How did the COVID-19 pandemic affect inpatient care for children in Germany? An exploratory analysis based on national hospital discharge data

BACKGROUND

The delivery of health services around the world faced considerable disruptions during the COVID-19 pandemic. While this has been discussed for a number of conditions in the adult population, related patterns have been studied less for children. In light of the detrimental effects of the pandemic, particularly for children and young people under the age of 18, it is pivotal to explore this issue further.

METHODS

Based on complete national hospital discharge data available via the German National Institute for the Reimbursement of Hospitals (InEK) data browser, we compare the top 30 diagnoses for which children were hospitalised in 2019, 2020, 2021 and 2022. We analyse the development of monthly admissions between January 2019 and December 2022 for three tracers of variable time-sensitivity: acute lymphoblastic leukaemia (ALL), appendicitis/appendectomy and tonsillectomy/adenoidectomy.

RESULTS

Compared to 2019, total admissions were approximately 20% lower in 2020 and 2021, and 13% lower in 2022. The composition of the most frequent principal diagnoses remained similar across years, although changes in rank were observed. Decreases were observed in 2020 for respiratory and gastrointestinal infections, with cases increasing again in 2021. The number of ALL admissions showed an upward trend and a periodicity prima vista unrelated to pandemic factors. Appendicitis admissions decreased by about 9% in 2020 and a further 8% in 2021 and 4% in 2022, while tonsillectomies/adenoidectomies decreased by more than 40% in 2020 and a further 32% in 2021 before increasing in 2022; for these tracers, monthly changes are in line with pandemic waves.

CONCLUSIONS

Hospital care for critical and urgent conditions among patients under the age of 18 was largely upheld in Germany during the COVID-19 pandemic, potentially at the expense of elective treatments. There is an alignment between observed variations in hospitalisations and pandemic mitigation measures, possibly also reflecting changes in demand. This study highlights the need for comprehensive, intersectoral data that would be necessary to better understand changing demand, unmet need/foregone care and shifts from inpatient to outpatient care, as well as their link to patient outcomes and health care efficiency.

Assessing capacities and resilience of health services during the COVID-19 pandemic: Lessons learned from use of rapid key informant surveys

This article is part of the Research Topic

'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict.'

Problem

Many countries lacked rapid and nimble data systems to track health service capacities to respond to COVID-19. They struggled to assess and monitor rapidly evolving service disruptions, health workforce capacities, health products availability, community needs and perspectives, and mitigation responses to maintain essential health services.

Method

Building on established methodologies, the World Health Organization developed a suite of methods and tools to support countries to rapidly fill data gaps and guide decision-making during COVID-19. The tools included: (1) a national "pulse" survey on service disruptions and bottlenecks; (2) a phone-based facility survey on frontline service capacities; and (3) a phone-based community survey on demand-side challenges and health needs.

Use

Three national pulse surveys revealed persisting service disruptions throughout 2020-2021 (97 countries responded to all three rounds). Results guided mitigation strategies and operational plans at country level, and informed investments and delivery of essential supplies at global level. Facility and community surveys in 22 countries found similar disruptions and limited frontline service capacities at a more granular level. Findings informed key actions to improve service delivery and responsiveness from local to national levels.

Lessons learned

The rapid key informant surveys provided a low-resource way to collect action-oriented health services data to inform response and recovery from local to global levels. The approach fostered country ownership, stronger data capacities, and integration into operational planning. The surveys are being evaluated to inform integration into country data systems to bolster routine health services monitoring and serve as health services alert functions for the future.

Perspective: Lessons from COVID-19 of countries in the European region in light of findings from the health system response monitor

Introduction

Decision-makers initially had limited data to inform their policy responses to the COVID-19 pandemic. The research community developed several online databases to track cases, deaths, and hospitalizations; however, a major deficiency was the lack of detailed information on how health systems were responding to the pandemic and how they would need to be transformed going forward.

Approach

In an effort to fill this information gap, in March 2020, the European Observatory on Health Systems and Policies, the WHO European Regional Office and the European Commission created the COVID-19 Health System Response Monitor (HSRM) to collect and organise up-to-date information on how health systems, mainly in the WHO European Region, were responding to the COVID-19 pandemic.

Findings

The HSRM analysis and broader Observatory work on COVID-19 shone light on a range of health system challenges and weaknesses and catalogued policy options countries put in place during the pandemic to address these. Countries prioritised policies on investing in public health, supporting the workforce, maintaining financial stability, and strengthening governance in their response to COVID-19.

Outlook

COVID-19 is likely to continue to impact health systems for the foreseeable future; the ability to cope with this pressure, and other shocks, depends on having good information on what other countries have done so that health systems develop adequate policy options. In support of this, the country information on the COVID-19 HSRM will remain available as a repository to inform decision makers on options for actions and possible measures against COVID-19 and other public health emergencies. Building on its previous work on health systems resilience, the European Observatory on Health Systems and Policies will sustain its focus on analysing key issues related to the recovery from the pandemic and making health systems more resilient. This includes policy knowledge transfer between countries and systematic resilience testing, aiming at contributing to an improved understanding of health system response, recovery, and preparedness.

Contribution to the literature in non-technical language

The COVID-19 Health System Response Monitor (HSRM) was the first database in the WHO European Region to collect and organise up-to-date information on how health systems were responding to the COVID-19 pandemic. The HSRM provides a repository of policies which can be used to inform decision makers in health and other policy domains on options for action and possible measures against COVID-19 and other public health emergencies. This initiative proved particularly valuable, especially during the early phases of the pandemic, when there was limited information for countries to draw on as they formulated their own policy response to the pandemic. Our perspectives paper highlights some key challenges within health systems that the HSRM was able to identify during the pandemic and considers policy options countries put in place in response. Our research contributes to literature on emergency responses and recovery, health systems performance assessment, particularly health system resilience, and showcases the Observatory experience on how to design such a data collection tool, as well as how to leverage its findings to support cross-country learning.

What can we learn from the effects of the COVID-19 pandemic on hospital care for children in Germany?

The COVID-19 pandemic created substantial disruptions in the delivery of health services around the world. Reductions in hospital admissions have been reported for several conditions in the adult population; less evidence currently exists for children. To what extent such changes reflect a risk for patients due to unmet care needs, or a “correction” of previous overprovision of care has not been thoroughly examined yet. Based on complete national hospital discharge data, we compare the top 30 diagnoses for which children were hospitalised in 2019, 2020 and 2021 in Germany. We also analyse the development of monthly admissions between January 2019 and December 2021 for three tracers of variable urgency and severity. Total admissions were approximately 20% lower in 2020 and 2021 compared to 2019. The composition of the most frequent diagnoses did not change dramatically across years, although changes in rank were observed. The number of admissions for acute lymphoblastic leukaemia (tracer 1) showed a slight increasing trend and a periodicity prima vista unrelated to pandemic factors. Appendicitis admissions (tracer 2) decreased by about 9% in 2020 and a further 8% in 2021, while tonsillectomies/adenoidectomies (tracer 3) decreased by more than 40% in 2020 and a further 30% in 2021; for these tracers, monthly changes are in line with pandemic waves. Observed variations in child hospitalisations reflect the effects of pandemic mitigation measures and/or changes in demand. In Germany, inpatient care for critical conditions appears to have been largely upheld, potentially at the expense of elective treatments. Complementary data on ambulatory care and health outcomes would enable a better understanding of change in healthcare patterns and effects on children's health.

Health services during Covid-19: What do we know of the degree of service disruption and size of the backlogs?

Since the onset of the COVID-19 pandemic, there have been concerns that shifting health system capacities towards acute COVID-19 cases can affect the provision of non-COVID-19 essential health services, causing severe disruptions and lack of care. Examples of this have been seen during other epidemic outbreaks, such as the 2014-2016 Ebola outbreak in West Africa. To capture the degree of service disruption across the European and Central Asian region, we analysed data from the World Health Organization's Pulse Survey on the Continuity of Essential Health Services, conducted in three rounds in 2020 and 2021. The key findings include:

– Health service provision has been heavily disrupted in virtually all countries. 91% of countries reported service disruptions in late 2021, indicating that health services continue to be disrupted at large scale.

– Service discontinuation has been substantial across all levels of care and in most service areas, often resulting in delays and cancellations of elective and emergency procedures, routine visits, prescription renewals, and referrals to specialty care. This has led to growing backlogs and record waiting times for services.

– Countries have been affected to varying degrees and report different levels of service disruption, size of the backlog, recovery of services aiming for pre-pandemic levels, and interventions to manage waiting lists.

The findings indicate that even as health systems are better learning to care for acute COVID-19 patients, the pandemic's impact on essential health services is massive and likely to affect the care for people's health and well-being post the acute phase of the public health emergency. Measuring the size of backlogs and implementing innovative care solutions are urgent and paramount.

The Acceptability of Task-Shifting from Doctors to Allied Health Professionals

BACKGROUND

The shifting of medical tasks (MT) to Qualified Medical Practice Assistants (MPA) is an option that can be pursued to ensure adequate health care in Germany despite the increasing scarcity of physicians. The goal of this study was to determine the acceptability of medical task-shifting to MPA among the general population.

METHODS

In a nationwide, representative telephone survey, 6105 persons aged 18 or older were asked whether they would be willing to receive care from a specially trained MPA at a physician's office. Their responses were tested for correlations with sociodemographic characteristics by means of bivariate (chi-squared test, Mann-Whitney U test) and multivariable statistics (logistic regression).

RESULTS

Of the respondents, 67.2% expressed willingness to accept the shifting of MT to an MPA for the treatment of a minor illness, and 51.8% for a chronic illness. Rejection of task-shifting was associated with old age, residence in western Germany, and citizenship of a country other than Germany. For example, non-Germans rejected task-shifting more commonly than Germans, for both minor illnesses (odds ratio [OR] 2.96; 95% confidence interval [2.28; 3.85]) and chronic illnesses (OR 1.61; [1.24; 2.10]).

CONCLUSION

Further studies are needed to investigate the motives for rejection of medical task-shifting to MPA in order to assess the likelihood of successful nationwide introduction of a uniform delegation model.

How can we monitor the impact of national health information systems? Results from a scoping review

Background

National health information (HI) systems provide data on population health, the determinants of health and health system performance within countries. The evaluation of these systems has traditionally focused on statistical practices and procedures, and not on data use or reuse for policy and practice. This limits the capacity to assess the impact of HI systems on healthcare provision, management and policy-making. On the other hand, the field of Knowledge Translation (KT) has developed frameworks to guide evidence into practice.

Methods

A scoping review of the KT literature to identify the essential mechanisms and determinants of KT that could help monitor the impact of HI systems.

Results

We examined 79 publications and we identified over 100 different KT frameworks but none of these were focused on HI systems per se. There were specific recommendations on disseminating evidence to stakeholders at the institutional and organizational level, and on sustaining the use of evidence in practice and the broader community setting.

Conclusions

We developed a new model, the HI-Impact framework, in which four domains are essential for mapping the impact of national HI systems: (i) HI Evidence Quality, (ii) HI System Responsiveness, (iii) Stakeholder Engagement and (iv) Knowledge Integration. A comprehensive impact assessment of HI systems requires addressing the use of HI in public health decision-making, health service delivery and in other sectors which might have not been considered previously. Monitoring Stakeholder Engagement and Knowledge Integration certifies that the use of HI in all policies is an explicit point of assessment.

Delegation of medical services to specially trained medical practice assistants

Background

Germany is one of the countries most affected by demographic change. Meaning the shift towards the population being older is growing. At the same time, the number of doctors is declining. In order to ensure adequate care in Germany, the delegation of medical services to specially trained medical practice assistants (MPAs) is currently discussed. The aim of this study was to assess the attitudes of the German population towards medical delegation.

Methods

The analysis was based on a population survey of 6.105 German-speaking residents aged 18 years and over. Associations between respondents’ attitudes towards the delegation and social determinants (age, gender, education, employment status, region, self-rated health) were assessed using standardised questionnaires. Bi- and multivariate (logistic regression) analyses were performed.

Results

In case of a chronic disease half of the German-speaking population (51. 8%) would accept getting treated by a MPA. More older participants (65 years and above) than younger participants (18 to 34 years old) (OR: 1,64; KI [1,24-2,18]), more lower than higher educated participants (OR: 1,20; KI [1,04-1,39]) and more non-German than German participants (OR: 1,61; KI [1,24-2,10]) are significantly more likely to not accept medical delegation in case of a chronic disease. Discussion: In the debate on delegation models the present results should be taken into account in order to be able to address relevant target-groups. Further qualitative studies that investigate the reasons for the critical view on delegation are recommended.

Key messages

Approximately 50% of the German-speaking study population would accept treatment by a MPA for chronic disease. Especially older study participants, lower educated people and non-German participants would not accept medical delegation in case of a chronic disease.

The Health-Information Impact Index: a tool to monitor the uptake of evidence in policy and practice

Background

The optimal use of data and evidence from national health information systems is paramount in public health. However, current tools to evaluate health information systems focus on data quality and availability rather than measuring how data are used by key stakeholders. This limits capacity to monitor the impact of evidence on health care management and health policy making.

Methods

Based on an extensive literature review we developed a new model, the Health Information (HI)-Impact framework, to monitor the impact of health information in health policy and practice. We further conducted a web-based Delphi survey between February and April 2019 among European public health professionals working in health policy, health care, research, and health monitoring to develop the HI-Impact Index.

Results

In the HI-Impact framework, four domains are essential for mapping public health data availability, dissemination, and use: (1) Health Information and Evidence Quality, (2) Health Information System Responsiveness, (3) Stakeholder Engagement, and (4) Knowledge Integration. This last domain has a broader reach on the determinants of health and reflects the use of evidence by community partners and across sectors. In the DELPHI survey, 127 experts from 38 European countries selected 30 criteria to integrate in the HI-Impact Index. This tool could be used by European public health agencies to monitor the impact of their information products, and inform national strategies for evidence-based public health.

Conclusions

It is crucial for routine health information systems to create a culture of accountability in the use of evidence. Data on the determinants and consequences of ill-health as well as stakeholder engagement in leveraging evidence for intervention are explicit points to consider for a full quality assessment of national health information systems, and a sustainable impact on health outcomes.

Patients' understanding of health information in Germany

Background: Patient-physician communication and textual health information are central to health care. Yet, how well patients understand their physicians and written materials is under-studied. Objectives: Focusing on outpatient health care in Germany, the aim of this research was to assess patients' levels of understanding oral and written health information and to identify associations with socioeconomic variables. Methods: This analysis drew on a 2017 health survey (n=6,105 adults 18 years of age and above). Measures for the quality of patient-physician communication were derived from the Ask Me 3 program questions for consultations with general practitioners (GPs) and specialists (SPs), and for textual health information via a question on the comprehensibility of written materials. Correlations with socioeconomic variables were explored using bivariate and multivariable logistic regression analyses. Results: Over 90% of all respondents reported that they had understood the GP's and SP's explanations. A lack of understanding was most notably correlated with patients' self-reported very poor health (odds ratio [OR]: 5.19; 95% confidence interval [CI]: 2.23-12.10), current health problem (OR: 6.54, CI: 1.70-25.12) and older age (65 years and above, OR: 2.97, CI: 1.10-8.00). Fewer patients reported that they understood written materials well (86.7% for last visit at GP, 89.7% for last visit at SP). Difficulties in understanding written materials were strongly correlated with basic education (OR: 4.20, CI: 2.76-6.39) and older age (65 years and above, OR: 2.66, CI: 1.43-4.96). Conclusions: In order to increase patients' understanding of health information and reduce inequalities among patient subgroups, meeting the communication needs of patients of older age, low educational status and with poor health is essential.

Patients' perceptions of health system responsiveness in ambulatory care in Germany

OBJECTIVE

To identify overall levels of health system responsiveness and the associations with social determinants for ambulatory health care in Germany from a user perspective.

METHODS

This analysis drew on a 2016 health survey sample of 6113 adults in Germany. Responsiveness was measured for general practitioners (GPs) and specialists (SPs) along the domains trust, dignity, confidentiality, autonomy and communication. Bivariate and multivariate logistic regression techniques were applied.

RESULTS

Over 90% of all patients assessed their last GP and SP visit as good regarding trust, dignity, autonomy and communication, but only half for confidentiality in the doctor office (GP visits: 50.3%; SP visits: 52.4%). For GP visits, patients' young age of 18-34 years showed most associations with poor assessment of the domains, for SP visits a current health problem as the reason for the last consultation.

CONCLUSION

While overall responsiveness levels for ambulatory care are high, ratings of confidentiality are distressing. Particularly patients' young age and bad health are associated with a poor assessment of responsiveness.

PRACTICE IMPLICATIONS

Measures to improve doctor office infrastructure and to enhance responsiveness towards patients under the age of 35 years and those with health problems are vital to increase responsiveness.