Breast cancer patients enrolled in the Swiss mammography screening program "donna" demonstrate prolonged survival.

STUDY GOAL: We compared the survival rates of women with breast cancer (BC) detected within versus outside the mammography screening program (MSP) "donna". METHODS: We merged data from the MSP with the data from corresponding cancer registries to categorize BC cases as within MSP (screen-detected and interval carcinomas) and outside the MSP. We analyzed the tumor stage distribution, tumor characteristics and the survival of the women. We further estimated hazard ratios using Cox-regressions to account for different characteristics between groups and corrected the survival rates for lead-time bias. RESULTS: We identified 1057 invasive (ICD-10: C50) and in-situ (D05) BC cases within the MSP and 1501 outside the MSP between 2010 and 2019 in the Swiss cantons of St. Gallen and Grisons. BC within the MSP had a higher share of stage I carcinoma (46.5% vs. 33.0%; p < 0.01), a smaller (mean) tumor size (19.1 mm vs. 24.9 mm, p < 0.01), and fewer recurrences and metastases in the follow-up period (6.7% vs. 15.6%, p < 0.01). The 10-year survival rates were 91.4% for women within and 72.1% for women outside the MSP (p < 0.05). Survival difference persisted but decreased when women within the same tumor stage were compared. Lead-time corrected hazard ratios for the MSP accounted for age, tumor size and Ki-67 proliferation index were 0.550 (95% CI 0.389, 0.778; p < 0.01) for overall survival and 0.469 (95% CI 0.294, 0.749; p < 0.01) for BC related survival. CONCLUSION: Women participating in the "donna" MSP had a significantly higher overall and BC related survival rate than women outside the program. Detection of BC at an earlier tumor stage only partially explains the observed differences.

Medication adherence halves COPD patients' hospitalization risk - evidence from Swiss health insurance data.

Medication adherence is vital for patients suffering from Chronic Obstructive Pulmonary Disease (COPD) to mitigate long-term consequences. The impact of poor medication adherence on inferior outcomes like exacerbations leading to hospital admissions is yet to be studied using real-world data. Using Swiss claims data from 2015-2020, we group patients into five categories according to their medication possession ratio. By employing a logistic regression, we quantify each category's average treatment effect of the medication possession ratio on hospitalized exacerbations. 13,557 COPD patients are included in the analysis. Patients with high medication adherence (daily medication reserve of 80% to 100%) are 51% less likely to incur exacerbation following a hospital stay than patients with the lowest medication adherence (daily medication reserve of 0% to 20%). The study shows that medication adherence varies strongly among Swiss COPD patients. Furthermore, high medication adherence immensely decreases the risk of hospitalized exacerbations.

The association of hospital profitability and digital maturity - An explorative study using data from the German DigitalRadar project.

INTRODUCTION: German hospitals largely rely on public investments for digitization. As these have been insufficient, hospitals had to use own profits to foster digital transformation. Thus, we assess if profitability affects digital maturity, and what other factors might be influential. METHODS: We use digital maturity data from the DigitalRadar (DR) project (2021) and financial statement data from the Hospital Rating Report from 2017 to 2019 (n = 860). We run linear regressions with the DR-score (continuous variable from 0 to 100) as dependent and three-year average EBITDA margin as independent variable. Besides, we conduct subgroup analyses stratifying by chain size. RESULTS: A one percentage point EBITDA margin increase is associated with a 0.359 points DR-score increase (p<0.01). This relationship holds in significance and holds or increases in magnitude for all specifications except when adding chain beds (0.212 point DR-score increase, p<0.05). Besides, chain membership and chain size are positively and significantly associated with hospitals' DR-score. EBITDA margins of the subgroups "large chains" and "Big 3″, i.e., the three largest chains, were strongly associated with the DR-score (2.685 and 3.197 points DR-score increase respectively, p<0.01). CONCLUSIONS: Higher profitability is associated with higher digital maturity. Larger chains are digitally more mature, because (1) they might follow a chain-wide IT-strategy, (2) can standardize IT-architecture, and policies and (3) might cross-finance investments.

Gender health gap pre- and post-joint arthroplasty: identifying affected patient-reported health domains.

BACKGROUND: As patient-reported outcomes (PROs) gain prominence in hip and knee arthroplasty (HA and KA), studies indicate PRO variations between genders. Research on the specific health domains particularly impacted is lacking. Hence, we aim to quantify the gender health gap in PROs for HA/KA patients, differentiating between general health, health-related quality of life (HrQoL), physical functioning, pain, fatigue, and depression. METHODS: The study included 3,693 HA patients (1,627 men, 2,066 women) and 3,110 KA patients (1,430 men, 1,680 women) receiving surgery between 2020 to 2021 in nine German hospitals, followed up until March 2022. Questionnaires used were: EQ-VAS, EQ-5D-5L, HOOS-PS, KOOS-PS, PROMIS-F-SF, PROMIS-D-SF, and a joint-specific numeric pain scale. PROs at admission, discharge, 12-months post-surgery, and the change from admission to 12-months (PRO-improvement) were compared by gender, tested for differences, and assessed using multivariate linear regressions. To enable comparability, PROs were transformed into z-scores (standard deviations from the mean). RESULTS: Observed differences between genders were small in all health domains and differences reduced over time. Men reported significantly better health versus women pre-HA (KA), with a difference of 0.252 (0.224) standard deviations from the mean for pain, 0.353 (0.243) for fatigue (PROMIS-F-SF), 0.327 (0.310) for depression (PROMIS-D-SF), 0.336 (0.273) for functionality (H/KOOS-PS), 0.177 (0.186) for general health (EQ-VAS) and 0.266 (0.196) for HrQoL (EQ-5D-5L). At discharge, the gender health gap reduced and even disappeared for some health dimensions since women improved in health to a greater extent than men. No gender health gap was observed in most PRO-improvements and at month 12. CONCLUSIONS: Men experiencing slightly better health than women in all health dimensions before surgery while experiencing similar health benefits 12-months post-surgery, might be an indicator of men receiving surgery inappropriately early, women unnecessarily late or both. As studies often investigate the PRO-improvement, they miss pre-surgery gender differences, which could be an important target for improvement initiatives in patient-centric care. Moreover, future research on cutoffs for meaningful between-group PRO differences per measurement time would aid the interpretation of gender health disparities. TRIAL REGISTRATION: German Register for Clinical Trials, DRKS00019916, 26 November 2019.

What is the association between gender and self-perceived health status when controlling for disease-specific conditions? A retrospective data analysis of pre- and post-operative EQ-5D-5L differences in total hip and knee arthroplasty.

BACKGROUND: The self-perceived health status of patients undergoing total hip and knee arthroplasty (THA and TKA) might differ post-operatively due to gender, age, or comorbidities. Patient-reported outcome measures (PROMs) such as the EQ-5D-5L measure the self-perceived health status. This study investigates whether the index score of the EQ-5D-5L is a valid tool for interpreting gender differences in outcomes for patients undergoing THA and TKA. METHODS: Routine and PROM-data of elective primary THA or TKA patients in two German hospitals between 2016 and 2018 were analyzed. Univariate analysis with Pearson's chi-square was conducted to identify control variables for gender. To quantify the association between gender and the EQ-5D-5L dimensions, a cumulative odds ordinal logistic regression with proportional odds was conducted. RESULTS: Two thousand three hundred sixty-eight​​ THA patients (m = 978; f = 1390) and 1629 TKA patients (m = 715; f = 914) were considered. The regression analysis of the individual EQ-5D-5L dimensions showed that female gender was significantly associated with better self-care (THA and TKA) and better post-operative mobility (THA). In contrast, male gender was significantly associated with less pain/discomfort (TKA) and less anxiety/depression (THA) pre-surgery and 3-months post-surgery. CONCLUSION: Our results confirmed that the self-perceived health status improved after surgery. However, due to the different associations of gender to the individual dimensions of the EQ-5D-5L, the weighted index score clouds the comparability between patients with different gender undergoing THA or TKA. Therefore, we argue to use the individual five dimensions for health status analysis, to reveal relevant additional information.

Patients undergoing total hip and knee arthroplasty (THA and TKA) can fill out standardized questionnaires pre- and post-surgery, such as the EQ-5D-5L, to measure the improvement in the self-perceived health status. The EQ-5D-5L includes mobility, self-care, usual activity, pain/discomfort, and anxiety/depression. We do not know whether male and female patients experience the same improvement in the dimensions or whether significant differences exist. Currently, only index scores of the EQ-5D-5L are used for the comparison of pre- and post-operative health status. However, due to the questionnaire's weighted composition, relevant changes in individual dimensions might be easily missed. Thus, we investigated whether significant differences between gender and the EQ-5D-5L dimensions in patients undergoing TKA and TKA are observable. We found that female patients reported significantly better scores in self-care (THA and TKA) and post-operative mobility (THA). In contrast, male gender was significantly associated with less pain/discomfort (TKA) and less anxiety/depression (THA) pre-surgery and 3-months post-surgery. The EQ-5D-5L's weighted index score, however, does not directly represent these differences. Therefore, we argue to use the individual five dimensions for health status analysis, as relevant additional information on improvement over time would otherwise be missed.

Making the cut on caesarean section: a logistic regression analysis on factors favouring caesarean sections without medical indication in comparison to spontaneous vaginal birth.

BACKGROUND: In the absence of medical necessity, opting for caesarean sections exposes mothers and neonates to increased risks of enduring long-term health problems and mortality. This ultimately results in greater economic burden when compared to the outcomes of spontaneous vaginal births. In Switzerland around 33% of all births are by caesarean section. However, the rate of caesarean sections without medical indication is still unknown. Therefore, we devise an identification strategy to differentiate caesarean sections without medical indication using routine data. In addition, we aim to categorize the influencing factors for women who undergo spontaneous vaginal births as opposed to those with caesarean sections without medical indication. METHOD: We use Swiss Federal Statistics data including 98.3% of all women giving birth from 2014 to 2018. To determine non-medically indicated caesarean sections in our dataset, we base our identification strategy on diagnosis-related groups, diagnosis codes, and procedure classifications. Subsequently, we compare characteristics of women who give birth by non-medically CS and external factors such as the density of practicing midwives to women with spontaneous vaginal birth. Logistic regression analysis measures the effect of factors, such as age, insurance class, income, or density of practicing midwives on non-medically indicated caesarean sections. RESULTS: Around 8% of all Swiss caesarean sections have no medical indication. The regression analysis shows that higher age, supplemental insurance, higher income, and living in urban areas are associated with non-medically indicated caesarean sections, whereas a higher density of midwives decreases the likelihood of caesarean sections without medical indication. CONCLUSIONS: By identifying non-medically indicated caesarean sections using routine data, it becomes feasible to gain insights into the characteristics of impacted mothers as well as the external factors involved. Illustrating these results, our recommendation is to revise the incentive policies directed towards healthcare professionals. Among others, future research may investigate the potential of midwife-assisted pregnancy programs on strengthening spontaneous vaginal births in absence of medical complications.

Electronic Patient-Reported Outcome Monitoring to Improve Quality of Life After Joint Replacement: Secondary Analysis of a Randomized Clinical Trial.

Importance: Although remote patient-reported outcome measure (PROM) monitoring has shown promising results in cancer care, there is a lack of research on PROM monitoring in orthopedics. Objective: To determine whether PROM monitoring can improve health outcomes for patients with joint replacement compared with the standard of care. Design, Setting, and Participants: A 2-group, patient-level randomized clinical trial (PROMoting Quality) across 9 German hospitals recruited patients aged 18 years or older with primary hip or knee replacement from October 1, 2019, to December 31, 2020, with follow-up until March 31, 2022. Interventions: Intervention and control groups received the standard of care and PROMs at hospital admission, discharge, and 12 months after surgery. In addition, the intervention group received PROMs at 1, 3, and 6 months after surgery. Based on prespecified PROM score thresholds, at these times, an automated alert signaled critical recovery paths to hospital study nurses. On notification, study nurses contacted patients and referred them to their physicians if necessary. Main Outcomes and Measures: The prespecified outcomes were the mean change in PROM scores (European Quality of Life 5-Dimension 5-Level version [EQ-5D-5L; range, -0.661 to 1.0, with higher values indicating higher levels of health-related quality of life (HRQOL)], European Quality of Life Visual Analogue Scale [EQ-VAS; range, 0-100, with higher values indicating higher levels of HRQOL], Hip Disability and Osteoarthritis Outcome Score-Physical Function Shortform [HOOS-PS; range, 0-100, with lower values indicating lower physical impairment] or Knee Injury and Osteoarthritis Outcome Score-Physical Function Shortform [KOOS-PS; range, 0-100, with lower values indicating lower physical impairment], Patient-Reported Outcomes Measurement Information System [PROMIS]-fatigue [range, 33.7-75.8, with lower values indicating lower levels of fatigue], and PROMIS-depression [range, 41-79.4, with lower values indicating lower levels of depression]) from baseline to 12 months after surgery. Analysis was on an intention-to-treat basis. Results: The study included 3697 patients with hip replacement (mean [SD] age, 65.8 [10.6] years; 2065 women [55.9%]) and 3110 patients with knee replacement (mean [SD] age, 66.0 [9.2] years; 1669 women [53.7%]). Exploratory analyses showed significantly better health outcomes in the intervention group on all PROMs except the EQ-5D-5L among patients with hip replacement, with a 2.10-point increase on the EQ-VAS in the intervention group compared with the control group (HOOS-PS, -1.86 points; PROMIS-fatigue, -0.69 points; PROMIS-depression, -0.57 points). Patients in the intervention group with knee replacement had a 1.24-point increase on the EQ-VAS, as well as significantly better scores on the KOOS-PS (-0.99 points) and PROMIS-fatigue (-0.84 points) compared with the control group. Mixed-effect models showed a significant difference in improvement on the EQ-VAS (hip replacement: effect estimate [EE], 1.66 [95% CI, 0.58-2.74]; knee replacement: EE, 1.71 [95% CI, 0.53-2.90]) and PROMIS-fatigue (hip replacement: EE, -0.65 [95% CI, -1.12 to -0.18]; knee replacement: EE, -0.71 [95% CI, -1.23 to -0.20]). The PROMIS-depression score was significantly reduced in the hip replacement group (EE, -0.60 [95% CI, -1.01 to -0.18]). Conclusions and Relevance: In this randomized clinical trial, the PROM-based monitoring intervention led to a small improvement in HRQOL and fatigue among patients with hip or knee replacement, as well as in depression among patients with hip replacement. Trial registration: Deutsches Register Klinischer Studien ID: DRKS00019916.

Robotic-assisted surgery for prostatectomy - does the diffusion of robotic systems contribute to treatment centralization and influence patients' hospital choice?

BACKGROUND: Between 2008 and 2018, the share of robotic-assisted surgeries (RAS) for radical prostatectomies (RPEs) has increased from 3 to 46% in Germany. Firstly, we investigate if this diffusion of RAS has contributed to RPE treatment centralization. Secondly, we analyze if a hospital's use of an RAS system influenced patients' hospital choice. METHODS: To analyze RPE treatment centralization, we use (bi-) annual hospital data from 2006 to 2018 for all German hospitals in a panel-data fixed effect model. For investigating RAS systems' influence on patients' hospital choice, we use patient level data of 4614 RPE patients treated in 2015. Employing a random utility choice model, we estimate the influence of RAS as well as specialization and quality on patients' marginal utilities and their according willingness to travel. RESULTS: Despite a slight decrease in RPEs between 2006 and 2018, hospitals that invested in an RAS system could increase their case volumes significantly (+ 82% compared to hospitals that did not invest) contributing to treatment centralization. Moreover, patients are willing to travel longer for hospitals offering RAS (+ 22% than average travel time) and for specialization (+ 13% for certified prostate cancer treatment centers, + 9% for higher procedure volume). The influence of outcome quality and service quality on patients' hospital choice is insignificant or negligible. CONCLUSIONS: In conclusion, centralization is partly driven by (very) high-volume hospitals' investment in RAS systems and patient preferences. While outcome quality might improve due to centralization and according specialization, evidence for a direct positive influence of RAS on RPE outcomes still is ambiguous. Patients have been voting with their feet, but research yet has to catch up.

A composite measure for patient-reported outcomes in orthopedic care: design principles and validity checks.

BACKGROUND: The complex, multidimensional nature of healthcare quality makes provider and treatment decisions based on quality difficult. Patient-reported outcome (PRO) measures can enhance patient centricity and involvement. The proliferation of PRO measures, however, requires a simplification to improve comprehensibility. Composite measures can simplify complex data without sacrificing the underlying information. OBJECTIVE AND METHODS: We propose a five-step development approach to combine different PRO into one composite measure (PRO-CM): (i) theoretical framework and metric selection, (ii) initial data analysis, (iii) rescaling, (iv) weighting and aggregation, and (v) sensitivity and uncertainty analysis. We evaluate different rescaling, weighting, and aggregation methods by utilizing data of 3145 hip and 2605 knee replacement patients, to identify the most advantageous development approach for a PRO-CM that reflects quality variations from a patient perspective. RESULTS: The comparison of different methods within steps (iii) and (iv) reveals the following methods as most advantageous: (iii) rescaling via z-score standardization and (iv) applying differential weights and additive aggregation. The resulting PRO-CM is most sensitive to variations in physical health. Changing weighting schemes impacts the PRO-CM most directly, while it proves more robust towards different rescaling and aggregation approaches. CONCLUSION: Combining multiple PRO provides a holistic picture of patients' health improvement. The PRO-CM can enhance patient understanding and simplify reporting and monitoring of PRO. However, the development methodology of a PRO-CM needs to be justified and transparent to ensure that it is comprehensible and replicable. This is essential to address the well-known problems associated with composites, such as misinterpretation and lack of trust.

Service-, needs-, and quality-based hospital capacity planning - The evolution of a revolution in Switzerland.

Most developed countries spend a large amount of their health budget on hospital capacities and inpatient services. However, those capacities and services are often not comprehensively planned what leads to vague service delivery steering and non-need driven hospital facilities. Switzerland is different as the planning procedure was completely reformed in 2012 and is further refined in 2021/2022. The Canton of Zurich, the frontrunner in Switzerland, has made a comprehensive update of its hospital capacity planning model for acute, psychiatric, and rehabilitative care. The result of this model is the hospital list. This list includes all hospitals which fulfill predefined quality, efficiency, and need requirements. Hospitals on the list receive a mandate to provide inpatient treatments for specific and selected service groups (n = 196), clustered in three areas (acute care, psychiatry, rehabilitation). The underlying health care policy process is transparent and is characterized by a high participation of all relevant actors. The building blocks of the planning model are a classification system of service groups, different quality and efficiency requirements attached to these groups, and an analysis of current and future need for health care. Hospitals which are willing to perform services must apply and demonstrate that the requirements are fulfilled. The canton then decides needs-based which hospital can deliver which services.

How Denmark, England, Estonia, France, Germany, and the USA Pay for Variable, Specialized and Low Volume Care: A Cross-country Comparison of In-patient Payment Systems.

BACKGROUND: Diagnosis-related group (DRG)-based hospital payment can potentially be inadequately low (or high) for highly variable, highly specialized, and/or low volume care. DRG-based payment can be combined with other payment mechanisms to avoid unintended consequences of inadequate payment. The aim of this study was to analyze these other payment mechanisms for acute inpatient care across six countries (Germany, Denmark, England, Estonia, France, the United States [Medicare]). METHODS: Information was collected about elements excluded from DRG-based payment, the rationale for exclusions, and payment mechanisms complementing DRG-based payment. A conceptual framework was developed to systematically describe, visualise and compare payment mechanisms across countries. RESULTS: Results show that the complexity of exclusion mechanisms and associated additional payment components differ across countries. England and Germany use many different additional mechanisms, while there are only few exceptions from DRG-based payment in the Medicare program in the United States. Certain areas of care are almost always excluded (eg, certain areas of cancer care or specialized pediatrics). Denmark and England use exclusion mechanisms to steer service provision for highly complex patients to specialized providers. CONCLUSION: Implications for researchers and policy-makers include: (1) certain areas of care might be better excluded from DRG-based payment; (2) exclusions may be used to incentivize the concentration of highly specialized care at specialized institutions (as in Denmark or England); (3) researchers may apply our analytical framework to better understand the specific design features of DRG-based payment systems.

Thresholds for meaningful improvement in WOMAC scores need to be adjusted to patient characteristics after hip and knee replacement.

PURPOSE: To calculate unstratified and patient-specific meaningful improvement (MI) and patient acceptable symptom states (PASS) for the WOMAC total score in patients after total hip (THR) or total knee replacement (TKR). METHODS: A retrospective observational cohort study. Anchor-based receiver operator characteristics curves were used to estimate MI and PASS thresholds. RESULTS: Recovery paths were specific to individual characteristics of patients. An unstratified 12-months MI threshold of 28.1 (PASS: 13.3) and 17.8 (PASS: 15.8) for patients after THR and TKR, respectively, would unfairly detect critical recovery paths. CONCLUSIONS: Thresholds for treatment success need to be as patient-specific as possible.

Can competition improve hospital quality of care? A difference-in-differences approach to evaluate the effect of increasing quality transparency on hospital quality.

Public reporting on the quality of care is intended to guide patients to the provider with the highest quality and to stimulate a fair competition on quality. We apply a difference-in-differences design to test whether hospital quality has improved more in markets that are more competitive after the first public release of performance data in Germany in 2008. Panel data from 947 hospitals from 2006 to 2010 are used. Due to the high complexity of the treatment of stroke patients, we approximate general hospital quality by the 30-day risk-adjusted mortality rate for stroke treatment. Market structure is measured (comparatively) by the Herfindahl-Hirschman index (HHI) and by the number of hospitals in the relevant market. Predicted market shares based on exogenous variables only are used to compute the HHI to allow a causal interpretation of the reform effect. A homogenous positive effect of competition on quality of care is found. This effect is mainly driven by the response of non-profit hospitals that have a narrow range of services and private for-profit hospitals with a medium range of services. The results highlight the relevance of outcome transparency to enhance hospital quality competition.

Defining minimum volume thresholds to increase quality of care: a new patient-oriented approach using mixed integer programming.

A positive relationship between treatment volume and outcome quality has been demonstrated in the literature and is thus evident for a variety of procedures. Consequently, policy makers have tried to translate this so-called volume-outcome relationship into minimum volume regulation (MVR) to increase the quality of care-yet with limited success. Until today, the effect of strict MVR application remains unclear as outcome quality gains cannot be estimated adequately and restrictions to application such as patient travel time and utilization of remaining hospital capacity are not considered sufficiently. Accordingly, when defining MVR, its effectiveness cannot be assessed. Thus, we developed a mixed integer programming model to define minimum volume thresholds balancing utility in terms of outcome quality gain and feasibility in terms of restricted patient travel time and utilization of hospital capacity. We applied our model to the German hospital sector and to four surgical procedures. Results showed that effective MVR needs a minimum volume threshold of 125 treatments for cholecystectomy, of 45 and 25 treatments for colon and rectum resection, respectively, of 32 treatments for radical prostatectomy and of 60 treatments for total knee arthroplasty. Depending on procedure type and incidence as well as the procedure's complication rate, outcome quality gain ranged between 287 (radical prostatectomy) and 977 (colon resection) avoidable complications (11.7% and 11.9% of all complications). Ultimately, policy makers can use our model to leverage MVR's intended benefit: concentrating treatment delivery to improve the quality of care.

[Quality Variation in Switzerland: Analysis of Mammary Resections for Breast Cancer using the Quality Indicator of Breast Preservation]. / Qualitätsvariation in der Schweiz: Analyse der Mamma-Resektionen bei Brustkrebs anhand des Qualitätsindikators der Brusterhaltung.

AIM OF STUDY: The aim of the study was to investigate whether there are regional differences in the treatment results of elective mammary resections for breast cancer in Switzerland and, if so, whether a possible cause could be found in the hospital planning by the cantons. METHODS: Using the Inpatient Quality Indicators (CH-IQI), the quality of outcomes was analysed at the level of the Swiss cantons and compared with the cantonal requirements for carrying out this treatment. RESULTS: Cantonal differences became apparent both in the quality of results based on the quality indicator of breast preservation and in the level of detail of the requirements for structural and process quality. CONCLUSION: The quality of treatment in Switzerland can hardly be compared in a transparent manner; interpreting the available quality information is demanding and hardly possible for patients. In order to reduce the quality differences shown, hospital planning should be intercantonal, as is the case in highly specialised medicine.

The impact of quality on hospital choice. Which information affects patients' behavior for colorectal resection or knee replacement?

Quality competition among hospitals, induced by patients freely choosing their hospital in a price regulated market, can only be realized if quality differences between hospitals are transparent, understandable, and thus influence patients' hospital choice. We use data from ~145,000 German patients and ~ 900 hospitals for colorectal resections and knee replacements to investigate whether patients value quality and specialization when choosing their hospital. Using a random utility choice model, we estimate patients' marginal utilities, willingness to travel and change in hospital demand for quality improvements. Patients respond to service quality and specialization and thus, quality competition seems to be present. Colorectal resection patients are willing to travel longer for more specialized hospitals (+9% for procedure volume, +9% for certification). Knee replacement patients travel longer for hospitals with better service quality (+6%) and higher procedure volume (+12%). However, clinical quality indicators, often difficult to access and interpret, barely play a role in patients' hospital choice. Furthermore, we find that competition on quality for colorectal resection is rather local, whereas for knee replacement we observe regional competition patterns.

The use of digitally collected patient-reported outcome measures for newly operated patients with total knee and hip replacements to improve post-treatment recovery: study protocol for a randomized controlled trial.

BACKGROUND: The number of total knee replacements (TKRs) and total hip replacements (THRs) has been increasing noticeably in high-income countries, such as Germany. In particular, the number of revisions is expected to rise because of higher life expectancy and procedures performed on younger patients, impacting the budgets of health-care systems. Quality transparency is the basis of holistic patient pathway optimization. Nevertheless, a nation-wide cross-sectoral assessment of quality from a patient perspective does not yet exist. Several studies have shown that the use of patient-reported outcome measures (PROMs) is effective for measuring quality and monitoring post-treatment recovery. For the first time in Germany, we test whether early detection of critical recovery paths using PROMs after TKR/THR improves the quality of care in a cost-effective way and can be recommended for implementation into standard care. METHODS/DESIGN: The study is a two-arm multi-center patient-level randomized controlled trial. Patients from nine hospitals are included in the study. Patient-centered questionnaires are employed to regularly measure digitized PROMs of TKR/THR patients from the time of hospital admission until 12 months post-discharge. An expert consortium has defined PROM alert thresholds at 1, 3, and 6 months to signal critical recovery paths after TKR/THR. An algorithm alerts study assistants if patients are not recovering in line with expected recovery paths. The study assistants contact patients and their physicians to investigate and, if needed, adjust the post-treatment protocol. When sickness funds' claims data are added, the cost-effectiveness of the intervention can be analyzed. DISCUSSION: The study is expected to deliver an important contribution to test PROMs as an intervention tool and examine the determinants of high-quality endoprosthetic care. Depending on a positive and cost-effective impact, the goal is to transfer the study design into standard care. During the trial design phase, several insights have been discovered, and there were opportunities for efficient digital monitoring limited by existing legacy care models. Digitalization in hospital processes and the implementation of digital tools still represent challenges for hospital personnel and patients. Furthermore, data privacy regulations and the separation between the in- and outpatient sector are roadblocks to effectively monitor and assess quality along the full patient pathway. TRIAL REGISTRATION: German Clinical Trials Register: DRKS00019916. Registered November 26, 2019 - retrospectively registered.

Emergency and urgent care systems in Australia, Denmark, England, France, Germany and the Netherlands - Analyzing organization, payment and reforms.

INTRODUCTION: Increasing numbers of hospital emergency department (ED) visits pose a challenge to health systems in many countries. This paper aims to examine emergency and urgent care systems, in six countries and to identify reform trends in response to current challenges. METHODS: Based on a literature review, six countries - Australia, Denmark, England, France, Germany and the Netherlands - were selected for analysis. Information was collected using a standardized questionnaire that was completed by national experts. These experts reviewed relevant policy documents and provided information on (1) the organization and planning of emergency and urgent care, (2) payment systems for EDs and urgent primary care providers, and (3) reform initiatives. RESULTS: In the six countries four main reform approaches could be identified: (a) extending the availability of urgent primary care, (b) concentrating and centralizing the provision of urgent primary care, (c) improving coordination between urgent primary care and emergency care, and (d) concentrating emergency care provision at fewer institutions. The design of payment systems for urgent primary care and for emergency care is often aligned to support these reforms. CONCLUSION: Better guidance of patients and a reconfiguration of emergency and urgent care are the most important measures taken to address the current challenges. Nationwide planning of all emergency care providers, closely coordinated reforms and informing patients can support future reforms.

Stroke units, certification, and outcomes in German hospitals: a longitudinal study of patient-based 30-day mortality for 2006-2014.

BACKGROUND: Treatment of stroke patients in stroke units has increased and studies have shown improved outcomes. However, a large share of patients in Germany is still treated in hospitals without stroke unit. The effects of stroke unit service line, and total hospital quality certification on outcomes remain unclear. METHODS: We employ annual hospital panel data for 1100-1300 German hospitals from 2006 to 2014, which includes structural data and 30-day standardized mortality. We estimate hospital- and time-fixed effects regressions with three main independent variables: (1) stroke unit care, (2) stroke unit certification, and (3) total hospital quality certification. RESULTS: Our results confirm the trend of decreasing stroke mortality ratios, although to a much lesser degree than previous studies. Descriptive analysis illustrates better stroke outcomes for non-certified and certified stroke units and hospitals with total hospital quality certification. In a fixed effects model, having a stroke unit has a significant quality-enhancing effect, lowering stroke mortality by 5.6%, while there is no significant improvement effect for stroke unit certification or total hospital quality certification. CONCLUSIONS: Patients and health systems may benefit substantially from stroke unit treatment expansion as installing a stroke unit appears more meaningful than getting it certified or obtaining a total hospital quality certification. Health systems should thus prioritize investment in stroke unit infrastructure and centralize stroke care in stroke units. They should also prioritize patient-based 30-day mortality data as it allows a more realistic representation of mortality than admission-based data.

Quality and resource efficiency in hospital service provision: A geoadditive stochastic frontier analysis of stroke quality of care in Germany.

We specify a Bayesian, geoadditive Stochastic Frontier Analysis (SFA) model to assess hospital performance along the dimensions of resources and quality of stroke care in German hospitals. With 1,100 annual observations and data from 2006 to 2013 and risk-adjusted patient volume as output, we introduce a production function that captures quality, resource inputs, hospital inefficiency determinants and spatial patterns of inefficiencies. With high relevance for hospital management and health system regulators, we identify performance improvement mechanisms by considering marginal effects for the average hospital. Specialization and certification can substantially reduce mortality. Regional and hospital-level concentration can improve quality and resource efficiency. Finally, our results demonstrate a trade-off between quality improvement and resource reduction and substantial regional variation in efficiency.