Healthcare Fact Check The Development of Regional Variations in German Health Care 3 Healthcare Fact Check The Development of Regional Variations in German Health Care Authors Marion Grote-Westrick (Bertelsmann Stiftung) Karsten Zich (IGES Institut Berlin) Prof. Dr. med. David Klemperer (OTH Regensburg) Uwe Schwenk (Bertelsmann Stiftung) Hans-Dieter Nolting (IGES Institut Berlin) Dr. med. Bernd Deckenbach (IGES Institut Berlin) Guido Schiffhorst (IGES Institut Berlin) Reviewers Prof. Dr. med. David Klemperer (OTH Regensburg) Prof. Dr. med. Thomas Mansky (TU Berlin) Prof. Dr. med. Bernt-Peter Robra (Otto von Guericke University Magdeburg) 4 Contents Contents 1. The „Healthcare Fact Check“ project – A provisional appraisal 7 2. Unwarranted regional variations – What has changed in Germany? 8 2.1 Unwarranted variations: How and where do they occur? 8 2.2 Regional variations in German health care: Background 12 2.3 Overarching results 13 2.4 Interpretation of results 17 2.5 Causes of unwarranted regional variations 19 2.6 Measures geared at achieving greater appropriateness in health care 22 2.7 Paradigm shift towards more patient-oriented care 23 3. Methods 25 3.1 Calculation of indicators 25 3.2 Presentation and evaluation of regional variations 27 3.3 Possibilities and constraints 29 4. Indicators selected 30 4.1 Caesarean section 30 4.2 Tonsillectomy in children and adolescents 34 4.3 Appendectomy in children and adolescents 38 4.4 Hysterectomy 42 4.5 Prostatectomy 46 4.6 Cholecystectomy 50 4.7 Primary knee replacement 54 4.8 Coronary bypass surgery 58 4.9 Implantation of a defibrillator 62 Contents 5 5. Data sources and use 66 5.1 General description of statistics used 66 5.2 Possible limitations 71 5.3 The indicators: Calculation methods and notes 73 6. References 82 6.1 References for Chapter 2 “Unwarranted regional variations” 82 6.2 References for Chapter 4 “Indicators selected” 85 7. Authors 93 8. Reviewers 93 Imprint 94 6 1. The „Healthcare Fact Check“ project – A provisional appraisal 7 1. The „Healthcare Fact Check“ project – A provisional appraisal Uwe Schwenk (Bertelsmann Stiftung) The “Healthcare Fact Check” project was launched Since the first report appeared in 2011, the Bertels- by the Bertelsmann Stiftung in 2011. The aim mann Stiftung, together with partners and experts, of the project is to highlight existing efficiency has published a series of single-subject Fact Check shortcomings and quality deficits in German health reports on Antibiotic prescriptions for children care. It is hoped that broad public debate will result (2013), Caesarean sections (2012), Tonsillectomy in measures designed to make medical care more (2013), Knee operations (2013), Depression (2014) closely oriented to the actual needs of the patients. and Density of physicians (2014 and 2015). All subjects reported on present examples of structural The project was rolled out by launching the website shortcomings in the German healthcare system, www.faktencheck-gesundheit.de and publishing such as a lack of planning and coordination, a lack “Regional Variations in German Healthcare”, the of responsibilities, financial disincentives and a central findings of which were presented at a confer- failure to involve the patient. For us, the fact that ence of international experts in Berlin in September these reports have been consistently well received 2011. The report clearly showed that unwarranted is a sign that there is still a need for commitment regional variations in health care in Germany do not in this area. merely occur in exceptional cases but are systemic in nature. The healthcare patterns revealed are The prime claim of the “Healthcare Fact Check” problematic because they can not be explained by is to portray the results of our analyses as clearly reference to regional variations in the distribution as possible and to develop practical recommenda- of medical conditions or divergent preferences tions for action by health policy makers. Our aim expressed by the population. is to continue systematically in this manner. The objective is to strengthen the citizens in their role In the present publication, which is an update of as patients, to provide them with practical benefits, the first report, the Bertelsmann Stiftung makes for example in the form of evidence-based decision a provisional appraisal. The results of this new aids, and to map the advantages and disadvantages study confirm that there is still need for action: The of different forms of treatment against one another. regional variations remain considerable and have This will form a key focus of our work in future. remained constant over time. The regional patterns of high or low utilisation have persisted unchanged. In the “Healthcare Fact Check”, the Bertelsmann And many regional and urban districts are charac- Stiftung collaborates with a large number of part- terised by extreme rates of surgical intervention in ners and experts from the field of health care who both periods studied. support the ideals and the goals of the project. Our thanks are due to them. It is only through this well- Even though the findings are somewhat sobering, founded and professional, often interdisciplinary they are far from surprising. We know from other and cross-institutional, cooperation that the quality countries that regional patterns of care often remain of the methods used in each Fact Check to analyse stable over a long period of time. It is very difficult to and interpret the results is assured. change structures, processes, habits and attitudes in such a way as to arrive at a more needs-based system We look forward to continuing to work with our of care. That is why it is important to repeatedly partners in future, too, in our mutual endeavour to highlight existing shortcomings. bring about more appropriate health care. 8 2. Unwarranted regional variations – What has changed in Germany? 2. Unwarranted regional variations – What has changed in Germany? Marion Grote-Westrick (Bertelsmann Stiftung) and Prof. Dr. David Klemperer (OTH Regensburg) Regional variations in health care exist for most how to evaluate regional differences in the density medical examinations and treatments. Many varia- of supply, the take-up of services or the level of tions are justified or even desirable, for example if expenditure? How to distinguish warranted from the incidence of a medical condition is higher in a unwarranted variations? What are the causes of particular region and consequently examinations unwarranted variations and how can these, and and treatments are more frequently found there only these, be reduced? than in other regions. However, many regional variations are not the result of differences in The Dartmouth Institute has since pursued this needs or preferences. It is important to identify further in numerous studies and publications and and reduce such unwarranted variations, not only thereby not only created a new awareness of this in order improve the appropriateness efficiency of problem, set methodological standards and encour- care in our health system, but above all in order to aged political debate, but also aroused the interest protect patients from unnecessary stress, anxiety of many research groups and health policy experts and harm. in other countries. In Australia, England, Spain and the Netherlands, detailed atlases of health care have been published and in recent years many 2.1 Unwarranted variations: scientists have defined variations in the provision How and where do they occur? or utilisation of services or the level of expenditure and analysed to what extent these are justified or International research into regional variations not.1 in health care has a long tradition in the Anglo- American countries. As early as 1938, in other Wennberg defines unwarranted variation as “varia- words more than 70 years ago, James Alison Glover tion that cannot be explained on the basis of illness, published findings on regional variations in care medical evidence, or patient preference” (Wen- in the county of Kent in England: In his study, he nberg 2010, 4). Accordingly, variations are deemed showed that a schoolchild living in Margate was unwarranted or unjustified if differences due to eight times more likely to undergo a tonsillectomy illness, medical evidence, or patient preference can than a schoolchild in the neighbouring town of be ruled out: Ramsgate. The likelihood of having the tonsils removed did not depend on the nature of the child’s Illness: Regional differences in the incidence and medical condition, but above all on the personal severity of a medical condition may be a reason for opinion of the physician concerned (Glover 1938). justified variations in utilisation. For example, an influenza epidemic that leads to more cases in one The seminal study by Wennberg and Gittelsohn region than in another can result in differences in (1973) of small-area variations in health care in the number of patients treated in outpatient and the US state of Vermont raised fundamental ques- inpatient care. tions for healthcare research such as, for example, 1 Corallo et al. (2014) provide a systematic overview of international studies on the topic. 2. Unwarranted regional variations – What has changed in Germany? 9 Medical Evidence: Variations in health care Overuse arises when the potential risk of a medi- also occur when a lack of evidence regarding cal service exceeds its possible benefit.Underuse healthcare outcomes allows considerable scope for refers to the failure to provide a medical service medical discretion.2 Resulting differences cannot which would have produced a favourable outcome be evaluated as either warranted or unwarranted. for the patient. Misuse occurs when appropriate However, they should provide the impetus for health care is provided but an avoidable compli- further research in order to increase certainty and cation occurs which prevents the patient from define optimum care. Variations are unwarranted obtaining the maximum benefit from the service if care deviates from evidence-based guidelines, provided.