Assessing health system responsiveness in Germany – patient centeredness in primary and specialist care

Hintergrund: Die Perspektive der Nutzer*innen von Gesundheitssystemen wird zunehmend als Ressource wahrgenommen, die Maßnahmen zur Steigerung der Qualität in der Erbringung von Versorgungsleistungen stimuliert. In diesem Kontext wurde das Konzept der Health System Responsiveness (HSR) entwickelt, das eines der übergeordneten Ziele eines jeden Gesundheitssystems darstellt. HSR umfasst die Fähigkeit eines Gesundheitssystems, die legitimen Erwartungen seiner Nutzer*innen an nicht- medizinische und nicht-finanzielle Aspekte des Versorgungsprozesses zu erfüllen. Für das deutsche Gesundheitssystem sind das bevölkerungsweite Niveau der HSR ebenso wie die Zusammenhänge mit sozialen Determinanten weitgehend unerforscht. Ziel: Mit der vorliegenden Arbeit wurde das Ziel verfolgt, die Bewertung der HSR in der haus- und fachärztlichen Versorgung sowie Differenzen zwischen Sub-Gruppen der Patient*innen in dieser Bewertung in Deutschland zu identifizieren. Damit wurde ein Beitrag zur Messung der Leistungsfähigkeit des deutschen Gesundheitssystems erbracht. Methoden: Die Untersuchung wurde auf Grundlage einer bevölkerungsweiten Versichertenbefragung der Kassenärztlichen Bundesvereinigung im Jahr 2016 in Deutschland durchgeführt, die eine Stichprobe von 6.113 Erwachsenen umfasste. HSR wurde für Haus- und Facharztkonsultationen entlang der Dimensionen Freundlichkeit, Autonomie, Diskretion, Kommunikation und Vertrauen gemessen. Bivariate und multivariate binäre logistische Regressionen wurden für die statistische Analyse gerechnet. Ergebnisse: Die Konsultation mit Haus- und Fachärzt*innen wurde von über 90 % der Befragten hinsichtlich Freundlichkeit, Autonomie, Kommunikation und Vertrauen als gut bewertet. Diskretion in der Arztpraxis wurde dagegen sowohl bei Haus- als auch Facharztbesuchen wesentlich schlechter beurteilt (50,3 % als gut bei Hausärzt*innen, 52,4 % als gut bei Fachärzt*innen). Eine negative Bewertung zeigte bei Hausarztkonsultationen einen Zusammenhang mit dem Alter (18 bis 34 Jahre) und Bildungsabschluss (höher als Hauptschule) der Befragten, bei Facharztkonsultationen ebenfalls mit dem Bildungsabschluss (höher als Hauptschule) sowie mit dem selbst eingeschätzten Gesundheitszustand (schlecht und sehr schlecht) und Grund des letzten Arztbesuchs (aktuelles Gesundheitsproblem). Diskussion: Die Befunde dieser Studie offenbaren einen Bedarf an Maßnahmen, die die Infrastruktur und Prozesse innerhalb von Arztpraxen so gestalten, dass die Diskretion für Patient*innen besser gewahrt wird, und die HSR gegenüber jüngeren Patient*innen, mit mittlerem und hohem Bildungsniveau sowie denjenigen in schlechter gesundheitlicher Verfassung während Arztkonsultationen verbessern. Aufgrund der steigenden Bedeutung der Patientenorientierung in der Bewertung der Leistungsfähigkeit von Gesundheitssystemen ist anzunehmen, dass HSR auch in Deutschland zukünftig weiter an Relevanz gewinnen wird.Background: The views of health system users are increasingly being appreciated as a resource for evaluating the provision of health services, promoting accountability and developing policies to prompt quality improvements in health care. In this context, the concept of Health System Responsiveness (HSR) has emerged as one of the major performance goals by which to measure health systems. HSR comprises the ability of a health system to meet the population’s legitimate expectations regarding non-medical and non-financial aspects of the care process. In Germany, overall population levels of HSR as well as associations with social determinants are understudied, however. Objective: The aim of this research was to determine overall population levels of HSR, as well as differences in the assessment between patient sub-groups for ambulatory health care, consisting of general practitioners (GPs) and specialists (SPs). This analysis contributes to the performance assessment of the German health system. Methods: This doctoral work drew on the 2016 national health survey Versichertenbefragung der Kassenärztlichen Bundesvereinigung in Germany, with a sample of 6,113 adults. HSR was measured for GP and SP consultations along the domains of dignity, autonomy, confidentiality, communication and trust. Bivariate and multivariate binary logistic regression techniques were applied for the statistical analyses. Results: Over 90 % of all respondents assessed the dignity, autonomy, communication and trust they experienced during their last GP and SP consultation as good. Only half of all study participants rated the confidentiality during their visit positively (for GP consultations: 50.3 %; for SP consultations: 52.4 %). For GP visits, patients 18–34 years of age, and patients with an intermediate or higher level of education were more likely to experience lower levels of HSR. For SP visits, patients with an intermediate or higher level of education, as well as patients with a (very) poor self-assessed health status and a current health problem were more likely to experience lower levels of HSR. Discussion: In German ambulatory care in 2016, a great majority of patients experienced high levels of HSR during their last consultation. However, the results imply a need for measures that improve health service delivery infrastructures and processes in doctors’ offices, as well as for targeted measures for young adults, patients with an intermediate or higher level of education, and those with the poorest health status. Due to the increasing focus on patient experiences in assessing the performance of health systems, further scrutiny of HSR in Germany is pertinent

Patients’ understanding of health information in Germany

Background: Patient–physician communication and textual health information are central to health care. Yet, how well patients understand their physicians and written materials is under-studied. Objectives: Focusing on outpatient health care in Germany, the aim of this research was to assess patients’ levels of understanding oral and written health information and to identify associations with socioeconomic variables. Methods: This analysis drew on a 2017 health survey (n=6,105 adults 18 years of age and above). Measures for the quality of patient–physician communication were derived from the Ask Me 3 program questions for consultations with general practitioners (GPs) and specialists (SPs), and for textual health information via a question on the comprehensibility of written materials. Correlations with socioeconomic variables were explored using bivariate and multivariable logistic regression analyses. Results: Over 90% of all respondents reported that they had understood the GP’s and SP’s explanations. A lack of understanding was most notably correlated with patients’ selfreported very poor health (odds ratio [OR]: 5.19; 95% confidence interval [CI]: 2.23–12.10), current health problem (OR: 6.54, CI: 1.70–25.12) and older age (65 years and above, OR: 2.97, CI: 1.10–8.00). Fewer patients reported that they understood written materials well (86.7% for last visit at GP, 89.7% for last visit at SP). Difficulties in understanding written materials were strongly correlated with basic education (OR: 4.20, CI: 2.76–6.39) and older age (65 years and above, OR: 2.66, CI: 1.43–4.96). Conclusions: In order to increase patients’ understanding of health information and reduce inequalities among patient subgroups, meeting the communication needs of patients of older age, low educational status and with poor health is essential

How did the COVID-19 pandemic affect inpatient care for children in Germany? An exploratory analysis based on national hospital discharge data

Background: The delivery of health services around the world faced considerable disruptions during the COVID-19 pandemic. While this has been discussed for a number of conditions in the adult population, related patterns have been studied less for children. In light of the detrimental effects of the pandemic, particularly for children and young people under the age of 18, it is pivotal to explore this issue further. Methods: Based on complete national hospital discharge data available via the German National Institute for the Reimbursement of Hospitals (InEK) data browser, we compare the top 30 diagnoses for which children were hospitalised in 2019, 2020, 2021 and 2022. We analyse the development of monthly admissions between January 2019 and December 2022 for three tracers of variable time-sensitivity: acute lymphoblastic leukaemia (ALL), appendicitis/appendectomy and tonsillectomy/adenoidectomy. Results: Compared to 2019, total admissions were approximately 20% lower in 2020 and 2021, and 13% lower in 2022. The composition of the most frequent principal diagnoses remained similar across years, although changes in rank were observed. Decreases were observed in 2020 for respiratory and gastrointestinal infections, with cases increasing again in 2021. The number of ALL admissions showed an upward trend and a periodicity prima vista unrelated to pandemic factors. Appendicitis admissions decreased by about 9% in 2020 and a further 8% in 2021 and 4% in 2022, while tonsillectomies/adenoidectomies decreased by more than 40% in 2020 and a further 32% in 2021 before increasing in 2022; for these tracers, monthly changes are in line with pandemic waves. Conclusions: Hospital care for critical and urgent conditions among patients under the age of 18 was largely upheld in Germany during the COVID-19 pandemic, potentially at the expense of elective treatments. There is an alignment between observed variations in hospitalisations and pandemic mitigation measures, possibly also reflecting changes in demand. This study highlights the need for comprehensive, intersectoral data that would be necessary to better understand changing demand, unmet need/foregone care and shifts from inpatient to outpatient care, as well as their link to patient outcomes and health care efficiency

Perspective: lessons from COVID-19 of countries in the European region in light of findings from the health system response monitor

Introduction: Decision-makers initially had limited data to inform their policy responses to the COVID-19 pandemic. The research community developed several online databases to track cases, deaths, and hospitalizations; however, a major deficiency was the lack of detailed information on how health systems were responding to the pandemic and how they would need to be transformed going forward. Approach: In an eort to fill this information gap, in March 2020, the European Observatory on Health Systems and Policies, the WHO European Regional Oce and the European Commission created the COVID-19 Health System Response Monitor (HSRM) to collect and organise up-to-date information on how health systems, mainly in the WHO European Region, were responding to the COVID-19 pandemic. Findings: The HSRM analysis and broader Observatory work on COVID-19 shone light on a range of health system challenges and weaknesses and catalogued policy options countries put in place during the pandemic to address these. Countries prioritised policies on investing in public health, supporting the workforce, maintaining financial stability, and strengthening governance in their response to COVID-19. Outlook: COVID-19 is likely to continue to impact health systems for the foreseeable future; the ability to cope with this pressure, and other shocks, depends on having good information on what other countries have done so that health systems develop adequate policy options. In support of this, the country information on the COVID-19 HSRM will remain available as a repository to inform decision makers on options for actions and possible measures against COVID-19 and other public health emergencies. Building on its previous work on health systems resilience, the European Observatory on Health Systems and Policies will sustain its focus on analysing key issues relate to the recovery from the pandemic and making health systems more resilient. This includes policy knowledge transfer between countries and systematic resilience testing, aiming at contributing to an improved understanding of health system response, recovery, and preparedness. Contribution to the literature in non-technical language: The COVID-19 Health System Response Monitor (HSRM) was the first database in the WHO European Region to collect and organise up-to-date information on how health systems were responding to the COVID-19 pandemic. The HSRM provides a repository of policies which can be used to inform decision makers in health and other policy domains on options for action and possible measures against COVID-19 and other public health emergencies. This initiative proved particularly valuable, especially during the early phases of the pandemic, when there was limited information for countries to draw on as they formulated their own policy response to the pandemic. Our perspectives paper highlights some key challenges within health systems that the HSRM was able to identify during the pandemic and considers policy options countries put in place in response. Our research contributes to literature on emergency responses and recovery, health systems performance assessment, particularly health system resilience, and showcases the Observatory experience on how to design such a data collection tool, as well as how to leverage its findings to support cross-country learning

Perspective: Lessons from COVID-19 of countries in the European region in light of findings from the health system response monitor

IntroductionDecision-makers initially had limited data to inform their policy responses to the COVID-19 pandemic. The research community developed several online databases to track cases, deaths, and hospitalizations; however, a major deficiency was the lack of detailed information on how health systems were responding to the pandemic and how they would need to be transformed going forward.ApproachIn an effort to fill this information gap, in March 2020, the European Observatory on Health Systems and Policies, the WHO European Regional Office and the European Commission created the COVID-19 Health System Response Monitor (HSRM) to collect and organise up-to-date information on how health systems, mainly in the WHO European Region, were responding to the COVID-19 pandemic.FindingsThe HSRM analysis and broader Observatory work on COVID-19 shone light on a range of health system challenges and weaknesses and catalogued policy options countries put in place during the pandemic to address these. Countries prioritised policies on investing in public health, supporting the workforce, maintaining financial stability, and strengthening governance in their response to COVID-19.OutlookCOVID-19 is likely to continue to impact health systems for the foreseeable future; the ability to cope with this pressure, and other shocks, depends on having good information on what other countries have done so that health systems develop adequate policy options. In support of this, the country information on the COVID-19 HSRM will remain available as a repository to inform decision makers on options for actions and possible measures against COVID-19 and other public health emergencies. Building on its previous work on health systems resilience, the European Observatory on Health Systems and Policies will sustain its focus on analysing key issues related to the recovery from the pandemic and making health systems more resilient. This includes policy knowledge transfer between countries and systematic resilience testing, aiming at contributing to an improved understanding of health system response, recovery, and preparedness.Contribution to the literature in non-technical languageThe COVID-19 Health System Response Monitor (HSRM) was the first database in the WHO European Region to collect and organise up-to-date information on how health systems were responding to the COVID-19 pandemic. The HSRM provides a repository of policies which can be used to inform decision makers in health and other policy domains on options for action and possible measures against COVID-19 and other public health emergencies. This initiative proved particularly valuable, especially during the early phases of the pandemic, when there was limited information for countries to draw on as they formulated their own policy response to the pandemic. Our perspectives paper highlights some key challenges within health systems that the HSRM was able to identify during the pandemic and considers policy options countries put in place in response. Our research contributes to literature on emergency responses and recovery, health systems performance assessment, particularly health system resilience, and showcases the Observatory experience on how to design such a data collection tool, as well as how to leverage its findings to support cross-country learning

Complex Functional Posttraumatic Shoulder Reconstruction Using Shoulder Arthroplasty and a Pedicled Innervated Latissimus Dorsi Flap—A Case Report and Literature Review

Background The shoulder joint is one of the most freely movable joints in the human body and has therefore high importance for upper limb functionality. Several techniques have been developed to replace the glenohumeral joint including humeral hemiarthroplasty, anatomical total shoulder arthroplasty, and reverse total shoulder arthroplasty, depending on the underlying pathology. For the soft tissue reconstruction, the innervated latissimus dorsi musculocutaneous flap is a reliable solution flap in shoulder and arm reconstruction. Case presentation We present the case of a 16‐year‐old male patient with a complete destruction of the shoulder joint and soft tissues after ballistic trauma. We performed the reconstruction of the shoulder joint using a humeral hemiarthroplasty with a mesh fixation to the remaining glenoid. The soft tissue coverage and the restoration of the deltoid muscle function were insured with a pedicled innervated latissimus dorsi musculocutaneous flap. One year postoperatively, the patient showed a good function of the shoulder joint with an excellent aesthetical result and no pain. Conclusion The pedicled latissimus dorsi musculocutaneous flap can safely restore the shoulder function, while the humeral hemiarthroplasty with mesh fixation can be a reliable solution for the reconstruction of a completely destructed shoulder joint

4. MVZ-Survey der KBV

Seit Einführung der Medizinischen Versorgungszentren (MVZ) im Jahr 2004 führt die Kassenärztliche Bundesvereinigung regelmäßig Umfragen zu deren Entwicklung durch. Neben den jährlich veröffentlichten Grunddaten zu MVZ, die auf der Grundlage einer Befragung der 17 Kassenärztlichen Vereinigungen erstellt werden, ist dies der MVZ-Survey. Zum vierten Mal wurde der MVZ-Survey im Jahr 2014 als Befragung aller ärztlichen Leiter bzw. Geschäftsführer von MVZ (Vollerhebung) seit 2005 durchgeführt. Von 2.006 (Stand 31.12.2013) angeschriebenen MVZ haben 339 den Online-Fragebogen bis zum Ende beantwortet, was einer Teilnahmequote von 17% entspricht. Der vierte MVZ-Survey dient der Bestandsaufnahme der Versorgungsform MVZ. Mittels Online-Befragung wurden insbesondere folgende Schwerpunkte betrachtet: Gründungsmotivation, wirtschaftliche Situation, Kooperation und Vernetzung sowie differenzierte Betrachtung der MVZ in ländlichen und städtischen Regionen. Ausgewählte Befragungsergebnisse werden im Folgenden beschrieben und ausgewertet, sowie Entwicklungstendenzen und Trends aufgezeigt

Perspective: Lessons from COVID-19 of countries in the European region in light of findings from the health system response monitor.

INTRODUCTION: Decision-makers initially had limited data to inform their policy responses to the COVID-19 pandemic. The research community developed several online databases to track cases, deaths, and hospitalizations; however, a major deficiency was the lack of detailed information on how health systems were responding to the pandemic and how they would need to be transformed going forward. APPROACH: In an effort to fill this information gap, in March 2020, the European Observatory on Health Systems and Policies, the WHO European Regional Office and the European Commission created the COVID-19 Health System Response Monitor (HSRM) to collect and organise up-to-date information on how health systems, mainly in the WHO European Region, were responding to the COVID-19 pandemic. FINDINGS: The HSRM analysis and broader Observatory work on COVID-19 shone light on a range of health system challenges and weaknesses and catalogued policy options countries put in place during the pandemic to address these. Countries prioritised policies on investing in public health, supporting the workforce, maintaining financial stability, and strengthening governance in their response to COVID-19. OUTLOOK: COVID-19 is likely to continue to impact health systems for the foreseeable future; the ability to cope with this pressure, and other shocks, depends on having good information on what other countries have done so that health systems develop adequate policy options. In support of this, the country information on the COVID-19 HSRM will remain available as a repository to inform decision makers on options for actions and possible measures against COVID-19 and other public health emergencies. Building on its previous work on health systems resilience, the European Observatory on Health Systems and Policies will sustain its focus on analysing key issues related to the recovery from the pandemic and making health systems more resilient. This includes policy knowledge transfer between countries and systematic resilience testing, aiming at contributing to an improved understanding of health system response, recovery, and preparedness. CONTRIBUTION TO THE LITERATURE IN NON-TECHNICAL LANGUAGE: The COVID-19 Health System Response Monitor (HSRM) was the first database in the WHO European Region to collect and organise up-to-date information on how health systems were responding to the COVID-19 pandemic. The HSRM provides a repository of policies which can be used to inform decision makers in health and other policy domains on options for action and possible measures against COVID-19 and other public health emergencies. This initiative proved particularly valuable, especially during the early phases of the pandemic, when there was limited information for countries to draw on as they formulated their own policy response to the pandemic. Our perspectives paper highlights some key challenges within health systems that the HSRM was able to identify during the pandemic and considers policy options countries put in place in response. Our research contributes to literature on emergency responses and recovery, health systems performance assessment, particularly health system resilience, and showcases the Observatory experience on how to design such a data collection tool, as well as how to leverage its findings to support cross-country learning