Evaluation of multi-dose repackaging for individual patients in long-term care institutions: savings from the perspective of statutory health insurance in Germany

Aims and objectives

Elderly people often have difficulty adhering to multi-drug medication regimens. The current study aimed to evaluate whether multi-dose repackaging for individual patients reduces medication expenses from the perspective of statutory health insurance in Germany.

Setting

A total of 307 residents, mean age 76.8 years, median age 80 years, from four long-term care facilities were included in the prospective pre—post study conducted from September 2004 to December 2005. Minimum periods of 9 months prior to and 9 months following the introduction of multi-dose packaging were compared at the individual level with respect to the expenses for medications that were repackaged in weekly blister packs.

Method

The main outcome measure was savings in medication expenses. Statistical evaluation was carried out using the program Rversion 2.1.0. Adjustments were made for effects of age and con currently increasing morbidity in so far as number of prescriptions were held constant at the individual level.

Key findings

In the subset of 181 people included in this analysis, approximately 6.0% (95% confidence interval, 5.1–7.0%; P < 0.001) of expenses for medication were saved: 2.0% (1.6–2.3%; P < 0.001) was due to price differences and 4.1% (3.2–5.0%; P < 0.001) to reduced wastage of prescribed medication. The probability of being prescribed a generic compared with a brand-name medication was significantly lower prior to the introduction of repackaging (0.92, 0.89–0.94; P < 0.01), although this did not have any effect on turnover of medications (0.996, 0.988–1.005; P < 0.01).

Conclusion

Significant savings in medication expenses were found. Nonetheless, cost savings should not be the sole objective in reorganising drug dispensing.

Uncertainty assessment of input parameters for economic evaluation: Gauss's error propagation, an alternative to established methods

In decision modeling for health economic evaluation, bootstrapping and the Cholesky decomposition method are frequently used to assess parameter uncertainty and to support probabilistic sensitivity analysis. An alternative, Gauss's error propagation law, is rarely known but may be useful in some settings. Bootstrapping, the Cholesky decomposition method, and the error propagation law were compared regarding standard deviation estimates of a hypothetic parameter, which was derived from a regression model fitted to simulated data. Furthermore, to demonstrate its value, the error propagation law was applied to German administrative claims data. All 3 methods yielded almost identical estimates of the standard deviation of the target parameter. The error propagation law was much faster than the other 2 alternatives. Furthermore, it succeeded the claims data example, a case in which the established methods failed. In conclusion, the error propagation law is a useful extension of parameter uncertainty assessment.

The German Coronary Artery Disease Risk Screening Model: development, validation, and application of a decision-analytic model for coronary artery disease prevention with statins

BACKGROUND

Coronary artery disease (CAD) is a major cause of death in industrial countries, leading to high health-related costs and decreased quality of life.

OBJECTIVE

To develop and validate a decision-analytic model for CAD risk screening in Germany (German Coronary Artery Disease Screening Model).

DESIGN

Markov model.

TARGET POPULATION

Age- and gender-specific cohorts of the German population.

DATA SOURCES

Mortality rates posted by the German Federal Statistical Office, the German Health Survey, social health insurance institutions, the MONICA Augsburg study, and the literature.

TIME HORIZON

Lifetime.

INTERVENTIONS

CAD risk screening for high-risk individuals using Framingham risk equation and use of statins as the primary preventive measure, compared with a setting without screening.

OUTCOME MEASURES

Life-years (LY) gained, quality-adjusted life-years (QALYs) gained.

RESULTS

The model-based CAD incidence corresponds well with empirical data from the MONICA Augsburg study. Health outcomes depend on the screening threshold (cutoff value of Framingham 10-year risk) and on the age and gender of the cohort screened (0.03 to 0.26 LYs and 0.06 to 0.42 QALYs gained per person screened in cohorts of 50- and 60-year-old men and women, respectively).

CONCLUSIONS

The model provides a valid tool for evaluating the long-term effectiveness of CAD risk screening in Germany. Using statins as a primary prevention intervention for CAD in high-risk individuals identified by screening could improve the long-term health of the German population.

[The influence of quality management on job satisfaction and work load--exemplary study in a German hospital]

Surveys among employees are getting more and more relevant in hospital settings since an increase in both (1) efficiency and (2) quality in connection with (3) enhanced patient orientation will only be achieved, if at the same time the employees' health status and satisfaction are taken into account. Thus, the objective of this study was to compare the satisfaction of employees in a single hospital enquired in 2002 with that of 2005. Particular consideration was given to their view of quality management. Is there a correlation between employees' satisfaction, their degree of information on quality management, and their assessment of quality management? In the survey of 2005 employees were more satisfied with their work and their working conditions than in the previous inquiry conducted in 2002. They felt less mental stress, despite the declining length of hospitalisation combined with a higher turnover of in-hospital cases and with lower numbers of full-time staff. The employees' satisfaction, however, differed widely among the three departments with regard to the items "involvement with decisions" and "support by the superiors". The overall assessment of quality management is positive. Specific items such as the assessment of the management's commitment to quality management were strongly influenced by the employees' degree of information on quality management, which varies between departments. In the department with the lowest work satisfaction quality management was attributed a high potential for change and improvement. After quality management will have been implemented throughout the hospital, a new survey should be undertaken to evaluate whether quality management affects the employees' satisfaction with their work.

Sex differences in treatment patterns of six chronic diseases: an analysis from the German statutory health insurance

OBJECTIVE

The goal of this study was to investigate gender-specific differences in prevalence, healthcare costs, and treatment patterns in the German Statutory Health Insurance (SHI).

METHODS

The study analyzed administrative claims data of over 26 million insured with respect to prevalence and cost of illness of six chronic diseases. Insured were identified using the ATC code for medication prescription and ICD-9 code for diagnosis. The influences of gender, age, and comorbidity on cost differences were analyzed via multivariate regression analysis.

RESULTS

Adjusted for age and comorbidity, gender had a significant influence on both hospital and medication spending. Hospital costs on average were 17.1% (95% CI 14.1; 20.2) higher for men compared with women. Medication spending for men exceeded that for women on average by 13.8% (95% CI 10.9; 16.7). The diagnoses with the highest prevalence were hypertension and heart failure. Women had a higher prevalence of diabetes, coronary artery disease (CAD), heart failure, and hypertension. Medication costs were higher for men in three of five diagnoses and comparable for two diagnoses (diabetes and asthma). Women received more medication prescriptions than men, but on average prescriptions for men were 14%-26% more expensive than prescriptions for women. Regarding treatment patterns men were treated with different drug classes in cardiovascular disease (CVD) compared with women. Total medication spending stratified by diagnosis was highest for diabetes.

CONCLUSIONS

Gender differences for costs and prescribing patterns for chronic diseases vary disease specifically, but generally men had higher inpatient costs and more expensive medication prescriptions, whereas women had higher numbers of prescriptions.

[Efficiency of computer-based documentation in long-term care--preliminary project]

In Germany the documentation of processes in long-term care is mainly paper-based. Planning, realization and evaluation are not supported in an optimal way. In a preliminary study we evaluated the consequences of the introduction of a computer-based documentation system using handheld devices. We interviewed 16 persons before and after introducing the computer-based documentation and assessed costs for the documentation process and administration. The results show that reducing costs is likely. The job satisfaction of the personnel increased, more time could be spent for caring for the residents. We suggest further research to reach conclusive results.

Waiting times for elective treatments according to insurance status: A randomized empirical study in Germany

Background

Health insurance coverage for all citizens is often considered a requisite for reducing disparities in health care accessibility. In Germany, health insurees are covered either by statutory health insurance (SHI) or private health insurance (PHI). Due to a 20%–35% higher reimbursement of physicians for patients with PHI, it is often claimed that patients with SHI are faced with longer waiting times when it comes to obtaining outpatient appointments. There is little empirical evidence regarding outpatient waiting times for patients with different health insurance status in Germany.

Methods

We called 189 specialist practices in the region of Cologne, Leverkusen, and Bonn. Practices were selected from publicly available telephone directories (Yellow Pages 2006/2007) for the specified region. Data were collected for all practices within each of five specialist fields. We requested an appointment for one of five different elective treatments (allergy test plus pulmonary function test, pupil dilation, gastroscopy, hearing test, MRT of the knee) by calling selected practices. The caller was randomly assigned the status of private or statutory health insuree. The total period of data collection amounted to 4.5 weeks in April and May 2006.

Results

Between 41.7% and 100% of the practices called were included according to specialist field. We excluded practices that did not offer the requested treatment, were closed for more than one week, did not answer the call, did not offer fixed appointments ("open consultation hour") or did not accept any newly registered patients. Waiting time difference between private and statutory policyholders was 17.6 working days (SHI 26.0; PHI 8.4) for allergy test plus pulmonary function test; 17.0 (25.2; 8.2) for pupil dilation; 24.8 (36.7; 11.9) for gastroscopy; 4.6 (6.8; 2.2) for hearing test and 9.5 (14.1; 4.6) for the MRT of the knee. In relative terms, the difference in working days amounted to 3.08 (95%-KI: 1,88 bis 5,04) and proved significant.

Conclusion

Even with comprehensive health insurance coverage for almost 100% of the population, Germany shows clear differences in access to care, with SHI patients waiting 3.08 times longer for an appointment than PHI patients. Wide-spread anecdotal reports of shorter waiting times for PHI patients were empirically supported. Discrepancies in access to care not only depend on accessibility to comprehensive health insurance cover, but also on the level of reimbursement for the physician. Higher reimbursements for the provider when it comes to comparable health problems and diagnostic treatments could lead to improved access to care. We conclude that incentives for adjusting access to care according to the necessity of treatment should be implemented.

Can evidence-based medicine implicitly rely on current concepts of disease or does it have to develop its own definition?

Decisions in healthcare are made against the background of cultural and philosophical definitions of disease, sickness and illness. These concepts or definitions affect both health policy (macro level) and research (meso level), as well as individual encounters between patients and physicians (micro level). It is therefore necessary for evidence-based medicine to consider whether any of the definitions underlying research prior to the hierarchisation of knowledge are indeed compatible with its own epistemological principles.

Prevalence of Anti-Erythropoietin Antibodies in Hemodialysis Patients without Clinical Signs of Pure Red Cell Aplasia

BACKGROUND/AIMS

The prevalence of anti-erythropoietin antibodies in renal patients without clinical evidence of pure red cell aplasia (PRCA) who respond poorly to epoetin is unknown. This study tested for anti-erythropoietin antibodies in hemodialysis patients who were either hypo- or normoresponsive to epoetin treatment.

METHODS

Epoetin hyporesponsiveness (hemoglobin < or =10.5 g/dl and epoetin > or =9,000 IU/week) and normoresponsiveness (hemoglobin >10.5 g/dl and epoetin <7,000 IU/week) were arbitrarily defined. Prevalence of anti-erythropoietin antibodies in hemodialysis patients without symptoms of PRCA was determined by screening sera of 536 patients from 35 German KfH dialysis units, using enzyme-linked immunosorbent assay (ELISA). Positive results were verified by radioimmunoprecipitation assay (RIP) and neutralizing activity was determined by bioassay.

RESULTS

Anti-erythropoietin antibodies were detected in 3 hyporesponsive and 3 normoresponsive patients using ELISA. One patient per group was verified as borderline by RIP testing; the other 4 were negative. The bioassay was negative for 1 patient; the other died unrelated to PRCA before testing. Follow-up with RIP testing after 15 months under continuous epoetin treatment was negative (4 patients, 2 deceased).

CONCLUSION

This survey did not identify anti-erythropoietin antibodies in hemodialysis patient's hyporesponsive to epoetin and does not support presumptive antibody screening as a routine work-up in these patients.

Cost-benefit analysis of a plant sterol containing low-fat margarine for cholesterol reduction

For decreasing the risk of coronary heart disease (CHD) it has been proposed to enrich food such as margarine with plant sterol esters which have been shown to reduce total and LDL cholesterol concentrations, two of the major risk factors. A Markov model was developed to assess the costs and benefits of consuming a low-fat plant sterol containing margarine (PS margarine). A health insurer's perspective was taken with a time frame of 10 years. Transition probabilities for CHD and CHD-related death were calculated on the basis of the Framingham risk equations. These were applied to a representative sample of the German population. The alteration in cholesterol levels after intake of PS margarine was estimated based on a meta-analysis of ten randomized controlled trials with parallel or crossover design that found a reduction of 5.7% in total cholesterol. Average annual costs of CHD were assumed to be at 3,000 euro. Costs for "no CHD" and "CHD-related death" were set to 0 euro since the intervention would solely be paid by the consumers. Sensitivity analyses were performed with regard to annual costs, risk estimation, PS margarine reduction in total cholesterol, discount factor, and risk of CHD-related death. The 10-year CHD risks are 6.1% (PS margarine) vs. 6.5% (control). Thus expected 10-year CHD costs are 696 euro (PS margarine) vs. 748 euro (control). The cost savings of 52 euro varied between 32 euro and 74 euro in the sensitivity analysis. A projection at the level of the population for which evidence (randomized controlled trials) exists that plant sterols lower cholesterol (25.35 million) leads to a reduction of 117,000 CHD cases over 10 years and a cost reduction of 1.3 billion euro for this time period (sensitivity analysis 0.8-1.9 billion euro).

[Effects of tobacco tax increase on cigarette consumption and the impact on health policy]

The purpose of this study is to analyse the recent development of tobacco taxes and demand for cigarettes in Germany and to describe consequences for health policy. A descriptive analysis of aggregated data of the Federal Statistical Office is used to show the development of tax income and consumer behaviour with regard to the degree of substitution between differently taxed tobacco products. From 1993 to 2002 the demand for cigarettes increased nearly continuously. In 2003 the demand for industrial cigarettes went down by 8.6% and in 2004 by 15.8%. The difference between taxes and prices of industrial cigarettes and substitutes increased over the time period and still continues to increase. Tax and price differences between tobacco products led to partial compensation of the decreasing demand for industrial cigarettes. Therefore a tax increase on substitute products like fine cut tobacco is recommended. There is still a lack of longitudinal epidemiological data on smoking behaviour in Germany that could affirm effects of tobacco taxation.

Diabetes--prevalence and cost of illness in Germany: a study evaluating data from the statutory health insurance in Germany

OBJECTIVE

This population-based study assesses the prevalence and cost of illness as a result of diabetes mellitus in Germany by retrospectively analysing routine health insurance data. Prevalence and costs were analysed from statutory health insurance (GKV) and societal perspectives.

RESEARCH DESIGN AND METHODS

The analysis comprises data of all insured persons of six large sickness funds. The insured with diabetes were identified via ICD-9 diagnosis and Anatomical Therapeutic Chemical Classification System (ATC) code for regular medication prescriptions. Costs for inpatient stay, medication and sickness benefits were taken from claims data. Costs for rehabilitation, premature death and early retirement were calculated using the human capital approach and data from national statistics.

RESULTS

Overall diabetes prevalence in this age and sex standardized census of six large sickness funds was 6.45%. The cost of illness for sickness funds including hospital cost, medication and sickness benefits, and excluding ambulatory doctor care, were Euro 3.69bn . The total cost of diabetes from a societal perspective was calculated at Euro 5.71bn for the year 1999.

CONCLUSION

In accordance with the results of recent studies using routinely collected health insurance data, our study suggests that the prevalence of diabetes mellitus has increased steadily in the past years. The prevalence in our population of 14.7 million insured was 6.45%. Total costs of diabetes mellitus amounted to Euro 5.71bn.

Kosteneffektivität der Prävention der koronaren Herzkrankheit in Deutschland

It is generally accepted that the incidence of coronary heart disease can effectively be reduced by strengthening prevention. At the same time, it is still unclear how large the effects of life-style oriented preventive measurements such as diet and exercising are in everyday life. Furthermore, there is an ongoing debate on what measurements are effective. Thus, against the background of dwindling financial resources in health care the input of health economic evaluation is explicated. General issues of health economic evaluation are presented. After that, an overview on the current findings of cost-effectiveness in primary prevention of coronary heart disease is given. Risk factors are separately discussed. It is demonstrated that preventive measurements dealing especially with hypertension and hypercholesterolemia can be cost-effective.

Evidence-based medicine is rooted in Protestant exegesis

Evidence-based medicine (EbM) has been practised for about a decade now. Until now, it has generally been accepted that EbM has its roots in medical thinking of mid-19th century France. Due to the startling fact that France never was a centre of EbM, historical tradition was reconsidered. Since EbM has mainly been flourishing in Protestant countries, a qualitative historical investigation was conducted according to the approach of Max Weber's "The Protestant Ethics". Thus, it could be shown that there are three major prerequisites for EbM to evolve apart from current technical developments, such as the computer and the internet: (1) historical critical exegesis functioned as a methodology to balance contradictory passages; (2) both an equality based relationship among physicians and a Protestant concept that lay people are considered equal in the theologic debate were fundamental to EbM as a new approach of medical thinking; (3) mostly nationally funded health care systems are prone to practise EbM as they are obliged to provide health care which is both fair in access and allocation to the whole population. Against the background of historical exegesis, it has to be taken into account that EbM implies a twist in medicine towards a concept of textual criticism rather than the mere introduction of statistics. Moreover, it both relies upon and enhances a more equal relationship between physicians.

European comparison of costs and quality in the treatment of acute back pain

STUDY DESIGN

Retrospective multicenter observational study.

OBJECTIVES

To compare the outpatient quality and costs of treating acute back pain in England, Germany, the Netherlands, and Switzerland.

SUMMARY OF BACKGROUND DATA

No study has yet attempted to compare the quality, costs, and resource utilization of acute back pain treatment in Europe.

METHODS

A total of 130 randomly selected physician practices assessed services for 1 hypothetical average patient during the first 4 weeks of treatment (cost evaluation) and 127 practices reported retrospective data on 1 real patient (quality evaluation) in 2001. Reimbursement fees served as unit costs for Germany and Switzerland. Average reimbursement fees were used to measure resource utilization in all countries. Quality of care was assessed in terms of the following unnecessary treatments and diagnoses: bed rest for more than 2 days; exercise therapy; scheduling of a radiograph or other imaging tests; and referral to another provider. Responses were weighted with the level of scientific evidence for overuse.

RESULTS

Weighted-average overuse ranged from 18% in the Netherlands to 31% in Germany. In England, Germany, and Switzerland, at least a third of the resources used to treat back pain were wasted.

CONCLUSIONS

There was considerable waste in treating acute back pain. The Netherlands had highest quality and lowest resource utilization in providing treatment for acute back pain.

Asthma: prevalence and cost of illness

The purpose of this study was to estimate the prevalence and cost of illness of asthma in Germany by retrospectively analysing routine health insurance data. This analysis investigated claims data from all insured persons of six large sickness funds. Insurants with asthma were identified via the International Classification of Diseases (ninth revision) diagnosis and the Anatomical Therapeutic Chemical Classification System Code for regular medication prescriptions. Costs for hospital care, medication and sick benefit were taken from claims data. Costs for rehabilitation, premature death and early retirement were estimated using the human capital approach and data from national statistics. Prevalence of asthma in the German statutory health insurance was 6.34%. Total costs for asthma, including direct and indirect costs, were calculated at euro 2.74 billion during 1999. The prevalence of asthma in the German statutory health insurance has previously been estimated to be 4-6%. The results of this large study show the prevalence of asthma in the German social insurance system to be approximately 6%. The study also indicates that there is room for substantial savings in the German social insurance system, with indirect costs amounting to 74.8% of total costs and payment of sick benefits through the sickness funds amounting to 58.3% of indirect costs. These costs may be reduced with better asthma control in patients.

Evidence-based Medicine: Why do Opponents and Proponents use the same Arguments?

There is quite some ethical controversy on Evidence-based Medicine (EbM) with regard to issues of physician autonomy as well as its allocative implications. Yet, there are some shortcomings in the current debate. First of all, some of the arguments brought up against EbM are similarly defaults of "classical medicine" as well, for instance its negligence of social aspects of medicine. Second, it is often maintained that EbM is just a tool to attain cost containment. This argument is false in two regards for neither is there any idea of cutting costs in the roots of EbM nor does EbM once practiced necessarily lead to less costs as there can be underuse as well as overuse. Third, both opponents and proponents of EbM come up with the same arguments against each other. Both maintain that the other way of practicing medicine does not allow for physicians' autonomy and free judgment. Therefore, we are going to search for the different presuppositions on which these "reproaches" rely. In this way we can demonstrate that both opponents and proponents rely on different notions of autonomy and free judgment in their argument. Finally, we hope to show that some of the ethical criticism may be raised against classical medicine as well and that allocation in terms of costs is not primarily an aim of EbM.

Appropriateness of Invasive Cardiovascular Interventions in German Hospitals (2000 - 2001): An Evaluation Using the RAND Appropriateness Criteria

OBJECTIVE

Germany has the highest per capita rate of percutaneous transluminal coronary angioplasties (PTCAs) in Europe and the third highest per capita rate of heart surgeries requiring a heart-lung machine. The goal of this study was to evaluate the appropriateness of PTCA, coronary artery bypass graft (CABG), and carotid endarterectomy (CEA) in German hospitals using RAND appropriateness criteria.

METHODS

A retrospective study in 121 randomly selected German hospitals (52 % of all hospitals contacted) was performed from December 2000 to August 2001. A total of 361 patients were enrolled providing information on the appropriateness of 128 PTCAs, 92 CABGs, and 141 CEAs.

RESULTS

Inappropriateness rates were 2 % (95 % CI 0 - 5 %), 4 % (95 % CI 1 - 9 %), and 3 % (95 % CI 1 - 7 %) for PTCA, CABG, and CEA, respectively. The overall rate of uncertain procedures was 42 % (95 % CI 36 - 47 %). Only 38 % (95 % CI 32 - 45 %) of patients who received a coronary intervention had had a pre-interventional stress test.

CONCLUSIONS

The study yielded little overt overuse in the performance of PTCAs, CABGs, and CEAs, but potentially large underuse of stress tests. Despite a high per capita rate of invasive cardiovascular interventions in Germany, the rate of inappropriate procedures was not larger than in other countries.

Leistungen und Kosten der Hochschulambulanzen in Forschung, Lehre und Versorgung

BACKGROUND

Outpatient clinics of university hospitals (Hochschulambulanzen) play a significant role in the German health care system. Universities have in contrast to other hospitals the right to implement an outpatient clinic, but the health care services they can render are restricted to clinical research and teaching activities. The university outpatient clinic study evaluates the intensity of medical care, teaching, research activities, and the related costs. METHOD AND DATABASE: 6 university hospitals with 51 outpatient departments in Germany were included. The prospective documentation of consultations was restricted to 800 visits per department. A total of 26,312 consultations with approximately 40,000 diagnoses and 150,000 services were documented. Furthermore, data concerning costs, teaching activities and research facilities were documented.

RESULTS

Clinical treatment without any correlation to research or teaching activities amounted to about 81 % of the working time in the outpatient department (research 11 %; teaching 8 %). The primary task of the university outpatient clinics takes up less than 20 % of the working time. The physicians documented that the disease of every fourth visit was in accordance with their main field of research. 6.9 % of the visits were asked to take part in clinical trials, of these 1.25 % were included for the first time, 3.7 % were already included. 6.5 % of the visits were addressed to participate in specific teaching activities. The average total costs per case added up to 149 Euro. No outpatient clinic could cover the total per case costs with the lump sum payments. On the average 31 % of these costs were covered by lump sum payments (without cases concerning research and teaching).

CONCLUSION

Treatment in outpatient departments of university clinics is far beyond research and teaching activities required by law. However, the ability of outpatient departments of universities to provide excellent outpatient services should have a more dominant role in the health care system. Therefore access to care should be deregulated for the patients and reimbursement schemes should be adjusted to adjust for the present losses.

[Guideline-based medical quality management in dialysis. Motivation and structuring of a quality-management system and integration of earlier disease stages of chronic renal failure]

BACKGROUND AND PURPOSE

Health services are challenged by increasingly complex medical processes and economic restraints in an aging population. Under these circumstances, medical quality management is developed and increasingly applied to survey especially complex and expensive clinical processes in the sense of controlling. In this process, practicability and relevance are fundamental.

METHODS

This paper presents the well-established quality management system QiN (quality in nephrology) in the context of dialysis in end-stage renal disease.

RESULTS

A quality-management system is well applicable in the case of dialysis. It can positively influence relevant indicators of process and outcome quality, as demonstrated here by the example of dialysis quantity.

CONCLUSIONS

Outcome and process quality in dialysis are quantifiable via defined indicators oriented on evidence-based medicine. The program based on benchmarking of basic clinical indicators leads to improved care of dialysis patients. A quality-management program of this type can represent an essential component of interdisciplinary, structured treatment programs, thereby influencing the whole treatment process.

Evidence-based medical quality management in dialysis - Part I: Routine implementation of QiN, a German quality management system

Increasing medical complexity, centrifugal forces of medical subspecialization and growing economic constraints are the key reasons for the introduction of quality management into routine care processes such as dialysis. Adequate quality assurance and improvement must be implemented in order to supply medical staff, care providers, and patients with the necessary information on critical issues of clinical management of dialysis patients. QiN (Quality in Nephrology), the quality management program of the largest German dialysis provider, is outlined here as a practicable example. The first of 2 parts provides information on the structure, implementation of QiN and achieved clinical improvement in routine care. The second part (quotation) analyzes longitudinal data in order to differentiate whether observed improvements during more than 5 years of QiN can be ascribed to the intervention (application of QiN) or whether they are due to other factors such as generally improved medical knowledge.

[Centralisation of breast cancer management by giving minimum work-load. Empirical effects in the region of North-Rhine, Germany]

INTRODUCTION

The concentration of treatment on a few hospitals is discussed to improve the outcome of care. For the treatment of the breast cancer the distributional effects are evaluated.

METHOD

A systematic literature search in Medline identified six studies dealing with the evidence on the relation between outcome and workload. Using administrative data of a sickness fund in the region of Rhineland, Germany, the number of hospitals and patients affected by minimum work-loads was determined.

RESULTS

Study results show that in general a minimum workload of 100 to 150 new diagnosed cases per year and hospital is recommended. These recommendations would lead to 46% of the presently treating hospitals being excluded (minimum work-load of 150 cases; year 2001). If the workload is set to 100 cases, 31% of the hospitals will be excluded from breast cancer management. No significant differences could be detected in the data of the years 2000 and 2001.

DISCUSSION

The association between minimum workload and outcome of care seems to be evident. Further studies involving larger regions are needed to evaluate the distributional effects and gains of outcome.

Costs and quality in the treatment of acute depression in primary care: a comparison between England, Germany and Switzerland

No study has yet compared the costs and quality of depression treatment between European countries. The present study aimed to compare the costs and quality of treatment for the first manifestation of an acute major depression in England, Germany and Switzerland. Seventy-four randomly selected physician practices assessed their services for one hypothetical average patient (cost evaluation) and 73 practices reported retrospective data on one real patient (quality evaluation) for the year 2001. Reimbursement fees served as unit costs for Germany and Switzerland. Average reimbursement fees were used to measure resource utilization in all countries. Resource utilization was lowest in Switzerland. The percentage of patients receiving evidence-based treatment for major depression was insignificantly higher in Switzerland and England compared to Germany (56%, 52% and 35%, respectively; P>0.30). Switzerland was both the most effective and the most efficient country (in terms of resource utilization) in providing outpatient treatment for depression.

[Health policy guidelines for ambulatory and brief inpatient surgery. Backgrounds, facts and possible future solutions]

Ambulatory and short-stay surgery in Germany are regulated by two different political committees with different members. Currently, hospitals are permitted to practice ambulatory surgery on the basis of a mere notification sent to the health insurance companies. The details for access, reimbursement, and quality assurance are negotiated between the hospitals' association, the health insurance companies, and the association of the physicians. Compared to other fields of ambulatory care, the legislation for ambulatory surgery is rather loose concerning hospitals' access to this field of health care provision. Short-stay surgery is designated under inpatient care. With the introduction of so-called diagnosis-related groups (DRG) in 2003, a steep decline in length of stay is expected. Further efforts of the government and health insurance companies to extend ambulatory surgery to further indications are expected, too. However, the hurdle of transferring services from the inpatient sector to the ambulatory sector is a major challenge in Germany. We recommend lowering the legislative hurdle hindering hospitals and physicians from entering the area of ambulatory surgery for specific diagnoses. Same-day treatment should also be encouraged.

Threshold volumes associated with higher survival in health care: a systematic review

BACKGROUND

To date, systematic reviews on the relationship between the volume of specific diagnoses and procedures and patient outcomes have several limitations, including the omission of the most recent publications.

OBJECTIVE

To investigate the relationship between hospital and physician volume and patient mortality rate for all diagnoses and interventions in health care.

RESEARCH DESIGN

Medline and the Cochrane Library were searched from January 1990 to December 2000 for all studies published in Dutch, English, French, German, and Italian. The following Boolean search statement was used: hospitals AND volume AND (outcome OR mortality OR quality). Studies were included in which patient enrollment ended within 10 years of the current study and that were adjusted for case-mix. For each diagnosis and intervention, the study most likely to provide an unbiased estimate of the effect of volume on mortality rate was identified using a specific algorithm (best study).

RESULTS

A total of 34 diagnoses and interventions with at least one qualifying study on the volume-outcome relationship were identified. The summary odds ratio/relative risk for the best studies on hospital and physician volume were 0.87 (95% confidence interval [CI], 0.85-0.89) and 0.87 (95% CI, 0.81-0.94), respectively. From the best studies on hospital volume, 48.5% (16 of 33) were published either in 1999 or 2000.

CONCLUSIONS

There is evidence for a volume-mortality relationship for hospitals and physicians. The use of appropriate methods for analyzing additional diagnoses and interventions as well as a continuous systematic evaluation of the evidence is recommended.

[Relevance of medical rehabilitation in disease management programmes]

Disease management programmes will increasingly be introduced in Germany due to the new risk adjustment scheme. The first disease management programmes started in 2003 for breast cancer and diabetes mellitus type II. German rehabilitation will have to face several challenges. Disease management programmes are strongly based on the notion of Evidence so that proof of the efficacy of a care giving task should be present. Verification of the evidence of the specifically German rehabilitation treatments must therefore be given. However, integration of rehabilitation in disease management programmes could lead to changes in the alignment of German rehabilitation. The essence of German rehabilitation, notably its holistic approach, could get lost with integration in disease management programmes.

The practice-makes-perfect hypothesis in the context of other production concepts in health care

Many studies have found a significant relationship between the volume of specific diagnoses and procedures and patient outcomes. Often, these studies have cited the "practice-makes-perfect" hypothesis as a potential explanation. However, the expression "practice-makes-perfect" hypothesis is inappropriate in most circumstances. This article suggests using the expression "routine" hypothesis instead. In addition, this article compares the routine hypothesis with other familiar concepts from industrial production, which also aim at explaining the relationship between factor input and output in health care: economies of scale, economies of scope, the learning curve, and the focused factory. To point out subtle differences among the concepts, this article suggests a taxonomy organized by type of output and outcome. This taxonomy may help ensure the appropriate use of terminology when applying these concepts.

Effectiveness of the glycoprotein IIb/IIIa antagonist abciximab during percutaneous coronary interventions (PCI) in clinical practice at a single high-volume center

OBJECTIVE

Randomized controlled trials (RCTs) showed that the glycoprotein (GP) IIb/IIIa antagonist abciximab is able to reduce ischemic complications during percutaneous transluminal coronary interventions (PCIs). Its effectiveness in daily clinical practice in unselected patients remains to be determined.

DESIGN, SETTING AND PATIENTS

From 7/1997 until 12/2000, 3310 PCIs were performed at the Heart Center Ludwigshafen. Out of them, 1076 (32.5%) patients were nonrandomly treated with a GP IIb/ IIa antagonist. Patients who were treated with abciximab were matched with patients not treated with abciximab. The matching procedure resulted in 590 pairs of patients.

RESULTS

Patients treated with abciximab were more likely to have a history of former PCI (13.7% versus 8.8%, p=0.008) or coronary artery bypass surgery (19.2% versus 12.8%, p=0.003). There were no differences in concomitant diseases, left ventricular function, number of vessels diseased or target vessel. However, patients treated with abciximab had a higher rate of more complex stenosis (> or =B2; 94.4% versus 80.7%, p<0.001) and a longer x-ray exposition (median 486 s versus 422 s, p<0.001). Treatment with abciximab was associated with a significantly lower incidence of the combined endpoint of death, reinfarction or stroke during the hospital stay (2.4% versus 4.4%, p=0.039). This was confirmed after adjustment for confounding parameters (p=0.034). There was no increase in the rate of severe bleeding in the abciximab group (p=0.347). After one year the rates for the combined endpoint were 8.5% in the control group and 6.2% in the abciximab group (univariate analysis, p=0.134; multivariate analysis, p=0.143).

CONCLUSION

Treatment with abciximab during PCI in daily clinical practice at a high volume center in patients with a high rate of acute coronary syndromes seems to be as effective as shown in RCTs.

[Prospective payment in medical rehabilitation]

After introducing DRGs (Diagnosis-Related Groups) in the prospective payment system for German hospitals, the use of per-case reimbursement for medical rehabilitation as well is being discussed. In particular two systems have already been tested internationally. FIM-FRG were especially developed for a prospective payment system for inpatient rehabilitation facilities. RUG-III are used for reimbursing long-term care in nursing homes and are based on a per-day payment. It is recommended to test the FIM-FRG or one of the refined systems in Germany in a pilot project.

Management patterns and health care use after intracerebral hemorrhage. a cost-of-illness study from a societal perspective in Germany

BACKGROUND

The German cost-of-illness study of stroke is a multicenter study in 6 departments of internal medicine, 9 departments of general neurology and 15 departments of neurology with an acute stroke unit. The aims of this study are to describe the management patterns, cost of treatment and overall resource utilization after intracerebral hemorrhage (ICH) as well as the major differences to ischemic stroke (IS).

METHODS

During a 12-month period, 30 participating centers with a special interest in stroke prospectively included 586 patients with ICH which were collected in a joint data bank. About 75% of all patients could be centrally followed up via structured telephone interviews after 3 and 12 months to assess further acute hospital and rehabilitation stays, outpatient resource utilization, functional outcome and quality of life.

RESULTS

Mortality after 3 months (33.5%) was markedly higher than in patients with IS from the same hospitals. Accordingly, only 30.9% of patients had regained independent functional status after 3 months. Cumulative cost of treatment amounted to 5301 EUR for inpatient stay in the documenting hospital and 8920 EUR for the overall hospital stay including rehabilitation. Mean direct cost after discharge during the first year amounted to 4598 EUR and the loss of work force was equivalent to 5537 EUR in all surviving patients.

CONCLUSION

This study provides a comprehensive overview of patient characteristics, treatment strategies and health care cost of ICH from a societal perspective in Germany.

[Quality control of outpatient imaging examinations in North Rhine-Westphalia, Part II]

PURPOSE

In the state of North Rhine-Westphalia (NRW), Germany, a survey was conducted on radiologic examinations ordered by general practitioners (GPs). Part II of this study aims to determine the quality of the process and outcome. The reference standard is the assessment of both radiologists and physicians without board certification in radiology working at a university hospital and in outpatient facilities.

MATERIALS AND METHODS

AllGPs in NRW were asked to cooperate. Participating GPs filled out a questionnaire for each patient. The patients recorded the symptoms prompting the imaging examinations. The radiologists or other physicians performing the examinations were asked to provide the images and written reports and to complete a questionnaire. A file was created for each of the 394 patients with image documentation of at least one examination. Each file, which included medical history, physical findings, imaging documentation and written report, was sequentially forwarded to a board-certified radiologist and to a physician without board certification in radiology working in a university hospital and in an outpatient facility. All physicians were requested to complete a structured questionnaire for each file.

RESULTS

The referral diagnoses were rated as medically plausible in 81%, the indications for imaging found correct in 76%, the examination techniques considered appropriate in 69%, the clinical question answered in 63%, the interpretation judged medically correct in 50% and all incidental findings documented in 49%. In retrospect, 32 % of the examinations were judged superfluous. The sequence of multiple examinations performed on a particular patient was rated as appropriate in 51%. The interpretation revealed specialty-related differences. The plausibility of the referral diagnoses had a significant impact on the appropriateness of subsequent diagnostic investigations. Marked deficits showed sonography, performance by non-radiologists, self-referrals by GPs, gastroenterologic radiology and the ICD-10 coding (suspicion of cardiovascular disease).

CONCLUSION

In the "best-case" scenario, the process quality proved to have moderate deficiencies and the outcome quality severe deficiencies. In consequence, GPs and radiologists should be more communicative by sharing information and exchanging opinions. GP self-referrals should be restricted. Sonography and examinations performed by physicians without board certification in radiology should undergo stricter quality controls. A more intensive interdisciplinary collaboration is needed to determine the optimum implementation of diagnostic imaging of gastroenterologic and cardiovascular diseases.

[Quality control of outpatient imaging examinations in North Rhine-Westphalia, part I]

PURPOSE

In the state of North-Rhine Westphalia (NRW), Germany, a survey was conducted on radiologic examinations ordered by general practitioners (GPs). Part I of this study aims to collect characteristic epidemiological data and to assess structural quality.

MATERIALS AND METHODS

All GPs in NRW were asked to cooperate. Participating GPs filled out a questionnaire for each patient. The patients recorded the symptoms prompting the imaging examinations. The radiologists or other physicians performing the examinations were asked to provide the images and written reports and to complete a questionnaire. Two university radiologists documented the pertinent test data from the submitted images and written records. Independently of each other, five university radiologists anonymously reviewed the image quality of each examination using structured questionnaires.

RESULTS

A total of 920 patients gave their informed consent and participated. Questionnaires from 787 patients, 852 GPs and 611 radiologists or other interpreting physicians as well as the complete survey data from 530 examinations were available. Of 1503 examinations, conventional radiography made up 52 %, sonography 17 %, computed tomography (CT) 13 % and magnetic resonance imaging (MRI) 5 %. Most indications involved the musculoskeletal (37 %) and respiratory systems (24 %). Physicians without board certification in radiology interpreted 1 % of the CT examinations, 26 % of the radiographic examinations and 71 % of the sonographic examinations. Of the 174 self-referrals, 1 % involved CT, 33 % conventional radiography and 66 % sonography. Written reports were available for 95 % of all 469 examinations performed by radiologists and 74 % of all 127 examinations conducted by non-radiologists. Only 44 % of the 23 sonographic studies were self-referrals by the patient's GP. On average, the radiographic techniques were acceptable in terms of diagnostic information and radiation hygiene. Conventional radiographs were better exposed when obtained by radiologists than by non-radiologists (p = 0.038). The delineation of anatomical structures was rated as good to acceptable for MRI, CT and conventional radiography, while the image quality was rated as diagnostically insufficient for sonography (p < 0.0001). The image quality of radiographic and sonographic examinations performed by radiologists was superior in comparison to examinations performed by physicians without board certification in radiology (p < 0.0001).

CONCLUSION

Examination technique and imaging quality of MRI, CT and conventional radiography performed on outpatients were in an acceptable diagnostic range, whereas the quality of sonography was inadequate.

European comparison of costs and quality in the prevention of secondary complications in Type 2 diabetes mellitus (2000-2001)

AIMS

To compare the out-patient costs and process quality of preventing secondary complications in patients with Type 2 diabetes mellitus in France, Germany, Italy, The Netherlands, Sweden, Switzerland, and the UK.

METHODS

A total of 188 European physician practices assessed annual services for one hypothetical average patient (cost evaluation) and 178 practices reported retrospective data on one or two real patients (quality evaluation) in 2000/2001. In countries with a detailed fee-for-service schedule (Germany, Italy, and Switzerland) reimbursement fees were used to approximate costs. These fee-for-service schedules were also used to develop index (average) fees for all countries, in order to measure resource utilization. The following process quality indicators were evaluated: control of HbA1c; control of lipids; urine test for (micro)albuminuria; control of blood pressure; foot examination; neurological examination; eye examination; and patient education. For each country an average quality rating was calculated by weighting the response to each quality indicator with the level of scientific evidence.

RESULTS

Average quality ratings ranged from 0.40 in The Netherlands to 0.62 in the UK (0 = lowest rating; 1 = highest rating). Total annual costs for secondary prevention were higher in Switzerland than in Germany and Italy (EUR475, EUR381, and EUR283, respectively). Resource utilization was highest in Germany and lowest in the UK.

CONCLUSIONS

The overall quality of preventive services documented was found to be poor in the seven European countries studied. The UK rated as both the most effective and the most efficient country in providing secondary prevention in Type 2 diabetes.

European comparison of costs and quality in the treatment of acute myocardial infarction (2000-2001)

AIMS

To compare the inpatient costs and process quality in the treatment of acute myocardial infarction in France, Germany, Italy, The Netherlands, Sweden, Switzerland, and the U.K.

METHODS

A total of 208 European hospitals assessed services for one hypothetical average patient with acute myocardial infarction (cost evaluation) and prospectively followed up one or two real acute myocardial infarction patients (quality evaluation) in 2000/2001. The following cost modules were evaluated: general medicine ward, critical care unit (both personnel costs only), and reperfusion therapy. The following process quality indicators were evaluated: reperfusion therapy; and prescription of aspirin, lidocaine, beta-blockers, and ACE inhibitors.

RESULTS

Switzerland, Germany, and France had the highest reperfusion costs due to a relatively high percentage of patients receiving percutaneous transluminal coronary angioplasties, stents, and glycoprotein IIb/IIIa blockers. Personnel costs for general medicine wards and critical care units were highest in Italy and Germany due to relatively long hospital stays. Average quality ratings ranged from 89% in the U.K. and France to 96% in Germany.

CONCLUSION

There was little variation in the process quality of care for treating acute myocardial infarction. Differences in resource use may result from differences in the types of reimbursement and in the rates of diffusion of new technology.

[Measuring case severity with a DRG-based reimbursement system]

BACKGROUND

The Australian Refined Diagnosis-Related Groups (AR-DRGs) will be the model for the German DRGs (G-DRGs). Their system to measure severity of illness will be a major point of interest.

METHOD

The most common systems for measuring severity of illness are presented and compared with the AR-DRGs based on criteria regarding applicability.

RESULTS

None of the systems for measuring severity of illness fits all the criteria. They can be used for reimbursement of inpatient care or for quality assurance, but not for both at the same time. The designated areas for the use of the systems should not be exceeded.

CONCLUSION

AR-DRGs are very complex in measuring the costs per case (severity of illness in terms of efficiency). They are not able to support quality assessment by risk adjustment (severity of illness in terms of medical complexity). A less complex system would have been easier to transfer to Germany with the same incentives for providing effective care.

[Effectiveness of structural quality in quality assurance--a review]

Minimum standards as a part of structural quality are often discussed for the sake of improving the quality of medical care. Before implementing obligatory standards, however, the effectiveness of the demands made should be evaluated.

THE METHOD

Our method was a systematrix review (with an eye to structural quality indicators) of literature found by searching Medline; the structural quality indicators taken into account were special forms of medical care, hospital characteristics, certification, internal quality management, internal peer-reviewing, telemedicine, continuing medical education, the use of guidelines, and the caseloads of physicians and hospitals?

THE RESULTS

A minimum caseload, the use of guidelines and continuing medical education show positive effects on the outcome of care. The other items show mixed study results or are not measurable in a sense that would make their results of use for quality improvement. Without evidence of effectiveness, minimum standards should not be introduced. Despite the inhomogeneity of the methods used by the studies, minimum caseloads for some diagnoses, the use of guidelines and well-organised continuing medical education are to be recommended.

A method for assessing the cost-effectiveness and the break-even point of clinical practice guidelines

Assessing the costs and benefits of developing a clinical practice guideline is important because investments in guidelines compete with investments in other clinical programs. Despite the considerable number of guidelines in many industrialized countries, little is known about their costs and cost-effectiveness. The authors have developed specific measures to determine the cost-effectiveness of guidelines, using a German evidence-based guideline on obesity for the diagnosis and treatment of obese patients as a model. The measures are: the number of people needed to cure, the number of people needed to prevent from developing the disease in question, and the number of people to treat in order to break even.

[Result-oriented remuneration for hospital inpatient care]

Fee-for-benefit means the adjustment of the reimbursement at the quality of care. Both a bonus and a penalty are possible. It is suggested to measure innovative therapies with outcome parameters and give a bonus as an incentive for quality improvements. Standard therapies should be measured with process parameters and be sanctioned with a penalty when the standards are missed. To determine the extend of the bonus and the penalty, the variable costs of a hospital could be used as a reference. Therefore a penalty should not exceed approximately 25 % of the reimbursement. The costs for the introduction and administration of the fee-for-benefit reimbursement must be seen in the context of the necessary improvement of quality insurance in per-case reimbursement with DRG (Diagnosis-Related Groups) in Germany. Related to the incidence of preventable adverse events and the additional costs of poor-quality outcome evaluated from studies fee-for-benefit will be cost-effective by avoiding every sixth adverse event. German legislation allows fee-for-benefit only in small model projects or local integrated networks. It is recommended to allow an optional opening of negotiations between hospitals and sickness funds for fee-for-benefit elements. A pilot study should evaluate the incidence and cost of preventable adverse events in Germany.

[Extent and causes of coding problems for total compensation on the basis of Diagnosis-Related Groups]

BACKGROUND AND QUESTION: In contrast to the per-day-reimbursement specific data like diagnoses, procedures and demographic data of the patient is needed for a per case reimbursement with Diagnosis Related Groups (DRG). Coding errors can have great impact on the height of the reimbursement. A review of the extent and the causes of coding problems does not exist at present.

METHODOLOGY

A systematic search in Medline using the search words >>coding<< and >>error<< and >>hospital<< was performed. Only articles with quantitative evaluation, written in English or German, were included. Literature cited in the articles was included as well.

RESULTS

A total of 33 studies (53 113 cases) were identified. An average of 23 % of cases was showing coding problems. Eighteen percent of the cases were assigned to a wrong DRG. Regarding the date of publication no effect in the extent of the coding accuracy could be detected.

CONCLUSION

An appreciable rate of cases with coding problems should be anticipated when introducing DRG. Training to improve coding accuracy is recommended. Whether coding should be a task of the ward or the management of the hospital could not be decided here, but it should be noted that this assignment of the coding task has major impact on the allocation of competence in the long run.