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May S, Könsgen N, Glatt A, Bruch D, Muehlensiepen F, Mählmann S, von Peter S, Pieper D, Neugebauer E, Prediger B. Does the second opinion directive in Germany reach the patient? A parallel-convergent mixed-methods study. BMC Health Serv Res 2023; 23:1198. [PMID: 37924040 PMCID: PMC10623803 DOI: 10.1186/s12913-023-10197-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
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.
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Affiliation(s)
- Susann May
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, 15562, Rüdersdorf, Germany
| | - Nadja Könsgen
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Angelina Glatt
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Dunja Bruch
- Department of Cardiovascular Surgery, Brandenburg Heart Center, Brandenburg Medical School Theodor Fontane, 16321, Bernau bei Berlin, Germany
- Faculty of Health Sciences, Brandenburg Medical School Theodor Fontane, 16816, Neuruppin, Germany
| | - Felix Muehlensiepen
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, 15562, Rüdersdorf, Germany
- Faculty of Health Sciences, Brandenburg Medical School Theodor Fontane, 16816, Neuruppin, Germany
| | - Sonja Mählmann
- Institute for Health Services and Health System Research, Faculty for Health Sciences, Brandenburg Medical School, 15562, Rüdersdorf, Germany
| | | | - Dawid Pieper
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, 15562, Rüdersdorf, Germany
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
- Institute for Health Services and Health System Research, Faculty for Health Sciences, Brandenburg Medical School, 15562, Rüdersdorf, Germany
| | - Edmund Neugebauer
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, 15562, Rüdersdorf, Germany
| | - Barbara Prediger
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany.
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May S, Bruch D, Muehlensiepen F, Prediger B, Pieper D, Ronckers C, von Peter S, Neugebauer E. Second opinion opportunity declined: patient typology and experiences regarding the decision-making process preceding elective surgeries in Germany. BMC Health Serv Res 2022; 22:1329. [PMCID: PMC9643974 DOI: 10.1186/s12913-022-08742-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
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.
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Könsgen N, Prediger B, Schlimbach A, Bora AM, Weißflog V, Loh JC, Bruch D, Pieper D. Telemedical Second Opinions in Germany: A Customer Survey of an Online Portal. Telemed J E Health 2022; 28:1664-1671. [PMID: 35394825 DOI: 10.1089/tmj.2022.0070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Nadja Könsgen
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Barbara Prediger
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Anna Schlimbach
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Ana-Mihaela Bora
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | | | | | - Dunja Bruch
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School, Neuruppin, Brandenburg, Germany
- Center for Health Services Research, and Institute for Health Services and Health System Research, Brandenburg Medical School (Theodor Fontane), Rüdersdorf, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
- Center for Health Services Research, and Institute for Health Services and Health System Research, Brandenburg Medical School (Theodor Fontane), Rüdersdorf, Germany
- Faculty of Health Sciences Brandenburg, Institute for Health Services and Health System Research, Brandenburg Medical School (Theodor Fontane), Rüdersdorf, Germany
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Ferreira GE, Zadro J, Liu C, Harris IA, Maher CG. Second opinions for spinal surgery: a scoping review. BMC Health Serv Res 2022; 22:358. [PMID: 35300677 PMCID: PMC8932184 DOI: 10.1186/s12913-022-07771-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain. METHODS We conducted a scoping review. Two independent researchers screened PubMed, EMBASE, Cochrane CENTRAL and CINAHL from inception to May 6th, 2021. Studies of any design published in any language were eligible provided they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) whether they reduce surgery and improve patient outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively. RESULTS We screened 6341 records, read 27 full-texts, and included 12 studies (all observational; 11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53 to 96%. Agreement for need for surgery between first and second opinions ranged from 0 to 83%. Second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and healthcare use (e.g. imaging), but might increase others (e.g. injections). CONCLUSIONS Second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. There is a need for high-quality randomised trials to determine the value of second opinion services for reducing spinal surgery.
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Affiliation(s)
- Giovanni E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia. .,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia.
| | - Joshua Zadro
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia
| | - Chang Liu
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,South Western Sydney Clinical School, Liverpool Hospital, The University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute of Applied Medical Research, Liverpool, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,School of Public Health, Faculty of Medicine and Health, The University of Sydney, PO Box M179, Missenden Road, Camperdown
- NSW
- , Sydney, New South Wales, 2050, Australia
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Könsgen N, Prediger B, Schlimbach A, Bora AM, Hess S, Caspers M, Pieper D. Attitude toward second opinions in Germany - a survey of the general population. BMC Health Serv Res 2022; 22:76. [PMID: 35033078 PMCID: PMC8760563 DOI: 10.1186/s12913-021-07422-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/15/2021] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Nadja Könsgen
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany.
| | - Barbara Prediger
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Anna Schlimbach
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Ana-Mihaela Bora
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Simone Hess
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Michael Caspers
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Institute for Health Services and Health System Research, Neuruppin, Germany
- Center for Health Services Research, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
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