Development and implementation of quality indicators in a group of nine psychiatric hospitals

Quality indicators (QI) are becoming increasingly important in mental healthcare in Germany. QI can be used for various purposes, such as for creating transparency as well as for benchmarking between hospitals. QI themselves are subject to high quality standards. The aim of this report is to describe the development and implementation of QI in a group of psychiatric hospitals. Since 2015, the LVR hospital group has developed and gradually implemented QI for the purposes of quality measurement, quality assurance and internal benchmarking in its nine psychiatric hospitals in a comprehensive, multidisciplinary, scientifically accompanied process. The full LVR-QI set, consisting of eight structure-, twelve process- and four outcome indicators as well as one patient satisfaction questionnaire, was implemented by 2019. In order to create high documentation quality and acceptance by clinicians, various implementation and dissemination strategies were used, such as written documentation manuals, staff training as well as regular face-to-face communication between the LVR hospitals, the LVR Institute for Health Services Research as the central coordinating body and the headquarters of the LVR hospital group. The QI led to a quality-oriented dialogue within and between the LVR hospitals.

Inpatient Suicides in Late Life: A Retrospective Analysis of a Hospital Group with Nine Psychiatric Clinics

OBJECTIVE

Inpatient suicides are rare incidents; however, the impacts of such events on associated families and hospital staff are severe. Therefore, preventive strategies need to focus on risk factors. Clinical management in a hospital setting must integrate the home environment and social life of patients. Nevertheless, home leaves require careful preparation.

METHODS

Suicides were reported systematically from all psychiatric departments of the Landschaftsverband Rheinland (an assembly of municipalities) using a structured form during two periods (1995-2004, 2005-2014). From these reports we extracted data on suicide methods and sociodemographic and clinical variables. Only patients 65 years and older were included.

RESULTS

From a total of 551 reports on suicides in the period of 1995-2014, 103 patients 65 years and older (60 women, 43 men) died by suicide. In contrast to the general trend in Germany during this period, no decline in overall suicide rates was found. Most patients were treated because of depression (73.8%); schizophrenic psychosis was diagnosed in 11.7%; and dementia was only diagnosed in 1.9%. The most frequent suicide method was hanging (40%). All suicides within the hospital were hangings. The majority of suicides occurred outside the hospital during approved home leaves. Only 7% of suicides occurred when patients left the hospital without permission. Almost half of the patients (n = 44) died by suicide during the first month of treatment. With longer duration of hospitalization, the risk of suicide decreased. There were no significant trends with regard to suicide methods between the two periods.

CONCLUSIONS

In the first weeks of hospitalizations the patients are most endangered to die by suicide. Therefore, home leaves need careful consideration.

Identification of risk factors for involuntary psychiatric hospitalization: using environmental socioeconomic data and methods of machine learning to improve prediction

BACKGROUND

The purpose of this study was to identify factors associated with a high risk of involuntary psychiatric in-patient hospitalization both on the individual level and on the level of mental health services and the socioeconomic environment that patients live in.

METHODS

The present study expands on a previous analysis of the health records of 5764 cases admitted as in-patients in the four psychiatric hospitals of the Metropolitan City of Cologne, Germany, in the year 2011 (1773 cases treated under the Mental Health Act and 3991 cases treated voluntarily). Our previous analysis had included medical, sociodemographic and socioeconomic data of every case and used a machine learning-based prediction model employing chi-squared automatic interaction detection (CHAID). Our current analysis attempts to improve the previous one through (1) optimizing the machine learning procedures (use of a different type of decision-tree prediction model (Classification and Regression Trees (CART) and application of hyperparameter tuning (HT)), and (2) the addition of patients' environmental socioeconomic data (ESED) to the data set.

RESULTS

Compared to our previous analysis, model fit was improved. Main diagnoses of an organic mental or a psychotic disorder (ICD-10 groups F0 and F2), suicidal behavior upon admission, admission outside of regular service hours and absence of outpatient treatment prior to admission were confirmed as powerful predictors of detention. Particularly high risks were shown for (1) patients with an organic mental disorder, specifically if they were retired, admitted outside of regular service hours and lived in assisted housing, (2) patients with suicidal tendencies upon admission who did not suffer from an affective disorder, specifically if it was unclear whether there had been previous suicide attempts, or if the affected person lived in areas with high unemployment rates, and (3) patients with psychosis, specifically those who lived in densely built areas with a large proportion of small or one-person households.

CONCLUSIONS

Certain psychiatric diagnoses and suicidal tendencies are major risk factors for involuntary psychiatric hospitalization. In addition, service-related and environmental socioeconomic factors contribute to the risk for detention. Identifying modifiable risk factors and particularly vulnerable risk groups should help to develop suitable preventive measures.

Volume-outcome relationship and minimum volume regulations in the German hospital sector - evidence from nationwide administrative hospital data for the years 2005-2007

BACKGROUND

This paper analyses the volume-outcome relationship and the effects of minimum volume regulations in the German hospital sector.

METHODS

We use a full sample of administrative data from the unselected, complete German hospital population for the years 2005 to 2007. We apply regression methods to analyze the association between volume and hospital quality. We measure hospital quality with a binary variable, which indicates whether the patient has died in hospital. Using simulation techniques we examine the impact of the minimum volume regulations on the accessibility of hospital services.

RESULTS

We find a highly significant negative relationship between case volume and mortality for complex interventions at the pancreas and oesophagus as well as for knee replacement. For liver, kidney and stem cell transplantation as well as for CABG we could not find a strong association between volume and quality. Access to hospital care is only moderately affected by minimum volume regulations.

CONCLUSION

The effectiveness of minimum volume regulations depends on the type of intervention. Depending on the type of intervention, quality gains can be expected at the cost of slightly decreased access to care.

The Volume-Outcome Relationship Revisited: Practice Indeed Makes Perfect

OBJECTIVE

To examine the causal effect of a hospital's experience with treating hip fractures (volume) on patient treatment outcomes.

DATA SOURCES

We use a full sample of administrative data from German hospitals for 2007. The data provide detailed information on patients and hospitals. We also reference the hospitals' addresses and the zip codes of patients' place of residence.

STUDY DESIGN

We apply an instrumental variable approach to address endogeneity concerns due to reverse causality and unobserved patient heterogeneity. As instruments for case volume, we use the number of potential patients and number of other hospitals in the region surrounding each hospital.

PRINCIPAL FINDINGS

Our results indicate that after applying an instrumental variables (IV) regression of volume on outcome, volume significantly increases quality.

CONCLUSIONS

We provide evidence for the practice-makes-perfect hypothesis by showing that volume is a driving factor for quality.

The volume-outcome relationship and minimum volume standards--empirical evidence for Germany

For decades, there is an ongoing discussion about the quality of hospital care leading i.a. to the introduction of minimum volume standards in various countries. In this paper, we analyze the volume-outcome relationship for patients with intact abdominal aortic aneurysm and hip fracture. We define hypothetical minimum volume standards in both conditions and assess consequences for access to hospital services in Germany. The results show clearly that patients treated in hospitals with a higher case volume have on average a significant lower probability of death in both conditions. Furthermore, we show that the hypothetical minimum volume standards do not compromise overall access measured with changes in travel times.

Defining hospital markets - an application to the German hospital sector

The correct definition of the product market and of the geographic market is a prerequisite for assessing market structures in antitrust cases. For hospital markets, both dimensions are controversially discussed in the literature. Using data for the German hospital market we aim at elaborating the need for differentiating the product market and at investigating the effects of different thresholds for the delineation of the geographic market based on patient flows. Thereby we contribute to the scarce empirical evidence on the structure of the German hospital market. We find that the German hospital sector is highly concentrated, confirming the results of a singular prior study. Furthermore, using a very general product market definition such as "acute in-patient care" averages out severe discrepancies that become visible when concentration is considered on the level of individual diagnoses. In contrast, varying thresholds for the definition of the geographic market has only impact on the level of concentration, while the correlation remains high. Our results underline the need for more empirical research concerning the definition of the product market for hospital services.

Explaining differences in remuneration rates of nursing homes in Germany

Remuneration rates of German nursing homes are prospectively negotiated between long-term care insurance (LTCI) and social assistance on the one side and nursing homes on the other. They differ considerably across regions while there is no evidence for substantial differences in care provision. This article explains the differences in the remuneration rates by observable characteristics of the nursing home, its residents and its region with a special focus on the largest federal state of North Rhine Westphalia, in which the most expensive nursing homes are located. We use data from the German Federal Statistical Office for 2005 on all nursing homes that offer full-time residential care for the elderly. We find that differences in remuneration rates can partly be explained by exogenous factors. Controls for residents, nursing homes and district characteristics explain roughly 30 % of the price difference; 40 % can be ascribed to a regionally different kind of negotiation between nursing homes and LTCI. Thirty percent of the raw price difference remains unexplained by observable characteristics.