Waiting times in the ambulatory sector - the case of chronically Ill patients

Aims: First, the influence of determinants on the waiting times of chronically ill patients in the ambulatory sector is investigated. The determinants are subdivided into four groups: (1) need, (2) socio-economic factors, (3) health system and (4) patient time pressures. Next, the influence of waiting times on the annual number of consultations is examined to assess whether the existing variation in waiting times influences the frequency of medical examinations. The waiting times of chronically ill patients are analysed since regular ambulatory care for this patient group could both improve treatment outcomes and lower costs. Data sources: Individual data from the 2010 Representative Survey conducted by the National Association of Statutory Health Insurance Physicians (KBV) together with regional data from the Federal Office of Construction and Regional Planning. Study design: This is a retrospective observational study. The dependent variables are waiting times in the ambulatory sector and the number of consultations of General Practitioners (GPs) and specialist physicians in the year 2010. The explanatory variables of interest are ‘need’ and ‘health system’ in the first model and ‘length of waiting times’ in the second. Negative binomial models with random effects are used to estimate the incidence rate ratios of increased waiting times and number of consultations. Subsequently, the models are stratified by urban and rural areas. Results: In the pooled regression the factor ‘privately insured’ shortens the waiting time for treatment by a specialist by approximately 28% (about 3 days) in comparison with members of the statutory health insurance system. The category of insurance has no influence on the number of consultations of GPs. In addition, the regression results stratified by urban and rural areas show that in urban areas the factor ‘privately insured’ reduces the waiting time for specialists by approximately 35% (about 3.3 days) while in rural areas there is no evidence of statistical influence. In neither of the models, however, does the waiting time have a documentable effect on the number of consultations in the ambulatory sector. Conclusions: In our random sample, characteristics of the health care system have an influence on the waiting time for specialists, but the waiting time has no documentable effect on the number of consultations in the ambulatory sector. In the present analysis this applies to consultations of both GPs and specialists. Nevertheless, it does not rule out the possibility that the length of waiting times might influence the treatment outcomes of certain patient populations

Revisiting Health Inequalities in Germany

Background: Our aim is a wide-ranging analysis of the determinants of health ine-qualities, which scrutinizes the propositions of the main theoretical approaches (ma-terialist or neo-materialist approach, cultural and behavioural approaches, psycho-social explanations, the life-course perspective and the newer capability approach) within one model thereby offering insights into their relative explanatory power. Methods: Using Fields’s (2004) regression techniques we decompose total variance into its factors and thereby generate insights about the contribution of specific vari-ables (and approaches) to explain health inequalities in Germany. Moreover, we stratify our sample by age and compare the contribution of each of the factors (con-stituting the different approaches) in four age groups. Data: The data is taken from the 2006 wave of the German Socioeconomic Panel (GSOEP). The GSOEP is a representative longitudinal study of private households and their members above the age of 16, which was started in 1984 and originally consisted of 12 000 individuals. We use the physical health scores derived from the 2006 GSOEP data wave as the dependent variable in our analysis. The scores are derived using an algorithm presented by Anderson et al., which is based on the 2004 GSOEP data wave as the norm sample. Furthermore, we use a comprehensive set of covariates capturing information on demographics, socio-economic background, life-style, social capital, self-assessed stress levels, feelings of national belonging, insurance status and regional levels of pollution, crime, noise and provision of health care to test the relative weight of the theoretical explanations. Results: Overall, we find that understanding the mechanisms of health inequalities crucially depends on taking a holistic perspective on individual’s health. Socio-eco-nomic factors, working conditions and lifestyle independently, interacted and com-pounded explain variation in health in specific age-groups in our analysis. Studies which take a reductionist approach and do not allow for the possibility that health inequalities are generated by a complex co-action of many factors may forego in-sightful findings. Online-Version published by Universitätsverlag der TU Berlin (www.univerlag.tu-berlin.de)

The Role of Health Shocks in Quitting Smoking

The European Union has stated interest in assessing the effectiveness and relevance of its messages about the adverse consequences of smoking in the context of its tobacco control policy. In the absence of disaggregated data on the direct relationship between health information and smoking decisions, we follow Clark et al. (2002) and investigate the impact of health shocks on the probability to quit daily smoking using eight waves of the European Union Community Household Panel (ECHP). Our intention is to assess whether individuals learn from changes in health i.e. successfully update new information about the consequences of tobacco consumption. As self assessed health is subjective and prone to reporting bias, we instrument self assessed health using “objective" health indicators and the socio-demographic variable age; the resulting variable is then used to model continuous and discrete changes in health, termed as health shocks. Estimating a discrete time hazard model with gamma distributed frailty, we find evidence that objective discrete health shocks increase the probability to quit daily smoking. Stratifying by gender reveals that in particular men above 55 quit following a negative health shock while the results for women are not statistically significant. Assuming that the increased hazard rate for men is associated with an increased perceived risk of coronary artery disease, we conclude that specific information about smoking related health shocks are the most effective health warnings. Online-Version published by Universitätsverlag der TU Berlin (www.univerlag.tu-berlin.de)

The wider determinants of inequalities in health: a decomposition analysis

<p>Abstract</p> <p>Background</p> <p>The common starting point of many studies scrutinizing the factors underlying health inequalities is that material, cultural-behavioural, and psycho-social factors affect the distribution of health systematically through income, education, occupation, wealth or similar indicators of socioeconomic structure. However, little is known regarding if and to what extent these factors can assert systematic influence on the distribution of health of a population independent of the effects channelled through income, education, or wealth.</p> <p>Methods</p> <p>Using representative data from the German Socioeconomic Panel, we apply Fields' regression based decomposition techniques to decompose variations in health into its sources. Controlling for income, education, occupation, and wealth, we assess the relative importance of the explanatory factors over and above their effect on the variation in health channelled through the commonly applied measures of socioeconomic status.</p> <p>Results</p> <p>The analysis suggests that three main factors persistently contribute to variance in health: the capability score, cultural-behavioural variables and to a lower extent, the materialist approach. Of the three, the capability score illustrates the explanatory power of interaction and compound effects as it captures the individual's socioeconomic, social, and psychological resources in relation to his/her exposure to life challenges.</p> <p>Conclusion</p> <p>Models that take a reductionist perspective and do not allow for the possibility that health inequalities are generated by factors over and above their effect on the variation in health channelled through one of the socioeconomic measures are underspecified and may fail to capture the determinants of health inequalities.</p

Cost-effectiveness of human leukocyte antigen matching in penetrating keratoplasty

Background: The matching of favorable human leukocyte antigen (HLA) combinations is rarely performed in penetrating keratoplasty procedures for primary prophylaxis of immune reactions. However, clinical studies suggest that the incidence of graft rejection decreases substantially when patients receive favorably matched grafts. Objective: The aim of this study was to assess the cost-effectiveness of HLA matching for patients undergoing penetrating keratoplasty in everyday clinical practice. Methods: In the absence of a randomized controlled clinical trial, we used administrative data from the Freiburg University Eye Hospital in Germany. Our study population consisted of all patients who underwent their first keratoplasty between 11/2003 and 01/2010 and for whom information on HLA histocompatibility was available. We used propensity score matching to estimate a causal effect of favorable HLA matching, parametric survival regression techniques to predict graft survival and expert opinion to model incremental cost for HLA matching. Because the availability of favorable HLA histocompatibility ultimately depends on the patients’ HLA phenotype, we modeled the incremental cost-effectiveness ratio (ICER) as a function of the probability that a patient will receive a favorably matched HLA, and used expert opinion to set a point estimate. Results: We predicted that corneal grafts with favorable HLA matching were associated with improved rejection-free graft survival time (more than 1,000 days). We estimated the incremental cost of HLA matching at EUR 1,200 and the ICER at EUR 4.62 per additional day of graft survival. Conclusions: The ICER of HLA matching is acceptable, given the high cost of alternative treatment and the shortage of corneal donors in Germany

Use of guideline-recommended drug therapy in patients undergoing percutaneous coronary intervention for stable coronary heart disease in Germany: a multilevel analysis of nationwide routine data

Objectives: To determine the prescription of guideline recommended drug therapy in patients with stable coronary heart disease (sCHD) prior to percutaneous coronary intervention (PCI) in Germany and to examine the role of patient characteristics and features of regional healthcare supply in a multilevel model. Design Secondary data analysis of factors associated with the prescription of guideline recommended drug therapy using a multilevel model to analyse regional-level effects, over and above the effects of patient-level demographic and health status. Setting Office-based prescriptions in the year prior to the invasive procedure. Participants A linked nationwide dataset from Germany's three largest statutory health insurance funds of all patients receiving PCI in the year 2016. Main outcome measures Patients' odds of receiving optimal medical therapy and symptom-oriented therapy within 1 year prior to PCI. Results 68.6% of patients received at least one lipid-lowering drug and one symptom-oriented therapy prior to PCI. 43.6% received at least two agents to control their symptoms. Patients who received treatment in accordance with the recommendations had a greater number of diagnosed risk factors, a more severe history of cardiac disease and used a higher volume of ambulatory office-based physician services. The prescriptions prevalence for the symptom-oriented therapies differed significantly between eastern and western Germany, with a higher prevalence in the eastern districts. Conclusions: Guidelines can only provide decision-making corridors, and the applicability of recommendations must always be assessed on a case by case basis. Nevertheless, our analysis indicates that the prevalence of prescriptions in routine practice is subject to substantial variation and that conservative therapy options are not fully exhausted prior to PCI. This suggests that there might be room for improvement in the care of patients with sCHD

Correlation of mesolevel characteristics of the healthcare system and socioeconomic inequality in healthcare use: a scoping review protocol

Introduction Although the impact of macrolevel characteristics of health systems on socioeconomic inequity in health has been studied extensively, the impact of access characteristics on a smaller scale of health systems has received less attention. These mesolevel characteristics can influence access to healthcare and might have the potential to moderate or aggravate socioeconomic inequity in healthcare use. This scoping review aims to map the existing evidence of the association of socioeconomic inequity in healthcare use and mesolevel access characteristics of the health system. Methods and analysis In conducting the scoping review, we follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols Extension for Scoping Reviews. The search will be carried out in four scientific databases: MEDLINE (via PubMed), Web of Science, Scopus and PsycINFO. Main eligibility criteria are inclusion in the analysis of a measure of socioeconomic position, a measure of individual healthcare use and a mesolevel determinant of access to healthcare services. The selection process consists of two consecutive screening stages (first: title/abstract; second: full text). At both stages, two reviewers independently assess the eligibility of studies. In case of disagreement, a third reviewer will be involved. Cohen’s kappa will be calculated to report inter-rater agreement between reviewers. Results are synthesised narratively, as a high heterogeneity of studies is expected. Ethics and dissemination No primary data are collected for the presented scoping review. Therefore, ethical approval is not necessary. The scoping review will be published in an international peer-reviewed journal, and findings will be presented on national and international conferences.Peer Reviewe

Making shared decision-making (SDM) a reality: protocol of a large-scale long-term SDM implementation programme at a Northern German University Hospital

Introduction: Shared decision-making (SDM) is not yet widely used when making decisions in German hospitals. Making SDM a reality is a complex task. It involves training healthcare professionals in SDM communication and enabling patients to actively participate in communication, in addition to providing sound, easy to understand information on treatment alternatives in the form of evidence-based patient decision aids (EbPDAs). This project funded by the German Innovation Fund aims at designing, implementing and evaluating a multicomponent, large-scale and integrative SDM programme-called SHARE TO CARE (S2C)-at all clinical departments of a University Hospital Campus in Northern Germany within a 4-year time period. Methods and analysis S2C tackles the aforementioned components of SDM: (1) training physicians in SDM communication, (2) activating and empowering patients, (3) developing EbPDAs in the most common/relevant diseases and (4) training other healthcare professionals in SDM coaching. S2C is designed together with patients and providers. The physicians' training programme entails an online and an in situ training module. The decision coach training is based on a similar but less comprehensive approach. The development of online EbPDAs follows the International Patient Decision Aid Standards and includes written, graphical and video-based information. Validated outcomes of SDM implementation are measured in a preintervention and postintervention evaluation design. Process evaluation accompanies programme implementation. Health economic impact of the intervention is investigated using a propensity-score-matched approach based on potentially preference-sensitive hospital decisions. Ethics and dissemination Ethics committee review approval has been obtained from Medical Ethics Committee of the Medical Faculty of the Christian-Albrechts-University Kiel. Project information and results will be disseminated at conferences, on project-hosted websites at University Hospital Medical Center Schleswig Holstein and by S2C as well as in peer-reviewed and professional journals

Inequalities in child mortality in ten major African cities

Background: The existence of socio-economic inequalities in child mortality is well documented. African cities grow faster than cities in most other regions of the world; and inequalities in African cities are thought to be particularly large. Revealing health-related inequalities is essential in order for governments to be able to act against them. This study aimed to systematically compare inequalities in child mortality across 10 major African cities (Cairo, Lagos, Kinshasa, Luanda, Abidjan, Dar es Salaam, Nairobi, Dakar, Addis Ababa, Accra), and to investigate trends in such inequalities over time. Methods: Data from two rounds of demographic and health surveys (DHS) were used for this study (if available): one from around the year 2000 and one from between 2007 and 2011. Child mortality rates within cities were calculated by population wealth quintiles. Inequality in child mortality was assessed by computing two measures of relative inequality (the rate ratio and the concentration index) and two measures of absolute inequality (the difference and the Erreyger's index). Results: Mean child mortality rates ranged from about 39 deaths per 1,000 live births in Cairo (2008) to about 107 deaths per 1,000 live births in Dar es Salaam (2010). Significant inequalities were found in Kinshasa, Luanda, Abidjan, and Addis Ababa in the most recent survey. The difference between the poorest quintile and the richest quintile was as much as 108 deaths per 1,000 live births (95% confidence interval 55 to 166) in Abidjan in 2011-2012. When comparing inequalities across cities or over time, confidence intervals of all measures almost always overlap. Nevertheless, inequalities appear to have increased in Abidjan, while they appear to have decreased in Cairo, Lagos, Dar es Salaam, Nairobi and Dakar. Conclusions: Considerable inequalities exist in almost all cities but the level of inequalities and their development over time appear to differ across cities. This implies that inequalities are amenable to policy interventions and that it is worth investigating why inequalities are higher in one city than in another. However, larger samples are needed in order to improve the certainty of our results. Currently available data samples from DHS are too small to reliably quantify the level of inequalities within cities