Journal articles on the topic 'Insurance (Sickness), Germany'

Frederick Ludwig Hoffman, statistician and insurance executive, was a formidable opponent of the emerging welfare state during the Progressive Era. As a vice president of the Prudential Insurance Company of Newark, New Jersey, Hoffman led a relentless campaign against proposals for government-ran compulsory health insurance between 1915 and 1920. While he acted in the interests of his insurance company employer, Hoffman's opposition also arose from his ardent beliefs about the nature of welfare states. Social insurance and other forms of state-organized assistance, Hoffman claimed, represented “alien governmental theories” based on “paternalism and coercion,” especially since they originated in autocratic Germany, where in 1885 Chancellor Otto von Bismarck had created the world's first sickness insurance system. “In so far as our right to oppose compulsory health insurance is concerned,” explained Hoffman, “it [is] the duty of every American to oppose German ideas of government control and state socialism.” In the anti-German atmosphere engendered by the First World War, his arguments had particular resonance.

Abstract In many countries, competition among health plans or sickness funds raises issues of risk selection. Funds may discourage or encourage potential enrollees from joining, and these actions may have efficiency or fairness implications. This article reviews the experience in the U.S., and comments on the evidence for risk selection in Germany. There is little evidence that risk selection causes efficiency problems in Germany, but risk selection does lead to an inequality in contribution rates. A simple approach to equalizing contribution rates that does not involve risk adjustment is presented and discussed.

Abstract: In Germany, there is a lively debate on a so-called „two-class-medicine“, meaning that privately insured persons get better medical treatment than sickness fund members. As an economist, the author is not in a position to judge whether this is true. However, the co-existence of social and private health insurance (GKV and PKV) constitutes a „two-class-health insurance“, which leads to severe inequities in the distribution of the financial burden of illness. In this article it is shown that there are legal ways to address and eliminate these inequities without abolishing the private health insurance system altogether. The instruments are the inclusion of private health insurance in the risk adjustment scheme of the sickness funds and the transformation of the GKV contributions into flat per-person amounts, independent of earnings, accompanied by a tax-financed compensation for families with below-average income, as in Switzerland and the Netherlands. Interestingly, this second reform proposal has been vigorously opposed by all leftist parties ever since, who fight for the chimaera of a „people's insurance“, which sounds good but cannot be implemented in a legal way and, moreover, would not even eliminate „two-class-medicine“.

Germany is generally regarded as a case of qualitative “change” in minimum income protection (MIP) schemes, while Sweden is perceived as one of institutional “inertia”. This paper seeks to qualify this view by embedding developments in MIP in wider policy and governance trends. Empirically, it is based on document analysis and qualitative expert interviews in the two countries. Theoretically, the paper applies recent institutional approaches that address patterns of change in more complex ways. In Sweden, an exclusive focus on formal continuity regarding social assistance would disguise its change in function from temporary security system of last resort into one that permanently provides income protection when neighboring policy fields, unemployment and sickness insurance, are downsized. Conversely, in Germany a merger of social assistance and unemployment assistance took place. Yet an exclusive focus on the Hartz reforms would downplay the degree of continuity that nevertheless exists in the unemployment insurance.

Abstract Introduction Perianal fistulas (PF) are presumably a frequent extraintestinal manifestation of Crohn’s disease (CD), causing significant functional impairment. This study aims to gain representative data on the prevalence, characteristics, and treatment of CD patients suffering from PF in Germany. Materials and methods A retrospective cross-sectional analysis of claims data from several German company health insurance funds included adult patients with CD and PF in 2015. The dataset comprised in- and outpatient services with diagnoses, drug prescriptions, and other patient data. It is representative for age, gender, and region and allows extrapolation to the total German statutory health insurance (SHI) population. A systematic literature review was conducted to discuss these results in the international context. Results A CD prevalence of 299 per 100 000 and a PF prevalence in CD patients of 3.4 % was observed in this cross-sectional study. PF are most prevalent in young age groups (< 24 to 39). One-third of patients with PF received biologics and surgery. Surgical procedures were performed in 31.3 % of PF patients in the inpatient setting and in 4.4 % of PF patients in the outpatient setting. All complicated perianal fistula patients received at least 1 inpatient surgery and 44.8 % received biologic therapy. Discussion This claims data analysis in German patients estimates a CD prevalence in the SHI population that corresponds well to previously reported data. The prevalence rate for PF in CD patients is comparable with a previous cross-sectional German claims data analysis but is markedly lower than cumulative risks reported in longitudinal cohort studies. PF patients are young and treatment intensive with one-third requiring biologic treatment or inpatient surgery.

The law on civil liability and civil procedure in force in Germany are in general designed to deal with the compensation of individual harm, and may not deal so adequately with mass torts. Because of this in many areas a corresponding reform of or addition to the legal rules is required. The law on civil liability is primarily called upon to provide the basis for an appropriate compensation for damage. A failure to satisfy this function should not therefore be accepted. Nor is this fundamental mission affected by the fact that the compensation for damage, which is determined by the rules of civil liability, in many areas intersects with systems for collective insurance and collecting measures for dealing with damage, such as for example liability, sickness and social insurance; for even in these cases as soon as one deals with the subrogated claim against the defendant, reference is made to the normal rules of civil liability, so that these must contain rules appropriate to mass torts.

Objectives: Interest in the composition of the health care menu has grown. Its outwardly comprehensive nature is as rhetorical as the slogans of universal access and affordability. This paper summarizes the international part of a report to the Swiss government, in which we explored the basic package of services covered by social health insurance in France, Germany, Israel, Luxembourg, The Netherlands and Switzerland. The aim of the initial report was to check the appropriateness of the Swiss catalogue, with special attention to the risk of unequal access to health care by rationing of effective services. In this paper, we highlight the major differences in service coverage between the countries and address the possible factors explaining those differences. Methods: The contents of the basic packages of the six countries were compared using data from government ministries and sickness funds. Results: Coverage is most comprehensive in Germany and Switzerland; these are also the countries with the greatest total health expenditure. Three countries separated nursing care from other types of health care by creating an independent insurance scheme. Some health care benefits are also covered under the heading of social care. High out-of-pocket payments are increasingly used as hidden rationing instruments. Conclusions: The present comparison highlights the multi-factorial character of the choices made in six countries in order to keep their health care menu within the possibilities offered by available resources.

Real-world evidence in multiple sclerosis (MS) is limited by the availability of data elements in individual real-world datasets. We introduce a novel, growing database which links administrative claims and medical records from an MS patient management system, allowing for the complete capture of patient profiles. Using the AOK PLUS sickness fund and the Multiple Sclerosis Documentation System MSDS3D from the Center of Clinical Neuroscience (ZKN) in Germany, a linked MS-specific database was developed (MSDS-AOK PLUS). Patients treated at ZKN and insured by AOK PLUS were recruited and asked for informed consent. For linkage, insurance IDs were mapped to registry IDs. After the deletion of insurance IDs, an anonymized dataset was provided to a university-affiliate, IPAM e.V., for further research applications. The dataset combines a complete record of patient diagnoses, treatment, healthcare resource use, and costs (AOK PLUS), with detailed clinical parameters including functional performance and patient-reported outcomes (MSDS3D). The dataset currently captures 500 patients; however, is actively expanding. To demonstrate its potential, we present a use case describing characteristics, treatment, resource use, and costs of a patient subsample. By linking administrative claims to clinical information in medical charts, the novel MSDS-AOK PLUS database can increase the quality and scope of real-world studies in MS.

Abstract Background Ulcerative colitis (UC) is a chronic inflammatory bowel disease that requires continuous medical treatment. Current epidemiological data about UC in Germany are lacking, and in particular, it is unknown how many patients are treated with advanced therapies. This study aimed to investigate the prevalence and incidence of UC in Germany and describe the frequency of advanced therapy use in this population. Methods We used claims data from a regional German sickness fund (AOK PLUS). Continuously insured persons from 01/01/2015 until 31/12/2019 or death with at least 2 outpatient diagnoses documented by a specialist in 2 quarters within 12 months or one inpatient diagnosis (ICD-10: K51.-) were defined to be UC prevalent. Patients were defined to be incident in 2019 if the respective selection criteria could be observed in 2019, but no UC diagnosis was documented in the previous 4 years. Age- and gender-standardized point prevalence was calculated on 01/01/2019, cumulative incidence was evaluated for the year 2019. Standardization was based on the age/gender distribution within the entire population of the German statutory insurance (KM-6 statistic), which covers about 90% of the whole German population. Main characteristics and comorbidity status were assessed at the index date based on diagnoses documented in the 12-month pre-index period (index: 01/01/2019 or date of incident diagnosis in 2019). The proportion of prevalent patients receiving advanced therapies (infliximab, adalimumab, golimumab, vedolizumab, tofacitinib) was evaluated in 2019, considering both out- and inpatient treatments. Results The standardized incidence in 2019 was 0.36 cases/1,000 persons. Incident patients were, on average, 59.7 years old (SD: 21.6; 95% CI: 58.2–61.1), and 56.1% were females. The mean Charlson Comorbidity Index (CCI) was 2.7 (SD: 3.1; 95% CI: 2.5–2.9). The standardized prevalence at 01/01/2019 was 5.29 cases/1,000 persons. In 2019, 12,736 prevalent patients were observed (12,510.8 person-years), with 56.2% of the patients being female. The mean age was 60.6 years (SD: 18.8; 95% CI: 60.2–60.9), and the mean CCI was 2.3 (SD: 2.8; 95% CI: 2.2–2.3). 827 patients (6.5%) were treated with advanced therapy in 2019. These patients were considerably younger (44.9 (95% CI: 43.9–46.0) versus 61.7 years (95% CI: 61.3–62.0)) and less comorbid (CCI: 1.2 (95% CI: 1.0–1.3) vs. 2.4 (95% CI: 2.3–2.4)) than patients who have not been treated with an advanced therapy. Conclusion Our analysis showed a considerable UC incidence and a high disease burden in Germany, with a prevalence surpassing 0.5%. Advanced therapies were prescribed only in a minority of UC patients, who were generally younger and less comorbid.

Abstract Background Ulcerative Colitis (UC) is a chronic inflammatory condition, which significantly impacts patients’ health-related quality of life and burdens healthcare budgets. Our objective was to provide an overview of the healthcare resource use (HCRU) for the treatment of moderate to severe UC in Germany. Methods A retrospective analysis was conducted using claims data from a German sickness fund (AOK PLUS). Patients were included if they had ≥2 outpatient diagnoses in different quarters and/or one inpatient UC diagnosis (ICD-10: K51), were aged ≥18 years and initiated an advanced therapy (anti-TNFs, vedolizumab, tofacitinib) between 01/01/2015-30/06/2019. HCRU associated with UC treatment was assessed in terms of outpatient visits, work-related sick leave days, and UC caused hospitalizations. Direct UC-related costs (inpatient, outpatient and medication costs based on pharmacy sales price at prescription date) were calculated from the perspective of the German statutory health insurance. All patients were followed from the start of treatment until the end of the study period, or loss to follow-up. In case of treatment discontinuation or change of index therapy, patient follow-up was censored 90 days after the last prescription of index therapy. UC-related HCRU and cost were reported per observable patient-year (PY) and stratified according to prior use of advanced therapies (naïve vs. experienced). Results 574 patients were included (adalimumab: 230, infliximab: 172, golimumab: 56, vedolizumab: 113, tofacitinib: 3). Mean age was 41.9 years; 53.5% were female. On average, 2.5 outpatient visits per PY were billed by general practitioners and 1.4 by gastroenterologists. 27.0% of patients had at least one UC-related hospitalization (mean length of stay: 11.2 days). The mean number of documented UC-related sick leave days amounted to 13.1 per PY. HCRU was similar in therapy-naïve vs. experienced patients (Table 1). Inpatient costs for any cause amounted on average to €4,522/PY, with UC accounting for €3,190/PY (70.5%). Total UC costs amounted to €34.068/PY (Table 2). Expenses for prescribed UC-related drugs amounted to €28,885/PY (95.6% of total drug costs), and outpatient treatment to €511/PY with only €123/PY for Gastroenterologists’ visits (0.4% of total UC-costs/PY). In addition, indirect cost resulting from sick leave due to UC were estimated at €2,979/PY. Conclusion Our study indicates a high economic burden in UC patients who initiated treatment with advanced therapies. UC-related medication was identified as the main cost driver. Furthermore, a substantial proportion of UC patients required hospitalization in the first 12 months after starting new advanced therapy.

By the mid nineteenth century, German miners relied on their own job-related social insurance scheme providing them with sickness, invalidity and survivorship insurance benefits. Addressing the period from 1867 to 1913, this article investigates whether the mineworkers' insurance funds, the Knappschaften, could effectively minimise their exposure to the actuarial risk inherent in their operations – and, in fact, inherent in all such insurance schemes – by increasing the scale of pooling. Contemporary observers of the Knappschaften tended to focus on whether financial stability could be improved by exploiting economies of scale, rather than by improving the pricing techniques themselves. Evidence suggests that actuarial risk was minimised at around 5,000 contributors in a Knappschaft's pension insurance section and at about 1,000 contributors in its sickness insurance section.

ABSTRACTThis study identifies the general structural, political and institutional configurations which conditioned the emergence of national health insurance in Finland. Due to late industrialisation, the Finnish case allows the evaluation of the importance of the agrarian versus working class interests in the emergence of the Scandinavian model. The study also seeks to answer how the contending theoretical approaches of the development of the welfare state serve to explain the characteristics of Finnish sickness provisions. After the historical overview, the results of the historical processes are examined by comparing the quality of Finnish sickness insurance with the Swedish, German and British cases, each representing different ideal types of the modern welfare state.

TheKnappschaftwas a mutual association through which German miners insured themselves against accident, illness, and old age. TheKnappschaftunderlies Bismarck's sickness and accident insurance legislation, and thus Germany's system today. This article focuses on moral hazard, which plagued theKnappschaftenin the later nineteenth century. Sick pay made it attractive for miners to feign illness that made them unable to work. We outline the moral hazard problem theKnappschaftenfaced as well as the mechanisms they devised to control it, and then use econometric models to demonstrate that those mechanisms were at best imperfect.

Since 1989 there have been enormous changes in all aspects of health policy, and the Former Socialist Economies (FSEs) are facing similar challenges. The general restructuring of politics and economies has resulted in two leading orientations in the transformation of health care systems: the separation of funding and service provision from the state, and the separation of funding and service provision from each other. Many FSEs have already passed legislation establishing a sickness insurance system under a single national funding institution, or a combination of compulsory and voluntary insurance, or a system involving private sector insurance companies in generating compulsory or voluntary health care funding. Due to the peculiarities and specific features of the German health care system, the uncritical intention to implement the “Bismarck model” in the FSEs faces several problems. These can be summarized in one main point: the relative stability of the German health care system, which may be attractive to the FSEs, is based on economic prosperity and on a strong ability to assert the will of the central state institutions; these preconditions are not present in the FSEs.

During the government of Count Eduard Taaffe a series of social laws were enacted in Austria that set maximum hours in factories and mines, placed restrictions on the employment of women and young people, and introduced accident and sickness insurance. With this legislation, Austria obtained a unique position: no other country had both extensive protective labor legislation, including the ”normal workday,” and obligatory sickness and accident insurance for industrial workers on its law books in the early 1890s. Despite this progressive record, social policymaking in the Taaffe era has drawn surprisingly little attention. My article begins to fill this gap. The first section briefly examines the historiography of social legislation to demonstrate that the interpretations of the early development of Austrian social politics in the 1880s have been unduly determined by the ”Bismarckian paradigm.” The second section discusses the models that Austrian legislators in the 1880s used for their social policies. They were influenced not only by German social insurance but also by the Swiss Factory Act of 1877. Austrian politicians thus followed two quite distinct strategies in tackling the ”labor question”: they promoted both protective legislation, which infringed upon the employer's authority to organize production at his own discretion, and social insurance, which involved state interference with the lives of workers outside the workshop or factory. The third section examines the motives of Austrian politicians behind this twofold labor policy by looking into the background and procedures of legislation. The final section offers a tentative assessment of social politics during the Taaffe era.

The Belgian healthcare system has a Bismarck-type compulsory health insurance, covering almost the entire population, combined with private provision of care. Providers are public health services, independent pharmacists, independent ambulatory care professionals, and hospitals and geriatric care facilities. Healthcare responsibilities are shared between the national Ministries of Public Health and Social Affairs, and the Dutch-, French-, and German-speaking Community Ministries of Health. The national ministries are responsible for sickness and disability insurance, financing, determination of accreditation criteria for hospitals and heavy medical care units, and construction of new hospitals. The six sickness and disability insurance funds are responsible for reimbursing health service benefits and paying disability benefits. The system's strength is that care is highly accessible and responsive to patients. However, the healthcare system's size remained relatively uncontrolled until recently, there is an excess supply of certain types of care, and there is a large number of small hospitals. The national government created a legal framework to modernize the insurance system to control budgetary deficits. Measures for reducing healthcare expenditures include regulating healthcare supply, healthcare evaluation, medical practice organization, and hospital budgets. The need to control healthcare facilities and quality of care in hospitals led to formal procedures for opening hospitals, acquiring expensive medical equipment, and developing highly specialized services. Reforms in payment and regulation are being considered. Health technology assessment (HTA) has played little part in the reforms so far. Belgium has no formal national program for HTA. The future of HTA in Belgium depends on a changing perception by providers and policy makers that health care needs a stronger scientific base.

AbstractDue to a multitude of reasons Randomized Control Trials on the basis of so-called “routine data” provided by insurance companies cannot be conducted. Therefore the estimation of “causal effects” for any kind of treatment is hampered since systematic bias due to specific selection processes must be suspected. The basic problem of counterfactual, which is to evaluate the difference between two potential outcomes for the same unit, is discussed. The focus lies on the comparison of the performance of different approaches to control for systematic differences between treatment and control group. These strategies are all based on propensity scores, namely matching or pruning, IPTW (inverse probability treatment weighting) and entropy balancing. Methods to evaluate these strategies are presented. A logit model is employed with 87 predictors to estimate the propensity score or to estimate the entropy balancing weights. All analyses are restricted to estimate the ATT (Average Treatment Effect for the Treated) Exemplary data come from a prospective controlled intervention-study with two measurement occasions. Data contain 35 857 chronically ill insurants with diabetes, congestive heart failure, arteriosclerosis, coronary heart disease or hypertension of one German sickness fund. The intervention group was offered an individual telephone coaching to improve health behavior and slow down disease progression while the control group received treatment as usual. Randomization took place before the insurants’ consent to participate was obtained so assumptions of an RCT are violated. A weighted mixture model (difference-in-difference) as the causal model of interest is employed to estimate treatment effects in terms of costs distinguishing the categories outpatient costs, medication costs, and total costs. It is shown that entropy balancing performs best with respect to balancing treatment and control group at baseline for the first three moments of all 87 predictors. This will result in least biased estimates of the treatment effect.

From its beginning, mankind suffered injuries through falling, fire, drowning and human aggression [1]. Although the frequency and the kinetics modifiy over millennia, trauma continues to represent an important cause of morbidity and mortality even in the modern society [1]. Significant progresses in the trauma surgery were due to military conflicts, which next to social sufferance came with important steps in injuries’ management, further applied in civilian hospitals. The foundation of modern trauma systems was started by Dominique Jean Larrey (1766-1842) during the Napoleonic Rin military campaign from 1792. The wounded who remained on the battlefield till the end of the battle to receive medical care, usually more than 24 hours, from that moment were transported during the conflict with flying ambulances to mobile hospitals. Starting with the First World War, through the usage of antiseptics, blood transfusions, and fracture management, the mortality decreased from 39% in the Crimean War (1853–1856) to 10%. One of the most preeminent figures of the Second World War was Michael DeBakey, who created the Mobile Army Surgical Hospitals (MASH), concept very similar to the Larrey’s unit. In 1941, in England, Birmingham Accident Hospital was opened, specially designed for injured people, this being the first trauma center worldwide. During the Golf War (1990–1991) the MASH were used for the last time, being replaced by Forward Surgical Teams, very mobile units satisfying the necessities of the nowadays infantry [1]. Nowadays, trauma meets the pandemic criteria, everyday 16,000 people worldwide are dying, injuries representing one of the first five causes of mortality for all the age groups below 60 [2]. A recent 12-month analysis of trauma pattern in the Emergency Hospital of Bucharest revealed 141 patients, 72.3% males, with a mean age of 43.52 ± 19 years, and a mean New Injury Severity Score (NISS) of 27.58 ± 11.32 [3]. The etiology was traffic related in 101 (71.6%), falls in 28 (19.9%) and crushing in 7 (5%) cases. The overall mortality was as high as 30%, for patients with a mean NISS of 37.63 [3]. At the scene, early recognition of severe injuries and a high index of suspicion according to trauma kinetics may allow a correct triage of patients [4]. A functional trauma system should continuously evaluate the rate of over- and under-triage [5]. The over-triage represents the transfer to a very severe patient to a center without necessary resources, while under-triage means a low injured patient referred to a highly specialized center. If under-triage generates preventable deaths, the over-triage comes with a high financial and personal burden for the already overloaded tertiary centers [5]. To maximize the chance for survival, the major trauma patients should be transported as rapid as possible to a trauma center [6]. The initial resuscitation of trauma patients was divided into two time intervals: ten platinum minutes and golden hour [6]. During the ten platinum minutes the airways should be managed, the exsanguinating bleeding should be stopped, and the critical patients should be transported from the scene. During the golden hour all the life-threatening lesions should be addressed, but unfortunately many patients spend this time in the prehospital setting [6]. These time intervals came from Trunkey’s concept of trimodal distribution of mortality secondary to trauma, proposed in 1983 [7]. This trimodal distribution of mortality remains a milestone in the trauma education and research, and is still actual for development but inconsistent for efficient trauma systems [8]. The concept of patients’ management in the prehospital setting covered a continuous interval, with two extremities: stay and play/treat then transfer or scoop and run/ load and go. Stay and play, usually used in Europe, implies airways securing and endotracheal intubation, pleurostomy tube insertion, and intravenous lines with volemic replacement therapy. During scoop and run, used in the Unites States, the patient is immediately transported to a trauma center, addressing the immediate life-threating injuries during transportation. In the emergency department of the corresponding trauma center, the resuscitation of the injured patients should be done by a trauma team, after an orchestrated protocol based on Advanced Trauma Life Support (ATLS). The modern trauma teams include five to ten specialists: general surgeons trained in trauma care, emergency medicine physicians, intensive care physicians, orthopedic surgeons, neurosurgeons, radiologists, interventional radiologists, and nurses. In the specially designed trauma centers, the leader of the trauma team should be the general surgeon, while in the lower level centers this role may be taken over by the emergency physicians. The implementation of a trauma system is a very difficult task, and should be tailored to the needs of the local population. For example, in Europe the majority of injuries are by blunt trauma, while in the United States or South Africa they are secondary to penetrating injuries. In an effort to analyse at a national level the performance of trauma care, we have proposed a national registry of major trauma patients [9]. For this registry we have defined major trauma as a New Injury Severity Score higher than 15. The maintenance of such registry requires significant human and financial resources, while only a permanent audit may decrease the rate of preventable deaths in the Romanian trauma care (Figure 1) [10]. Figure 1 - The website of Romanian Major Trauma Registry (http://www.registrutraume.ro). USA - In the United States of America there are 203 level I centers, 265 level II centers, 205 level III or II centers and only 32 level I or II pediatric centers, according to the 2014 report of National Trauma Databank [11]. USA were the first which recognized trauma as a public health problem, and proceeded to a national strategy for injury prevention, emergency medical care and trauma research. In 1966, the US National Academy of Sciences and the National Research Council noted that ‘’public apathy to the mounting toll from accidents must be transformed into an action program under strong leadership’’ [12]. Considerable national efforts were made in 1970s, when standards of trauma care were released and in 1990s when ‘’The model trauma care system plan’’[13] was generated. The American College of Surgeons introduced the concept of a national trauma registry in 1989. The National Trauma Databank became functional seven years later, in 2006 being registered over 1 million patients from 600 trauma centers [14]. Mortality from unintentional injury in the United States decreased from 55 to 37.7 per 100,000 population, in 1965 and 2004, respectively [15]. Due to this national efforts, 84.1% of all Americans have access within one hour from injury to a dedicated trauma care [16]. Canada - A survey from 2010 revealed that 32 trauma centers across Canada, 16 Level I and 16 Level II, provide definitive trauma care [18]. All these centers have provincial designation, and funding to serve as definitive or referral hospital. Only 18 (56%) centers were accredited by an external agency, such as the Trauma Association of Canada. The three busiest centers in Canada had between 798–1103 admissions with an Injury Severity Score over 12 in 2008 [18]. Australia - Australia is an island continent, the fifth largest country in the world, with over 23 million people distributed on this large area, a little less than the United States. With the majority of these citizens concentrated in large urban areas, access to the medical care for the minority of inhabitants distributed through the territory is quite difficult. The widespread citizens cannot be reached by helicopter, restricted to near-urban regions, but with the fixed wing aircraft of the Royal Flying Doctor Service, within two hours [13]. In urban centers, the trauma care is similar to the most developed countries, while for people sparse on large territories the trauma care is far from being managed in the ‘’golden hour’’, often extending to the ‘’Golden day’’ [19]. Germany - One of the most efficient European trauma system is in Germany. Created in 1975 on the basis of the Austrian trauma care, this system allowed an over 50% decreasing of mortality, despite the increased number of injuries. According to the 2014 annual report of the Trauma Register of German Trauma Society (DGU), there are 614 hospitals submitting data, with 34.878 patients registered in 2013 [20]. The total number of cases documented in the Trauma Register DGU is now 159.449, of which 93% were collected since 2002. In the 2014 report, from 26.444 patients with a mean age of 49.5% and a mean ISS of 16.9, the observed mortality was 10% [20]. The United Kingdom - In 1988, a report of the Royal College of Surgeons of England, analyzing major injuries concluded that one third of deaths were preventable [21]. In 2000, a joint report from the Royal College of Surgeons of England and of the British Orthopedic Association was very suggestive entitled "Better Care for the Severely Injured" [22]. Nowadays the Trauma Audit Research network (TARN) is an independent monitor of trauma care in England and Wales [23]. TARN collects data from hospitals for all major trauma patients, defined as those with a hospital stay longer than 72 hours, those who require intensive care, or in-hospital death. A recent analysis of TARN data, looking at the cost of major trauma patients revealed that the total cost of initial hospital inpatient care was £19.770 per patient, of which 62% was attributable to ventilation, intensive care and wards stays, 16% to surgery, and 12% to blood transfusions [24]. Global health care models Countries where is applied Functioning concept Total healthcare costs from GDP Bismarck model Germany Privatized insurance companies (approx. 180 nonprofit sickness funds). Half of the national trauma beds are publicly funded trauma centers; the remaining are non-profit and for-profit private centers. 11.1% Beveridge model United Kingdom Insurance companies are non-existent. All hospitals are nationalized. 9.3% National health insurance Canada, Australia, Taiwan Fusion of Bismarck and Beveridge models. Hospitals are privatized, but the insurance program is single and government-run. 11.2% for Canada The out-of-pocket model India, Pakistan, Cambodia The poorest countries, with undeveloped health care payment systems. Patients are paying for more than 75% of medical costs. 3.9% for India GDP – gross domestic product Table 1 - Global health care models with major consequences on trauma care [17]. Traumas continue to be a major healthcare problem, and no less important than cancer and cardiovascular diseases, and access to dedicated and timely intervention maximizes the patients’ chance for survival and minimizes the long-term morbidities. We should remember that one size does not fit in all trauma care. The Romanian National Trauma Program should tailor its resources to the matched demands of the specific Romanian urban and rural areas.

Abstract Background The COVID-19 pandemic has revealed the importance of social protection systems including income security when health problems arise. Particularly the protection of those with precarious work felt short in some countries. For some time there has been an interest in the European variation in sick-pay schemes but still we still lack knowledge on country differences and similarities. This is particularly the case regarding precarious workers, while they have higher chances for sickness absence. Our aim is to understand, in the context of precarious work, the differences in risk sharing of sickness absence between employer, worker and social insurance. Methods Data had been collected in a study on sickness absence follow-up regimes in nine countries (the Nordic countries (Sweden, Denmark, Finland, Norway and Iceland) and in Germany, the Netherlands, Belgium and the UK). Comparative statistics were collected and scholars familiar with their countries system were invited to answer a list of 51 questions on system characteristics. Data were re-analysed from the perspective of precarious work, using actor-network theory and insider-outsider theory of employment. Results Countries with shorter employer periods of sick pay have stricter follow-up responsibility for employers as they are regarded gatekeeper except for The Netherlands. The tax-based systems that target all citizens offer more protection for precarious workers while the employee-focused systems define their target population more strictly, leaving precarious workers underserved. There is a large difference in how self-employed are supported or not. Conclusions Despite small economic differences in the nine countries studied, the systems for dealing with sickness absence in the context of precarious work vary largely. Even though, in all systems those with secure jobs seem insiders and those with precarious work outsiders. Social protection systems should be updated to avoid an increasing inequality. Speakers/Panellists Anita Tisch Working time and Organization, Federal Institute for Occupational Safety and Health, Dortmund, Germany Angelique De Rijk Department of Social Medicine, Maastricht University, Maastricht, Netherlands

Abstract Background This presentation analyses the dynamics of digital health from a governance perspective. It aims to explore the driving forces for the implementation of digital health in Germany. Germany is chosen as a case study of a social health insurance system, which is based on joint self-governance of sickness funds and providers, and strong corporatist power of the medical profession. Methods A qualitative explorative approach is applied, drawing on document analysis and other secondary sources. The research is based on a governance approach adapted from Glassman and Buse's model of public health policy reform. Results The WHO Global Strategy for Digital Health 2020-2024 serves as a key international policy framework. However, the analysis reveals firstly that implementation is shaped by national healthcare systems and may create different results; secondly, the global strategy provides only a weak guidance on the national level. In Germany, strong corporatism and weak state intervention is supporting market forces and private actors. Poorly developed digital health governance has opened a window of opportunity for market powers as driving forces for digital health, thus creating new risks of social inequalities. There is an urgent need for public health to step up advocacy for health literacy to improve the accessibility to digital health for all citizens. Conclusions National healthcare systems strongly shape the implementation of international digital health frameworks, which makes digital health an issue of governance. Stronger public health orientation and a people-centred approach are needed to counteract new emergent social inequalities created by market power. Key messages Market power and private actors are important drivers of digital health in the German healthcare system. Social health insurance systems may be vulnerable to market powers and new digital health inequalities.

Abstract Purpose The aim of this study was to investigate the burden of disease among a real-world cohort of patients with prevalent Crohn’s disease (CD) in Germany. Methods We conducted a retrospective cohort analysis using administrative claims data from the German AOK PLUS health insurance fund. Continuously insured patients with a CD diagnosis between 01 October 2014 and 31 December 2018 were selected and followed for at least 12 months or longer until death or end of data availability on 31 December 2019. Medication use (biologics, immunosuppressants (IMS), steroids, 5-aminosalicylic acid) was assessed sequentially in the follow-up period. Among patients with no IMS or biologics (advanced therapy), we investigated indicators of active disease and corticosteroid use. Results Overall, 9284 prevalent CD patients were identified. Within the study period, 14.7% of CD patients were treated with biologics and 11.6% received IMS. Approximately 47% of all prevalent CD patients had mild disease, defined as no advanced therapy and signs of disease activity. Of 6836 (73.6%) patients who did not receive advanced therapy in the follow-up period, 36.3% showed signs of active disease; 40.1% used corticosteroids (including oral budesonide), with 9.9% exhibiting steroid dependency (≥ 1 prescription every 3 months for at least 12 months) in the available follow-up. Conclusions This study suggests that there remains a large burden of disease among patients who do not receive IMS or biologics in the real world in Germany. A revision of treatment algorithms of patients in this setting according to the latest guidelines may improve patient outcomes.

Europe is currently witnessing demographic change which, on the one hand, with longer average life expectancy, gives rise to a growing number of seniors in need of long termcare and on the other, with the number of births declining, leads to fewer family members willing to provide such care. The change provokes a question about the most promising and practicable solution strategies to ensure public quality care. The European secondary law coordinating social insurance schemes does not provide for nursing care insurance benefits. The benefits are identified with “sickness allowances” as construed by the said secondary law. Therefore, long-term care risk is in many countries covered partly from health insurance . A separate nursing care insurance still remains rare in Europe. Hence, the possibly most comprehensive social insurance that includes long-term care risk is postulated by multiple environments. Germany introduced a public statute-based nursing care insurance scheme in 1995. It is constantly being developed, which is considered an example to be followed in the international arena. As part of social insurance for farmers, farmers’ nursing care insurance is only different with respect to a few special features, notably contribution provisions. Also this insurance falls under Book XI of the Social Code (SGB XI). Later on, the fundamental structural assumptions defined in § 1 (1–4) and (6) of SGB XI will be investigated in-depth, chiefly from legal perspective. The analysis will follow primarily l and systemic interpretation methods. The following issues will be discussed: separate character of nursing care insurance, role of nursing care insurance, scope of insurance (public insurance), solidarity-based funding and organisation.

Abstract Background As vaccines for COVID-19 became available, many countries introduced an obligation in 2021 for employees to prove their COVID-19 status at work, known in Germany as the 3G rule (vaccinated, recovered, tested). In view of the controversial debate, there was concern that employees might try to avoid providing mandatory COVID-19 certificates by taking sick leave. The aim of this study was to investigate whether mandatory COVID-19 tests in the workplace led to such an evasive response. Method For an empirical panel analysis, we collected data from official sources and combined aggregated health insurance data on sick leave, epidemiological data on laboratory-confirmed COVID-19 infections, and vaccination rates for the German states from September 2021 to January 2022. We used a regional panel data analysis to estimate the impact of the mandatory COVID-19 certificates at the workplace on workers’ sick leave. The regional vaccination rate reflected differences in treatment intensity. Results This study contributes to the limited evidence on the potential impact of introducing mandatory COVID-19 certificates at the workplace on sickness absence rates. In fact, our results showed that after controlling for infection rates, a one percentage point lower vaccination rate led to a 0.021 percentage point increase in the sickness absence rate when the 3G rule came into effect. This effect was measured with high statistical precision. In addition, in robustness checks, we controlled for a number of other possible influencing factors that may have affected sickness behaviours, such as time-varying labour market situations. However, the results remained robust. Conclusions The results of our empirical panel analysis implied that mandatory COVID-19 certificates in the workplace led to evasive responses and to additional days of sick leave of a relevant magnitude. Testing obligations were meant to help contain the epidemic. However, when introducing controversial obligations, it is important to consider evasive responses and to design the rules appropriately and communicate them convincingly.

Abstract Background Opioid Use Disorder (OUD) is a substance use disorder with a chronic course associated with comorbid mental and somatic disorders, a high burden of psychosocial problems and opioid maintenance treatment (OMT) as a standard treatment. In the US, OUD imposes a significant economic burden on society, with annual societal costs estimated at over 55 billion dollars. Surprisingly, in Europe and especially in Germany, there is currently no detailed information on the healthcare costs of patients with OUD. The goal of the present research is to gather cost information about OUD patients in OMT with a focus on maintenance medication and relapses. Methods We analysed health claims data of four million persons covered by statutory health insurance in Germany, applying a cost-of-illness approach and aimed at examining the direct costs of OMT patients in Germany. Patients with an ICD-10 code F11.2 and at least one claim of an OMT medication were stratified into the treatment groups buprenorphine, methadone or levomethadone, based on the first prescription in each of the follow-up years. Costs were stratified for years with and without relapses. Group comparisons were performed with ANOVA. Results We analysed 3165 patient years, the total annual sickness funds costs were on average 7470 € per year and patient. Comparing costs of levomethadone (8400 €, SD: 11,080 €), methadone (7090 €, SD: 10,900 €) and buprenorphine (6670 €, SD: 7430 €) revealed significant lower costs of buprenorphine compared to levomethadone (p < 0.0001). In years with relapses, costs were higher than in years without relapses (8178 € vs 7409 €; SD: 11,622, resp. 10,378 €). In years with relapses, hospital costs were the major cost driver. Conclusions The present study shows the costs of OUD patients in OMT for the first time with a German dataset. Healthcare costs for patients with an OUD in OMT are associated with more than two times the cost of an average German patients. Preventing relapses might have significant impact on costs. Patients in different OMT were dissimilar which may have affected the cost differences.

There is an increasing emphasis on activating workers on sick leave and on using their residual work capacity. This article compares activation via graded-work schemes in Germany, Austria, Switzerland and the Netherlands, with a focus on the role of employers. The analysis of literature sources and survey data reveals an ongoing reform activity, as well as great diversity in terms of employer obligations and incentives in the countries studied. These differences are very consequential for the intensity of employer efforts to activate sick-listed workers, even when comparing countries that otherwise share many institutional features. The distinction between public and privatised systems of sickness insurance, on the contrary, seems to be less relevant for the question of employer participation in activation. The findings are consistent with the expectation that less comprehensive employer participation is correlated with stronger selectivity in activation efforts. Depending on the prevailing approach in the individual countries and on developments to date, policy-makers are confronted with different challenges and priorities.

ContextDigital health applications that support patients in managing their condition can have a positive impact on patients' health and improve the overall care process. In late 2019, as the first country worldwide, Germany included digital health applications in the benefit basket of the statutory health insurance (SHI) system to enable fast, broad-scale patient access and encourage innovation in the digital health industry. While the policy is widely recognized as a pioneering step toward improving patient care through digital technologies, there are concerns regarding the mechanics of the policy and the resulting financial risks for the SHI system.GoalsThe primary objective of this article is to provide a comprehensive and balanced overview of the German policy by evaluating its success in achieving its goals and by reviewing challenges that have emerged. The secondary objective is to delineate prospective policy options and areas warranting future research.ApproachThe article analyzes publicly available data of the Federal Institute for Drugs and Medical Devices collected between February 1st and July 17th, 2023, and complements it with empirical findings published by academic institutions and sickness funds. It discusses policy options and related areas of future research to overcome the identified challenges without jeopardizing the purpose of the legislation to encourage innovation in the digital health industry to improve patient care.ConclusionIn line with the goals of the reimbursement policy, the inclusion of digital health applications in the SHI benefit basked has entailed new digital treatment options for patients across multiple disease areas. However, from a health policy perspective, the policy has several shortcomings, including low prescription rates, the temporary reimbursement of digital health applications that lack proven benefit, and a pricing framework that does not take into account the efficacy and efficiency of a treatment and may lead to a suboptimal allocation of public resources. Rather than the public system covering digital health applications without proven benefit, the authors suggest giving SHI organizations more budget authority to directly incentivize research and development activities and to introduce value-based pricing. More research is needed to determine the details of these mechanisms.

Abstract Background Fabry disease (FD), an X-linked lysosomal storage disorder, is caused by mutations in the gene encoding α-galactosidase A, resulting in lysosomal accumulation of globotriaosylceramide and other glycosphingolipids. Early detection of FD is challenging, accounting for delayed diagnosis and treatment initiation. This study aimed to develop an algorithm using a logistic regression model to facilitate early identification of patients based on ICD-10-GM coding using a German Sickness Fund Database. Methods The logistic regression model was fitted on a binary outcome variable based on either a treated FD cohort or a control cohort (without FD). Comorbidities specific to the involved organs were used as covariates to identify potential FD patients with ICD-10-GM E75.2 diagnosis but without any FD-specific medication. Specificity and sensitivity of the model were optimized to determine a likely threshold. The cut-point with the largest values for the Youden index and concordance probability method and the lowest value for closest to (0,1) was identified as 0.08 for each respective value. The sensitivity and specificity for this cut-point were 80.4% and 79.8%, respectively. Additionally, a sensitivity analysis of the potential FD patients with at least two codes of E75.2 diagnoses was performed. Results A total of 284 patients were identified in the potential FD cohort using the logistic regression model. Most potential FD patients were < 30 years old and female. The identification and incidence rates of FD in the potential FD cohort were markedly higher than those of the treated FD cohort. Conclusions This model serves as a tool to identify potential FD patients using German insurance claims data.

Abstract BACKGROUND AND AIMS Lupus nephritis (LN) is the most common severe manifestation of systemic lupus erythematosus (SLE) and can lead to end-stage renal disease and death. However, there are limited data to contextualize the burden of LN in Germany, with no published studies using national claims data. This cross-sectional study aimed to estimate the annual prevalence of SLE and LN from 2011–17 using claims data from the Betriebskrankenkassen (BKK) German Sickness Fund Database. METHOD For each study year (2011–17), three patient populations were identified using International Classification of Diseases, Tenth Revision, German Modification (ICD-10-GM) codes: (1) Patients with SLE (≥1 SLE inpatient claim or ≥1 outpatient claim with a confirmatory claim in a separate quarter within ± 3 years); (2) Patients with LN, sensitive definition (based on the presence of SLE [as above] with ≥ 1 nephritis claim within ± 1 year from the initial SLE claim) and (3) Patients with LN, specific definition (based on the presence of SLE [as above] with ≥ 2 nephritis claims in separate quarters within ± 1 year from the initial SLE claim). For each year, the annual prevalence of SLE and LN/100 000 was estimated by dividing the number of patients identified in each population by the number of individuals insured in the database in that year. The proportion of SLE patients with LN was also estimated. To estimate the total number of patients with SLE and LN in Germany by age and sex standardization, the German statutory health insurance (SHI) system (covering 87% of the German population) was used to extrapolate from the prevalence calculated in the BKK database. RESULTS Approximately 5 million patients were insured in the BKK database between 2011–17; the ratio of insured males to females was ∼1:1 throughout the study period. The annual prevalence of SLE and LN/100 000 increased from 2011 (SLE, 37.68; LN sensitive, 12.79; LN specific, 9.99) to 2017 (SLE, 54.74; LN sensitive, 19.06; LN specific, 15.16) (Fig. 1). In 2017, the ratio of males to females/100 000 patients was ∼1:5.5 for the SLE cohort, 1:4.5 for the LN-sensitive cohort and 1:4.4 for the LN-specific cohort. The proportion of SLE patients with LN remained consistent across the study period, ranging from 26.51% (specific definition) and 33.96% (sensitive definition) in 2011 to 27.69% and 34.82%, respectively, in 2017. When extrapolating the prevalence estimates to the wider German SHI system, the estimated number of SLE patients was &gt;41 000 in 2017, with the total LN patient population ranging from 11 515 (specific definition) to 14 483 (sensitive definition) (Fig. 2). CONCLUSION The prevalence of LN increased between 2011 and 2017 among patients insured in the BKK database and is estimated to impact &gt;11 000 patients in the wider German SHI system. Limitations include an absence of renal biopsy information and the inability to distinguish patients with active nephritis from those with historical or inactive LN based on clinical parameters. Nonetheless, these data highlight the prevalence of LN among patients with SLE and the need for effective screening and disease management to improve patient outcomes. Further work to understand the treatment and economic burden of LN among patients with SLE in Germany is ongoing.

Abstract Background Up to 27% of the German population suffers from recurrent or persistent pain (lasting more than three months). Therefore, prevention of chronic pain is one major object of pain management interventions. The aim of this nationwide, multicentre, randomised controlled trial is to evaluate the efficacy of a 10-week ambulatory (outpatient) interdisciplinary multimodal pain therapy (A-IMPT) for patients with recurrent pain and at risk of developing chronic pain. This project was initiated by the German Pain Society (Deutsche Schmerzgesellschaft e.V.) and the public health insurance provider BARMER. It is currently funded by the German Innovation Fund (01NVF20023). The study PAIN2.0 focuses on reducing pain intensity and pain-related disability and investigates whether this intervention can improve physical activity, psychological well-being, and health literacy. Methods PAIN2.0 is designed as a multicentre 1:1 randomised controlled trial with two parallel groups (randomisation at the patient level, planned N = 1094, duration of study participation 12 months, implemented by 22 health care facilities nationwide). After 6 months, patients within the control group also receive the intervention. The primary outcomes are pain intensity and pain-related impairment, measured as Characteristic Pain Intensity (PI) and Disability Score (DS) (Von Korff), as well as patient-related satisfaction with the intervention. Secondary outcomes are the number of sick leave days, sickness allowance, treatment costs, psychological distress, health-related quality of life, and catastrophizing. The effects of the intervention will be analysed by a parallel-group comparison between the intervention and control groups. In addition, the long-term effects within the intervention group will be observed and a pre-post comparison of the control group before and after the intervention will be performed. Discussion Recurrent or persistent pain is common in the German population and causes high costs for patients and society. The A-IMPT aims to improve pain and pain-related impairments in pain patients at risk of chronification, thereby reducing the risk of developing chronic pain with its high socioeconomic burden. This new therapy could easily be integrated into existing therapy programs if positively evaluated. Trial registration The trial PAIN2.0 has been registered in the German Clinical Trials Register (DRKS) since 21/11/2022 with the ID DRKS00030773.

Workplace wellness programs raise the question: Who owns the health and sickness of the employee? Once, they belonged to the person and his/her doctor, in a kind of binary health relationship. Now companies have made it a triangular relationship. But actually, it's rectangular - the government is also shaping this relationship by occupying a fourth corner. As Nikolas Rose (1989) points out in his exploration of the place of individual in the corporate state, history suggests that it might be the government whose corner is dominant. Rose notes that "Taylorism", the scientific pursuit of maximum efficiency of human labour which was fashionable early last century, is now seen not just as the creation of industrialists like Henry Ford. Much more broadly, it reflected a philosophy current in the western industrialised nations like the US, UK and Germany. Achieving optimum output from men and machines was "part of a wide family of political programmes that sought to use scientific knowledge to advance national efficiency through making the most productive use of material and human resources." Reflecting prevailing political climates, national governments had already begun to introduce legislation which regulated the relationship between capital and labour. Ostensibly, these laws were intended to protect the rights of workers, but Rose suggests that their ultimate motivation was to ensure the nation received social dividends from the labour market. That was then. Now, social dividends from employment may be different but governments are still pursuing them. It was a labour government in Australia in the 1980s which first required employees to fund their own aged pensions (by trading off pay increases for superannuation). In another manifestation of their worry about the costs of an ageing population, governments are now prodding workers to become their own health managers, through the agency of wellness programs at work. Wellness programs really began to flourish in the last 20 years, most visibly in the Unites States where pressure from the employee health insurance system and high participation targets set by the Federal Government have made them the rule. "As a result, work-site health promotion programs are becoming increasingly prevalent. In 1985, 65 percent of work sites with 50 or more employees offered at least one health promotion activity. The [Government's] Healthy People 2000 goals aim to increase this proportion to 85 percent and to increase employee participation in these programs." (Meurer et al. 1997, p. 384) In other countries, pressure from insurance/litigation may be weaker, but employers have increasingly seen workplaces as suitable locations for health campaigns targeted at their employees, and governments have become supportive of such programs because of the public health benefits and convenience. They might be viewed as privatised community health promotion. In Australasia: "The idea of using workplaces as sites to promote health is attractive from a public health point of view. It provides an opportunity for adults to gain access to health promotion initiatives and enables them to participate in programs planned according to their needs in a familiar physical and social setting. It also provides an opportunity for health promotion efforts to extend to the worker's home and involve his/her family." (Williams 1991, p. 490) From an employer's perspective, workers' sickness has always been a matter of interest because of the duty of care. In the distinctive social environment of work, their health has belonged at least partly to the company, but the wellness programs may be further stripping away the autonomy of health. Moral philosopher R S Downie and his co-writers (1990) believe that health promotion is not value-free. "It endeavours to persuade people to adopt certain lifestyles.") It attempts to transfer to the employees values held by the organisation, promoting a particular lifestyle - in this case, a healthy one. Participation in wellness programs provides benefits which flow in two directions. The company donates the resources which allow the employees to avoid sickness and to live healthier lives. The employees donate a longer and more productive working life to the company and society. In this way, these programs conform with the dominant current management philosophy describing the relationship between employee and employer. Just as Hirschhorn (1988) describes how workers won social freedoms in exchange for psychological "unfreedoms" (the work ethic) in the industrial revolution , so Rose describes how modern, caring management practice is all about "aligning the wishes, needs and aspirations of each individual who works for the organisation with the successful pursuit of its objectives". A win-win situation? In some organisations, some employees may not see it that way. The fact that wellness programs are declared "voluntary" may not necessarily rectify a perception of compulsion. Employees may believe that nothing is truly voluntary at work. With these concerns in mind, Stokols et al. (1995) advocate ethical guidelines to prevent job discrimination based on health status and related potential conflicts of interest. They say that the bottom-line benefits to management of health-promotion campaigns cannot legitimately include discriminating against employees who refuse to make healthy lifestyle choices. Discrimination might exist on another level. What is the company to make of workers who choose to continue an unhealthy lifestyle which may put them at greater risk of a succumbing to a health hazard at work? The most well-known of such consequences is the predisposition to bronchial illness caused by smoking. Of course, there are two sources of sickness at work; self-induced and work-induced. Smoking cigarettes may cause self-induced sickness. Mining asbestos may cause work-induced sickness. If it was once clear who was responsible for which sickness, the advent of workplace wellness programs has reduced the clarity. Such health promotion can make it seem that the employer has taken responsibility for both self-induced and work-induced sickness, or perhaps the worker has. Wellness programs are culturally ambiguous. Their very introduction signifies the employer's care for employees' health, but the function of the program is to teach the employees how to take responsibility for it. So Blewett and Shaw (1995) wonder whether health promotion programs change the balance of responsibility between employer and employee. The origin of this issue, they suggest, is in the World Health Organisation's 1986 Ottawa Charter for Health Promotion, which describes health promotion as "the process of enabling individuals and communities to increase control over the determinants of health and thereby improve their health." (cited in Blewett & Shaw 1995, p. 462) The writers argue that the health promotion rhetoric is increasingly focused on promoting 'self-responsibility' for health in the workplace, and the skills of health self-care. If governments value wellness programs, and business likes them, is the workplace a conducive cultural setting for wellness to be marketed? Do workplace health promotion programs obviate the well-documented communication barriers from which community programs suffer? It seems they might. "Worksites afford a high degree of leverage for influencing the health of the population," according to Stokols et al. (1995, p. 1136) "Leverage" is a reference to the big percentage of the population (the employed) they reach, as well as the power of persuasion in a workplace. The persuasion can derive from the corporate culture which employers strive to create in their organisations - a mono-culture whose values are aligned with those of all members. It can also derive from company rules - all members of the organisation, whether value-sharers or value-rejectors, are captured by the requirement to conform with wellness objectives. Thus, in western industrial democracies, where smoking is banned it is usually because they are places of work. It is necessary to ask the question: Do employees exposed to health promotion at work make good use of self-care skills. Williams (1991) notes that the uptake of health promotion campaigns, not at work but in the broad community, is greatest among those who least need the benefits - that is, it correlates with socio-economic status. Wellness programs in industrial settings provide opportunities for health promotion to reach lower-paid trades and "blue-collar" employees not well served by these community campaigns. However, poor health behaviours are based on life-long habits, usually reinforced by people's lifestyles, reference groups and family structure. These habits take time and persistence to counteract. It is only in the long term that participation gives employees positive benefits, and therefore positive reinforcement for their healthy efforts. Noblet and Murphy (1995, p. 18) report that "early workplace programs relied heavily on behaviour change techniques as their health promotion strategy." Therefore, many failed to produce lasting change because they did not take advantage of the complex social and cultural structure that exists within each workplace. The writers suggest that recently "activities have expanded beyond risk reduction strategies to a settings approach that addresses the social, organisational, environmental and cultural factors." (Noblet and Murphy 1995, p. 18) In conclusion, it is likely that the motivation for companies to run health promotion campaigns will increase, but wellness may be a concept which fits somewhat awkwardly in the employer-employee relationship. Perhaps care for employees is the factor which will bring outcomes beneficial to all. Farnell (1987) expresses such care this way: An organisation's health comprises three components, its financial health, its organisational health (openness, trust, morale, etc) and the personal health of its members. No employer should consider the organisation in good shape without addressing each component. References Blewett, V. and Shaw, A. "Health promotion, handle with care." Journal of Occupational Health and Safety Australia and New Zealand 11 (1995): 461-5. Downie, R., Fyfe, C. and Tannahill, A. Health Promotion - Models and Values, Oxford UP: Oxford,1990. Farnell, L."Corporate culture change - the healthy way." Journal of Occupational Health and Safety Australia and New Zealand 3 (1987): 46-52. Hirschhorn, L. The workplace within: psychodynamics of organizational life. Cambridge, Mass: M.I.T. Press,1988. Leigh, J. and Harrison, J. "Reduction of Ischaemic heart disease risk factors following direct probabilistic risk communication in the workplace.", Journal of Occupational Health and Safety Australia and New Zealand 7 (1991): 467-72. Meurer, L., Meurer, J. and Holloway, R. "New models of health care in the home and in the work site.", American Family Physician 56 (1997): 384-7. Noblet, A.J. and Murphy, C. "Adapting the Ottowa Charter for Health Promotion to the Workplace Setting." Health Promotion Journal of Australia 5 (1995): 18-22. Rose, N. Governing the soul: the shaping of the private self. London: Routledge, 1989. Stokols, D., Pelletier, K. and Fielding, J. "Integration of medical care and worksite health promotion.", Journal of the American Medical Association 273 (1995): 1136-42. Williams, P. 1991, "Planning factors contributing to on-going health promotion programs." Journal of Occupational Health and Safety Australia and New Zealand 7 (1991): 489-94.

Abstract Background Common mental disorders are one of the leading causes for sickness absence and early retirement due to reduced health. Furthermore, a treatment gap for common mental disorders has been described worldwide. Within this study, psychotherapeutic consultation at work defined as a tailored, module-based and work-related psychotherapeutic intervention will be applied to improve mental health care. Methods This study comprises a randomised controlled multicentre trial with 1:1 allocation to an intervention and control group. In total, 520 employees with common mental disorders shall be recruited from companies being located around five study centres in Germany. Besides care as usual, the intervention group will receive up to 17 sessions of psychotherapy. The first session will include basics diagnostics and medical indication of treatment and the second session will include work-related diagnostics. Then, participants of the intervention group may receive work-related psychotherapeutic consultation for up to ten sessions. Further psychotherapeutic consultation during return to work for up to five sessions will be offered where appropriate. The control group will receive care as usual and the first intervention session of basic diagnostics and medical indication of treatment. After enrolment to the study, participants will be followed up after nine (first follow-up) and fifteen (second follow-up) months. Self-reported days of sickness absence within the last 6 months at the second follow-up will be used as the primary outcome and self-efficacy at the second follow-up as the secondary outcome. Furthermore, a cost-benefit assessment related to costs of common mental disorders for social insurances and companies will be performed. Discussion Psychotherapeutic consultation at work represents a low threshold care model aiming to overcome treatment gaps for employees with common mental disorders. If successfully implemented and evaluated, it might serve as a role model to the care of employees with common mental disorders and might be adopted in standard care in cooperation with sickness and pension insurances in Germany. Trial registration The friaa project was registered at the German Clinical Trial Register (DRKS) at 01.03.2021 (DRKS00023049): https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023049.

BackgroundThe Expanded Disability Status Scale (EDSS) quantifies disability and measures disease progression in multiple sclerosis (MS), however is not available in administrative claims databases.ObjectivesTo develop a claims-based algorithm for deriving EDSS and validate it against a clinical dataset capturing true EDSS values from medical records.MethodsWe built a unique linked dataset combining claims data from the German AOK PLUS sickness fund and medical records from the Multiple Sclerosis Management System 3D (MSDS3D). Data were deterministically linked based on insurance numbers. We used 69 MS-related diagnostic indicators recorded with ICD-10-GM codes within 3 months before and after recorded true EDSS measures to estimate a claims-based EDSS proxy (pEDSS). Predictive performance of the pEDSS was assessed as an eight-fold (EDSS 1.0–7.0, ≥8.0), three-fold (EDSS 1.0–3.0, 4.0–5.0, ≥6.0), and binary classifier (EDSS &lt;6.0, ≥6.0). For each classifier, predictive performance measures were determined, and overall performance was summarized using a macro F1-score. Finally, we implemented the algorithm to determine pEDSS among an overall cohort of patients with MS in AOK PLUS, who were alive and insured 12 months prior to and after index diagnosis.ResultsWe recruited 100 people with MS insured by AOK PLUS who had ≥1 EDSS measure in MSDS3D between 01/10/2015 and 30/06/2019 (620 measurements overall). Patients had a mean rescaled EDSS of 3.2 and pEDSS of 3.0. The pEDSS deviated from the true EDSS by 1.2 points, resulting in a mean squared error of prediction of 2.6. For the eight-fold classifier, the macro F1-score of 0.25 indicated low overall predictive performance. Broader severity groupings were better performing, with the three-fold and binary classifiers for severe disability achieving a F1-score of 0.68 and 0.84, respectively. In the overall AOK PLUS cohort (3,756 patients, 71.9% female, mean 51.9 years), older patients, patients with progressive forms of MS and those with higher comorbidity burden showed higher pEDSS.ConclusionGenerally, EDSS was underestimated by the algorithm as mild-to-moderate symptoms were poorly captured in claims across all functional systems. While the proxy-based approach using claims data may not allow for granular description of MS disability, broader severity groupings show good predictive performance.

Abstract Purpose Communities play a crucial role for health promotion, especially for disadvantaged groups. At the same time, rural communities face specific challenges when planning and conducting health promotion projects. This presentation focuses on the challenges and opportunities rural communities experienced in two German projects for physical activity promotion. Methods Data were obtained from city administration staff participating in the GESTALT and the BIG projects (N = 13). Data were gathered via three storywall surveys. In addition, a real-world lab with city-administration staff, representatives of sickness funds and researchers was used to follow the communities over time and consult them on project implementation. Results The challenges and opportunities occurred can be categorized in five domains: Infrastructure/mobility: Rural areas are often not well connected to public transport. This can hinder people to attend exercise classes. Voluntarily organized transport services or neighborhood assistance might help overcoming this challenge. Networking Networking is a double-edged sword. Some staff reported to experience benefits of already existing contacts to relevant stakeholder due to closely-knit communities. Others reported that it is challenging to get in touch with the network partners in the rural areas. Durability In some cases, the project funding was seen as a window of opportunity and a starting point for developing new structures for health promotion. Range of offers A need of exercise classes in rural areas resulted in the success of the projects. However, the implementation of new programs and activities can be time-consuming. Especially in rural districts, solutions often are planned and implemented on a very small scale. Implementation Regarding implementation, there are several challenges to overcome. The communities lacked gyms and qualified instructors for the classes. Reaching the target population was another challenge. Conclusions Rural communities face unique as well as general challenges when implementing exercise programs, which can impact success of project implementation. However, rural structures can also result in opportunities for the participating communities. Support/Funding Source Funded by the German Federal Centre for Health Education (BZgA) on behalf of and with funds from the statutory health insurance companies according to § 20a SGB V.