Organization and quality of care in patient-sharing networks.

Healthcare systems seek to provide continuous and coordinated care of high quality. However, patient pathways in the ambulatory sector may differ and result in various provider units. Our aim was to analyze whether health outcomes and the quality of care differ between different types of patient-sharing physician networks. We analyzed administrative data on patients with diagnosed heart failure in Germany. We investigated distinct networks of ambulatory physicians by using a modular-based optimization algorithm and characterized each network as having either a key physician at its center or some other kind of configuration. We subsequently conducted multilevel regression analyses to estimate the impact a network's configuration has on hospitalization rates and guideline-based process indicators. We identified 1,847 networks, of which 27% had a key physician at their center. Compared to physician networks with other configurations, networks that had a key physician at their center were associated in our regression analysis with (a) somewhat lower hospitalization rates, and (b) heart failure treatment that was more frequently in concordance with the German national treatment guideline. Organizing healthcare for people with chronic disease into units that have a key physician at their center and include the relevant specialists may foster treatment that is effective and of higher quality.

Do physician networks with standardized audit and feedback deliver better quality care for older patients compared to regular care?: a quasi-experimental study using claims data from Bavaria, Germany.

BACKGROUND: Physician networks (PNs) are a recent development in Germany, designed to improve the coordination and quality of healthcare. We compared the performance of PNs that use a standardized system of audit and feedback to that of regular care. METHODS: We analysed a large sample of claims data from Bavaria, Germany, using nearest-neighbour propensity score matching. Patients who had ambulatory care-sensitive conditions (ACSCs) and were enrolled in PNs were matched with control patients receiving regular care. We examined potentially avoidable hospitalizations related to the 13 most common ACSCs (primary endpoints), as well as processes-of-care indicators for disease prevention, pharmacotherapy and coordination of care. RESULTS: There were no significant differences in rates of potentially avoidable hospitalizations between the two groups. However, the networks showed higher vaccination rates, increased participation in disease management programmes, and more frequent use of referrals when consulting specialist physicians. On average, network patients visited a greater number of specialists and had lower continuity of care compared to patients receiving regular care. Polypharmacy and PRISCUS-list prescriptions were more prevalent in the networks. CONCLUSIONS: PNs using audit and feedback do not appear to perform better than regular care in preventing hospitalizations due to ACSCs. However, they do perform better in disease prevention measures while showing inconclusive results for care coordination and pharmacotherapy. Further research is needed to understand effective collaboration among providers and its impact on the quality of care within PNs.

Regional variations in multimorbidity burden among office-based physicians in Germany.

BACKGROUND: Multimorbidity is associated with higher utilization of healthcare services. However, many countries do not consider multimorbidity when estimating physician supply. The main aim of this study was to assess how regional multimorbidity levels can be integrated when estimating the need for office-based physician supply. METHODS: Claims data were used to measure and compare the proportions of multimorbid patients of GPs, ophthalmologists, orthopaedic specialists and neurologists, and examine spatial variations through Bernoulli cluster analysis of regional multimorbidity levels. To explore the interrelationship between current capacities and spatial occurrence of high-rate clusters, clusters were compared with the current supply of physicians. RESULTS: About 17 239 488 individuals out of approximately 67 million records were classified as multimorbid. Multimorbidity levels varied greatly between physician disciplines (31.5-60.1%). Bernoulli cluster analysis demonstrated that many high-rate areas were found for all specialized physicians, but clusters varied partially by size and location. The comparison with current physician supply at cluster level showed that more than a third of clusters with a significantly higher share of morbid patients seeing a GP are met, on an average, by GP supply below targeted values. In turn, clusters with significantly higher multimorbidity levels of specialized physicians were met, on an average, by supply that exceeded targeted values. CONCLUSION: Our study offers an approach to how to include discipline-specific multimorbidity at area level when estimating physician supply and discusses its relevance. The outcomes of our article can be used by policymakers to advance current planning strategies and to improve the quality of office-based care.

Diffusion of a new drug among ambulatory physicians-The impact of patient pathways.

When drugs enter the market, physicians' prescribing behavior plays a crucial role in the diffusion process. Although regulations to foster economically efficient prescribing exist, physicians have some degree of freedom in choosing medication and are subject to various influencing factors. The aim of the present analysis is to investigate how interaction among patients and physicians affects the diffusion. We look at two different ways that patient pathways might influence physicians and examine these effects for Sacubitril/Valsartan (S/V), a new drug for patients with heart failure. Using administrative data from Germany, we identify physicians who prescribed S/V in the first 2 years of its availability. We apply survival models to estimate the impact of the patient-physician interaction on the physicians' adoption time. To this end, we determine whether individual physicians treated patients that had been prescribed S/V, and how many other physicians already prescribing S/V were connected in patient-sharing networks. Our main findings are that patients with a previous prescription seem to induce adoption by demanding repeat prescriptions. Moreover, patients establish connections between physicians that may lead to prescriptions for new patients. Our results therefore suggest that patient pathways play a significant role in the diffusion of a new drug.

Health economic evaluation of the 'Flying Intervention Team' as a novel stroke care concept for rural areas: study protocol of the TEMPiS-GÖA study.

INTRODUCTION: Providing comprehensive stroke care poses major organisational and financial challenges to the German healthcare system. The quasi-randomised TEMPiS-Flying Intervention Team (TEMPiS-FIT) study aims to close the gap in the treatment of patients who had ischaemic stroke in rural areas of Southeast Bavaria by flying a team of interventionalists via helicopter directly to patients in the regional TEMPiS hospitals instead of transporting the patients to the next comprehensive stroke centre. The objective of the present paper is to describe the methods for the economic evaluation (TEMPiS-Gesundheitsökonomische Analyse (TEMPiS-GÖA)) alongside the TEMPiS-FIT study to determine whether the new form of care is cost-effective compared with standard care. METHODS AND ANALYSIS: The within-trial cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) will be performed from a statutory health insurance perspective as well as from a societal perspective over the time horizon of 12 months after the patients' hospital discharge. Direct costs from outpatient and inpatient care are collected from routine data of the participating health insurance funds, while medical and non-medical costs from a patient's perspective are retrieved from primary data collected during the TEMPiS-FIT study and follow-up questionnaires. Results will be presented as incremental cost-effectiveness ratio and incremental cost-utility ratio quantifying the incremental costs and health benefits compared with standard care practice. The outcome of the CEA will be measured in costs per minute reduction in mean process time to thrombectomy. The outcome of the CUA will be presented as costs per quality-adjusted life year gained. ETHICS AND DISSEMINATION: Ethical approval for the TEMPiS-FIT study was granted by the Bavarian State Medical Association Ethics Committee (# 17056). Results will be disseminated via reports, presentations of the results in publications and at conferences and on the TEMPiS website. TRIAL REGISTRATION NUMBER: German Clinical Trials Register DRKS00023885. Registered on 2 July 2021 - retrospectively registered.

Routine data-based quality indicators for the treatment of gonarthrosis and coxarthrosis patients in the ambulatory care sector - A study protocol for a cluster-randomised pilot trial to evaluate the MobilE-ARTH study.

BACKGROUND: In 2019, Germany had the highest rate of hip replacement surgery and the fourth highest rate of knee replacement surgery among more than 30 OECD countries. The age-standardised rates were estimated at 174 hip joint and 137 knee joint replacements per 100,000 population. Against this background, the contrast between financial incentives for surgery and missing incentives for non-surgical treatment options is repeatedly discussed. Quality indicators (QIs) can serve to measure and transparently present the quality of evidence-based care. Comparing results in the form of audit and feedback has been shown to improve e.g. guideline-compliant ambulatory care. Existing QIs targeting the care of gon- and coxarthrosis mainly focus on discharge management after joint replacement surgery and/or require additional data collection. Therefore, as part of the MobilE-ARTH project, a set of QIs for ambulatory care prior to joint replacement surgery calculable based on routine data is being developed. The present study's aim is to evaluate the impact of this QI set in terms of providing feedback on the quality of care. METHODS: The MobilE-ARTH project comprises (Phase 1) developing a QI set following the RAND/UCLA Appropriateness Method, (Phase 2) implementing the QIs in established physician networks of a German statutory health insurance (SHI) within a prospective, non-blinded, cluster-randomised pilot study, and (Phase 3) evaluating the QI set's effectiveness. The physicians in the intervention networks will (a) receive feedback reports providing information about the routine data-based QIs of their gon- and/or coxarthrosis patients and aggregated results for their network, and (b) be invited to two voluntary, facilitated network meetings. In these network meetings, the physicians can use the information provided on the feedback reports to discuss multiprofessional care pathways for patients with gon- and/or coxarthrosis. Selected indicators of the QI set will serve as primary and secondary outcome measures. Routine data will be analysed within multi-level models using an intention-to-treat approach. DISCUSSION: Feedback reports help maintaining clinical standards and closing the gap between evidence and medical practice, thus enabling an overall improvement in health care. Providing physicians with QI-based information on quality of care promotes identifying strengths and weaknesses in medical treatments. TRIAL REGISTRATION: German Clinical Trials Register, number DRKS00027516 , Registered 25th January 2022 - Prospectively registered.

Development of indicators to assess quality and patient pathways in interdisciplinary care for patients with 14 ambulatory-care-sensitive conditions in Germany.

BACKGROUND: In settings like the ambulatory care sector in Germany, where data on the outcomes of interdisciplinary health services provided by multiple office-based physicians are not always readily available, our study aims to develop a set of indicators of health care quality and utilization for 14 groups of ambulatory-care-sensitive conditions based on routine data. These may improve the provision of health care by informing discussions in quality circles and other meetings of networks of physicians who share the same patients. METHODS: Our set of indicators was developed as part of the larger Accountable Care in Deutschland (ACD) project using a pragmatic consensus approach. The six stages of the approach drew upon a review of the literature; the expertise of physicians, health services researchers, and representatives of physician associations and statutory health insurers; and the results of a pilot study with six informal network meetings of office-based physicians who share the same patients. RESULTS: The process resulted in a set of 248 general and disease specific indicators for 14 disease groups. The set provides information on the quality of care provided and on patient pathways, covering patient characteristics, physician visits, ambulatory care processes, pharmaceutical prescriptions and outcome indicators. The disease groups with the most indicators were ischemic heart diseases, diabetes and heart failure. CONCLUSION: Our set of indicators provides useful information on patients' health care use, health care processes and health outcomes for 14 commonly treated groups of ambulatory-care-sensitive conditions. This information can inform discussions in interdisciplinary quality circles in the ambulatory sector and foster patient-centered care.

Patterns of pregabalin prescribing in four German federal states: analysis of routine data to investigate potential misuse of pregabalin.

OBJECTIVES: The objectives of this study were to investigate the utilisation patterns of pregabalin, to identify users potentially misusing pregabalin and to compare this group of patients to patients prescribed recommended doses of pregabalin concerning their personal characteristics and the coordination among their prescribers. Unintended coprescription of drugs with addictive potential might occur when care is insufficiently coordinated. DESIGN: Secondary data analysis of linked data from three regional sickness funds in Germany (AOK) for the years 2014-2016. SETTING: Ambulatory and hospital care sector in four German federal states. METHODS: On the basis of routine data, patients who received at least three prescriptions of pregabalin were identified and classified into patients prescribed pregabalin as recommended and those dispensed with a higher than recommended dose (>600 mg/day). Social network analysis was applied to identify prescription networks and to analyse cooperation among the prescribers. With descriptive statistics and univariate statistical tests, typical characteristics of the group of patients potentially misusing pregabalin were compared with the others. RESULTS: Among the 53 049 patients prescribed pregabalin, about 2% (877) were classified as potentially misusing pregabalin. The majority of this group was male and aged between 30 and 60 years. Of the patients misusing pregabalin, 365 (42%) had a diagnosed history of substance use disorders and 359 (41%) had been prescribed another drug with addictive potential (opioids) before. The prescribers of those patients potentially misusing pregabalin were more loosely connected within networks compared with prescribers of patients prescribed pregabalin as recommended. CONCLUSION: This study found that patients could exceed recommended doses of pregabalin by getting prescriptions from multiple physicians. Specific patients were at increased risk of potentially misusing pregabalin, and these patients sought to obtain their prescriptions from physicians who were as loosely connected as possible. Coordination and sharing a relevant number of patients seem to be levers to avoid these problems of unintended coprescribing.

Using social network analysis methods to identify networks of physicians responsible for the care of specific patient populations.

BACKGROUND: Coordinating health care within and among sectors is crucial to improving quality of care and avoiding undesirable negative health outcomes, such as avoidable hospitalizations. Quality circles are one approach to strengthening collaboration among health care providers and improving the continuity of care. However, identifying and including the right health professionals in such meetings is challenging, especially in settings with no predefined patient pathways. Based on the Accountable Care in Germany (ACD) project, our study presents a framework for and investigates the feasibility of applying social network analysis (SNA) to routine data in order to identify networks of ambulatory physicians who can be considered responsible for the care of specific patients. METHODS: The ACD study objectives predefined the characteristics of the networks. SNA provides a methodology to identify physicians who have patients in common and ensure that they are involved in health care provision. An expert panel consisting of physicians, health services researchers, and data specialists examined the concept of network construction through informed decisions. The procedure was structured by five steps and was applied to routine data from three German states. RESULTS: In total, 510 networks of ambulatory physicians met our predefined inclusion criteria. The networks had between 20 and 120 physicians, and 72% included at least ten different medical specialties. Overall, general practitioners accounted for the largest proportion of physicians in the networks (45%), followed by gynecologists (10%), orthopedists, and ophthalmologists (5%). The specialties were distributed similarly across the majority of networks. The number of patients this study allocated to the networks varied between 95 and 45,268 depending on the number and specialization of physicians per network. CONCLUSIONS: The networks were constructed according to the predefined characteristics following the ACD study objectives, e.g., size of and specialization composition in the networks. This study shows that it is feasible to apply SNA to routine data in order to identify groups of ambulatory physicians who are involved in the treatment of a specific patient population. Whether these doctors are also mainly responsible for care and if their active collaboration can improve the quality of care still needs to be examined.

Improving the continuity and coordination of ambulatory care through feedback and facilitated dialogue-a study protocol for a cluster-randomised trial to evaluate the ACD study (Accountable Care in Germany).

BACKGROUND: Patients in Germany are free to seek care from any office-based physician and can always ask for multiple opinions on a diagnosis or treatment. The high density of physicians and the freedom to choose among them without referrals have led to a need for better coordination between the multiple health professionals treating any given patient. The objectives of this study are to (1) identify informal networks of physicians who treat the same patient population, (2) provide these physicians with feedback on their network and patients, using routine data and (3) give the physicians the opportunity to meet one another in facilitated network meetings. METHODS: The Accountable Care Deutschland (ACD) study is a prospective, non-blinded, cluster-randomised trial comprising a process and economic evaluation of informal networks among 12,525 GPs and office-based specialists and their 1.9 million patients. The units of allocation are the informal networks, which will be randomised either to the intervention (feedback and facilitated meetings) or control group (usual care). The informal networks will be generated by identifying connections between office-based physicians using complete datasets from the Regional Associations of Statutory Health Insurance (SHI) Physicians in Hamburg, Schleswig Holstein, North Rhine and Westphalia Lip, as well as data from three large statutory health insurers in Germany. The physicians will (a) receive feedback on selected indicators of their own treatment activity and that of the colleagues in their network and (b) will be invited to voluntary, facilitated network meetings by their Regional Association of SHI physicians. The primary outcome will be ambulatory-care-sensitive hospitalisations at baseline, at the end of the 2-year intervention period, and at six months and at 12 months after the end of the intervention period. Data will be analysed using the intention-to-treat principle. A pilot study preceded the ACD study. DISCUSSION: Cochrane reviews show that feedback can improve everyday medical practice by shedding light on previously unknown relationships. Providing physicians with information on how they are connected with their colleagues and what the outcomes are of care delivered within their informal networks can help them make these improvements, as well as strengthen their awareness of possible discontinuities in the care they provide. TRIAL REGISTRATION: German Clinical Trials Register DRKS00020884 . Registered on 25 March 2020-retrospectively registered.