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Abstract Background Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use. Methods We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the ‘Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)’ recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered. Results Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies. Conclusions Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Abstract Background In settings like the ambulatory care sector in Germany, where data on the outcomes of interdisciplinary health services provided by multiple office-based physicians are not always readily available, our study aims to develop a set of indicators of health care quality and utilization for 14 groups of ambulatory-care-sensitive conditions based on routine data. These may improve the provision of health care by informing discussions in quality circles and other meetings of networks of physicians who share the same patients. Methods Our set of indicators was developed as part of the larger Accountable Care in Deutschland (ACD) project using a pragmatic consensus approach. The six stages of the approach drew upon a review of the literature; the expertise of physicians, health services researchers, and representatives of physician associations and statutory health insurers; and the results of a pilot study with six informal network meetings of office-based physicians who share the same patients. Results The process resulted in a set of 248 general and disease specific indicators for 14 disease groups. The set provides information on the quality of care provided and on patient pathways, covering patient characteristics, physician visits, ambulatory care processes, pharmaceutical prescriptions and outcome indicators. The disease groups with the most indicators were ischemic heart diseases, diabetes and heart failure. Conclusion Our set of indicators provides useful information on patients’ health care use, health care processes and health outcomes for 14 commonly treated groups of ambulatory-care-sensitive conditions. This information can inform discussions in interdisciplinary quality circles in the ambulatory sector and foster patient-centered care.

Abstract Background Coordinating health care within and among sectors is crucial to improving quality of care and avoiding undesirable negative health outcomes, such as avoidable hospitalizations. Quality circles are one approach to strengthening collaboration among health care providers and improving the continuity of care. However, identifying and including the right health professionals in such meetings is challenging, especially in settings with no predefined patient pathways. Based on the Accountable Care in Germany (ACD) project, our study presents a framework for and investigates the feasibility of applying social network analysis (SNA) to routine data in order to identify networks of ambulatory physicians who can be considered responsible for the care of specific patients. Methods The ACD study objectives predefined the characteristics of the networks. SNA provides a methodology to identify physicians who have patients in common and ensure that they are involved in health care provision. An expert panel consisting of physicians, health services researchers, and data specialists examined the concept of network construction through informed decisions. The procedure was structured by five steps and was applied to routine data from three German states. Results In total, 510 networks of ambulatory physicians met our predefined inclusion criteria. The networks had between 20 and 120 physicians, and 72% included at least ten different medical specialties. Overall, general practitioners accounted for the largest proportion of physicians in the networks (45%), followed by gynecologists (10%), orthopedists, and ophthalmologists (5%). The specialties were distributed similarly across the majority of networks. The number of patients this study allocated to the networks varied between 95 and 45,268 depending on the number and specialization of physicians per network. Conclusions The networks were constructed according to the predefined characteristics following the ACD study objectives, e.g., size of and specialization composition in the networks. This study shows that it is feasible to apply SNA to routine data in order to identify groups of ambulatory physicians who are involved in the treatment of a specific patient population. Whether these doctors are also mainly responsible for care and if their active collaboration can improve the quality of care still needs to be examined.

IntroductionHealth inequalities start early in life. The time of young adulthood, between late teens and early twenties, is especially interesting in this regard. This time of emerging adulthood, the transition from being a child to becoming an adult, is characterized by the detachment from parents and establishing of an own independent life. From a health inequality perspective, the question about the importance of the socio-economic background of parents is important. University students are an especially interesting group. Many students come from a privileged background and the question of health inequality among university students has not yet been properly studied.MethodsBased on the National Educational Panel Study (NEPS), we analyzed health inequalities among 9,000 students in Germany (∅ 20 years in the first year of their studies) over a period of 8 years.ResultsWe found that most university students (92%) in Germany reported a good and very good health. Yet, we still found substantial health inequalities. Students whose parents had a higher occupational status reported less health problems. Additionally, we observed that health inequalities had indirect impact on health via health behavior, psychosocial resources, and material conditions.DiscussionWe believe our study is an important contribution to the understudied subject of students' health. We see the impact of social inequality on health among such a privileged group like university students as an important sign of the importance of health inequality.

Einleitung: Praxisnetze können als regionale Zusammenschlüsse von Leistungserbringer:innen im medizinischen Bereich definiert werden, welche darauf abzielen, die Versorgung einer Gruppe gemeinsam versorgter Patient:innen zu verbessern. Ziel dieser Befragung war es, Informationen zur Organisation von Praxisnetzen, deren Kooperation und Kommunikation sowie etablierten Initiativen zur Verbesserung der Versorgungsqualität zu erlangen und systematisch darzustellen. Methodik: Ein Fragebogen mit dem Ziel der Erhebung etablierter struktureller Bedingungen, Qualitätssicherungsmaßnahmen und vorhandener Kommunikationsmittel wurde an Praxisnetze in Deutschland versendet. Weiterhin sollten die Akzeptanz von Qualitätssicherungsmaßnahmen, Einschätzungen zur Kooperation im Netz sowie Erfolgsfaktoren und Hemmnisse erfragt werden. Ergebnisse: Insgesamt wurden Fragebögen von 49 Praxisnetzen zurückerhalten. Die Ausgestaltung der Netze in Bezug zum strukturellen Aufbau als auch zu festgelegten Zielsetzungen variiert. So liegt die Anzahl an teilnehmenden Ärzt:innen zwischen 10 und 300 und es wurden über 20 verschiedene Schwerpunkte genannt. Maßnahmen der Qualitätssicherung sind weitreichend implementiert, ebenso sind Wege der Kommunikation innerhalb der Netze konsentiert. Diesbezüglich geben beispielsweise 86% der Netze an, dass es konsentierte Behandlungspfade gibt und 68%, dass sichere Mail-Verbindungen und Faxlisten etabliert sind. Schlussfolgerung: Die Versorgungslandschaft der Praxisnetze scheint stark heterogen zu sein. In vielen Fällen gibt es gefestigte Strukturen und etablierte Maßnahmen der Qualitätssicherung. Die Netze haben klar formulierte Ziele, um die Qualität der Versorgung für Patient:innen zu verbessern. Weitere Forschung ist notwendig, um die Entwicklung der Praxisnetze abzubilden und deren Leistung zu evaluieren.

Hintergrund: Die Zahl der ambulanten Notfälle in deutschen Krankenhäusern ist in den letzten Jahren deutlich angestiegen. Diese Entwicklung lässt sich teilweise durch das steigende Durchschnittsalter der Bevölkerung bedingt durch den demografischen Wandel erklären. Allerdings ist auch eine Veränderung der behandelten Erkrankungen zu beobachten. So wird angenommen, dass der Anteil der Bagatellkrankheiten, welche in Notaufnahmen behandelt wurden, in den letzten Jahren deutlich zunahm. Ziele: Ziel der Arbeit war es, eine konsentierte Liste ambulant-sensitiver Diagnosen zu entwickeln, welche häufig in Notaufnahmen behandelt werden und durch den ambulanten Bereich potenziell behandelbar wären. Weiterhin sollten Prädiktoren der Inanspruchnahme bei diesen Diagnosen identifiziert werden. Methoden: Basierend auf einer Delphi-Befragung mit 30 Ärzten wurde eine Liste an ambulant-sensitiven Notfalldiagnosen erstellt. Zusätzlich identifizierte die Gruppe mögliche Gründe, warum Patienten mit den ausgewählten Diagnosen eher die Notaufnahme als den ambulanten Bereich aufsuchen. Die gewonnenen Erkenntnisse wurden für räumliche Regressionsanalysen verwendet, um auf Ebene der Kreise und kreisfreien Städte Assoziationen mit Patienteneigenschaften und ambulanter Versorgung zu untersuchen. Ergebnisse: Unsere Studie bietet eine erste Liste an ambulant-sensitiven Diagnosen für den Kontext deutscher Notaufnahmen. Deskriptive Ergebnisse zeigen, dass Notaufnahmen mit den ausgewählten Diagnosen insbesondere durch jüngere Patienten in Anspruch genommen werden. Das Einschätzen von Dringlichkeit durch Patienten sowie Patientenpräferenzen wurden als Hauptgründe für die Inanspruchnahme von Notaufnahmen bei ambulant-sensitiven Diagnosen identifiziert. Ergebnisse der Regressionsanalysen deuten darauf hin, dass ambulant-sensitive Notfallraten signifikant höher in Kreisen mit geringerer Arztdichte sind. Diskussion: Die Liste ambulant-sensitiver Diagnosen kann als Monitoringinstrument und für weitere Analysen auf Basis von Routinedaten genutzt werden.