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Fast zwanzig Prozent aller Mütter, Väter und pflegenden Angehörigen benötigten bereits vor der Pandemie eine Rehabilitations- oder Vorsorgemaßnahme. Zahlreiche Studien zeigen, dass sich dieser Bedarf mit großer Wahrscheinlichkeit durch die Pandemie erheblich erhöhen wird. In Befragungen bewerten Ärzt:innen wie ehemalige Patient:innen die Wirkung der von der GKV angebotenen spezifischen Mutter-Vater-Kind-Maßnahmen zumindest kurz- bis mittelfristig positiv, weisen aber auch auf ihre nicht ausreichende Nachhaltigkeit und zahlreiche Defizite im Bereich der Nachsorge hin. Um dem zukünftigen Bedarf gerecht werden zu können, sind Reformen beim Leistungsangebot, der Organisation und Finanzierung von Nachsorge notwendig.

Viele anfangs für universell und ewig gehaltenen Programme oder Interventionen müssen kontinuierlich an geänderte Verhältnisse angepasst werden. Dies gilt auch für die gesundheitsbezogene Versorgung und dort besonders, wenn es um die Sicherung und Verbesserung ihrer Qualität geht. Was herauskommt, wenn dieser ständige Selbstüberprüfungs- und Änderungsprozess unter breiter Beteiligung aller Akteure zu lange versäumt wird, soll aus gesundheitswissenschaftlicher Sicht am Beispiel von QS Reha, dem Qualitätssicherungsverfahren für die medizinische Rehabilitation und Vorsorge für GKV-Versicherte, kritisch beleuchtet werden. Außerdem wird skizziert um was sich eine „Qualitätssicherung der Qualitätssicherung“ kümmern und wie QS Reha® 2.0 aussehen könnte.

Zusammenfassung Die Bevölkerungsgruppe mit mangelhafter Gesundheitskompetenz ist wegen der rund 15% Analphabeten wahrscheinlich noch erheblich größer als berichtet. Wegen der Mängel der medialen Gesundheitsinformationen und bei der Hilfe von Ärzten ihren Patienten evidente Informationen zu beschaffen, ist das Ziel von besserer Gesundheitskompetenz allein durch mehr Medienkompetenz oder Arztgespräche nicht zu erreichen. Dies ist nur durch gleichzeitige Eingriffe auf der Angebotsseite zu schaffen.

Der Aufsatz untersucht an den Beispielen des Personalmangels und der Okonomisierung arztlichen Handelns, dass und wie die Debatte uber das Innenleben der Krankenhauser seine Komplexitat unterschatzt und so stark reduziert, dass es zu Fehlverstandnissen kommt und die auf dieser Basis entwickelten Reformmasnahmen nicht den erwunschten Effekt haben, unerwunschte Strukturen und Vorgange zementieren und die Suche nach wirksameren Aktivitaten ver- oder behindern.

Contrary to the practice in some countries, access to flexible and integrated forms of psychiatric care (FIT models) is limited in Germany. Several legislations have been introduced to improve this situation, notably the recent §64b (flexible and integrative treatment model; FIT64b) of the German Social Code, which allows for a capitation-based accounting of fees for services. The aim of this study was to explore the effects of FIT64b implementation on various stakeholders (patients, informal caregivers and staff) in 12 psychiatric hospital departments across Germany. Structural as well as quantitative and qualitative data are included, with integration of different methodological approaches. In all departments, the implementation of the new accounting system resulted into a relatively stable set of structural and processual changes where rigid forms of mainly inpatient care shifted to more flexible and integrated types of outpatient and outreach treatments. These changes were more likely to be perceived by patients and staff, and likewise received better evaluations, in those departments showing higher level or longer duration of implementation. Patients' evaluations, furthermore, were largely influenced by the advent of continuous forms of care, better accessibility, and by their degree of autonomy in steering of their services.

Objectives The provision of orthodontic (dental) care is part of the German Public Health sector comprising 90% of German population. The current regulations for the provision of orthodontic care in the public sector have been adopted in 2004 as a negotiation-process between providers and public health insurance companies without patient participation. To date patient-related data on the impact of the 2004 regulation on the quality and quantity of orthodontic services are lacking. In addition, patients (mostly adolescents) preferences and perceptions toward orthodontic treatment are almost unknown. Therefore, we first examined the content of the 2004 regulations in terms of formal criteria for treatment access, diagnostic and treatment guidelines as well as treatment duration. Secondly, we analyzed medical health record data to obtain information on real utilization of orthodontic services as diagnostic and treatment procedures. Finally we examined patient’s preferences and their role in the decision-making process. Method In the first stage we examined the formal criteria of the regulation of orthodontic services regarding treatment access, appropriateness criteria for diagnostic and treatment procedures as well as quality control. In the second stage we surveyed adolescents aged 10 to 14 years (n=2.991, 29% response rate) insured by a public health care insurance company before or at the beginning of treatment related to their perceptions of toward orthodontic treatment need using validated and standardized questionnaires. Finally, in the third stage we analyzed medical record data of patients undergoing orthodontic treatment from 2012–2017 (n=5.514) insured by a second, independent public health care insurance company to obtain quantitative data on the real utilization of detailed orthodontic services including diagnostic records, treatment procedures, costs as well as treatment duration time. Results Treatment guidelines adopted 2004 are mandatory for both providers and insurance companies. They regulate access through objective criteria and define criteria for the use of diagnostic and treatment procedures. Parallel guidelines adopted simultaneously regulate payment system and quality control. The described regulation has following impact on utilization of orthodontic services: Diagnostic procedures as panoramic X-ray and cephalograms were performed routinely (85%–90%) although their use is limited to defined diagnoses according to radiation guidelines and should not exceed 30%. About 64% of the patients received removable appliances despite their inappropriateness and inefficiency in comparison to fixed appliances. The mean treatment duration time was 36 months given that the published standard for a mean duration should be no longer than 18–20 months. Dentists were reported (81% of respondents) to be the primary driver for patients to start treatment. 93% of the patients reported to no complaints before starting treatment. Conclusions The use of inappropriate diagnostic and treatment procedures as well as prolonged treatment duration indicate overuse of orthodontic services in German public health sector. As diagnostic and treatment procedures are strictly regulated by treatment guidelines adopted by provides and public health insurance companies the overuse of orthodontic services seems to be driven by regulators, health authorities and providers.

Development and evaluation of a patient decision aid for young people and parents considering fixed orthodontic appliances by Marshmann et al. (2016). J Orthod. 43:276-287. The development of the first fixed appliance decision aid (FADA) may be an enormous advancement in improving the quality of orthodontic care (Marshmann et al. 2016). The importance of the work arises especially from the fact that decision aids may facilitate the shared decision-making process by means of providing up-todate scientific evidence on benefits and harms if presented in an appropriate format and at a right time point during the patient-physician communication. That is to say, through better information and better understanding, FADA may strengthen patient autonomy which is the fundament of bioethics and professional ethics. As we read through the study however, we have certain doubts that authors conclusion that the FADA provides patient-relevant information, a hallmark of decision aids, probably cannot be drawn from this study. According to the criteria of the International Patients Decision Aids Standards (IPDAS), relevant treatment options presented in the decision aids have to include also the ‘comprehensive, critically appraised, and up-to-date syntheses of the scientific evidence’ (IPDAS 2012). However, according to the section Methods of the study, the authors did not conduct any systematic review and critical appraisal of the available evidence to inform the content of FADA. For example the FADA’s content on root resorption, white spot lesions and patient experience were supported by only few selected single studies without clear selection criteria (Marshmann et al. 2016). Yet if the FADA fails to include some up-to-date and critically appraised evidence it may misinform patients (ethical dimension), cause unnecessary treatments (quality of care dimension) and thus resulting in more harm than good (Montori et al. 2013). We are aware of the difficulties associated with providing up-to-date scientific evidence for available treatment options, often limited funding, time consuming appraisal of literature, or low quality of available systematic reviews, just to mention a few. However, those limitations should be explicitly mentioned in the study so readers may be aware of them when drawing conclusion from the results. Also, strategies have been suggested to overcome the limitations of traditional decision aids and they could be useful in developing the FADA (Agoritsas et al. 2015). To conclude, the authors made a first and probably most important step toward strengthening patient autonomy, given that the content and the presentation of the FADA is truly evidence-based. In orthodontic care, where probably misinformation and subsequent excessive overtreatment are common (Ackermann 2010; Spassov et al. 2015), decision aids may be one valuable strategy to overcome those problems that may causes unnecessary harm and costs to patients and society.

Einleitung Die Orientierung an und auf die Bedarfe, Bedürfnisse und Präferenzen von Patienten gehört seit vielen Jahren zum Basisrepertoire der Gesundheitsrhetorik. Trotz einiger praktischer Schritte in diese Richtung, sieht der Alltag im deutschen Gesundheitswesen aber noch deutlich anders aus. Erst wenn Versorgungsforscher, gesundheitspolitisch Verantwortliche und Versorgungspraktiker Patientenorientierung zum archimedischen Punkt ihrer Sicht- und Handlungsweise machen, wird sich daran etwas ändern.

Die ab 1996 zunachst fur die Kalkulation und Bezahlung von rund 25 % aller Krankenhausleistungen eingefuhrten Fallpauschalen und die ab 2003 fur samtliche Leistungen mit Ausnahme der Behandlung psychiatrisch Kranker eingefuhrten DRGs oder diagnosis related groups sind die grosten und tiefgreifendsten Reformen der Finanzierung aber auch Sicht-, Arbeits- oder Handlungsweisen im deutschen Gesundheitswesen. Sie losten das langjahrig dominante System der tagesgleichen Pflegesatze durch die Festlegung diagnoseund prozedurenspezifischer, aber auch vom Einsatz von Ressourcen abhangiger Preise und Liegezeiten-Limitierungen ab.

Fur das „Eindringen okonomischer Kalkule in das patientenbezogene Denken und Handeln“ (Kuhn/Simon 2001: 61) in das Gesundheitssystem, d.h. die Okonomisierung und die sie begleitenden und fordernden Strukturveranderungen, sind die stationare Versorgung und die Krankenhauser aus vielen Grunden und wegen ihrer Scharnier-Stellung innerhalb von Gesamtversorgungsprozessen pradestinierte Bereiche. So pendelt die Anzahl der im Krankenhaus vollstationar behandelten Erkrankungsfalle seit Anfang der 1990er Jahre mit insgesamt steigender und erst in den letzten Jahren stagnierender oder abgeschwachter Tendenz unter- und oberhalb der 16-Millionen-Marke. Dahinter stecken aktuell mehr als 12 Millionen Personen. Da ein relativ groser Teil der im Krankenhaus behandelten Personen nicht geheilt entlassen wird, sondern weiter behandlungsbedurftig ist, „strahlen“ die Umstande und ein Teil ihrer Behandlungsleistungen weit in andere Versorgungssektoren aus. Konkret wirkt sich etwa die Versorgungsqualitat im Krankenhaus mittelbar oder im Falle der stationar verordneten Medikamente auch direkt auf die Art und die Kosten der ambulanten Weiterversorgung aus.

This article describes public trust in health care in three European countries. Public trust is a generalised attitude, influenced by people’s experiences in contacts with representatives of institutions, in its turn influencing how people enter these contacts. In general, people in Germany have less trust in health care, while people in England and Wales have the highest trust levels. Cultural differences between the three countries could be an important source of differences. That makes public trust a less straightforward candidate for use as indicator of the future oriented dimension of user views in an international, comparative performance framework.

Sickness funds became the focal point of health insurance reforms in the 1990s. Policy makers expected funds to become more consumer-oriented and more active in managing the provision of health care. This is especially true for two countries in the heart of Europe that, on first view, have many similar institutional characteristics. Both Germany and The Netherlands have introduced competition between sickness funds in the last decade. We present extensive quantitative, as well qualitative, data with regard to the behaviour of consumers after the introduction of free choice between sickness funds. National data was used with regard to contribution rates and member flows and survey data was used to investigate personal motives for actual change and perception of differences between sickness funds. In Germany, contribution rates between sickness funds differ significantly. Accordingly, these differences are the main reason for consumers to switch funds, which occurs on a considerable scale. However, survey data show that other reasons may be important too. In The Netherlands, premium differences are much lower. The same is true for the degree of change. Survey data show that consumers perceive very small differences between sickness funds and do not see much reason for change. Our findings support the claim that the degree of actual changing depends strongly on economic incentives, especially with regard to the extent of financial risk sickness funds have to bear and to the extent premiums or contribution rates can differ. However, the higher the financial risk of individual sickness funds actually is, the higher the incentives for risk selection.

We describe here a new island flap from the dorsum of the index finger, transferred on the first dorsal metacarpal artery with one or two veins and the terminal branches of the radial nerve. This vascular bundle is a reliable one, for we have had no necrosis in 12 consecutive cases. The quality of its venous outflow and the use of a dorsal donor site give it advantages over the Moberg-Littler island flap, unless a dorsal vein from the latter flap is preserved and sutured to a vein in the recipient site. The arterial vascularization without any skin pedicle makes this "kite" flap a more practical one than the "flag" flaps of Vilain or Holevitch or Kuhn. Finally, a one-stage transfer is usually preferable to a two-stage one (e.g. Adamson, Braillar). In a single operation, this transfer provides composite resurfacing of the thumb while bringing in new blood and nerve supply.

Bereits Mitte der 70er Jahre legten verschiedene Studien prinzipielle Mangel unseres Gesundheitswesens offen (vgl. u.a. WSI 1973, ROSENBERG 1975, REINERS/VOLKHOLZ 1977), die darauf hinwiesen, das die Probleme weniger in zu hohen Gesamtausgaben liegen, sondern mit dem, was Okonomen „Fehlallokation von Ressourcen“nennen, zu tun haben: Das Geld wird in die falschen Kanale geschleust. Mittlerweile hat sich die Kritik hin zur Parole „Vorsicht, Arzt!“(HALTER 1981) verscharft: „Medizinische Forschung und medizinische Dienste sind fehlgeleitet“(MCKEOWN 1982, S. 22). Es gibt hinreichend Belege fur die Thesen, das die traditionelle kurative Medizin immer weniger in der Lage ist, mit den auftretenden Krankheiten fertig zu werden; und das es nach wie vor soziale Unterschiede bei den Krankheitsrisiken und der Lebenserwartung gibt.