Germany

Background

A fundamental facet of the German health care system is the sharing of decision-making between the Länder and the federal government. Another special feature of the regulation of medical services is the important role, alongside that of the legislature, played by the self-governing bodies of service providers and health insurance funds. The Social Code Book V (SGB V) defines their rights and responsibilities.

On a national level legislature creates the legal framework; the medical self-governing bodies, formed by the national associations of statutory health insurance physicians and dentists, the German Hospital Federation and the federal associations of health insurance funds, formulate and implement in detail which services will be provided and under which conditions. Since 2004 national groups representing patients were given the right to file applications and to participate in the consultations of the G-BA (Gemeinsamer Bundesausschuss, Federal Joint Kommitee).

The payers’ side is made up of autonomous sickness funds which are organised on a regional and/or federal basis. About 90 % of the population is covered by statutory health insurance which is compulsory for all who earn less than a defined threshold. In 2007 there were about 250 statutory sickness funds with about 72 million insured persons (50.7 million members plus their dependants) and 52 private health insurance companies covering around 7.1 million fully insured people. All statutory sickness funds have non-profit status and are based on the principle of self-government, elected by the membership. Insurance payments are based on a percentage of income, divided between employee and employer.

Due to the highly subdivided structure of the German health care system, health care provision is carried out within sectors or along sectoral borders.

Outpatient services supplied to the public are largely under the responsibility of independent physicians practising on a freelance basis. Physicians caring for patients of statutory sickness funds must be registered by law by the regional association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung). The mandate of regional associations of Statutory Health Insurance Physicians is to ensure ambulatory health services to the public and to negotiate contracts with the statutory sickness funds.

Inpatient care is provided by different types of hospitals which mainly the Länder are accountable for; public hospitals (Öffentliche Krankenhäuser) run by the local authorities, the towns and the “Länder”; and voluntary non-profit making hospitals (Frei gemeinnützige Krankenhäuser) run by churches or non-profit making organisations such as the German Red Cross, and private hospitals (Privatkrankenhäuser) run as free commercial enterprises.

Guideline related data

The German Programme for National Disease Management Guidelines is a not-for-profit project that was set up in 2002 by the German Medical Association in order to provide evidence-based medical guidance for disease management programmes. In 2003 the “German DM-CPG programme” became a joint initiative of the German Medical Association (GMA), the National Association of Statutory Health Insurance Physicians (NASHIP) and the Association of the Scientific Medical Societies (AWMF). A steering committee representing GMA, NASHIP and AWMF as programme partners oversees the DM-CPG programme. As a joint project of the federal umbrella organisations of scientific medical societies and medical self administration, the DM-CPG programme stands for the development of high quality guidelines. From the beginning, the programme has been organised by the Agency for Quality in Medicine, Berlin (AEZQ) - a founding member of the Guidelines International Network.

Online at: www.versorgungsleitlinien.de/english

Aims of the German DM-CPG Programme

The aims of the programme are to promote the effective delivery of health services within the framework of disease management or integrated care, respectively, based on best available evidence from research and practice. The DM-CPG programme guarantees state of the art development, updating and implementation of evidence based guidelines. The DMCPG programme relies on a collaborative network of experts with a diverse background, ranging from medical research, in- and outpatient care to opinion leaders and consumers, who design tools for the promotion of evidence-based health care services. These tools include evidence-based guidelines in long, short and pocket versions as well as practice aids and patient guidelines.

DM-CPGs are available for asthma, COPD, chronic coronary heart disease, diabetic foot syndrome and diabetic retinopathy. The DM-CPG for chronic heart failure and the update of the asthma DM-CPG are nearly completed. DM-CPGs for depression, diabetic nephropathy, diabetic neuropathy, education for patients with diabetes and unspecific low back pain are being developed.

All these guidelines focus on improving the integration of care. Algorithms on diagnostic or therapeutic procedures are mutually developed by the respective guideline panel. For example, specific care for patients with diabetic complications ie referrals to foot care specialists is often delayed. To address this issue the guideline group developed a standard procedure on how to manage care for these patients. Another example is the inexplicably high rate of cardiac catheter examinations in Germany. In this case the expert panel similarly developed standard criteria for when this examination is regarded as appropriate.

Recent developments within the German DM-CPG programme

The influence of DM-CPGs on structures, processes and outcomes of care needs to be assessed, however, quality assessment in integrated health care is challenging. One reason for this is the multitude of potential areas of measurement, key players and perspectives. Another problem is the difficulty in identifying and assessing measures evaluating the function of the diagnostic and therapeutic chain in terms of cooperation and coordination of care. To address this issue an expert panel created a manual on the development of quality indicators for DM-CPGs. As a result, each new published DM-CPG now contains suggestions for quality indicators derived from goals or recommendations stated within the guideline.

Methodological developments

More and more clinical practice guidelines are based on other guidelines as a source of evidence. Until now, none of the broadly available assessment instruments for guidelines (AGREE, German adaptation DELBI) have addressed the methodological issues related to this approach. In order to bridge this gap a multidisciplinary panel of guideline developers designed an additional domain for DELBI called “Methodological Accuracy of Guideline Development based on pre-existing Clinical Guidelines”. After performing a pre-test the new domain was added to DELBI.

Perspective

In order to further improve implementation of guidelines and evidence-based medicine we are developing a web based platform offering information like quality audited clinical practice guidelines, short versions and pocket versions of audited CPGs, practice aids like standardised questionnaires, patient guidelines etc. We also plan to extend the range of information on offer with options for online based CME and links to databases such as the Cochrane Library.