Zeitschrift fur Evidenz Fortbildung und Qualitaet im Gesundheitswesen最新文献

Background

Patients with initial stroke or transient ischemic attack (TIA) are at high risk for further strokes, death or cardiovascular events. Even the first-ever stroke is associated with a high chance of disability and need for assistance. The risk of long-term health care demands increases with each subsequent event. Although the inpatient sector already provides a high standard of care in Germany, it can be difficult to obtain cross-sectoral aftercare. Thus, the study investigated whether a structured case management program can avoid stroke recurrences.

Methods

The study was conducted with a quasi-experimental study design in three regions in North Rhine-Westphalia. Patients with first-ever stroke or TIA were eligible to participate. The intervention group was prospectively recruited and supported by a case manager during a one-year follow-up. Optimal Full Matching was used to generate a control group based on statutory claims data. The primary outcome was the stroke recurrence. Recurrence and mortality were analysed by using Cox regression; other secondary outcomes were examined with test-based procedures and with logistic regressions. Additionally, subgroup analyses were performed.

Results

From June 2018 to March 2020, 1,512 patients were enrolled in the intervention group. Claims data from 19,104 patients have been transmitted for establishing the control group. After the matching process, 1,167 patients of each group were included in the analysis. 70 recurrences (6.0 %) occurred in the intervention group and 67 recurrences (5.7 %) in the control group. With a hazard ratio of 1.06 (95 % CI: [1.42-0.69]; p = 0.69), no significant effect was found for the primary outcome. With regard to the secondary outcome mortality, 36 patients in the intervention group and 46 in the control group died (3.1 % vs. 3.9 %). Again, there was no significant effect (HR: 0.86; 95 % CI: [0.58-1.28], p = 0.46).

Discussion

Based on the present findings, the case management approach for stroke patients evaluated here was unable to demonstrate an improvement in health care. Potential effects of case management might not be adequately depicted in short observation periods. Thus, future studies should consider longer observation periods.

Conclusion

A panel of experts should discuss whether the core approach of case management to support cost-intensive individual cases is contrary to a broad implementation with a one-size-fits-all intervention for stroke patients. In this case, further research should focus on more specific study populations.

With each update of meta-analyses from living systematic reviews, treatment effects and their confidence intervals are recalculated. This often raises the question whether or not multiplicity is an issue and whether a method to adjust for multiplicity is needed. It seems that answering these questions is not that straightforward. We approach this matter by considering the context of systematic reviews and pointing out existing methods for handling multiplicity in meta-analysis. We conclude that multiplicity is not a relevant issue in living systematic reviews when they are planned with the aim to provide up-to-date evidence, without any direct control on the decision over future research. Multiplicity might be an issue, though, in living systematic reviews designed under a protocol involving a “stopping decision”, which can be the case in living guideline development or in reimbursement decisions. Several appropriate methods exist for handling multiplicity in meta-analysis. Existing methods, however, are also associated with several technical and conceptual limitations, and could be improved in future methodological projects. To better decide whether an adjustment for multiplicity is necessary at all, authors and users of living systematic reviews should be aware of the context of the work and question whether there is a dependency between the effect estimates of the living systematic review and its stopping/updating or an influence on future research.

Facing increasing economization in the health care sector, clinicians have to adapt not only to the ever-growing economic challenges, but also to a patient-oriented health care.

Treatment costs are the most important variable for optimizing success when facing scarce human resources, increasing material- and infrastructure costs in general, as well as low revenue flexibility due to flat rates per case in Germany, the so-called Diagnosis-Related Groups (DRG). University hospitals treat many patients with particularly serious illnesses. Therefore, their share of complex and expensive treatments, such as liver cirrhosis, is significantly higher. The resulting costs are not adequately reflected in the DRG flat rate per case, which is based on an average calculation across all hospitals, which increases this economic pressure. Thus, the aim of this manuscript is to review cost and revenue structures of the management of varices in patients with cirrhosis at a university center with a focus on hepatology. For this monocentric study, the data of 851 patients, treated at the Gastroenterology Department of a University Hospital between 2016 and 2020, were evaluated retrospectively and anonymously. Medical services (e.g., endoscopy, radiology, laboratory diagnostics) were analyzed within the framework of activity-based-costing. As part of the cost unit accounting, the individual steps of the treatment pathways of the 851 patients were monetarily evaluated with corresponding applicable service catalogs and compared with the revenue shares of the cost center and cost element matrix of the German (G-) DRG system. This study examines whether university-based high-performance medicine is efficient and cost-covering within the framework of the G-DRG system. We demonstrate a dramatic underfunding of the management of varicose veins in cirrhosis in our university center. It is therefore generally questionable whether and to what extent an adequate care for this patient collective is reflected in the G-DRG system.

Background

Quality measurement in the German statutory program for quality in health care follows a two-step process. For selected areas of health care, quality is measured via performance indicators (first step). Providers failing to achieve benchmarks in these indicators subsequently enter into a peer review process (second step) and are asked by the respective regional authority to provide a written statement regarding their indicator results. The statements are then evaluated by peers, with the goal to assess the provider’s quality of care. In the past, similar peer review-based approaches to the measurement of health care quality in other countries have shown a tendency to lack reliability. So far, the reliability of this component of the German statutory program for quality in health care has not been investigated.

Method

Using logistic regression models, the influence of the respective regional authority on the peer review component of health care quality measurement in Germany was investigated using three exemplary indicators and data from 2016.

Results

Both the probability that providers are asked to provide a statement as well as the results produced by the peer review process significantly depend on the regional authority in charge. This dependence cannot be fully explained by differences in the indicator results or by differences in case volume.

Conclusions

The present results are in accordance with earlier findings, which show low reliability for peer review-based approaches to quality measurement. Thus, different results produced by the peer review component of the quality measurement process may in part be due to differences in the way the review process is conducted. This heterogeneity among the regional authorities limits the reliability of this process. In order to increase reliability, the peer review process should be standardized to a higher degree, with clear review criteria, and the peers should undergo comprehensive training for the review process. Alternatively, the future peer review component could be adapted to focus rather on identification of improvement strategies than on reliable provider comparisons.

Background/Aim

Evidence-based practice (EBP) provides an important basis for improving both the quality of care and patient safety. Formulating a research question, searching the literature, and critical appraisal are crucial to developing evidence-based practice. The aim of this survey was to provide an overview of how these topics are integrated into bachelor's degree programs in nursing in Austria, Germany, and the German-speaking part of Switzerland. We also aimed to show how teachers implement these subjects and how they experience and assess the implementation.

Method

We conducted an exploratory cross-sectional study using an online survey sent out to program directors and teaching staff of all 58 bachelor's degree programs in nursing in Austria, Germany and the German-speaking part of Switzerland. For data collection, a questionnaire was developed containing items on general teaching conditions, contents, and methods of evidence-based nursing practice, as well as on the estimated thematic interest of students. The data were analysed descriptively.

Results

The program directors returned 24 questionnaires (41 %). Of 75 questionnaires forwarded to the faculty, 17 (23 %) were received from nine programs. On average, 5.6 teaching units (SD 2.6) are used for formulating a research question, 10 teaching units (SD 4.1) for literature review, and 11.3 teaching units (SD 6.9) for critical appraisal. Half of the teaching staff indicated that linkages between education and nursing care practice have been established. The traditional teaching method of frontal teaching is used predominantly. Student interest in topics was rated as moderate by most teachers.

Conclusions

Topics on evidence-based practice are an integral part of bachelor's degree programs in nursing in German-speaking countries. An increase in teaching units, active learning methods and the growing interconnection between education and practice could improve the acquisition of competencies and attitudes of students regarding EBP and further advance its implementation in practice.

Evidence-based and comprehensible health information is a key element of evidence-based medicine and public health. The goal is informed decision-making based on realistic estimations of health risks and accurate expectations about benefits and harms of interventions. In Germany, standards of evidence-based risk information were poorly followed during the COVID-19 pandemic. Frequently, public information was biased, fragmentary and misleading. Pandemic-related threat scenarios induced emotional distress and unnecessary anxiety. A systematic and comprehensive evaluation of the pandemic measures is crucial, but still pending in Germany. A critical analysis of risk communication by experts, politicians and the media during the pandemic should be a key element of the evaluation process. Evaluation of decision making and media reporting during the pandemic should improve preparedness for future crises.

Background

The delegation of medical tasks (DMT) plays a significant role in the everyday practice of inpatient care but also presents a potential challenge in interprofessional collaboration. Assessing the conditions of DMT in everyday work is crucial to identify areas for optimization.

Methods

In a nationwide exploratory study, physicians, nursing and allied health professionals working for inpatient care facilities were surveyed regarding various aspects of DMT using a standardized online questionnaire.

Results

The majority of the 757 participants (64.9 % physicians), perceived DMT to be both economically and time-efficient (88.5 % agreement) and in the best interest of patients (74 %). For 78.7 % of the respondents, DMT represents a potential conflict in their daily work, depending on the quality of interprofessional communication. Inadequate staffing was identified as a barrier to a broader implementation of DMT by 83.8 % of participants. 63.2 % of the participants considered their knowledge of legal aspects related to DMT to be at least good (participants with less than 5 years of professional experience: 52.6 %). Physicians primarily acquire relevant knowledge through professional practice (71.3 % vs. non-physicians 39.5 %).

Conclusion

Across the different professional groups DMT was considered beneficial and serving the interests of patients. Targeted promotion of safe and cost-effective DMT should be incorporated into medical education. Achieving greater benefits from DMT requires explicit legal frameworks, effective communication within the team and, in particular, adequate staffing among the professional groups responsible for delegated tasks.

During 2021 and 2023, a team of researchers at the Robert Koch Institute (RKI) and partnering institutions conducted two living systematic reviews (LSRs) on the effectiveness of COVID-19 vaccines in different age groups to inform recommendations of the Standing Committee on Vaccination in Germany (Ständige Impfkommission, STIKO). Based on our experience from the realization of these LSRs, we developed certain criteria to assess the needs and feasibility of conducting LSRs. Combining these with previously established criteria, we developed the following set to inform future planning of LSRs for STIKO: Needs criterion (N)1: Relevance of the research question, N2: Certainty of evidence (CoE) at baseline; N3: Expected need for Population-Intervention-Comparator-Outcome (PICO) adaptations; N4: Expected new evidence over time; N5: Expected impact of new evidence on CoE; Feasibility criterion (F)1: Availability of sufficient human resources; F2: Feasibility of timely dissemination of the results to inform decision-making. For each criterion we suggest rating options which may support the decision to conduct an LSR or other forms of evidence synthesis when following the provided flowchart.

The suggested criteria were developed on the basis of the experiences from exemplary reviews in a specific research field (i.e., COVID-19 vaccination), and did not follow a formal development or validation process. However, these criteria might also be useful to assess whether questions from other research fields can and should be answered using the LSR approach, or assist in determining whether the use of an LSR is sensible and feasible for specific questions in health policy and practice.