Appropriateness and Efficiency Bonn 2001 ADVISORY COUNCIL for the Concerted Action in Health Care Appropriateness and Efficiency Volume III Overuse, underuse and misuse Report 2000/2001 Executive Summary Table of Contents Preface 11 1. Introduction and Overview 13 2. Observations on the Legal Tasks of the Council 22 3. Need, Appropriate Care, Overuse, Underuse and Misuse 24 3.1 Background 24 3.2 Introduction 24 3.3 Observations on the German Social Health Insurance System 26 3.4 The application to population based issues 31 3.5 The level of supply 33 4. Survey Objectives and Methods 35 4.1 Background and goals of the survey 35 4.2 Participants, survey design and evaluation of survey results 35 4.3 Rating categories of the Council 37 5. Summary of the Survey Results 40 5.1 The response rate 40 5.2 The survey of medical societies 40 5.3 Survey of patient groups 41 5.4 Survey of state governments, doctors' associations and health insurance associations 45 5.5 Recommendations for future surveys of the health care system 47 5 6. Indicators of Differences between the Eastern German States and the Western German States 50 6.1 Health status 50 6.2 The health care situation 52 6.3 Summary and recommendations 54 7. The Care of Patients with Chronic Diseases 55 7.1 Introduction 55 7.2 The epidemiology and costs of chronic diseases 56 7.3 Requirements for the care of the chronically ill 57 7.4 Overuse, underuse and misuse 60 7.5 Lessons from ten years of diabetes care in Germany 70 7.6 The care of the terminally ill 74 7.7 Summary and recommendations 75 8. Ischemic Heart Disease, Including Heart Attack 78 8.1 The burden of disease 78 8.2 The views of the interviewed groups 78 8.3 The Council's viewpoint 81 8.4 Summary and recommendations 86 9. Cerebrovascular Diseases and Stroke 90 9.1 The burden of disease 90 9.2 The views of the interviewed groups 90 9.3 The Council's viewpoint 93 9.4 Summary and recommendations 97 6 10. Chronic Obstructive Lung Disease 99 10.1 The burden of disease 99 10.2 The views of the interviewed groups 101 10.3 Summary and recommendations 104 10.3.1 The structure of care 104 10.3.2 Asthma 105 10.3.3 COPD 108 11. Back Pain 109 11.1 The burden of disease 109 11.2 The views of the interviewed groups 110 11.3 The Council's viewpoint 114 11.4 Prevention and workplace health promotion 117 11.5 Summary and recommendations 122 12. Oncological Diseases 125 12.1 Lung cancer 125 12.1.1 The burden of disease 125 12.1.2 The views of the interviewed groups 126 12.1.3 The Council's viewpoint 129 12.1.4 Summary and recommendations 134 12.2 Breast cancer 138 12.2.1 The burden of disease 138 12.2.2 The views of the interviewed groups 139 12.2.3 The Council's viewpoint 142 12.2.4 Summary and recommendations 149 12.3 General aspects of the care of cancer patients 150 12.3.1 The burden of disease 151 12.3.2 The views of the interviewed groups 152 12.3.3 Summary and recommendations 155 7 13. Depressive Disorders 158 13.1 The burden of disease 158 13.2 The views of the interviewed groups 158 13.3 The Council's viewpoint 162 13.3.1 General issues in the care of psychiatric patients 162 13.3.2 The diagnosis and treatment of depressive disorders in family practice 164 13.3.3 Depression in the elderly 166 14. Oral, Dental and Orthodontic Health 170 14.1 The views of the interviewed groups 170 14.2 Overuse, underuse and misuse in general dentistry 171 14.2.1 Current problems in dentistry 171 14.2.2 Current activities for the improvement of quality 174 14.2.3 Future approaches for improving quality 175 14.2.4 Measures for improving the framework 176 14.2.5 Economic effects 179 14.3 Overuse, underuse and misuse in orthodontics 179 14.4 Summary and recommendations 180 15. Appendix 183 15.1 Legal basis of the Advisory Council for the Concerted Action in Health Care (as of January 1, 2000) 183 15.2 Surveyed organizations 184 15.3 Text of the survey 217 15.4 Summary of the Council's most urgent recommendations (A) for reducing overuse, underuse and misuse in the health care system 223 15.5 Members of the Advisory Council for Concerted Action in Health Care 230 8 List of Tables Table 1: System for the classification of problems and solutions 17 Table 2: The new rules of health care in the 21st century 21 Table 3: The definition of overuse, underuse and misuse 31 Table 4: The need for intervention, development and investigation 39 Table 5: The number of responses 40 Table 6: Average life expectancy at birth in the eastern and western states 51 Table 7: Health insurance status of the population 53 Table 8: Models, concepts and measures of health 63 Table 9: Objectives of the St. Vincent Declaration of 1989 70 Table 10: Organizations that provided information on overuse, underuse and misuse in the area of ischemic heart disease 79 Table 11: Facts on cardiology in Germany (1999) 82 Table 12: Trends in the number of invasive cardiologists, cardio-surgical facilities and the number of cardiological interventions (1990 - 1999) 83 Table 13: Organizations that provided information on overuse, underuse and misuse in the area of cerebrovascular diseases and stroke 91 Table 14: Data sources on stroke in Germany 94 Table 15: Organizations that provided information on overuse, underuse and misuse in the area of chronic obstructive pulmonary disease 102 Table 16: A selection of important risk factors for the development of chronic back pain 109 Table 17: Organizations that provided information on overuse, underuse and misuse in the area of back pain 115 Table 18: Overview of diseases associated with smoking 125 Table 19: Organizations that provided information on overuse, underuse and misuse in the area of lung cancer (including the prevention of tobacco use) 126 Table 20: Organizations that provided information on overuse, underuse and misuse in the area of breast cancer 140 Table 21: EUREF standards on the minimum number of mammographies per year 145 9 Table 22: Organizations that provided information on overuse, underuse and misuse in the area of cancer or pain therapy 156 Table 23: Organizations that provided information on overuse, underuse and misuse in the area of depressive disorders 159 Table 24: Examples for concrete targets, conditions and estimated length of time needed for improving dental health care 178 List of Figures Figure 1: Structure of the data base of survey results 38 Figure 2: Model of the simultaneity and co-ordination of non-sequential courses of disease 61 Figure 3: Algorithm for the diagnosis and treatment of back pain 116 Figure 4: The innovation cycle 147 Figure 5: Number of bone marrow transplants for breast cancer recorded in the EBMT Registry 148 10 Preface With Volume III of the report on "Appropriateness and Efficiency", the Advisory Council for Concerted Action in Health Care fulfils a substantial part of its legal tasks as defined in Germany's Social Health Insurance Law. In view of the scope of this task, it was necessary to focus Volume III - entitled "Overuse, underuse and misuse" - on selected diseases and target groups. Many topics that were suggested to the Council will have to be dealt with in the future. The legal mandate of evaluating the appropriateness of health care is a permanent task of health policy that requires many more resources than have been dedicated to it in the past. The Council extends its gratitude to a large number of institutions, organizations and individuals. This pertains to the many organizations that participated in the survey of the Council and without whom the report could not have been completed in its present form (a list of the participants is provided in the appendix). Furthermore, the Council was always able to rely on the expert support of the German Ministry for Health. In addition, the Council would like to thank the following persons: Ulrike Bahrdt, Uni- versity of Applied Sciences Braunschweig-Wolfenbüttel; Dr. Anke Bramesfeld M.D., University of Hannover Medical School; Dr. Katja Bromen MPH, University of Essen; Dr. Elke Jakubowski M.D./MSP, World Health Organization, Copenhagen; Prof. Dr. Karl-Heinz Jöckel M.D., University of Essen; Dr. Monika Grüßer M.D., Central Insti- tute of Ambulatory Health Care in Germany, Cologne; Dr. Uwe Lenhardt, Social Sci- ence Research Center - Berlin; Dr. A. Mühlich, National Association of Statutory Health Insurance Physicians, Cologne; Ines Ney, University of Applied Sciences Braunschweig-Wolfenbüttel; Dr. Matthias Perleth M.D./MPH, University of Hannover Medical School; Prof. Dr. Dr. Heiner Raspe, University of Lübeck Medical School; Rüdiger Saekel, Ministerial Counsellor (retired), Meckenheim; Dr. Bettina Schmidt, University of Bielefeld; Dr. Angelika Schreiber-Wazlak MPH, Berlin; Prof. Dr. Dr. H. J. Staehle, University of Heidelberg; Dr. Ulla Walter, University of Hannover Medical School. The preparation of the report placed an extraordinary strain on the resources of the Council’s office and in particular on its professional and administrative staff, including Antje Freytag, Dr. Antonius Helou M.D./MPH, Dr. Ulrike Heyer M.D./MPH, Dr. Friederike Hoepner-Stamos, Dr. Karin Hummel, Dr, Sabine List M.D./MPH, Annette Riesberg MPH and the office director, Dr. Lothar Seyfarth. The Council owes special thanks to its office staff.