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The integrated care system Gesundes Kinzigtal (ICSGK), one of the most comprehensive population-based ICS in Germany, started its work nearly 9 years ago. The ICSGK is pursuing the Triple Aim: improving the health of the population, improving the individual's experience of care, and at the same time reducing the per capita costs of care.To evaluate the impact of the ICSGK on the Triple Aim.The ICSGK is being evaluated externally and internally via a mix of diverse quantitative and qualitative methods. This paper presents selected results for each Triple Aim dimension.Regarding population health, most of the quality indicators examined by the external scientific evaluation show positive development. For example, the prevalence of patients with fractures among all insurants with osteoporosis is presented. In 2011, this prevalence was approximately 26 % in the "Kinzigtal" population (aged ≥ 20 years old) in comparison to 33 % in the control group. As far as patient experience is concerned, to the question "Would you recommend becoming a member of Gesundes Kinzigtal to your friends or relatives?" 92.1 % of those questioned answered "Yes, for sure" or "Yes, probably." Twenty-four percent of those questioned further stated that they would now live "more healthy" than before enrolment in the ICSGK. In the subgroup of questioned insurants who had objective agreements with their doctors 45.4 % answered in this way. On the subject of cost-effectiveness, for both participating socil health insurance schemes, cost savings relative to the costs normally expected for the ICSGK population concerned are observed every year. In the seventh intervention year (2012) the total is 4.56 million Euros for the AOK Baden-Württemberg (BW), which is a contribution margin of 146 Euros per insurant for the 31.156 insurants concerned (LKK BW = 322 Euros per insurant relative to cost savings). The results presented in this paper indicate positive effects in all three Triple Aim dimensions. Further longitudinal studies are recommended to validate those first results together with a detailed analysis to obtain in-depth insights into the specific influence of subcomponents of the total intervention.

Numerous gender differences in health-related behaviour are relevant in the planning of health promotion and prevention. More men than women consume amounts of alcohol that are a risk to their health. Tobacco consumption has fallen slightly among men but has risen among women. Women eat more healthy food. Man behave risky in leisure time and traffic, thus their mortality rates due to accidents are much higher, especially in young age groups. The epidemiological data lead to the conclusion that gender sensitive health promotion and prevention is necessary. Gender mainstreaming is declared as the main strategy to enhance gender equity in health. The paper focuses on the public health action cycle and demonstrates that at each step gender mainstreaming improves the quality of intervention. To implement gender mainstreaming in health promotion and prevention, a process of sensitization has to be initialized. An instrument is presented that supports this process at the foundation "Health Promotion Switzerland". A short description of some examples of gender adequate interventions is given at the end of the paper.

As part of the measures to combat the shortage of general practitioners (GPs) particularly in rural areas, health services planning is becoming increasingly important.This paper shows how the quality of health services planning can be improved by combining population forecasts and physician number forecasts based on the cohort component method. On the basis of already available data (population data and doctors' registers), developments in the levels of care supply can be predicted on a small regional scale. The regional and temporal differentiation allows for early identification of specific needs for action. However, it is important to consider limitations in the interpretation of results.The example of Lower Saxony shows that by 2035 a decline of more than 20% in the number of GPs is expected. At the same time, regions are affected to varying degrees, and even within the more vulnerable rural areas there are heterogeneous developments which require regionally adapted responses.The greater the gap between supply and demand, the more important high-quality planning for efficient allocation of health services becomes. Against this background, care supply projections can serve as a useful building block of evidence-based care planning.

The analysis of geographic variations has spurred arguments that area of residence determines access to and quality of healthcare. In this paper we argue that unwarranted geographic variations can be traced back to actions of individual patients and their healthcare providers (doctors, hospitals). These actors interact in a complicated web of shared responsibilities. Designing effective interventions to reduce unwarranted geographic variations may therefore depend on methods to identify these interactions and communities of providers with a shared accountability. In the US, Canada, and Germany, routine data have been used to identify self-organized informal or virtual networks of physicians and hospitals, so-called patient-sharing networks (PSNs). This is an emerging field of analysis. We attempt to provide a brief report on the state of work in progress. It can be shown that variation between PSNs in a given area is effectively greater than variation between regions. While this suggests that reducing unwarranted variation needs to start at the level of PSN, methods to identify PSNs still vary widely. We compare epidemiological approaches and approaches based on graph theory and social network analysis. We also present some preliminary findings of exploratory analyses based on comprehensive claims data of physician practices in Germany. Defining PSNs based on usual provider relationships helps to create distinctive patient populations while PSNs may not be mutually exclusive. Social network analysis, on the other hand, appears better equipped to differentiate between provider communities with stronger and weaker ties; it does not yield distinctive patient populations. To achieve accountability and to support change management, analytic methods to describe PSNs still need refinement. There are first projects in Germany which use PSNs as an intervention platform in order to achieve improved cooperation and reduce unwarranted variation in their care processes.

The aim of this paper is to identify systematic differences due to sociodemographic and health-related determinants in outpatient healthcare utilisation and access in Germany for the period from 2006 to 2016. The study focuses on frequent users and those reporting particularly long wait times for their physician appointments, and it contributes to assessing the level of health equity in Germany.The investigation draws on nine population surveys conducted by the German National Association of Statutory Health Insurance Physicians (NASHIP), which interviewed 42,925 respondents aged 18 and above. "Frequent users" were operationalised as those respondents who reported more than ten consultations with outpatient general practitioners (GPs) and specialists (SPs) in the preceding twelve months. Respondents who experienced wait times of more than one month for their last doctor appointment were categorised as "very long wait times". Sociodemographic determinants included age, gender, educational and occupational status, population and region of place of residence, as well as type of health insurance of the respondents. Health-related factors were self-assessed health status and reason for last medical consultation. Statistical analyses were conducted using bivariate and multivariate techniques (logistic regression).Utilisation: Frequent users of GPs and SPs are predominantly respondents in poor health, retirees and younger persons (18 to 34 years of age). Furthermore, people with a lower educational background consult their GPs significantly more often than people with higher levels of education. Also, patients with statutory health insurance coverage visit GPs more frequently than those having private health insurance, whereas the opposite holds true for SP consultations. Access: Very long wait times for GP and SP appointments were most often experienced by respondents who consult GPs and SPs for preventive medical check-ups or health screenings, have statutory health insurance, live in eastern Germany and who are above 60 years of age. In addition, people with higher levels of education are significantly more likely to experience wait times for SP appointments of more than one month than people with a lower educational background. The proportion of frequent users as well as of those reporting very long wait times for SP appointments has increased in Germany over the period examined.This study reveals that a high frequency of GP and SP consultations is primarily associated with self-assessed poor health, indicating that prioritisation is based on clinical need. In order to ensure the same needs-based prioritisation in the access to outpatient healthcare, regulatory measures are required to decrease wait times of more than one month for SP appointments, with a special focus on people with statutory health insurance coverage, residents of eastern Germany and the elderly.

There is a growing body of literature recognizing the importance of outpatient psychotherapy. Several studies investigated the efficacy of outpatient psychotherapy and aspects of the health care system under natural conditions. This paper gives an overview of studies from German speaking countries (TRANS-OP-, TK-, PAP-S- and QS-PSY-BAY-study).The results of the different studies indicate both, positive outcome of the therapies (e. g., reduction of symptoms with an average ES of 1,03; improvement of symptoms despite premature termination) as well as an economic benefit (end of treatment depending on treatment outcome and not limited by therapy sessions; extensions of psychotherapy only if patient is highly impaired and therapeutic alliance is positive; high reduction of supply costs and sick leave). However, the low health care density in rural areas and the waiting periods before starting therapy are indicators of structural problems of the health care system with respect to outpatient psychotherapy.The efficacy of outpatient psychotherapies under natural conditions is sufficiently supported. Future studies should investigate structural aspects of the health care system, for example by focussing on the establishment of inter-sectoral connections between different professional groups and a reduction of bureaucratic actions.

In addition to primary and secondary special care, a special type of care was created in the 2015 German Health Care Strengthening Act [GKV-Versorgungsstärkungsgesetz]: medical care centres for adult people with mental and multiple disabilities (MCAMD). This closed a gap in the German healthcare system and part of Article 25 of the UN Convention on the Rights of Persons with Disabilities was implemented.Experiences from pilot projects are useful while implementing these centres. The issue is therefore: which are the supporting (s) and inhibiting (i) factors when establishing MCAMDs in the view of health care providers?Based on open guided expert interviews medical directors and initiators of existing and planned centres were interviewed. Data analysis was done by qualitative content analysis.Healthcare providers think reducing barriers in people's minds is most important. In the course of approval procedures, reservations from different actors and institutions were considered (i). During financial negotiations, health insurance companies requested a characterisation of the target group using the ICD-lists, which doesn't comply with the needs of the users (i). Implementation was only possible with a great effort from the initiators paired with willingness from actors of the association of statutory health insurance physicians and the health insurances (s).This paper describes the process used to implement MCAMDs. Potential centre providers can be inspired by these results. Further research on the process of implementation of these medical centres is needed, especially taking into account all involved parties.

This paper on psychiatric and psychosomatic day hospitals in Austria first looks at the overall situation of Austrian day clinics then, in a second step, compares psychiatric and psychosomatic day hospitals. For this purpose, a questionnaire was developed and sent to all psychiatric and psychosomatic day hospitals in Austria. The first part consisted of closed questions and was used to gather and evaluate the categories: general conditions for treatment in day hospitals, tasks of day hospitals, therapeutic paradigms, indication and contraindication, diagnostics, day hospital organisation, interdisciplinary cooperation and the offering in day hospitals. The second section consisted of open questions which were used to gather and evaluate active factors, difficulties, specifics and requests for future treatment in day hospitals. The results show that there is a trend towards more day hospitals. Psychosomatic day hospitals are a rather new phenomenon. Furthermore, the distinction between psychiatric and psychosomatic day hospitals is important in order to offer patients distinguishable treatment options in future. The results show that psychiatric and psychosomatic day hospitals both have a strong focus on psychotherapy and both fulfill the active factors for psychotherapy by Grawe.

Access to health services in rural regions represents a challenge. The development of care models that respond to health service shortages and pay particular attention to the increasing health care needs of the elderly is an important concern. A model that has been implemented in other countries is that of mobile health units. But until now, there is no overview of their possible objectives, functions and implementation requirements.This paper is based on a literature analysis and an internet research on mobile health units in rural regions.Mobile health units aim to avoid regional undersupply and address particularly vulnerable population groups. In the literature, mobile health units are described with a focus on specific illnesses, as well as those that provide comprehensive, partly multi-professional primary care that is close to patients' homes. The implementation of mobile health units is demanding; the key challenges are (a) alignment to the needs of the regional population, (b) user-oriented access and promotion of awareness and acceptance of mobile health units by the local population, and (c) network building within existing care structures to ensure continuity of care for patients. To fulfill these requirements, a community-oriented program development and implementation is important.Mobile health units could represent an interesting model for the provision of health care in rural regions in Germany. International experiences are an important starting point and should be taken into account for the further development of models in Germany.Die Sicherstellung einer bedarfsgerechten Versorgung stellt in ländlichen Regionen Deutschlands eine zunehmende Herausforderung dar. Die Entwicklung von Versorgungsmodellen, die gezielt auf Probleme reagieren und besonders den steigenden Bedarf an Versorgungsleistungen für alte Menschen berücksichtigen, ist daher ein wichtiges Anliegen. Ein Modell, das in anderen Ländern bereits Verbreitung gefunden hat, sind mobile Versorgungseinrichtungen. Bisher gibt es aber keinen Überblick über ihre möglichen Ziele, Funktionsweisen und Implementationsanforderungen.Die vorliegende Überblicksarbeit basiert auf der Auswertung internationaler Literatur und einer Internetrecherche über mobile Versorgungseinrichtungen im ländlichen Raum.Mobile Einrichtungen zielen auf die Vermeidung regionaler Unterversorgung und adressieren besonders vulnerable Bevölkerungsgruppen. In der Literatur werden mobile Einrichtungen beschrieben, die bestimmte Krankheitsbilder fokussieren, ebenso solche, die eine umfassende, teils multiprofessionelle wohnortnahe Primärversorgung leisten. Oft steht die Versorgung von Menschen mit chronischen Krankheiten im Zentrum. Die Implementation mobiler Einrichtungen ist anspruchsvoll; zentrale Anforderungen sind (a) die Ausrichtung am Bedarf der regionalen Bevölkerung, (b) ein nutzerorientierter Zugang und die Förderung der Bekanntheit und Akzeptanz des Angebots sowie (c) die Vernetzung mit bestehenden Versorgungsstrukturen zur Sicherstellung von Versorgungskontinuität. Um diesen Anforderungen gerecht zu werden, ist eine gemeindeorientierte Arbeitsweise bei der Programmentwicklung und -implementation wichtige Grundlage.Mobile Einrichtungen können für die Versorgung ländlicher Regionen Deutschlands ein interessantes Modell darstellen und werden auch hierzulande bereits erprobt. Internationale Erfahrungen stellen einen wichtigen Ausgangspunkt dar und sollten bei der Konzeptentwicklung berücksichtigt werden.

Ambient Assisted Living (AAL) summarizes various connected digital networked assisting technologies with the aim to support elderly and chronically ill people and to improve their quality of life. This paper defines the term AAL and shows different fields of application for AAL technologies. It illustrates the role of AAL against the background of the societal and demographic changes, of the expected growth of older people in need of care, and of the ongoing trend of singularisation of elderly. We describe medical application areas with new opportunities for the use of AAL technologies. The article highlights further the importance of the technical acceptance of these technologies by the end users, which we deem to be the most critical factor for the diffusion and use of AAL technologies in the forthcoming years.

Telemedicine aims to create new forms of health care delivery by the use of information and communication technologies (ICT),for example, to improve the access to health care for patients in rural regions. There is a need for assistive technologies and innovative technological solutions due to the demographic change. Population trends of western societies show concurrently an ageing population and the wish of elderly people to live at home as long as possible while there is a tendency that older people live in greater distances to their kin nowadays. More complex diseases and multimorbidity urge improved interconnectedness between different health care professionals. Hence, different health systems pursue e-health strategies with the aim to implement electronic patient records (EPR) and similar technological solutions as a first approach to tackle those challenges. Telemedicine represents an open and evolving concept which is subject to a regular process of further development as a consequence of accelerated technological progress. The increased articulated demand for patient centered health care is one driver for the use of telemedicine. In the context of the trend of shorter hospital stays technological solutions can provide an opportunity for better support and care at home to reduce health risks and improve caregiving quality after hospital discharges. Despite the still prevalent reservations of elderly people about the use of ICT research shows that acceptance and the willingness to use technical devices is increasing. The article describes different aspects of telemedicine in the context of the aging population: definitions, an overview of trends and various fields of use with specific practical examples. A synoptic view of research results of evaluations of telemedicine applications regarding their effectiveness and cost-benefit analysis complement the paper.

In 19. and early 20. centuries several million emigrants from German speaking countries entered the United States of America. How migrants coped with sickness, how they preserved their health and to which ressources and institutions of help they had access is yet an academic void. Using Ego-documents--letters, autobiographic texts and diaries--of near-illiterate men this paper will analyse 'healthy lifestyles' and practices of coping with sickness and contrast them with recent research findings in the field of 'mens' health'. Thereby the recent concept of ,male health-idiots' will be challenged in historical perspective.

GP-centered health care ("Hausarztzentrierte Versorgung", HzV)-the terms of which are described in § 73b of the Social Code Book V-came into effect in Baden-Württemberg, Germany, on 1 July 2008. The HzV is aimed at enhancing health care for patients with chronic diseases and complex health care needs (e.g., those requiring long-term care).On the basis of four working packages (WP I-WP IV), the present paper examines the impact that GP-centered health care has had on patients insured by the "AOK" regional sickness fund and their GPs. WP I addresses the association between HzV participation and the corresponding health care utilization of patients on the basis of claims data. WP II looks at any changes that GPs and patients noticed were potentially attributable to HzV participation. WP III focuses on health care assistants in primary care ("Versorgungsassistenten in der Hausarztpraxis", VERAH). These assistants play a special role within the framework of the HzV. WP IV analyzes the quality of health care for patients aged 65 years and over, also on the basis of claims data.A mixed methods design was used for this evaluation, and quantitative and qualitative approaches taken. This design enabled insights into the implementation of the HzV in regular health care to be obtained from different perspectives.Numerous positive associations between HzV participation and the variables of interest were observed for all WPs. These are presented in detail in the paper.The results obtained so far clearly support the continuation of HzV and associated evaluations.

Decisions about therapeutic interventions to be made by physicians, patients, and healthcare purchasers essentially depend on their classification in a credible context of justification, especially in a world dominated by contradicting experts. To some extent, this framing is done by sorting terms and their undertones, including the case of so-called CAM measures. In this paper, the authors reflect on ways to deal with the term CAM and the underlying supply-side approaches to healthcare from a primarily science-oriented perspective.

Assistive services in the workplace are an important aspect of the participation of people with hearing impairment in working life. This article presents the results of the GINKO study and an survey conducted by the University of Cologne on behalf of the MAIS in order to provide a comprehensive examination of the employment situation of hearing impaired people in North Rhine-Westphalia. The GINKO study examines the impact of laws on the integration of hard-of-hearing and deaf people as well as people who have become deaf as adults, focusing on communication and organizations; this project was funded by the German Federal Ministry for Labour and Social Affairs (BMAS).In the GINKO study, conducted in cooperation with the German Association of the Hard of Hearing and the German Association of the Deaf, a standardised questionnaire with questions about the workplace was administered to employed people with hearing impairments. The questionnaire was administered on paper and was also available online accompanied by sign language videos. The University of Cologne study in North Rhine-Westphalia examined the service situation of hard-of-hearing, deaf and deaf-blind people through face-to-face interviews and government statistics.The results of the nationwide GINKO study show that hearing-impaired people in North Rhine-Westphalia draw on assistive services in employment more often than hearing-impaired people in the rest of Germany. The study found statistically significant differences in the categories of "maintenance and development of professional knowledge and skills" and "psychosocial support in conflict situations resulting from disability".One reason for the more positive evaluations of the participants in North Rhine-Westphalia as compared to other regions in Germany could be the particular network of support services in that state. However, the overall positive results from North Rhine-Westphalia should not obscure the fact that a majority of participants in many areas of North Rhine-Westphalia reported much less positive evaluations. They reported that they did not (yet) have an accessible workplace and that assistive services are not available to all hearing impaired workers.

Providing mental health care to patients with depressive disorders is accompanied by deficits in the diagnostics and in the access and adequacy of treatment. Analyzing regional variations in mental health care is of increasing importance in order to detect and explain these supply shortfalls. This paper discusses different explanatory approaches to the regional variations in diagnosed depressive disorders and their treatment. Differences in demographic structures and in patients' attitudes toward mental disorders as well as in their preferences in the choice of treatment may explain regional variation. Furthermore, the number and distribution of care providers between regions may have an effect on variation. In addition to the density and availability of care givers, the quality of care may differ because of factors such as sensitivity to the detection of depressive disorders, coding quality of diagnosis and treatment, guideline-oriented treatment, as well as treatment outcome. Small-area analyses should consider all perspectives in order to understand the complexity of regional variation in the provision of health-care services and to derive recommendations for health-care services that meet people's needs.

This paper describes socio-demographic, clinical, and treatment-related parameters of psychiatric patients who were hospitalized for at least two months on an acute psychiatric ward compared to patients with a shorter inpatient treatment episode. Furthermore, it is evaluated how frequent these long-staying patients are awaiting a room in a sheltered housing facility.We investigated the longest inpatient treatment period of all patients aged between 18 and 65 years on an acute ward of the Psychiatric University Hospital Zurich (n = 3,928) using the basic documentation of the years 2006 to 2010.20 % of all patients on acute wards had a stay of more than 60 days. Socio-demographic and clinical characteristics are similar to those of "heavy users" of mental health services. Social work is involved more frequently, and placement in sheltered housing facilities is intended in one third of those patients.A substantial part of the patients who stay at least once longer than two months on an acute ward are discharged to sheltered housing. Besides severity of illness it is likely that lack of availability of an adequate housing option contributes to length of stay. Intensified cooperation of the psychiatric clinic with sheltered housing facilities as well as alternative options for those in need of assisted housing and mental health care might help to reduce their extensive usage of inpatient treatment capacities. Interventions and services have to be adapted to local conditions.

This paper describes the public health discourse on the accessibility and access paths, theoretical approaches as well as factors influencing the utilisation of prevention and health promotion interventions, and requirements for their evaluation. Various projects funded by the German Federal Ministry of Education and Research address many aspects of accessibility and describe extensive experiences with access paths, approaches to information transfer, target group-driven supply chain design, etc. Recommendations for practice and research are given at the end of the article.

The socioeconomic status (SES) is a central analytical concept for epidemiologic research and health reporting in Germany. Within the German Cardiovascular Prevention Study (GCP), a multidimensional aggregated index of SES has been developed, which is used to this date. We have revised this index critically and reworked it according to the necessities of German health monitoring at the Robert Koch Institute (RKI). The main changes involve the operationalization and categorization of the status-constituting dimensions education, occupation, and income as well as the categorization of the resulting socioeconomic status groups. This paper explains the steps of the revision process and the ideas behind it. In addition, it provides empirical evidence on the association of the revised index with three important health outcomes (self-rated health, obesity, and smoking) using data of the German Health Update 2009 (GEDA) study. It is planned to apply the revised SES concept in all studies on German health monitoring at the RKI, i.e., not only to GEDA but also to the German Health Interview and Examination Survey for Adults (DEGS) and the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) in the same way.

Fair rationing in publicly accessible health care has become a subject of current international debate. One suggestion is to cut reimbursement for any medical intervention below some threshold of small clinical benefit. One can further differentiate between thresholds of small expectable clinical benefit as such and thresholds of low chances for clinical success. Public acceptance of both types of thresholds has been tested in a population survey. Results are presented and discussed in this paper. (As supplied by publisher).

Decisions on priority setting and rationing in health care have both informational and distributional aspects, which is why they require expert knowledge and specialised bodies on the one hand and democratic consent on the other hand. The paper presents normative criteria for the evaluation and empirical categories for the description and comparison of respective bodies. As procedural decisions always have implications for resulting distributional decisions, the bodies charged with priority setting and rationing decisions must be subject to democratic institutional design. (As supplied by publisher).

The German debate on prioritisation in medicine is getting well under way. This development has raised the question of which substantial and procedural criteria should be used to guide fair and legitimate prioritisation. It seems to be obvious that in a pluralist, democratic society citizens should be involved in such a discussion. But which is the adequate method, and what is the potential of citizen participation? In this paper we compare the results of a regional citizens' conference on prioritisation in medicine with various European reports on principles and criteria for prioritisation, and thereby aim to identify the conference members'contributions to the German debate on prioritisation criteria. The results of this exemplary deliberative event can provide hints towards the general potential of discursive participation. (As supplied by publisher).