[DNVF Memorandum Health Services Research in Oncology]. / DNVF-Memorandum Versorgungsforschung in der Onkologie.

Health services research in oncology deals with all situations which cancer patients face. It looks at the different phases of care, i. e. prevention / early detection, prehabilitation, diagnostics, therapy, rehabilitation and palliative care as well as the various actors, including those affected, the carers and self-help. It deals with healthy people (e. g. in the context of prevention / early detection), patients and cancer survivors. Due to the nature of cancer and the existing care structures, there are a number of specific contents for health services research in oncology compared to general health services research while the methods remain essentially identical. This memorandum describes the subject, illustrates the care structures and identifies areas of health services research in oncology. This memorandum has been prepared by the Oncology Section of the German Network for Health Services Research and is the result of intensive discussions.

[Cancer Patients and the Last Year of Life: Palliative Care, Hospitalization and Place of Death]. / Krebserkrankung und das letzte Lebensjahr: Palliative Leistungen, Krankenhausaufenthalte und Sterbeort.

INTRODUCTION: Palliative care patients frequently suffer from cancer diagnoses. Specialised palliative home care (German acronym 'SAPV') enables patients with complex symptoms and intensive care needs to receive home care until death. In the German Federal State of Hesse, the first SAPV teams were set up in 2009. Against this background, the aim of this study was (i) to investigate the utilization of SAPV and specialised inpatient palliative care in the last year of life of cancer patients, (ii) to detect the medical professions prescribing SAPV and (iii) to analyse the place of death and the hospitalization rate in the last 91 days of life. METHODS: A retrospective secondary data analysis was conducted. Routine data from the statutory health insurance company AOK Hesse in Germany for 2009-2014 were analysed using descriptive statistical methods. The study population comprised breast, prostate, and colorectal cancer patients who died in the year of observation (2010-2014) and who were fully insured 360 days before death. RESULTS: Depending on the year of observation, 492-545 breast, 546-625 prostate, and 709-752 colorectal cancer patients were included in the study. The analysis showed an increase of cancer patients receiving palliative care from 2010 to 2014. A higher proportion of breast, prostate, and colorectal cancer patients received SAPV as compared to services from palliative care units or inpatient hospices. All in all, over 90% of the SAPV prescriptions were issued by family doctors. The hospitalization rate of cancer patients in the last 91 days of life as well as the share of those dying in hospital decreased between 2010 and 2014. CONCLUSION: The results must be assessed in the context of the implementation of SAPV in the state of Hesse. The increase of SAPV services and the reduction of hospitalizations at the end of life indicate a successful introduction of SAPV in the state of Hesse.

[Results of a Pilot Study to Assess Quality Indicators in Outpatient Cancer Care]. / Ergebnisse einer Pilotstudie zur Erfassung von Qualitätsindikatoren in der ambulanten onkologischen Versorgung.

AIMS: Indicators of process quality were developed for outpatient oncology care in Germany with the aim to advance quality monitoring and assurance. In this pilot study, data to assess these quality indicators (QI) were gathered and analyzed for the first time. METHODS: Data were retrieved from patient records in oncology practices using an online data tool. Data were collected by practice-internal and in 7 (wave 1), 9 (wave 2) and 7 (wave 3) practices, respectively, by an external documentalist. RESULTS: Altogether, 5,160 patient records from 37 oncology practices were analyzed. The adherence rates varied considerably between QI as well as between practices (0-100%). In summary, adherence rates were higher for QI of basis documentation (81%) than for therapy planning and implementation (72%), holistic care and psychosocial wellbeing (71%) or pain management (63%). CONCLUSION: The ranges and high standard deviations show a high spread of adherence rates of QI. However, except for pain management, 100% fulfilment of QI requirements in some practices suggests that adherence to QI is generally feasible. Data collection for QI is resource intensive (time and personnel). Yet, collecting and examining data for QI provides useful information about areas with potential for improvement. QI can help improve the quality of care in oncology.

Feasibility of Nurse Consultation in Oral Tumor Therapy: A Web-Based Survey among Physicians and Nonmedical Specialists.

BACKGROUND: Oral antiproliferative therapies have become increasingly important in the treatment of tumors. To ensure patient safety, medical care is focused on adherence and side effects. OBJECTIVES: To meet increased personnel and time requirements, delegation of tasks to nonmedical specialists (NMS) may be a solution; however, presently, little is known about the options in Germany. METHOD: At least 3,300 members of the German Society for Hematology and Medical Oncology (DGHO), 580 members of the Professional Association of Office-Based Hematologists and Oncologists in Germany (BNHO), and 1,500 members of the Conference on Oncology Nursing and Pediatric Nursing (KOK) were contacted via a web-based survey. The survey focused on the feasibility of oncology nurse consultation as an additional consulting service for patients undergoing oral tumor therapy. RESULTS: In total, 255 (physicians) and 206 (NMS) questionnaires were evaluable; 90.9% of the physicians were hematologists/oncologists, 87.8% advocated oncology nurse consultation, 34.1% had previously implemented/scheduled such consultations, 58.3% of the NMS were nursing staff, 46.1% had advanced training in oral tumor therapy, 94.2% were interested in further qualifications, 37.8% worked at facilities with established/planned nurse consultations, and 62.1% personally conducted/preferred conducting consultations. CONCLUSIONS: Throughout Germany, there seems to exist a group of qualified NMS who are motivated to provide care to patients undergoing oral tumor therapy. Particular physicians actively support these nurse consultations. Extensive implementation of delegation concepts in standard care of patients undergoing oral tumor therapy is not yet underway.

[DNVF-Memorandum III - Methods for Health Services Research, Part 4 - Concept and Methods for Organizational Health Services Research: Short Version]. / DNVF-Memorandum III ­ Methoden für die Versorgungsforschung, Teil 4 ­ Konzept und Methoden der organisationsbezogenen Versorgungsforschung: Kurzfassung.

Organizational health services research in Germany is of increasing relevance. Based on the guide on methods for organizational health services research of the Memorandum III, part 1 from the year 2009, the fundamentals and standards have now been refined. The memorandum captures the theoretical framework, basic methodological approaches and methods in health services research for the design, evaluation and implementation of complex interventions in healthcare organizations.

[DNVF-Memorandum III - Methods For Health Services Research, Part 4 - Concept and Methods For Organizational Health Services Research. Chapter 1 - Definition and Concept of Organizational Health Services Research]. / DNVF-Memorandum III ­ Methoden für die Versorgungsforschung, Teil 4 ­ Konzept und Methoden der organisationsbezogenen Versorgungsforschung. Kapitel 1 ­ Definition und Konzept der organisationsbezogenen Versorgungsforschung.

Organizational health services research is still a relatively young field of research in Germany which is of increasing interest. The German Network Health Services Research e.V. (DNVF e.V.) published in 2009 - supported by expert associations and individual members of the DNVF - a guide on "Methods for organizational health services research" of the Memorandum III, part 1[1]. Originating from this publication and facilitated by the increasing relevance of the field, a necessity to refine the conceptual and methodological basis became evident. The update and extension of the publication from 2009 consists of three chapters: (1) Definition and concept of organizational health services research, (2) Methodological approaches in organizational health services research: indicators, data sources, data collection and data analysis, (3) Methodological approaches for the design, evaluation and implementation of complex interventions in health care organizations. The aim of the first chapter is to present the theoretical framing and the definition of terms and tasks within organizational health services research.

[Readiness to Participate in Ambulatory Special Medical Care (ASV): A Critical Appraisal - Results of a Survey Amongst Office-Based Oncologists in Germany]. / Bereitschaft zur Teilnahme an der ambulanten spezialfachärztlichen Versorgung (ASV): eine kritische Bestandsaufnahme.

BACKGROUND: Outpatient specialized care (ASV) is intended to improve interdisciplinary, transsectoral care for patients with rare or complex diseases, especially cancer. Up to now, only very few such specialized care teams have been established. The aim of our study was to evaluate the current state of information and participation as well as reasons for the reluctance of office-based hematologists and oncologists. METHODS: We conducted a web-based survey amongst office-based hematologists and oncologists in Germany and received responses from 145 institutions comprising more then 350 doctors working there. The questions comprised 22 items concerning the state of information, implementation as well as obstacles to participation and evaluation of the ASV. RESULTS: The majority of the interviewed doctors was well informed about ASV. Only a minority was in principle against this concept. 6% of them had already treated patients within ASV, 8% had completed the preparation, 16% were in the preparation process, 26% were indecisive and 45% had decided not to participate. The main reasons for non-participation or barriers were high expenditure and a lack of benefit for patients, strategic positioning as well as reimbursement. CONCLUSIONS: Although implemented more than 5 years ago, ASV plays no relevant role in patient care. The reluctance seems not to be due to information deficits, but rather to obstacles in the participation procedure. Relevant advantages for patient care, interdisciplinary communication or reimbursement are not anticipated. As long as the current low acceptance to participate in ASV is not improved, it cannot unfold its potential.

[Feedback strategies for routine surveys of quality indicators in outpatient oncology care]. / Feedbackstrategien bei routinemäßigen Erhebungen von Qualitätsindikatoren in der ambulanten onkologischen Versorgung.

OBJECTIVES: The study deals with the efficiency and possible improvements of quality promotion with quality indicators (QI). The goal is to investigate the practical use of feedback from QI surveys in the field of oncology office practices. It captures both the acceptance of results and the independent initiation of search- and improvement strategies. The value of best practice examples is of further interest. METHODS: Within one year, data of six QI of 31 physicians from 24 oncology practices were collected twice and the results were sent back in individual reports including a benchmarking. Practices with particularly good results in individual QI sectors were surveyed in semi-structured telephone interviews about their processes. Based on these results, best practice examples were created and provided to all participating practices to stimulate improvement. Further, two paper-based surveys about the acceptance and handling of results as well as the use of best practice examples were conducted. RESULTS: The practices accepted the reported results as an instrument to assess their own care quality (70 %) and indicated that had been able to identify improvement potentials (75 %). Improvement strategies were developed or planned by approximately every second practice in the respective sectors. The practices were interested in the best practice examples and rated them as helpful (70 %). Many of them indicated that they were already taking up some of the suggestions for improving the organization of their own processes or were planning to do so. CONCLUSION: The extraction of information on QI from patient files is a tedious task for the practices. Both the implementation of the necessary internal measures after receiving the results report as well as the adaptation of external process examples to their own processes is challenging. Nevertheless, oncology practices benefit from the feedback of the results of QI surveys and best practice examples. Thus, QI surveys and the reporting of results can actively encourage quality development.

[Internet Use by Oncology Outpatients: Results of a Survey in Germany]. / Internetnutzung von Patienten in der ambulanten onkologischen Versorgung: Ergebnisse einer deutschlandweiten Patientenbefragung.

OBJECTIVE: Internet has become an important source of information for cancer patients regarding disease and treatment. A national survey was conducted to assess the importance of Internet in the routine care of cancer patients in Germany. METHOD: The cross-sectional survey included 5,984 outpatients (56.7% female, M=64.3 years, SD=12). 3 groups were identified: Internet users, non-users whose families/friends did online research for them, and "complete" non-users. The data was analyzed using descriptive statistics and group comparisons. RESULTS: 1 patient in 2 used the Internet to research health-related information. Internet users considered this research to be helpful, felt better able to participate in health-related decisions, and less alone with their disease. However, the information found online contributed to a feeling of uncertainty. 72.5% of Internet users researched treatment options and 21.3% talked to their doctor about their research. CONCLUSION: The Internet was shown to be an important source of information for cancer patients. For patients to be able to use Internet research meaningfully, it could be helpful that they receive support from their oncologist.

Oncologists' views on the importance of general practitioners for cancer patients: a qualitative interview study from Germany.

Background: Integrated cancer care requires cooperation between specialists and general practitioners (GPs). Mutual understanding of each other's tasks and responsibilities is essential if cooperation is to be successful. While GPs' opinions about oncologists have been addressed in previous studies, less is known about oncologists' views on the role of GPs' in cancer care, especially with regard to GPs' patient-centred, communication-based tasks. Objective: To assess oncologists' views on the importance of GPs for cancer patients. Methods: We conducted 15 qualitative guideline-based telephone interviews with oncologists using open-ended questions and analysed these interviews using thematic analysis. Results: Oncologists situated GPs as persons of trust for patients in a rather amicable sphere of caring in contrast to themselves who were situated in a rather biomedical sphere of evidence-based treatment decisions. Oncologists' appraisal of an overlapping of these spheres varied: While most stressed opportunities for patients (and themselves), others also mentioned risks. Conclusion: Our analysis found that oncologists clearly distinguish between their own sphere of evidence-based treatment decision-making and GPs' sphere of psychosocial caring. The question remains how these roles get interconnected in real life situations in order to meet patients' needs adequately. So far it seems that it is often the patient who is travelling between both spheres and needs to initiate interconnection to get comprehensive cancer care.

Patients' Trust in Physician, Patient Enablement, and Health-Related Quality of Life During Colon Cancer Treatment.

In cancer care, where patients and their families experience significant emotional distress and patients have to deal with complex medical information, patient centeredness is an important aspect of quality of care. The aim of this study is to examine the impact of patients' trust in their oncologists and patients' enablement on changes in health-related quality of life of colon cancer patients during follow-up care. We conducted a prospective study in a representative sample of private practices of German oncologists (N = 44). Patients (N = 131) filled out a standardized questionnaire prior to their first consultation (T0), directly after the first consultation (T1) and after two months (T2). Data were analyzed by structural equation modeling. Significant associations were found between trust in physician and changes in physical functioning between T1 and T2, and between trust in physician and patient enablement. Patient enablement is significantly associated with changes in physical functioning between T1 and T2. The results underline the importance of building a close and trustful patient-physician relationship in the oncology encounter. A central mechanism of the association between the quality of the relationship and health outcomes seems to be patient enablement. To enable patients to cope with their situation by making them understand their diagnosis, treatments, and side effects can impact health-related quality of life in physical domains.

Recovery opportunities, work-home conflict, and emotional exhaustion among hematologists and oncologists in private practice.

Hematologists and oncologists in private practice play a central role in the care provided for cancer patients. The present study analyzes stress and relaxation aspects in the work of hematologists and oncologists in private practice in Germany in relation to emotional exhaustion, as a core dimension of burnout syndrome. The study focuses on the opportunities for internal recovery using breaks and time out during the working day, the frequency of working on weekends and on vacation, and the physician's work-home and home-work conflict. Postulated associations between the constructs were analyzed using a structural equation model. If work leads to conflicts in private life (work-home conflict), it is associated with greater emotional exhaustion. Working frequently at the weekend is associated with greater work-home conflict and indirectly with greater emotional exhaustion. By contrast, the availability of opportunities to relax and recover during the working day is associated with less work-home conflict and indirectly with less emotional exhaustion. These results underline the importance of internal recovery opportunities during the working day and a successful interplay between working and private life for the health of outpatient hematologists and oncologists.

Tumor Boards from the Perspective of Ambulant Oncological Care.

BACKGROUND: Cancer therapy requires the cooperation of physicians from different disciplines. At the core of the collaboration are 'tumor boards' (also known as 'multidisciplinary team meetings' and 'tumor conferences'). However, there is limited health care research that addresses the multiple facets of such meetings. MATERIAL AND METHODS: Data were analyzed from 3 routinely conducted surveys comprising information from (i) office-based hematologists and oncologists, (ii) their patients, and (iii) quality indicators. RESULTS: Most office-based oncologists stated that they participate in tumor boards taking place in hospitals. Although tumor boards are viewed as time intensive and lack financial compensation, they are considered as beneficial for patient care. Less than half of patients knew that their cases were discussed at a tumor board; those who knew rated the collaboration between their treating doctors as more positive, but also experienced slightly higher distress levels. The quality indicators showed that tumor board meetings were documented in three-quarters of the patient charts, but only half included the tumor board's recommendation. CONCLUSIONS: Participation in tumor boards is perceived as beneficial by oncologists and not just considered as a fulfillment of societies' recommendations or guidelines. The higher distress levels in patients who knew that their case was discussed at a tumor board may have occurred because more difficult cases are discussed at tumor boards and since the oncologists spend more time explaining the therapy process in complex cases, including the tumor board results.

[Prognosis of population-related morbidity for common cancers in Germany--Effects on health care]. / Deutschlandweite, regionalisierte Prognose der bevölkerungsbezogenen Morbidität für häufige Krebserkrankungen--Auswirkungen auf die Versorgung.

INTRODUCTION: The demand for outpatient and inpatient oncology care will rise in the next years. In this analysis, the number of new cases and the prevalence in 2020, the number of hospital days, types of treatment, sickness costs, and the number of oncology specialists are prognosed. METHODS: Projections of incidence and prevalence of cancer overall and of the three most common cancers were conducted with data from the German Population-Based Cancer Registries and from the German Federal Statistics Office. The average number of hospital days was extrapolated until 2020 on the basis of these population projections. Outpatient care was analyzed with billing data obtained from the WINHO. Projections of sickness costs in 2020 were calculated based on data from the German Federal Statistics Office under the assumption that cost per prevalent case remains constant within a given age group over the projection period. Numbers of specialists in hematology and oncology were taken from the database of the Association of Statutory Health Insurance Physicians. These forecasts are based on a series of assumptions. RESULTS: The number of new cancer cases will increase by about 67,000 cases until 2020 (reference year 2008). Prevalent cases will increase by about 176,000 cases. The needed number of hospital days will increase about 13% to 15.513 million days in 2020. An increase of 30% in cytoreductive and 23% in chemotherapy treatment of lung cancer was shown between 2008 and 2011. The number of contracted doctors with focus in hematology and oncology has increased in 2011 compared to 2005. Between 2002 and 2008, sickness costs increased by 52% in the outpatient sector and by 31% in the inpatient sector. In 2020, the increase of sickness costs is expected to reach about 1.7 billion EUR/year. CONCLUSIONS: Due to the increase of incident and prevalent cancer cases, the number of hospital days and sickness costs will increase. The results of the analyses show an increase of medical care services in the outpatient sector.

The initial clinical interview--can it reduce cancer patients' fear?

PURPOSE: A common phenomenon among cancer patients is a fear of cancer recurrence or cancer progression (FOP). The aim of the present study was to analyze whether the oncologist is able to reduce patients' FOP at the initial clinical interview. METHOD: A prospective, longitudinal study included patients who were consulting private-practice oncologists in Germany for the first time. Recruitment was carried out by 44 members of the Professional Organization of Office-Based Hematologists and Oncologists. In the patient surveys, data on colon cancer patients' perceptions of communications with their oncologist and on patient-reported outcomes were collected over a period of 6 months. The present study analyzed the patients' data before their first consultation (T 0) and within 3 days after the first consultation (T 1). RESULTS: A total of 169 patients agreed to participate in the study. Backwards multiple regression analysis was conducted to determine whether the change (T 0-T 1) in FOP is associated with demographic, medical, or psychosocial determinants, or with the physician-patient communication. A significant association was found between the change in FOP and interruptions to the conversation, the comprehensibility of the information provided, the extent of perceived empathy from the physician, and the patient's social support and family status. CONCLUSION: Private social support and the initial medical encounter can help reduce FOP. Particularly, oncologists should ensure that they facilitate the presentation of information in a comprehensible way while avoiding interruptions and that they take particular care of patients with poor social support.

[WINHO quality indicators for outpatient oncology care in Germany]. / WINHO-Qualitätsindikatoren für die ambulante onkologische Versorgung in Deutschland.

The aim of the WINHO indicators project is to describe and enhance the quality of outpatient oncology care in Germany with indicators. This paper deals with the development of a set of evidence- and consensus-based meaningful indicators to assess the quality of outpatient oncology care in Germany. These indicators are intended to be applied in assessments of quality of patient care in oncology practices, in quality reports and in peer-to-peer benchmarking. A set of 272 already existing indicators was identified through internet and literature searches. After redundancy reduction and addition of newly developed indicators for areas of ambulatory oncology care that were not yet covered, a preliminary set of 67 indicators was established. The further development of the indicator set was based on a modified version of the two-step RAND/UCLA expert evaluation method, which has been internationally established for developing quality indicator sets. The indicators were modified after the first round of ratings. After completing and assessing the second round of ratings, a set of 46 homogeneously positively rated quality indicators is now available for outpatient oncology care in Germany.

[Care requirements for elderly cancer patients]. / Erfordernisse älterer Tumorpatienten vor dem Hintergrund der Versorgungsrealität.

The oncology care system is insufficiently directed to the treatment situation of elderly tumour patients. There is a lack of specific studies focusing on the application and effects of antineoplastic substances in elderly patients to forward the utilisation of all available therapeutical options. The reality of care of elderly patients, especially elderly women, is marked by problems of access to the treatment opportunities. Questions of social support have to be raised. A specialised geriatric assessment in oncology can improve diagnostic preconditions in the treatment of the elderly. Restrictions of activities of daily living, comorbidities, cognitive handicaps, and malnutrition are to be surveyed among all patients > 70 years of age. Studies for the systematic involvement of assessments in the treatment routine are necessary. The cooperation of geriatricians and oncologists has to become a more routine process to work out diagnosis and treatment standards for elderly cancer patients. The oncology care system has to meet the challenge of providing adequate care which links specialised tumour treatment with palliative care, especially for elderly patients with advanced tumour diseases.

Patient satisfaction with care in office-based oncology practices.

INTRODUCTION: The purpose of patient surveys is to measure the quality of health care from the patient's point of view. They are recommended as a way to detect the strengths and weaknesses of patient care and to locate areas of potential improvement. METHODS: In the autumn of 2006, patients undergoing care in subspecialty oncology practices across Germany were given a questionnaire to be answered in writing. A total of 15 272 patients participated (response rate, 68.8%). The questionnaire addressed patient satisfaction with practice staff and organization as well as with the treating physicians themselves. RESULTS: The practices, their staffs, and the doctors were generally rated at least "good" in all aspects of patient care. Less highly rated aspects of practice organization, despite overall satisfaction, were waiting times and accessibility in emergencies. Appointment scheduling was considered good. Patients were particularly satisfied with the time their doctors devoted to them, but less satisfied with their advice about "alternative" treatments. The doctors involved them in the treatment process to differing extents and gave a variable degree of psychosocial care. CONCLUSION: The questionnaires documented high overall satisfaction with oncology practices with little variation among the individual items. There were a few specific areas that accounted for the differences between well and poorly rated practices and physicians; in these areas, there is a potential for improvement.