[Memorandum III: Methods for Health Services Research (Part 2)]

Bausteine und Strukturen für eine leistungsfähige Real-World-Data-Analyse

Hintergrund

Die Real-World-Data (RWD)-Analyse hat in den vergangenen Jahren eine erhebliche Dynamik entwickelt, gefördert durch gestiegene Möglichkeiten der (explorativen) Analyse großer Datenmengen und parallel durch die zunehmende Verfügbarkeit bislang für die Wissenschaft nicht zugänglicher Datenkörper.

Ziel der Arbeit

Der nächste Entwicklungsschritt der RWD-Analyse ist ihre wissenschaftliche Etablierung in Form von Netzwerkbildung und formeller Organisation sowie Generierung spezifischer Methoden. Auf diesem Weg können Erfahrungen aus der Entwicklung der Sekundärdatenanalyse als Teil der RWD-Analyse hilfreich sein. Es wird diskutiert, inwieweit maßgebliche Schritte in diesem Prozess und dabei entstandene wissenschaftliche Produkte als Vorbild für die RWD-Analyse dienen können, exemplarisch dargestellt an den Aktivitäten der Arbeitsgruppe Erhebung und Nutzung von Sekundärdaten (AGENS).

Material und Methoden

Aus maßgeblichen Entwicklungsphasen der AGENS in den vergangenen 25 Jahren werden potenzielle Prozesse und Strukturen für eine Fortentwicklung der RWD-Analyse abgeleitet.

Ergebnisse

Die wesentlichen Charakteristika der aktuellen Arbeit der AGENS und damit auch der Strukturen der Sekundärdatenanalyse sind: a) Netzwerkbildung von Wissenschaftler:innen aus Forschung und Entwicklung sowie Vertreter:innen der Dateneigner:innen, b) Entwicklung spezifischer wissenschaftlicher Standards, c) die wissenschaftliche Sichtbarkeit durch Schwerpunktbeiträge, Journale und Tagungsformate, d) eigenständige Angebote für Aus- und Weiterbildung von Nachwuchswissenschaftler:innen, e) die laufende Verbesserung des Forschungsfelds durch Erschließung neuer Datenkörper.

Schlussfolgerung

Die Entwicklung der Sekundärdatenanalyse als wichtiger Teil der RWD-Analyse liefert Ansatzpunkte für deren Etablierung als eigenständiger Wissenschaftszweig.

[DNVF Memorandum: Health Services Research in the Last Year of Life]

This memorandum outlines current issues concerning health services research on seriously ill and dying people in the last year of their lives as well as support available for their relatives. Patients in the last phase of life can belong to different disease groups, they may have special characteristics (e. g., people with cognitive and complex impairments, economic disadvantage or migration background) and be in certain phases of life (e. g., parents of minor children, (old) age). The need for a designated memorandum on health services research in the last year of life results from the special situation of those affected and from the special features of health services in this phase of life. With reference to these special features, this memorandum describes methodological and ethical specifics as well as current issues in health services research and how these can be adequately addressed using quantitative, qualitative and mixed methods. It has been developed by the palliative medicine section of the German Network for Health Services Research (DNVF) according to the guidelines for DNVF memoranda.

Optimal@NRW: optimized acute care of nursing home residents using an intersectoral telemedical cooperation network - study protocol for a stepped-wedge trial

Background

Increasing life expectancy is associated with a growing number of people living in nursing homes, while the availability of outpatient medical care, especially from family doctors, is stagnating in this sector. Consequently, numerous and often avoidable, low-threshold hospitalizations of nursing home residents are observed. This results in unnecessary use of resources such as emergency services and emergency rooms as well as in potential health risks to the nursing home residents related to hospitalization. This study aims to improve this healthcare gap by implementing an intersectoral telemedicine approach.

Methods

Twenty-five nursing homes are participating and provided with telemedical equipment to perform teleconsultations. Additionally, an early warning system and a digital patient record system are implemented. Telephysicians based at RWTH Aachen University Hospital are ready to support the nursing homes around the clock if the family doctor or an emergency service practice is not available in time. Mobile non-physician practice assistants from the telemedicine centre can be dispatched to perform delegable medical activities. General practitioners and the medical emergency practices also have access to the telemedical infrastructure and the non-physician practice assistants.

Discussion

Optimal@NRW adds a telemedicine component to standard care — combining elements of outpatient and inpatient health care as well as emergency service practices — to enable timely medical consultation for nursing home residents in case of the development of an acute medical condition. In addition to optimized medical care, the goal is to reduce unnecessary hospital admissions. The intersectoral approach allows for the appropriate use of resources to match the individually needed medical treatment.

Trial registration

ClinicalTrials.govNCT04879537. Registered on May 10, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06613-1.

SALUS-a non-inferiority trial to compare self-tonometry in glaucoma patients with regular inpatient intraocular pressure controls: study design and set-up

Purpose

The SALUS study aims to improve the healthcare situation for glaucoma patients in Germany. In order to detect diurnal intraocular pressure (IOP) fluctuations, inpatient monitoring of IOP in an eye hospital for a minimum of 24 h is the current standard. SALUS assesses the benefits of a new form of outpatient care, where IOP can be measured by the patients themselves at home using a self-tonometer. This approach should promote the patient’s health competence and empowerment within the healthcare system while reducing treatment costs.

Methods

The SALUS study is a randomized controlled, open non-inferiority trial, alongside an economic analysis, determining whether outpatient monitoring of IOP with self-tonometry is at least as effective as current standard care and would reduce treatment costs. Participants (n = 1980) will be recruited by local ophthalmologists in the area of Westphalia-Lippe, Germany, and randomized to receive 7-day outpatient or 24-h inpatient monitoring. Participants in both study arms will also receive 24-h blood pressure monitoring. Furthermore, patient data from both study groups will be collected in an electronic case file (ECF), accessible to practitioners, hospitals, and the study participants. The primary endpoint is the percentage of patients with IOP peaks, defined as levels 30% above the patient-specific target pressure. Data will also be collected during initial and final examinations, and at 3, 6, and 9 months after the initial examination.

Results

The study implementation and trial management are represented below.

Conclusion

SALUS is a pioneering prospective clinical trial focused on the care of glaucoma patients in Germany. If SALUS is successful, it could improve the healthcare situation and health literacy of the patients through the introduction of various telemedical components. Furthermore, the approach would almost certainly reduce the treatment costs of glaucoma care.

Trial registration

ClinicalTrials.gov ID: NCT04698876, registration date: 11/25/2020.

DRKS-ID: DRKS00023676, registration date: 11/26/2020.

[Health services research in intensive care medicine in Germany : Status quo and future challenges exemplified by acute pulmonary failure]

Health services research (HSR) is a multidisciplinary field of research that describes disease treatment and health care and their framework conditions. In the last 20 years, the HSR aspect became more and more the clinical focus of intensive care medicine. Under this aspect HSR investigates the use of clinical measures and their impact on patient outcome under routine intensive care medical conditions. This article provides an overview of the current state of HSR in intensive care medicine in Germany using the example of acute respiratory distress syndrome (ARDS). The ARDS still represents a clinical disease with high intra-hospital mortality (30-60%) despite progress in intensive care medicine. Survivors of ARDS have substantial long-term limitations on physical and mental health. The treatment of ARDS patients is tedious, laborious for intensive care unit staff and complex. Despite evident treatment recommendations, these are only insufficiently implemented in the clinical routine. With the help of quality indicators, benchmarking, certification and peer review procedures, the quality of intensive care treatment in the clinical routine can be documented and improved. An important role in HSR is patient safety and focusing on the outcome with evaluation of the patient's will. As part of the establishment of the innovation fund for HSR, promising intensive medical care projects have been promoted to improve the quality of care and the quality of long-term outcome for intensive care patients. An important focus lies on the identification of factors that improve long-term quality of life after intensive care. The expansion of registries and telemedicine in intensive care offers the opportunity to bundle and share experiences more effectively and thereby establish (guideline-based) treatment recommendations faster in the clinical practice.

[A standard data set for the evaluation of venous leg ulcers in selective contracts : National consensus]

BACKGROUND

Selective agreements are becoming increasingly important in health care management. To date, no standard recommendations for the evaluation of selective contracts are available.

OBJECTIVES

Against this background, a recommendation on the evaluation of selective contracts in patients with leg ulcers (LU) was developed and approved by the nationwide consensus conference.

MATERIALS AND METHODS

Based on a systematic literature review and followed by a manual search through other possible evaluation indicators in the care of patients with LU, a Delphi-based consensus process was performed by various scientific societies, professional associations, insurances and supply networks.

RESULTS

For the evaluation of efficiency and quality of care, a recommendation on the evaluation of selective agreements with patients with LU was consented in six meetings and in five multistage online surveys. In total, 44 evaluation indicators were identified in the quality subareas structure, process, and outcome. The outcome indicators are divided into clinical, patient-related, and cost-related indicators.

CONCLUSIONS

The developed evaluation indicators represent the quality of care in patients with LU. The indicators can be applied individually, depending on the agreed contract-specific supply target. After implementation of this national standard, the comparability of selective agreements in the management of patients with LU can be ensured and consolidated.

mosaicQA - A General Approach to Facilitate Basic Data Quality Assurance for Epidemiological Research

BACKGROUND

Epidemiological studies are based on a considerable amount of personal, medical and socio-economic data. To answer research questions with reliable results, epidemiological research projects face the challenge of providing high quality data. Consequently, gathered data has to be reviewed continuously during the data collection period.

OBJECTIVES

This article describes the development of the mosaicQA-library for non-statistical experts consisting of a set of reusable R functions to provide support for a basic data quality assurance for a wide range of application scenarios in epidemiological research.

METHODS

To generate valid quality reports for various scenarios and data sets, a general and flexible development approach was needed. As a first step, a set of quality-related questions, targeting quality aspects on a more general level, was identified. The next step included the design of specific R-scripts to produce proper reports for metric and categorical data. For more flexibility, the third development step focussed on the generalization of the developed R-scripts, e.g. extracting characteristics and parameters. As a last step the generic characteristics of the developed R functionalities and generated reports have been evaluated using different metric and categorical datasets.

RESULTS

The developed mosaicQA-library generates basic data quality reports for multivariate input data. If needed, more detailed results for single-variable data, including definition of units, variables, descriptions, code lists and categories of qualified missings, can easily be produced.

CONCLUSIONS

The mosaicQA-library enables researchers to generate reports for various kinds of metric and categorical data without the need for computational or scripting knowledge. At the moment, the library focusses on the data structure quality and supports the assessment of several quality indicators, including frequency, distribution and plausibility of research variables as well as the occurrence of missing and extreme values. To simplify the installation process, mosaicQA has been released as an official R-package.

[What can and cannot be achieved by registries : Perspective of the registry working group of the German Network of Health Services Research]

In addition to clinical trials, registries and cohort studies are the fundamental basis of patient-orientated research. The importance of registries is increasing because more questions involving patient care under routine conditions (real world data) need to be answered. This article supplies answers to the questions: what can be achieved with registries and what are the limitations? Starting with a consensus definition of a registry from the German Network of Health Services Research (DNVF), the question of existing registries was examined and it was concluded that there was a lack of transparency. Consequently, a registry of registries similar to clinical trials registries is urgently needed as well as an evaluation of the quality of existing registries. Criteria are deduced that allow an assessment of the quality of a registry and which comprehensive possibilities registries can provide are discussed in eight different areas of interest to clinicians. The limitations of registries compared to randomized clinical trials and cohort studies are emphasized and discussed in this article. In the future, the use of registry-based randomized clinical trials (RRCT) will allow data related to efficacy as well as to effectiveness to be collated.

[Benefit assessment in health services research and epidemiology]

The legal terms "benefit" and "added benefit" and the procedures related to their assessment, given the application of a new medical intervention for approval, should help to restrict the market to those products for which there is much evidence of their benefit or added benefit. The term implies the fiction of an overall benefit for all patients with the same disease. However, from the perspective of health services research and that of epidemiology the term inevitably has to be extended to cover the benefit to a variety of groups of patients or users of a broad spectrum of medical interventions in the real world, ranging from inpatient treatment to vaccination or screening programs. Thus, the assessment of benefit requires a comparison of the new product with all the alternatives currently available for routine care, explicitly taking into account user preferences. Hence, the assessment of benefit in health services research is not one-dimensional and requires new types of studies that go beyond the traditional phase III trials (efficacy trials). New approaches are mainly developed by comparative effectiveness research (CER). CER studies also use randomized designs, because they are currently the best available method for causal inferences. However, randomization in CER is extended to a much broader framework, including health-related databases, registers, epidemiological studies, feasibility studies, and post hoc analyses. CER has developed the necessary and appropriate designs and statistical methods. In addition, some of these methods allow an adaptive assessment of benefit, which can be used to monitor the implementation of new health care interventions or programs.

[Health care research: potential beneficiary of big data]

Health care research focuses on the description and analysis of the health care system and its requirements. Research-derived innovations are the subject of trials and evaluation of the transfer to daily routine. For this purpose health care research has developed a broad theory-based spectrum of methods. On the other hand, the concept of big data is an new informatics-driven approach to large data sets independent of content. With its technical vocabulary the concept of big data does not easily fit into traditional health care research. Central tasks of health care research such as the generation of theories, norm-oriented evaluations or proof of causality can neither be supported nor replaced by big data. However, the concept of big data has the potential to support health care research, with traditional tasks such as data linkage, analysis of health care paths, quick access to up-to-date data on the distribution and acceptance of health care services, as well as prediction and the generation of hypotheses. The prerequisite for all this is a trust-based linkage of different medical and nonmedical data sources on the basis of the legal regulation of data access and data protection.

[Outcomes and health services research in ophthalmology]

This article describes the role of outcomes and health services research in the field of ophthalmology in Germany. First, the need for more information and data on the performance of ophthalmic care in Germany is explored. The concept, goals and methods of outcomes and health services research are explained and illustrated by examples of already existing research projects in ophthalmology. Future topics for research projects are highlighted. The article also describes how the field of outcomes and health services research can become a more important part within the scientific ophthalmological community in Germany.

[Memorandum III "methods for health services research", Part 1 [authors: H. Pfaff, G. Glaeske, E. A. M. Neugebauer, M. Schrappe] and Part 2 [authors: E. A. M. Neugebauer, A. Icks, M. Schrappe] of the Deutsches Netzwerk Versorgungsforschung e.V.: A summary]

This article presents an overview of the recently published first two parts of the Memorandum III "Methods for Health Services Research" discussed and approved by the member societies of the German Network Health Services Research [Deutsches Netzwerk Versorgungsforschung e.V.]. Part one of this memorandum covers methodical principles and minimum standards for the subject areas of health services research "Epidemiological Methods for Health Services Research", "Methods for Organisational Health Services Research" and "Methods for Quality of Life Research", the second part the topics "Methods of Health Economic Evaluation" and "Registries for the Health Services Research". The Memorandum is addressed to health services researchers and to reviewers who are planning, conducting, publishing studies as well as evaluating research proposals and publications. Assurance of quality and increase of the health services research are the aims of the Memorandum III. According to the advanced knowledge in health services research the Memorandum needs regular updates. Therefore the Memorandum has to be understood as "work in progress".