Sozioökonomische und regionale Aspekte der Gesundheit

Einleitung / Introduction

Hausbesuchsprogramme für ältere Personen sind heterogen in Zielgruppen und Ausrichtung. Die Wirksamkeit ist nicht eindeutig nachgewiesen. Unspezifische positive Impulse zeigen sich in der Weiterentwicklung kommunaler Strukturen. Vor diesem Hintergrund wurde der Hamburger Hausbesuch als aufsuchendes, freiwilliges und kostenloses Angebot von der Behörde für Gesundheit und Verbraucherschutz eingeführt. In der Modellphase 09/2018-12/2019 wurde die Machbarkeit des Hamburger Ansatzes untersucht, dessen Ziel es ist, die aktive selbstständige Lebensführung in der eigenen Häuslichkeit durch ein individuelles Informationsgespräch zu fördern. Personen, die ihren 80. Geburtstag hatten und in zwei Modellbezirken (urban und ländlich geprägt) wohnen, erhalten seit 09/2018 ein Hausbesuchsangebot.

Methode / Method

Zentrale Aufgaben: Bildung einer Fachstelle, Abstimmung von Geburtstagsanschreiben, Informationsmaterialien (u.a. zu Ernährung, Mobilität, soziale Einbindung, Wohnsituation, Hilfsbedürftigkeit); Gewinnung und Schulung selbstständig-tätiger Besuchskräfte auf Honorarbasis; Datenschutzkonzept; Durchführung der Hausbesuche inkl. Terminkoordination, Anschreibenversand, Bearbeitung von Zusagen, Verschiebungen und Absagen, Dokumentation und Rechnung sowie Berichtswesen.

Ergebnisse / Results

59 Besuchskräfte wurden gewonnen. 4.963 Personen hatten ihren 80. Geburtstag. Allen wurde ein Hausbesuchsangebot inkl. eines Termins (Datum, Uhrzeit, Besuchskraft) gemacht, das 35 % annahmen. Der Hausbesuch wurde sowohl im hochverdichteten urbanen als auch im eher ländlichen geprägten Bezirk akzeptiert. Die häufigsten Gesprächsthemen waren gesundheitliche Situation, Mobilität und Wohnsituation.

Zusammenfassung / Conclusion

Voraussetzungen für die Umsetzung sind abgegrenzte räumliche Strukturen, Datenschutzkonzept, funktionierende Einbindung von Kommune und lokalen Akteuren sowie Gewinnung Schulung und Bindung der Besuchskräfte. Die im Vorwege formulierte Akzeptanzquote von 25 % wurde um 10 Prozentpunkte übertroffen. Die Relevanz der Themen deckt sich mit Ergebnissen aus gerontologisch-geriatrischem Assessment. Beeinträchtigte Mobilität hat bei wenigen oder fehlenden Kompensationsmöglichkeiten u.U. beträchtliche Konsequenzen, z.B. Einschränkungen sozialer Teilhabe oder personelle Hilfe bei Pflegebedürftigkeit. Aufgrund der hohen Akzeptanz wurde mit der Ausweitung des Angebots auf ganz Hamburg zu Beginn des Jahres 2020 begonnen, d.h. ca. 15.000 Personen mit 80. Geburtstag. Mit Aufkommen der Corona-Pandemie wurde der Hausbesuch während des Lockdowns als Telefonat angeboten, das allerdings sehr selten nachgefragt wurde. Ein Hygienekonzept wurde für die Durchführung der Hausbesuche entwickelt, dass auch vor Übertragung anderer ansteckender Krankheiten schützen soll.

AutorInnen

Lilli Neumann, Albertinen Haus, Zentrum für Geriatrie und Gerontologie, Wissenschaftliche Einrichtung an der Universität Hamburg

Ulrike Dapp, Albertinen Haus, Zentrum für Geriatrie und Gerontologie, Wissenschaftliche Einrichtung an der Universität Hamburg

Silke Böttcher-Völcker, Freie und Hansestadt Hamburg, Behörde für Gesundheit und Verbraucherschutz (bis Juni 2020)

Elisabeth Kleinhans, Freie und Hansestadt Hamburg, Behörde für Gesundheit und Verbraucherschutz (bis Juni 2020)

Wolfgang von Renteln-Kruse, Albertinen Haus, Zentrum für Geriatrie und Gerontologie, Wissenschaftliche Einrichtung an der Universität Hamburg

Einleitung / Introduction

Medical technologies impact the efficacy of treatments but are not diffusing uniformly across and within health systems. One explanation why regions differ in the uptake of technologies are pioneer physicians and knowledge production in the context of product development. In this study, we develop measures of knowledge production by technology at regional level. We empirically examine the link between regional knowledge production and long-term medical device use rates in Europe.

Methode / Method

We develop measures of knowledge production based on bibliometric and clinical trial information for medical device categories that vary by cost and outcomes at regional (NUTS3) level in four countries: Germany, Italy, Switzerland, and Hungary. We consider three high-volume hospital procedures: total hip arthroplasty vs. hemiarthroplasty in patients with femoral neck fractures, insertion of drug-eluting vs. bare metal stents in patients with myocardial infarction, and instrumented vs. non-instrumented spinal surgery in patients with lumbar spinal stenosis. For 2012-2016 and per device category, we collect use rates based on patient-level administrative data, data on 11,301 scientific publications by 38 medical subject headings and geolocation based on the US National Library of Medicine (PubMed), and data of hospital characteristics and socio-economic determinants of regions. We estimate multivariate linear regressions by region to investigate the relationship between knowledge production and use rates of medical devices.

Ergebnisse / Results

We find large within and across country variation in use rates of medical devices and knowledge production. Use rates of total hip arthroplasties were highest in Switzerland (68.2%), followed by Hungary (47.95%), Germany (27.88%), and Italy (28.6%). Within countries, use rates of total hip arthroplasties vary between 0% and 95% by region. The overall number of medical device related publications was highest in Germany (1,968), followed by Italy (538), Switzerland (129) and Hungary (96). The mean number of journal articles per region was highest in Switzerland (30.28 articles), followed by Italy (11.97 articles), Germany (7.11 articles) and Hungary (2.81 articles). The use of medical devices is significantly correlated with knowledge production at medical device level in a region. We find that the sum of case-related publications in 2007-2011 (-.0.050, p=0.007), the number of researchers with high reputation (-0.030, p=0.051) and the number of first authors in a region (-0.031, p=0.079) are negatively associated with the use rate of total hip arthroplasties.

Zusammenfassung / Conclusion

Knowledge production by physicians in a region has an effect on medical device use rates. Reductions in the variation in medical device use may be achieved by targeting regions with low innovative activity.

AutorInnen

Meilin Möllenkamp, Hamburg Center for Health Economics, Universität Hamburg

Jonas Schreyögg, Hamburg Center for Health Economics, Universität Hamburg

Katharina Elisabeth Blankart, CINCH – Health Economics Research Center, Universität Duisburg-Essen

COMED Team

Einleitung / Introduction

Similar to Germany and the Netherlands, the health insurance system in Switzerland is organized according to principles of regulated competition. To maintain risk solidarity, basic health insurance is mandatory and premiums are community-rated, potentially placing a high financial burden on low-income households. Therefore, means-tested premium subsidies are awarded to maintain affordability. However, how to optimally design the payout system has remained an open question. While cash transfers offer more budget choices, in-kind transfers might incentivize the recipients to increase their expenditures on subsidized goods. We analyze different premium subsidy payout systems in order to assess their effect on the financial situation of transfer recipients.

Methode / Method

Before 2014, some cantons (i.e. states) paid the premium subsidy in-kind while other cantons applied a cash transfer. A reform led to a federally mandated harmonization of the transfer payout across all cantons, that is, all cantons must pay the premium subsidy in-kind since 2014. We can exploit this setting and apply a difference-in-differences approach on individual level data. Our analysis is based on accounting data of the largest health insurer in Switzerland. Under the cash system employed prior to the reform, health insurance providers did not know who received premium subsidies. Thus, we utilize multiple machine learning algorithms to identify recipients.

Ergebnisse / Results

We find that switching from cash to in-kind leads to an approximately 20% reduction in the probability that subsidized households miss paying their health insurance premiums on time and an approximately 12% reduction in the default probability. The effects set in immediately after the reform and financial problems persistently remain on this lower level over the six years after the harmonization our data covers. Finally, we also provide suggestive evidence that restricting budget choices had no negative spillover effect on other household expenditures as people are not less likely to pay co-payment bills (which are never subsidized) on time after the regime change.

Zusammenfassung / Conclusion

How should payout systems of means-tested benefits be designed to improve the financial situation of needy recipients most effectively? We analyze a payout system reform in Switzerland to empirically assess this question. We find that relative to cash transfers, in-kind transfers reduce payment problems for health insurance premiums without having a negative effect on the ability to pay for other health related bills.

AutorInnen

Nicolas Schreiner, CSS Institute for Empirical Health Economics

Christian Schmid, CSS Institute for Empirical Health Economics

Alois Stutzer, University of Basel

Einleitung / Introduction

Although a growing share of the population in many countries is being vaccinated against the Sars-Cov-2 virus, social distancing and hygienic non-pharmaceutical interventions still play a substantial role in containing the pandemic. The goal of this study was to investigate which factors are correlated with a higher compliance with these regulations in the context of a regional cohort study in the city of Munich, southern Germany, during the summer of 2020, i.e. after the first lockdown phase.

Methode / Method

Using self-reported compliance with six regulations and personal hygiene rules (washing hands, avoiding touching face, wearing a mask, keeping distance, avoiding social gatherings, avoiding public spaces) we constructed a compliance factor score. Using linear and logistic regression, we estimated the correlation of several socio-demographic, health-related and risk perception variables with both the score and its single dimensions.

Ergebnisse / Results

A higher age, being female, being retired, having a migration background and having had no positive serologic test at baseline were positively related with compliance. Income and education were not related with compliance. Publicly announced risk cutoffs based on cumulative 7-day incidence per 100.000 inhabitants and subjective risk perception dimensions also correlated with compliance. Particularly, risk aversion proved to be a consistent and significant driver of compliance across all dimensions and specifications.

Zusammenfassung / Conclusion

Targeted measures to improve compliance with Covid-19 regulation should focus on younger, male and risk-taking individuals, and those who presented a positive serologic test. Cues to action based on clear cutoffs might prove an effective ally as well.

AutorInnen

Sara Pedron, Technische Universität München

Michael Laxy, Technische Universität München

Lars Schwettmann, Helmholtz Zentrum München

Reiner Leidl, Helmholtz Zentrum München