Quality and resource efficiency in hospital service provision: A geoadditive stochastic frontier analysis of stroke quality of care in Germany

We specify a Bayesian, geoadditive Stochastic Frontier Analysis (SFA) model to assess hospital performance along the dimensions of resources and quality of stroke care in German hospitals. With 1,100 annual observations and data from 2006 to 2013 and risk-adjusted patient volume as output, we introduce a production function that captures quality, resource inputs, hospital inefficiency determinants and spatial patterns of inefficiencies. With high relevance for hospital management and health system regulators, we identify performance improvement mechanisms by considering marginal effects for the average hospital. Specialization and certification can substantially reduce mortality. Regional and hospital-level concentration can improve quality and resource efficiency. Finally, our results demonstrate a trade-off between quality improvement and resource reduction and substantial regional variation in efficiency.DFG, 325093850, Open Access Publizieren 2017 - 2018 / Technische Universität Berli

Comparative study of motor cortical excitability changes following anodal tDCS or high‐frequency tRNS in relation to stimulation duration

Background In this study, we investigate the capacity of two different non‐invasive brain stimulation (NIBS) techniques (anodal transcranial direct current stimulation (anodal tDCS) and high‐frequency transcranial random noise stimulation (hf‐tRNS)) regarding the relationship between stimulation duration and their efficacy in inducing long‐lasting changes in motor cortical excitability. Methods Fifteen healthy subjects attended six experimental sessions (90 experiments in total) and underwent both anodal tDCS of 7, 13, and 20 min duration, as well as high‐frequency 1mA‐tRNS of 7, 13, and 20 min stimulation duration. Sessions were performed in a randomized order and subjects were blinded to the applied methods. Results For anodal tDCS, no significant stable increases of motor cortical excitability were observed for either stimulation duration. In contrast, for hf ‐tRNS a stimulation duration of 7 min resulted in a significant increase of motor cortical excitability lasting from 20 to 60 min poststimulation. While an intermediate duration of 13 min hf‐tRNS failed to induce lasting changes in motor cortical excitability, a longer stimulation duration of 20 min hf‐tRNS led only to significant increases at 50 min poststimulation which did not outlast until 60 min poststimulation. Conclusion Hf‐tRNS for a duration of 7 min induced robust increases of motor cortical excitability, suggesting an indirect proportional relationship between stimulation duration and efficacy. While hf‐tRNS appeared superior to anodal tDCS in this study, further systematic and randomized experiments are necessary to evaluate the generalizability of our observations and to address current intensity as a further modifiable contributor to the variability of transcranial brain stimulation

The use of digitally collected patient-reported outcome measures for newly operated patients with total knee and hip replacements to improve post-treatment recovery: study protocol for a randomized controlled trial

Background The number of total knee replacements (TKRs) and total hip replacements (THRs) has been increasing noticeably in high-income countries, such as Germany. In particular, the number of revisions is expected to rise because of higher life expectancy and procedures performed on younger patients, impacting the budgets of health-care systems. Quality transparency is the basis of holistic patient pathway optimization. Nevertheless, a nation-wide cross-sectoral assessment of quality from a patient perspective does not yet exist. Several studies have shown that the use of patient-reported outcome measures (PROMs) is effective for measuring quality and monitoring post-treatment recovery. For the first time in Germany, we test whether early detection of critical recovery paths using PROMs after TKR/THR improves the quality of care in a cost-effective way and can be recommended for implementation into standard care. Methods/design The study is a two-arm multi-center patient-level randomized controlled trial. Patients from nine hospitals are included in the study. Patient-centered questionnaires are employed to regularly measure digitized PROMs of TKR/THR patients from the time of hospital admission until 12 months post-discharge. An expert consortium has defined PROM alert thresholds at 1, 3, and 6 months to signal critical recovery paths after TKR/THR. An algorithm alerts study assistants if patients are not recovering in line with expected recovery paths. The study assistants contact patients and their physicians to investigate and, if needed, adjust the post-treatment protocol. When sickness funds’ claims data are added, the cost-effectiveness of the intervention can be analyzed. Discussion The study is expected to deliver an important contribution to test PROMs as an intervention tool and examine the determinants of high-quality endoprosthetic care. Depending on a positive and cost-effective impact, the goal is to transfer the study design into standard care. During the trial design phase, several insights have been discovered, and there were opportunities for efficient digital monitoring limited by existing legacy care models. Digitalization in hospital processes and the implementation of digital tools still represent challenges for hospital personnel and patients. Furthermore, data privacy regulations and the separation between the in- and outpatient sector are roadblocks to effectively monitor and assess quality along the full patient pathway.TU Berlin, Open-Access-Mittel – 202

PRO B: evaluating the effect of an alarm-based patient-reported outcome monitoring compared with usual care in metastatic breast cancer patients—study protocol for a randomised controlled trial

Background: Despite the progress of research and treatment for breast cancer, still up to 30% of the patients afflicted will develop distant disease. Elongation of survival and maintaining the quality of life (QoL) become pivotal issues guiding the treatment decisions. One possible approach to optimise survival and QoL is the use of patient-reported outcomes (PROs) to timely identify acute disease-related burden. We present the protocol of a trial that investigates the effect of real-time PRO data captured with electronic mobile devices on QoL in female breast cancer patients with metastatic disease. Methods: This study is a randomised, controlled trial with 1:1 randomisation between two arms. A total of 1000 patients will be recruited in 40 selected breast cancer centres. Patients in the intervention arm receive a weekly request via an app to complete the PRO survey. Symptoms will be assessed by study-specific optimised short forms based on the EORTC QLQ-C30 domains using items from the EORTC CAT item banks. In case of deteriorating PRO scores, an alarm is sent to the treating study centre as well as to the PRO B study office. Following the alarm, the treating breast cancer centre is required to contact the patient to inquire about the reported symptoms and to intervene, if necessary. The intervention is not specified and depends on the clinical need determined by the treating physician. Patients in the control arm are prompted by the app every 3 months to participate in the PRO survey, but their response will not trigger an alarm. The primary outcome is the fatigue level 6 months after enrolment. Secondary endpoints include among others hospitalisations, use of rescue services and overall QoL. Discussion: Within the PRO B intervention group, we expect lower fatigue levels 6 months after intervention start, higher levels of QoL, less unplanned hospitalisations and less emergency room visits compared to controls. In case of positive results, our approach would allow a fast and easy transfer into clinical practice due to the use of the already nationwide existing IT infrastructure of the German Cancer Society and the independent certification institute OnkoZert

Towards a methodical framework for comprehensively assessing forest multifunctionality

Funded by Deutsche Forschungsgemeinschaft. Grant Number: DFG FOR 891/1-3 National Natural Science Foundation of China. Grant Numbers: 30710103907, 30930005, 31170457, 31210103910 Swiss National Science Foundation (SNSF) Sino-German Centre for Research Promotion in Beijing. Grant Number: GZ 986Peer reviewedPublisher PD

Quality transparency in Germany and its use to improve quality of care in hospital service provision

Hintergrund und Ziele: Aufgrund hoher Informationsasymmetrien zwischen Patienten und behandelnden Ärzten haben Patienten nur geringe Möglichkeiten, die Behandlung im Krankenhaus und deren Erfolgsaussichten ex ante einzuschätzen. Qualitätstransparenz kann helfen, Informationsasymmetrien zu reduzieren und Patientenmündigkeit zu stärken. Jedoch ist das Wissen über Qualitätstransparenz und deren Wirkung fragmentiert, veraltet und im deutschen Kontext nur ansatzweise vorhanden. Die Qualität im Krankenhaus soll gesteigert werden, doch ist der Zusammenhang zwischen vielen Strukturfaktoren und Ergebnisqualität unzureichend erforscht. Diese Forschungsarbeit soll die wissenschaftliche Grundlage für den politischen Diskurs zu Transparenz und Verbesserung von Behandlungsqualität im Krankenhaus ausbauen und konkrete Empfehlungen für die Weiterentwicklung der Qualitätssicherung und den Ausbau qualitätsfördernder Strukturfaktoren in Deutschland geben. Methodik: Als primäre empirische Grundlage fungiert eine umfassende Datenbank, welche die in Deutschland verfügbaren Struktur-, Prozess- und Ergebnisdaten auf Krankenhaus- und Fachabteilungsebene integriert. Zusätzlich werden Nutzerdaten des weisse-liste.de Public Reporting Portals verwendet. Methodisch interdisziplinär nutzt diese Arbeit verschiedene Ansätze und Techniken aus der Versorgungsforschung, der Gesundheitsökonomie und Big Data Marketing Forschung. Zum einen werden Qualitätstransparenzsysteme qualitativ untersucht. Dabei stehen insbesondere die Messung, Veröffentlichung und Incentivierung von Behandlungsqualität im Krankenhaus im Mittelpunkt eines internationalen Vergleiches. Zum anderen untersuchen Regressionsanalysen und eine stochastische Analyse der Effizienzgrenzen den Einfluss bestimmter Strukturfaktoren auf Qualität und Effizienz in der Krankenhausversorgung. Als Zielvariable wird primär Ergebnisqualität betrachtet. Ergebnisse: Kapitel 1 untersucht die Einflussfaktoren auf Behandlungsqualität aus Patienten- und Leistungserbringersicht und erläutert die Konzepte Qualitätssicherung und Public Reporting. Als internationale Vergleichsarbeit identifiziert Kapitel 2 gesundheitspolitische Ansätze zur Steigerung von Qualitätstransparenz in fünf OECD Ländern. Unter anderem spielen Regierungen eine zentrale Rolle in der Etablierung von Standards und Anreizen für Qualitätstransparenz und integrierte Datensysteme in der Gesundheitsversorgung. Qualitätstransparenz benötigt einen stärkeren Fokus auf Ergebnisqualität und sollte sich auf Krankenhaus- und Leistungsbereichsebene konzentrieren, um Vergleichbarkeit und sinnvolle Wahlmöglichkeiten für Patienten zu garantieren. Kapitel 3 richtet den Fokus auf Deutschland und zeigt große Unterschiede in der risiko-adjustieren Qualität zwischen Krankenhäusern auf nationaler und regionaler Ebene für ausgewählte Notfall- und elektive Leistungsbereiche. Je nach Leistungsbereich liegt das risiko-adjustierte Mortalitäts- bzw. Komplikationsrisiko bis zu 50-mal höher in Krankenhäusern mit schlechter Qualität im Vergleich zu den qualitativbesten Krankenhäusern. Kapitel 4 untersucht Nutzerverhalten in der Krankenhaussuche auf dem Public Reporting Portal „WeisseListe.de“. Die Nutzung ist im Zeitraum von 2013 bis 2015 um 38% auf 2 750 Nutzer pro Tag angestiegen. Nutzer suchen insbesondere Qualitätsinformationen für onkologische und orthopädische Leistungsbereiche, doch sind für nur 5 der 20 meistgesuchten Leistungsbereiche Prozess- oder Ergebnisindikatoren verfügbar. Dicht besiedelte Gebiete in Westdeutschland mit höherer Krankenhausdichte weisen eine stärkere Portalnutzung auf als Ost- oder Süddeutschland. Unterschiedliche Nutzergruppen mit spezifischen Charakteristika konnten identifiziert werden und verdeutlichen die Notwendigkeit für nutzerorientiertes Public Reporting. Kapitel 5 untersucht den systematischen Einfluss von Spezialisierung der Krankenhausinfrastruktur und -prozesse und von Zertifizierung auf Qualität am Beispiel der Schlaganfallbehandlung. Krankenhäuser mit einer Stroke Unit haben eine 6% geringere Schlaganfallsterblichkeit. Ein zusätzlicher systematischer Einfluss für ein Stroke Unit Zertifikat kann nicht festgestellt werden. Kapitel 6 richtet den Fokus auf den Krankenhausmarkt als Ganzes und analysiert den Einfluss von Qualitätswettbewerb auf die Behandlungsqualität in den Leistungsbereichen Schlaganfall, Herzinfarkt und Hüft-Total-Endoprothetik. Ein signifikanter Einfluss von Krankenhauswettbewerb auf die Qualität der Versorgung kann nicht festgestellt werden, was möglicherweise auf das weiterhin unzureichende öffentliche Bewusstsein für Qualitätsunterschiede und gegenläufige Effekte durch Krankenhauszentralisierung und Spezialisierung zurückzuführen ist. Letztlich kombiniert Kapitel 7 Qualität und Ressourceneffizienz in einer neuen Methode zur Bestimmung qualitätsadjustierter technischer Krankenhauseffizienz. Dabei werden deutliche Effizienzpotentiale identifiziert, welche insbesondere durch Spezialisierung und Konzentration von Leistungen zu adressieren sind. Fazit: Die Arbeit verdeutlicht Verbesserungspotentiale im Qualitätstransparenzsystem und in der Versorgungsqualität und Effizienz deutscher Krankenhäuser. Neben den aktuellen Bestrebungen im Rahmen des Krankenhausstrukturgesetzes kann ein internationaler Best Practice Austausch, Qualitätssicherung mit tatsächlichen Konsequenzen für schlechte Qualität, ein stärkerer Fokus auf Ergebnisqualität, Spezialisierung und Zentralisierung in der Versorgung, eine nutzenorientierte Verbesserung des Public Reportings und eine weitere Stärkung des Qualitätswettbewerbs die Versorgungsqualität in Deutschland nachhaltig steigern.Background and objectives: Due to large information asymmetries between patients and physicians, patients often have limited opportunity to assess treatment options, process of care and their prospective treatment outcomes in advance. Quality of care transparency can help to reduce information asymmetries and increase patient autonomy. Yet, the scientific knowledge around quality of care transparency and its effects on outcomes is fragmented, outdated and, in the German context, rudimentary. In order to enhance quality transparency and to improve hospital outcome quality, the dynamics around quality of care transparency and the relationship between important structural factors and outcomes must be better understood. This research project aims to expand the scientific foundation for policymaking on quality transparency and quality improvement in hospital care. The goal is to provide concrete policy recommendations for improvement of quality transparency and the expansion of quality-enhancing structural factors in the German hospital sector and beyond. Methods: The empirical foundation for this project is a comprehensive database, which integrates the available structural, procedural and outcome quality metrics at both a hospital and medical department level. In addition, website data for the weisse-liste.de public reporting portal is used. Based on an interdisciplinary health economics approach, this project employs different methodologies from health systems research, health economics and big data e-commerce marketing research. First, this project investigates quality of care transparency systems qualitatively by analyzing how they measure, report and incentivize better outcomes. Second, this project uses regression analysis and stochastic efficiency modeling to examine the influence of certain structural factors on quality and efficiency in hospital service delivery. Outcome quality, as opposed to process quality, is the main focus and dependent variable. Results: Chapter 1 examines the factors impacting quality of care on the patient demand side and the care provider supply side, as well as reviews quality assurance and public reporting in the German context. As an international comparison, Chapter 2 examines health policy approaches to enhance quality of care in five mature OECD health systems. Among others, the results suggest governments play an essential role in establishing standards and incentives for quality of care transparency and integrated IT systems in heath service delivery. Furthermore, quality transparency needs a stronger emphasis on outcome quality and should focus at the medical condition and hospital level to ensure patients are empowered with accessible and meaningful information to guide healthcare decisions. Chapter 3 sets the focus on Germany and uncovers large differences in risk-adjusted outcomes between hospitals—both at a national and regional level—as well as for emergency and elective conditions. Depending on the treatment area, the risk-adjusted mortality or complication risk is up to 50 times higher in hospitals with poor outcome quality, relative to hospitals with the best outcome quality of care. Chapter 4 examines website user patterns for the hospital search function of the public reporting portal weisse-liste.de. Between 2013 and 2015, usage of the website increased by 38% annually, to 2,750 user sessions per day. In particular, users searched for quality of care information for oncological and orthopedic treatment areas. Process and outcome quality metrics are only available for 5 of 20 most searched-for treatment areas. In Western Germany, users from densely populated areas with a high number of hospitals conducted relatively more searches than users in Southern and Eastern Germany. From the website data, user groups with distinct characteristics could be identified and confirm the need for customized public reporting options. Chapter 5 evaluates the systematic influence of hospital certification, hospital infrastructure, and process specialization on stroke care outcome quality. Hospitals with a dedicated stroke unit have, on average, a 6% lower risk-adjusted 30-day stroke mortality, ceterius paribus. However, a stroke unit certification showed no systematic influence on 30-day stroke mortality. Chapter 6 focuses on the provider market at large—examining the influence of provider competition on outcomes for hip replacement surgery, and stroke and heart attack emergency care. The influence of provider competition on outcomes remains unclear and insignificant, which can be partially attributed to currently insufficient awareness about outcome differences and where to access the right information. It also hints at the potentially countervailing outcomes influences of hospital centralization and specialization. Chapter 7 combines the concepts of quality and efficiency of care in hospital service provision in a new stochastic frontier analysis model, estimating quality-adjusted technical hospital efficiency. Large inefficiencies are identified, which can be addressed in part through specialization and concentration in care delivery. Conclusions: This research project illustrates substantial potential for improvement in the German quality transparency system, as well as opportunities to enhance the quality of care and efficiency in German hospital service delivery. Possible solutions to increase quality of care in Germany may include, among others: an international best practice exchange, stronger focus on outcome quality, actual regulatory consequences for hospitals with insufficient quality of care, specialization and centralization in hospital care, a user oriented public reporting system, and a substantial strengthening of hospital quality of care competition

The myth of Baker-Miller pink: Effects of colored light on physiology, cognition, and emotion?

Besides aesthetic aspects, color can have impact on human perception and behaviour. A special pink hue, the so called Baker-Miller pink, is assumed to induce calming effects. In this study, we evaluated pink and white lighting conditions with N = 29 subjects, through tests of attention, measurements of skin conductance and emotional state ratings. With an exposure time of 15 minutes including measurements, no color effect was found in skin conductance and attentional performance. There was also no difference in ratings of emotional valence and arousal between the two lighting conditions. Although, subjects rated Baker-Miller pink light significantly less activating than white light. A significant sex effect showed that women preferred pink light more than men. These results indicate that there are indeed differences in subjective perception of white and Baker-Miller pink light although they cannot be found in objective measures of physiological and cognitive processes

Stability of hospital quality indicators over time: A multi-year observational study of German hospital data.

BackgroundRetrospective hospital quality indicators can only be useful if they are trustworthy signals of current or future quality. Despite extensive longitudinal quality indicator data and many hospital quality public reporting initiatives, research on quality indicator stability over time is scarce and skepticism about their usefulness widespread.ObjectiveBased on aggregated, widely available hospital-level quality indicators, this paper sought to determine whether quality indicators are stable over time. Implications for health policy were drawn and the limited methodological foundation for stability assessments of hospital-level quality indicators enhanced.MethodsTwo longitudinal datasets (self-reported and routine data), including all hospitals in Germany and covering the period from 2004 to 2017, were analysed. A logistic regression using Generalized Estimating Equations, a time-dependent, graphic quintile representation of risk-adjusted rates and Spearman's rank correlation coefficient were used.ResultsFor a total of eight German quality indicators significant stability over time was demonstrated. The probability of remaining in the best quality cluster in the future across all hospitals reached from 46.9% (CI: 42.4-51.6%) for hip replacement reoperations to 80.4% (CI: 76.4-83.8%) for decubitus. Furthermore, graphical descriptive analysis showed that the difference in adverse event rates for the 20% top performing compared to the 20% worst performing hospitals in the two following years is on average between 30% for stroke and AMI and 79% for decubitus. Stability over time has been shown to vary strongly between indicators and treatment areas.ConclusionQuality indicators were found to have sufficient stability over time for public reporting. Potentially, increasing case volumes per hospital, centralisation of medical services and minimum-quantity regulations may lead to more stable and reliable quality of care indicators. Finally, more robust policy interventions such as outcome-based payment, should only be applied to outcome indicators with a higher level of stability over time. This should be subject to future research

Lower Albian benthic foraminifera

The Early Albian Oceanic Anoxic Event 1b (OAE 1b) black shale is interrupted by one or more ventilation events that display significant changes in benthic and planktic populations. Within the OAE 1b sections studied, at ODP Site 1049, DSDP Site 545, and the Vocontian Basin, the benthic foraminiferal repopulation events last between ~500 and ~1,250 years and occur with a cyclicity of approximately 5.7 kyr. This period may represent an amplitude modulation of the precessional cycle. The OAE 1b sections from the marginal setting of the Vocontian Basin exhibit up to eight repopulation events. In contrast, there is only one repopulation event identified in the Atlantic OAE 1b sections from the Mazagan Plateau (DSDP 545) and Blake Nose (ODP 1049). Within the margin of dating uncertainties, this supraregional repopulation event occurred synchronously in the Vocontian Basin and the Atlantic Ocean. While the OAE 1b black shale formed under extremely warm and humid conditions, the repopulation events occurred during intervals of short-term cooling and reduced humidity at deep-water formation sites. The resulting increase in evaporation led to enhanced formation of low-latitude deep water, thus improving the ventilation of the sea floor