Hausärztliche Betreuung von Palliativpatienten innerhalb und außerhalb der SAPV: eine Querschnittserhebung im Rahmen des Verbundprojektes "SAVOIR - Evaluierung der SAPV-Richtlinie: Outcomes, Interaktionen, Regionale Unterschiede"

Hintergrund: Hausärzte spielen eine zentrale Rolle in der ambulanten Palliativversorgung. Ziel der Studie: ist die Beschreibung der hausärztlichen palliativmedizinischen Tätigkeitsübernahme in Art und Umfang sowie eine Darstellung über die hausärztlich empfundene Wichtigkeit der SAPV und deren Einbeziehung, die der bundesweit heterogenen SAPV-Landschaft und den Versorgungsstrukturen Rechnung trägt. Methode: Es erfolgte eine querschnittliche quantitative Untersuchung mittels selbst konzipiertem, pilotiertem Fragebogen auf postalischem Weg im Frühjahr 2018. Hierfür wurde eine Zufallsstichprobe von insgesamt 6000 Hausärzten aus acht Kassenärztlichen Vereinigungen (KVen) (n=750 pro KV) ermittelt und angeschrieben. Ergebnisse: Die Netto-Rücklaufrate betrug 19,1% (n=1144). Die befragten Hausärzte sind in einem hohen Maße palliativmedizinisch aktiv; jedoch mit deutlichen Unterschieden im Ausübungsumfang der einzelnen Tätigkeiten. Unterschiede bestehen auch in Abhängigkeit der KV-Zugehörigkeit. Bei Tätigkeiten, die selten oder nie ausgeführt werden (Durchführung apparativer/invasiver Maßnahmen, 24-Stunden-Erreichbarkeit) ist die Hinzuziehung von SAPV für Hausärzte besonders wichtig. Multivariate Analysen zeigten, dass folgende Variablen mit hoher palliativmedizinischer Aktivität assoziiert waren: Kompetenzempfinden, Selbstverständnis, Versorgungsqualität der umgebenden allgemeinen Infrastruktur, Qualifikation- und Abrechnungslevel, Patienten pro Quartal. Negativ korreliert zeigten sich: Versorgungsqualität des SAPV-Teams, Anzahl der SAPV-Verordnungen. Schlussfolgerung: Die Ergebnisse deuten auf ein hohes Engagement der Hausärzte in der Palliativversorgung hin. Die Stärkung von Kompetenz, Erfahrung und/oder Qualifikation sowie Vergütung könnten die hausärztliche Einbringung in die Palliativversorgung weiter befördern. Eine flexible Hinzuziehung von SAPV in Abhängigkeit der vor Ort verfügbaren AAPV-Infrastruktur und deren Leistbarkeit scheint sinnvoll

Structural characteristics and contractual terms of specialist palliative homecare in Germany

Background Multi-professional specialist palliative homecare (SPHC) teams care for palliative patients with complex symptoms. In Germany, the SPHC directive regulates care provision, but model contracts for each federal state are heterogeneous regarding staff requirements, cooperation with other healthcare providers, and financial reimbursement. The structural characteristics of SPHC teams also vary. Aim We provide a structured overview of the existing model contracts, as well as a nationwide assessment of SPHC teams and their structural characteristics. Furthermore, we explore whether these characteristics serve to find specifc patterns of SPHC team models, based on empirical data. Methods This study is part of the multi-methods research project “SAVOIR”, funded by the German Innovations Fund. Most model contracts are publicly available. Structural characteristics (e.g. number, professions, and affiliations of team members, and external cooperation) were assessed via an online database (“Wegweiser Hospiz- und Palliativversorgung”) based on voluntary information obtained from SPHC teams. All the data were updated by phone during the assessment process. Data were descriptively analysed regarding staff, cooperation requirements, and reimbursement schemes, while latent class analysis (LCA) was used to identify structural team models. Results Model contracts have heterogeneous contract partners and terms related to staff requirements (number and qualifications) and cooperation with other services. Fourteen reimbursement schemes were available, all combining different payment models. Of the 283 SPHC teams, 196 provided structural characteristics. Teams reported between one and 298 members (mean: 30.3, median: 18), mainly nurses and physicians, while 37.8% had a psychosocial professional as a team member. Most teams were composed of nurses and physicians employed in different settings; for example, staff was employed by the team, in private practices/nursing services, or in hospitals. Latent class analysis identified four structural team models, based on the team size, team members’ affiliation, and care organisation. Conclusion Both the contractual terms and teams’ structural characteristics vary substantially, and this must be considered when analysing patient data from SPHC. The identified patterns of team models can form a starting point from which to analyse different forms of care provision and their impact on care quality

Palliativversorgung am Lebensende in Deutschland: Inanspruchnahme und regionale Verteilung

Background!#!Palliative care supply increased in Germany in recent years. But how many people use which forms of palliative care and how does this differ between regions?!##!Method!#!Retrospective cohort study with claims data from insured persons who died in 2016: Based on services billed at least once in the last six months of life, we determined the use of primary palliative care (PPC), specialized palliative homecare (SPHC), as well as inpatient palliative and hospice care, using regional billing codes for PPC and SPHC services for the first time.!##!Results!#!Of the 95,962 deceased in the study population, 32.7% received palliative care nationwide, with variations from 26.4% in Bremen to 40.8% in Bavaria. PPC services were billed at 24.4% (16.9% in Brandenburg to 34.1% in Bavaria). SPHC services received 13.1% (6.3% in Rhineland-Palatinate to 18.9% in Brandenburg and 22.9% in Westphalia-Lippe with different SPHC practices). Inpatient palliative care was received by 8.1% (6.7% in Schleswig-Holstein/Hesse to 13.0% in Thuringia); 3.3% (1.6% in Bremen to 5.6% in Berlin) with hospice services.!##!Conclusion!#!SPHC is used more frequently than previously reported, while PPC is declining. Utilization seems to be based less on objective needs than on region-specific framework conditions. Besides needs criteria, further development of palliative care should be oriented more towards outcomes and relevant framework conditions

Study protocol for a multi-methods study: SAVOIR - evaluation of specialized outpatient palliative care (SAPV) in Germany: outcomes, interactions, regional differences

Abstract Background Since 2007, the German statutory health insurance covers Specialized Outpatient Palliative Care (SAPV). SAPV offers team-based home care for patients with advanced and progressive disease, complex symptoms and life expectancy limited to days, weeks or months. The introduction of SAPV is ruled by a directive (SAPV directive). Within this regulation, SAPV delivery models can and do differ regarding team structures, financing models, cooperation with other care professionals and processes of care. The research project SAVOIR is funded by G-BA’s German Innovations Fund to evaluate the implementation of the SAPV directive. Methods The processes, content and quality of SAPV will be evaluated from the perspectives of patients, SAPV teams, general practitioners and other care givers and payers. The influence of different contracts, team and network structures and regional and geographic settings on processes and results including patient-reported outcomes will be analyzed in five subprojects: [1] structural characteristics of SAPV and their impact on patient care, [2] quality of care from the perspective of patients, [3] quality of care from the perspective of SAPV teams, hospices, ambulatory nursing services, nursing homes and other care givers, content and extent of care from [4] the perspective of General Practitioners and [5] from the perspective of payers. The evaluation will be based on different types of data: team and organizational structures, treatment data based on routine documentation with electronic medical record systems, prospective assessment of patient-reported outcomes in a sample of SAPV teams, qualitative interviews with other stakeholders like nursing and hospice services, a survey in general practitioners and a retrospective analysis of claims data of all SAPV patients, covered by the health insurance fund BARMER in 2016. Discussion Data analysis will allow identification of variables, associated with quality of SAPV. Based on these findings, the SAVOIR study group will develop recommendations for the Federal Joint Committee for a revision of the SAPV directive. Trial registration German Clinical Trials Register (DRKS): DRKS00013949 (retrospectively registered, 14.03.2018), DRKS00014726 (14.05.2018), DRKS00014730 (30.05.2018). Subproject 3 is an interview study with professional caregivers and therefore not registered in DRKS as a clinical study