[Minimum Standards for the Spatial Accessibility of Primary Care: A Systematic Review]. / Mindeststandards für die räumliche Erreichbarkeit hausärztlicher Versorgung: Ein systematischer Review.

BACKGROUND: Regional disparities of access to primary care are substantial in Germany, especially in terms of spatial accessibility. However, there is no legally or generally binding minimum standard for the spatial accessibility effort that is still acceptable. Our objective is to analyse existing minimum standards, the methods used as well as their empirical basis. METHODS: A systematic literature review was undertaken of publications regarding minimum standards for the spatial accessibility of primary care based on a title word and keyword search using PubMed, SSCI/Web of Science, EMBASE and Cochrane Library. RESULTS: 8 minimum standards from the USA, Germany and Austria could be identified. All of them specify the acceptable spatial accessibility effort in terms of travel time; almost half include also distance(s). The travel time maximum, which is acceptable, is 30 min and it tends to be lower in urban areas. Primary care is, according to the identified minimum standards, part of the local area (Nahbereich) of so-called central places (Zentrale Orte) providing basic goods and services. The consideration of means of transport, e. g. public transport, is heterogeneous. The standards are based on empirical studies, consultation with service providers, practical experiences, and regional planning/central place theory as well as on legal or political regulations. CONCLUSIONS: The identified minimum standards provide important insights into the effort that is still acceptable regarding spatial accessibility, i. e. travel time, distance and means of transport. It seems reasonable to complement the current planning system for outpatient care, which is based on provider-to-population ratios, by a gravity-model method to identify places as well as populations with insufficient spatial accessibility. Due to a lack of a common minimum standard we propose - subject to further discussion - to begin with a threshold based on the spatial accessibility limit of the local area, i. e. 30 min to the next primary care provider for at least 90% of the regional population. The exceeding of the threshold would necessitate a discussion of a health care deficit and in line with this a potential need for intervention, e. g. in terms of alternative forms of health care provision.

[Memorandum 'Development of health services research in Bavaria from the perspective of the Bavarian State Working Group 'Health Services Research (LAGeV)': status quo - potential - strategies']. / Memorandum "Weiterentwicklung der Gesundheitsversorgungsforschung in Bayern aus Sicht der Landesarbeitsgemeinschaft Gesundheitsversorgungsforschung: Status quo - Entwicklungspotenziale - Strategien".

The aim of the memorandum on the development of health services research (HSR) in Bavaria is to operationalise the global objectives of the State Working Group "Health Services Research" (LAGeV) and to collectively define future topics, specific implementation steps, methods as well as ways of working for the future course of the LAGeV. The LAGeV is an expert committee that integrates and links the competencies of different actors from science, politics and health care regarding HSR and facilitates their cooperation. The memorandum is based on an explorative survey among the LAGeV members, which identified the status quo of health services research in Bavaria, potential for development, important constraints, promoting factors, specific recommendations as well as future topics for the further development of HSR in Bavaria. From the perspective of the LAGeV members, the 12 most important future topics are: 1) Interface and networking research, 2) Innovative health care concepts, 3) Health care for multimorbid patients, 4)Health care for chronically ill patients, 5) Evaluation of innovations, processes and technologies, 6) Patient orientation and user focus, 7) Social and regional inequalities in health care, 8) Health care for mentally ill patients, 9) Indicators of health care quality, 10) Regional needs planning, 11) Practical effectiveness of HSR and 12) Scientific use of routine data. Potential for development of HSR in Bavaria lies a) in the promotion of networking and sustainable structures, b) the establishment of an HSR information platform that bundles information and results in regard to current topics and aims to facilitate cooperation as well as c) in the initiation of measures and projects. The latter ought to pinpoint health care challenges and make recommendations regarding the improvement of health care and its quality. The cooperation and networking structures that were established with the LAGeV should be continuously expanded and be used to work on priority topics in order to achieve the global objectives of the LAGeV.

[Status quo and potential of health services research: the perspective of Bavarian actors]. / Stand und Potenziale der Versorgungsforschung: Die Perspektive der Akteure in Bayern.

In 2011, the Bavarian Parliament decided to advance health services research (HSR) in Bavaria by bundling scientific competencies in a State Working Group and integrating other actors in it. The establishment of such a State Working Group "Health Services Research" -(LAGeV) together with members from science, health care and politics followed in 2012. The objective of this study is to identify the status quo of HSR in Bavaria including its determinants and potential for development based on the actors' perspective.After the inaugural meeting a semi-structured questionnaire was sent to all 36 members from 28 organisations. Items comprise information on the respondent's background as well as status quo, future topics and potential for development of HSR in Bavaria.27 members took part in the survey, resulting in a response rate of 75.0%. Satisfaction of actors with the status quo of HSR is rather low, especially regarding the effectiveness of policy advice. Researchers and health care providers are also not much satisfied with the HSR environment. For the future of HSR, respondents prioritise the topics interface and networking research, followed by innovative care concepts, care for patients with multiple or chronic conditions as well as evaluation of innovations, processes and technologies. Potential for development and thus improvement of care is primarily seen in the abolishment of existing constraints by an overall HSR concept (including selective research promotion), networking and cooperation, research funding as well as improving the interface between politics and science. Respondents assess the benefit of an increased networking within the LAGeV as high.Status quo of HSR in Bavaria is not very satisfactory. The survey reveals important constraints as well as promoting factors based on the viewpoints of different groups of actors. It also prioritises future HSR topics and identifies potential for development, which are important for the LAGeV. The findings can be used for advancing HSR in Bavaria and beyond.

[Impact of small-area context on health: proposing a conceptual model]. / Die Bedeutung des kleinräumigen Kontexts für Gesundheit: Entwurf eines Erklärungsmodells.

BACKGROUND: Recent empirical studies stress the impact of features related to the small-area context on individual health. However, so far there exists no standard explanatory model that integrates the different kinds of such features and that conceptualises their relation to individual characteristics of social inequality. METHODS: A review of theoretical publications on the relationship between social position and health as well as existing conceptual models for the impact of features related to the small-area context on health was undertaken. RESULTS: In the present article we propose a conceptual model for the health impact of the small-area context. This model conceptualises the location of residence as one dimension of social inequality that affects health through the resources as well as stressors which are inherent in the small-area context. CONCLUSION: The proposed conceptual model offers an orientation for future empirical studies and can serve as a basis for further discussions concerning the health relevance of the small-area context.

[The use of routine data to study rehabilitative care in populations with a migrational background: potential and limitations]. / Die Nutzung von Routinedaten in der rehabilitationswissenschaftlichen Versorgungsforschung bei Menschen mit Migrationshintergrund: Möglichkeiten und Grenzen.

OBJECTIVE: Little is known about the rehabilitative care of populations with a migrational background. Using the assessment of rehabilitation effectiveness as an example, we outline the potentials and limitations routine data from social security carriers has for this research field. METHODS: We draw on an 80% random sample of all completed medical rehabilitations in the year 2006 funded by the German Statutory Pension Insurance Scheme (n=634 529). The assessment of rehabilitation effectiveness was based on the occupational performance at the time the rehabilitation was completed. Migrational background was defined by nationality. By means of logistic regression adjusted for socio-economic/-demographic and health-related variables, we examine whether rehabilitation effectiveness differs between German and non-German nationals. RESULTS AND DISCUSSION: Non-German nationals have a higher chance of completing medical rehabilitation with a lower occupational performance - irrespective of differences in socio-economic/-demographic and health-related variables. Odds ratios for a lower rehabilitation effectiveness were 1.23 [95%-CI=1.16;1.30] for Turkish nationals and 1.47 [95%-CI=1.38;1.56] for persons from the former Yugoslavia. Different aspects limit the validity of the analysis. (1) By using nationality, only a selection of all persons with a migrational background can be identified. (2) Important covariates cannot be considered. (3) The assessment of rehabilitation effectiveness is inaccurate, because valid data on occupational performance prior to rehabilitation is missing. CONCLUSION: Similar to routine data from other social security carriers, data from the German Statutory Pension Insurance Scheme has limitations for health services research on populations with a migrational background. Solutions comprise the application of computer-aided procedures for an accurate operationalisation of migrational background and the use of survey data for a valid assessment of rehabilitation effectiveness.

[Increasing regional disparities in living conditions in Germany and their role in the explanation of health inequalities]. / Zunehmende regionale Unterschiede bei den Lebensverhältnissen in Deutschland und ihre Bedeutung für die Erklärung gesundheitlicher Ungleichheit.

BACKGROUND: Social inequalities in Germany are on the increase. Past studies have pointed out that social inequalities and their health consequences include a regional component. This study aims at systematically describing the development of regional disparities in living conditions across Germany. MATERIAL AND METHODS: The level of analysis was that of the 439 counties in Germany. Based on the data sets INKAR as well as Statistik regional, selected indicators of social structure (unemployment rate, employment rate, disposable income, density of statutory health insurance physicians, and proportion of females among the 18-29 year-olds) were compared for the years 1995 and 2005/2006, respectively. The results were stratified for East and West Germany to assess the development of regional disparities within these two large entities. RESULTS: For the indicators statutory health physician density and proportion of females there is an increase in regional disparities across Germany (i. e., interquartile ranges of physician density 1995: 37 physicians per 100,000 inhabitants, 2005: 54) as well as in East and West [i. e., interquartile range of physician density 1995 (West): 42.1 physicians per 100,000 inhabitants, 2005 (West): 61.3]. Furthermore, regional disparities in the unemployment rate increased across Germany as well as within West Germany (interquartile range Germany 1995: 6.4 percentage points, 2006: 8.1; interquartile range West 1995: 3.5 percentage points, 2006: 5). Disparities between East and West increased for all the indicators. CONCLUSION: This study illustrates the substantial level of regional differences in Germany as well as their temporal dynamics. Increasing regional disparities were identified across the whole of Germany as well as within the two entities East and West. Regionally diverse living conditions are linked to different capabilities and life chances. Thus, regional characteristics are relevant for an individual's social situation and ought to be, as exposures at the meso level, included in epidemiological studies.