Second opinion programmes in Germany: a mixed-methods study protocol

[Obtaining a Second Opinion in Germany: an Analysis of the Billing Data of the Health Insurer AOK Nordost]

OBJECTIVES

The aim of this billing data analysis was to examine the implementation of the second opinion directive in Germany and to investigate how often informing patients about their right to a second opinion (SO) and obtaining a SO are documented.

METHODS

To examine the frequency of "informing about SO" and "obtaining an SO", insured patients who received an indication for tonsillectomy, tonsillotomy or hysterectomy in 2019 or 2020 were included, as well as insured patients who received an indication for shoulder arthroscopy in Q2-Q3 2020. Data were analyzed descriptively.

RESULTS

During the study period, 5307 surgeries were reported for the above-mentioned indications. "Informing about SO" was documented for 121 patients with surgery and "obtaining an SO" was documented for 12 patients with surgery. The proportion of documented "informing about SO" compared to the number of surgeries was highest for tonsillectomy/tonsillotomy<18 years (4%) and lowest for shoulder arthroscopy (0.6%). In total, no patient was documented for both "informing about SO" and "obtaining an SO".

CONCLUSIONS

The present billing data analysis shows that information about the right to an SO according to the directive as well as the obtaining of such an SO has not yet been implemented in standard care as required by law.

Does the second opinion directive in Germany reach the patient? A parallel-convergent mixed-methods study

BACKGROUND

A Second Opinion Directive (SOD) was introduced in Germany in December 2018 for elective surgeries such as hysterectomy, tonsillotomy, tonsillectomy, and shoulder arthroscopy. The aim of the SOD is to avoid surgeries which are not medically induced and to support patients in their decision-making process. A physician who indicates an SOD-relevant procedure must inform the patient about the SOD and its specifications. At this time, it is not clear whether physicians provide information about the SOD to patients and whether and how the SOD is implemented in daily practice. Furthermore, nothing is known about how patients react when they are told that they have the right to seek a second opinion according to the SOD.

METHODS

To assess this, we undertook a parallel-convergent mixed-methods study with a qualitative and quantitative phase. Qualitative data were analysed by structured qualitative content analysis and survey data were analysed descriptively.

RESULTS

26 interviews were conducted with patients for whom one of the above-mentioned surgeries was indicated. In parallel, a questionnaire survey with 102 patients was conducted. The results show that the SOD is not implemented in Germany for the selected indications because patients were not informed as intended. At the same time, when the right to obtain a second opinion was explained, it seemed to have a positive effect on the physician-patient relationship from patients` perspective.

CONCLUSIONS

It is possible that there is a lack of information for physicians, which in turn leads to an information deficit for patients. Better information for physicians might be part of the solution, but a negative attitude towards the SOD might also result in the low education rate. Therefore, in addition, potential patients or even the general population should be better informed about the possibility of obtaining a second opinion.

Second opinion opportunity declined: patient typology and experiences regarding the decision-making process preceding elective surgeries in Germany

BACKGROUND

To address the problem of overuse of elective surgery and to support patients in their decision-making process, a Second Opinion Directive was introduced in Germany, which enables patients with statutory health insurance to obtain a second opinion for certain surgical indications. The study aims to identify, based on the experiences of patients who have undergone elective surgery, the role of seeking a second opinion in reaching their decision.

METHODS

Sixty-two patients who had undergone an elective surgery (hysterectomy, tonsillectomy, shoulder arthroscopy) were recruited using purposive sampling and interviewed during October to December 2020. The transcribed interviews were analysed using a framework analysis to create a typology from the patient's perspective.

RESULTS

The time spent by patients in making the decision to undergo surgery varies between individuals, and is influenced by factors such as the type of physician-patient relationship, individual patient aspects, prior experiences in the health care system, as well as information needs. Within the framework of the analysis, we were able to identify three patterns of patient types based on the three different time-points or phases when decisions were typically made, with one type being divided into two subtypes: Type 1a: Quick decision making, Type 1b: Overwhelmed quick decision making, Type 2: Time to consider, Type 3: Struggling with the decision.

CONCLUSIONS

Patients who followed a recommendation for elective surgery appreciate having the possibility to seek a second opinion. However, various factors influenced their opting for a second opinion during the decision-making process. Patients have differing information needs, such that a one-size-fits-all second opinion service may not fit adequately for all patients.

A photograph of the researcher on the invitation letter did not affect the participation rate of a postal survey: a randomized study within a trial (SWAT)

Objective

Participant recruitment is one of the main challenges in research. It is suggested that including researcher photographs might increase participation rates, but empirical evidence is lacking. This study within a trial (SWAT) aims to assess whether invitation letters including researcher photographs increase the participation rate in the context of a survey on medical second opinions.

Methods

Through 25 local register offices in Berlin and Brandenburg (Germany), we identified a random sample of 9990 persons. We randomly assigned our sample to the intervention group (IG) receiving an invitation letter with researcher photographs and control group (CG) receiving an invitation letter without photographs in a 1:1 ratio. Our primary outcome was the participation rate. Furthermore, we compared participants to non-participants’ characteristics.

Results

Of 9990 invitations, 9797 could be delivered (IG: 4890, CG: 4907). Of these, 1349 (13.8%) participated. There were 682/4890 (13.9%) participants in the IG and 662/4907 (13.5%) in the CG with an odds ratio of 1.030 (95% confidence interval: 0.918–1.156). Additional analyses on non-participant characteristics did not show any differences.

Conclusion

We could not find any difference in the participation rates. Our study does not confirm the results of previous studies. The length of our questionnaire may have affected our results.

Trial registration

Queens University Belfast – SWAT Store, SWAT 104.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01717-3.

Physicians' Perspectives on the Implementation of the Second Opinion Directive in Germany-An Exploratory Sequential Mixed-Methods Study

A new Second Opinion Directive (SOD) was introduced in Germany in December 2018 for hysterectomy, tonsillotomy, and tonsillectomy to support shared decision making and to avoid unnecessary surgeries. Owing to its recent implementation, evidence and insights regarding outcomes and challenges encountered with the SOD are lacking, notably from the physicians' perspective. To assess this, we undertook an exploratory sequential mixed-methods design with an initial qualitative phase followed by a quantitative evaluation. A qualitative analysis of 22 interviews with specialists in gynecology and otorhinolaryngology was followed by a statistical analysis of a survey of 136 physicians in those disciplines. The specialists expressed a generally positive opinion of the new SOD, emphasizing the aspects of patient orientation, support in decision making, and patient safety. However, they also highlighted the following structural problems regarding the SOD implementation: In addition to an increased organisational effort, the specialists criticised the SOD with regard to its implementation in rural regions with a low availability of specialists for referral. Barriers that impede the implementation of the current directive, such as the adaptation of the qualifying requirements for authorized second opinion physicians, as well as the inclusion of relevant indications, need focused consideration to obtain better alignment with everyday practice.

Telemedical Second Opinions in Germany: A Customer Survey of an Online Portal

Introduction: Second medical opinions (SOs) can strengthen patients' certainty in decision making. In Germany, both personally delivered and telemedical SOs (often based on documents only) are provided. Our aim was to analyze the experiences of people who obtained telemedical SOs. We also investigated different routes of SO delivery (personally/by phone/documents only). Materials and Methods: German residents who obtained a telemedical SO via an online portal between January 2016 and February 2019 (n = 1,247) were contacted by post between August and November 2019 up to three times. The results were analyzed descriptively. Results: The 368 participants (response rate 30%) were 54% male, 95% statutory health insured, and 61 years old (median; interquartile range 51-72). Approximately 75% were (rather) satisfied with obtaining the SO via the online portal. The most preferred route of SO delivery was a personally delivered SO, which 80% would (rather) consider, followed by 70% (rather) considering SOs based on documents only and 48% (rather) considering SOs by phone. The most often mentioned advantage of telemedical SOs was independence of time and place, while the most important disadvantage was the standardized process resulting in a lack of direct and personal contact between the patient and the physician. Discussion: Although our results show that SOs (based on documents only) support patients and that patient satisfaction was high, personally delivered SOs were still preferred. Future research on the use of SOs based on documents only (in which patient population and in what situations) is needed.

Attitude toward second opinions in Germany - a survey of the general population

BACKGROUND

Second medical opinions (SOs) can assist patients in making informed treatment decisions and improve the understanding of their diagnosis. In Germany, there are different approaches to obtain a structured SO procedure: SO programs by health insurers and SOs according to the SO Directive. Through a direct survey of the population, we aimed to assess how structured SOs should be provided to fulfil patients' needs.

METHODS

A stratified sample of 9990 adults (≥18 years) living in the federal states of Berlin and Brandenburg (Germany) were initially contacted by post in April and sent a reminder in May 2020. The survey results were analyzed descriptively.

RESULTS

Among 1349 participants (response rate 14%), 56% were female and the median age was 58 years (interquartile range (IQR) 44-69). Participants wanted to be informed directly and personally about the possibility of obtaining an SO (89%; 1201/1349). They preferred to be informed by their physician (93%; 1249/1349). A majority of participants would consider it important to obtain an SO for oncological indications (78%; 1049/1349). Only a subset of the participants would seek an SO via their health insurer or via an online portal (43%; 577/1349 and 16%; 221/1349). A personally delivered SO was the preferred route of SO delivery, as 97% (1305/1349) would (tend to) consider this way of obtaining an SO. Participants were asked to imagine having moderate knee pain for years, resulting in a treatment recommendation for knee joint replacement. They were requested to rate potential qualification criteria for a physician providing the SO. The criteria rated to be most important were experience with the recommended diagnosis/treatment (criterion (very) important for 93%; 1257/1349) and knowledge of the current state of research (criterion (very) important for 86%; 1158/1349). Participants were willing to travel 60 min (median; IQR 60-120) and wait 4 weeks (median; IQR 2-4) for their SO in the hypothetical case of knee pain.

CONCLUSION

In general, SOs were viewed positively. We found that participants have clear preferences regarding SOs. We propose that these preferences should be taken into account in the future design and development of SO programs.

The impact of the COVID-19 pandemic on professional practice and patient volume in medical practices: A survey among German physicians and psychotherapists

Introduction

This study examines the consequences of the COVID-19 pandemic on outpatient care in the German federal state of Brandenburg during the first ‘lockdown’ between 22 March and 4 May 2020, focusing on the burden for physicians and psychotherapists in outpatient practices and on alternative ways to provide care, in particular telehealth.

Methods

We conducted an online cross-sectional survey among outpatient health care professionals. The responses of n = 277 physicians and n = 87 psychotherapists were included in the analysis. Frequencies are shown; the relationship between categorical variables was examined using the χ² test; we used a qualitative content analysis for free text answers.

Results

Almost all (96 %) physicians and 59 % of the psychotherapists reported a patient volume reduction since the COVID-19 outbreak. Cancellations were most often initiated by patients rather than physician offices. Among the physicians, routine check-ups and preventive care consultations were cancelled most frequently, and patients also appeared less frequently in open consultations. 72 % of the physicians and 29 % of the psychotherapists reported economic losses. While personal patient-physician contact was reduced, the use of telehealth has increased since the COVID-19 outbreak: during the first ‘lockdown’, two thirds of the psychotherapists (66 %) and 14 % of the physicians used telehealth for the first time. The COVID-19 pandemic contributed to a positive change in attitudes towards telehealth; this trend was significantly stronger among psychotherapists than among physicians.

Discussion

The reduction in patient volume shown in this study is confirmed by outpatient billing data analyses. Clinical routines changed due to COVID-19 and led to a growth in telehealth usage. By facilitating formal billing options, the increased use of telehealth can also be promoted after the pandemic.

Conclusion

Shortly after the COVID-19 outbreak, outpatient physicians and psychotherapists were faced with various challenges: Through their spontaneous and flexible response to the COVD-19 pandemic, outpatient providers were able to maintain their work despite high stress levels. Telehealth is becoming more important as a result of COVID-19.