Gibt es Belege für den Impact qualitätssichernder/-fördernder Verfahren in anderen Ländern?

 

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Zusammenfassung

Ziel der Studie: Die in Zielsetzungen für die Gesundheitsversorgung festgelegte Qualität gilt es zu sichern und gegebenenfalls fortlaufend zu verbessern. Qualitätseinbußen werden nicht zuletzt infolge pauschalierender Vergütung befürchtet. Länderübergreifend werden Problemlösungen von verschiedenen Konzepten der Qualitätssicherung und -förderung erwartet. Die Frage nach deren Eignung ist offen. Die vorliegende Arbeit untersucht dazu Bewertungen, Belege und in der Literatur dargelegte Studien aus Ländern, die bereits über mehrjährige Erfahrung mit einem DRG-System verfügen. Methodik: Recherche in der Cochrane-Datenbank sowie in den Datenbanken des International Network of Agencies for Health Technology Assessment (DARE, NHSEED und HTA), in DIMDI und der Medline-Datenbank des NIH. Recherchiert wurde außerdem im Länderbezug generell im Internet. Ergebnisse: Instrumente der Qualitätssicherung und -förderung wie z. B. Akkreditierung, Einsatz von EbM, Leitlinien und Indikatorensets sind in den meisten der 18 untersuchten Ländern etabliert, nationalspezifisch geprägt sind insbesondere Verfahren wie Register oder Audits. Bei vergleichbaren Problemen besteht weitreichender internationaler Konsens zu den in der Qualitätsförderung zu adressierenden Aspekten. Insgesamt ergibt sich nur limitierte Evidenz für Effektivität und generelle Anwendbarkeit der verschiedenen Qualitätsverbesserungsansätze. Insbesondere sind positive Auswirkungen auf das Outcome nicht belegt. Auch im Hinblick auf den Kostenimpact fehlt eine systematische Evaluation, entsprechende Evidenzberichte sind eher anekdotischer Art. Reflexion und Qualitätsförderungsprozesse im lokalen Bezug werden vielfach günstig beurteilt, ohne dass ein Impact auf das Gesamtsystem belegt ist. Schlussfolgerungen: Keines der bisher verbreiteten Modelle erweist sich bislang als generell überlegen. Es fehlt letztlich das Wissen, welche Ansätze für welche angestrebte Verbesserung und in welchem Kontext angemessen sind. Qualitätsförderung erfährt als Strategie breite Zustimmung und erscheint gesundheitspolitisch korrekt. Ob sie tatsächlich eine bessere, effizientere und auf das Behandlungsergebnis und den Patienten zentrierte Versorgung fördert, bleibt durch die Versorgungsforschung weiter zu klären. Neue Modelle (wie beispielsweise die Integration verschiedener Ansätze oder DMP-Systeme) bedürfen systematischer und systemischer Evaluation bereits vor dem verbreiteten Einsatz. Als Bindeglied ist die Sozialmedizin gefordert, zwischen den gesellschaftlich konsentierten Zielen der Gesundheitsversorgung und der Medizin operational zu vermitteln.

Abstract

Aims: Internationally, the implementation of diagnosis-related group systems has underlined the importance of quality assurance and improvement in health care systems. Support is expected by various concepts based on different theories and traditions. Published experience and knowledge of other countries with long-standing DRG systems and data in literature are studied to see whether there is an evidence-based impact of quality assurance and quality improvement on health care systems. Methods: Relevant data was searched for in the Cochrane-database, the INAHTA-databases DARE, NHSEED and HTA, in DIMDI and the Medline-database of the NIH as well as generally in the internet, addressing the different countries. Results: Several tools of quality assurance and quality improvement like accreditation, evidence-based medicine and guidelines exist in most of the 18 countries studied. Some of them, such as registries and audits, have marked national characteristics. Similar problems in provision of health care are reported internationally. There is broad consensus as to the aspects to be addressed in quality improvement concepts. Though international consensus on effective organization and methods of external assessment is growing there is only limited evidence for efficiency and general applicability of the different tools. Their cost impact, too, has not undergone systematic evaluation. Procedures like feedback strategies and reflection have been identified as having the potenzial to change the practice of health care professionals on a local level, but evidence for system-related impact is missing. Above all, for all concepts of quality improvement there is no real evidence of clinical benefit in the sense of better patient outcomes. Conclusions: None of the various tools for quality improvement in health care proves superior so far. It remains unclear which tool suits best for which intended improvement and in which context. Although quality improvement as a strategy meets with wide approval and appears to be a correct health policy, it remains doubtful whether it really improves clinical outcome and patient-centred health care. Public health research should address these questions. New concepts (e. g. integrating different tools of quality assurance and improvement or DMP systems) need evaluation prior to their broad implementation. Social medicine is called upon to mediate between the consented health care aims of society and medicine.

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1 häufig nicht adäquat kontrolliert und ohne Randomisierungsstrategie für die teilnehmenden Ärzte, vorrangig kleinzahlige Vorher-Nachher-Vergleiche

Dr. med. Elisabeth Simoes

KCQ beim MDK Baden-Württemberg

Ahornweg 2

77933 Lahr/Schwarzwald

Email: e.simoes@mdkbw.de