[Requirements for the provision of healthcare to socially disadvantaged population groups: evaluation of 10 years of medical care provided to the homeless in Hanover]. / Anforderungen an die Gesundheitsversorgung sozialer Randgruppen: Eine Evaluation der medizinischen Versorgung für Wohnungslose in Hannover über zehn Jahre.

In 2007, the German Federal Government introduced a general health insurance obligation, but there are still vulnerable groups such as poor and homeless people without access to medical care. Especially for social fringe groups, a visit to the doctor involves many obstacles. Ten years ago the project "Outreach medical care for homeless people and people threatened by homelessness in Hanover" was established in order to reduce those gaps in healthcare provision. A continuously conducted evaluation of the project shows that low-threshold consulting hours are accepted and the transition to medical specialists is becoming increasingly easy. So the evaluation plays an important part in the development of the project. Since the healthcare reform in 2004, however, the number of cases has increased by 30 % while the actual homeless target group has remained the same. In order to guarantee access to the healthcare system for patients who cannot afford additional payments, the abolition of the quarterly practice fee and other additional payments for people on a low income is an important step. The growing requirements, resulting from a changing clientele and changes in the general conditions, are raising questions as to the nature of such projects and its future funding. In the long run it isn't the aim of this non-profit project to take on central tasks of a mutually supportive community. Therefore the data and results collected on the evaluation not only serve to improve the projects management, but also provide important information to other initiatives outside Hanover whether and how to support the respective groups of patients.

The impact of the time interval between two successive deliveries in an obstetric unit in terms of the mode of each delivery and the rate of perinatal mortality.

OBJECTIVE: To analyze the relationship of the time interval between two deliveries, done by one obstetric team, on the delivery mode of the subsequent birth; to define the length of this interval; and to evaluate this time interval as a risk factor for increased perinatal mortality in a population-based cohort. METHODS: All singleton deliveries at ≥ 24 weeks' gestation in Lower Saxony, Germany, between 2001 and 2005 (a total of 317,663 deliveries including 402 cases of perinatal mortality) were analyzed. The mode of the previous and the subsequent delivery, the time interval between the two deliveries, the time of birth, the hospital volume, and the existence of an affiliated neonatal ward were investigated. RESULTS: When the first vaginal delivery was <45 min, there was a reduced probability that the subsequent birth would be a cesarean section. In case of a previous cesarean section, the cesarean rate of the following birth was influenced up to 165 min. In a multivariate analysis, vaginal deliveries following an earlier vaginal birth and occurring within <45 min were associated with increased perinatal mortality. Repeated cesarean sections within <165 min were associated with increased perinatal mortality when occurring at night or on weekends. CONCLUSION: A short time interval between two deliveries in an obstetric unit constitutes an independent risk factor for perinatal mortality.

Maternal near-miss among women with a migrant background in Germany.

OBJECTIVE: To examine the association between region of origin and severe illness bringing a mother close to death (near-miss). DESIGN: Retrospective cohort study. SETTING: Maternity units in Lower Saxony, Germany. POPULATION: 441 199 mothers of singleton newborns in 2001-2007. METHODS: Using chi-squared tests, bivariate and multivariable logistic regression we examined the association between maternal region of origin and near-miss outcomes with prospectively collected perinatal data up to seven days postpartum. MAIN OUTCOME MEASURES: Hysterectomy, hemorrhage, eclampsia and sepsis rates. RESULTS: Eclampsia was not associated with region of origin. Compared to women from Germany, women from the Middle East (OR 2.24; 95%CI 1.60-3.12) and Africa/Latin America/other countries (OR 2.17; 95%CI 1.15-4.07) had higher risks of sepsis. Women from Asia (OR 3.37; 95%CI 1.66-6.83) and from Africa/Latin America/other countries had higher risks of hysterectomy (OR 2.65; 95%CI 1.36-5.17). Compared to German women, the risk of hemorrhage was higher among women from Asia (OR 1.55; 95%CI 1.19-2.01) and lower among women from the Middle East (OR 0.66, 95%CI 0.55-0.78). Adjusting for maternal age, parity, occupation, partner status, smoking, obesity, prenatal care, chronic conditions and infertility showed no association between country of origin and risk of sepsis. CONCLUSION: Region of origin was a strong predictor for near-miss among women from the Middle East, Asia and Africa/Latin America/other countries. Confounders mostly did not explain the higher risks for maternal near-miss in these groups of origin. Clinical studies and audits are required to examine the underlying causes for these risks.

[State-wide follow-up of extremely preterm infants: a model of cross-sectoral quality analysis]. / Landesweite Nachuntersuchung extrem unreifer Frühgeborener: Ein Modell sektorübergreifender Qualitätsanalyse.

A long-term outcome project for the special high-risk group of extremely preterm (ELBW) infants has been established in the federal state of Lower Saxony, which is unique in Germany. All departments of neonatology and all divisions of paediatric neurology are participating. Since October 2004 children who were born at <28 weeks gestation are examined using a standardised concept at defined follow-up intervals (at the age of 6 months, 2, 5 and 10 years). The aim is to achieve a cross-sectoral improvement of quality in healthcare on the basis of neurodevelopmental outcome parameters (the right therapy for the right child, at the right time). So far 739 extremely preterm infants (81% of the survivors) were examined at the age of six months, 513 ELBW infants (74% of the survivors) at the age of two years, and 99 children (59% of the survivors) at the age of five years. The comparison of the follow-up intervals has demonstrated an increase of children with minor and major impairment, which indicates the importance of the long-term scheme. At the age of five years 27% of the children exhibit normal development, 49% minor impairment and 24% major impairment. Many ELBW infants need therapy. The model of the project can be transferred to other federal states or regions and other high-risk groups.

[Benchmarking to evaluate the care of patients with cystic fibrosis: an established tool to improve patient care]. / Benchmarking in der Versorgung von Mukoviszidose-Patienten/innen - Ein etabliertes Instrument zur Verbesserung der Patientenversorgung.

Benchmarking, i.e. learning from the best, by means of appropriate and established quality indicators is one of the central management tools to improve patient care in the field of cystic fibrosis in Germany. The Deming cycle is used as a controlling instrument to realise purposeful and stringent measures in hospitals. Benchmarking only works on a voluntary and confidential basis. This is the most important factor to drive motivation and activities. Benchmarking is changing and optimising the quality of structures, processes and outcome performance. The implementation of an independent external expert as a moderator and methodologist is a successful element of the benchmarking process.

Benchmarking improves quality in cystic fibrosis care: a pilot project involving 12 centres.

OBJECTIVE: Health care quality monitoring has been introduced in cystic fibrosis (CF) by a few groups and national registries. Based upon this, continuous quality improvement can be achieved by applying the benchmarking method which is focused on learning from best practice. SETTING: A group of 12 CF centres in Germany, treating a total of 1200 patients of all ages, enrolled in a nationwide pilot benchmarking project from 2004 to 2007. INTERVENTION: Key nutritional and respiratory parameters were used as quality indicators. Numerical benchmarks were set and used for ranking. Applying the plan-do-check-act cycle, quality improvement interventions were introduced, such as harmonization of definitions and references, improvement of measurement standards, data quality, completion of missing data, enforcement of early aggressive antibiotic treatment and individual adaptation of dietary counselling. RESULTS: Ranking alone was not sufficient for identification of the best performing centres unless it was accompanied by longitudinal follow-up. Improvement was possible in the 3 years' period as shown by benchmarking for single centres that introduced new interventions in nutritional and antibiotic treatment most consequently. CONCLUSION: CF provides a model of the link between processes of health care delivery and health outcomes of patients. Quality improvement is a continuous goal in CF care with realistic potential as exemplified by our data. Accountability was introduced and transparency was improved by our pilot benchmarking project. Using the benchmarking procedure, our long-term project will reinforce standards, programmes, and individual attitudes and principles to ensure continuous quality improvement in CF health care.

Self-testing of vaginal pH to prevent preterm delivery: a controlled trial.

BACKGROUND: From 2004 to 2006, in a model project carried out by four German health insurers, expectant mothers were offered self-testing of vaginal pH in order to prevent preterm delivery. They were given pH test gloves on request so that they could measure their vaginal pH twice a week from the 12(th) to the 32(nd) week of gestation. They were instructed to consult with a gynecologist after any positive result. All further diagnostic or therapeutic decisions were at the discretion of the treating gynecologist. We assessed the effectiveness of the screening intervention, using delivery before the 37th week of gestation as the primary endpoint. METHODS: In this prospective, controlled trial, we collected data on deliveries from 2004 to 2006 that were covered by the four participating insurers in five German federal states. We compared the outcomes of pregnancy in women who did and did not request test gloves (intervention group, [IG], and control group, [CG]). The data were derived from claims data of the participating insurers, as well as from a nationwide quality assurance auditing program for obstetrics and perinatal care. Propensity score matching and multivariate adjustment were used to control for the expected self-selection bias. RESULTS: The study sample comprised 149 082 deliveries. 13% of the expectant mothers requested test gloves, about half of them up to the 16(th) week of gestation. As expected, women with an elevated risk of preterm birth requested test gloves more often. Delivery before the 37(th) week of gestation was slightly more common in the intervention group than in the control group (IG 7.97%, CG 7.52%, relative risk 1.06, 95% confidence interval 1.00-1.12). This result was of borderline statistical significance in the propensity score matched analysis, but it was not statistically significant in the multivariate model. CONCLUSION: This trial did not demonstrate the efficacy of self-testing of vaginal pH for the prevention of preterm delivery (< 37 weeks of gestation).

Head injury in Germany: A population-based prospective study on epidemiology, causes, treatment and outcome of all degrees of head-injury severity in two distinct areas.

INTRODUCTION: Little is known about the ratio of mild traumatic brain injury (TBI) to moderate and severe TBI, about the time that elapses until primary care is given, about the number of patients requiring immediate surgery and about the early outcome and the costs. METHOD: In a prospective study two regions taken as model examples were investigated: the City of Hanover with its surrounding catchment area and Münster with its regions. RESULTS: From 1 March 2000 until 28 February 2001 all patients were recruited who were admitted to a hospital emergency department due to a TBI; 6783 patients (58.4% male, 41.6% female; 29.7% children < 16 years) were included; 5220 (73%) received in-hospital treatment; and 258 were given early rehabilitation. The incidence of TBI is 332 per 100 000 head of population. The GCS (Glasgow Coma Scale) or other forms of neurological examinations were performed in only 56% of all cases. According to the GCS status, 90.2% are classified as mild, 3.9% as moderate and 5.2% as severe. Intubation is given only to 76.1% of patients with severe TBI. Lethality was 1%. The predominant cause of TBI is falls, with 52.5% of all cases, while 26.3% were due to road accidents. The time elapsing between the accident event and initial examination at the hospital is less than 1 hour in 63% of all cases. X-rays were taken in 82% of all cases of TBI, with 19.3% of the patients receiving a CT scan; 58.7% of all TBI patients have additional injuries of the facial skull, 8.8% of the vertebral column, 7.2% of the thorax, 2.6% of the abdomen, 3.4% of the pelvis and 19.6% of one or more extremities. One year after the accident, 50% of all patients still required treatment even after mild TBI. CONCLUSION: It is necessary to follow the TBI guidelines, e.g. regarding intubation and neurological examination. The indication for cranial x-rays and CT should be reconsidered.

[In-house team seminars: working together as a team--from data and statistics to quality development]. / Inhouse-Teamschulungen: Gemeinsam mit dem Team--von den Daten und Statistiken zur Qualitätsentwicklung.

The concept of the "ZQ In-house Seminars" provided by external trainers/experts pursues the specific aim to enable all healthcare staff members of hospital departments to analyse statistical data--especially from external quality measurements--and to initiate in-hospital measures of quality improvement based on structured team work. The results of an evaluation in Lower Saxony for the period between 2004 and 2008 demonstrate a sustainable increase in outcome quality of care and a strengthening of team and process orientation in clinical care.

Does underutilization of prenatal care explain the excess risk for stillbirth among women with migration background in Germany?

OBJECTIVE: To explore the role of utilization of prenatal care on the risk for stillbirth among women with migration background in Germany by comparing stillbirth rates of women from different origins characterized by adequate and inadequate utilization of prenatal care to German women with adequate utilization of care. DESIGN: Retrospective cohort study. SETTING: Lower Saxony, Germany. POPULATION: Singletons born in 1990, 1995 and 1999 (n = 182,444). METHODS: We analyzed perinatal data collected by obstetricians and midwives prospectively during pregnancy and after birth. The Adequacy of Prenatal Care Utilization Index was applied. Chi-squared tests and bivariate and multivariable logistic regression models were used. MAIN OUTCOME MEASURES: Stillbirth rates. RESULTS: In crude analyses, inadequate utilization of prenatal care (OR = 1.86, 95% CI 1.52, 2.28), and origin from Central and Eastern Europe (OR = 2.05, 95% CI 1.63, 2.58), the Mediterranean (OR = 1.77, 95% CI 1.38, 2.65), the Middle East (OR = 2.63, 95% CI 2.24, 3.09) and other countries (OR = 1.79, 95% CI 1.10, 2.89) were related to stillbirths. After adjustment for age, parity, smoking, inter-pregnancy interval, employment status and year of observation, compared to Germans with adequate utilization of prenatal care, women with adequate utilization of care from Central and Eastern Europe (OR = 1.74, 95% CI 1.33, 2.29) and the Middle East (OR = 1.98, 95% CI 1.64, 2.39) and women with inadequate utilization of prenatal care from the Mediterranean (OR = 3.00, 95% CI 1.71, 5.26) were at higher risk for stillbirths. CONCLUSION: There are inconsistent relation patterns between stillbirth, area of origin and utilization of prenatal care. Among women from the Mediterranean, increasing utilization of prenatal care may result in lower stillbirth rates.

Reproductive outcomes in adolescents who had a previous birth or an induced abortion compared to adolescents' first pregnancies.

BACKGROUND: Recently, attention has been focused on subsequent pregnancies among teenage mothers. Previous studies that compared the reproductive outcomes of teenage nulliparae and multiparae often did not consider the adolescents' reproductive histories. Thus, the authors compared the risks for adverse reproductive outcomes of adolescent nulliparae to teenagers who either have had an induced abortion or a previous birth. METHODS: In this retrospective cohort study we used perinatal data prospectively collected by obstetricians and midwives from 1990-1999 (participation rate 87-98% of all hospitals) in Lower Saxony, Germany. From the 9742 eligible births among adolescents, women with multiple births, >1 previous pregnancies, or a previous spontaneous miscarriage were deleted and 8857 women <19 years remained. Of these 8857 women, 7845 were nulliparous, 801 had one previous birth, and 211 had one previous induced abortion. The outcomes were stillbirths, neonatal mortality, perinatal mortality, preterm births, and very low birthweight. Bivariate and multivariable logistic regression models were conducted. RESULTS: In bivariate logistic regression analyses, compared to nulliparous teenagers, adolescents with a previous birth had higher risks for perinatal [OR = 2.08, CI = 1.11,3.89] and neonatal [OR = 4.31, CI = 1.77,10.52] mortality and adolescents with a previous abortion had higher risks for stillbirths [OR = 3.31, CI = 1.01,10.88] and preterm births [OR = 2.21, CI = 1.07,4.58]. After adjusting for maternal nationality, partner status, smoking, prenatal care and pre-pregnancy BMI, adolescents with a previous birth were at higher risk for perinatal [OR = 2.35, CI = 1.14,4.86] and neonatal mortality [OR = 4.70, CI = 1.60,13.81] and adolescents with a previous abortion had a higher risk for very low birthweight infants [OR = 2.74, CI = 1.06,7.09] than nulliparous teenagers. CONCLUSION: The results suggest that teenagers who give birth twice as adolescents have worse outcomes in their second pregnancy compared to those teenagers who are giving birth for the first time. The prevention of the second pregnancy during adolescence is an important public health objective and should be addressed by health care providers who attend the first birth or the abortion and the follow-up care. Also, health care workers should attempt to improve the pregnancy outcomes of subsequent teenage pregnancies by addressing modifiable risk factors, for example, supporting smoking cessation and utilization of prenatal care.

Obstetrical volume and early neonatal mortality in preterm infants.

OBJECTIVE: Regionalised perinatal care with antenatal transfer of high risk pregnancies to Level III centres is beneficial. However, levels of care are usually not linked to caseload requirements, which remain a point for discussion. We aimed to investigate the impact of annual delivery volume on early neonatal mortality among very preterm births. METHODS: All neonates with gestational age 24-30 weeks, born 1991-1999 in Lower Saxony were included into this population-based cohort study (n = 5,083). Large units were defined as caring for more than 1,000 deliveries/year, large NICUs as those with at least 36 annual very low birthweight (<1,500 g, VLBW) admissions. Main outcome criterion was mortality until day 7. Adjusted Odds Ratios (adj. OR) and 95% confidence intervals (CI) were calculated based on generalised estimating equation models, accounting for correlation of individuals within units. RESULTS: Within the first week of life, 20.6% of all neonates deceased; 10.2% were stillbirths, 3.7% died in the delivery unit, and 6.7% in the NICU. The crude OR for early neonatal mortality after having been delivered in a small delivery unit (excluding stillbirths) was 1.36 (95%CI 1.04-1.78; adj. OR 1.16 (0.82-1.63)). It increased to 1.96 (1.54-2.48; adj. OR 1.21 (0.86-1.70)) after the inclusion of stillbirths. CONCLUSION: This study has shown a slight, but non-significant association between obstetrical volume and early neonatal mortality. In future studies the impact of caseload on outcome may become more evident when referring to high-risk patients instead of to the overall number of deliveries.

Hospital volume and neonatal mortality among very low birth weight infants.

BACKGROUND: Very low birth weight infants (< 1500 g) are at increased mortality risk. Data on the impact of NICU volume are sparse, in comparison with those on the level of care. We hypothesized that neonatal mortality would be higher in small NICUs (< 36 very low birth weight admissions per year) than in large NICUs, with adjustment for volume of the delivery unit. METHODS: We analyzed population-based data from a quality assurance program in Lower Saxony (Germany). Perinatal data for almost all very low birth weight infants born in 1991 to 1999 (n = 7745) were available. Analyses were restricted to infants born at 24 to 30 weeks (n = 4379). Data validation procedures, univariate data analyses, and logistic regression models based on general estimating equations were performed. RESULTS: Neonatal mortality among infants admitted to NICUs was 12.2% in small NICUs and 10.2% in large NICUs. The mortality rate in small NICUs was increased significantly. Compared with infants from large delivery hospitals (> 1000 births per year) and large NICUs, the adjusted odds ratio was 1.94 for neonates for whom both units were small, 1.75 for those from large delivery units but small neonatal units, and 1.16 for those for whom only the NICU was large. Stratification according to gestational age revealed the greatest impact on mortality for infants of < 29 weeks. CONCLUSIONS: Results suggest that creating larger perinatal centers may improve perinatal health care. The volume of the NICU was associated more strongly with 28-day mortality than was the volume of the delivery hospital, and it had the largest impact on survival for infants of < 29 weeks.

The role of mediating factors in the association between social deprivation and low birth weight in Germany.

This study examines whether the association between social inequalities and low birth weight (LBW) (occurring in both pre- and full-term births) in Germany can be explained by several potentially confounding factors. These include maternal age, occupational status, marital status, nationality, employment status, smoking, prenatal care, psychosocial stress, obesity, short stature, short inter-pregnancy interval, chronic conditions, and several obstetrical risk factors such as pregnancy induced hypertension. We also examined how the risk for LBW varies over time within each socioeconomic group. We analyzed routinely collected perinatal data on singletons born in the federal state of Lower Saxony, Germany, in 1990, 1995, and 1999 (n = 182,444). After adjustment for all potentially confounding factors in multivariate logistic regression models, working class women, unemployed women, single mothers, and women over 39 years of age were at increased risk for pre- and full-term LBW infants. Migrant status was not related to LBW. We examined variations in the risk for LBW over time within groups, using the 1990 birth cohort as the referent group for the 1995 and 1999 birth cohorts. Compared to 1990, in 1999 women aged 19-34 years, housewives, unemployed women, women of German nationality and women with partners had higher risks for pre- and full-term LBW infants; the eldest subgroup had lower risks for LBW after adjustment for confounding factors. The factors we examined partly explain the social inequalities in LBW occurring in pre- and full-term infants. The subgroups with higher rates of LBW in 1999 compared to 1990, included women experiencing childbirth in an optimal stage of life or in a privileged social context. Public health policies in Germany should target social inequalities contributing to the aetiology of LBW and to the factors that result in increased LBW rates.

The German electronic doctor's license: the introduction of a health professional card.

The rapid increase of the use of electronic communication in the healthcare sector in the last decade made it more and more important to implement an appropriate general security infrastructure. Improved security is necessary for both patients and health professionals. One corner stone in all these concepts is the introduction of the so-called Health Professional Card as an important security tool. Accordingly, the professional organisations for physicians in Germany started to introduce a standardised electronic identity card for their members at the end of the nineties. The existing physicians' identity paper will be transformed into an electronic identity document as a prototype for a Health Professional Card for all German health professionals. The main goal is to achieve a high level of standardisation and interoperability. Thus, all activities were carried out in close cooperation with different national and international institutions, organisations and working groups.