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According to Sixth Book of the Social Code (SGB VI), the German Pension Insurance (GPI) has the mandate to maintain or restore the employability of its insured persons. In order to achieve this goal, the GPI offers its insurees rehabilitation benefits. These are, on the one hand, services for prevention and medical rehabilitation (rehab) and, on the other hand, services for return-to-work or stay-at-work, respectively. In order to fulfill this mandate in the best possible way, in 1990 the GPI introduced instruments of external quality assurance (EQS) with scientific support. The system was firmly established in 1997. Since then, all rehab facilities owned and managed by the GPI are obliged to participate in the EQS system.Over the years, a large number of instruments and procedures have been developed that can map various aspects of quality as structure, process, and outcome. Until 2017, results of the EQS had no influence on the cooperation between the GPI and service providers. With the binding decision of the Federal Executive Board of the GPI in 2017, for the first time the GPI linked the allocation of rehab services for specific patients with the results of EQS. On this basis - confirmed by article 3 of the Digital Pension Overview Act - new paths are being taken. As part of the technically supported selection of a suitable facility for insured persons, quality should systematically and transparently acquire special importance and be consistently taken into account when occupying rehab facilities.This article gives an overview of the development of the proved and tested instruments of rehab quality assurance (QA), their current application, and an outlook on the rehab QA of the future.Die Deutsche Rentenversicherung (DRV) hat entsprechend dem Sozialgesetzbuch VI den Auftrag, die Erwerbsfähigkeit ihrer Versicherten zu erhalten bzw. wiederherzustellen. Um dieses Ziel zu erreichen, bietet die DRV ihren Versicherten Leistungen zur Teilhabe an. Das sind einerseits Leistungen zur Prävention und medizinischen Rehabilitation (Reha) und andererseits Leistungen zur Teilhabe am Arbeitsleben (berufliche Rehabilitation). Um diesen Auftrag bestmöglich zu erfüllen, begann die DRV in den 1990er-Jahren mit wissenschaftlicher Unterstützung Instrumente der externen Qualitätssicherung (QS) einzuführen. Das System wurde 1997 fest etabliert. Seither nehmen alle rentenversicherungseigenen Rehaeinrichtungen sowie die von der DRV federführend belegten Rehaeinrichtungen verpflichtend daran teil.Im Laufe der Jahre wurde eine Vielzahl an Instrumenten und Verfahren entwickelt, die verschiedene Aspekte von Qualität abbilden können: Struktur‑, Prozess- und Ergebnisqualität. Bis 2017 hatten die Ergebnisse der externen Qualitätssicherung keinen Einfluss auf die Zusammenarbeit der RV-Träger mit den Leistungserbringern. Mit der „Verbindlichen Entscheidung“ des Bundesvorstandes der DRV aus dem Jahr 2017 hat die DRV erstmalig die Zuweisung von Rehabilitand*innen mit den Ergebnissen der externen QS verknüpft. Auf dieser Grundlage werden nun – bestätigt durch Artikel 3 des Gesetzes Digitale Rentenübersicht – neue Wege beschritten: Im Rahmen der technisch unterstützten Auswahl einer geeigneten Einrichtung für Versicherte soll Qualität systematisch und transparent eine besondere Bedeutung erlangen und bei der Belegung von Rehaeinrichtungen konsequent berücksichtigt werden.Dieser Beitrag gibt einen Überblick über die Entwicklung der bewährten Instrumente der Reha-QS, über ihre aktuelle Anwendung sowie einen Ausblick auf die Reha-QS der Zukunft.

Background: Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases. Methods: The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the “Association of the Scientific Medical Societies in Germany” (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation. Results: Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction

OBJECTIVE: To perform a European survey of the evidence needs and training demands of insurance medicine professionals related to professional tasks and evidence-based practice. DESIGN: International survey. SUBJECTS: Professionals working in insurance medicine. METHODS: Experts designed an online questionnaire including 26 questions related to 4 themes: evidence needs; training demands; evidence-seeking behaviour; and attitudes towards evidence-based medicine. Descriptive statistics were presented by country/conference and the total sample. RESULTS: A total of 782 participants responded. Three-quarter of participants experienced evidence needs at least once a week, related to mental disorders (79%), musculoskeletal disorders (67%) and occupational health (65%). Guidelines (76%) and systematic reviews (60%) were the preferred types of evidence and were requested for assessment of work capacity (64%) and prognosis of return-to-work (51%). Evidence-based medicine was thought to facilitate decision-making in insurance medicine (95%). Fifty-two percent of participants felt comfortable finding, reading, interpreting, and applying evidence. Countries expressed similar needs for reviews on typical topics. CONCLUSION: This study reveals evidence gaps in key areas of insurance medicine, supporting the need for further research, guidelines and training in evidence-based insurance medicine. Importantly, insurance medicine professionals should recognize that evidence-based practice is crucial in producing high-quality assessments.

Zusammenfassung Einleitung Evidenzbasierte Medizin (EbM) wurde ursprunglich als Masnahme zur arztlichen Weiterbildung entwickelt, weist aber gerade in Deutschland in den letzten Befragungen der Assistenzarzte zur arztlichen Weiterbildung aus den Jahren 2009 und 2011 durch die Bundesarztekammer die grosten Defizite aller gefragten Themenkomplexe auf. Eine Ursache dafur konnte ein mangelndes Angebot an speziellen Weiterbildungsangeboten sein. In einer randomisiert-kontrollierten Warte-Kontroll Studie wurde ein moglicher Wissenszuwachs und die Akzeptanz eines online Kurses in EbM fur arztliche Berufsanfanger untersucht. Methoden Arztliche Berufsanfanger am Universitatsklinikum Frankfurt erhielten die Moglichkeit, freiwillig an einem online Kurs in EbM teilzunehmen. Der tutorgestutzte Kurs bestand aus 5 Modulen, angelehnt an die 5 Schritte der EbM, mit jeweils dazu passenden praktischen Modulaufgaben. Die Teilnehmer erhielten den Kurs entweder sofort oder nach einer dreimonatigen Wartezeit mittels Telefonrandomisation zugelost. Das Hauptzielkriterium Wissen wurde mittels multiple-choice Fragen in zwei Sets mit je 13 Fragen vor und nach den Kursen sowie nach 6 und 12 Monaten uberpruft. Subjektiv wurde der Kurs mit Schulnoten und semiquantitativ die Schwierigkeit bewertet, sowie nach dem Nutzen fur den klinischen Alltag gefragt. Ergebnisse Von 120 randomisierten Teilnehmern nahmen 114 teil. Die Sofort-Interventionsgruppe (n=58) erreichte nach dem Kurs im Median 10 (95% Konfidenzintervall 10-11) richtige Fragen, wahrend die Warte-Interventionsgruppe (n=56) nach der dreimonatigen Wartezeit im Median nur 4 (95% Konfidenzintervall 4-5) richtige Fragen aufwies (p≤0.0001). Der mediane Wissenszuwachs beider Gruppen im Kursverlauf betrug 5 Punkte (p≤0.0001) und zeigte sich im Zwolfmonatszeitraum konstant. Sechs Monate nach Kursende schatzten 96.4% aller Teilnehmer das vermittelte Wissen als hilfreich fur den klinischen Alltag ein und 38.1% wurden an weiterfuhrenden Veranstaltungen teilnehmen. Der Kurs wurde im Median mit der Schulnote 2 bewertet. Diskussion und Schlussfolgerungen Ein deutschsprachiger online Kurs in Evidenzbasierter Medizin fur arztliche Berufsanfanger fuhrt zu einem deutlichen und anhaltenden Wissenszuwachs, wird gut bewertet und die Inhalte werden als klinisch relevant eingestuft. Dieser tutorgestutzte, praxisnahe Kurs ist variabel einsetzbar und konnte einen wichtigen Beitrag zur Facharztweiterbildung in EbM leisten.

Summary Aim To evaluate the educational effectiveness of a clinically integrated e-learning course for teaching basic evidence-based medicine (EBM) among postgraduate medical trainees compared to a traditional lecture-based course of equivalent content. Methods We conducted a cluster randomized controlled trial to compare a clinically integrated e-learning EBM course (intervention) to a lecture-based course (control) among postgraduate trainees at foundation or internship level in seven teaching hospitals in the UK West Midlands region. Knowledge gain among participants was measured with a validated instrument using multiple choice questions. Change in knowledge was compared between groups taking into account the cluster design and adjusted for covariates at baseline using generalized estimating equations (GEE) model. Results There were seven clusters involving teaching of 237 trainees (122 in the intervention and 115 in the control group). The total number of postgraduate trainees who completed the course was 88 in the intervention group and 72 in the control group. After adjusting for baseline knowledge, there was no difference in the amount of improvement in knowledge of EBM between the two groups. The adjusted post course difference between the intervention group and the control group was only 0.1 scoring points (95% CI −1.2–1.4). Conclusion An e-learning course in EBM was as effective in improving knowledge as a standard lecture-based course. The benefits of an e-learning approach need to be considered when planning EBM curricula as it allows standardization of teaching materials and is a potential cost-effective alternative to standard lecture-based teaching.

Die chronische Herzinsuffizienz ist eine Erkrankung des hoheren Lebensalters. Sie gehort in Deutschland zu den haufigsten Todesursachen und zu den haufigsten Diagnosen bei vollstationaren Patienten. Durch den prognostizierten Anstieg der Lebenserwartung wird sich die Anzahl der Betroffenen in den kommenden Jahren weiter erhohen. Vor diesem Hintergrund wurde die Nationale VersorgungsLeitlinie (NVL) Chronische Herzinsuffizienz (HI) von einer multi- und interdisziplinaren Expertengruppe entwickelt. Der NVL Expertengruppe gehorten Vertreter aller relevanten wissenschaftlichen medizinischen Fachgesellschaften und Patientenvertreter an. Durch Handlungsempfehlungen zu der nach dem momentanen Stand des Wissens am besten belegten Vorgehensweise bei der Versorgung der betroffenen Patientinnen und Patienten zielt sie darauf ab, Arzte und Patienten bei Entscheidungen zu konkreten klinischen Fragestellung zu unterstutzen. Bedingt durch das hohe Lebensalter und haufig zusatzlich vorliegende Begleiterkrankungen haben Patienten mit chronischer Herzinsuffizienz komplexe Versorgungsbedarfe. Aus diesem Grund sind entsprechende Komorbiditaten bei der Therapieplanung und -steuerung sowie bei der Kommunikation mit den Patienten angemessen zu berucksichtigen. Die allgemeine Behandlungsstrategie bei nachgewiesener chronischer Herzinsuffizienz umfasst deshalb neben der Therapie der Risiko- und Prognosefaktoren, die angemessene Berucksichtigung der Begleiterkrankungen sowie die Unterstutzung der Patienten bei der Etablierung eines gesunden Lebensstils und dem eigenverantwortlichen Umgang mit der Erkrankung. Da psychosoziale Aspekte sowohl fur die arztliche Therapiesteuerung als auch fur die Akzeptanz und das Selbstmanagement der Patienten eine grose Rolle spielen, sollten sie im arztlichen Gesprach angemessen thematisiert werden. Die Nationale VersorgungsLeitlinie Chronische Herzinsuffizienz ist eine schnittstellenubergreifende interdisziplinare Leitlinie. Sie bietet eine Zusammenstellung evidenz- und konsensbasierter Empfehlungen zu Diagnostik und Therapie der chronischen Herzinsuffizienz, die zur qualitativen Verbesserung der Versorgung von Patientinnen und Patienten mit Chronischer Herzinsuffizienz beitragen soll. Damit dies tatsachlich geschehen kann, muss die NVL HI im Alltag der Arztinnen und Arzte, aber auch der Patientinnen und Patienten Anwendung finden. Um dies zu unterstutzen, wurde zusatzlich eine Patientenversion dieser Leitlinie entwickelt. In dem Beitrag werden die wichtigsten Inhalte der NVL Chronische Herzinsuffizienz zusammengefasst.

Zusammenfassung Fur die Nationalen VersorgungsLeitlinien wurde gemeinsam mit einem Expertenkreis eine Methode der strukturierten Bestimmung von Qualitatsindikatoren entwickelt. Wesentliche Schritte sind die Instruktion der NVL-Autoren fruh im Prozess der Leitlinienerstellung, die methodische Vorauswahl von Leitlinienempfehlungen, aus denen potentiell messbare Indikatoren abgeleitet werden konnen, die schriftliche Bewertung dieser Messgrosen nach 5 Kriterien (u.a. Bedeutung fur das Gesundheitssystem und Klarheit der Definition) und die anschliesende formale Konsentierung. Fur die NVL Herzinsuffizienz wurden bislang neun Indikatoren zu wesentlichen, starken Empfehlungen (Empfehlungsgrad A) aus den Bereichen Diagnostik (2), allgemeine Behandlungsstrategie (2), spezifische therapeutische Masnahmen (3), Verlaufskontrolle/Monitoring (1) und Versorgungssmanagement (1) bestimmt. Die Indikatoren mussen in einem zweiten Schritt in einem Praxistext validiert werden. Die Ableitung und Bewertung der moglichen Qualitatsindikatoren zeigte Verbesserungspotential der NVL Entwicklung vor allem in Bezug auf Daten zur Versorgungslage und Spezifizierung von Empfehlungen auf.

In December 2009, the first version of the German Disease Management Guideline (DM-CPG) for chronic heart failure was completed, including a set of proposed quality indicators for heart failure. This article explores whether proposed indicators can be derived from data collected routinely in general practices. For this purpose, previous experiences and data from the research project CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork) conducted under guidance of the Department of General Medicine and Health Services Research at the University of Heidelberg, Germany, were applied. The availability of numerators and denominators needed for calculating the four quality indicators for diagnosis and pharmacotherapy proposed in the DM-CPG was checked within so-called "routine data" from the existing dataset of the CONTENT project. Within the given context, routine data are defined as data that are periodically transmitted from health care providers to cost units within the health care system. A thorough assessment has revealed that within the given context only one indicator could be deduced from routine data collection. This was the indicator measuring the proportion of patients receiving beta receptor antagonists, compared to all patients with heart failure NYHA class II to IV. Indeed, this single indicator will only be computable if the NYHA grade of heart failure severity and the presence or absence of contraindications to beta receptor antagonist therapy are routinely collected and the data merged into a central database. Against the background of these results it is obvious that a fully developed, transsectoral concept for data collection and data transfer needs to be implemented.

Unipolare Depressionen zahlen zu den haufigsten Beratungsanlassen und Erkrankungen in der Versorgung. Obwohl die Diagnostik und Therapie der Depression in den letzten Jahren Fortschritte gemacht hat, besteht noch deutliches Optimierungspotenzial. Die Ausrichtung der Behandlung an evidenzbasierten Leitlinien bildet hierbei einen zentralen Ansatzpunkt. Die neue S3- und Nationale Versorgungsleitlinie Unipolare Depression, deren Erstellung von der DGPPN koordiniert und die von 29 Fachgesellschaften und Berufsverbanden konsentiert wurde, stellt den ambitionierten Versuch dar, Evidenz und klinischen Konsens zum „state of the art“ in der Depressionsbehandlung abzubilden. Fur die Pharmakotherapie der Depression konnen differenzierte Empfehlungen, auch in Abgrenzung und in Erganzung zur Psychotherapie, gegeben werden.

Trotz der hohen Inzidenz und einer durch verschiedene Optionen zur Primartherapie gegebenen Versorgungsvariabilitat fehlte in Deutschland bisher eine umfassende Leitlinie zum Prostatakarzinom. Die Deutsche Gesellschaft fur Urologie (DGU) fasste deshalb im Jahre 2005 den Beschluss, eine interdisziplinare evidenzbasierte S3-Leitlinie zur Fruherkennung, Diagnostik und Therapie der verschiedenen Stadien des Prostatakarzinoms zu erstellen. An der Leitlinienentwicklung waren 76 Experten aus 10 verschiedenen Fachgesellschaften bzw. Organisationen einschlieslich einer Patientenorganisation beteiligt. Insgesamt wurden 42 Schlusselfragen bearbeitet. Fur die 2009 fertig gestellte Leitlinie wurden 170 Empfehlungen und 42 Kernaussagen mit Hilfe systematischer Literaturrecherchen und formalisierter Konsensverfahren formuliert und verabschiedet. Dieser Artikel beschreibt Ziele, Entwicklungsprozess und Inhalte der Leitlinie im Hinblick auf die Zusammenarbeit von klinischen Experten und Methodikern und die Evidenz- bzw. Konsensbasierung von Empfehlungen.

Zusammenfassung Gesundheit wie auch Krankheit differieren nach sozialen Merkmalen, wie u. a. Geschlecht, sozialer Status und Ethnizitat. Evident sind Geschlechterunterschiede in der Krankheitsentstehung und dem Krankheitsverlauf sowie in der Diagnostik, der Therapie und dem Therapieergebnis. Die Anzahl der Publikationen in diesem Forschungsfeld, die auf den Einfluss biologisch (sex) und sozial bedingter (gender) Geschlechterunterschiede fur eine Vielzahl von Erkrankungen hindeuten, hat sich in den letzten Jahren stetig vergrosert. Trotz dieser Entwicklung und einer beginnenden Etablierung der Gendermedizin sind noch zahlreiche Fragen offen. Auch hinsichtlich der Anwendung dieses Wissens in der medizinischen Praxis bzw. im Gesundheitssystem bestehen noch erhebliche Defizite, die sich bspw. in einem verzogerten Transfer des Wissens in die medizinische Behandlung widerspiegelt. Dies trifft auch fur die Erstellung von Leitlinien, als wichtigem Instrument der Qualitatsverbesserung der medizinischen Versorgung, zu, wo bis dato keine systematische Einbeziehung moglicher Geschlechterunterschiede erfolgt ist. Ziel des Beitrages ist es, an diesem Punkt anzuknupfen und aufzuzeigen, welche Anforderungen sich durch eine systematische Berucksichtung der Geschlechterperspektive fur die Erstellung und Beurteilung von Leitlinien ergeben und mittels welcher methodischer Vorgehensweisen eine Realisierung gelingen konnte. Letztgenanntes wird anhand eines Beispiels, einer Pilotstudie, bei der vier internationale Leitlinien zur Depression analysiert wurden, verdeutlicht. Neben einer quantitativen Auszahlung geschlechterrelevanter Begriffe wurden, basierend auf einer systematischen Literaturrecherche, relevante Geschlechterunterschiede fur die Depression ermittelt und jeweils mit den Leitlinien abgeglichen. Die Pilotstudie zeigte, dass in diesen Leitlinien Geschlechterdifferenzen, obgleich eine wissenschaftliche Evidenz fur das Vorhandensein ebensolcher vorhanden ist, nur marginal thematisiert wurden. In Anbetracht der Reichweite und des Potentials von Leitlinien, die Versorgungsqualitat zu verbessern, kommt ihnen auch hinsichtlich einer zeitnahen und umfassenden Berucksichtigung von Geschlechterunterschieden eine herausragende Rolle zu. Dies wird bislang noch nicht ausreichend genutzt und sollte integraler Bestandteil sowohl des Erstellungs- als auch des Reviewprozesses von Leitlinien werden.

Zusammenfassung Seit sieben Jahren existiert das Programm der Nationalen VersorgungsLeitlinien (NVL) unter der Tragerschaft von Bundesarztekammer (BAK), Kassenarztlicher Bundesvereinigung (KBV) und Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). Ziel des NVL-Programms ist es, versorgungsbereichsubergreifende nationale Leitlinien zu ausgewahlten Erkrankungen zu entwickeln und zu implementieren. Dabei sind die strikte Evidenzbasierung einerseits und die Vermeidung konkurrierender Empfehlungen mithilfe neutral moderierter Konsensprozesse andererseits die Kernpunkte der methodischen Entwicklung. Trotz standardisierter Leitlinienmethodik haben sich strukturelle und inhaltliche Besonderheiten herauskristallisiert, welche jede NVL zu einem Unikum machen. Die komplexe Erkrankung des Typ-2-Diabetes wird zum Beispiel themen- und problemorientiert in NVL-Modulen abgehandelt. Das Thema unipolare Depression wurde erstmals zeitgleich als S3-Leitlinie und NVL realisiert. Auch inhaltlich besas jede NVL ihre themenspezifischen Herausforderungen, so wurde bei der NVL Kreuzschmerz unter anderem intensiv und kontrovers uber die Definition des nichtspezifischen Kreuzschmerzes diskutiert. Die NVL Asthma adressiert nicht ausschlieslich Erwachsene, sondern auch Kinder und Jugendliche, und in der NVL Chronische Herzinsuffizienz wurden erstmals weitere versorgungsrelevante Aspekte wie Multimorbiditat und psychosoziale Aspekte detailliert thematisiert. Der folgende Artikel soll einen kurzen Einblick in die Vielfaltigkeit der Entwicklung Nationaler VersorgungsLeitlinien geben und die Komplexitat der Leitlinienerstellung verdeutlichen.

Within the context of the development of evidence-based oncology guidelines, the Agency for Quality in Medicine undertook evidence reviews for diagnostic imaging procedures. Systematic searches retrieved no randomised controlled trials, but only cohort studies and case series of mostly moderate quality. The identified studies provided only a restricted basis for the guideline recommendations as their validity was limited and only outcomes of diagnostic accuracy were examined. However, decision criteria for recommending diagnostic strategies significantly comprise judgements about required resources and availability of diagnostic imaging procedures. These criteria as well as patient out-comes were mostly implicit and should be explicated in future. In order to increase the relevance of evidence reviews for oncological diagnosis, high quality studies which examine resources and patient-centred outcomes for diagnostic strategies are required.

Background: Over the past decade, evidence-based medicine (EBM) has gained recognition as a means to improve the quality of health care provision. However, little is known about learning opportunities to acquire EBM-associated skills. The EUebm-Unity partnership explored current educational activities for EBM practice for doctors across Europe. Methods: We surveyed organizations offering postgraduate EBM courses across Europe inquiring about their course programme, teaching content and strategies, and interest in a Europe-wide curriculum in EBM. Results: One hundred and fifty-six organizers in eight European countries reported 403 courses that had started first-time from 1996 to 2006. Despite a steady increase, in absolute terms, the frequency of courses was low and varied from 1 first-time offering of a course per 640 doctors (Spain) to 1 first-time offering per 5600 doctors (Austria) over 10 years. Most adopted the McMaster EBM teaching concept of small group, problem-based learning focussing on interventions, diagnostic tests and guidelines, and included efforts to link EBM to patient care. Teaching staff consisted of doctors from academic and non-academic settings, supported by methodologists. Efforts to formally integrate EBM in postgraduate activities were only partially successful. Most organizations welcomed a standardized European qualification in EBM. A limitation of the survey is the lack of follow-up information about the continuation of courses following the first-time offering. Conclusions: All countries offer some EBM courses with varying teaching intensity. Learning opportunities are insufficient to ensure widespread dissemination of knowledge and skills. Most countries welcome more efforts to develop inexpensive and feasible educational activities at a postgraduate level.

Integrative concepts of teaching and learning with close reference to individual work routines are better suited to bring about attitudinal and behavioural modification--apart from a gain in knowledge and skills--than traditional educational approaches. All the same, the vast majority of continuing training courses in Evidence-based Medicine takes place during weekend courses or evening classes, outside the work environment. To counteract this deficit a modular curriculum framework for Evidence-based Medicine was developed within the scope of the European research project EUebm which aims to achieve both a harmonisation of EbM education and training in Europe and a better integration of education and training with everyday clinical practice. The modules of this curriculum are intended to seamlessly fit into our day-to-day clinical work for and with patients and thus facilitate close interaction between the actual clinical work and the learning of EbM techniques and their implementation into our own patients' care. On the basis of a survey conducted among all the project partners in Austria, England, Germany, Hungary, Italy, The Netherlands, Poland, Spain and Switzerland the demand for training and continuing education in EbM in the individual countries was identified. Taking into account the results of this survey as well as previous work such as, for example, the curriculum of the German Network for Evidence-based Medicine or material provided by the Centre for Evidence-based Medicine in Oxford, an Internet-based teaching and learning module on systematic reviews and meta-analyses was developed and tested in five of the participating countries. The test demonstrated that in this way harmonisation of EbM education and training and a better integration of training with our everyday clinical work becomes feasible.

Depressive Storungen zahlen zu den haufigsten Beratungsanlassen und Erkrankungen in der Versorgung. Obwohl sie gut behandelbar sind, besteht – trotz der Fortschritte in den vergangenen Jahren – weiterhin Optimierungsbedarf hinsichtlich der Diagnostik und Therapie. Die Implementierung evidenz- und konsensusbasierter Leitlinien ist eine geeignete Masnahme, um die Versorgung depressiver Patienten zu verbessern. Zurzeit wird fur Deutschland eine evidenzbasierte Leitlinie Depression erarbeitet. Um ihre Akzeptanz und weite Verbreitung sicherzustellen, wird diese Leitlinie im Konsens aller relevanten Akteure verabschiedet. Zukunftige Aufgabe ist es, eine an Leitlinien orientierte Diagnostik und Behandlung regelhaft in der Versorgung zu verankern.

The Programme for National Disease Management Guidelines (German DM-CPG Programme) was established in 2002 by the German Medical Association (umbrella organisation of the German Chambers of Physicians) and joined by the Association of the Scientific Medical Societies (AWMF)--umbrella organisation of more than 150 professional societies--and by the National Association of Statutory Health Insurance Physicians (NASHIP) in 2003. The programme provides a conceptual basis for disease management, focussing on high priority healthcare topics and aiming at the implementation of best practice recommendations for prevention, acute care, rehabilitation and chronic care. It is organised by the German Agency for Quality in Medicine, a founding member of the Guidelines International Network G-I-N. The main objective of the German DM-CPG Programme is to establish consensus among the medical professions on evidence-based key recommendations covering all sectors of healthcare provision and facilitating the coordination of care for the individual patient through time and across interfaces. Within the last year DM-CPGs have been published for asthma, COPD, type 2 diabetes and coronary heart disease. In addition, experts from national patient self-help groups have been developing patient guidance based upon the recommendations for healthcare providers. The article describes background, methods and tools of the DM-CPG programme using the DM-CPG Method Report 2007.

Evidence-based Medicine (EbM) was originally developed as a teaching tool for young doctors, but in Germany the last surveys among residents in 2009 and 2011 demonstrated that, across all topics, the largest deficits were seen in the field of EbM. One reason may be a deficit in customised offers for continuing medical education in EbM. In a randomised controlled trial with a wait-control design we investigated a possible gain in knowledge and the acceptance of an online course in EbM for first-year residents.All first-year residents at the Hospital of the Goethe University in Frankfurt received the offer to voluntarily take part in an online EbM course. The tutored course consisted of five modules according to the five steps of EbM, each module being complemented by practical tasks. The participants were randomised via telephone to the course right away or after a three-month waiting period. The primary endpoint (i.e., knowledge) was tested via two sets of 13 multiple choice questions before and after the course and after 6 and 12 months. The participants were asked to subjectively evaluate the course by using an A-F grading system and to semiquantitatively assess its level of difficulty; they were also asked to evaluate the usefulness of its content in their clinical setting.114 out of the 120 randomised participants took part. After 3 months the immediate intervention group (n=58) achieved a median of 10 (95 % confidence interval 10 to 11) correct answers following the course, whereas the waiting intervention group only received a median of 4 (95% confidence interval 4 to 5) correct answers after the three month waiting period (p ≤ 0.0001). The median gain in knowledge for both groups throughout the course was 5 correct answers (p ≤ 0.0001), and this proved to remain constant within a twelve month period. Six months after the course, this course was rated as clinically useful by 96.4 % of the participants, and 38.1% stated that they would volunteer again in further teaching activities. The course received a median grade of B.A German online EbM course for first-year residents leads to a remarkable and sustainable gain in knowledge, is well marked, and its contents were regarded as clinically relevant. This tutored practical course is applicable to various settings and could provide an important contribution to EbM residency programs.

Introduction: Evidence-based medicine (EBM) improves the quality of health care. Courses on how to teach EBM in practice are available, but knowledge does not automatically imply its application in teaching. We aimed to identify and compare barriers and facilitators for teaching EBM in clinical practice in various European countries. Methods: aEuro integral A questionnaire was constructed listing potential barriers and facilitators for EBM teaching in clinical practice. Answers were reported on a 7-point Likert scale ranging from not at all being a barrier to being an insurmountable barrier. Results: aEuro integral The questionnaire was completed by 120 clinical EBM teachers from 11 countries. Lack of time was the strongest barrier for teaching EBM in practice (median 5). Moderate barriers were the lack of requirements for EBM skills and a pyramid hierarchy in health care management structure (median 4). In Germany, Hungary and Poland, reading and understanding articles in English was a higher barrier than in the other countries. Conclusion: aEuro integral Incorporation of teaching EBM in practice faces several barriers to implementation. Teaching EBM in clinical settings is most successful where EBM principles are culturally embedded and form part and parcel of everyday clinical decisions and medical practice

In December 2009, the first version of the German Disease Management Guideline (DM-CPG) for chronic heart failure was completed, including a set of proposed quality indicators for heart failure. This article explores whether proposed indicators can be derived from data collected routinely in general practices. For this purpose, previous experiences and data from the research project CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork) conducted under guidance of the Department of General Medicine and Health Services Research at the University of Heidelberg, Germany, were applied. The availability of numerators and denominators needed for calculating the four quality indicators for diagnosis and pharmacotherapy proposed in the DM-CPG was checked within so-called "routine data" from the existing dataset of the CONTENT project. Within the given context, routine data are defined as data that are periodically transmitted from health care providers to cost units within the health care system. A thorough assessment has revealed that within the given context only one indicator could be deduced from routine data collection. This was the indicator measuring the proportion of patients receiving beta receptor antagonists, compared to all patients with heart failure NYHA class II to IV. Indeed, this single indicator will only be computable if the NYHA grade of heart failure severity and the presence or absence of contraindications to beta receptor antagonist therapy are routinely collected and the data merged into a central database. Against the background of these results it is obvious that a fully developed, transsectoral concept for data collection and data transfer needs to be implemented.

Within the context of the development of evidence-based oncology guidelines, the Agency for Quality in Medicine undertook evidence reviews for diagnostic imaging procedures. Systematic searches retrieved no randomised controlled trials, but only cohort studies and case series of mostly moderate quality. The identified studies provided only a restricted basis for the guideline recommendations as their validity was limited and only outcomes of diagnostic accuracy were examined. However, decision criteria for recommending diagnostic strategies significantly comprise judgements about required resources and availability of diagnostic imaging procedures. These criteria as well as patient out-comes were mostly implicit and should be explicated in future. In order to increase the relevance of evidence reviews for oncological diagnosis, high quality studies which examine resources and patient-centred outcomes for diagnostic strategies are required.

Gender and diversity have a strong impact on health and illness as evidenced by sex and gender differences in the onset and progression of diseases as well as in diagnosis, therapy, and therapeutic outcome. The number of sex/gender-specific studies in medicine has increased steadily in recent years, indicating sex (biological) and gender (social) differences in numerous diseases. Despite this evidence, however, sex/gender differences are rarely considered in medical practice or in health systems, suggesting a delay in transferring such research into evidence-based medical treatment. Similarly, quality improvement guidelines in medical care do not systematically integrate the sex/gender perspective. Against this backdrop, this paper seeks to enumerate the necessary components of a guideline development and evaluation process that systematically integrates sex/gender differences in addition to providing a sex/gender-based methodological approach. The latter is illustrated by a pilot study in which four international guidelines on depression were selected. The sex/gender appropriateness of these guidelines was analysed using two methods: first, sex/gender-relevant words were counted; and second, relevant sex/gender differences were summarised based on a systematic literature review and then compared with the information given in the guidelines. The findings of the pilot study revealed that although strong evidence exists on sex/gender differences in depression, such research was rarely implemented in the guidelines. Given the scope and potential of guidelines to improve the quality of health care, it is essential that they consider the crucial role of sex/gender differences. To date, sex/gender differences have been insufficiently addressed in guideline development and evaluation when they should be an integral component of the process.

For seven years the German National Disease Management Guidelines Programme (NDMG Programme) has been supported by its funding bodies: the German Medical Association, the National Association of Statutory Health Insurance Physicians, and the Association of Scientific Medical Societies. The objectives of the NDMG Programme are to develop and to implement comprehensive national clinical guidelines for the management of selected illnesses. Key points of NDMG methodology are the strict adherence to the principles of evidence-based medicine as well as the avoidance of contradictory recommendations by means of neutrally facilitated consensus rounds. Despite the standardised NDMG methodology each guideline has individual structural and content features that make it unique. For example, the complex illness type 2 diabetes is presented in topic- and problem-oriented NDMG modules. For unipolar depression, the NDMG was simultaneously developed as a S3 guideline. Furthermore each NDMG group was faced with its own content-based challenges. For instance, in the case of the NDMG Low-back Pain the guideline group intensely and controversially discussed the definition of unspecific low-back pain. The NDMG Asthma does not solely address adults, but also children and adolescents, and the NDMG Heart Failure for the first time covers other health care relevant aspects such as multimorbidity and psychosocial factors in detail. The following article aims to deliver insight into the diversity of the development of National Disease Management Guidelines and to demonstrate the complexity of guideline development.

After seven years the National Disease Management Guidelines Programme (German DM-CPG Programme) that was established under the auspices of the German Medical Association, the National Association of Statutory Health Insurance Physicians and the Association of the Scientific Medical Societies in Germany has been widely accepted by both health care professionals and patients. DM-CPGs are available as tools for knowledge and quality management for widespread chronic diseases showing need for improvement in treatment pathways and coordination between health care providers. The main objective of the German DM-CPG Programme is to establish consensus among the medical professions on evidence-based key recommendations covering all sectors of health care provision and facilitating the coordination of care for the individual patient over time and across interfaces. German DM-CPGs provide a conceptual basis for disease management and integrative care aiming at the implementation of best practice recommendations for prevention, acute care, rehabilitation, chronic care and management aspects for high priority health care topics. Thus, representatives of all disciplines, professions and patients concerned with the topic of an individual German DM-CPG are involved in the development process. The methodology of guideline development is in accordance with international standards. However, the improvement of strategies for effective implementation and continuous update remain challenging. Future work will also focus on content-related aspects such as co-morbidity, gender and migration background.

Over the past decade, evidence-based medicine (EBM) has gained recognition as a means to improve the quality of health care provision. However, little is known about learning opportunities to acquire EBM-associated skills. The EUebm-Unity partnership explored current educational activities for EBM practice for doctors across Europe.We surveyed organizations offering postgraduate EBM courses across Europe inquiring about their course programme, teaching content and strategies, and interest in a Europe-wide curriculum in EBM.One hundred and fifty-six organizers in eight European countries reported 403 courses that had started first-time from 1996 to 2006. Despite a steady increase, in absolute terms, the frequency of courses was low and varied from 1 first-time offering of a course per 640 doctors (Spain) to 1 first-time offering per 5600 doctors (Austria) over 10 years. Most adopted the McMaster EBM teaching concept of small group, problem-based learning focussing on interventions, diagnostic tests and guidelines, and included efforts to link EBM to patient care. Teaching staff consisted of doctors from academic and non-academic settings, supported by methodologists. Efforts to formally integrate EBM in postgraduate activities were only partially successful. Most organizations welcomed a standardized European qualification in EBM. A limitation of the survey is the lack of follow-up information about the continuation of courses following the first-time offering.All countries offer some EBM courses with varying teaching intensity. Learning opportunities are insufficient to ensure widespread dissemination of knowledge and skills. Most countries welcome more efforts to develop inexpensive and feasible educational activities at a postgraduate level.

Together with an expert committee a structured approach to determining quality indicators for National Disease Management Guidelines has been developed. The key steps of this approach include: introducing guideline authors to the methodology at an early stage of the process of guideline development, pre-selecting recommendations of the guideline which are potentially measurable by means of quality indicators, assessing the potentially measurable quality indicators in written form using five criteria (including their importance for the health care system and clarity of definitions) and approving them in a formal consensus process. For lack of a database these quality indicators must be regarded as preliminary. For the National Disease Management Guideline "Chronic Heart Failure" nine rate-based indicators have been chosen. The indicators correspond to important strong recommendations (grade of recommendation: A) from the fields of diagnosis (two), general therapeutic strategy (two), specific treatment (three), clinical monitoring (one) and co-ordination of care (one). In a second step, the quality indicators have to be validated within a pilot project. The determination and assessment of the potential quality indicators have revealed room for improvement of guideline development. In particular, there is a need for more health care data and for specification of recommendations.

Background: To evaluate the educational effects of a clinically integrated e-learning course for teaching basic evidence-based medicine (EBM) among postgraduates compared to a traditional lecture-based course of equivalent content. Methods: We conducted a cluster randomised controlled trial in the Netherlands and the UK involving postgraduate trainees in six obstetrics and gynaecology departments. Outcomes (knowledge gain and change in attitude towards EBM) were compared between the clinically integrated e-learning course (intervention) and the traditional lecture based course (control). We measured change from pre- to post-intervention scores using a validated questionnaire assessing knowledge (primary outcome) and attitudes (secondary outcome). Results: There were six clusters involving teaching of 61 postgraduate trainees (28 in the intervention and 33 in the control group). The intervention group achieved slightly higher scores for knowledge gain compared to the control, but these results were not statistically significant (difference in knowledge gain: 3.5 points, 95% CI -2.7 to 9.8, p = 0.27). The attitudinal changes were similar for both groups. Conclusion: A clinically integrated e-learning course was at least as effective as a traditional lecture based course and was well accepted. Being less costly than traditional teaching and allowing for more independent learning through materials that can be easily updated, there is a place for incorporating e-learning into postgraduate EBM curricula that offer on-the-job training for just-in-time learning. Trial registration: Trial registration number: ACTRN12609000022268.

Integrative concepts of teaching and learning with close reference to individual work routines are better suited to bring about attitudinal and behavioural modification--apart from a gain in knowledge and skills--than traditional educational approaches. All the same, the vast majority of continuing training courses in Evidence-based Medicine takes place during weekend courses or evening classes, outside the work environment. To counteract this deficit a modular curriculum framework for Evidence-based Medicine was developed within the scope of the European research project EUebm which aims to achieve both a harmonisation of EbM education and training in Europe and a better integration of education and training with everyday clinical practice. The modules of this curriculum are intended to seamlessly fit into our day-to-day clinical work for and with patients and thus facilitate close interaction between the actual clinical work and the learning of EbM techniques and their implementation into our own patients' care. On the basis of a survey conducted among all the project partners in Austria, England, Germany, Hungary, Italy, The Netherlands, Poland, Spain and Switzerland the demand for training and continuing education in EbM in the individual countries was identified. Taking into account the results of this survey as well as previous work such as, for example, the curriculum of the German Network for Evidence-based Medicine or material provided by the Centre for Evidence-based Medicine in Oxford, an Internet-based teaching and learning module on systematic reviews and meta-analyses was developed and tested in five of the participating countries. The test demonstrated that in this way harmonisation of EbM education and training and a better integration of training with our everyday clinical work becomes feasible.

Introduction: The aim of this study was to investigate routine administrative data from a major German health insurance fund, Techniker Krankenkasse, which covers 5.4 million insured individuals. Using a retrospective cohort design, this study analysed data collected from patients with a hospital diagnosis of schizophrenia in 2003 (index hospitalisation) in order to evaluate prescription patterns of antipsychotic drugs. Methods: Patients with an ICD-10 diagnosis of schizophrenia, at least one year prior member- ship with the insurance fund and a follow-up period of one year were identifi ed. Results were standardised by age and stratifi ed by the severity of their illness, defi ned by the number of hospi- tal bed days during the three years preceding the index hospitalisation. Results: A total of 3 121 patients with schizo- phrenia (male 56.4 % , female 43.6 % ) received 56 692 single prescriptions of antipsychotics. Of these, 35.4 % of the prescriptions were for typical and 64.6 % for atypical antipsychotics; 55 % were for high-potency, 45 % for low-potency typical antipsychotics. The most frequently prescribed drugs were olanzapine (26.6 % ), clozapine (21.3 % ) and risperidone (19 % ). There were no relevant gender diff erences concerning prescription pat- terns. During a 12-month follow-up period after the fi rst hospitalisation, 1 372 patients (43.9 % ) were treated exclusively with an atypical anti- psychotic, another 499 patients (16 % ) had a combination of an atypical plus a low-potency typical antipsychotic. Thus, basal therapy with an atypical was observed in 59.9 % of our study population. Only 327 patients (10.5 % ) were treated exclusively with a typical antipsychotic. A total of 645 patients (20.7 % ) were treated with a combination of atypical plus typical antipsy- chotic. Changes of medication within one sub- stance group occurred more often with typical antipsychotics (50 % ) as compared to atypical antipsychotics (25 % ). Discussion: At 60 % , the proportion of patients in this study treated with atypical antipsychot- ics was surprisingly high. Of signifi cant interest is the frequent prescription of clozapine (14 % ). The results are discussed in comparison to com- parable studies from other countries.

Background: We developed and evaluated the outcomes of an e-learning course for evidence based medicine (EBM) training in postgraduate medical education in different languages and settings across five European countries. Methods: We measured changes in knowledge and attitudes with well-developed assessment tools before and after administration of the course. The course consisted of five e-learning modules covering acquisition (formulating a question and search of the literature), appraisal, application and implementation of findings from systematic reviews of therapeutic interventions, each with interactive audio-visual learning materials of 15 to 20 minutes duration. The modules were prepared in English, Spanish, German and Hungarian. The course was delivered to 101 students from different specialties in Germany (psychiatrists), Hungary (mixture of specialties), Spain (general medical practitioners), Switzerland (obstetricians-gynaecologists) and the UK (obstetricians-gynaecologists). We analysed changes in scores across modules and countries. Results: On average across all countries, knowledge scores significantly improved from pre- to post-course for all five modules (p < 0.001). The improvements in scores were on average 1.87 points (14% of total score) for module 1, 1.81 points (26% of total score) for module 2, 1.9 points (11% of total score) for module 3, 1.9 points (12% of total score) for module 4 and 1.14 points (14% of total score) for module 5. In the country specific analysis, knowledge gain was not significant for module 4 in Spain, Switzerland and the UK, for module 3 in Spain and Switzerland and for module 2 in Spain. Compared to pre-course assessment, after completing the course participants felt more confident that they can assess research evidence and that the healthcare system in their country should have its own programme of research about clinical effectiveness. Conclusion: E-learning in EBM can be harmonised for effective teaching and learning in different languages, educational settings and clinical specialties, paving the way for development of an international e-EBM course.

In two recent randomised clinical trials, a meta-analysis and in an effectiveness study analysing routine data from the U.S. Veterans Administration the superiority of the newer atypical drugs over typical antipsychotic drugs, concerning both their efficacy and their side-effect profile, has been questioned.To analyse the effectiveness and cost of atypical versus typical antipsychotic treatment for schizophrenia in routine care.Cohort study using routine care data from a statutory sickness fund with 5.4 million insured in Germany. To be included, patients had to be discharged with a diagnosis of schizophrenia in 2003 and fulfil membership criteria. Main outcome measures were rehospitalisation rates, mean hospital bed days, mean length of stay, cost of inpatient and pharmaceutical care to the sickness fund during follow-up and medication used to treat side-effects.3121 patients were included into the study. There were no statistically significant differences in the effectiveness of atypical and typical antipsychotics on rehospitalisation during follow-up (rehospitalisation rate ratio 1.07, 95% confidence interval 0.86 to 1.33). However, there were consistent observations of atypical antipsychotics being more effective for severe cases of schizophrenia (14.6% of study population;61 prior bed days per year in 2000-2002) in the follow-up period, whereas for the other severity strata typical antipsychotics seemed more effective in reducing various rehospitalisation outcomes. Patients treated with atypical antipsychotics received significantly less prescriptions for anticholinergics or tiaprid (relative risk 0.26, 95% confidence interval 0.18 to 0.38).The effectiveness of atypical antipsychotics for schizophrenia on rehospitalisation measures appeared similar to that of typical antipsychotics. With the exception of severe cases, the higher costs for atypical antipsychotics were not offset by savings from reduced inpatient care. Major limitations include the lack of statistical power for subgroup analyses, the lack of clinical severity scale data and of life-course medical history data which both increase the risk of residual confounding by disease severity.This study provides evidence that the effectiveness of atypical and typical antipsychotics measured in terms of hospital readmissions appears to be similar in routine care.From a clinical perspective, this study provides evidence that the effectiveness of atypical and typical antipsychotics measured in terms of hospital readmissions appears to be similar in routine care.Routine data studies can yield valuable information for policy decision-makers on the costs and the effectiveness of pharmaceuticals in routine care, complementing efficacy data from randomised clinical trials currently used for licensing and reimbursement decisions.The non-significant differences in the effectiveness of atypical compared to typical antipsychotics according to severity of disease should be investigated in a prospective observational study or in a randomised clinical trial.

The Programme for National Disease Management Guidelines (German DM-CPG Programme) was established in 2002 by the German Medical Association (umbrella organisation of the German Chambers of Physicians) and joined by the Association of the Scientific Medical Societies (AWMF)--umbrella organisation of more than 150 professional societies--and by the National Association of Statutory Health Insurance Physicians (NASHIP) in 2003. The programme provides a conceptual basis for disease management, focussing on high priority healthcare topics and aiming at the implementation of best practice recommendations for prevention, acute care, rehabilitation and chronic care. It is organised by the German Agency for Quality in Medicine, a founding member of the Guidelines International Network G-I-N. The main objective of the German DM-CPG Programme is to establish consensus among the medical professions on evidence-based key recommendations covering all sectors of healthcare provision and facilitating the coordination of care for the individual patient through time and across interfaces. Within the last year DM-CPGs have been published for asthma, COPD, type 2 diabetes and coronary heart disease. In addition, experts from national patient self-help groups have been developing patient guidance based upon the recommendations for healthcare providers. The article describes background, methods and tools of the DM-CPG programme using the DM-CPG Method Report 2007.

Background: Over the last years key stake holders in the healthcare sector have increasingly recognised evidence based medicine (EBM) as a means to improving the quality of healthcare. However, there is considerable uncertainty about the best way to disseminate basic knowledge of EBM. As a result, huge variation in EBM educational provision, setting, duration, intensity, content, and teaching methodology exists across Europe and worldwide. Most courses for health care professionals are delivered outside the work context ('stand alone') and lack adaptation to the specific needs for EBM at the learners' workplace. Courses with modern 'adaptive' EBM teaching that employ principles of effective continuing education might fill that gap. We aimed to develop a course for post-graduate education which is clinically integrated and allows maximum flexibility for teachers and learners. Methods: A group of experienced EBM teachers, clinical epidemiologists, clinicians and educationalists from institutions from eight European countries participated. We used an established methodology of curriculum development to design a clinically integrated EBM course with substantial components of e-learning. An independent European steering committee provided input into the process. Results: We defined explicit learning objectives about knowledge, skills, attitudes and behaviour for the five steps of EBM. A handbook guides facilitator and learner through five modules with clinical and e-learning components. Focussed activities and targeted assignments round off the learning process, after which each module is formally assessed. Conclusion: The course is learner-centred, problem-based, integrated with activities in the workplace and flexible. When successfully implemented, the course is designed to provide just-in-time learning through on-the-job-training, with the potential for teaching and learning to directly impact on practice.

Background: In two recent randomised clinical trials, a metaanalysis and in an effectiveness study analysing routine data from the U.S. Veterans Administration the superiority of the newer atypical drugs over typical antipsychotic drugs, concerning both their efficacy and their side-effect profile, has been questioned. Aims of the Study: To analyse the effectiveness and cost of atypical versus typical antipsychotic treatment for schizophrenia in routine care. Methods: Cohort study using routine care data from a statutory sickness fund with 5.4 million insured in Germany. To be included, patients had to be discharged with a diagnosis of schizophrenia in 2003 and fulfil membership criteria. Main outcome measures were rehospitalisation rates, mean hospital bed days, mean length of stay, cost of inpatient and pharmaceutical care to the sickness fund during follow-up and medication used to treat side-effects. Results: 3121 patients were included into the study. There were no statistically significant differences in the effectiveness of atypical and typical antipsychotics on rehospitalisation during follow-up (rehospitalisation rate ratio 1.07, 95% confidence interval 0.86 to 1.33). However, there were consistent observations of atypical antipsychotics being more effective for severe cases of schizophrenia (14.6% of study population; >61 prior bed days per year in 2000-2002) in the follow-up period, whereas for the other severity strata typical antipsychotics seemed more effective in reducing various rehospitalisation outcomes. Patients treated with atypical antipsychotics received significantly less prescriptions for anticholinergics or tiaprid (relative risk 0.26, 95% confidence interval 0.18 to 0.38). Discussion: The effectiveness of atypical antipsychotics for schizophrenia on rehospitalisation measures appeared similar to that of typical antipsychotics. With the exception of severe cases, the higher costs for atypical antipsychotics were not offset by savings from reduced inpatient care. Major limitations include the lack of statistical power for subgroup analyses, the lack of clinical severity scale data and of life-course medical history data which both increase the risk of residual confounding by disease severity. Conclusions: This study provides evidence that the effectiveness of atypical and typical antipsychotics measured in terms of hospital readmissions appears to be similar in routine care. Implications for Health Care Provision and Use: From a clinical perspective, this study provides evidence that the effectiveness of atypical and typical antipsychotics measured in terms of hospital readmissions appears to be similar in routine care. Implications for Health Policies: Routine data studies can yield valuable information for policy decision-makers on the costs and the effectiveness of pharmaceuticals in routine care, complementing efficacy data from randomised clinical trials currently used for licensing and reimbursement decisions. Implications for Further Research: The non-significant differences in the effectiveness of atypical compared to typical antipsychotics according to severity of disease should be investigated in a prospective observational study or in a randomised clinical trial.