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Potential limits and risk of digitalization in public health will be a core topic of the High profile Research Area Health Sciences at the University of Bremen in coming years. A white paper was developed to support positioning in this dynamic research. The paper describes the Health Sciences viewpoint on core evaluation criteria for digital public health, identifies interfaces and approaches for interdisciplinary cooperation and discusses cross-cutting themes as well as demarcations with respect to digitalization in medicine (digital health). An abbreviated version of the white paper is presented for discussion., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

With this discussion paper, the subgroup Mixed Methods of the working group Qualitative Research Methods in the non-profit organization German Network Health Services Research (DNVF) is taking up the topic of three previous discussion papers on the significance and potentials of qualitative research methods in health services research. Mixed methods are being increasingly used and demanded in health services research. However, there are also areas of conflict in the planning and implementation of mixed methods studies, and these are addressed in this paper from the perspective of qualitative research. Special attention is given to the aspect of integration as the fundamental signature of mixed methods research. With this discussion paper, our aim was to stimulate critical as well as constructive exchange of ideas on what constitutes high-quality health services research characterised by a diversity of methods and the framework conditions under which this can succeed., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

From 2014 to 2022, the BMBF has funded five research networks in prevention research and health promotion that are also jointly coordinated (Research Network Primary Prevention and Health Promotion, www.fp2g.net). The researchers have produced a large number of relevant research outputs with insights gained into essential aspects of prevention research and health promotion. The networks research focused on basic principles, application-relevant findings, and implementation conditions of long-term prevention and health promotion for non-communicable diseases (NCDs). The constraints imposed by the pandemic from 2020 onwards were partly addressed by integrating Corona-related research and transfer activities. The importance of resilience for dealing with multiple health and social challenges got increased attention and was analyzed and discussed during the pandemic. For prevention research, research questions such as how to better implement prevention measures through digital tools are gaining additional importance. Together, the research networks have presented achievements and desiderata for future research. This perspective paper with its nine theses formulated in conclusion is intended as a stimulus for discussion among funders as well as the communty of researchers on the subject of successful prevention and health promotion. It is explicitly part of the continuity of the memoranda on prevention research developed in 2012., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

The methodological challenges of evaluating digital interventions (DI) for health services research are omnipresent. The Digital Health Working Group of the German Network for Health Services Research (DNVF) presented and discussed these challenges in a two-part discussion paper. The first part addressed challenges in definition, development and evaluation of DI. In this paper, which represents the second part, the definition of outcomes, reporting of results, synthesis of evidence, and implementation are addressed as methodological challenges of DI. Potential solutions are presented and the need to address these challenges in future research are discussed., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

The development and application of digital interventions in health-related topics are gaining momentum in health service research. Digital interventions are often complex and need to be evaluated and implemented in complex settings. Due to their characteristics, this poses methodological challenges for health services research that have to be identified and addressed. Hence, the Working Group on Digital Health of the German Network for Health Services Research (DNVF) has prepared a discussion paper. This paper discusses methodological, practical and theoretical challenges associated with the development and evaluation of digital interventions from the perspective of health services research. Possible solutions are suggested and future research needs to address these methodological challenges are identified., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Goals for health and health care are an indispensable basic requirement for a functioning health care system. The dilemma of the German health care system is that it has not been designed in a planned way, but that it has grown historically. In recent years, it has developed through the free play of forces into what it is today. The OECD characterizes the current state as follows: The costs of the German health system do not correspond to the often only average health outcomes for the population. To meet the legal requirements (especially SGB V §§ 12, 27 and 70), health care/the health system in Germany needs concrete goals. An orientation towards health care goals entails measures on all levels of health care: on the macro level (overall system/total population), on the meso level (subdivided according to regions, specific population groups, etc.) as well as on the micro level (patients and health care providers). Based on national and international experiences, this position paper of the DNVF e.V. (German Network for health services research) shows the potential of how operationalised health care targets can ensure effective, affordable and high-quality health care. The coalition agreement of the current government propagates a reorientation with patient-related health care goals. Now it is important to derive concrete and realisable goals from this declaration of intent and to involve all important groups in the process. In addition, values and ethical standards for implementation shall be agreed upon in this process. The Health Ministry (BMG) should facilitate and promote the process of societal will-building for the definition of national health care goals. This requires a clear political will. As a result, the National Health Care Goals are available at the end of the process, which are published and maintained together with evidence-based facts as well as valid and resilient data in a Manual "National Health Care Goals". The operational responsibility for implementation could lie with the newly to be founded Federal Institute of Public Health, as already announced in the agreement of the governing coalition. The DNVF is willing to actively participate in the development of health care targets., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Research in mental health services in Germany is of increasing relevance. To this end, the recently founded "Mental Health Working Group" as part of the German Network of Health Services Research (DNVF) has written a discussion paper presenting key specifics, challenges, and goals of health service research in the field of mental health. Some research-relevant specifics in the area of mental health care, pragmatic challenges of research organization, ethical problems, and particular research topics in this field are presented and discussed critically., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonfliktbesteht., (Thieme. All rights reserved.)

Within the framework of the early benefit assessment, the Federal Joint Committee (G-BA) has been authorised since 2019 by the law for more safety in the supply of pharmaceuticals GSAV to request additional application-related data capture for certain pharmaceutical drugs. This results in certain challenges, especially in the area of conflict between methodological requirements and practical feasibility. The position paper provides an overview and takes up the general regulations defined by the Federal Ministry of Health (BMG) as well as the process defined by the G-BA. Subsequently, possible solutions are discussed and recommendations for implementation are given from the perspective of health care research., Competing Interests: Alle AutorInnen sind persönlich oder über eine Mitgliedsorganisation Mitglied des Deutschen Netzwerk Versorgungsforschung (DNVF).Drei AutorInnen geben an, in der pharmazeutischen Industrie tätig zu sein: Dr. Sandra Kluge (Chiesi GmbH), Kerstin Olbrich (Janssen-Cilag GmbH), Dr. Stephan Rauchensteiner (Pfizer)., (Thieme. All rights reserved.)

The term "digital health" is currently the most comprehensive term that includes all information and communication technologies in healthcare, including e-health, mobile health, telemedicine, big data, health apps and others. Digital health can be seen as a good example of the use of the concept and methodology of health services research in the interaction between complex interventions and complex contexts. The position paper deals with 1) digital health as the subject of health services research; 2) digital health as a methodological and ethical challenge for health services research. The often-postulated benefits of digital health interventions should be demonstrated with good studies. First systematic evaluations of apps for "treatment support" show that risks are higher than benefits. The need for a rigorous proof applies even more to big data-assisted interventions that support decision-making in the treatment process with the support of artificial intelligence. Of course, from the point of view of health services research, it is worth participating as much as possible in data access available through digital health and "big data". However, there is the risk that a noncritical application of digital health and big data will lead to a return to a linear understanding of biomedical research, which, at best, accepts complex conditions assuming multivariate models but does not take complex facts into account. It is not just a matter of scientific ethical requirements in health services care research, for instance, better research instead of unnecessary research ("reducing waste"), but it is primarily a matter of anticipating the social consequences (system level) of scientific analysis and evaluation. This is both a challenge and an attractive option for health services research to present itself as a mature and responsible scientific discipline., Competing Interests: Interessenkonflikt: Ursula Kramer und Horst Christian Vollmar sind Sprecher der AG Digital Health des DNVF e. V.; Ursula Kramer ist Inhaberin einer Agentur für Gesundheitskommunikation, zudem ist Sie Gründerin der Plattform HealthOn, die Gesundheits-Apps analysiert und bewertet. Alle anderen Autoren sind Mitglied der AG Digital Health und geben an, keine Interessenskonflikte zu haben., (© Georg Thieme Verlag KG Stuttgart · New York.)

Goal of the Study: An intent of the Patient Protection and Affordable Care Acts (ACA), also know as Obama Care, was to slow the expenditure growth in the public Medicare-System by shifting the accountability for health care outcomes and costs to the provider. For this purpose, provider were allowed to form networks, which would then take accountability for a defined population - Accountable Care Organizations (ACOs). Ten years after the introduction of ACOs, this paper looks at the impact of ACOs both on quality of care and costs of care to assess if ACOs can be a model of care delivery for Germany., Methods: In a mixed-method approach, a rapid review was conducted in Health System Evidence and PubMed. This was supported with further papers identified using the snowballing-technique. After screening the abstracts, we included articles containing information on cost- and/or quality impact of US-Medicare-ACOs. The findings of the rapid review were challenged with 16 ACO-experts and stakeholder in the USA., Results: In total, we included 60 publications which incorporated 6 reports that were either conducted directly by governmental institutions or ordered by them, along with 3 previous reviews. Among these, 31 contained information on costs of care, 18 contained information on quality of care and 11 had information on both aspects. The publications show that ACOs reduced costs of of care. Cost reductions were achieved compared to historic costs, to populations not cared for in ACOs, and counterfactuals. Quality of care stayed the same or improved., Conclusion: ACOs contributed to slowing the cost growth in US Medicare without compromising quality of care. Thus, a transferal of this model of care to Germany should be considered. However, various policies have led to ACOs failing to unleash their full potential. Against this background, and against the background of stark differences between US Medicare and the German health care system, a critical reflection of the necessary policies underlying ACOs-like structures in Germany, needs to be undertaken., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: The SARS-Cov-2 outbreak in the spring of 2020 challenged the health care system, and thus primary care, on an unprecedented scale. Knowledge about the new disease was low, whereas the dynamics of knowledge generation were high and inhomogeneous. A number of new primary care tasks related to the pandemic situation emerged. Guidance in the management of COVID-19 was therefore needed, although robust evidence was not yet available. The information required concerned not only the virus and the new disease COVID-19, but also regulatory requirements and organizational issues. In this situation, a flexible, web-based information tool, easy to update and usable at the point of care, was developed at Karl Landsteiner Private University Krems and put online under the name of "COVID-19: prevention and management in primary care practices" on March 25, 2020. In a retrospective process description, we describe the needs-triggered process of developing and disseminating a practice-based tool to support practicing primary care physicians in a period of high uncertainty with an urgent need for information. Afterwards, we reflect on the learning process from a purely pragmatic to an increasingly structured approach and try to draw conclusions regarding optimization possibilities in terms of creation and dissemination., Conclusion and Outlook: In situations of high uncertainty combined with an acute need for action and decision-making, there is a significant need for information that is as reliable as possible. Science transfer must be done in such a way that information can be implemented quickly. Dissemination, as always, plays an essential role. Gaps must be accepted. A structured process of quality assurance must be established in parallel. Funds and resources for knowledge transfer should be included in future pandemic plans., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: The project "Health for Everyone in the District" was implemented in Nuremberg from May 2017 to October 2022 as part of the law passed to strengthen health promotion and disease prevention with funding from Public Health Insurance, Bavaria. The aim was to implement health promotion measures through a decentralized system in four deprived parts of the city and thus promote health equity on site. Among other aspects, program loyalty, project scope, and acceptance, as well as continuity and establishment of permanent structures underwent external assessment., Method: As part of the evaluation, quantitative data from the paper-and-pencil feedback forms of the measures (n=580), four qualitative focus group interviews with participants of the project (n=20), and an in-depth partially standardized predominantly quantitative online survey of participants and course instructors from the districts (n=67) were conducted., Results: The programs were accepted by those most in need, namely women, elderly people and those with a migration background. Women, senior citizens and people with a migration background were well reached by the measures. The very high level of satisfaction with the measures showed that there were opportunities for implementation of health promotion measures into daily life taking into consideration the local environment and deprived target groups. The specifications of the guidelines for prevention, however, represented a hurdle for the long-term establishment of the measures in these districts., Conclusion: The project "Health for Everyone in the District " represents a local low-threshold approach to social situation-related health promotion in the municipal setting and is suitable for reaching deprived target groups with health-promoting measures. Adjustments to the guidelines for prevention could help create permanent structures on a broader scale., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Studies using secondary data such as health care claims data are often faced with methodological challenges due to the time-dependence of key quantities or unmeasured confounding. In the present paper, we discuss approaches to avoid or suitably address various sources of potential bias. In particular, we illustrate the target trial principle, marginal structural models, and instrumental variables with examples from the "GePaRD" database. Finally, we discuss the strengths and limitations of record linkage which can sometimes be used to supply missing information., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Underimmunization against influenza has been increasing in recent years. A spatial clustering of underimmunization is suspected. These clusters can pose risks to health care and make achieving immunization quality standards difficult. The objectives of this paper are to (a) identify and describe PLZ-level spatial clusters with high levels of underimmunization against influenza, (b) compare the clusters with other preventive services, and (c) model possible factors influencing underimmunization., Material and Methods: From the routine data of the Association of Statutory Health Insurance physicians Westphalia-Lippe, patients ≥ 60 years and vaccinations between 2012-2017 were extracted. As a methodology, the spatial scan statistics were chosen, which show high relative risks of underimmunization in clusters., Results and Discussion: Four statistically significant clusters of underimmunization against influenza were identified, which proved to be stable even after adjustment with the temporal trend of local underimmunization rates. In the flu season 2016/2017, the underimmunization rate in the higher risk clusters (RR>1) was 71.9-74.7% and the rate outside these clusters was 67.0%. As influencing factors on underimmunization, socio-economic factors and vaccination behavior in the preseason were identified. Underimmunization rates are geographically clustered. The spatial scan statistics can be used for the identification of persistent clusters in order to carry out targeted spatial and addressee-specific measures to reduce underimmunization rates., Competing Interests: Der Autor gibt an, dass kein Interessenskonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim of Study: An occupational health management system was initiated at 11 departments under the German Ministry of Defense (MoD) at the beginning of 2015. The departments were characterized by the heterogeneity of employees and the tasks of the departments. The aim of this pilot phase was to get experience and knowledge for implementation of this system in other departments. At the beginning of the pilot phase, an employee attitude survey was conducted to examine the situation., Methods: The survey included all 9,267 employees of the eleven departments. A combination of a web-based online survey and a paper-pencil survey was used., Results: In total, 2,076 (22.4%) of all employees took part in the survey. There were significant difference between the departments in all topics assessed ("leadership behaviour/social issues", "work habits", "job design", "work equipment", "environment conditions", "mental health", "stress", "diet", "exercise", "job responsibility") but not in "health behavior"., Conclusion: This study shows clearly that a department-based analysis is necessary for a goal-oriented meaningful occupational health management system, especially if only limited resources are available., Competing Interests: Sammito ist aktiver Sanitätsoffizier der Bundeswehr. Rose und das Institut für Arbeits-, Sozial- und Umweltmedizin erhalten Forschungsmittel aus dem BMVg., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Employed informal caregivers often experience role conflicts between caring for an elderly person in need of care at home and their employment. The goal of this paper was to identify a risk profile of care-related termination of employment., Methods: Analyses are based on the cross-sectional Benefits of Being a Caregiver Study (October 2019 - March 2020) with data from 481 informal caregivers of elderly persons in need of care. The data collected relate to characteristics of the care recipient, the informal caregiver, and the caregiving situation, as well as aspects of the employment situation. The risk profile of care-related cessation of employment is based on a binary logistic regression., Results: Approximately one in nine in the present sample (n=55) terminated employment because of having to offer informal care to an elderly person at home. Factors characterizing the risk profile of a care-related termination of employment were female gender of the caregivers, younger age of the care receiver, co-residence with the care receiver, and a higher care level of the care receiver., Conclusions: In order to reduce care-related cessation of employment, support and relief services need to be adapted to the factors of the identified risk profile. In particular, the form and content of informal caregiver counselling should be modified in order to reach informal caregivers at an early stage. Adapted support programs should focus on and reach in particular female employed caregivers., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Objective: Reconciling informal caregiving and gainful employment is a challenge for many informal caregivers. The goals of this paper are to identify factors influencing care-related employment reduction, and to record work-related wishes for improving the compatibility of informal caregiving and being employed., Methods: Analyses were based on the cross-sectional Benefits of Being a Caregiver Study of 426 employed caregivers of an older person in need of care. Data were collected on characteristics of the care receivers and caregivers, and aspects of the caregiving and employment situation. Potential influencing factors of care-related employment reduction (n=426) were analyzed using binary logistic regression. The wishes regarding the compatibility of informal care at home and employment were examined descriptively using structured content analysis according to Mayring., Results: One quarter of the employed informal caregivers (n=108) reduced their hours of employment due to the demands of caregiving. The profile of influencing factors of a care-related employment reduction was composed of a higher number of working hours, higher effort for activities of daily living, and co-residence with the care receiver. Employed caregivers primarily expressed a desire for flexibility in working hours, a reduction in working hours, and some concessions with regard to absenteeism., Conclusions: Relieving the burden on caregivers in the activities of daily living in form of formal and informal support services can probably reduce the likelihood of a care-related reduction in gainful employment., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Introduction: Despite the growing numbers of physicians in outpatient care, continuing discussion about the planning of physician requirements suggests remaining problems in this field, which could be due to focussing on the ratio of physician to population rather than on morbidity-based evaluations. Against this background, this paper tries to depict the latent need in outpatient care, illustrates supply and demand and further tests the hypothesis that there is a relative inequality in distribution due to physicians preferring to locate in socially privileged areas in the German state of Brandenburg., Methods: We aggregated all data available on a small scale with potential impact on demand and examined it via principal component analysis. The generated factor was mapped together with the locations of general practitioners and specialists in general care. Using linear regressions, the number of practitioners was compared to the local index value to determine regional inequalities., Results: The PCA suggested a one factor solution; that factor was designated Social Structure Index due to its values. The mapping showed a tendency of higher index values towards the central areas of Brandenburg surrounding Berlin. Regressions of the number of practitioners against the index values revealed no significant differences between communities with high and low index values., Conclusion: The extension of factors concluding the evaluation of physician demand in outpatient care confirms the problems of physician supply in rural areas, where sparse populations meet social disadvantages and poor accessibility. An underlying inequality in distribution in terms of physicians preferring socially privileged areas could not be detected., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Urbanization is advancing worldwide and thus, cities are increasingly living spaces for people. Therefore, it is essential to place the health and well-being of city dwellers at the center of urban planning. The research funding program "City of the Future - Healthy and Sustainable Metropolises" from the Fritz and Hildegard Berg Foundation at the German Stiftungszentrum has been providing important inter- and transdisciplinary research impulses on this topic since 2010. Junior research groups at the interfaces of health sciences and other disciplines in the natural and social sciences were funded. One focus of the research program is to enable intensive cooperation with practitioners, in order to reflect upon and work on problems and issues from practice using the best possible scientific methods and to catalyze the transfer of knowledge. The research consortia are accompanied by annual conferences on a wide variety of urban health topics at various venues in Germany. In addition, transdisciplinary networks have been established and further initiatives (e. g., founding of an institute) have been launched. In this paper, the development of the multifaceted research funding program "City of the Future - Healthy and Sustainable Metropolises" is presented, including an outlook into its future development., Competing Interests: Mitglieder (Fehr, Hornberg, Zerbe) im Programmbeirat des Programms "Stadt der Zukunft" der Berg-Stiftung (Koordination Frau Macher, Deutsches Stiftungszentrum)., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

The field of urban health, i.e., the application of public health for people in the city, is oriented towards both scientific knowledge and practical action. In the international arena, a scientific infrastructure exists for this purpose. Despite the common roots of public health and urban planning in Germany, the connection between these fields of work was not very apparent for a long time. Legal requirements for the participation of public health service in (urban) planning processes have had little impact so far. The aim of this study was to connect to international urban health developments in order to make the topic more visible, to support professional exchange and to give impulses for research and practice. To express the close links between human health, ecological stability and social justice, the approach was conceived as sustainable urban health. With this in mind, the program "City of the Future - Healthy, Sustainable Metropolises" was initiated in 2011.This article characterizes the basic approach as integrating and describes the underlying guiding principles, i.e., "View field expansion" as an epistemological principle and "Bridge building" as an action-guiding principle, and outlines the details. The spectrum of topics ranges from medical and nursing care over "classical" prevention and health promotion to health in all policies. Within this approach, "smaller" tasks can be pursued, e.g., an overview of local health actions and actors, networking promotion, or preserving significant developments in collective memory. At the same time, it is about contributions to the solution of "big" tasks, e.g., the derivation of conclusions from the Corona learning experience, a more consistent implementation of health in all policies, or transformation steps towards an ecologically sustainable development of society. Legal norms, public health services, health reporting, and urban planning come up as leitmotifs. The article also outlines the genesis of the position papers in this supplementary volume and concludes with an outlook., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Having to face the challenges posed by a shortage of skilled care workers and an increasing number of older people in need of care, policy makers and economic enterprises perceive care robotics as a promising solution. However, studies have shown that potential users have little interest in technology and that technology developers have little knowledge about the needs and wishes of potential users. Against this background, this paper explores, based on 16 qualitative interviews with stakeholders from the area of technology development, marketing, and nursing care (science), which assumptions and expectations regarding age and gender of users are relevant in this field. The results revealed three perspectives of the stakeholders regarding the users of care robotics: 1) the need to take age and gender in development and implementation of care robotics was acknowledged, 2) the relevance of other social categories, such as education, culture and illness, was mentioned, and 3) the relevance of social categories was rejected altogether. These results are discussed in the context of discourses about diversity in care-robotics and conclusions are drawn for user-centred and diversity-sensitive technology development and implementation., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Schizophrenia psychoses can be treated much better today due to the introduction of antipsychotics about 70 years ago in conjunction with the implementation of specific psychotherapies. However, current treatment options are still limited in the area of negative symptoms and disease-associated cognitive deficits. In the last 15 years, randomised controlled trials (RCTs) have been able to show that physical training and especially endurance training could represent a comprehensive complementary treatment approach and could lead to a significant improvement in positive, but especially also in negative symptoms and cognitive deficits. As a result, sports therapy for schizophrenia psychoses has found its way not only into the national treatment guidelines of the German Society for Psychiatry, Psychotherapy, Psychosomatics and Neurology (DGPPN), but also into European recommendations such as those of the European Psychiatric Association (EPA). With the introduction of the "Living guideline" format (here an update takes place at least once a year), a broader implementation in health care will be easier in the future. Based on a narrative review, this paper describes the process of implementing sports therapy for schizophrenia psychoses from its beginnings to its incorporation into guidelines and can be applied analogously to other forms of therapy., Competing Interests: RS, AS, LR und IM haben keinen Interessenkonflikt. PF ist Mitherausgeber der deutschen (DGPPN) Schizophrenie-Behandlungsleitlinien und Mitverfasser der Schizophrenie-Behandlungsleitlinien der WFSBP; er ist in Beiräten tätig und erhält Vortragshonorare von Janssen, Lundbeck, Otsuka, Servier und Richter., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Objective: Families with one parent suffering from cancer are exposed to extraordinary emotional and organizational burdens, affecting underaged children. To help coordinated access to social and logistic support options and thus reduce the stress on family members, the project Brückenschlag was founded. The aim of this paper was to evaluate the implementation of this pilot project following the healthcare utilization model by Andersen., Methods: A cross-sectional observational study was conducted using a mixed-method approach. Semi-structured written expert surveys (n=10) and secondary analysis of routine data of the care model (n=171 families) were combined., Results: Quantitative secondary analysis: The participating families had 1-7 children (median (m) 2, range (s) 6). In 66% of the cases, the mother was affected by cancer, in 20% the diseased parent was in a single parent household. The communication structure in these families was rated "limited" to "rather open". Of the total of 171 contacts (study period 9/14 to 11/17), 133 families made use of Brückenschlag; 59.2% of the contacts were made by psycho-oncologists and the social services department of the hospital. If the contact was initiated by the patients themselves or by psycho-oncologists, a guidance was established significantly more frequently (significance of chi-squared test 0.047). Qualitative analysis: There was a lack of awareness and coordination of existing support services and a lack of family resources to use existing support offers. Both the desired and the established support fell primarily in the area of organizational support. Brückenschlag improved networking and took on a navigating function for the families., Conclusion: The data collected indicate that in families, matching the German average in their socio-demographic characteristics, a great need for organizational support develops as soon as one parent becomes sick with cancer. The model project Brückenschlag creates an access to support services for families with one parent suffering from cancer., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Study Aim: Psychosocial stress can complicate the first phase of life for young families. One group that has received little attention so far are families with increased parental stress and conflict potential. This paper aims to 1) classify knowledge and use of support services for families with increased parental stress and conflict potential and 2) describe the psychosocial characteristics and parenting behaviours of these families., Methods: For this purpose, data from a representative cross-sectional study in 2015 with n=7 549 families as well as the follow-up study with n=905 families were analyzed. Parents who took their child to a pediatrician's office for a screening examination (U3-U7a) completed a written questionnaire. Knowledge and use of services were assessed using four pre-defined stress groups (unstressed, socioeconomically stressed, with parental stress and conflict potential, and highly burdened)., Results: Families with increased parental stress and conflict potential are less likely to receive support offers. Despite high knowledge of selective prevention services, they use these offers less frequently than socioeconomically or highly stressed families. They are more likely to report dysfunctional parenting behaviors., Conclusion: This raises the question of whether families with increased parental stress and conflict potential receive too little support because they have no clearly visible need for help or whether they are adequately provided for due to the high socioeconomic resources, service knowledge, and use of universal medical and family education services. The results provide important information for the care of families in various stressful situations and contribute to the assessment of the need for support., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

The German research data center for health will provide claims data of statutory health insurances. The data center was set up at the medical regulatory body BfArM pursuant to the German data transparency regulation (DaTraV). The data provided by the center will cover about 90% of the German population, supporting research on healthcare issues, including questions of care supply, demand and the (mis-)match of both. These data support the development of recommendations for evidence-based healthcare. The legal framework for the center (including §§ 303a-f of Book V of the Social Security Code and two subsequent ordinances) leaves a considerable degree of freedom when it comes to organisational and procedural aspects of the center's operation. The present paper addresses these degrees of freedom. From the point of view of researchers, ten statements show the potential of the data center and provide ideas for its further and sustainable development., Competing Interests: Stefanie March, Falk Hoffmann, Holger Gothe, Ingo Meier, Sebastian Claudius Semler, Christoph Stallmann, Enno Swart und Peter Ihle erklären, dass Sie innerhalb der vergangenen 3 Jahre Gutachtertätigkeit für das Bundesministerium für Gesundheit ausgeübt haben, und einzelne Autor*innen am begleitenden Arbeitskreis zum Forschungsdatenzentrum Gesundheit beim BfArM beteiligt sind., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: In order to manage the Covid-19 pandemic in Germany in March 2020, the government implemented non-pharmaceutical interventions including school closures, case-based measures, social distancing, and a ban of all public events. Under these circumstances, professional societies and associations in the healthcare sector recommended the use of video consultations. The objective of this analysis was to generate statistically relevant insights into the use of video consultations before and during the Covid-19 pandemic METHODS: This study is based on the analysis of a comprehensive claims data set comprising anonymized data of 5.6 million beneficiaries of a large German health insurance fund. The dataset encompassed healthcare claims from 1 January 2019 to 30 June 2020 covering 29,464,913 patient contacts. The claims were divided into video consultations and face-to-face consultations. This paper presents descriptive statistics and analyses associations between variables., Results: In 8,077 out of all contacts, a video consultation had taken place. This translates into 3.12 of 10,000 contacts. There was no significant difference in the utilization of video consultations by gender. However, the age differed significantly (Chi-square:2280.01, Sig: 0.000) between the contacts with or without use of video consultation. There is a significant increase of up to 27 times the use of video consultation in the first lockdown compared to the same month in 2019., Conclusions: Apparent higher usage of telemedicine by patients in the age group 50 to 64 years and the very low usage in the group of 65 to 74 years shows that the use of video consultation is age sensitive and should be subject to goal-oriented implementation of telemedical offers. The observed increase, however, is small relative to the total number of patient contacts and is not significant. Thus, there is no evidence in this large dataset to support the claim that video consultation had risen dramatically through the Covid-19 pandemic. Qualitative research to determine the factors for patients and general practitioners that lead to or hinder the use of video consultation should help in addressing the slow digitalization in the outpatient sector in Germany., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Introduction: (Excess) mortality and years of life lost are important measures of health risks from the Corona pandemic. The aim of this paper was to identify methodological factors that affect the calculation of mortality and further to point out possible misinterpretations of years of life lost., Methodology: Standardized mortality ratios (SMRs) can be used to compare mortalities (e. g., an SMR of 1.015 means excess mortality of 1.5%, an SMR of 0.990 means that mortality is reduced by 1.0%). In this study, SMRs as a measure of association for mortality in Germany were calculated for 2020 using different methods. In particular, the influence of different data sources and reference periods was examined. Furthermore, its influence on the calculated mortality was also examined to take into account increasing life expectancy. In addition, published results on years of life lost were critically analyzed., Results: Using January 2022 data from the Federal Statistical Office on mortality for 5-year age groups resulted in higher SMR values than using preliminary data from February 2021 with 20-year age groups (SMR=0.997, 95% confidence interval (CI): 0.995-0.999 versus SMR=0.976 (95% CI: 0.974-0.978)). The choice of the reference period had a large impact on calculated mortality (for men, SMR=1.024 (95% CI: 1.022-1.027) with 2019 as the reference year versus SMR=0.998 (95% CI: 0.996-1.001) with 2016 to 2019 as the reference period). Analyses in which declining mortality in 2016 to 2019 was carried forward into 2020 when calculating expected deaths resulted in significantly higher SMR values (for men SMR=1.024 (95% CI: 1.021-1.026) with, and SMR=0.998 (95% CI: 0.996-1.001) without carrying forward declining mortality). Figures for pandemic-related years of life lost per person who died from COVID-19 should be interpreted with caution: Calculation from remaining life reported in mortality tables can lead to misleading results., Conclusion: When calculating mortality and years of life lost during the pandemic, a number of methodological assumptions must be made that have a significant impact on the results and must be considered when interpreting the results., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Aim of the Study: To outline basic information on communication structures and obstacles between GPs and nursing homes as well as GPs' perspectives on usage of E-health technology., Methods: A questionnaire-based cross-sectional study carried out among n=600 randomly selected GPs in Germany sent by mail., Results: The response rate was 20% (n=114). The respondent's mean age was 53 years (min=35; max=77), two-thirds were women (65%). GPs mainly used fax (92%) and telephone (87%) to communicate with nursing homes. Less than 10% routinely used digital technologies like E-mail (7%), E-health software (6%) or chat-services (1%). About half of GPs reported unnecessary (52%) or unspecific (51%) nursing home visit requests as well as unreported medication plan changes by other physicians (51%) as a common but avoidable problem. Many GPs wanted to use E-medication plans (85%), E-follow-up prescriptions (79%) and E-letters of referral (69%) in the future. 33% of GPs were already using fully digitalized patient files. Only 9% worked exclusively paper-based., Conclusion: Though GPs are open to digitalized communication with nursing homes, fax and telephone are still mostly used. GPs prefer to execute less complex tasks digitally, such as change of medication plans and letters of referral. Fewer can imagine digital solutions for complex procedures such as acute health problems and ward rounds. Only 8% do not want to work digitally at all., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Aim of the Study: The digital transformation in healthcare is also of fundamental importance for healthcare research. For this reason, experts should agree on, prioritize and identify key topics for a medium-term strategy of the German Network for Health Services Research and classify the general development of digital health in the context of health services research., Methods: Between April and September 2018, the working groups "Digital Health" and "Validation and Linkage of Secondary Data" of the German Network for Health Services Research were asked to submit their expertise online using the methodological approach of a Delphi study. For this purpose, a multi-stage modified Delphi method with quantitative and qualitative approaches was chosen. Initially, a list of theses was drawn from the network's published position papers on digital health applications and medical apps. A total of 131 statements were formulated. The final survey instrument included questions on the biographical background of the participants, 42 developed items (33 statements and 8 open-ended questions), and one free-text field to add further aspects. Items were evaluated with a five-point Likert scale. A statement was accepted if the agreement rate was 75% or higher., Results: Of the 110 potential participants, 50 (46%) took part in the first round and 39 (36%) in the second round of the Delphi survey. In the first round, there was a clear result for 24 of 33 statements. There were 20 statements "agreed with" and four "disagreed with." Nine statements were between 60 and 75% and were presented to the participants again for evaluation in the second round. In round two, of these nine statements, four statements were "agreed with" and five statements were "disagreed with." Digital Health Literacy" emerged as a particular focus in this Delphi study., Conclusion: In this Delphi study, experts were involved in selecting and prioritizing possible topics for the Digital Health working group and assessing future developments in digital health in the context of health services research. The results reflect both the expectations and interests of the members and are largely consistent with the recommendations of the report "Digitalization for Health" made by the expert council for assessing developments in the health sector., Competing Interests: Horst Christian Vollmar und Ursula Kramer sind Sprecher der „AG Digital Health“ des Deutschen Netzerk für Versorgungsforschung (DNVF e. V.). Ursula Kramer ist Inhaberin einer Agentur für Gesundheitskommunikation, zudem ist sie Gründerin der Plattform HealthOn, die Gesundheits-Apps analysiert und bewertet. Jutta G. Richter ist Sprecherin der Kommission Digitale Rheumatologie der Deutschen Gesellschaft für Rheumatologie und Mitglied in der Kommission Digitale Transformation in der Inneren Medizin der Deutschen Gesellschaft für Innere Medizin. Madlen Fiebig ist Mitglied der AG „Digitalisierung in der Pflege“ beim Bundesverband Gesundheits-IT-bvitg e. V. Alle anderen Autoren sind Mitglieden der AG Digital Health oder der AG Validierung und Linkage von Sekundärdaten. Sie geben an, keine Interessenskonflikte zu haben., (Thieme. All rights reserved.)

Introduction: To reduce outpatient specialist waiting times and to help patients with statutory health insurance to get appointments and urgent referrals within four weeks, phone appointment service centres (ASC) were introduced in Germany in January 2016. The aim of this study was to analyse these booking patterns in the Westphalia-Lippe (WL) region, and to compare the types of regular specialist referrals with those made by the centers. Furthermore, neurology services to patients with ASC referrals were compared to those without., Methods: Appointment data from the second quarter of 2016 to the third quarter of 2019 were used, and an algorithm was developed to determine the range of services provided in appointments made by the ASCs. A total of 24,286,157 accounting slips were compared with 12,648 specialist service records from the Association of Statutory Health Insurance Physicians in the WL region., Results: The average waiting time for an appointment with a specialist was 21 days for 84% of the callers with a referral (aged mostly 35-59 years). Requests for appointments with neurologists, internists, and radiologists were the most frequent ones; 45% of service centre specialist appointments were made with neurologists, despite these comprising only 4% of total referrals in WL. There were only a few differences in the use of services in neurologist appointments with and without the mediation of the ASC. The higher level of ASC used for making neurologist appointments for initial psychotherapeutic assessment was statistically significant. However, the effect was small., Conclusions: Despite its relatively low use (0.19% of specialist referrals in general), ASCs in the WL region are able to make urgent specialist appointments for patients with statutory insurance, with average waiting times significantly lower than the legally set maximum waiting period. However, patients also take other factors into account when making appointments. While the benefits of these centres, especially for three types of specialists, was demonstrated, further discussion on the form of the ASCs in their current form is warranted. This paper provides a basis for evaluation of methodology and content for further decision-making., Competing Interests: Frau Sobiech-Eruhimovic ist Angestellte bei der KVWL. Sie wurde für die wissenschaftlichen Arbeiten im Rahmen ihrer Promotion zeitweise (20%) freigestellt. Es besteht kein Interessenkonflikt, da die KVWL keinen Einfluss auf die die Themenauswahl und die Bearbeitung der Ergebnisse hatte., (Thieme. All rights reserved.)

Background: Many people in German-speaking countries have a limited proficiency in the German language. In the health care system, this may result in barriers to accessing and utilization of health services. The aim of this review was to present the current state of research on the relevance of language barriers in medical care and to explain strategies used to address language-related communication problems., Methods: The review is based on a synthesis of German- and English-language systematic reviews on the topic of 'language interpretation in the health care sector', including also all original papers from Germany published since 2015., Results: The most common method used in hospitals for language problems was interpretation by relatives of patients or by bilingual staff of the hospital. The quality of this language mediation by untrained laypersons was often limited, which can affect health care outcomes. Using professional interpreters was associated with significantly better health care outcomes and, particularly in the form of interpretation via telephone, was a flexible and cost-effective approach., Conclusion: Language-based communication is an important prerequisite for patient-centered care and must be ensured by the health care system for ethical, social and legal reasons. In this context, professional interpretation solutions should be used, for which the required financial resources and infrastructure must also be made available., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Employees in a low socio-economic position (SEP) are more likely to leave the labour market after medical rehabilitation for health reasons than those in a better social position. So far, almost nothing is known about whether certain types of rehabilitative care can reduce this inequality in rehabilitation success. This paper examines whether certain types of care modify the SEP's influence on return-to-work (RTW)., Method: The study is based on administrative data from the German statutory pension insurance on 266,413 medical rehabilitations of 253,311 persons fully integrated into working life. Poisson regression analyses were used to check whether there was a correlation between SEP (income, education, occupational position) and the probability of RTW in the year following the measure, and whether this correlation was lower in follow-up treatment (AHB), inpatient treatment or treatment with subsequent graded RTW compared to rehabilitation that did not meet these characteristics., Results: People with a low income, education or occupational position were at increased risk of incomplete return to work after medical rehabilitation. This correlation was comparatively lower for all 3 SEP indicators when the return to work was gradual. In the case of AHB and inpatient rehabilitation, this only applied to income., Conclusion: Socio-economically disadvantaged population groups are comparatively more likely not to return fully to work after medical rehabilitation. These inequalities are less pronounced for certain types of rehabilitative care. This tends to be the case with an active structuring role of the care system. However, there is a need for further research on the modification of effects by the type of treatment. This should be further investigated using data collected for this purpose to exclude selection effects., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: During the state of emergency in Bavaria in the early Corona phase 2020, some physicians in ambulatory care were appointed as regional medical coordinators (RMCs). The aim of the present study was to evaluate this newly introduced but temporary position., Methods: In November 2020, a paper-based questionnaire was sent out to all 85 RMCs who could be identified through an internet research and to all 197 teaching practices of the Institute of General Practice and Health Services Research at the Technical University of Munich. The data analysis was descriptive and anonymised., Results: Overall, 75 (88%) RMCs and 156 (79%) general practitioners (GPs) were included. 97% of the RMCs and 67% of the GPs assessed the introduction of RMCs in ambulatory care as reasonable, but also as an intervention concerning the self-administration of physicians (RMCs: 59% and GPs: 42%). 37% of the GPs stated that RMCs should be avoided as far as possible in future pandemic situations. Overall, GPs with more intensive contact to an RMC showed higher levels of agreement. Both groups rated the collaboration and communication strategies of politics, authorities and the Bavarian Association of Statutory Health Insurance Physicians as difficult and often contradictory. However, most of the RMCs assessed the cooperation with politics and authorities at the local level as positive. The lack of medical protective equipment at the beginning of the pandemic was judged critically by both groups of the respondents., Conclusions: The establishment of RMCs in the early Corona phase 2020 in Bavaria was considered sensible by almost all RMCs and the majority of the surveyed GPs. For the future, it seems necessary to involve primary care physicians more intensively and permanently in decision-making processes and to strengthen existing structures., Competing Interests: Die Autoren PW und FV waren selbst als Versorgungsärzte tätig. Alle weiteren Autor*innen erklären, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

The national registry "HerediCaRe" for the evaluation and improvement of risk-adjusted prevention in hereditary breast and ovarian cancer is one of six "model registries in health services research" funded by the BMBF. In this paper, we describe and discuss the documentation and IT solution chosen for standardized data collection based on the specific functional requirements previously defined. The documentation is divided into different modules to be used individually for each patient, which are based on a previously defined catalog of documentation items. Due to special functional requirements, a specific data entry application based on ORACLE and ORACLE Forms was developed and implemented. The specific requirements included the integration of graphical pedigree representations, the structured upload of pedigree data and molecular genetic information, the automated transfer of old data from the previous system, as well as the free programmability of complex database queries for central data quality control. A database for patient-independent management of genetic risk variants was seamlessly integrated into the application and linked to the patient-related data. The advantages and disadvantages of the chosen IT solution are critically discussed. Overall, we come to the conclusion that, in view of the complex documentation and the special functional requirements, there are no alternative ready-made software products to the in-house development we have chosen., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Aim of the Study: Ethics committees (ECs) have an indispensable monitoring and regulatory function in research on human beings. In multicenter observational studies, approvals of several local ECs are often required. The aim of this analysis was to provide an overview of the resources used and the process for consulting ECs about a multicenter observational study in Germany., Methods: For this purpose, a cross-sectional analysis was carried out. Resources and activities within the consultation process were documented by the central study management for the period April 2018-April 2019. The study for which the consultation was obtained involved 106 certified colorectal cancer centers in 15 federal states in Germany., Results: We submitted applications to ECs in 14 medical associations and 7 university hospitals. In total, 6,305 euros consultation fees were charged by the ECs, with the fees varying between 50 and 1,400 euros. For the application documents, at least 2,986 sheets of DIN A4 paper were printed and sent by post to the EC. Partly, several copies of the application documents were required. The central study management spent about 210 working hours. The median of the processing time was 32 days (range: 5-177 days)., Conclusion: In order to significantly reduce the financial, material and personnel costs for scientists and ECs, a standardized and nationwide procedure for consulting ECs about multicenter studies should be pursued in the future. In the interests of economic and ecological sustainability, online procedures should be considered., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Since the introduction of the Medicines Market Reorganization Act (AMNOG) in 2011, there have been some structural changes for pharmaceutical manufacturers, due to the early assessment of benefits in the market launch of innovative drugs. This means that the manufacturer is constantly faced with challenges in determining the target population by using prevalence and incidence. Even given the same indication, there are often different approaches and models used for estimating the target population. In bladder carcinoma, the fourth most common tumor in men, there have been many advances in the field of immunotherapy for the treatment of locally advanced or metastatic carcinomas. These can be used to compare existing dossiers. The aim of this study was to evaluate the quality of the prevalence and incidence calculations of the dossiers in the indication urothelial carcinoma and to identify the recommendations for action that can be derived for their future determination. This problem was examined based on the methods paper of the Institute for Quality and Efficiency in Health Care and the benefit assessments of the decisions on additional benefits. Our comparison showed similarities in the use of epidemiological measures, but identified mainly differences in the calculation steps of the target population. As a result, the target population was mostly underestimated or overestimated. The quality of the dossiers differed mostly in the traceability of the calculations and the origin of data. With regard to external validity and generalizability to the German health care system, there is still room for improvement., Competing Interests: Dr. Daniel Wirth ist Mitarbeiter von Janssen Pharmaceutical Companies of Johnson & Johnson., (Thieme. All rights reserved.)

Objective: Since 2006, with the opening of emergency practices (EP) in Germany, out-of-hours patient care has been carried out by general practitioners. Additionally, emergency departments (ED) of the hospitals ensure acute care. Thus, optimal coordination of care is a much discussed subject. The aim of this study was to provide reasons for encounter and subjective reasons to visit each of these institutions., Methods: In a mixed method trial, patients with non-urgent conditions (Manchester Triage System level 4 and 5) were interviewed in 2 ED in Schleswig-Holstein and 2 EP in Baden-Württemberg regarding their reasons for encounter from July 2015 to August 2016 during the out of hours primary care practices. Data collection was carried out using a paper-based questionnaire and a semi-structured interview. The statistical program SPSS was used for descriptive analysis, text data analysis was carried out with the method of qualitative content analysis., Results: In total, 398 patients were interviewed. Most frequently, reasons for encounter in ED and EP were related to musculoskeletal complaints (39%, n=116 and 23%, n=23, respectively). Within technical examination services, the laboratory diagnostics were used as a priority in ED (59%, n=175). In the EP, one patient (2%) underwent laboratory diagnostics. The main reasons for encounter in both facilities were increasing complaints (50%, n=147 in ED; 70%, n=70 in EP) and a desire for quick diagnosis (73%, n=217 in ED; 48%, n=48 in EP). In total, 112 patients (28%) had a medication plan, and 67 (60%) brought it into the facility. Two-thirds of ED patients (n=197) were handed over to outpatient care. In EP, 89% (n=89) continued as outpatient. Qualitative content analysis revealed similar complaint categories in both facilities, but with significant differences in the severity and experienced urgency. In both facilities, patients expected to have their symptoms clarified. In ED, the desire for a rapid and specific diagnosis was expressed more frequently., Conclusion: Indications for medical treatment were seen in most consultations in both care facilities. There was a distinction between the ED and EP in the urgency of the consultations., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenskonflikt besteht., (Thieme. All rights reserved.)

Recently, several acts have been passed by the German Ministry of Health to drive the digital transformation of the healthcare system. These aim at far-reaching innovations to improve care and increase the efficiency of the healthcare system. At the same time, the demands on users in dealing with digital applications and information are increasing. Digital health literacy is thus becoming particularly relevant. However, available studies show that the digital health literacy of the population in Germany is often limited. This paper explores challenges, gaps, and prospects regarding the implementation of these new digital health policies, particularly in terms of the implications for improving digital health literacy and increasing user involvement and participation by providing six major aspects that should be considered., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Legal regulations and funding programmes of (integrated) urban development, both at the federal and Hamburg level, require socio-spatial collaboration with health promotion., Research Question: To what degree can the programmatic integration of health promotion into urban development be found in implementation documents?, Material and Methods: An internet search was conducted in the "Transparency Portal" of Hamburg, containing more than 100,000 official documents, using three approaches: 1.) search with 7 central concepts of urban development and the appearance of health themes within them; 2.) finding the "Integrated Development Concepts" (planning papers) of 10 model projects of the funding programme "Social City" and identification of health themes within them; 3.) search of the internet pages of the two most important institutions for health promotion after identifying documents indicating their cooperation with bodies of urban development (Hamburg Authority for Health and Consumer Protection; Hamburg Working Group for Health Promotion)., Results: Health aspects in areas with special needs have not been taken into consideration as much as the programmes would require. However, there are some positive examples. Current details of collaboration can be seen on the internet pages of the Hamburg Working Group for Health Promotion., Discussion and Conclusions: The (pilot) study has the problem that references to health in official documents can lead to both over- and under-estimations of the activities in reality. However, it could be shown that there are models of good practice which should be more widely used in order to reduce the gap between programmes and reality. Some recommendations for this purpose are presented for further discussion., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: The COVID-19 pandemic requires containment measures such as contact restrictions and hygiene requirements. It is accompanied by psychological problems and the fear of infection or of a severe course of the disease. This paper examines the relationship between fear of infection and adherence to rules of hygiene as well as the utilization of medical services., Methods: 1005 patients (20-79 years, 626=62.4% female) were interviewed by online questionnaire before starting a psychosomatic rehabilitation program. Data are presented descriptively and analysed by variance analyses., Results: 68.6% were rarely/sometimes afraid and 17.9% were always afraid of contracting coronavirus or of a severe course of the disease. Those who were afraid intended to wash their hands more frequently (97.2%) than those who were not afraid. Regardless of any change in their physical and mental health status, participants felt it to be risky to seek medical care., Conclusion: The intention to follow hygiene rules in people with pre-existing mental illness depends on a fear of infecting oneself or others with the coronavirus or of contracting a severe form of the disease. Especially mentally or psychosomatically affected individuals need to be informed adequately about the coronavirus and the necessary individual protective measures in order to reduce resistance and to increase willingness to seek medical help., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objectives: The aim of this study was to give an early snapshot of primary care strategies that were implemented to cope with the early period of the COVID-19 pandemic in Baden-Wuerttemberg (Germany)., Methods: In June 2020, all 271 outpatient SARS-CoV-2 contact points, established by the National Association of Statutory Health Insurance Physicians (16 centers for testing, 204 specialized family practices, 51 Outpatients Corona Centers), and a randomly generated sample of 400 primary care practices of Baden-Wuerttemberg were invited to take part in a paper-based questionnaire. The data were gathered anonymously and analysed descriptively., Results: Out of those invited, n=63 (15.8%) primary care practices and n=92 (33.9%) SARS-CoV-2 contact points participated; 78.7% of the primary care practices cooperated with SARS-CoV-2 contact points (n=48). In all, 92.1% had implemented a compulsory registration by phone for patients with (suspected) COVID-19 (n=58) and 81% offered consultation exclusively by phone or video in case of a mild courses (n=51). The new outpatient SARS-CoV-2 contact points were established in collaboration with several stakeholders, mainly led by primary care physicians (n=76, 82.6%) and almost 50% of these were established in March 2020 (n=42, 48.3%). The most commonly reported method of registration was regulated mainly by primary care practices (n=88, 95.7%) and public health departments (n=74, 80.4%). In 92.4% (n=85) of cases, it was possible to register by phone. The consultation response was most commonly given in the form of oral information to the patient (n=65, 77.4%). Less then 50% of the SARS-CoV-2 contact points used standardized sheets for registration, documentation and consultation. The assessment of future primary care structures for (suspected) COVID-19 patients were heterogeneous., Conclusions: Effort, improvisation and collaboration were required for a successful and rapid implementation of measures for primary care during the initial period of the COVID-19 pandemic. Impulses for ongoing development of primary care strategies during a pandemic can be derived out of these results., Competing Interests: AB, SM, FPK, CR, SSc und MW geben keine Interessenskonflikte an. NBG und SSt haben im März/April je eine Fieberambulanz aufgebaut. NBG erhielt Dienstpauschalen, SSt eine Aufwandsentschädigung für den Aufbau von der KVBW., (Thieme. All rights reserved.)

Aims: During the COVID-19 pandemic, many health-related questions require rapid answers. In the Competence Network Public Health COVID-19, founded by representatives of several scientific societies in March 2020, rapid reviews are often conducted to generate evidence-based answers that are useful for policy makers. The aim of this paper is to reflect on the practical experience with rapid reviews in the context of the Competence Network Public Health. Methods for high-quality and practicable implementation of rapid reviews were developed, which are particularly helpful for rapid evidence generation based on observational studies., Methods: Using the 8-step approach proposed by Tricco et al. [1], we describe the acute challenges that have arisen in the Public Health Competence Network COVID-19 while conducting rapid reviews on public health-related issues related to the COVID-19-pandemic. The 8 steps are: 1. conceptualization of the research question, 2. literature search, 3. title/abstract and full text screening, 4. data extraction, 5. risk of bias assessment, 6. evidence synthesis, 7. dissemination, 8. update. We develop a methodological approach for conducting rapid reviews by expert consensus of the members (n=42 as of 01/28/2021) of the Rapid Reviews Working Group in the Competence Network Public Health COVID-19., Results: A standardized approach is presented that closely follows the approach of the Cochrane Rapid Reviews Methods Group and takes into account the special requirements of etiological - but often also ecological - observational studies on COVID-19., Conclusions: The proposed approach for conducting rapid reviews can form an important basis for evidence-based policy advice - certainly beyond questions related to COVID-19. Flexible and rapid funding concepts should be made available for the short-term realization of methodologically high-quality rapid reviews on emerging questions. Scientific cooperation in conducting rapid reviews needs to be expanded, and more methodologically high-quality approaches such as prospective meta-analyses should be used., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Aim of the Study: Self-rated health is an important indicator of current and future health. However, panel data-based findings are lacking that take into consideration the background features of differentiated development of self-reported adolescent health. This paper examines the development of self- rated health through secondary education from grade 5-12 in Germany, analyzing differences according to indicators of socio-economic position and other background characteristics such as gender and family structure., Methodology: 5 th to 10 th grade data from the "Class 5" cohort and 9 th to 12 th grade data from the "9 th grade" cohort of the National Education Panel were combined. Growth curve models based on multi-level analysis were used to examine the level and course of self-rated health and to examine differences according to type of school, parenting, household income, gender and family structure. The final model contains 28,987 observations from 11,290 individuals over 8 time points., Results: Self-reported health declines slightly from 5 th to 12 th grade. Adolescents attending high school, living in higher-income households or parents with higher education status reported better health. Boys and adolescents growing up in nuclear families showed a more favorable course of self-rated health through secondary education., Conclusion: This study provides a comprehensive overview of the development of self-rated health of adolescents in secondary education. In addition to the static differences according to background characteristics, girls and adolescents who do not live in nuclear families also had a worse prognosis for the development of self-rated health over the school career., Competing Interests: Die Autoren erklären, dass keine Interessenkonflikte bestehen., (Thieme. All rights reserved.)

Background: Integrated care has gained popularity in recent decades and is advocated by the World Health Organization. This study examined the global progress, current foci, and the future of integrated care., Methods: We conducted a scientometric analysis of data exported from the Web of Science database. Publication number and citations, co-authorship between countries and institutions and cluster analysis were calculated and clustered using Histcite12.03.07 and VOS viewer1.6.4., Results: We retrieved 6127 articles from 1997 to 2016. We found the following. (1) The United States, United Kingdom, and Canada had the most publications, citations, and productive institutions. (2) The top 10 cited papers and journals were crucial for knowledge distribution. (3) The 50 author keywords were clustered into 6 groups: digital medicine and e-health, community health and chronic disease management, primary health care and mental health, healthcare system for infectious diseases, healthcare reform and qualitative research, and social care and health policy services., Conclusions: This paper confirmed that integrated care is undergoing rapid development: more categories are involved and collaborative networks are being established. Various research foci have formed, such as economic incentive mechanisms for integration, e-health data mining, and quantitative studies. There is an urgent need to develop performance measurements for policies and models., Competing Interests: The authors declare no conflicts of interest., (Thieme. All rights reserved.)

Aim of the Study: There is greater deployment of external staff in the German health care system. In political debates as well as in demands of employers' organizations, economic aspects are raised. But the point of view of those affected should not be neglected. This paper aims to describe different perspectives of professional groups., Methodology: The empirical results are based on eleven partly structured interviews. These were subjected to Mayring's qualitative content analysis. The group of interviewees consists of representatives of the care sector, workforce representatives and personnel management., Results: While employing temporary personnel in ward care of patients, economic, social and professional aspects should be taken into account by all professions involved in the German health care system., Conclusions: In discussions on this subject, besides rising costs, professional and social acceptance as well as training programs and special introductions are very important., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenskonflikt besteht., (Thieme. All rights reserved.)

Background: Outpatient intensive care for people with long-term mechanical ventilation is a rapidly growing area with a wide range of care demands. The aim of this Scoping Review is to present the current state of research on the quality of care for people with home mechanical ventilation in Germany and to identify research gaps., Methods: Based on predefined inclusion criteria, 4 databases were searched for publications dealing with the care of people with home ventilation in Germany. The method of "data driven thematic analysis" led the data extraction and analysis. Distinction was made between research and expert opinion., Results: The search resulted in 493 matches of which 68 publications were included in the this study: two guidelines (3%), 45 (66%) research papers and 21 (31%) expert opinions. The following topics were identified: Organization and control of ventilation (n=43; 63%), nursing (n=23; 34%), medical (n=39; 57%), therapeutic (n=7; 10%) and assistive technologies care (n=24; 35%), as well as the perspective of people with home mechanical ventilation and their relatives (n=33; 49%) and other topics (n=13; 19%)., Conclusion: Although the debate on the quality of care for people living with home mechanical ventilation is conducted broadly, studies focusing on individual care demands, autonomy and participation depending on the living situation or on the role of specific health professionals within the interprofessional team are missing., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenskonflikt besteht. Peter Heuschmann berichtet neben den Zuwendungen des Gemeinsamen Bundesausschusses (G-BA) im Rahmen des Innovationsfonds (welcher im Artikel als offizieller Förderer der Studie genannt ist) über weitere Zuwendungen außerhalb der Studie: – Bundesministerium für Forschung und Bildung– Deutsche Forschungsgemeinschaft– Europäische Union– Charité – Universitätsmedizin Berlin – Ärztekammer Berlin– Deutsche Parkinson-Gesellschaft– Universitätsklinikum Würzburg– Robert-Koch-Institut– Deutsche Herzstiftung– Gemeinsamer Bundesausschuss (G-BA) im Rahmen des Innovationsfonds– Universitätsklinikum Heidelberg (im Rahmen von RASUNOA-prime; gefördert durch ein unbefristetes Forschungsstipendium an das Universitätsklinikum Heidelberg von Bayer, BMS, Boehringer-Ingelheim, Daiichi Sankyo)– Charité – Universitätsmedizin Berlin (innerhalb Mondafis; gefördert durch ein unbefristetes Forschungsstipendium an die Charité von Bayer)– Universität Göttingen (innerhalb FIND-AF randomisiert; gefördert durch ein unbefristetes Forschungsstipendium an die Universität Göttingen von Boehringer-Ingelheim), (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

This article is a reminder of an early example of health services research and quality assurance in Germany. The occasion for this was the 50th anniversary of the opening of the Institute of Social Medicine and Epidemiology at Hannover Medical School in 1968. The founding director of the institute, Prof. Dr. med. Manfred Pflanz, a board-certified internist, had gained reputation by publishing on psychosomatic and medico-social issues. In 1971, Sigrid Lichtner, a doctoral student, and Pflanz published a paper on the epidemiology and medical care pattern of appendectomy [1]. In the late 1960s certified appendicitis mortality in the Federal Republic of Germany used to be 3 times higher than in comparable countries. A regional analysis of all appendectomies in Hannover discovered further "odd" findings such as a weekly profile of operations not in line with an acute emergency condition and clear social as well as regional differences in the appendectomy rate. The most probable reason why the mortality from appendicitis was 3 times higher in the Federal Republic than in any other country, the authors conjectured, was that appendectomy was performed 3 times more frequently than elsewhere - questioning the doctrine of early surgical intervention in suspected appendicitis. Since then, management of appendicitis has changed, quality assurance has been implemented, evidence broadened, laparoscopic and non-operative treatment evaluated in RCTs. Appendicitis mortality has continued to decline with an acceleration of the falling trend in the early 1970s. Absolute numbers of deaths are now very low. Numbers of appendectomies are declining. In this respect, health services have become more effective and efficient., Competing Interests: BPR war studentische Hilfskraft und 1979-1980 wissenschaftlicher Mitarbeiter bei Manfred Pflanz., (© Georg Thieme Verlag KG Stuttgart · New York.)

In this paper we describe the process and content of our ad hoc public health ethics consultation for a Bavarian health authority in relation to Covid-19., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Goal: Participatory Health Research (PHR) approaches are becoming more common in Germany. In this paper, appropriate support strategies for the funding and implementation of PHR projects in Germany are described., Method: Nine strategies are discussed, based on the research experience of the German Network for Participatory Health Research (PartNet) and other international networks., Results: In order to foster PHR in Germany, 1) funds have to be available for those participating in the research process, and 2) for the participatory processes themselves; 3) the requirement to promote participation should be incorporated routinely in tender notices, as well as 4) in special funding programs as a funding requirement; 5) participation in research projects should be part of a formative evaluation; 6) methodology development in this field needs specific funding; 7) review processes for research bids need to be adapted to take into account the specifics of PHR; 8) coordination needs to be established across participatory research projects; 9) and successful models and examples of participation in research should be disseminated., Conclusion: It is necessary to adapt research funding programs in Germany to the specific requirements of PHR so as to promote meaningful participation on the part of non-academic partners and to avoid tokenism., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Due to numerous complaints regarding the bad condition of the toilets in schools in Frankfurt am Main, a structured survey was conducted in schools in June 2018. The objectives of the survey were: investigation of problem situations and collection of good-practice examples METHODS: One questionnaire was developed for the school management and another one for the students, to be completed by each class. Experiences and suggestions for improvement were asked for from both the management and the students RESULTS: All 147 schools in Frankfurt were contacted. 86 directors (57.8%) returned the questionnaires for the management, out of 107 (72.8%) of the schools, 982 class questionnaires were completed and returned. 18.6% of directors were satisfied with the condition of the toilets; as success factors they listed pedagogical measures and provision of sufficient hygiene articles (each 14%) as well as increased cleaning frequency (12%). As a cause of problems, 73% of the directors reported student behavior. Suggestions for improvement included: more frequent cleaning, additional supervisors, construction/renovation work and a higher budget for toiletries. About 10% of the 982 classes had no complaints about their school toilets, 92% of the classes complained of stench, 85% of dirt, and 70% of missing toilet paper. As a reason for problems, 89% of the classes stated student behavior. Suggestions for improvement of the students ranged from improved cleaning and more cleaning personnel, more personnel for control and supervision, etc. to technical solutions such as a chip and code system., Conclusions: The survey confirms the need for addressing the problems related to school toilets. Both school directors and classes most often cited user behavior and vandalism as the cause, well ahead of problems with cleaning or old toilets. Therefore, although improved cleaning is often required, it is not enough. A change in the behavior of students ís necessary as well. The proposed improvement measures should be tested and if found to be effective, implemented., Competing Interests: Die Autoren geben an, dass kein Interessenkonflit besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)