Development of indicators to assess quality and patient pathways in interdisciplinary care for patients with 14 ambulatory-care-sensitive conditions in Germany

BACKGROUND

In settings like the ambulatory care sector in Germany, where data on the outcomes of interdisciplinary health services provided by multiple office-based physicians are not always readily available, our study aims to develop a set of indicators of health care quality and utilization for 14 groups of ambulatory-care-sensitive conditions based on routine data. These may improve the provision of health care by informing discussions in quality circles and other meetings of networks of physicians who share the same patients.

METHODS

Our set of indicators was developed as part of the larger Accountable Care in Deutschland (ACD) project using a pragmatic consensus approach. The six stages of the approach drew upon a review of the literature; the expertise of physicians, health services researchers, and representatives of physician associations and statutory health insurers; and the results of a pilot study with six informal network meetings of office-based physicians who share the same patients.

RESULTS

The process resulted in a set of 248 general and disease specific indicators for 14 disease groups. The set provides information on the quality of care provided and on patient pathways, covering patient characteristics, physician visits, ambulatory care processes, pharmaceutical prescriptions and outcome indicators. The disease groups with the most indicators were ischemic heart diseases, diabetes and heart failure.

CONCLUSION

Our set of indicators provides useful information on patients' health care use, health care processes and health outcomes for 14 commonly treated groups of ambulatory-care-sensitive conditions. This information can inform discussions in interdisciplinary quality circles in the ambulatory sector and foster patient-centered care.

Patients at high risk for a severe clinical course of COVID-19 - small-area data in support of vaccination and other population-based interventions in Germany

BACKGROUND

Research has shown that the risk for a severe course of COVID-19 is increased in the elderly population and among patients with chronic conditions. The aim of this study was to provide estimates of the size of vulnerable populations at high risk for a severe COVID-19 course in Germany based on the currently available risk factor data.

METHODS

We used nationwide outpatient claims data from the years 2010 to 2019 collected according to § 295 of the Code of Social Law V, covering data for all statutory health insurees (SHI) which is nearly 87% of the entire German population. We considered 15 chronic disorders based on the current state of knowledge about clinically relevant risk factors. Three risk groups for a severe COVID-19 course were defined: 1. individuals in the age group 15 to 59 years with at least two comorbid disorders; 2. individuals aged 60 to 79 years with at least one disorder and 3. all individuals 80 years and older irrespective of the presence of chronic conditions. Regional analysis was conducted at the level of administrative districts (n = 401).

RESULTS

Overall, 26% of individuals over 15 years were at high risk for a severe COVID-19 course in 2019 amounting to a total number of nearly 18.5 million individuals in Germany. This included 3.8 million individuals in risk group 1, 9.2 million in risk group 2, and 5.4 million in risk group 3, corresponding to 8, 50 and 100% of German inhabitants in the respective age groups. On the level of the 17 administrative regions formed by the Association of SHI Physicians (ASHIP regions), the proportion of individuals at high risk ranged between 21% in Hamburg and 35% in Saxony-Anhalt. Small-area estimates varied between 18% in Freiburg (Baden-Württemberg) and 39% in the district Elbe-Elster (Brandenburg).

CONCLUSIONS

The present study provides small-area estimates of populations at high risk for a severe COVID-19 course. These data are of particular importance for planning of preventive measures such as vaccination.

TRIAL REGISTRATION

not applicable.

Improving the continuity and coordination of ambulatory care through feedback and facilitated dialogue-a study protocol for a cluster-randomised trial to evaluate the ACD study (Accountable Care in Germany)

Background

Patients in Germany are free to seek care from any office-based physician and can always ask for multiple opinions on a diagnosis or treatment. The high density of physicians and the freedom to choose among them without referrals have led to a need for better coordination between the multiple health professionals treating any given patient. The objectives of this study are to (1) identify informal networks of physicians who treat the same patient population, (2) provide these physicians with feedback on their network and patients, using routine data and (3) give the physicians the opportunity to meet one another in facilitated network meetings.

Methods

The Accountable Care Deutschland (ACD) study is a prospective, non-blinded, cluster-randomised trial comprising a process and economic evaluation of informal networks among 12,525 GPs and office-based specialists and their 1.9 million patients. The units of allocation are the informal networks, which will be randomised either to the intervention (feedback and facilitated meetings) or control group (usual care). The informal networks will be generated by identifying connections between office-based physicians using complete datasets from the Regional Associations of Statutory Health Insurance (SHI) Physicians in Hamburg, Schleswig Holstein, North Rhine and Westphalia Lip, as well as data from three large statutory health insurers in Germany. The physicians will (a) receive feedback on selected indicators of their own treatment activity and that of the colleagues in their network and (b) will be invited to voluntary, facilitated network meetings by their Regional Association of SHI physicians. The primary outcome will be ambulatory-care-sensitive hospitalisations at baseline, at the end of the 2-year intervention period, and at six months and at 12 months after the end of the intervention period. Data will be analysed using the intention-to-treat principle. A pilot study preceded the ACD study.

Discussion

Cochrane reviews show that feedback can improve everyday medical practice by shedding light on previously unknown relationships. Providing physicians with information on how they are connected with their colleagues and what the outcomes are of care delivered within their informal networks can help them make these improvements, as well as strengthen their awareness of possible discontinuities in the care they provide.

Trial registration

German Clinical Trials Register DRKS00020884. Registered on 25 March 2020—retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05584-z.

Sachstandsbericht: Strukturierte medizinische Ersteinschätzung in Deutschland (SmED)

Ab 01.01.2020 müssen die Kassenärztlichen Vereinigungen eine telefonische Ersteinschätzung im 24/7-Betrieb anbieten. Ziel ist die Ersteinschätzung der Dringlichkeit akuter Beschwerden und eine Vermittlung an die angemessene Versorgungsstufe. Sehr schwer kranke Patienten müssen unmittelbar der Notfallversorgung, weniger oder nicht dringliche Anliegen alternativen Versorgungsangeboten zugeführt werden. Diese anspruchsvolle Aufgabe werden Fachpersonen übernehmen, die durch geeignete Software unterstützt werden. Im Ausland existieren hierfür Vorbilder. Das Zentralinstitut für die kassenärztliche Versorgung (Zi) überträgt gemeinsam mit der Health Care Quality System GmbH (HCQS) das in Teilen der Schweiz bereits angewendete Swiss Medical Assessment System (SMASS) für eine Anwendung in Deutschland. Das System soll unter dem Namen Strukturierte medizinische Ersteinschätzung in Deutschland (SmED) im Jahr 2019 in den Arztrufzentralen unter der Nummer 116117 eingeführt werden. Auch eine Anwendung für den sogenannten „gemeinsamen Tresen“ von Bereitschaftsdienstpraxen und Krankenhausnotaufnahmen wird entwickelt. Beide Anwendungen werden in dem vom Innovationsfonds geförderten DEMAND-Projekt evaluiert. Die Entwicklung von SmED erfolgt unter Einbeziehung von Vertretern des Marburger Bundes sowie der Deutschen Gesellschaft Interdisziplinäre Notfall- und Akutmedizin (DGINA) und Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI). Eine technische Integration mit der 112 ist in Arbeit.

[Developments in Emergency Care - Analysis of Emergency Cases in In- and Outpatient Care from 2009 To 2015 in Germany]

BACKGROUND

Increasing numbers of emergency cases, different stakeholders involved (physicians' practices vs. hospitals providing ambulatory and inpatient care) and changing patient utilization patterns lead to changes in health care needs. This study aimed at analyzing changes in patient characteristics as well as indications for in- and outpatient emergency care between 2009 and 2015 and their potential reasons.

METHODS

Based on in- and outpatient routine data, we descriptively analyzed changes in emergency diagnosis, population-based emergency prevalence as well as regional differences and their changes over time. Using generalized linear models (GLM), we examined regional shifts in emergency cases being treated in ambulatory and inpatient settings.

RESULTS

Between 2009 and 2014 the number of cross-sectoral ambulatory emergency cases increased by 4 % (in emergency departments an increase by 42% with the highest incidence rate ratio (IRR) in the 20-34-year-old age group). Inpatient emergency cases increased by 20% with older patients representing the largest group. The ICD chapter "Diseases of the circulatory system", responsible for most inpatient hospital cases, had the second highest probability of hospital addmissions (64.7%). There were larger variations in indications for outpatient care. Regression analysis showed that there was greater use of ambulatory emergency services by the healthier (IRR 1.15 [KI 95%: 1.13; 1.16]) and urban population (IRR 1.14 [KI 95%: 1.13; 1.15]).

CONCLUSIONS

The first time cross-sector analysis of indication-specific emergencies based on nationwide inpatient and outpatient billing data from 2009-2015 provides insightsinto healthcare provision at the interface between the sectors. Indications that are treated in physician practices and emergency outpatient clinics and those that lead to hospital admissions point out the potential for managing patient care appropriately. Patient behaviors in healthcare utilization can be addressed by interventions for specific patient subgroups. However, a prerequisite for the development of such measures is the inclusion of a cross-sectoral perspective in the system of emergency care.

[Patient-sharing networks : New approaches in the analysis and transformation of geographic variation in healthcare]

The analysis of geographic variations has spurred arguments that area of residence determines access to and quality of healthcare. In this paper we argue that unwarranted geographic variations can be traced back to actions of individual patients and their healthcare providers (doctors, hospitals). These actors interact in a complicated web of shared responsibilities. Designing effective interventions to reduce unwarranted geographic variations may therefore depend on methods to identify these interactions and communities of providers with a shared accountability. In the US, Canada, and Germany, routine data have been used to identify self-organized informal or virtual networks of physicians and hospitals, so-called patient-sharing networks (PSNs). This is an emerging field of analysis. We attempt to provide a brief report on the state of work in progress. It can be shown that variation between PSNs in a given area is effectively greater than variation between regions. While this suggests that reducing unwarranted variation needs to start at the level of PSN, methods to identify PSNs still vary widely. We compare epidemiological approaches and approaches based on graph theory and social network analysis. We also present some preliminary findings of exploratory analyses based on comprehensive claims data of physician practices in Germany. Defining PSNs based on usual provider relationships helps to create distinctive patient populations while PSNs may not be mutually exclusive. Social network analysis, on the other hand, appears better equipped to differentiate between provider communities with stronger and weaker ties; it does not yield distinctive patient populations. To achieve accountability and to support change management, analytic methods to describe PSNs still need refinement. There are first projects in Germany which use PSNs as an intervention platform in order to achieve improved cooperation and reduce unwarranted variation in their care processes.

[Correlation between Area-Level Sociodemographic Patterns and Estimates of Need for Medical Care]

OBJECTIVE

Besides the known determinants age, sex, and morbidity, regional sociodemographic factors may be important for the level of health care needs. This study proposes a possible characterisation of area-level sociodemographic patterns and proves their association to variation in morbidity, mortality and health service utilisation.

METHODS

We used the 412 counties of Germany as unit of analysis. To describe area-level sociodemographic patterns a factor analysis was conducted on a set of 27 indicators from official statistics. Two factors were retained and rotated according to the Varimax criteria, which explained 34.2 and 33.0% of variance. Mortality, utilisation of inpatient health services as well as parameters of the nationwide outpatient claims data [relative risk score (RRS) and the level of health care use (LB)] served as determinants of need for medical care and were correlated to the extracted factors.

RESULTS

Factor 1 describes regional disparities in socio-economic and health status variables and is called socio-economic health index (SGX). Factor 2 characterises the spatial distribution of interregional migration and household size and is called urbanity index (UX). There was a strong positive correlation between SGX and RRS (r=0.77), mortality (r=0.68 and r=0.78 for overall and premature death rate) and inpatient health care use (r=0.62). UX was not correlated with RRS but weakly inversely correlated with inpatient health care use (r=-0.28). Both SGX and UX were significantly correlated to the level of outpatient health care use (r=0.39 and r=0.40). Stratification of LB by type of practitioner revealed that SGX was mainly associated with health care provided by general practitioners while UX was linked to health care provided by specialists, particularly psychotherapists.

CONCLUSIONS

The extracted factors to describe area-level sociodemographic patterns showed distinct correlations to indicators for medical care use. While SGX was mainly associated with overall morbidity, UX showed consistent relations with specific medical care needs, which may be linked to urban living conditions. Therefore, UX may refer to need for care independently from overall morbidity on the one hand and to structural specifics in health care services on the other hand. The meaning of SGX and UX needs to be further investigated taking additional determining factors into account.

[Patient shifting between inpatient care and ambulatory care - exploring methods to measure the relevance of patient shifting]

BACKGROUND

The financial dimension of long term changes in the medical division of labour between inpatient care and ambulatory care has yet to be systematically monitored. While this is of general interest for health systems research there is now an acute need for the development of reliable methods to measure the effects of shifts in care as part of physician payment reform in Germany. The Social Code Book V (§ 87a Sec 4 No 3) requires the collective contracting partners to determine risk adjusted payment targets for regional populations thereby also taking into account shifts between inpatient and ambulatory care.

METHODS

Using predictive modelling patient groups are identified which meet the following two criteria in two consecutive years: 1) increases in actual cost exceeded expected cost in sector a while expected cost exceeded actual cost in sector b; 2) absolute number of cases increased in sector a and decreased in sector b. The model is based on the definition of a limited set of risk groups as defined by the risk adjustment scheme applied to German sickness funds. For our study these risk groups have been calibrated separately for each sector creating a common set of predictors. The second criterion focuses the approach on patient shifting as the most tangible effect of shifted care. In order to quantify the effect of patient shifting another predictive modelling approach is developed using the difference between expected and actual inpatient cases per risk group to estimate the resulting change in ambulatory case load. The cost of the additional case load per risk group is calculated for Germany based on population-based claims data (77 million patients).

RESULTS

The criteria for patient shifting as defined above apply to 26 out of 95 risk groups. At the level of risk groups hardly any patient shifting into ambulatory care was detected. On average for each patient with the respective risk factors 0.6 additional cases in ambulatory care were estimated as result of reduced incidence of inpatient care. In total the additional cost associated with patient shifting from inpatient care to ambulatory care was estimated 424 million € (2007). This represents 1.5% of total spending on ambulatory care and underlines the importance of the issue to health services research. Roughly 80% of this amount is likely to be eligible to physician services relevant to morbidity adjusted targets under payment reform. Prior to implementation as a payment formula, however, the approach needs to be based on a comprehensive risk adjustment model and needs further refinement.