Steffen Flessa

University of Greifswald, Griefswald, Mecklenburg-Vorpommern, Germany

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Publications (75)120.53 Total impact

  • Journal of Alzheimer's disease: JAD 08/2014; · 4.17 Impact Factor
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    ABSTRACT: Individualized Medicine aims at providing optimal treatment for an individual patient at a given time based on his specific genetic and molecular characteristics. This requires excellent clinical stratification of patients as well as the availability of genomic data and biomarkers as prerequisites for the development of novel diagnostic tools and therapeutic strategies. The University Medicine Greifswald, Germany, has launched the "Greifswald Approach to Individualized Medicine" (GANI_MED) project to address major challenges of Individualized Medicine. Herein, we describe the implementation of the scientific and clinical infrastructure that allows future translation of findings relevant to Individualized Medicine into clinical practice.Methods/design: Clinical patient cohorts (N > 5,000) with an emphasis on metabolic and cardiovascular diseases are being established following a standardized protocol for the assessment of medical history, laboratory biomarkers, and the collection of various biosamples for bio-banking purposes. A multi-omics based biomarker assessment including genome-wide genotyping, transcriptome, metabolome, and proteome analyses complements the multi-level approach of GANI_MED. Comparisons with the general background population as characterized by our Study of Health in Pomerania (SHIP) are performed. A central data management structure has been implemented to capture and integrate all relevant clinical data for research purposes. Ethical research projects on informed consent procedures, reporting of incidental findings, and economic evaluations were launched in parallel.
    Journal of translational medicine. 05/2014; 12(1):144.
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    ABSTRACT: Infections with methicillin-resistant Staphylococcus aureus (MRSA) are assumed to have a high economic impact due to increased hygienic measures and prolonged hospital length of stay. However, surveys on the real expenditure for the prevention and treatment of MRSA are scarce, in particular with regard to the German Diagnosis-Related Groups (G-DRG) payment system. The aim of our study is to empirically assess the additional cost for MRSA management measures and to identify the main cost drivers in the whole process from the hospital's point of view. We conducted a one-year retrospective analysis of MRSA-positive cases in a German university hospital and determined the cost of hygienic measures, laboratory costs, and opportunity costs due to isolation time and extended lengths of stay. A total of 182 cases were included in the analysis. The mean length of hospital stay was 22.75 days and the mean time in isolation was 17.08 days, respectively. Overall, the calculated MRSA-attributable costs were 8,673.04 per case, with opportunity costs making up, by far, the largest share (77.45 %). Our study provides a detailed up-to-date analysis of MRSA-attributed costs in a hospital. It allows a current comparison to previous studies worldwide. Moreover, it offers the prerequisites to investigate the adequate reimbursement of MRSA burden in the DRG payment system and to assess the efficiency of targeted hygienic measures in the prevention of MRSA.
    05/2014;
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    ABSTRACT: Objectives: The study objective was to identify the size of different hospital financing sources for different hospital services and their impact on the uninsured.
    International Journal for Equity in Health 05/2014; 13(1):40. · 1.71 Impact Factor
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    ABSTRACT: Im Rahmen einer perioperativen Prozessanalyse an der Universitätsmedizin Greifswald wurden am Beispiel der ambulanten Katarakt-Operation die Prozessabläufe im Zentral-OP, in der Poliklinik sowie der Patientenbegleitung auf dem Weg zum Zentral-OP und wieder zurück dokumentiert. Wichtige Aspekte des Prozessmanagements wie Durchlaufzeit der Patienten in den einzelnen Teilbereichen (präoperativ, operativ und postoperativ), Wartezeiten, Termintreue der Patienten sowie des Hol- und Bringedienstes konnten ermittelt und ausgewertet werden. Damit verbunden war eine Validierung der Dokumentationsqualität der aktuellen Operationsbelegungspläne. Perioperative Prozessanalyse des OP- Managements 75 Die Erhebung bietet Ansatzpunkte für aktuelle Prozessdefizite, Störgrößen und Schnittstellenprobleme, vor allem im kostenintensiven OP-Bereich, aber auch in den prä- und postoperativen Abläufen. Insbesondere die Personalverfügbarkeit im OP und in der Poliklinik führen neben dem Patientenbestellsystem und der längeren IST-Zeit der OPs zu zeitlichen Verzögerungen, die den gesamten Behandlungsablauf betreffen. Aus den ermittelten Untersuchungsergebnissen leiten sich konkrete Verbesserungspotenziale bezüglich Qualität, Zeit, Kosten, Planungssicherheit sowie Mitarbeiter- und Patientenzufriedenheit ab. Darüber hinaus liefert die Studie eine Basis für weiterführende Untersuchungen im Bereich des Prozess- und des OPManagements. Dafür bietet sich bevorzugt die Anwendung von Simulationstechniken an.
    05/2014: pages 59-80; , ISBN: 978-3-658-05133-4
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    ABSTRACT: Aseptic loosening is one of the most common intermediate and long-term complications after total hip replacement (THR). These complications cause suffering and require expensive revision surgery. Little concrete data on direct costs are available from the hospital's, moreover operating department's perspective. We here provide a detailed analysis of the costs of THR revision and relate them to reimbursement underlying the German diagnosis-related groups (DRG) system. Major cost parameters were identified using for orientation the cost matrix of the German Institute for Hospital Reimbursement (InEK GmbH). We then retrospectively analysed the major direct costs of aseptic revision THR in terms of contribution margins I and II. The analysis included a total of 114 patients who underwent aseptic revision from 1 January 2009 to 31 March 2012. Data were retrieved from the hospital information system and patient records. All costs of surgery, diagnostic tests, and other treatments were calculated as purchase prices in EUR. The comparative analysis of direct costs and reimbursements was done for DRG I46A and I46B from the hospital's, especially treating department's rather than the society or healthcare insurance's perspective. The average direct cost incurred by the hospital for a THR revision was 4,380.0. The largest share was accounted for surgical costs (62.7 % of total). Implant and staff costs were identified as the most important factors that can be influenced. The proportion of the daily contribution margin that was left to cover the hospital's indirect cost decreased with the relative cost weight of the DRG to which a patient was assigned. Our study for the first time provides a detailed analysis of the major direct case costs of THR revision for aseptic loosening from the provider's perspective. Our findings suggest that these revision operations could be performed cost-beneficially by the operating unit. From an economic perspective, cases with higher cost weights are more favorable for a hospital. These results need to be confirmed in multicenter studies.
    Archives of Orthopaedic and Trauma Surgery 01/2014; · 1.36 Impact Factor
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    ABSTRACT: The number of septic and aseptic total hip replacements (THR) revisions will increase, which involves a greater financial burden. We here provide a retrospective consecutive analysis of the major variable direct costs involved in revision THA for aseptic and septic failure. A total of 144 patients (30 septic, 114 aseptic) treated between Jan. 1, 2009 and March 31, 2012 was included. The management of septic THR loosening is much more expensive than that of aseptic loosening ($14,379.8 vs. $5,487.4). This difference is mainly attributable to the two-stage exchange technique used for septic failure (hospital stay: 40.2 vs. 15.6 days) and significantly higher implant costs ($3,930.9 vs. $2,298.2). The septic implantation part is on average $3,384.6 more expensive than aseptic procedures (p < .001).
    The Journal of arthroplasty 01/2014; · 1.79 Impact Factor
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    ABSTRACT: Societal cost-of-illness in a German sample of patients with borderline personality disorder (BPD) was calculated for 12 months prior to an outpatient Dialectical Behavior Therapy (DBT) program, during a year of DBT in routine outpatient care and during a follow-up year. We retrospectively assessed resource consumption and productivity loss by means of a structured interview. Direct costs were calculated as opportunity costs and indirect costs were calculated according to the Human Capital Approach. All costs were expressed in Euros for the year 2010. Total mean annual BPD-related societal cost-of-illness was €28,026 (SD = €33,081) during pre-treatment, €18,758 (SD = €19,450) during the DBT treatment year for the 47 DBT treatment completers, and €14,750 (SD = €18,592) during the follow-up year for the 33 patients who participated in the final assessment. Cost savings were mainly due to marked reductions in inpatient treatment costs, while indirect costs barely decreased. In conclusion, our findings provide evidence that the treatment of BPD patients with an outpatient DBT program is associated with substantial overall cost savings. Already during the DBT treatment year, these savings clearly exceed the additional treatment costs of DBT and are further extended during the follow-up year. Correspondingly, outpatient DBT has the potential to be a cost-effective treatment for BPD patients. Efforts promoting its implementation in routine care should be undertaken.
    Behaviour Research and Therapy. 01/2014;
  • Moritz Fehrle, Marc P. Philipp, Steffen Flessa
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    ABSTRACT: Eine Grundlage für herausragende Forschungsergebnisse in der Biomedizin bildet der Zugang zu hochentwickelten und investitionsintensiven Technologieplattformen (Haley 2011). Dem steht ein zunehmender Kostendruck in der öffentlichen Forschung gegenüber. Als ein Lösungsansatz in diesem Spannungsfeld haben öffentliche Forschungseinrichtungen Core Facilities etabliert. Diese lassen sich als zentralisierte, kollektiv genutzte Organisationseinheiten definieren, die den Wissenschaftlern Forschungsgroßgeräte, wissenschaftliche Dienstleistungen und spezielle Expertise zur Verfügung stellen (Farber/Weiss 2011).
    Wissenschaftsmanagement - Zeitschrift für Innovation. 12/2013; 19(6):40-43.
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    Jörg G Heinsohn, Steffen Flessa
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    ABSTRACT: Pharmaceutical products are an important component of expenditure on public health insurance in the Federal Republic of Germany. For years, German policy makers have regulated public pharmacies in order to limit the increase in costs. One reform has followed another, main objective being to increase competition in the pharmacy market. It is generally assumed that an increase in competition would reduce healthcare costs. However, there is a lack of empirical proof of a stronger orientation of German public pharmacies towards competition thus far. This paper analyses the self-perceptions of owners of German public pharmacies and their orientation towards competition in the pharmacy markets. It is based on a cross-sectional survey (N = 289) and distinguishes between successful and less successful pharmacies, the location of the pharmacies (e.g. West German States and East German States) and the gender of the pharmacy owner. The data are analysed descriptively by survey items and employing bivariate and structural equation modelling. The analysis reveals that the majority of owners of public pharmacies in Germany do not currently perceive very strong competitive pressure in the market. However, the innovativeness of the pharmacist is confirmed as most relevant for net revenue development and the profit margin. Some differences occur between regions, e.g. public pharmacies in West Germany have a significantly higher profit margin. This study provides evidence that the German healthcare reforms aimed at increasing the competition between public pharmacies in Germany have not been completely successful. Many owners of public pharmacies disregard instruments of active customer-orientated management (such as customer loyalty or an offensive position) and economies of scale), which could give them a competitive advantage. However, it is clear that those pharmacists who strive for systematic and innovative management and adopt an offensive and competitive stance are quite successful. Thus, pharmacists should change their attitude and develop a more professional business model.
    BMC Health Services Research 10/2013; 13(1):407. · 1.77 Impact Factor
  • Steffen Fleßa, Olav Götz
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    ABSTRACT: Gesundheitsmanagement ist ein relativ neues Fach im Kanon der Speziellen Betriebswirtschaftslehren. Im engeren Sinne bezeichnet das Gesundheitsmanagement eine Branchenlehre, d. h. die Betriebswirtschaftslehre des Gesundheitswesens. Im weiteren Sinne ist das Gesundheitsmanagement die Wissenschaft der Steuerung von Gesundheitssystemen. Dies umfasst sowohl alle Institutionen als auch alle Prozesse, die letztlich der Verbesserung, Erhaltung oder Wiederherstellung der Gesundheit einer Bevölkerung dienen. Gesundheitsmanagement hat dabei stets die Intention, das System nicht nur zu verstehen oder zu bewerten, sondern zielsystemkonform zu gestalten.
    Wist - Wirtschaftswissenschaftliches Studium. 09/2013; 42(9):478-484.
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    ABSTRACT: The Health Care sector in general and the hospitals and outpatient departments in special have faced many challenges over the last years. Economic analyses of the processes inside the hospital systems like patient flow, pathways, workflow or utilization of resources are getting more and more into the focus. We constructed a stochastic discrete-event simulation model to represent the cataract intervention. The model is based on empirical data, gathered in a time study (2nd of May until 30th of May 2011). We verified and validated the basic model by using animation, tracing and debugging, interviews or testing against historical data. Afterwards we analyzed the effects of changes to that model by including several scenarios with different policies, e.g. different appointment policy or new personnel. The results of the simulation model showed that it was possible to represent the patient flow of a cataract intervention in the basic model including the corresponding times close to the observed times of the real system. Furthermore, changing the input variables represented through different scenarios showed effects on the total times in system, waiting times, times in operation and on the utilization rates of the personnel and locational resources. For example it was possible to reduce the utilization of the operation theatre by 22.72 % in comparison to the basic model by adding one additional physician in the preparation room. The strength of our study is the use of real empirical data. This approach will be incorporated in further investigations by including the costs of resources, personnel and locations, to the simulation model or widen the focus to other interventions in a hospital or outpatient department. This will lead to a deeper understanding of the patient treatment processes and help to focus on the success of a hospital and its outpatient departments in the future. We conclude that Simulation provides a powerful tool to monitor the important questions inside the health care sector. It helps to analyze processes and can support decisions of the involved policymakers.
    Recent Research on Health Care Management; 05/2013
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    ABSTRACT: OBJECTIVES: Real costs of teleradiology services have not been systematically calculated. Pricing policies are not evidence-based. This study aims to prove the feasibility of performing an original cost analysis for teleradiology services and show break-even points to perform cost-effective practice. METHODS: Based on the teleradiology services provided by the Greifswald University Hospital in northeastern Germany, a detailed process analysis and an activity-based costing model revealed costs per service unit according to eight examination categories. The Monte Carlo method was used to simulate the cost amplitude and identify pricing thresholds. RESULTS: Twenty-two sub-processes and four staff categories were identified. The average working time for one unit was 55 (x-ray) to 72 min (whole-body CT). Personnel costs were dominant (up to 68 %), representing lower limit costs. The Monte Carlo method showed the cost distribution per category according to the deficiency risk. Avoiding deficient pricing by a likelihood of 90 % increased the cost of a cranial CT almost twofold as compared with the lower limit cost. CONCLUSIONS: Original cost analysis is possible when providing teleradiology services with complex statutory requirements in place. Methodology and results provide useful data to help enhance efficiency in hospital management as well as implement realistic reimbursement fees. KEY POINTS: • Analysis of original costs of teleradiology is possible for a providing hospital • Results discriminate pricing thresholds and lower limit costs to perform cost-effective practice • The study methods represent a managing tool to enhance efficiency in providing facilities • The data are useful to help represent telemedicine services in regular medical fee schedules.
    European Radiology 04/2013; · 4.34 Impact Factor
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    ABSTRACT: Aim: Review of the relevance of time studies in the German hospital industry. Method: Based on extensive experience in the field of time studies this paper gives an overview of the major fields of application and the methodology of time-taking and statistical analysis of the retrieved data. Results: Time studies are employed in German hospitals in order to retrieve data for cost accounting and process simulation. In particular the stochastic simulations require professional fitting of distributions with a structured procedure. Generally, skewed and flexible distributions seem to be most suitable. Conclusion: Increasing cost pressure leads to a growing importance of time studies in the hospitals. This should be reflected in respective Training programs.
    Gesundheitsökonomie &amp Qualitätsmanagement 12/2012; 10.1055/s-0032-1325601:23-30.
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    ABSTRACT: BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) infections represent a serious challenge for health-care institutions. Rapid and precise identification of MRSA carriers can help to reduce both nosocomial transmissions and unnecessary isolations and associated costs. The practical details of MRSA screenings (who, how, when and where to screen) remain a controversial issue. METHODS: Aim of this study was to determine which MRSA screening and management strategy causes the lowest expected cost for a hospital. For this cost analysis a decision analytic cost model was developed, primary based on data from peer-reviewed literature. Single and multiplex sensitivity analyses of the parameters "costs per MRSA case per day", "costs for pre-emptive isolation per day", "MRSA rate of transmission not in isolation per day" and "MRSA prevalence" were conducted. RESULTS: The omission of MRSA screening was identified as the alternative with the highest risk for the hospital. Universal MRSA screening strategies are by far more cost-intensive than targeted screening approaches. Culture confirmation of positive PCR results in combination with pre-emptive isolation generates the lowest costs for a hospital. This strategy minimizes the chance of false-positive results as well as the possibility of MRSA cross transmissions and therefore contains the costs for the hospital. These results were confirmed by multiplex and single sensitivity analyses. Single sensitivity analyses have shown that the parameters "MRSA prevalence" and the "rate of MRSA of transmission per day of non-isolated patients" exert the greatest influence on the choice of the favorite screening strategy. CONCLUSIONS: It was shown that universal MRSA screening strategies are far more cost-intensive than the targeted screening approaches. In addition, it was demonstrated that all targeted screening strategies produce lower costs than not performing a screening at all.
    BMC Health Services Research 12/2012; 12(1):438. · 1.77 Impact Factor
  • Michael Simon, Daniel W. Tsegai, Steffen Fleßa
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    ABSTRACT: The tremendous human resource and economic burden of HIV/AIDS, malaria and diarrhoeal diseases is well acknowledged in many developing countries. Most of these diseases have multifaceted causes such as malnutrition, the consumption of contaminated water or poor education. Thus, cross-sectoral action is needed to lower the burden of disease in the long run.However, little has been done to investigate the causal relationship between investments in ‘health related’ sectors and the reduction of disease prevalence. This paper aims at analysing the marginal health returns to cross-sectoral government spending for the case of Tanzania. For this, the normative assumption is to maximise the amount of Disability Adjusted Life Years (DALYs) averted per dollar invested. A Simultaneous Equation Model (SEM) is developed to estimate the required elasticities. The results of the quantitative analysis show that the highest returns on DALYs are obtained by improved nutrition and access to safe water sources, followed by sanitation. Looking at the impact of indirect factors, the health effect of investments in mother education exceeds the effect of additional short- and long-term public spending on water.
    12/2012;
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    ABSTRACT: BACKGROUND: The AGnES-concept (AGnES: GP-supporting, community-based, e-health-assisted, systemic intervention) was developed to support general practitioners (GPs) in undersupplied regions. The project aims to delegate GP-home visits to qualified AGnES-practice assistants, to increase the number of patients for whom medical care can be provided. This paper focuses on the effect of delegating GP-home visits on the total number of patients treated. First, the theoretical number of additional patients treated by delegating home visits to AGnES-practice assistants was calculated. Second, actual changes in the number of patients in participating GP-practices were analyzed. METHODS: The calculation of the theoretical increase in the number of patients was based on project data, data which were provided by the Association of Statutory Health Insurance Physicians, or which came from the literature. Setting of the project was an ambulatory healthcare centre in the rural county Oberspreewald-Lausitz in the Federal State of Brandenburg, which employed six GPs, four of which participated in the AGnES project. The analysis of changes in the number of patients in the participating GP-practices was based on the practices' reimbursement data. RESULTS: The calculated mean capacity of AGnES-practice assistants was 1376.5 home visits/year. GPs perform on average 1200 home visits/year. Since home visits with an urgent medical reason cannot be delegated, we included only half the capacity of the AGnES-practice assistants in the analysis (corresponding to a 20 hour-work week). Considering all parameters in the calculation model, 360.1 GP-working hours/year can be saved. These GP-hours could be used to treat 170 additional patients/quarter year. In the four participating GP-practices the number of patients increased on average by 133 patients/quarter year during the project period, which corresponds to 78% of the theoretically possible number of patients. CONCLUSIONS: The empirical findings on the potential to increase the number of patients in GP-practices through delegation of tasks come close to the theoretical calculations. Differences between the calculated and the real values may be due to differences in the age and mortality distribution of the patients. The results indicate that a support system based on practice assistants can alleviate the consequences of GP-shortages in rural areas.
    BMC Health Services Research 10/2012; 12(1):355. · 1.77 Impact Factor
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    ABSTRACT: The aim of this study is to examine whether rapid polymerase chain reaction (PCR)-based screening is a cost-efficient tool to optimize pre-emptive antibiotic therapy of methicillin-resistant and methicillin-sensitive Staphylococcus aureus (MRSA and MSSA, respectively) infections. A decision analytic cost model was developed, based on data from the peer-reviewed literature. Sensitivity analyses were undertaken to investigate the impact of variation in the MRSA rate, cost ratio of the cost of inappropriate antibiotic therapy to the cost of appropriate antibiotic therapy, PCR test cost, and total hospital costs per case. At a current MRSA rate of 24.5 % in Germany, PCR-guided treatment regimens are cost-efficient compared to empirical strategies. The costs of alternative treatment strategies differ, on average, up to 1,780 per case. An empirical MRSA treatment strategy is least costly when the cost ratio is less than 1.06. When the total hospital cost per MRSA case is increased, pre-emptive MSSA treatment with PCR tests achieves the lowest average cost. Early verification and adaptation of an initial pre-emptive antibiotic treatment of S. aureus infections using PCR-based tests are advantageous in Germany and other European countries. PCR tests, accordingly, should be considered as elements in antimicrobial stewardship programs.
    European Journal of Clinical Microbiology 06/2012; 31(11):3065-72. · 3.02 Impact Factor
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    ABSTRACT: In recent years, decisions regarding the treatment of individual patients have increasingly been affected by economic considerations. The G-DRG system reimburses sledge endoprosthetic implantations at a much lower rate than surface replacements and at significantly different cost weights (CW). Therefore, when only G-DRG payments are considered, TKA produces higher gains. Taking only these revenues alone into consideration, however, does not provide the basis of an economically sound decision-making process. The target of this research was to present a comparison between variable costs of the two procedures. The mean cost and performance data of 28 Endo-Modell (Link company) sledge implantations (UKS) and of 85 NexGen CR surface replacement total knee arthroplasties (TKA; Zimmer company) were compared in 2007. From the perspective of the hospital, UKS treatment is of greater economic advantage when the medical indication is given. In preferring UKS marginal contribution can be improved, and although the relative weighting is comparatively low, the costs are significantly lower than in a comparative analysis of TKA. Based on the length of stay required for each procedure the average daily CW for UKS can be calculated as 0.1728, while being 0.1955 for TKA. The earlier release of the first patient results in another patient being admitted 1.5 days earlier and thus an increase in case mix. Meanwhile, the case-mix index and the costs of care per case decrease ceteris paribus. Assuming the correct medical indication, the hospital seeking to maximize its marginal contribution would be wise to select sledge endoprosthesis implantation. Considering the economic perspective of gains and costs, the assumption that TKA is advantageous could not be confirmed in the present study.
    Archives of Orthopaedic and Trauma Surgery 05/2012; 132(8):1165-72. · 1.36 Impact Factor
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    ABSTRACT: BACKGROUND: The provision of appropriate medical and nursing care for people with dementia is a major challenge for the healthcare system in Germany. New models of healthcare provision need to be developed, tested and implemented on the population level. Trials in which collaborative care for dementia in the primary care setting were studied have demonstrated its effectiveness. These studies have been conducted in different healthcare systems, however, so it is unclear whether these results extend to the specific context of the German healthcare system. The objective of this population-based intervention trial in the primary care setting is to test the efficacy and efficiency of implementing a subsidiary support system on a population level for persons with dementia who live at home. Methods and study design The study was designed to assemble a general physician-based epidemiological cohort of people above the age of 70 who live at home (DelpHi cohort). These people are screened for eligibility to participate in a trial of dementia care management (DelpHi trial). The trial is a cluster-randomised, controlled intervention trial with two arms (intervention and control) designed to test the efficacy and efficiency of implementing a subsidiary support system for persons with dementia who live at home. This subsidiary support system is initiated and coordinated by a dementia care manager: a nurse with dementia-specific qualifications who delivers the intervention according to a systematic, detailed protocol. The primary outcome is quality of life and healthcare for patients with dementia and their caregivers. This is a multidimensional outcome with a focus on four dimensions: (1) quality of life, (2) caregiver burden, (3) behavioural and psychological symptoms of dementia and (4) pharmacotherapy with an antidementia drug and prevention or suspension of potentially inappropriate medication. Secondary outcomes include the assessment of dementia syndromes, activities of daily living, social support health status, utilisation of health care resources and medication. DISCUSSION: The results will provide evidence for specific needs in ambulatory care for persons with dementia and will show effective ways to meet those needs. Qualification requirements will be evaluated, and the results will help to modify existing guidelines and treatment paths. Trial registration NCT01401582.
    Trials 05/2012; 13(1):56. · 2.21 Impact Factor

Publication Stats

350 Citations
120.53 Total Impact Points

Institutions

  • 2005–2014
    • University of Greifswald
      • • Faculty of Law and Economics
      • • Institute of Diagnostic Radiology and Neuroradiology
      • • Institute of Hygiene and Environmental Medicine
      • • Department of Preventive and Pediatric Dentistry
      Griefswald, Mecklenburg-Vorpommern, Germany
    • Friedrich Loeffler Institute
      Griefswald, Mecklenburg-Vorpommern, Germany
  • 2011
    • Deutsches Zentrum für Neurodegenerative Erkrankungen
      Bonn, North Rhine-Westphalia, Germany
    • University of Malaya
      • Department of Social Preventive Medicine
      Kuala Lumpur, Kuala Lumpur, Malaysia
  • 2004–2009
    • Universität Heidelberg
      • Institute of Public Health
      Heidelburg, Baden-Württemberg, Germany
  • 2000
    • Fachhochschule der Wirtschaft
      Paderborn, North Rhine-Westphalia, Germany