Stegbauer Constance, Willms Gerald, Kleine-Budde Katja, Bramesfeld Anke, Stammann Carina, Szecsenyi Joachim
AQUA Institute for Applied Quality Improvement and Research in Health Care GmbH, Göttingen, Germany.
AQUA Institute for Applied Quality Improvement and Research in Health Care GmbH, Göttingen, Germany.
Z Evid Fortbild Qual Gesundhwes. 2017 Oct;126:13-22. doi: 10.1016/j.zefq.2017.07.006. Epub 2017 Oct 11.
This paper describes the development of quality indicators for an external statutory and cross-sectoral quality assurance (QA) procedure in the context of the German health care system for adult patients suffering from schizophrenia, schizotypal and delusional disorders (F20-F29).
Indicators were developed by a modified RAND/UCLA Appropriateness Method with 1) the compilation of an indicator register based on a systematic literature search and analyses of health care claims data, 2) the selection of indicators by an expert panel that rated them for relevance and for feasibility regarding implementation. Indicators rated positive for both relevance and feasibility formed the final indicator set.
847 indicators were identified by different searches. Out of these, 56 were selected for the indicator register. During the formal consensus process the expert panel recommended another 45 indicators so that a total of 101 indicators needed to be considered by the panel. Of these, 27 indicators rated both relevant and feasible were included in the final set of indicators: this set included 4 indicators addressing structures, 19 indicators addressing processes and 4 indicators addressing outcomes. 17 indicators of the set will be reported by hospitals and 8 by psychiatric outpatient facilities. Two indicators considered to be cross-sectoral will be reported by both sectors.
F20-F29 and its treatment show some specific features which so far have not been addressed by any procedure within the statutory QA program of the German health care system. These features include: Schizophrenia and related disorders a) are potentially chronic conditions, b) are mainly treated in outpatient settings, c) require a multi-professional treatment approach and d) are treated regionally in catchment areas. These specific features in combination with the peculiarities of some legal, political and organizational characteristics of the German health care system and its statutory QA program have strongly influenced the development of indicators. The result was a seemingly "imbalanced" set of indicators with a greater number of indicators for inpatient than for outpatient care despite the fact that clinical reality is otherwise.
The circumstances of the German health care system that restricted the development of this cross-sectoral QA procedure addressing care for F20-F29 are also most likely to emerge with the development of cross-sectoral QA procedures for other (potentially) chronic conditions that are mainly treated in the outpatient setting by multi-professional teams or by networks of different providers. In order to be able to develop a QA procedure that mirrors the reality of service provision for (potentially) chronic diseases such as F20-F29 we need to explore further current and new data sources, diminish sectoral borders, and implement health care responsibility on the level of catchment areas.
本文描述了在德国医疗保健系统中，针对患有精神分裂症、分裂型障碍和妄想性障碍（F20 - F29）的成年患者的外部法定跨部门质量保证（QA）程序的质量指标的制定。
指标通过改良的兰德/加州大学洛杉矶分校适宜性方法制定，具体如下：1）基于系统的文献检索和医疗保健索赔数据分析编制指标登记册；2）由专家小组选择指标，并对其相关性和实施可行性进行评级。在相关性和可行性方面均获得肯定评级的指标构成最终指标集。
通过不同检索识别出847个指标。其中，56个被选入指标登记册。在正式的共识过程中，专家小组又推荐了45个指标，因此专家小组总共需要考虑101个指标。其中，27个在相关性和可行性方面均获评级的指标被纳入最终指标集：该指标集包括4个涉及结构的指标、19个涉及过程的指标和4个涉及结果的指标。该指标集中的17个指标将由医院报告，8个由精神科门诊机构报告。两个被视为跨部门的指标将由两个部门共同报告。
F20 - F29及其治疗表现出一些特定特征，而德国医疗保健系统法定QA计划中的任何程序迄今均未涉及这些特征。这些特征包括：精神分裂症及相关障碍a）可能是慢性病；b）主要在门诊环境中治疗；c）需要多专业治疗方法；d）在集水区进行区域治疗。这些特定特征与德国医疗保健系统及其法定QA计划的一些法律、政治和组织特征的特殊性相结合，对指标的制定产生了强烈影响。结果是一组看似“不平衡”的指标，尽管临床实际情况并非如此，但住院护理的指标数量多于门诊护理。
限制针对F20 - F29护理的这一跨部门QA程序发展的德国医疗保健系统情况，很可能在针对其他主要由多专业团队或不同提供者网络在门诊环境中治疗的（潜在）慢性病的跨部门QA程序发展过程中再次出现。为了能够制定一个反映针对F20 - F29等（潜在）慢性病服务提供实际情况的QA程序，我们需要进一步探索当前和新的数据来源，减少部门边界，并在集水区层面落实医疗保健责任。
