[How do internal medicine patients choose their hospital? A cross-sectional study]

Einleitung  Die freie Krankenhauswahl durch Patienten wird gesundheitspolitisch gefördert und soll durch die Qualitätsberichte der Krankenhäuser unterstützt werden. Doch wie entscheiden sich Patienten für ein Krankenhaus? Wie viele können selber entscheiden, wo informieren sie sich und was sind in der konkreten Situation ihre Entscheidungskriterien? Dies soll für stationäre Patienten der Inneren Medizin im Vergleich zu denen anderer Fachgebiete beantwortet werden.

Methoden  Die Daten entstammen einer Beobachtungsstudie. Die nach Fachgebieten und Krankenhausversorgungsstufen geschichtete Zufallsstichprobe wurde in 46 Fachabteilungen von 17 Krankenhäusern aus 15 Städten und Gemeinden Nordrhein-Westfalens erhoben. Die gewichtete Stichprobe wertet 758 Patienten der Inneren Medizin und 1168 Patienten anderer Fachgebiete deskriptiv und inferenzstatistisch aus.

Ergebnisse  Internistische Patienten sind älter, häufiger Männer, ohne Migrationshintergrund und chronisch krank, zudem öfter stationär vorbehandelt. Etwa die Hälfte entscheidet selbst über das Krankenhaus, wobei die eigene Kenntnis des Krankenhauses durch einen Voraufenthalt die wichtigste Informationsquelle darstellt und wichtige Entscheidungskriterien die eigene Vorerfahrung, der Ruf des Krankenhauses und die Empfehlung der ambulanten Behandler sind. Der kleine Anteil Patienten mit mehr Zeit vor der Aufnahme wählt das Krankenhaus aktiver.

Diskussion  In der Inneren Medizin können weniger Patienten selbst über das Krankenhaus bestimmen. Diese entscheiden dann überwiegend aufgrund ihrer Vorerfahrung mit dem Krankenhaus und setzen die erneute Behandlung im ihnen bekannten Krankenhaus, in dem auch sie bekannt sind, fort. Ein kleiner Anteil jüngerer, gebildeterer und weniger krankenhauserfahrener Patienten informiert sich aktiver vor elektiven Eingriffen. Die Behandlungserfahrungen der Patienten sind zentral bei der eigenen Krankenhauswahl und über den sozialen Austausch auch bei der ihrer Angehörigen.

Patient safety incidents in ambulatory care in Germany

Background

In contrast to the inpatient sector, reliable data on the epidemiology and public health impact of patient safety incidents (PSI) are hardly found in the outpatient sector. Thus, this study focusses on the incidence of PSI; the distribution among the various specialist groups; the harmful consequences; the causes and how affected patients deal with PSI in Germany.

Methods

We conducted a cross-sectional study using a newly developed computer-assisted-telephone-interview survey tool. Based on random telephone numbers, citizens >39 years were asked to report whether they had experienced a PSI in the last year or since their 40th birthday; whereby the PSI happened, what consequences the PSI had for them and if they reported the PSI back to their physician. We performed descriptive and multivariate analyses and extrapolated the results to the total population >39 years in Germany.

Results

10037 citizens were surveyed (response rate 13%): 8841 had an outpatient visit last year, of whom 1570 (18%) had experienced at least one PSI. In total, 2832 PSI were reported. General practitioners caused 43% of PSI. Among specialists (54%), most PSI were found among orthopedists (15%) and internists (9%) and arose in connection with anamnesis and clinical examination (61%) as well as drug prescriptions (15%). 72% of the PSI caused health related harm. The most frequent harm was a deterioration in health (23%) and persistent pain (22%). 54% of those affected described the harm as severe or very severe. 27% considered doctors’ stress and lack of time or poor communication (18%) as causes for PSI. 32% of PSI were reported back to the treating physician.

Discussion

Extrapolated to the total population >39 years in Germany (47.2 million), an incidence of 12 million PSI per year must be expected with around 6.6 million affected outpatients. Thus, PSI in the outpatient sector are of immense public health importance in Germany.

Key messages

Patient safety incidents (PSI) often happen in the German outpatient sector. Outpatient PSI can also be accompanied by severe harm for patients.

[How Steady are Hospitals in Complying with Minimum Volume Standards? A Retrospective Longitudinal Data Analysis of the Years 2006, 2008, and 2010]

BACKGROUND

The outcome volume relationship has been analysed for more than 30 years and debated ever since. For German hospitals minimum volume standards (MVS) have been introduced for some procedures in 2004. Hospitals have to report procedure volumes in their quality reports. This study analyses for the first time how constant hospitals comply with minimum volume standards over time.

MATERIALS AND METHODS

Data used are the reported volumes, which hospitals published in their quality reports in 2006, 2008, and 2010. The case volumes of complex oesophageal and pancreatic interventions, total knee replacements, and liver, kidney and stem cell transplantations (KTX, LTX, STX) are analysed in a retrospective, longitudinal study design.

RESULTS

More than 80 % of hospitals conducting LTX, KTX, and total knee replacements are complying with MVS constantly, in STX 57 % of hospitals comply, and with complex pancreatic and oesophageal interventions compliance is 44 and 28 %, respectively. Twenty-seven to 36 % of hospitals conducting the three last mentioned procedures vary in complying with the MVS over time. 3.5 % (total knee replacements) up to 26 % (pancreatic interventions) and 37 % (oesophageal interventions) of all hospitals constantly fail to comply with MVS. Hospitals constantly over the MVS treat more than 80 % of all patients, except in complex oesophageal interventions. Hospitals with varying compliance in oesophageal and pancreatic interventions are mainly hospitals with 100 to 599 beds. Only very few hospitals of these two procedure types stop conducting the interventions after failing to comply with MVS earlier, the other some 120 hospitals for each intervention type treat 2 cases on average per year.

CONCLUSION

The MVS on KTX, LTX, STX, and total knee replacement are almost constantly complied with. A considerable number of hospitals conducting oesophageal and pancreatic interventions never or rarely meet the MVS without discontinuing this type of intervention. At least for hospitals that never comply with MVS on oesophageal and pancreatic interventions, requirements and possibilities for a regional patient transfer should be studied in depth.

[The information needs of non-hospital based physicians regarding admissions and transfers]

BACKGROUND

This study examines the quality criteria which, from the perspective of non-hospital based physicians, are relevant in order to give patients quality-oriented recommendations in the selection of a suitable hospital or specialist.

METHODS

A primary telephone survey of 300 physicians from 5 specialist groups collected relevance assessments of 59 quality criteria for hospitals, GPs and specialist practices. A descriptive bi- and multivariate analysis was performed using McNemar tests, correlation and regression analysis.

RESULTS

Next to the personal experiences which the physician and his patients made with the hospital or non-hospital based colleague in the past, there is a general interest in vital structural and outcome parameters of hospitals and medical practices. Physicians deem the nature and scope of services offered by the hospitals and medical practices as less relevant. In 12 of the 59 examined quality criteria, the relevance assessments differ depending on whether the physician is dealing with an elective admission to hospital or a referral to a GP or specialist. In the analysis of possible correlations between preferences and factors which might be influencing the physician, gender, age and specialisation were found to have an effect.

[Breast cancer centres in North Rhine-Westphalia - case volume trends 2004-2010]

BACKGROUND

To improve quality of breast cancer care, in 2004 the state of North Rhine-Westphalia (NRW), Germany, began to appoint 51 breast cancer centres. These centres comprise 91 hospitals performing breast cancer surgery which have - amongst other things - to fulfill minimum volume standards. The aim of our study was to analyse if the intended regionalisation of care from 252 hospitals performing breast cancer surgery formerly to the appointed hospitals had taken place by the year 2010.

METHODS

We used data for the years 2004-2010 from the agency for quality assurance in North Rhine-Westphalia concerning breast cancer care and analysed trends concerning the number of hospitals performing breast cancer surgery, case volumes, and achievement of minimum volume standards by performing descriptive and inferential statistics.

RESULTS

Between 2004 and 2010 the number of breast cancer cases increased by 36.6% from 12 975 to 17 724 cases (p<0.001, Wilcoxon test). Simultaneously, the number of hospitals performing breast cancer surgery decreased from 252 to 208 whereby more than double the number of planned hospitals still performed breast cancer surgery. The case volumes of the 71 appointed hospitals for which we had individual data over the entire period of time increased by 49.4% from 8 103 cases in year 2004 to 12 105 cases in 2010. Assuming that case volume trends of those 20 appointed hospitals of which we did not have individual data developed uniformly to all other appointed hospitals, the proportion of cases that were operated in not appointed hospitals decreased from 20% in year 2004 to 12.5% in 2010 (p<0.001, χ2 test). Simultaneously, the proportion of cases that were operated in hospitals not achieving minimum volume standards decreased from 42.7% in year 2004 to 12.1% in 2010 (p<0.001, χ2 test).

CONCLUSION

The establishment of breast cancer centres in NRW regionalised breast cancer surgery. In fact, in 2010 breast cancer surgery still took place in more than 100 not appointed hospitals. However, these hospitals were responsible for only a small proportion of breast cancer surgery.

[Medical decision making in symptoms of type 2 diabetes mellitus in general practice]

BACKGROUND

Patient and physician attributes influence medical decisions as non-medical factors. The current study examines the influence of patient age and gender and physicians' gender and years of clinical experience on medical decision making in patients with undiagnosed diabetes type 2.

METHOD

A factorial experiment was conducted to estimate the influence of patient and physician attributes. An identical physician patient encounter with a patient presenting with diabetes symptoms was videotaped with varying patient attributes. Professional actors played the "patients". A sample of 64 randomly chosen and stratified (gender and years of experience) primary care physicians was interviewed about the presented videos.

RESULTS

Results show few significant differences in diagnostic decisions: Younger patients were asked more frequently about psychosocial problems while with older patients a cancer diagnosis was more often taken into consideration. Female physicians made an earlier second appointment date compared to male physicians. Physicians with more years of professional experience considered more often diabetes as the diagnosis than physicians with less experience.

CONCLUSION

Medical decision making in patients with diabetes type 2 is only marginally influenced by patients' and physicians' characteristics under study.

[Public reporting--forms and effects]

Since 2004 hospitals in Germany publish structured report cards bi-yearly. Content and scope of these mandatory public reports are still under discussion. Therefore we provide an up to date overview on forms and effects of public reports. By enabling transparency, comparative reports on the quality of health care aim at supporting patients to choose better performing health care providers and motivating health care providers to enhance quality improvement activities. Internationally existing public reports range from reports on national health systems on the whole to reports on the quality of particular procedures of individual health care providers. Contrary to the multitude of public reports, the evidence on the effects of public reporting remains scant. The few existing studies show that hospitals react on the public reports by some quality improvements. However, regarding the selection of providers and the quality of care they only show inconsistent effects of public reporting. Moreover, unsolved methodical problems of pubic reporting and potentially unintended consequences have to be considered. Therefore the question remains whether the expected effects in terms of quality improvements outbalance the unintended consequences in the long run and if the investments in public reporting will be paid off.

[Minimum hospital volumes for total knee replacement]

BACKGROUND

As requested by the Federal Joint Committee, the German Hospital Institute and the Heinrich-Heine University of Düsseldorf carried out an investigation of the minimum volume regulation for hospitals based on the Social Legislation Code. Total knee replacement forms one minimum volume field. Since 2006 hospitals with a performance rate of less than the minimum volume of 50 patients a year with knee replacement are no longer permitted to conduct this procedure. The object of the present analysis is to investigate the impact of the minimum volume regulation for total knee replacement.

METHODS

The results are based on two hospital surveys on the application of the minimum volume regulation for total knee replacement. 279 hospitals (response rate: 41,8%) participated in 2006 and 297 hospitals in 2007 (response rate: 47,5%). The results are representative of General hospitals with total knee replacements.

RESULTS

As expected, hospitals above and below the minimum volume cut-off differ in size. To date the minimum volume regulation has led to a rather selective exclusion of hospitals from care. In the case of total knee replacement 13,7% of the hospitals have been excluded. Most hospitals that do not reach the minimum volume are still participating in care. A decisive reason for this is the existence of exception rules. In hospitals exceeding the minimum volume, certain quality management tools for knee replacement are more widely spread than in hospitals that do not reach the minimum volume. As a consequence of the minimum volume regulation, the participating hospitals improved their position in the market. Vice versa, the excluded hospitals are more concerned about the damage to their image that may result from being excluded from care. With respect to the further development of the minimum volume regulation, the hospitals do not share the same point of view.

DISCUSSION

Because, as yet, only few hospitals with low case numbers have been excluded from care, the immediate effects of the minimum volume regulation on the affected hospitals and hospital care in general are limited. The surveys showed a considerable uncertainty among all participants about the application and effects of the minimum volume regulation in hospitals.

[Hospitals failing minimum volumes in 2004: reasons and consequences]

BACKGROUND

In 2004 Germany introduced annual minimum volumes nationwide on five surgical procedures: kidney, liver, stem cell transplantation, complex oesophageal, and pancreatic interventions. Hospitals that fail to reach the minimum volumes are no longer allowed to perform the respective procedures unless they raise one of eight legally accepted exceptions. The goal of our study was to investigate how many hospitals fell short of the minimum volumes in 2004, whether and how this was justified, and whether hospitals that failed the requirements experienced any consequences.

METHOD

We analysed data on meeting the minimum volume requirements in 2004 that all German hospitals were obliged to publish as part of their biannual structured quality reports. We performed telephone interviews: a) with all hospitals not achieving the minimum volumes for complex oesophageal, and pancreatic interventions, and b) with the national umbrella organisations of all German sickness funds.

RESULTS

In 2004, one quarter of all German acute care hospitals (N=485) performed 23,128 procedures where minimum volumes applied. 197 hospitals (41%) did not meet at least one of the minimum volumes. These hospitals performed N=715 procedures (3.1%) where the minimum volumes were not met. In 43% of these cases the hospitals raised legally accepted exceptions. In 33% of the cases the hospitals argued using reasons that were not legally acknowledged. 69% of those hospitals that failed to achieve the minimum volumes for complex oesophageal and pancreatic interventions did not experience any consequences from the sickness funds. However, one third of those hospitals reported that the sickness funds addressed the issue and partially announced consequences for the future. The sickness funds' umbrella organisations stated that there were only sparse activities related to the minimum volumes and that neither uniform registrations nor uniform proceedings in case of infringements of the standards had been agreed upon.

DISCUSSION

In spite of the high number of hospitals that failed to achieve the minimum volumes in 2004, only few hospitals experienced consequences from the sickness funds. The reluctance of the payers may be explained, amongst others, by the small number of patients affected and the percentage of cases where legally accepted exceptions applied. In view of the partly unclear definitions of the exceptions and difficulties in the interpretation and execution of the minimum volumes in the hospitals and at the sickness fund level, it may be helpful to formulate more concrete instructions for the implementation of the standards.

[Influence of minimum volumes on the structure of inpatient care]

OBJECTIVE

In 2004 five minimum volumes were introduced for the first time into German hospitals. The structural effects of these minimum volumes are presented as the first part of a health service research to evaluate the minimum volume regulation. DESIGN/METHODOLOGY/METHODS: The investigation is based on the mandatory hospital quality reports for 2004. Data were extracted from 1710 quality reports, descriptively analysed and applied to the modified minimum volumes for 2006.

RESULTS

In 2004, 485 out of 1710 German hospitals providing acute care and approximately 23,128 cases, i.e., 0.14% of all hospital cases, were affected by at least one minimum volume regulation. The number of affected hospitals varies considerably between the German Federal Sates with 16% in Bavaria and 75% in Bremen. In 2004 (and presumably 2006) the following hospital numbers will comply with the minimum volume regulation: liver transplantation 100% (63%), kidney transplantation 91% (84%), stem cell transplantation 84% (65%), complex oesophageal interventions 71% (40%), complex pancreatic interventions 82% (51%). On a case level, 4% of kidney transplantation cases and up to 22% of complex oesophageal interventions were to be redistributed. Viewing the hospital size by number of beds, smaller (100-300 beds) and medium size hospitals (300-600 beds) are affected in complex oesophageal and pancreatic interventions, whereas in transplantations medium and large hospitals (>600 beds) are affected. Considering the regional distribution on a district level, the number of districts with at least one hospital providing the respective service will decrease from 2004 to 2006, with the strongest reduction in complex oesophageal interventions from 172 to 82 districts (-53%).

CONCLUSION

In 2004 the minimum volume regulation has moderate structural effects on the care setting. In 2006 these effects will be stronger due to the doubled number of interventions required for most of the minimum volumes. The effects on transplantations have to be differentiated from those on oesophageal and pancreatic interventions since the former are already highly centralised whereas the latter are mainly provided on a medium hospital care level and will be shifted on to the maximum hospital care level. This process should stimulate a debate on geographically equal access to care within and among the Federal Sates.