereas access to off-hour care was perceived as difficult by 54.1% of the respondents, 6.7% of the respondents reported unmet needs within the last 12 months due to waiting times. 51,5% of these persons with unmet needs due to waiting times were still (very) satisfied with the overall waiting time for physicians' appointments. 73,6% of persons with unmet needs who perceived discrimination in their care reported waiting times as the area of discrimination (vs. 53,4% of all participants who perceived discrimination).

Conclusions

Privately insured persons in Germany perceived the performance of the health system very differently and also partially inconsistent. Further analyses will complete the picture of the persons with PHI's perspective in health system performance assessment.

Key messages

Persons with private health insurance perceive the performance of the German health care system very differently and also partially inconsistent. Despite unmet needs due to waiting time in 6.7% of the respondents, 51,5% of these persons were still (very) satisfied with waiting times.

Measuring efficiency of the German health care system from the population perspective

Background

Human and financial resources in health care systems are limited and require efficient use. Efficiency is one of the final goals of the WHO Health Systems Framework but measuring efficiency and finding room for improvement is complex; a rarely used approach is the assessment from the population perspective. This study aims to analyse, if inefficiencies in the German health care system are present and can be identified by the population.

Methods

In 2018, a survey was conducted with a random sample of 20,000 insured persons of a German private health insurance (PHI) company. Three aspects of efficiency were operationalized in the questionnaire: self-reported duplicate tests, prescription of unnecessary health services, and adequacy of insurance premiums. Results are based on descriptive analyses.

Results

In total, 3,601 respondents (age 58.9 ± 14.5; 64.9% male) were included (18.0%) in the analyses. Efficiency was rated as follows: 20% of respondents experienced duplicate tests due to a lack of coordination between physicians. This rate was even higher (38%) among those who perceived (very) poor/fair coordination. Unnecessary services (self-assessed) were prescribed to 22% of all respondents and was 50% among patients who experienced that physicians' consultations and treatments were led by motives other than the patients' wellbeing. A total of 33% rated their premiums as (too) high, 63% as fair and 4% as (very) low with differences according to income, sex and health status.

Conclusions

From a population perspective, the German health care system has the potential to be more efficient e.g. by reducing duplicate tests. Patients with PHI experience unnecessary services and duplicate tests, which put a strain on both, the already limited financial and personnel resources on a macro level, and the level of the individual PHI premium.

Key messages

Patients perceived tests or services as unnecessary, and hence, can detect inefficiencies of a health care system. Efficiency can be improved e.g. by a better coordination of care between health care providers.

Integrating the Population Perspective into Health System Performance Assessment (IPHA): Study Protocol for a Cross-Sectional Study in Germany Linking Survey and Claims Data of Statutorily and Privately Insured

Background:Health system performance assessment (HSPA) is a major tool for evidence-based governance in health systems and patient/population-orientation is increasingly considered as an important aspect. The IPHA study aims (1) to undertake a comprehensive performance assessment of the German health system from a population perspective based on the intermediate and final dimensions defined by the World Health Organization (WHO) and (2) to identify differences in HSPA between (a) common user characteristics and (b) user types, which differ in their interactions and patterns of action within the health system.

Methods and Analysis: A cross-sectional survey was conducted between October and December 2018 with statutorily and privately health insured to assess the German health system from a population perspective related to the past 12 months. The random sample consists of 32 000 persons insured by AOK Nordost and 20 000 persons insured by Debeka. Data from the survey will subsequently be linked with health insurance claims data at the individual level for each respondent who has given consent for data linkage. Claims data covers the time period January 1, 2017 to June 30, 2018. The combination of the 2 data sources allows to identify associations between insured patient characteristics and differences in the assessment of health system performance. The survey consists of 71 items measuring all final and intermediate health system goals defined by the WHO and user characteristics like health literacy, self-efficacy, the attention an individual pays to his or her health or disease, the personal network, autonomy, compliance and sociodemographics. The claims data contains information on morbidity, care delivery, service utilization, (co)payments and sociodemography.

Discussion: The study represents a promising attempt to perform a holistic HSPA using a population perspective. For this purpose, a questionnaire was designed that contains both validated and new items in order to collect data on all relevant health system dimensions. In particular, linking survey data on HSPA with claims data is of high potential for assessing and analysing determinants of health system performance from the population perspective.

What are the motivating and hindering factors for health professionals to undertake new roles in hospitals? A study among physicians, nurses and managers looking at breast cancer and acute myocardial infarction care in nine countries

BACKGROUND

Many European countries experience health workforce skill-mix changes due to population ageing, multimorbidity and medical technology. Yet, there is limited cross-country research in hospitals.

METHODS

Cross-sectional, observational study on staff role changes and contributing factors in nine European countries. Survey of physicians, nurses and managers (n = 1524) in 112 hospitals treating patients with breast cancer or acute myocardial infarction. Group differences were analysed across country clusters (skill-mix reform countries [England, Scotland and the Netherlands] versus no reform countries [Czech Republic, Germany, Italy, Norway, Poland and Turkey]) and stratified by physicians, nurses and managers, using Chi-squared, Mann-Whitney U and Kruskal Wallis tests.

RESULTS

Nurses in countries with major skill-mix reforms reported more frequently being motivated to undertake a new role (66.5%) and having the opportunity to do so (52.4%), compared to nurses in countries with no reforms (39.2%; 24.8%; p < .001 each). Physicians and nurses considered intrinsic motivating factors (personal satisfaction, use of qualifications) more motivating than extrinsic factors (salary, career opportunities). Reported barriers were workforce shortages, facilitators were professional and management support. Managers' recruitment decisions on choice of staff were mainly influenced by skills, competences and experience of staff.

CONCLUSION

Managers need to know the motivational factors of their employees and enabling versus hindering factors within their organisations to govern change effectively.

New professional roles and patient satisfaction: Evidence from a European survey along three clinical pathways

This paper reports the results of an empirical analysis exploring the impact of new professions (eg a physician associate) and new professional roles on patient experiences of and satisfaction with care. A sub set of data from a patient survey conducted as part of the MUNROS programme of work was used. The overall survey aim was to describe and quantify the use of new professionals and new roles for established health care professionals other than medical doctors, in primary and secondary care sectors in three care pathways in nine European countries Ordered logit models were used to investigate the association between: (1) patient satisfaction with the last visit; (2) with their care provider; (3) with the information provided and a set of covariates explaining the involvement of new professional roles in three clinical pathways: type 2 diabetes, heart disease and breast cancer. For patients with breast cancer, high levels of satisfaction are associated with the involvement of new professions/professional roles in the provision of conditions specific education and monitoring. For patients with heart disease, the involvement of new professions/professional roles is likely to have a negative impact on satisfaction. For patients with Type 2 diabetes results are ambivalent. Patients belonging to countries experiencing innovative models of healthcare delivery and with high levels of involvement of new professions/professional roles are generally more satisfied. In conclusion, the introduction of new professions does not affect patient satisfaction negatively, therefore introducing new health professional roles is a pursuable strategy from a patient satisfaction perspective, at least for breast cancer and type 2 diabetes.

Task shifting between physicians and nurses in acute care hospitals: cross-sectional study in nine countries

BACKGROUND

Countries vary in the extent to which reforms have been implemented expanding nurses' Scopes-of-Practice (SoP). There is limited cross-country research if and how reforms affect clinical practice, particularly in hospitals. This study analyses health professionals' perceptions of role change and of task shifting between the medical and nursing professions in nine European countries.

METHODS

Cross-sectional design with surveys completed by 1716 health professionals treating patients with breast cancer (BC) and acute myocardial infarction (AMI) in 161 hospitals across nine countries. Descriptive and bivariate analysis on self-reported staff role changes and levels of independence (with/without physician oversight) by two country groups, with major SoP reforms implemented between 2010 and 2015 (Netherlands, England, Scotland) and without (Czech Republic, Germany, Italy, Norway, Poland, Turkey). Participation in 'medical tasks' was identified using two methods, a data-driven and a conceptual approach. Individual task-related analyses were performed for the medical and nursing professions, and Advanced Practice Nurses/Specialist Nurses (APN/SN).

RESULTS

Health professionals from the Netherlands, England and Scotland more frequently reported changes to staff roles over this time period vs. the other six countries (BC 74.0% vs. 38.7%, p < .001; AMI 61.7% vs. 37.3%, p < .001), and higher independence in new roles (BC 58.6% vs. 24.0%, p < .001; AMI 48.9% vs. 29.2%, p < .001). A higher proportion of nurses and APN/SN from these three countries reported to undertake tasks related to BC diagnosis, therapy, prescribing of medicines and information to patients compared to the six countries. Similar cross-country differences existed for AMI on prescribing medications and follow-up care. Tasks related to diagnosis and therapy, however, remained largely within the medical profession's domain. Most tasks were reported to be performed by both professions rather than carried out by one profession only.

CONCLUSIONS

Higher levels of changes to staff roles and task shifting were reported in the Netherlands, England and Scotland, suggesting that professional boundaries have shifted, for instance on chemotherapy or prescribing medicines. For most tasks, however, a partial instead of full task shifting is practice.

Forgone care among chronically ill patients in Germany-Results from a cross-sectional survey with 15,565 individuals

The decision not to seek health care although one feels that care is needed (forgone care), is influenced by various factors. Within the study "Responsiveness in ambulatory care" 15,565 chronically ill (coronary heart disease and/or type 2 diabetes) patients in Germany were surveyed in 2013. The survey included questions on forgone care, perceived discrimination when seeking care, net-income, subjective health status and subjective socioeconomic status (subSES). Survey data were linked on patient-level with administrative claims data by a German sickness fund. We applied multivariate binomial logistic regression analyses to assess the association between age, sex, comorbidities, living area, subjective health status, subSES, experienced discrimination, net-equivalent income and reported forgone care. The majority in the sample are men (71.4%), the average age is 69.4 (SD: 10.2) years and 14.1% reported forgone care. In the multivariate model, we find that younger age, female gender, perceived discrimination, depression, and a poor subjective health status increase the odds of reporting forgone care. Overall, our results suggest that a negative experience with the health care system, i.e. perceived discrimination/unfair treatment, are strong predictors of forgone care among the chronically ill.

A 163-bp deletion in the neurofibromatosis 2 (NF2) gene associated with variant phenotypes [corrected]

We have analyzed cDNA from a 46-year-old atypical neurofibromatosis type 2 (NF2) patient who had lumbar tumors, cataract and schwannomas of peripheral nerves but no vestibular schwannomas, and have identified a 163-bp deletion in the NF2 transcript. The deletion is predicted to remove 54, alter 15 and add four extra amino acids at the C-terminus of the NF2-gene product. The same deletion was found in her two daughters and in a 3-year-old grandson. Bilateral vestibular schwannomas were detected in the two asymptomatic daughters, whereas no abnormality was found in the grandson.

Glioma biology in vitro: goals and concepts

Gliomas are heterogeneous in their cellular composition, affecting therapeutic efforts such as surgical removal, radiotherapy, chemotherapy and immunotherapy. 106 gliomas were taken into culture in our laboratory and 12 cell lines could be established there from. Experiments were carried out in as many early cultures as possible and with the constant experimental system of the cell lines. To subdivide and possibly classify the heterogeneous group of gliomas the following approaches emerged: Immunostaining of cells for glial markers such as GFAP, A4, A2B5, Leu 7 as well as fibronectin will allow one to distinguish different groups of glial cultures. Performance of growth factor sensitivity tests allows the assessment of major aspects of growth control in cultured gliomas. Cytogenetic evaluation in early cultures and correlation with the expression of oncogenes may yield useful information on mechanisms of escape from normal growth control. One of our cell lines (NCE-G28) in which cells switch from GFAP to fibronectin expression and transiently express the x-hapten may serve as a model to study crucial aspects of cellular differentiation. Using different extracellular matrices for the initiation of cultures even from very benign lesions with low proliferative potential it is possible to include these into comparative studies with glioblastomas.