Transitional Care Model in Germany: Findings from an economic analysis of a randomized controlled trial.

INTRODUCTION: The statutory discharge management system in German hospitals does not provide adequate transitional care for geriatric patients. The American Transitional Care Model (TCM), where a qualified professional supports the patient for a period before, during, and after discharge, could help to address this problem. In this study, we compared both approaches from an economic perspective. Our research questions were: (1) How do treatment costs per person differ when geriatric patients are supported according to the TCM compared with routine discharge management? (2) What are the intervention costs? METHODS: The present economic analysis was part of a randomized controlled trial conducted at a hospital in Germany. In this study, geriatric patients in the intervention group received care according to TCM and those in the control group received routine care. We obtained data from the hospital and a health insurance company. In a cost-cost analysis, we compared the treatment costs per patient incurred in both study groups. In cases where higher costs occurred in the intervention group, we also conducted a cost-utility analysis, using the 12-Item Short Form Survey questionnaire to collect quality of life data for the Quality Adjusted Life Years calculation. Intervention costs were calculated on the basis of staff salaries, working hours, and the cost of acquiring the necessary equipment. RESULTS: The intervention group consisted of 109 geriatric patients, the control group of 119. The average quality of life score was slightly higher in the intervention group, but the difference was not significant. On average, the intervention group was less expensive. However, for individual cost types (e.g., rehabilitation), the intervention group incurred higher costs than the control group. The differences between the study groups were not significant for all cost types (p > 0.05). Intervention costs were estimated to be approximately 800 euros per patient. DISCUSSION: The TCM approach leads to savings. However, the amount of savings will depend on intervention costs, which vary in practice. After outlier exclusion, an unfavorable incremental cost-effectiveness ratio is observed for the TCM approach. CONCLUSION: From an economic perspective, TCM in its present form provides no additional value to patient care compared with routine discharge management. However, we see an urgent need to optimize the existing discharge management system to ensure better transitional care for those affected. Therefore, we recommend that different TCM components should be tested in further studies to address the questions that could not be clarified in the present study.

'. . . and then no more kisses!' Exploring patients' experiences on multidrug-resistant bacterial microorganisms and hygiene measures in end-of-life care A mixed-methods study.

BACKGROUND: In end-of-life care hygiene, measures concerning multidrug-resistant bacterial microorganisms may contradict the palliative care approach of social inclusion and be burdensome for patients. OBJECTIVES: To integrate patients' perspectives on handling multidrug-resistant bacterial microorganisms at their end of life, their quality of life, the impact of positive multidrug-resistant bacterial microorganisms' diagnosis, protection and isolation measures on their well-being and patients' wishes and needs regarding their care. DESIGN: A mixed-methods convergent parallel design embedded quantitative data on the patients' multidrug-resistant bacterial microorganisms' trajectory and quality of life assessed by the Schedule for the Evaluation of Individual Quality of Life in qualitative data collection via interviews and focus groups. Data analysis was performed according to Grounded Theory and qualitative and quantitative results were interrelated. SETTING/PARTICIPANTS: Between March 2014 and September 2015 at two hospitals adult patients diagnosed with multidrug-resistant bacterial microorganisms and treated in a palliative care department or a geriatric ward were included in the sample group. RESULTS: Patients in end-of-life and geriatric care reported emotional and social impact through multidrug-resistant bacterial microorganisms' diagnosis itself, hygiene measures and lack of information. This impact affects aspects relevant to the patients' quality of life. Patients' wishes for comprehensive communication/information and reduction of social strain were identified from the focus group discussion. CONCLUSION: Patients would benefit from comprehensible information on multidrug-resistant bacterial microorganisms. Strategies minimizing social exclusion and emotional impact of multidrug-resistant bacterial microorganisms' diagnosis in end-of-life care are needed as well as adaption or supplementation of standard multidrug-resistant bacterial microorganisms' policies of hospitals.

Perspectives on multidrug-resistant organisms at the end of life : A focus group study of staff members and institutional stakeholders.

BACKGROUND: There is a lack of research into how hospital staff and institutional stakeholders (i. e. institutional representatives from public health authorities, hospital hygiene, and the departments of microbiology, palliative care, and geriatrics) engage with patients who are carriers of multidrug-resistant organisms and receiving end-of-life care. Knowledge of their experiences, workload, and needs should be considered in dealing with hospitalized carriers of multidrug-resistant organisms as well as staff education. OBJECTIVE: This study explored and compared staff members' and stakeholders' perspectives on multidrug-resistant organisms and on provision of end-of-life care to carrier patients. METHODS: In this study four focus groups consisting of hospital staff members and institutional stakeholders were formed within a mixed-methods parent study in a palliative care unit at a university clinic and a geriatric ward of a Catholic and academic teaching hospital. Participants discussed results from staff and stakeholder interviews from a former study phase. Data were analyzed according to Grounded Theory and perspectives of staff members and institutional stakeholders were compared and contrasted. RESULTS: Key issues debated by staff members (N = 19) and institutional stakeholders (N = 10) were 1) the additional workload, 2) reasons for uncertainty about handling carrier patients, 3) the format of continuing education, and 4) the preferred management approach for dealing with multidrug-resistant organism carrier patients. Although similar barriers (e. g. colleagues' ambiguous opinions) were identified, both groups drew different conclusions concerning the management of these barriers. While institutional stakeholders recommended making decisions on hygiene measures under consideration of the specific patient situation, staff members preferred the use of standardized hygiene measures which should be applied uniformly to all patients. DISCUSSION: Staff members and institutional stakeholders perceived similar barriers to practice caused by multidrug-resistant organisms and similar needs for continuing education. The staff members' preferred management approach might originate from an uncertainty about the multidrug-resistant organism infection risk. Experiences and visions of both groups should be included in a specific recommendation for end-of-life care to ensure behavioral confidence.

Multidrug-resistant bacterial microorganisms (MDRO) in end-of-life care: development of recommendations for hospitalized patients using a mixed-methods approach.

PURPOSE: Palliative care professionals are frequently confronted with patients colonized or infected with MDRO. One major challenge is how to balance necessary isolation measures and social inclusion as one of the main principles of palliative and end-of-life care. To date, MDRO-specific policies and protocols vary widely between institutions. AIM: provide empirical recommendations on how to deal with hospitalized MDRO patients in end-of-life care. METHODS: Recommendations were developed based on (i) initial results of face-to-face interviews and focus groups, (ii) impartial experts' comments and consensus on the draft via online survey and (iii) a face-to-face meeting with consortium members to finalize recommendations. Findings of 158 interviews and six focus groups (39 participants) with patients, family caregivers, staff members and institutional stakeholders contributed to the recommendations. The assessments of 17 experts were considered. RESULTS: In total, 21 recommendations were approved. The recommended strategy in dealing with MDRO at the end of life allows case-based application of protection and isolation measures. MDRO diagnostics and therapy involve screening at admission. The recommendations suggest consideration of required accommodation facilities, provided material as well as staff and time resources. The recommendations further highlight the importance of providing for strategies enabling the patient's social inclusion and provision of verbal and written information about MDRO for patients and family caregivers, transparent medical documentation, and staff member training. CONCLUSION: The recommendations summarize the perspectives of individuals and groups affected by MDRO at the end of life and provide practical guidance for clinical routine. Further dissemination and implementation requirements are discussed and should contain the evaluation of the knowledge, views, worries, and anxieties of the target groups.

[Costs of Medial Care of MRSA Patients at the End-of-Life in a Geriatric Ward]. / Die Kosten von MRSA in der stationären geriatrischen Versorgung von Patienten am Lebensende (End-of-Life Care).

OBJECTIVE: The present study addresses the financial effects of incidences of MRSA in the geriatric ward of a German hospital on patients receiving end-of-life care. The main cost drivers will be identified and the costs calculated. METHODOLOGY: A retrospective analysis for a period of one year was conducted for the geriatric ward of a German hospital. In addition to the duration of the patient's stay and the total costs of his/her case, individual cost categories such as personnel and material costs were also examined. In order to enable a cost comparison of MRSA-positive and MRSA-negative patients, matching was used. T-tests were used for purposes of comparison with the case groups. FINDINGS: A total of 107 cases were included in the study; in 27 of these cases, MRSA was detected. Patients with MRSA were found to have a longer average stay and to incur higher average costs. There were no statistically significant differences in the duration of hospital stay between MRSA-positive and MRSA-negative patients. Furthermore, no statistically significant differences were seen in the total costs per case. Significantly higher daily personnel costs for nursing staff were observed for MRSA-positive patients in the case group of patients with lower than average total costs. For MRSA-positive patients, these costs amounted to € 97.18, while MRSA-negative patients incurred € 80.44 in costs. Costs of doctors, medical technicians and non-medical personnel and material costs for infrastructure showed an opposite tendency. If the case groups for different total costs are not considered, no significant differences between MRSA-positive and MRSA-negative patients were found for the individual cost categories examined. CONCLUSIONS: Although we demonstrated that MRSA-positive patients had longer stays and caused higher overall costs in the geriatric ward, we did not find any statistically significant differences between MRSA-positive and MRSA-negative patients. One of the main cost drivers in the care of MRSA-positive patients was identified as the daily personnel costs for nursing staff. Analysing processes related to patients' nursing care can be the first step in attempts to make care for MRSA-positive patients more effective and efficient.

Understanding institutional stakeholders' perspectives on multidrug-resistant bacterial organism at the end of life: a qualitative study.

BACKGROUND: Information lacks about institutional stakeholders' perspectives on management approaches of multidrug-resistant bacterial organism in end-of-life situations. The term "institutional stakeholder" includes persons in leading positions with responsibility in hospitals' multidrug-resistant bacterial organism management. They have great influence on how strategies on multidrug-resistant bacterial organism management approaches in institutions of the public health system are designed. This study targeted institutional stakeholders' individual perspectives on multidrug-resistant bacterial organism colonization or infection and isolation measures at the end of life. METHODS: Between March and December 2014, institutional stakeholders of two study centers, a German palliative care unit and a geriatric ward, were queried in semistructured interviews. Interviews were audiotaped, transcribed verbatim, and analyzed qualitatively with the aid of the software MAXQDA for qualitative data analysis using principles of Grounded Theory. In addition, two external stakeholders were interviewed to enrich data. RESULTS: Key issues addressed by institutional stakeholders (N=18) were the relevance of multidrug-resistant bacterial organism in palliative and geriatric care, contradictions between hygiene principles and patients' and family caregivers' needs and divergence from standards, frame conditions, and reflections on standardization of multidrug-resistant bacterial organism end-of-life care procedures. Results show that institutional stakeholders face a dilemma between their responsibility in protecting third persons and ensuring patients' quality of life. Until further empirical evidence establishes a clear multidrug-resistant bacterial organism management approach in end-of-life care, stakeholders suggest a case-based approach. CONCLUSION: The institutional stakeholders' perspectives and their suggestion of a case-based approach advance the development process of a patient-, family-, staff-, and institutional-centered approach of how to deal with multidrug-resistant bacterial organism-positive patients in end-of-life care. Institutional stakeholders play an important role in the implementation of recommendations following this approach.

A cross-sectional study assessing the association between online ratings and structural and quality of care measures: results from two German physician rating websites.

BACKGROUND: Even though physician rating websites (PRWs) have been gaining in importance in both practice and research, little evidence is available on the association of patients' online ratings with the quality of care of physicians. It thus remains unclear whether patients should rely on these ratings when selecting a physician. The objective of this study was to measure the association between online ratings and structural and quality of care measures for 65 physician practices from the German Integrated Health Care Network "Quality and Efficiency" (QuE). METHODS: Online reviews from two German PRWs were included which covered a three-year period (2011 to 2013) and included 1179 and 991 ratings, respectively. Information for 65 QuE practices was obtained for the year 2012 and included 21 measures related to structural information (N = 6), process quality (N = 10), intermediate outcomes (N = 2), patient satisfaction (N = 1), and costs (N = 2). The Spearman rank coefficient of correlation was applied to measure the association between ratings and practice-related information. RESULTS: Patient satisfaction results from offline surveys and the patients per doctor ratio in a practice were shown to be significantly associated with online ratings on both PRWs. For one PRW, additional significant associations could be shown between online ratings and cost-related measures for medication, preventative examinations, and one diabetes type 2-related intermediate outcome measure. There again, results from the second PRW showed significant associations with the age of the physicians and the number of patients per practice, four process-related quality measures for diabetes type 2 and asthma, and one cost-related measure for medication. CONCLUSIONS: Several significant associations were found which varied between the PRWs. Patients interested in the satisfaction of other patients with a physician might select a physician on the basis of online ratings. Even though our results indicate associations with some diabetes and asthma measures, but not with coronary heart disease measures, there is still insufficient evidence to draw strong conclusions. The limited number of practices in our study may have weakened our findings.