Original article
One in five patients over the age of 65 in Germany receiving primary care suffers from peripheral arterial disease (PAD) (Diehm et al 2009). As a chronic, slowly progressive disease that progresses in stages, it is usually the result of a manifestation of atherosclerosis in the arteries supplying the leg. Atherosclerosis is a systemic disease and one of the most important causes of cardiovascular disease and death in western industrialized nations (Barrows et al 2009). In the course of PAD, there can be significant limitations in the patient's mobility, exercise capacity and quality of life. A feared long-term consequence is amputation (DGA 2009).
31.03.2015
The quality assessment of medical care based on quality indicators plays an important role in the German health care system. The quality dimensions "Structure, process and result quality" developed by Donabedian in 1966 represent an established classification for quality indicators (1). Another way of classifying quality indicators is, for example, the throughput model according to Pfaff (2), which differentiates between input, throughput, output and outcome of the respective measurement objectives. In this context, measurement targets represent the event of the quality indicator to be measured. “Quality indicator” is not a protected term and is used by different actors in the healthcare system for a variety of issues. In inpatient care in particular, quality indicators are used to measure and depict the quality of care (3,4). Quality indicators are also increasingly used in the outpatient area (5-7) and across sector boundaries (8) to measure the effect of healthcare.
31.03.2015
Health statistics from the Organization for Economic Cooperation and Development (OECD) are often used to classify healthcare provision in Germany. Accordingly, the German case number rates for certain procedures are among the top internationally. These country rankings are repeatedly taken up in the specialist and daily press. A frequently cited example is hip replacement surgery, which, according to OECD statistics, is only carried out more frequently in Switzerland than in Germany (Fig. 1). Another question that is often discussed is the amount of health care spending. Here, the German healthcare system is considered expensive by international comparison, as shown by the OECD country ranking of healthcare spending per capita, in which Germany ranks 6th (Fig. 2). However, ranking using OECD data as a benchmark is fraught with a number of methodological problems. These problems result, on the one hand, from incomplete data in the reports to the OECD and from their lack of comparability. On the other hand, the OECD data generally do not take into account the influence of the different age structure in the individual countries, although the use of services and the level of health expenditure are age-dependent.
31.03.2015
Quality and benefit are also frequently used terms in the healthcare system, with which we emphasize that significant resources are used to ensure optimal “quality of care” and to create “benefits” for those affected. Examples are the proportion of medical manpower (approx. 20%) that is committed to quality assurance and the expenses that arise as part of the approval of medicines for the creation of benefit dossiers (approx. 1 million euros/dossier). Quality and benefit are are therefore used as different dimensions of added health value, whereby quality could be a necessary prerequisite for providing benefit, but benefit is not necessarily a prerequisite for quality. The increasing scarcity of resources in health systems requires not only the critical analysis of new expenditure, but also the justification of existing expenditure. The not insignificant expenditure on ensuring the quality and benefit of health services can no longer be accepted as an end in itself1. On the one hand, they must be subjected to a “clinical-economic” analysis, through which the effort and the returns achieved for patients and society are compared. In addition, the differentiated analysis of quality and benefit opens up new considerations for financing health services. In order to carry out this analysis, it is first necessary to describe what is meant by “quality” and “benefit” in the healthcare system.
31.03.2015
While in the United States (the “motherland” of health services research [8,13,16]) more than one billion US dollars have been invested in research projects since 2009 to expand the health services research concepts of comparative effectiveness research (CER) and patient-centered outcomes research ( PCOR) in everyday research [3-7], health services research in Germany is still at an early stage of development [8]. At least in Baden-Württemberg, there has been a state-funded program to promote health services research since 2011 [17,18]. Here, too, the discipline has not yet been implemented across the board in research and teaching, and health services research has not yet been included as a compulsory subject in the study regulations for human medicine by the medical faculties in Baden-Württemberg (as of December 2013). The possibilities for anchoring health care research in studies are therefore limited, especially since content relevant to health care research has hardly been implemented in the cross-sectional area (QB) “health economics, health system, public health care” that was included in the licensing regulations in 2003 and in socio-medical teaching [9-12] . The question therefore arises as to how health services research can be successfully implemented into medical studies in order to sensitize future doctors and scientists to the issues facing the discipline. In addition to the QB and socio-medical teaching, corresponding teaching content could be implemented in the clinical subjects and as part of a compulsory elective course (WPV). In principle, the requirements for an elective course are regulated differently at the universities in Baden-Württemberg; in Tübingen (according to the study regulations of May 6, 2013) a minimum number of hours of 40 teaching units is required.
31.03.2015
Health services research - or in international parlance with comparable meaning "Real World Evidence (RWE) studies", "Health Services Research" or "Health Economics Outcomes Research (HEOR)" are scientific disciplines that address "real patient care" - increasing importance has been predicted for years, especially in the area of pharmaceutical products. Something similar can also be determined for Germany4, both if one follows announcements from politicians and self-administration, discussions on the current Statutory Health Insurance Care Strengthening Act as well as published positions from actors from the medical profession or the pharmaceutical and medical technology industries.
31.03.2015
With the Hospital Structure Act (KHSG)1, politicians are once again focusing on the hospital sector for a comprehensive reform, six years after the Hospital Financing Reform Act (KHRG)2. As similar as the two acronyms are, the focus of many of the measures in these laws is different. While the KHRG specifically focused on financing under the framework conditions of a DRG per-case flat-rate system with many new degrees of freedom for hospitals that was being fully applied for the first time, the KHSG's measures point in the right direction under the impression of a considerable number of false incentives that have arisen as a result structural specifications and planning bonds. The deregulation of the KHRG is followed by a regulatory approach again
31.03.2015
Health services research can be classified into a system with several levels and uses a range of study designs at each level (Hey/Maschewsky-Schneider 2006: Chapter 6; Pfaff et al. 2011). In general, studies are important instruments for gaining knowledge in health services research (e.g. Meyer et al. 2012; Karbach et al. 2012). Study designs with several hierarchy levels (so-called multilevel data structures) are increasingly being used. An important aspect in healthcare research is the need to adjust for possible significant confounders, “since healthcare-relevant parameters are the focus of the analysis” (Hey/Maschewsky-Schneider 2006: 251). This can result in study designs with more than one hierarchy level and additional consideration of covariates. These designs are referred to below as study designs with a complex hierarchical data structure. Examples are longitudinal studies to examine time courses (e.g. body weight) with additional consideration of influencing variables (e.g. gender, age at baseline) or cluster-randomized studies with additional consideration of other cluster characteristics (e.g. proportion of migrants, baseline value of the target variable). A specific example of such a study is URMEL-ICE, a cluster-randomized trial to examine the effectiveness of a school-based program to prevent obesity in primary school children (Brandstetter et al. 2012). In addition to the group membership (intervention group vs. control group), the baseline value and time interval between measurements were also taken into account in the analysis.
31.03.2015
In recent weeks and months there has been an increase in public perception and in the media of reports and images of people trying to reach European soil via the Mediterranean. They risk their lives in overcrowded boats hoping for a better life in Europe. In the TV and newspaper reports, capsized boats and drowned people are often reported. If illegal immigrants do reach European territory, they usually end up in overcrowded refugee camps with the hope of escaping to Germany or another European country. The number of asylum seekers in Germany is currently higher than ever before, and new records are being broken every month. For 2015, almost 330,000 initial asylum applications were recorded (as of October 2015), which corresponds to an increase of 1,44% compared to 2014. The numbers appear even more serious compared to previous years: in 2007 there were only 19,000 initial asylum applications in Germany and 41,000 in 2010 (Federal Office for Migration and Refugees 2015a). The overall protection rate, i.e. all positive decisions according to Art. 16a Paragraph 1 GG, according to Section 3 Paragraph 1 AsylVfG, according to Section 4 Paragraph 1 AsylVfG and according to Section 60 Paragraphs 5 and 7 Residence Act, is 39.1% in 2015 is thus higher than in the previous year (31.5%) (Federal Office for Migration and Refugees 2015a). The remaining asylum seekers have few options to be able to live permanently in Germany. One possibility: you decide to live illegally under the residency law.
31.03.2015
„Versorgungsforschung kann gestalten, wenn sie die aktuellen Herausforderungen mit einer positiven Grundstimmung annimmt“, erklärte Prof. Dr. Matthias Schrappe, der unter dem Titel „Linearität versus Komplexität: Ist die Versorgungsforschung reif für die politische Arena?“ anlässlich der DNVF-Spring School 2015 im Bonner Gustav Stresemann Institut einen übergreifenden Vortrag* hielt. Einen Vortrag zudem, der von der Historie der Versorgungsforschung in Deutschland, über die unterschiedlichen Sichtweisen und Beweggründe der Wissenschaft und Politik und die Einflüsse von sich ändernden gesellschaftlichen Strukturen zu einer zukunftsgerichteten Zentralforderung führte: Versorgungsforschung, so Schrappe, müsse „konzeptstärker“ werden, ohne diese noch aufzubauende Stärke werde sie nicht glaubwürdig sein, keine Vorhersagen treffen, geschweige denn sinnvolle Fragestellungen formulieren können.