Development and implementation of quality indicators in a group of nine psychiatric hospitals.

Quality indicators (QI) are becoming increasingly important in mental healthcare in Germany. QI can be used for various purposes, such as for creating transparency as well as for benchmarking between hospitals. QI themselves are subject to high quality standards. The aim of this report is to describe the development and implementation of QI in a group of psychiatric hospitals. Since 2015, the LVR hospital group has developed and gradually implemented QI for the purposes of quality measurement, quality assurance and internal benchmarking in its nine psychiatric hospitals in a comprehensive, multidisciplinary, scientifically accompanied process. The full LVR-QI set, consisting of eight structure-, twelve process- and four outcome indicators as well as one patient satisfaction questionnaire, was implemented by 2019. In order to create high documentation quality and acceptance by clinicians, various implementation and dissemination strategies were used, such as written documentation manuals, staff training as well as regular face-to-face communication between the LVR hospitals, the LVR Institute for Health Services Research as the central coordinating body and the headquarters of the LVR hospital group. The QI led to a quality-oriented dialogue within and between the LVR hospitals.

Inpatient Suicides in Late Life: A Retrospective Analysis of a Hospital Group with Nine Psychiatric Clinics.

OBJECTIVE: Inpatient suicides are rare incidents; however, the impacts of such events on associated families and hospital staff are severe. Therefore, preventive strategies need to focus on risk factors. Clinical management in a hospital setting must integrate the home environment and social life of patients. Nevertheless, home leaves require careful preparation. METHODS: Suicides were reported systematically from all psychiatric departments of the Landschaftsverband Rheinland (an assembly of municipalities) using a structured form during two periods (1995-2004, 2005-2014). From these reports we extracted data on suicide methods and sociodemographic and clinical variables. Only patients 65 years and older were included. RESULTS: From a total of 551 reports on suicides in the period of 1995-2014, 103 patients 65 years and older (60 women, 43 men) died by suicide. In contrast to the general trend in Germany during this period, no decline in overall suicide rates was found. Most patients were treated because of depression (73.8%); schizophrenic psychosis was diagnosed in 11.7%; and dementia was only diagnosed in 1.9%. The most frequent suicide method was hanging (40%). All suicides within the hospital were hangings. The majority of suicides occurred outside the hospital during approved home leaves. Only 7% of suicides occurred when patients left the hospital without permission. Almost half of the patients (n = 44) died by suicide during the first month of treatment. With longer duration of hospitalization, the risk of suicide decreased. There were no significant trends with regard to suicide methods between the two periods. CONCLUSIONS: In the first weeks of hospitalizations the patients are most endangered to die by suicide. Therefore, home leaves need careful consideration.

Volume-outcome relationship and minimum volume regulations in the German hospital sector - evidence from nationwide administrative hospital data for the years 2005-2007.

BACKGROUND: This paper analyses the volume-outcome relationship and the effects of minimum volume regulations in the German hospital sector. METHODS: We use a full sample of administrative data from the unselected, complete German hospital population for the years 2005 to 2007. We apply regression methods to analyze the association between volume and hospital quality. We measure hospital quality with a binary variable, which indicates whether the patient has died in hospital. Using simulation techniques we examine the impact of the minimum volume regulations on the accessibility of hospital services. RESULTS: We find a highly significant negative relationship between case volume and mortality for complex interventions at the pancreas and oesophagus as well as for knee replacement. For liver, kidney and stem cell transplantation as well as for CABG we could not find a strong association between volume and quality. Access to hospital care is only moderately affected by minimum volume regulations. CONCLUSION: The effectiveness of minimum volume regulations depends on the type of intervention. Depending on the type of intervention, quality gains can be expected at the cost of slightly decreased access to care.

The Volume-Outcome Relationship Revisited: Practice Indeed Makes Perfect.

OBJECTIVE: To examine the causal effect of a hospital's experience with treating hip fractures (volume) on patient treatment outcomes. DATA SOURCES: We use a full sample of administrative data from German hospitals for 2007. The data provide detailed information on patients and hospitals. We also reference the hospitals' addresses and the zip codes of patients' place of residence. STUDY DESIGN: We apply an instrumental variable approach to address endogeneity concerns due to reverse causality and unobserved patient heterogeneity. As instruments for case volume, we use the number of potential patients and number of other hospitals in the region surrounding each hospital. PRINCIPAL FINDINGS: Our results indicate that after applying an instrumental variables (IV) regression of volume on outcome, volume significantly increases quality. CONCLUSIONS: We provide evidence for the practice-makes-perfect hypothesis by showing that volume is a driving factor for quality.

The volume-outcome relationship and minimum volume standards--empirical evidence for Germany.

For decades, there is an ongoing discussion about the quality of hospital care leading i.a. to the introduction of minimum volume standards in various countries. In this paper, we analyze the volume-outcome relationship for patients with intact abdominal aortic aneurysm and hip fracture. We define hypothetical minimum volume standards in both conditions and assess consequences for access to hospital services in Germany. The results show clearly that patients treated in hospitals with a higher case volume have on average a significant lower probability of death in both conditions. Furthermore, we show that the hypothetical minimum volume standards do not compromise overall access measured with changes in travel times.

Concentration of gynaecology and obstetrics in Germany: is comprehensive access at stake?

Financial soundness will become more and more difficult in the future for all types of hospitals. This is particularly relevant for gynaecology and obstetrics departments: while some disciplines can expect higher demand due to demographic changes and progress in medicine and medical technology, the inpatient sector for gynaecology and obstetrics is likely to lose patients in line with these trends. In this paper we estimate future demand for gynaecology and obstetrics in Germany and develop a cost model to calculate the average profitability in this discipline. The number of inpatient cases in gynaecology and obstetrics can be expected to decrease by 3.62% between 2007 and 2020 due to the demographic change and a potential shift from inpatient to outpatient services. Small departments within the fields of gynaecology and obstetrics are already incurring heavy losses, and the anticipated decline in cases should increase this financial distress even more. As such, the further centralisation of services is indicated. We calculate travel times for gynaecology and obstetrics patients and estimate the anticipated changes in travel times by simulating different scenarios for this centralisation process. Our results show that the centralisation of hospital services in gynaecology and obstetrics may be possible without compromising comprehensive access as measured by travel times.

Defining hospital markets - an application to the German hospital sector.

The correct definition of the product market and of the geographic market is a prerequisite for assessing market structures in antitrust cases. For hospital markets, both dimensions are controversially discussed in the literature. Using data for the German hospital market we aim at elaborating the need for differentiating the product market and at investigating the effects of different thresholds for the delineation of the geographic market based on patient flows. Thereby we contribute to the scarce empirical evidence on the structure of the German hospital market. We find that the German hospital sector is highly concentrated, confirming the results of a singular prior study. Furthermore, using a very general product market definition such as "acute in-patient care" averages out severe discrepancies that become visible when concentration is considered on the level of individual diagnoses. In contrast, varying thresholds for the definition of the geographic market has only impact on the level of concentration, while the correlation remains high. Our results underline the need for more empirical research concerning the definition of the product market for hospital services.

Explaining differences in remuneration rates of nursing homes in Germany.

Remuneration rates of German nursing homes are prospectively negotiated between long-term care insurance (LTCI) and social assistance on the one side and nursing homes on the other. They differ considerably across regions while there is no evidence for substantial differences in care provision. This article explains the differences in the remuneration rates by observable characteristics of the nursing home, its residents and its region with a special focus on the largest federal state of North Rhine Westphalia, in which the most expensive nursing homes are located. We use data from the German Federal Statistical Office for 2005 on all nursing homes that offer full-time residential care for the elderly. We find that differences in remuneration rates can partly be explained by exogenous factors. Controls for residents, nursing homes and district characteristics explain roughly 30 % of the price difference; 40 % can be ascribed to a regionally different kind of negotiation between nursing homes and LTCI. Thirty percent of the raw price difference remains unexplained by observable characteristics.

The trade-off between efficiency and quality in hospital departments.

PURPOSE: Hospital managers are confronted with decisions that have to account for multiple objectives, which may be in conflict with regard to efficiency and quality of care. In empirical studies occupancy and staffing ratios as well as in-hospital mortality are frequently used measures for efficiency and quality-of-care, respectively. Efficiency and quality measures vary on a daily basis. However, most empirical studies fail to take this variation into account, especially because data of daily staffing levels are lacking. The paper seeks to exploit the notion that staffing levels are planned according to expected occupancy levels, i.e. estimated daily occupancy levels account for unobserved daily staffing levels. DESIGN/METHODOLOGY/APPROACH: Using administrative data from 2004 for a sample of 62 departments in 33 German hospitals, the relation between daily occupancy levels and in-hospital mortality count on the department level is analyzed. In an OLS-framework the paper estimates daily occupancy level for all departments and then uses the predicted occupancy levels in a zero-inflated Poisson (ZIP) regression framework to explain in-hospital mortality count. FINDINGS: The results show a potential trade-off relation between predicted occupancy rates and mortality. More specifically, the paper finds that the trade-off relation is less pronounced in hospitals with a higher number of available staff per bed. ORIGINALITY/VALUE: First, the paper shows evidence for a negative trade-off between measures of managerial and medical performance on a day-to-day basis. Second, interactions between single measures of efficiency are modeled, namely predicted occupancy rate and staff per bed ratios, and policy implications are developed. Third, first empirical results in this respect using German data are presented.