Progress on quality management in the German health system – a long and winding road

Breckenkamp J, Wiskow C, Laaser U. Progress on quality management in the German health system – a long and winding road. Health Research Policy and Systems. 2007;5(1): 7.The interest in quality management in health care has increased in the last decades as the financial crises in most health systems generated the need for solutions to contain costs while maintaining quality of care. In Germany the development of quality management procedures has been closely linked with health care reforms. Starting in the early nineties quality management issues gained momentum in reform legislation only 10 years later. This review summarizes recent developments in medical quality management as related to the federal reform legislation in Germany. It provides an overview on the infrastructure, actors and on the current discussion concerning quality management in medical care. Germany had to catch up on implementing quality management in the health system compared to other countries. Considerable progress has been made, however, it is recognized that the full integration of quality management will require long-term commitment in developing methods, instruments and communication procedures. The most ambitious project at present is the development of a comprehensive comparative quality management system for hospitals at national level, including public reporting. For the time being medical quality management in Germany is dealt with as a technical and professional issue while the aspects of patient orientation and transparency need further advancement

Quality Improvement in Health Care and Health Promotion: Health Grants

The public offer of health grants is a possibility to get an overview of project activities within a certain region. Innovative, economic and qualitative highly valuated approaches can be made familiar to the general public by this procedure. If applicable, such problem-solving approaches can be taken over by other projects in a modified form. In so far the identified projects can serve for quality improvement in various fields of health care and health promotion

Social Mechanisms in Epidemiological Publications on Small-Area Health Inequalities-A Scoping Review

Zolitschka KA, Razum O, Breckenkamp J, Sauzet O. Social Mechanisms in Epidemiological Publications on Small-Area Health Inequalities-A Scoping Review. FRONTIERS IN PUBLIC HEALTH. 2019;7: 393.Background: Small-area social mechanisms-social processes involving the social environment around the place of residence-may be playing a role in the production of health inequalities. Understanding how small-area health inequalities (social environment affects health and consequently contribute to inequalities between areas) are generated and the role of social mechanisms in this process may help defining interventions to reduce inequalities. In mediation and pathway analyses, social mechanisms need to be treated as processes or factors. We aimed to identify which types of social mechanisms explaining the process leading from small-area characteristics to health inequalities have been considered and investigated in epidemiological publications and to establish how they have been operationalized. Methods: We performed a scoping review for social mechanisms in the context of small-area health inequalities in the database PubMed. Epidemiological publications identified were categorized according to the typology proposed by Galster (social networks, social contagion, collective socialization, social cohesion, competition, relative deprivation, and parental mediation). Furthermore, we assessed whether the mechanisms were operationalized at the micro or macro level and whether mechanisms were considered as processes or merely as exposure factors. Results: We retrieved 1,019 studies, 15 thereof were included in our analysis. Eight forms of operationalization were found in the category social networks and another nine in the category social cohesion. Other categories were hardly represented. Furthermore, all studies were cross sectional and did not consider mechanisms as processes. Except for one, all studies treated mechanisms merely as factors whose respective association to health outcomes was tested. Conclusion: In epidemiological publications, social mechanisms in studies on small-area effects on health inequalities are not operationalized as processes in which these mechanisms would play a role. Rather, the focus is on studying associations. To understand the production of health inequalities and the causal effect of social mechanisms on health, it is necessary to analyze mechanisms as processes. For this purpose, methods such as complex system modeling should be considered

Results of the Prospective Data Collection of 111 Births

Objectives: Does the incidence and/or indication(s) for emergency cesarean section differ if the pregnant woman has an immigrant background (IB)? Does a lack of language proficiency (communication problems) and a low acculturation level result in a longer decision-to-delivery interval (D-D interval)? Are neonates born to women with IB by emergency cesarean section in a poorer condition post delivery? Patient cohorts and method: Standardized interviews were carried out before or immediately after delivery in three Berlin obstetric hospitals. Questions were asked about the sociodemographic background and care aspects as well as about immigration and level of acculturation. Collected data were linked to information obtained from the expectant motherʼs antenatal records and to care data and perinatal data routinely recorded by the hospitals. Data was analyzed using regression models which adjusted for age, parity, and socio-economic status. Results: The total patient population consisted of 7100 women (rate of response: 89.6%); of these women, 111 required emergency cesarean section (50 women without IB, 61 immigrant women). Risk factors such as late first antenatal check-up, gestational diabetes, pregnancy-induced hypertension, fetal macrosomia, smoking, and weight gain were similar in both patient cohorts. The incidence of and indications for emergency cesarean section and the D-D interval were similar for both groups. Limited German language proficiency and low levels of acculturation among immigrant women did not prolong the D-D interval. There were no statistically relevant differences between immigrant and non-immigrant cohorts with regard to adverse neonatal conditions (5-minute Apgar score ≤ 7, umbilical cord arterial pH < 7.00) or with regard to immediate transfer of the neonate to a pediatric clinic following emergency cesarean section. Conclusion: The factor “immigrant background” did not affect the indication or obstetric outcome following emergency cesarean section

Does social cohesion mediate neighbourhood effects on mental and physical health? Longitudinal analysis using German Socio-Economic Panel data

Kress S, Razum O, Zolitschka KA, Breckenkamp J, Sauzet O. Does social cohesion mediate neighbourhood effects on mental and physical health? Longitudinal analysis using German Socio-Economic Panel data. BMC Public Health. 2020;20: 1043.Background Neighbourhood has risen as a relevant determinant of health. While there is substantial evidence that environmental factors affect health, far less evidence of the role of social mechanisms in the causal chain between neighbourhood characteristics and health is available. Method To evaluate the role of social cohesion as a mediator between four different neighbourhood characteristics and health using data from German Socio-Economic-Panel (SOEP), a longitudinal mediation analysis was performed. Multilevel linear regression models adjusted for socio-economic variables involved three time points and two measures of physical and mental health (physical and mental component scores (PCS and MCS) of the SF12 Questionnaire. Participants were followed-up for 4 and 10 year starting in 2004. Results A total of 15,518 measures of MCS and PCS on 10,013 participants living in 4985 households were included. After adjusting for values of MCS and PCS at baseline and demographic/socio-economic variables, social cohesion was a significant positive predictor of both MCS and PCS (β-coefficient MCS: 1.57 (0.27); PCS: 1.50 (0.24)). Interaction between social cohesion and follow-up were significant for PCS. The effect of environmental and built characteristics on health was consistently mediated by social cohesion with proportion varying between 10 and 23%. Discussion We show that social cohesion is part of the causal chain between environmental and built characteristics of a neighbourhood and health, with increasing mediation effect over time for physical health. Social mechanisms should be considered when studying the effect of neighbourhood characteristics on health inequalities making social cohesion as a legitimate target of public health interventions at neighbourhood level

Caesarean Section Frequency among Immigrants, Second- and Third-Generation Women, and Non-Immigrants: Prospective Study in Berlin/Germany

David M, Borde T, Brenne S, Henrich W, Breckenkamp J, Razum O. Caesarean Section Frequency among Immigrants, Second- and Third-Generation Women, and Non-Immigrants: Prospective Study in Berlin/Germany. PLoS ONE. 2015;10(5): e0127489.Objective The frequency of caesarean section delivery varies between countries and social groups. Among other factors, it is determined by the quality of obstetrics care. Rates of elective (planned) and emergency (in-labor) caesareans may also vary between immigrants (first generation), their offspring (second- and third-generation women), and non-immigrants because of access and language barriers. Other important points to be considered are whether caesarean section indications and the neonatal outcomes differ in babies delivered by caesarean between immigrants, their offspring, and non-immigrants. Methods A standardized interview on admission to delivery wards at three Berlin obstetric hospitals was performed in a 12-month period in 2011/2012. Questions on socio-demographic and care aspects and on migration (immigrated herself vs. second- and third-generation women vs. non-immigrant) and acculturation status were included. Data was linked with information from the expectant mothers' antenatal records and with perinatal data routinely documented in the hospital. Regression modeling was used to adjust for age, parity and socio-economic status. Results The caesarean section rates for immigrants, second- and third-generation women, and non-immigrant women were similar. Neither indications for caesarean section delivery nor neonatal outcomes showed statistically significant differences. The only difference found was a somewhat higher rate of crash caesarean sections per 100 births among first generation immigrants compared to non-immigrants. Conclusion Unlike earlier German studies and current studies from other European countries, this study did not find an increased rate of caesarean sections among immigrants, as well as second- and third-generation women, with the possible exception of a small high-risk group. This indicates an equally high quality of perinatal care for women with and without a migration history

Technical Report: "Pilot project for the panel study" Project C1: "Transnationality and inequality"

Tuncer H, Breckenkamp J, Razum O, Faist T. Technical Report: "Pilot project for the panel study" Project C1: "Transnationality and inequality". SFB 882 Technical Report Series. Vol 16. Bielefeld: DFG Research Center (SFB) 882 From Heterogeneities to Inequalities; 2015

Utilisation of rehabilitation services for non-migrant and migrant groups of higher working age in Germany - results of the lidA cohort study

Background: An ageing and a shrinking labour force implies that the prevention of a premature exit from work due to poor health will become more relevant in the future. Medical rehabilitation is a health service that aims at active participation in working life. The provision of this service will be relevant for an increasing part of the ageing labour force, namely, employees with a migrant background and their different subgroups. Thus, this study examines whether first- and second-generation employees with migrant background differ from non-migrants in their utilisation of rehabilitation services and whether within the subsample of migrant employees, those persons with foreign nationality differ from those with German nationality. Methods: Socially insured employees born in 1959 or 1965 were surveyed nationwide in 2011 as part of the lidA cohort study (n=6303). Survey data of the first study wave were used to identify the dependent variable of the utilisation of rehabilitation (in- and outpatient), the independent variable of migrant status and the covariates of sociodemographic, work- and non-work-related factors. Applying bivariate statistics with tests of independence and block-wise logistic regressions, differences between the groups were investigated. Additionally, average marginal effects were computed to directly compare the adjusted models. Results: The study showed that first-generation migrants had a significantly lower likelihood of utilising outpatient rehabilitation than non-migrants (fully adj. OR 0.42, 95% CI 0.22-0.82) and that average marginal effects indicated higher differences in the full model than in the null model. No significant differences were found between the first- or second-generation migrants and non-migrants when comparing the utilisation of inpatient rehabilitation or any rehabilitation or when analysing German and foreign employees with migrant background (n=1148). Conclusions: Significant differences in the utilisation of outpatient rehabilitation between first-generation migrants and non-migrants were found, which could not be explained by sociodemographic, work- and non-work-related factors. Thus, further factors might play a role. The second-generation migrants resemble the non-migrants rather than their parent generation (first-generation migrants). This detailed investigation shows the heterogeneity in the utilisation of health services such as medical rehabilitation, which is why service sensitive to diversity should be considered

Technical Report: "Pilot project for the panel study" Project C1: "Transnationality and inequality"

Tuncer H, Breckenkamp J, Razum O, Faist T. Technical Report: "Pilot project for the panel study" Project C1: "Transnationality and inequality". SFB 882 Technical Report Series. Vol 16. Bielefeld: DFG Research Center (SFB) 882 From Heterogeneities to Inequalities; 2015

Transnationality and inequality: codebook of the pilot project for the panel study

Breckenkamp J, Tuncer H, Akbulut N, Faist T. Transnationality and inequality: codebook of the pilot project for the panel study. SFB 882 Technical Report Series. Vol 17. Bielefeld: DFG Research Center (SFB) 882 From Heterogeneities to Inequalities; 2015