Data for health services research – insights for Germany from the international experience

Gedruckt erschienen im Universitätsverlag der TU Berlin, ISBN 978-3-7983-3217-1 (ISSN 2197-8123)Eine unabdingbare Voraussetzung für die Beantwortung der Forschungsfragen der Versorgungsforschung sind das Vorhandensein und die Zugänglichkeit von umfassenden Daten hoher Qualität. Es ist davon auszugehen, dass die Versorgungsforschung in den kommenden Jahren auf der Verlinkung (Datenlinkage, „data linkage“), also der Verknüpfung mehrerer Datenquellen auf Basis von geeigneten gemeinsamen Schlüsselvariablen beruhen wird. In Deutschland werden umfassende Daten hoher Qualität routinemäßig gesammelt, allerdings sind diese für Forschungszwecke nur bedingt geeignet und eingeschränkt verfügbar. Daher liegt der Ursprung dieses Gutachtens in den Grundfragen, welche Fragestellungen der Versorgungsforschung im Ausland auf Basis besserer Daten besser beantwortet werden können, und auf welchen Wegen eine solche Verbesserung der Datengrundlage in Deutschland erzielt werden könnte. Fallbeispiele interessanter Verlinkungsansätze aus zwölf Ländern wurden identifiziert und anhand eines vordefinierten Konzeptes analysiert. Informationen wurden für alle Vergleichsländer bzw. Fallstudien zunächst auf Basis von öffentlich zugänglichen Quellen identifiziert. Anschließend wurde pro Land ein Profil erstellt und geeigneten Länderexperten zur Validierung und Ergänzung weitergeleitet. Das Gutachten stellt eine Übersicht der eingeschlossenen Fallstudien vor (Kapitel 3), sowie im Anhang wichtige Eckdaten pro Land und Fallstudie. Es folgen eine nähere Betrachtung der Möglichkeiten der Nutzung von Routinedaten (Kapitel 4), der Verlinkungsmöglichkeiten mit und ohne eindeutigem personenbezogenen Merkmal (Kapitel 5), der unterschiedlichen Zugriffswege für Forscher (Kapitel 6), der Ausgestaltung des Einsatzes von Daten aus elektronischen Patienten- bzw. Gesundheitsakten für die Forschung (Kapitel 7) und ein Zwischenfazit (Kapitel 8). Das Gutachten endet mit einer Wunschliste für mögliche regulatorische Änderungen in Anbetracht der aktuellen politischen Diskussion (Kapitel 9). Wichtig ist hier zu beleuchten, dass die thematisierten Fallstudien aus dem internationalen Vergleich wichtige Aspekte hervorheben, die für die Problematik in Deutschland von Bedeutung sein könnten. Neben dem Mehrwert von vergleichsmäßig einfach zugänglichen, umfangreiche(re)n Abrechnungsdaten, die schneller als in Deutschland vorliegen, sektorenübergreifende Analysen erlauben und personenbezogen mit Gesundheits- sowie auch mit Regionaldaten verknüpfbar sind, wird auch das Potential von Datenbanken beleuchtet, die auf Basis der routinemäßigen Dokumentation (i.d.R. elektronischen Gesundheitsakten) von Leistungserbringern entstehen. Eine Investition in diese Richtung kann nicht nur für das eigene Gesundheitssystem Einsichten ermöglichen, sondern auch die internationale Kooperation fördern und zur internationalen Sichtbarkeit wissenschaftlicher Exzellenz beitragen. Eine Nebeneinanderstellung der in Deutschland vorhandenen Datenbestände und der in anderen Ländern eingesetzten Daten deutet darauf hin, dass sich die Diskussion hierzulande an erster Stelle mit der Ausgestaltung der zur Verfügung stehenden Daten befassen sollte und ergänzend die Erfassung zusätzlicher Informationen bedenken kann.The availability and accessibility of comprehensive, high-quality data are indispensable prerequisites for effective health services research. It can be assumed in the coming years that health services research will increasingly be based on data linkage, i.e. the linking of several data sources based on suitable common key variables. In Germany, comprehensive high-quality data are routinely collected, but their suitability and availability for research purposes is limited. Therefore, the motivation for this report lies in the answering of two basic questions: which questions of health services research can be better answered abroad on the basis of better data, and in which ways such conditions could be achieved in Germany. Case studies of interesting linkage approaches from twelve countries were identified and analyzed based on a predefined conceptual framework. Information on all comparison countries or case studies was first identified from publicly available sources. Profiles were then created for each country and case study and forwarded to appropriate country experts for validation and completion. The report presents an overview of the included case studies (chapter 3), as well as key information per country and case study in the appendix. This is followed by a closer look at the possibilities of using routine data (chapter 4), linkage approaches with and without unique personal identifiers (chapter 5), the different access routes for researchers (chapter 6), options for using data from electronic patient or health records for research (chapter 7), and an interim conclusion (chapter 8). The report ends with a wish list for possible regulatory changes in light of the current policy debate in Germany (Chapter 9). It is important to underline here that case studies from the international comparison were selected to highlight important aspects that could be relevant to the challenges in Germany. In addition to the added value of comparatively easily accessible, extensive claims data, which are available more quickly than in Germany, allow cross-sector analyses and can be linked to health data and regional data on a person-by-person basis, the potential of databases created on the basis of the routine documentation of service providers (usually electronic health records) is also discussed. Investing in this direction can not only provide insights for a country’s own healthcare system, but also promote international cooperation and contribute to the international visibility of scientific excellence. A juxtaposition of the data sets available in Germany and those used in other countries suggests that the discussion in Germany should focus first and foremost on optimizing the availability and accessibility of existing data and consider new approaches to the collection of additional information as a supplement

Health-related preferences of older patients with multimorbidity: the protocol for an evidence map

Introduction: Interaction of conditions and treatments, complicated care needs and substantial treatment burden make patient–physician encounters involving multimorbid older patients highly complex. To optimally integrate patients’ preferences, define and prioritise realistic treatment goals and individualise care, a patient-centred approach is recommended. However, the preferences of older patients, who are especially vulnerable and frequently multimorbid, have not been systematically investigated with regard to their health status. The purpose of this evidence map is to explore current research addressing health-related preferences of older patients with multimorbidity, and to identify the knowledge clusters and research gaps. Methods and analysis: To identify relevant research, we will conduct searches in the electronic databases MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL, Social Science Citation Index, Social Science Citation Index Expanded and the Cochrane library from their inception. We will check reference lists of relevant articles and carry out cited reference research (forward citation tracking). Two independent reviewers will screen titles and abstracts, check full texts for eligibility and extract the data. Any disagreement will be resolved and consensus reached with the help of a third reviewer. We will include both qualitative and quantitative studies, and address preferences from the patients’ perspectives in a multimorbid population of 60 years or older. There will be no restrictions on the publication language. Data extraction tables will present study and patient characteristics, aim of study, methods used to identify preferences and outcomes (ie, type of preferences). We will summarise the data using tables and figures (ie, bubble plot) to present the research landscape and to describe clusters and gaps. Ethics and dissemination: Due to the nature of the proposed evidence map, ethics approval will not be required. Results from our research will be disseminated by means of specifically prepared materials for patients, at relevant (inter)national conferences and via publication in peer-reviewed journals

Exploring Health System Responsiveness in Ambulatory Care and Disease Management and its Relation to Other Dimensions of Health System Performance (RAC) – Study Design and Methodology

Background: The responsiveness of a health system is considered to be an intrinsic goal of health systems and an essential aspect in performance assessment. Numerous studies have analysed health system responsiveness and related concepts, especially across different countries and health systems. However, fewer studies have applied the concept for the evaluation of specific healthcare delivery structures and thoroughly analysed its determinants within one country. The aims of this study are to assess the level of perceived health system responsiveness to patients with chronic diseases in ambulatory care in Germany and to analyse the determinants of health system responsiveness as well as its distribution across different population groups. Methods and Analysis: The target population consists of chronically ill people in Germany, with a focus on patients suffering from type 2 diabetes and/or from coronary heart disease (CHD). Data comes from two different sources: ( i ) cross-sectional survey data from a postal survey and ( ii ) claims data from a German sickness fund. Data from both sources will be linked at an individual-level. The postal survey has the purpose of measuring perceived health system responsiveness, health related quality of life, experiences with disease management programmes (DMPs) and (subjective) socioeconomic background. The claims data consists of information on (co)morbidities, service utilization, enrolment within a DMP and sociodemographic characteristics, including the type of residential area. Discussion: RAC is one of the first projects linking survey data on health system responsiveness at individual level with claims data. With this unique database, it will be possible to comprehensively analyse determinants of health system responsiveness and its relation to other aspects of health system performance assessment. The results of the project will allow German health system decision-makers to assess the performance of nonclinical aspects of healthcare delivery and their determinants in two important areas of health policy: in ambulatory and chronic disease care

Septins suppress the release of vaccinia virus from infected cells.

Septins are conserved components of the cytoskeleton that play important roles in many fundamental cellular processes including division, migration, and membrane trafficking. Septins can also inhibit bacterial infection by forming cage-like structures around pathogens such as Shigella We found that septins are recruited to vaccinia virus immediately after its fusion with the plasma membrane during viral egress. RNA interference-mediated depletion of septins increases virus release and cell-to-cell spread, as well as actin tail formation. Live cell imaging reveals that septins are displaced from the virus when it induces actin polymerization. Septin loss, however, depends on the recruitment of the SH2/SH3 adaptor Nck, but not the activity of the Arp2/3 complex. Moreover, it is the recruitment of dynamin by the third Nck SH3 domain that displaces septins from the virus in a formin-dependent fashion. Our study demonstrates that septins suppress vaccinia release by "entrapping" the virus at the plasma membrane. This antiviral effect is overcome by dynamin together with formin-mediated actin polymerization

Exploring Health System Responsiveness in Ambulatory Care and Disease Management and its Relation to Other Dimensions of Health System Performance (RAC) – Study Design and Methodology

Background The responsiveness of a health system is considered to be an intrinsic goal of health systems and an essential aspect in performance assessment. Numerous studies have analysed health system responsiveness and related concepts, especially across different countries and health systems. However, fewer studies have applied the concept for the evaluation of specific healthcare delivery structures and thoroughly analysed its determinants within one country. The aims of this study are to assess the level of perceived health system responsiveness to patients with chronic diseases in ambulatory care in Germany and to analyse the determinants of health system responsiveness as well as its distribution across different population groups. Methods and Analysis The target population consists of chronically ill people in Germany, with a focus on patients suffering from type 2 diabetes and/or from coronary heart disease (CHD). Data comes from two different sources: (i) cross-sectional survey data from a postal survey and (ii) claims data from a German sickness fund. Data from both sources will be linked at an individual-level. The postal survey has the purpose of measuring perceived health system responsiveness, health related quality of life, experiences with disease management programmes (DMPs) and (subjective) socioeconomic background. The claims data consists of information on (co)morbidities, service utilization, enrolment within a DMP and sociodemographic characteristics, including the type of residential area. Discussion RAC is one of the first projects linking survey data on health system responsiveness at individual level with claims data. With this unique database, it will be possible to comprehensively analyse determinants of health system responsiveness and its relation to other aspects of health system performance assessment. The results of the project will allow German health system decision-makers to assess the performance of nonclinical aspects of healthcare delivery and their determinants in two important areas of health policy: in ambulatory and chronic disease care

The change in the method of production using the example of “Star Wars” from an economic perspective

Die vorliegende Bachelorarbeit beschäftigt sich mit den durch George Lucas beeinflussten Veränderungen in der Produktion von Science Fiction Filmen. Anhand der Darstellung der Produktionsweise der zwei „Star Wars“ Trilogien wird erläutert, welche Auswirkungen die von Lucas und seiner Firma ILM erfundenen und immer weiter optimierten digitalen Techniken auf die Filmwirtschaft hatten. Zum allgemeinen Verständnis wird im ersten der fünf Hauptkapitel der Bachelorarbeit die Struktur der Filmwirtschaft erklärt. Im zweiten Kapitel folgt ein geschichtlicher Abriss der Filmproduktion, speziell von Science Fiction Filmen. In den weiteren drei Kapiteln wird die Produktion der Trilogien beschrieben und ein kurzer Ausblick auf die zukünftigen „Star Wars“ Filme gegeben. Fazit der Darstellung ist, dass der Einsatz der innovativen Methoden und der technischen Möglichkeiten, wie der Einsatz von non-linearen Schnittsystemen, von computergenerierten Bildern und von digitaler Aufnahmetechnik, die Lucas als einer der ersten anwendete, die Filmwirtschaft nachhaltig beeinflusste

Selective enrollment in Disease Management Programs for coronary heart disease in Germany – An analysis based on cross-sectional survey and administrative claims data

Abstract Background In 2002, Disease Management Programs (DMPs) were introduced within the German healthcare system with the aim to increase the quality of chronic disease care. Due to the enrollment procedures, it can be assumed a) that only certain patients actively decide to enroll in a DMP and/or b) that only certain patients get the recommendation for DMP enrollment from their physician. How strong this assumed effect of self- and/or professional selection is, is still unclear. Methods We used data from a cross-sectional postal-survey linked on individual level with administrative claims data from a German sickness fund. The sample consisted of individuals suffering from coronary heart disease (CHD) who i) were either enrolled in the respective DMP or ii) fulfilled the disease related criteria for enrollment but were not enrolled. We applied multivariate logistic regression analyses to assess factors on patient level associated with DMP enrollment. Results We included 7070 individuals in our analyses. Male sex, higher age and receiving old age pension, a higher Charlson Score and a diagnosis of type 2 diabetes increased the odds for DMP-CHD enrollment significantly. Individuals with a diagnosed myocardial infarction (MI) were also more likely to be enrolled in the DMP-CHD. We found a significant interaction effect for MI and sex, indicating that the association between MI and DMP enrollment is stronger for women than for men. Conclusion DMP-enrollees and non-enrollees differ in various factors. Studies analyzing the effectiveness of DMP-CHD should carefully take into account these group differences. Furthermore, the results suggest that the DMP-CHD assessed reaches men better than women

Integrating the Population Perspective into Health System Performance Assessment (IPHA): Study Protocol for a Cross-Sectional Study in Germany Linking Survey and Claims Data of Statutorily and Privately Insured

Background: Health system performance assessment (HSPA) is a major tool for evidence-based governance in health systems and patient/population-orientation is increasingly considered as an important aspect. The IPHA study aims (1) to undertake a comprehensive performance assessment of the German health system from a population perspective based on the intermediate and final dimensions defined by the World Health Organization (WHO) and (2) to identify differences in HSPA between (a) common user characteristics and (b) user types, which differ in their interactions and patterns of action within the health system.Methods and Analysis: A cross-sectional survey was conducted between October and December 2018 with statutorily and privately health insured to assess the German health system from a population perspective related to the past 12 months. The random sample consists of 32 000 persons insured by AOK Nordost and 20 000 persons insured by Debeka. Data from the survey will subsequently be linked with health insurance claims data at the individual level for each respondent who has given consent for data linkage. Claims data covers the time period January 1, 2017 to June 30, 2018. The combination of the 2 data sources allows to identify associations between insured patient characteristics and differences in the assessment of health system performance. The survey consists of 71 items measuring all final and intermediate health system goals defined by the WHO and user characteristics like health literacy, self-efficacy, the attention an individual pays to his or her health or disease, the personal network, autonomy, compliance and sociodemographics. The claims data contains information on morbidity, care delivery, service utilization, (co)payments and sociodemography.Discussion: The study represents a promising attempt to perform a holistic HSPA using a population perspective. For this purpose, a questionnaire was designed that contains both validated and new items in order to collect data on all relevant health system dimensions. In particular, linking survey data on HSPA with claims data is of high potential for assessing and analysing determinants of health system performance from the population perspective

Assessing the responsiveness of chronic disease care -Is the World Health Organization's concept of health system responsiveness applicable?

a b s t r a c t The concept of health system responsiveness is an important dimension of health system performance assessment. Further efforts have been made in recent years to improve the analysis of responsiveness measurements, yet few studies have applied the responsiveness concept to the evaluation of specific health care delivery structures. The objective of this study was to test the World Health Organization's (WHO's) responsiveness concept for an application in the evaluation of chronic disease care. In September and October 2012 we conducted four focus groups of chronically ill people (n ¼ 38) in Germany, in which participants discussed their experiences and expectations regarding health care. The data was analyzed deductively (on the basis of the WHO responsiveness concept) and inductively using directed content analysis. Ten themes related to health system responsiveness and one theme (finances) not directly related to health system responsiveness, but of high importance to the focus group participants, could be identified. Eight of the ten responsiveness themes are consistent with the WHO concept. Additionally, two new themes were identified: trust (consultation and treatment are not led by any motive other than the patients' wellbeing) and coordination (treatment involving different providers is coordinated and different actors communicate with each other). These findings indicate the suitability of the WHO responsiveness concept for the evaluation of chronic disease care. However, some amendments, in particular an extension of the concept to include the two domains trust and coordination, are necessary for a thorough assessment of the responsiveness of chronic disease care