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Background: In an expert analysis by the IGES Institute, it was examined which inpatient hospital treatments could also be carried out on an outpatient basis. A method of determining the feasibility of performing any particular treatment in the outpatient setting based on routine documentation was proposed in the report. A new version of the German catalogue of operations that can be performed on an outpatient basis and other outpatient procedures (the AOP catalogue) was issued accordingly. In addition, sector-blind (hybrid DRG) reimbursement of selected treatments was introduced, i.e., the amount of the reimbursement is now the same regardless of whether the treatment is provided on an inpatient or outpatient basis., Methods: The present analysis is based on German nationwide hospital discharge data from 2022. It was calculated how many inpatient treatments could have been carried out on an outpatient basis according to the criteria of the IGES report and the AOP catalogue, and how many cases would fall under hybrid DRGs., Results: Of 14.8 million inpatient treatment cases (excluding deliveries and neonates), 7.2% were identified that might have been provided on an outpatient basis according to both models, and a total of 17.3% and 21.8%, respectively, according to the IGES model or the AOP catalogue. The estimated number of potential hybrid DRG cases was 153 000, or 1.0%., Conclusion: Both the IGES model and the AOP catalogue identified a relevant potential for providing treatment on an outpatient rather than inpatient basis. However, the overlap between the two approaches is small. Further development of the AOP catalogue appears necessary for the more accurate identification of treatment cases that can be provided in the outpatient setting. The extent to which the new AOP catalogue and hybrid DRG remuneration can promote the provision of outpatient rather than inpatient care will need to be determined in future analyses. more...

By reducing healthcare services that offer little benefit or potential harm to patients (low-value care), resources can be redirected towards more adequate treatments, improving healthcare efficiency and patient outcomes. This study aimed to systematically incorporate clinical expertise across medical disciplines through a Delphi process to establish indicators for measuring low-value care, ensuring their acceptance by medical societies, the broader medical community, and patients. We developed two versions (one with higher sensitivity and one with higher specificity) for almost each of the 42 indicators identified as potentially measurable in a previous systematic review. We conducted a three-round modified Delphi panel based on the RAND/UCLA appropriateness methodology, with 62 experts from 52 Scientific Medical Societies and professional organisations, and patient representatives. In round one, each indicator was rated for its ability to indicate low-value healthcare and its measurability in German claims data. This was followed by an online discussion in round two. The indicators were then modified based on expert feedback and re-assessed in round three. As a result, 24 indicators were deemed appropriate for measuring low-value care, covering areas such as pharmaceuticals, diagnostic tests, screening, and treatment. For example, one indicator identified patients with cancer who received chemotherapy in the last month of life. These indicators will help identify healthcare services that may require policy-level interventions to improve the quality of care. However, most low-value care indicators can only be measured in German claims data if documentation requirements for relevant information are expanded., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Pioch et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.) more...

Objectives: Low-value care refers to medical services whose benefits do not outweigh the costs and potential harm. This study estimates the prevalence, distribution, and associated costs of 24 low-value care services within the German public healthcare system., Methods: This study was designed as a large-scale retrospective observational study using statutory health insurance data provided by the Techniker Krankenkasse, spanning from 2018 to 2021, covering approximately 11.1 million insured individuals annually. The prevalence of 24 low-value service indicators, which were identified through a systematic review and expert consultations, was calculated. To address uncertainties in distinguishing between appropriate and low-value care, both broad (potential overestimation) and narrow definitions (potential underestimation) were applied to all suitable indicators, providing a range within which the true extent of low-value care is expected to lie., Results: Between 2019 and 2021, 1.6 million patients were identified as having received at least 1 low-value service using the 24 indicators. Of all 10.6 million delivered services (cases) evaluated, on average per year, 1.1 million cases (broad definition) and 0.43 million cases (narrow definition) were classified as low-value care, corresponding to 10.4% and 4.0%, respectively. The costs incurred by the identified services were approximately euros €15.5 million (broad definition) and €9.9 million (narrow definition) annually., Conclusions: Despite the limitations of German statutory health insurance data, considerable low-value care was found within several of the 24 low-value indicators. The findings highlight the necessity for targeted interventions to mitigate low-value care in Germany, guiding healthcare policy and practice to enhance quality and safety effectively., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2024. Published by Elsevier Inc.) more...

Introduction: Universal health coverage (UHC) is a global priority, ensuring equitable access to quality healthcare services without financial hardship. Many countries face challenges in progressing towards UHC. Health financing is pivotal for advancing UHC by raising revenues, enabling risk-sharing through pooling of funds and allocating resources. Digital technologies in the healthcare sector offer promising opportunities for health systems. In low-income and middle-income countries (LMICs), digital technologies for health financing (DTHF) have gained traction, supporting these three main functions of health financing for UHC. As existing information on DTHF in LMICs is limited, our scoping review aims to provide a comprehensive overview of DTHF in LMICs. Our objectives include identifying and describing existing DTHF, exploring evaluation approaches, examining their positive and negative effects, and investigating facilitating factors and barriers to implementation at the national level., Methods and Analysis: Our scoping review follows the six stages proposed by Arksey and O'Malley, further developed by Levac et al and the Joanna Briggs Institute. The reporting adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework. Eligibility criteria for studies reflect the three core elements of the search: (1) health financing, (2) digital technologies and (3) LMICs. We search multiple databases, including Medline via PubMed, EMBASE via Ovid, the Web of Science Core Collection, CENTRAL via Cochrane and the Global Index Medicus by the WHO. The extracted information is synthesised from both quantitative and qualitative studies., Ethics and Dissemination: As our scoping review is based solely on information gathered from previously published studies, documents and publicly available scientific literature, ethical clearance is not required for its conduct. The findings are presented and discussed in a peer-reviewed article, as well as shared at conferences relevant to the topic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.) more...

Introduction: Nearly all patients with primary ciliary dyskinesia (PCD) report ear-nose-throat (ENT) symptoms. However, scarce evidence exists about how ENT symptoms relate to pulmonary disease in PCD. We explored possible associations between upper and lower respiratory disease among patients with PCD in a multicentre study., Methods: We included patients from the ENT Prospective International Cohort (EPIC-PCD). We studied associations of several reported ENT symptoms and chronic rhinosinusitis (defined using patient-reported information and examination findings) with reported sputum production and shortness of breath, using ordinal logistic regression. In a subgroup with available lung function results, we used linear regression to study associations of chronic rhinosinusitis and forced expiratory volume in 1 s (FEV 1 ) accounting for relevant factors., Results: We included 457 patients (median age 15 years, interquartile range 10-24 years; 54% males). Shortness of breath associated with reported nasal symptoms and ear pain of any frequency, often or daily hearing problems, headache when bending down (OR 2.1, 95% CI 1.29-3.54) and chronic rhinosinusitis (OR 2.3, 95% CI 1.57-3.38) regardless of polyp presence. Sputum production associated with daily reported nasal (OR 2.2, 95% CI 1.20-4.09) and hearing (OR 2.0, 95% CI 1.10-3.64) problems and chronic rhinosinusitis (OR 2.1, 95% CI 1.48-3.07). We did not find any association between chronic rhinosinusitis and FEV 1 ., Conclusion: Reported upper airway symptoms and signs of chronic rhinosinusitis associated with reported pulmonary symptoms, but not with lung function. Our results emphasise the assessment and management of upper and lower respiratory disease as a common, interdependent entity among patients with PCD., Competing Interests: Conflict of interest: J-F. Papon reports personal fees from Sanofi, GSK, Medtronic and ALK, outside the submitted work. Conflict of interest: M. Alexandru received personal fees from Sanofi and ALK outside the submitted work. Conflict of interest: M. Boon reports grants from Forton grant (King Baudouin Foundation) 2020-J1810150-217926 for cystic fibrosis research and personal fees from Vertex outside the submitted work. Conflict of interest: N. Lorent received honoraria to her institution from GSK, INSMED and AN2 Therapeutics outside the submitted work, and a travel grant from Pfizer. Conflict of interest: J. Roehmel received grants, clinical study reimbursement from Vertex, INSMED, Medical Research Council/UK, BMBF and Mukoviszidose Institut, outside the submitted work. Conflict of interest: The other authors report no competing interests., (Copyright ©The authors 2024.) more...

Importance: Otologic disease is common among people with primary ciliary dyskinesia (PCD), yet little is known about its spectrum and severity., Objective: To characterize otologic disease among participants with PCD using data from the Ear-Nose-Throat Prospective International Cohort., Design, Setting, and Participants: This cross-sectional analysis of baseline cohort data from February 2020 through July 2022 included participants from 12 specialized centers in 10 countries. Children and adults with PCD diagnoses; routine ear, nose, and throat examinations; and completed symptom questionnaires at the same visit or within 2 weeks were prospectively included., Exposures: Potential risk factors associated with increased risk of ear disease., Main Outcomes and Measures: The prevalence and characteristics of patient-reported otologic symptoms and findings from otologic examinations, including potential factors associated with increased risk of ear inflammation and hearing impairment., Results: A total of 397 individuals were eligible to participate in this study (median [range] age, 15.2 [0.2-72.4] years; 186 (47%) female). Of the included participants, 204 (51%) reported ear pain, 110 (28%) reported ear discharge, and 183 (46%) reported hearing problems. Adults reported ear pain and hearing problems more frequently when compared with children. Otitis media with effusion-usually bilateral-was the most common otoscopic finding among 121 of 384 (32%) participants. Retracted tympanic membrane and tympanic sclerosis were more commonly seen among adults. Tympanometry was performed for 216 participants and showed pathologic type B results for 114 (53%). Audiometry was performed for 273 participants and showed hearing impairment in at least 1 ear, most commonly mild. Season of visit was the strongest risk factor for problems associated with ear inflammation (autumn vs spring: odds ratio, 2.40; 95% CI, 1.51-3.81) and age 30 years and older for hearing impairment (41-50 years vs ≤10 years: odds ratio, 3.33; 95% CI, 1.12-9.91)., Conclusion and Relevance: In this cross-sectional study, many people with PCD experienced ear problems, yet frequency varied, highlighting disease expression differences and possible clinical phenotypes. Understanding differences in otologic disease expression and progression during lifetime may inform clinical decisions about follow-up and medical care. Multidisciplinary PCD management should be recommended, including regular otologic assessments for all ages, even without specific complaints. more...

Background: Segmenting the population into homogenous groups according to their healthcare needs may help to understand the population's demand for healthcare services and thus support health systems to properly allocate healthcare resources and plan interventions. It may also help to reduce the fragmented provision of healthcare services. The aim of this study was to apply a data-driven utilisation-based cluster analysis to segment a defined population in the south of Germany., Methods: Based on claims data of one big German health insurance a two-stage clustering approach was applied to group the population into segments. A hierarchical method (Ward's linkage) was performed to determine the optimal number of clusters, followed by a k-means cluster analysis using age and healthcare utilisation data in 2019. The resulting segments were described in terms of their morbidity, costs and demographic characteristics., Results: The 126,046 patients were divided into six distinct population segments. Healthcare utilisation, morbidity and demographic characteristics differed significantly across the segments. The segment "High overall care use" comprised the smallest share of patients (2.03%) but accounted for 24.04% of total cost. The overall utilisation of services was higher than the population average. In contrast, the segment "Low overall care use" included 42.89% of the study population, accounting for 9.94% of total cost. Utilisation of services by patients in this segment was lower than population average., Conclusion: Population segmentation offers the opportunity to identify patient groups with similar healthcare utilisation patterns, patient demographics and morbidity. Thereby, healthcare services could be tailored for groups of patients with similar healthcare needs., (© 2023. The Author(s).) more...

Background: Sinonasal symptoms are a common feature of primary ciliary dyskinesia (PCD); however, literature about their severity and frequency, particularly during the life course, is scarce. Using baseline data from the Ear, nose and throat (ENT) Prospective International Cohort of PCD patients, we describe sinonasal disease in PCD., Methods: We included participants who had a routine sinonasal examination during which they completed a symptoms questionnaire. We compared frequency of reported symptoms and examination findings among children and adults, and identified characteristics potentially associated with higher risk of sinonasal disease using ordinal regression., Results: 12 centres contributed 384 participants; median age was 16 years (IQR 9-22), and 54% were male. Chronic nasal problems were the most common feature, reported by 341 (89%). More adults (33; 24%) than children (10; 4%) described hyposmia. Quality of life was moderately affected by rhinosinusitis among 136 participants with completed SNOT-22 questionnaires (median score 31; IQR 23-45). Examinations revealed nasal polyps among 51 of 345 participants (15%) and hypertrophic inferior nasal turbinates among 127 of 341 participants (37%). Facial pain was detected in 50 of 342 participants (15%). Nasal polyps, hypertrophic turbinates, deviated septum and facial pain were found more commonly in adults than children. The only characteristic associated with higher risk of sinonasal disease was age 10 years and older., Conclusions: Based on our findings, regular sinonasal examinations are relevant for patients with PCD of all ages. There is a need for improved management of sinonasal disease supported by evidence-based guidelines., Competing Interests: Conflict of interest: P. Latzin received grants or honoraria for participation in data safety monitoring boards or advisory boards from Vertex, Vifor, OM Pharma, Polyphor, Santhera (DMC) and Sanofi Aventis within the last 36 months. J. Roehmel received grants and clinical study remuneration from Vertex, INSMED, Medical Research Council/UK, BMBF and Mukoviszidose Institut. All other authors have nothing to declare., (Copyright ©The authors 2023.) more...