Health system efficiency in Germany: results of a pilot study to assess health system performance

Background

Improved efficiency is one overall goal in WHO’s Health Systems Framework. Efficiency is an important dimension of health system performance assessment (HSPA). HSPA is used as a tool to monitor and evaluate the performance of health systems and to support evidence-based policymaking. In the pilot study for a first German HSPA, efficiency was assessed as one dimension.

Methods

Indicators were selected based on a systematic search of established instruments in national and international HSPA initiatives. Criteria for the inclusion of indicators were data availability and international comparability. Where possible, indicators were evaluated in terms of their development over time (2000-2020), in comparison to eight European countries (e.g., Austria, Denmark, France), and regarding equity aspects (e.g., age, gender, region).

Results

Eight indicators to assess the efficiency of the German health system were identified and analysed accordingly. They cover the pharmaceutical sector, outpatient and inpatient care, and system-wide efficiency. Trend analyses were possible for all indicators, and most were also suitable for international comparisons. Overall, results of the chosen indicators indicate a moderate health system efficiency. The volume of generics as share of all pharmaceuticals, e.g., was 83% in Germany in 2019 (country average: 54%) and has been steadily increasing since 2000. In contrast, expenses for pharmaceuticals overall rose from 1.4% of GDP in 2004 to 1.7% in 2019, whereas it declined from 1.3% to 1.1% on average in the other countries.

Conclusions

Within this first pilot study, a systematic and comparative German HSPA measuring the efficiency of the German health system using eight predefined indicators was proven to be feasible. The results give insights into efficiency measurements across different sectors, e.g., pharmaceuticals, identify developments of efficiency over time, and can support evidence-based policymaking.

Key messages

• In the pilot study for a first German HSPA, efficiency was evaluated using eight indicators covering pharmaceuticals, outpatient and inpatient care, and system-wide efficiency.

• Based on the available data, which allowed trend analyses for all indicators and comparisons to eight European countries for most indicators, Germany’s health system efficiency can still be improved.

Piloting a Health System Performance Assessment for Germany - insights from trend and equity analyses

Background

Health System Performance Assessment (HSPA) is a tool for the evaluation of the performance and efficiency of a health system and can be used for evidence-based policymaking. For the first time, a country specific HSPA for the German health system is piloted with a focus on trend and equity analyses.

Methods

Based on the conceptual framework developed in a feasibility study, the pilot study in Germany has being conducted between 2020 and 2023. The framework includes 90 internationally compatible indicators, each of which can be assigned to one of nine dimensions (e.g., access, quality, population health, responsiveness, efficiency). The aim of this pilot study is to conduct trend analyses over the period 2000-2020 and equity analyses (e.g., age, gender, region, education). Data from 56 different national and international secondary data sources (e.g., epidemiologic registry data, claims data, and survey data) were collected, analyzed, and compiled in a report.

Results

In total, 84 of the 90 indicators could be analyzed with data for Germany. The indicators (e.g., access to acute care, 30-day mortality, amenable mortality rate) are prepared as a trend analysis for Germany for up to 20 years and with regard to various equity aspects. Most indicators can be presented in international comparison with eight selected European countries (e.g., Denmark, France). Furthermore, recommendations were derived to improve the availability and/or quality of data.

Conclusions

The first German HSPA pilot study provides valuable insights into the performance of the health system. The results based on the analysis of the 90 indicators are an important basis for identifying inequities and needs for improvement. In the future, the lessons learned from the pilot study can be helpful for a permanent implementation of a German HSPA. However, the fragmented data structure in Germany will be a future challenge.

Key messages

• The first country specific health system performance assessment for the German health system was conducted as a pilot study.

• Trends over time, inequities, and needs for improvement can be derived from the analysis of 90 indicators.

Quality of health care in Germany: results of a pilot study to assess health system performance

Background

Health System Performance Assessment (HSPA) is used as a tool to monitor and evaluate the performance of health systems and to inform evidence-based policymaking. For the first time, a systematic HSPA was piloted for Germany. The conceptual framework includes different dimensions, e.g., access, population health, efficiency, and quality of care. In the following, Germany’s performance is analysed in terms of quality of care.

Methods

Indicators to assess the dimension of quality of care were selected based on a systematic search of established instruments in national and international HSPA initiatives. Other criteria for the inclusion of indicators were data availability and international comparability. The indicators were evaluated in terms of their time trend (2000-2020) and in international comparison (e.g., Austria, Denmark, France).

Results

Overall, 17 indicators were selected to assess quality of care, of which two could not be analysed due to missing data. Indicators include, e.g., emergency readmissions after hospital stays, patient-reported medical errors, coercive measures in psychiatric wards, and in-hospital mortality. Trend analyses were possible for 14 indicators and most of them showed positive developments. In country comparisons, which were feasible for seven indicators, Germany mostly ranked below average. In-hospital mortality for acute myocardial infarction, e.g., was 8% in 2019 in Germany (other countries: 4%-7%) and has been stable since 2014. For stroke, Germany performs better and ranks three of five (6%; range: 5%-9%) in 2019.

Conclusions

Measuring quality of care for a systematic and comparative German HSPA was proven to be feasible. However, some indicators could not be mapped so far due to lack of data. The results give insights into quality measurements across different sectors and can support evidence-based policymaking.

Key messages

• In the first health system performance assessment (HSPA) for Germany, quality of care was evaluated over time (2000-2020) and compared to eight European countries using 17 indicators.

• Measurement of quality was feasible, but data availability should be strengthened in the future as country comparisons were possible for only half the indicators and two could not be analysed at all.

Improving population health in Germany – lessons of a pilot study to assess health system performance

Background

Improving the population health, both its level and equity, is a major goal of health systems. Health System Performance Assessment (HSPA) is a tool to evaluate the performance of different health system dimensions, e.g., population health, access, efficiency. For the first time, a systematic HSPA was piloted for Germany including the dimension population health.

Methods

The conceptual framework for the German HSPA pilot has been developed in a previous feasibility study. The selection of indicators was based on established indicators used in other HSPA initiatives. Another inclusion criterium was data availability. The ten indicators to measure population health cover e.g., maternal and neonatal health, amenable mortality, infectious diseases, and cancer screening. The indicators are evaluated in terms of their trend over time (2000-2020), in international comparison (e.g., Austria, Denmark, France), and by various equity criteria (e.g., age, gender, region).

Results

Overall, Germany's health system performs moderately regarding population health, especially when compared to selected European countries. While Germany performs very well in terms of incidence rates of infectious diseases, amenable mortality is an area with need for improvements. However, trends over time show improvements of the population health in Germany.

Conclusions

Measuring population health in Germany using ten predefined indicators reveals areas for improvement. Furthermore, subgroup analyses indicate inequities. These results should be considered in further efforts aiming at the improvement of population health in Germany.

Key messages

Angiography-based quantitative coronary contrast-flow ratio measurements correlate with myocardial ischemia assessed by stress MRI

Contrast-flow quantitative flow ratio (cQFR) is a new technology for quantitative evaluation of coronary stenosis using computational fluid dynamics based on angiograms. The aim of this study was to assess the sensitivity and specificity of cQFR to detect myocardial ischemia using stress magnetic resonance imaging (MRI) as a reference standard. Patients who received stress MRI and coronary angiography were selected from the hospital database. Relevant ischemia on stress MRI was defined as a perfusion deficit in ≥ 2 of 16 segments. cQFR was quantitated based on 3-dimensional quantitative coronary angiography using QAngio XA3D1.1 software by two blinded and independent investigators. A cQFR of ≤ 0.80 was considered abnormal. Among 87 patients 230 vessels met the criteria for full analysis by cQFR (88%). In vascular territories with a significant perfusion deficit, cQFR was significantly lower compared to areas with normal perfusion (0.72 (0.62–0.78) vs. 0.96 (0.89–0.99); p < 0.001). The sensitivity of cQFR in detecting significant epicardial stenoses of coronary vessels with documented ischemia in stress MRI was 81% (68–90%), the specificity was 88% (82–92%). Diameter stenoses (DS) and area stenoses (AS) in vessels with positive stress MRI were significantly higher than in vessels without ischemia (DS 59.1% (49.4–68.4%) vs. 34.8% (27.1–46.1%) p < 0.001; AS 75.6% (63.0–85.2%) vs. 45.0% (30.8–63.6%), p < 0.001). The analysis reveals a high correlation between coronary stenosis measured by cQFR and ischemic areas detected by stress MRI. The data set the stage to plan randomized studies assessing cQFR measurements with regard to clinical outcomes.

Methamphetamine-related cardiovascular diseases

Aims

Abuse of crystal methamphetamine (MA) poses a growing problem for health services worldwide. This review summarizes the current literature on the effects of MA on the cardiovascular system.

Methods and results

This article is a presentation of a case report and review of the current literature. In Europe, especially the eastern countries and the eastern states of Germany are affected. MA increases the concentration of catecholamines in the synaptic gap leading to euphoria, alertness, and hunger suppression as well as psychiatric and gastrointestinal complications. MA consumption is associated with hypertension, acute and chronic myocardial toxicity, stroke, coronary artery disease, and sudden cardiac death. Although many aspects of the underlying pathophysiology remain unknown, catecholamine‐mediated pathologies appear to play an important role. The duration of MA consumption is the most important determinant for the prognosis.

Conclusions

Awareness is needed as cardiac complications are important causes of morbidity and mortality in patients with MA consumption. Drug abstinence is the mainstay of therapy, cardiac and other complications should be treated according to the respective guidelines. Incompliance to therapy and frequent relapses are the main challenges for successful treatment. Further research is required to improve the understanding of this rapidly increasing cardiomyopathy.

P2701Comparison of myocardial ischemia assessed by contrast-flow quantitative flow ratio (cQFR) and by stress MRI in patients with stable coronary artery disease

Background

Contrast-flow quantitative flow ratio (cQFR) is a new technology for evaluation of coronary stenosis. cQFR allows to derive the fractional flow reserve (FFR) from coronary angiograms. Based on a three dimensional coronary model, FFR is calculated from computational fluid dynamics. Head to head comparisons with FFR showed an overall diagnostic accuracy of 85%. cQFR does not require coronary wires or hyperemia. However, the ability of cQFR to detect myocardial ischemia is unknown. Therefore, the aim of this study was to evaluate the relationship between cQFR and myocardial ischemia assessed by stress magnetic resonance imaging (stress MRI).

Methods

cQFR analysis was performed in patients selected from the hospital database who received stress MRI and coronary angiography. A relevant ischemia on stressMRI was defined as a perfusion deficit in ≥2 of 16 segments. The cQFR was based on 3-dimensional quantitative coronary angiography (3D-QCA) using the QAngio XA 3D 1.1, Medis Medical Imaging System, Leiden, The Netherlands. Two blinded investigators analysed all 3 main coronary vessels of each patient measuring diameter stenosis (DS), area stenosis (AS) and cQFR. A cQFR of ≤0.8 was considered abnormal. The primary endpoint was sensitivity and specificity of cQFR using stress MRI as a reference standard.

Results

125 vessels of 53 patients could be fully analysed by cQFR (78.6%). The sensitivity of cQFR in detecting significant epicardial stenoses of coronary vessels with documented ischemia in stress MRI was 75%, the specificity was 87%. The 3D-QCA-derived diameter stenoses and area stenoses in vessels with positive stress MRI were significantly higher than in vessels without ischemia (see Table 1).

Table 1. Means of diameter stenosis (DS) und area stenosis (AS) with interquartile range (IQR) Total (n=125) Ischemia (n=32) No Ischemia (n=93) p-value DS [%] 42.3 (28.3–53.1) 57.1 (47–68.5) 37.7 (27.6–45.1) <0.0001 AS [%] 51.8 (32.4–69.7) 68.9 (56.8–85.9) 46.5 (29.7–62.7) <0.0001

Conclusion

The analysis reveals a high correlation between relevant coronary stenosis measured by cQFR and ischemic areas detected by stress MRI. Differences between the two methods are plausible because stress MRI detects ischemia due to other reasons than epicardial stenosis. Further randomized studies are mandatory to verify the prognostic significance of the cQFR measurements.