University, Diss.--Bonn, 2004.

Objective: To examine health services use on the basis of alcohol consumption. Material and Methods: A cross-sectional study was carried out on patients visiting the Primary Health Care (PHC) settings in Catalonia during 2011 and 2012; these patients had a history of alcohol consumption. Information about outpatient visits in the PHC setting, hospitalizations, specialists’ visits and emergency room visits for the year 2013 was obtained from 2 databases (the Information System for the Development of Research in PHC and the Catalan Health Surveillance System). Risky drinkers were defined as those who consumed more than 280 g per week for men or more than 170 g per week for women, or any amount of alcohol while being involved in a high risk work activity, or taking medication that significantly interferes with alcohol or when being pregnant. Binge drinkers (>60 g in men or >50 g in women in a short amount of time more than once a month) were also considered risky drinkers. Results: A total of 606,948 patients reported consuming alcohol (of which 10.5% were risky drinkers). Risky drinkers were more likely to be admitted to hospitals or emergency departments (range of ORs 1.08–1.18) compared to light drinkers. Male risky drinkers used fewer PHC services than male light drinkers (OR 0.89, 95% CI 0.87–0.92). In general, risky alcohol users used services more and had longer hospital stays. When stratifying by socioeconomic level of the residential area, we found that risky drinking failed significance, while current or past cigarette smoking was associated with higher healthcare use. Conclusions: Risky drinkers use more expensive services, such as hospitals and emergency rooms, but not PHC services, which may suggest that prevention strategies and alcohol interventions should also be implemented in those settings.

Wartezeiten von durchschnittlich mehreren Monaten sind auch nach Inkrafttreten des Psychotherapeutengesetzes in der deutschen Psychotherapieversorgung die Regel. Behandlungsbedürftige Störungen, für die ein Behandlungswunsch besteht, unversorgt zu lassen, ist weder unter ethischen, noch praktischen und therapeutischen Gesichtspunkten vertretbar. Aus diesem Grund schlagen viele Praktiker ihren wartenden Patienten niedrigschwellige Selbsthilfeangebote vor, die von psychoedukativen Informationen über Bibliotherapie bis zu Gruppenangeboten reichen. Die vorliegende Arbeit gibt einen Überblick über verschiedene Möglichkeiten, wartende Psychotherapiepatienten gut auf die bevorstehende Therapie vorzubereiten und während der Wartezeit zugleich sekundäre Prävention zu betreiben. Hierbei muss nach unserer Einschätzung vor allem die Maxime gelten, dass die vorgeschlagenen Maßnahmen mit dem Rational der darauf folgenden Therapie vereinbar sein sollten. / Even after the new psychotherapy law has been implemented, waiting times of several months remain rather common in the German mental health care system. For ethical, practical, and therapeutic reasons, however, patients who are in serious need of treatment should not be left unattended. Many practitioners therefore suggest self-help treatments such as psychoeducational information, bibliotherapy, or supportive groups to their waiting patients. The present study provides an overview on possibilities of preparing waiting psychotherapy patients for their upcoming therapy as well as implementing secondary prevention during the waiting time. As a basic, we suggest that the proposed methods should be in line with the treatment rationale of the subsequent therapy. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Because of evidence of regional variation in health and healthcare use, this thesis used health equity and access to care theory to examine regional differences in access to primary care, using survey- as well as secondary data in four empirical studies. First, a systematic literature review was used to categorize forms and reasons for regional healthcare shortages and access barriers, with a particular focus on rural areas. After information extraction from the selected studies and a thematic content analysis, the forms and causes identified in the literature were grouped and discussed. Following the literature-based review of these thematic foundations, a study was then designed to evaluate patient-reported access to primary care in exemplary German regions and assess empirical differences in rural vs. urban populations. This allowed the importance to patients of different access dimensions to be evaluated. For a subgroup of study participants with multidisciplinary care needs, care coordination failures and the supportive role of the general practitioner as a primary point of access was investigated. Finally, regional factors that are associated with variations in need, health, and utilisation beyond individual health determinants were identified, and placed on different regional framework conditions. These health-related factors were summarised in a regional deprivation measure and small-scale regions in Germany were differentiated by their regional deprivation by the main dimensions (material, social, ecological). Finally, their association to regional health outcomes were cross-sectionally estimated. To reduce unwarranted access variation, while also taking the patient perspective (by region) into account, the thesis concludes with a chapter on implications. Here, concepts for regional and multidimensional access monitoring, as well as further regulatory measures in capacity and distribution planning of primary care, are discussed.:Content Tables ........................................................................................................................... V Figures ....................................................................................................................... VI Abbreviations ........................................................................................................... VII 1. Background and research objectives .................................................................. 9 1.1. Health equity and access to health care ........................................................ 10 1.2. Regional variation as a contradiction to the equity principle ....................... 16 1.3. Reducing unwarranted regional variation in health care .............................. 20 1.4. Research objectives and thesis structure ...................................................... 24 References ............................................................................................................... 28 Legal sources .......................................................................................................... 33 2. Rural health care shortages and access barriers ............................................. 34 3. Regional access and satisfaction with primary care........................................ 35 Appendix 3 .............................................................................................................. 36 4. Access to primary care and outpatient care coordination .............................. 48 4.1. Introduction .................................................................................................. 49 4.2. Background ................................................................................................... 51 4.2.1. The patient perspective of care coordination ......................................... 51 4.2.2. Coordinating mechanisms ..................................................................... 52 4.3. Methods ........................................................................................................ 55 4.3.1. Data collection and sample .................................................................... 55 4.3.2. Measures ................................................................................................ 55 4.3.3. Data analysis .......................................................................................... 58 4.4. Results .......................................................................................................... 59 4.5. Discussion and limitations ............................................................................ 62 4.6. Implications .................................................................................................. 65 References ............................................................................................................... 69 Appendix 4 .............................................................................................................. 73 5. Area deprivation and its impact on health ....................................................... 76 6. Summary of implications ................................................................................... 77 6.1. Establishing a framework to assess primary care access and performance .. 77 6.2. Strengthening patient involvement in health care structure planning .......... 81 6.3. Strengthening access to GPs as outpatient care coordinators ....................... 84 6.4. Including regional deprivation factors in health care structure planning ..... 86 References ............................................................................................................... 90

Despite the relevance of pressure ulcers (PU) in inpatient care, the predictive power and role of care-related risk factors (e.g. anesthesia) remain unclear. We investigated the predictability of PU incidence and its association with multiple care variables. We included all somatic cases between 2014 and 2018 with length of stay ≥ 2d in a German university hospital. For regression analyses and prediction we used Bayesian Additive Regression Trees (BART) as nonparametric modeling approach. To assess predictive accuracy, we compared BART, random forest, logistic regression (LR) and least absolute shrinkage and selection operator (LASSO) using area under the curve (AUC), confusion matrices and multiple indicators of predictive performance (e.g. sensitivity, specificity, F1, positive/ negative predictive value) in the full dataset and subgroups. Analysing 149,006 cases revealed high predictive variable importance and associations between incident PU and ventilation, age, anesthesia (≥ 1 h) and number of care-involved wards. Despite high AUCs (range 0.89–0.90), many false negative predictions led to low sensitivity (range 0.04–0.10). Ventilation, age, anesthesia and number of care-involved wards were associated with incident PU. Using anesthesia as a proxy for immobility, an hourly repositioning is indicated. The low sensitivity indicates major challenges for correctly predicting PU based on routine data.

Bisher wurden die Einzugsgebiete der Gesundheitszentren mit den administrativen Grenzen des Sektors, in dem das Gesundheitszentrum liegt, gleichgesetzt. Das Hauptanliegen dieser Arbeit ist es, die tatsächlichen Einzugsgebiete zu erfassen und bisher verwendete methodische Ansätze auf ihre Eignung zu testen, Einzugsgebiete für Gesundheitszentren möglichst realistisch zu modellieren. Darüber hinaus sollen Gründe für räumliche Unterschiede in der Inanspruchnahme von Gesundheitszentren ermittelt werden. Fragenbögen, die mit Patienten in den Gesundheitszentren ausgefüllt wurden, sowie aus Registrierungsbüchern erfasste Daten geben Aufschluss über die räumlichen Unterschiede bei der Inanspruchnahme und dienen als Referenzdaten für die weiteren Analysen. Die Studie zeigt, dass keine der getesteten Methoden dazu geeignet ist, die Einzugsgebiete zufriedenstellend zu modellieren. Ein selbst entwickelter Ansatz, der verschiedene Methoden kombiniert, liefert bezüglich der Bevölkerung nur zweitbeste Ergebnisse nach Thiessen Polygonen, während für keine der Methoden die Grenzen mit den Grenzen übereinstimmen, die für die tatsächliche Nutzung ermittelt wurden. / Until now catchment areas of health centers are considered as the administrative boundaries of the sector where the health center is situated. The main objective of this study is to determine the actual catchment areas of health centers in Huye District (Southern Province, Rwanda) and to test approaches used in other studies in a geographical information system for an improved estimation of catchment areas. Furthermore reasons for disparities in health center utilization are to be revealed. Questionnaires filled with patients at health centers as well as data retrieved from registration books aim to give information about spatial disparities in health center utilization and serve as evaluation basis for further analysis. The study shows that none of the tested methods is able to predict catchment areas or the population to be served in a satisfying accuracy. An own approach that combines different methods gives only second best results after Thiessen polygons regarding the served population while for none of the methods the boundaries match well the catchment areas as they are defined by the data.

Ausgangspunkt dieser Studie stellt die sog. „Patientenrichtlinie“ 2011/24/EU dar. Diese beruht auf der Rspr. des EuGH, wonach für die Inanspruchnahme grenzüberschreitender Gesundheitsleistungen die Dienstleistungsfreiheit Anwendung findet. Bezogen auf den Bereich des Gesundheitswesens steht die Dienstleistungsfreiheit jedoch in einem Spannungsverhältnis zu der Organisationshoheit der Mitgliedstaaten für ihre Gesundheitssysteme. Diese Arbeit widmet sich daher zunächst dem Begriff der Gesundheitsleistungen und führt das Bestehen des Spannungsverhältnisses auf die historische Entwicklung der Sozialregelungen in den Verträgen zurück. In einem weiteren Schritt wird dann die tatsächliche Anwendbarkeit der Dienstleistungsfreiheit für den Bereich der Gesundheitsleistungen untersucht. Im Anschluss daran erfolgt eine Analyse der Rechtsprechung des EuGH. Dieser versucht das Spannungsverhältnis auf der Ebene der „Rechtfertigung“ zu lösen. Letztlich führt jedoch dieser Ansatz nicht zur Lösung dieses Spannungsverhältnisses, da durch die Auslegungsbedürftigkeit des Primärrechts rechtliche Unsicherheiten entstehen. Auch die Patientenrichtlinie, welche auf der Rechtsprechung des EuGH beruht, kann daher nur bedingt zur Beseitigung der bestehenden Unsicherheiten bei grenzüberschreitenden Gesundheitsleistungen beitragen. Ebenso können weitere in der Literatur vorgestellte Alternativen das Grundproblem nicht lösen. Notwendig wäre vielmehr eine klarere Abgrenzung der Regelungszuständigkeiten im Primärrecht selbst. / The starting point for this study is the so-called „Patient Directive“ 2011/24/EU. This is based on the jurisdiction of the European Court of Justice, according to which when using cross-border healthcare services the free movement of services finds application. Referring to the area of healthcare the free movement of services however is in a relationship of tension with the organisational sovereignty of member states for their healthcare systems. For this reason this work addresses itself firstly to the concept of healthcare services and leads the existence of a relationship of tension back to the historical development of social regulations in the contracts. In a further step then the actual applicability of the free movement of services for the area healthcare services is examined. Following this an analysis of the jurisdiction of the European Court of Justice takes place. This attempts to solve the relationship of tension at the level of „justification“. In the end however this starting-point does not lead to solving this tension relationship, for through the need for interpretation of primary law legal uncertainties arise. Also the patient directive, which is based on the jurisdiction of the European Court of Justice, can for this reason only partially contribute to the removal of uncertainties existing with cross-border healthcare services. Equally further alternatives presented in literature cannot solve the basic problem. Rather a clearer delimitation in the primary law itself would be required.

Introduction: The study ‘Mental healthcare provision for adults with intellectual disability and a mental disorder’ (MEMENTA) is a cross-sectional epidemiological study carried out in three different regions of Germany. Its main aim is to assess the prevalence of mental disorders in adults with intellectual disability (ID) as well as quality of mental healthcare for this population. Methods and analysis: The target population are persons aged between 18 and 65 years with a mild or moderate ID. The study population will be recruited through service providers. A representative sample is realised by two-stage sampling. First, institutions providing services for people with ID (sheltered workshops) are selected in a stratified cluster sampling, with strata being (1) types of service-providing non-governmental organisations and (2) sizes of their sheltered workshops. Then persons working in selected sheltered workshops are selected by simple random sampling. An estimated number of 600 adults with ID will be included. Information will be obtained from the group leaders in the sheltered workshops, informal carers or staff members in sheltered housing institutions and the person with ID. Besides the main outcome parameter of psychiatric symptomatology and problem behaviour, other outcome parameters such as needs for care, quality of life, caregiver burden, health services utilisation and costs for care are assessed using well-established standardised instruments. If a comorbid mental disorder is diagnosed, quality of mental healthcare will be assessed with open questions to all interview partners and, in addition, problem-focused interviews with a small subgroup. Analyses will be carried out using quantitative and qualitative methods. Ethics and dissemination: Approval of all three local ethics committees was obtained. Research findings will add much needed empirical information in order to improve services provided to this vulnerable group of patients.

Introduction: The study ‘Mental healthcare provision for adults with intellectual disability and a mental disorder’ (MEMENTA) is a cross-sectional epidemiological study carried out in three different regions of Germany. Its main aim is to assess the prevalence of mental disorders in adults with intellectual disability (ID) as well as quality of mental healthcare for this population. Methods and analysis: The target population are persons aged between 18 and 65 years with a mild or moderate ID. The study population will be recruited through service providers. A representative sample is realised by two-stage sampling. First, institutions providing services for people with ID (sheltered workshops) are selected in a stratified cluster sampling, with strata being (1) types of service-providing non-governmental organisations and (2) sizes of their sheltered workshops. Then persons working in selected sheltered workshops are selected by simple random sampling. An estimated number of 600 adults with ID will be included. Information will be obtained from the group leaders in the sheltered workshops, informal carers or staff members in sheltered housing institutions and the person with ID. Besides the main outcome parameter of psychiatric symptomatology and problem behaviour, other outcome parameters such as needs for care, quality of life, caregiver burden, health services utilisation and costs for care are assessed using well-established standardised instruments. If a comorbid mental disorder is diagnosed, quality of mental healthcare will be assessed with open questions to all interview partners and, in addition, problem-focused interviews with a small subgroup. Analyses will be carried out using quantitative and qualitative methods. Ethics and dissemination: Approval of all three local ethics committees was obtained. Research findings will add much needed empirical information in order to improve services provided to this vulnerable group of patients.

Background: Maintaining independence in instrumental activities of daily living (IADL) is crucial for older adults. This study explored the association between cognitive and functional performance in general and in single IADL domains. Also, risk factors for developing IADL impairment were assessed. Methods: Here, 3,215 patients aged 75–98 years were included. Data were collected during home visits. Results: Cognitive functioning was associated with IADL both cross-sectionally and longitudinally. Regarding the single IADL domains cross-sectionally, executive functioning was especially associated with shopping, while episodic memory was associated with responsibility for own medication. Conclusion: Reduced performance in neuropsychological tests is associated with a greater risk of current and subsequent functional impairment.