[How do internal medicine patients choose their hospital? A cross-sectional study]. / Wie wählen internistische Patienten ihr Krankenhaus? Eine Querschnittstudie.

BACKGROUND: The free choice of hospital by patients is promoted by health policy and is to be supported by the quality reports of hospitals. But how do patients choose a hospital? How many can decide for themselves, where do they inform themselves and what are their decision criteria in the specific situation? This will be answered for inpatients of internal medicine in comparison to those of other specialties. METHODS: The data originate from an observational study. The random sample, stratified by specialties and hospital care levels, was collected in 46 departments of 17 hospitals from 15 cities and municipalities in North Rhine-Westphalia. The weighted sample evaluates 758 patients of internal medicine and 1168 patients of other specialties descriptively and inferentially. RESULTS: Internal medicine patients are older, more often men, without a migration background and chronically ill, and also more often pretreated as inpatients. About half decide on the hospital themselves, with their own knowledge of the hospital through a previous stay being the most important source of information and the important decision criteria being their own previous experience, the hospital call and the recommendation of outpatient treatment providers. The small proportion of patients with more time before admission choose more actively. CONCLUSIONS: In internal medicine, fewer patients can decide on the hospital themselves. These then decide quite predominantly on the basis of their previous experience with the hospital and continue the renewed treatment in the hospital with which they are also familiar. A small proportion of younger, more educated and less hospital-experienced patients inform themselves more actively before elective procedures. Patients' treatment experiences are central to their own and their relatives' choice of hospital via social exchange.

[Problems with Using Hospital Quality Reports as a Secondary Data Source for Health Services Research in Germany]. / Probleme bei der Verwendung von Qualitätsberichtsdaten für die Versorgungsforschung.

Background Since 2005, German hospitals are required by law to publish structured quality reports (QRs). Because of the detailed data basis, the QRs are being increasingly used for secondary data analyses in health services research. Up until now, methodological difficulties that can cause distorted results of the analyses have essentially been overlooked. The aim of this study is to systematically list the methodological problems associated with using QR and to suggest solution strategies. Methods The QRs from 2006-2012 form the basis of the analyses and were aggregated in a database using an individualized data linkage procedure. Thereafter, a correlation analysis between a quality indicator and the staffing of hospitals was conducted, serving as an example for both cross-sectional as well as longitudinal studies. The resulting methodological problems are described qualitatively and quantitatively, and potential solutions are derived from the statistical literature. Results In each reporting year, 2-15% of the hospitals delivered no QR. In 2-16% of the QRs, it is not recognizable whether a report belongs to a hospital network or a single location. In addition, 6-66% of the location reports falsely contain data from the hospital network. 10% of the hospitals changed their institution code (IC), in 5% of the cases, the same "IC-location-number-combination" was used for different hospitals over the years. Therefore, 10-20% of the QRs cannot be linked with the IC as key variable. As a remedy for the linking of QR, the combination of the IC, the address and the number of beds represents a suitable solution. Using this solution, hospital network reports, location reports and missing reports can be identified and considered in an analysis. Conclusions Secondary data analyses with quality reports provide a high potential for error due to the inconsistent data base and the problems of the data linkage procedure. These can distort calculated parameters and limit the validity of results. Only the unequivocal identification of the reporting hospitals guarantees meaningful results.

[How Steady are Hospitals in Complying with Minimum Volume Standards? A Retrospective Longitudinal Data Analysis of the Years 2006, 2008, and 2010]. / Wie konstant halten Krankenhäuser die Mindestmengenvorgaben ein? Eine retrospektive, längsschnittliche Datenanalyse der Jahre 2006, 2008 und 2010.

BACKGROUND: The outcome volume relationship has been analysed for more than 30 years and debated ever since. For German hospitals minimum volume standards (MVS) have been introduced for some procedures in 2004. Hospitals have to report procedure volumes in their quality reports. This study analyses for the first time how constant hospitals comply with minimum volume standards over time. MATERIALS AND METHODS: Data used are the reported volumes, which hospitals published in their quality reports in 2006, 2008, and 2010. The case volumes of complex oesophageal and pancreatic interventions, total knee replacements, and liver, kidney and stem cell transplantations (KTX, LTX, STX) are analysed in a retrospective, longitudinal study design. RESULTS: More than 80 % of hospitals conducting LTX, KTX, and total knee replacements are complying with MVS constantly, in STX 57 % of hospitals comply, and with complex pancreatic and oesophageal interventions compliance is 44 and 28 %, respectively. Twenty-seven to 36 % of hospitals conducting the three last mentioned procedures vary in complying with the MVS over time. 3.5 % (total knee replacements) up to 26 % (pancreatic interventions) and 37 % (oesophageal interventions) of all hospitals constantly fail to comply with MVS. Hospitals constantly over the MVS treat more than 80 % of all patients, except in complex oesophageal interventions. Hospitals with varying compliance in oesophageal and pancreatic interventions are mainly hospitals with 100 to 599 beds. Only very few hospitals of these two procedure types stop conducting the interventions after failing to comply with MVS earlier, the other some 120 hospitals for each intervention type treat 2 cases on average per year. CONCLUSION: The MVS on KTX, LTX, STX, and total knee replacement are almost constantly complied with. A considerable number of hospitals conducting oesophageal and pancreatic interventions never or rarely meet the MVS without discontinuing this type of intervention. At least for hospitals that never comply with MVS on oesophageal and pancreatic interventions, requirements and possibilities for a regional patient transfer should be studied in depth.

[The information needs of non-hospital based physicians regarding admissions and transfers]. / Informationsbedarf niedergelassener Ärzte bei Ein- und Überweisungen.

BACKGROUND: This study examines the quality criteria which, from the perspective of non-hospital based physicians, are relevant in order to give patients quality-oriented recommendations in the selection of a suitable hospital or specialist. METHODS: A primary telephone survey of 300 physicians from 5 specialist groups collected relevance assessments of 59 quality criteria for hospitals, GPs and specialist practices. A descriptive bi- and multivariate analysis was performed using McNemar tests, correlation and regression analysis. RESULTS: Next to the personal experiences which the physician and his patients made with the hospital or non-hospital based colleague in the past, there is a general interest in vital structural and outcome parameters of hospitals and medical practices. Physicians deem the nature and scope of services offered by the hospitals and medical practices as less relevant. In 12 of the 59 examined quality criteria, the relevance assessments differ depending on whether the physician is dealing with an elective admission to hospital or a referral to a GP or specialist. In the analysis of possible correlations between preferences and factors which might be influencing the physician, gender, age and specialisation were found to have an effect.

[Breast cancer centres in North Rhine-Westphalia - case volume trends 2004-2010]. / Brustkrebszentren in Nordrhein-Westfalen - Fallzahlentwicklung 2004-2010.

BACKGROUND: To improve quality of breast cancer care, in 2004 the state of North Rhine-Westphalia (NRW), Germany, began to appoint 51 breast cancer centres. These centres comprise 91 hospitals performing breast cancer surgery which have - amongst other things - to fulfill minimum volume standards. The aim of our study was to analyse if the intended regionalisation of care from 252 hospitals performing breast cancer surgery formerly to the appointed hospitals had taken place by the year 2010. METHODS: We used data for the years 2004-2010 from the agency for quality assurance in North Rhine-Westphalia concerning breast cancer care and analysed trends concerning the number of hospitals performing breast cancer surgery, case volumes, and achievement of minimum volume standards by performing descriptive and inferential statistics. RESULTS: Between 2004 and 2010 the number of breast cancer cases increased by 36.6% from 12 975 to 17 724 cases (p<0.001, Wilcoxon test). Simultaneously, the number of hospitals performing breast cancer surgery decreased from 252 to 208 whereby more than double the number of planned hospitals still performed breast cancer surgery. The case volumes of the 71 appointed hospitals for which we had individual data over the entire period of time increased by 49.4% from 8 103 cases in year 2004 to 12 105 cases in 2010. Assuming that case volume trends of those 20 appointed hospitals of which we did not have individual data developed uniformly to all other appointed hospitals, the proportion of cases that were operated in not appointed hospitals decreased from 20% in year 2004 to 12.5% in 2010 (p<0.001, χ2 test). Simultaneously, the proportion of cases that were operated in hospitals not achieving minimum volume standards decreased from 42.7% in year 2004 to 12.1% in 2010 (p<0.001, χ2 test). CONCLUSION: The establishment of breast cancer centres in NRW regionalised breast cancer surgery. In fact, in 2010 breast cancer surgery still took place in more than 100 not appointed hospitals. However, these hospitals were responsible for only a small proportion of breast cancer surgery.

[How do patients choose a hospital for elective surgery?]. / Wie wählen Patienten ein Krankenhaus für elektive operative Eingriffe?

BACKGROUND: Patients want to decide on health care providers. Published quality reports are supposed to help but are rarely used. How patients manage choosing a hospital for elective surgery in Germany and whether they use the hospital quality reports was explored for the Federal Joint Committee. METHOD: A cross-sectional survey asked 48 hospitalized patients from 5 specialties in 4 hospitals after elective surgery about their criteria and sources of information, and their use of the compulsory quality reports for choosing the hospital. Data were analyzed descriptively. RESULTS: To choose their hospital is very important for patients with elective surgery and they do so. Usually there is enough time to obtain information before admission. The three main criteria are own experience with a hospital, short distance from their homes, and the hospital's expertise. The main sources of information are relatives, contact with the hospital's outpatient departments, and patient's ambulatory health care provider. Written information is only used as supplementary information. The compulsory quality reports are not known and, hence, are not used.

[Medical decision making in symptoms of type 2 diabetes mellitus in general practice]. / Hausärztliche entscheidungen bei symptomen für diabetes mellitus typ 2.

BACKGROUND: Patient and physician attributes influence medical decisions as non-medical factors. The current study examines the influence of patient age and gender and physicians' gender and years of clinical experience on medical decision making in patients with undiagnosed diabetes type 2. METHOD: A factorial experiment was conducted to estimate the influence of patient and physician attributes. An identical physician patient encounter with a patient presenting with diabetes symptoms was videotaped with varying patient attributes. Professional actors played the "patients". A sample of 64 randomly chosen and stratified (gender and years of experience) primary care physicians was interviewed about the presented videos. RESULTS: Results show few significant differences in diagnostic decisions: Younger patients were asked more frequently about psychosocial problems while with older patients a cancer diagnosis was more often taken into consideration. Female physicians made an earlier second appointment date compared to male physicians. Physicians with more years of professional experience considered more often diabetes as the diagnosis than physicians with less experience. CONCLUSION: Medical decision making in patients with diabetes type 2 is only marginally influenced by patients' and physicians' characteristics under study.

[Distances to hospitals performing minimum volume relevant procedures in Germany 2004 to 2006]. / Distanzen zu Krankenhäusern mit Mindestmengen-relevanten Eingriffen 2004 bis 2006.

INTRODUCTION: In 2004, Germany introduced annual minimum volumes nationwide on five surgical procedures (kidney, liver, stem cell transplantation, complex oesophageal, and pancreatic interventions). In 2006, minimum volumes for total knee prosthesis were added and the five established minimum volumes were almost doubled. Since minimum volumes usually result in the regionalisation of procedures, especially patients from rural areas are impeded by geographical access problems. The aim of our study was to analyse regional and time-related differences in the distances patients travelled to hospitals performing minimum volume relevant procedures between 2004 and 2006 in Germany. METHODS: We performed a secondary analysis of data from the Institute for the Hospital Remuneration System (InEK). Using a geographical information system we analysed the distances that patients who underwent one of the six minimum volume procedures travelled to the hospital in the years 2004-2006. We performed t-tests to analyse differences between the 16 German Federal States and the years of observation while correcting for multiple testing. RESULTS: On average patients travelled between 28.6/28.0 km (2004/2006) for knee prosthesis and 78.9 km for stem cell transplantation (2004) and 97.4 km for liver transplantation (2006). In 2004, distances travelled differed up to a factor of 9.9 [comparing distances travelled to stem cell transplantation of patients of the states of Berlin (30.6 km) and Hamburg (303 km)]. In 2006, the maximum difference (factor 12.2) was observed for oesophageal interventions comparing distances travelled in the states of Bremen (7.2 km) and Saarland (88.8 km). For almost all comparisons there were significant differences of the minimum and maximum distances travelled in one of the Federal States compared to the federal average. Comparing distances travelled in 2004 and 2006 we found only small and inconsistent variations. DISCUSSION: We found that geographical access to inpatient care for minimum volume procedures in Germany differs sizably between the Federal States in 2004 and 2006. In spite of doubling the minimum volumes in 2006, the distances patients travelled to hospitals hardly change. This may be caused by an inert implementation of the minimum volume regulation leading to an unchanged number of hospitals providing the respective procedures.

[Public reporting--forms and effects]. / Public Reporting -Formen und Effekte öffentlicher Qualitätsberichterstattung.

Since 2004 hospitals in Germany publish structured report cards bi-yearly. Content and scope of these mandatory public reports are still under discussion. Therefore we provide an up to date overview on forms and effects of public reports. By enabling transparency, comparative reports on the quality of health care aim at supporting patients to choose better performing health care providers and motivating health care providers to enhance quality improvement activities. Internationally existing public reports range from reports on national health systems on the whole to reports on the quality of particular procedures of individual health care providers. Contrary to the multitude of public reports, the evidence on the effects of public reporting remains scant. The few existing studies show that hospitals react on the public reports by some quality improvements. However, regarding the selection of providers and the quality of care they only show inconsistent effects of public reporting. Moreover, unsolved methodical problems of pubic reporting and potentially unintended consequences have to be considered. Therefore the question remains whether the expected effects in terms of quality improvements outbalance the unintended consequences in the long run and if the investments in public reporting will be paid off.

[Minimum hospital volumes for total knee replacement]. / Mindestmengen bei Knie-TEP-Implantationen.

BACKGROUND: As requested by the Federal Joint Committee, the German Hospital Institute and the Heinrich-Heine University of Düsseldorf carried out an investigation of the minimum volume regulation for hospitals based on the Social Legislation Code. Total knee replacement forms one minimum volume field. Since 2006 hospitals with a performance rate of less than the minimum volume of 50 patients a year with knee replacement are no longer permitted to conduct this procedure. The object of the present analysis is to investigate the impact of the minimum volume regulation for total knee replacement. METHODS: The results are based on two hospital surveys on the application of the minimum volume regulation for total knee replacement. 279 hospitals (response rate: 41,8%) participated in 2006 and 297 hospitals in 2007 (response rate: 47,5%). The results are representative of General hospitals with total knee replacements. RESULTS: As expected, hospitals above and below the minimum volume cut-off differ in size. To date the minimum volume regulation has led to a rather selective exclusion of hospitals from care. In the case of total knee replacement 13,7% of the hospitals have been excluded. Most hospitals that do not reach the minimum volume are still participating in care. A decisive reason for this is the existence of exception rules. In hospitals exceeding the minimum volume, certain quality management tools for knee replacement are more widely spread than in hospitals that do not reach the minimum volume. As a consequence of the minimum volume regulation, the participating hospitals improved their position in the market. Vice versa, the excluded hospitals are more concerned about the damage to their image that may result from being excluded from care. With respect to the further development of the minimum volume regulation, the hospitals do not share the same point of view. DISCUSSION: Because, as yet, only few hospitals with low case numbers have been excluded from care, the immediate effects of the minimum volume regulation on the affected hospitals and hospital care in general are limited. The surveys showed a considerable uncertainty among all participants about the application and effects of the minimum volume regulation in hospitals.

[Influence of minimum volumes on the structure of inpatient care]. / Auswirkung der Mindestmengenvereinbarung auf die stationäre Versorgungsstruktur.

OBJECTIVE: In 2004 five minimum volumes were introduced for the first time into German hospitals. The structural effects of these minimum volumes are presented as the first part of a health service research to evaluate the minimum volume regulation. DESIGN/METHODOLOGY/METHODS: The investigation is based on the mandatory hospital quality reports for 2004. Data were extracted from 1710 quality reports, descriptively analysed and applied to the modified minimum volumes for 2006. RESULTS: In 2004, 485 out of 1710 German hospitals providing acute care and approximately 23,128 cases, i.e., 0.14% of all hospital cases, were affected by at least one minimum volume regulation. The number of affected hospitals varies considerably between the German Federal Sates with 16% in Bavaria and 75% in Bremen. In 2004 (and presumably 2006) the following hospital numbers will comply with the minimum volume regulation: liver transplantation 100% (63%), kidney transplantation 91% (84%), stem cell transplantation 84% (65%), complex oesophageal interventions 71% (40%), complex pancreatic interventions 82% (51%). On a case level, 4% of kidney transplantation cases and up to 22% of complex oesophageal interventions were to be redistributed. Viewing the hospital size by number of beds, smaller (100-300 beds) and medium size hospitals (300-600 beds) are affected in complex oesophageal and pancreatic interventions, whereas in transplantations medium and large hospitals (>600 beds) are affected. Considering the regional distribution on a district level, the number of districts with at least one hospital providing the respective service will decrease from 2004 to 2006, with the strongest reduction in complex oesophageal interventions from 172 to 82 districts (-53%). CONCLUSION: In 2004 the minimum volume regulation has moderate structural effects on the care setting. In 2006 these effects will be stronger due to the doubled number of interventions required for most of the minimum volumes. The effects on transplantations have to be differentiated from those on oesophageal and pancreatic interventions since the former are already highly centralised whereas the latter are mainly provided on a medium hospital care level and will be shifted on to the maximum hospital care level. This process should stimulate a debate on geographically equal access to care within and among the Federal Sates.