In light of the ongoing discussions about the provision of medical care - especially in rural, economically underdeveloped regions of Germany, the term "rural doctor" is a commonly used term. To date, however, a concrete definition of the concept of a rural doctor has been lacking. This deficit is to be addressed by the rural doctor's selection algorithm (La-Abal). Based on an uniform selection system, the differentiation between rural doctors and city/urban doctors can now be implemented. This article provides information on whether La-Abal is generally applicable to the whole of Germany, the regions in which rural doctors are located, and the extent to which the regions identified as rural doctors' regions correspond to the regions that are underserved by general practitioners. The methodology of La-Abal is based on the three parameters: "Basic Centre", "Rural Settlement" and "Geographical Location". Municipal communities and municipal associations serve as an analysis area in this context. Unambiguous conditions defined by the La-Abal make it possible to define and identify municipal communities/municipal associations as a rural doctor's area. As a result, the La-Abal is applicable to the whole of Germany. There are also some rural doctor's areas which correspond to regions that are underserved by general practitioners. The La-Abal is a result-oriented, practical and standardised model, which makes it possible to establish a uniform understanding of rural doctors. This is necessary to develop answers to social changes and the associated demands to specifically plan and control the guaranteeing of the current and future health care.

ZusammenfassungVor dem Hintergrund der anhaltenden Diskussionen um die Sicherstellung der medizinischen Versorgung – insbesondere in ländlichen, strukturschwachen Regionen Deutschlands, ist der Begriff „Landarzt“ ein häufig verwendeter Terminus. Bis dato mangelte es jedoch an einer konkreten Definition des Landarztbegriffes. Dieses Defizit soll durch den Landarzt-Abgrenzungsalgorithmus (La-Abal) behoben werden. Anhand einer einheitlichen Abgrenzungssystematik kann nun die Differenzierung zwischen Land- und städtisch/urban tätigen Ärzten realisiert werden. Der vorliegende Artikel gibt Auskunft darüber, ob der La-Abal generell auf Gesamtdeutschland anwendbar ist, in welchen Regionen sich Landärzte befinden und inwieweit die als Landarztbereiche identifizierten Regionen mit hausärztlich unterversorgten Regionen übereinstimmen. Die Methodik des La-Abals basiert im Kern auf den drei Parametern: „Grundzentrum“, „Ländliche Besiedelung“ und „Räumliche Lage“. Einheitsgemeinden und Gemeindeverbände dienen in diesem Kontext als Analyseebene. Eindeutige, durch den La-Abal vorgegebene Bedingungen ermöglichen es, Einheitsgemeinden/Gemeindeverbände als Landarztbereiche zu definieren und somit zu identifizieren. Als Ergebnis zeigt sich, dass der La-Abal auf Gesamtdeutschland anwendbar ist. Des Weiteren existieren Landarztbereiche, einige davon korrespondieren mit denen als hausärztlich unterversorgt geltenden Regionen. Der La-Abal ist ein ergebnisorientiertes, praktikables und standardisiertes Modell, das es ermöglicht, ein einheitliches Landarztverständnis zu etablieren. Dies ist notwendig, um Antworten auf gesellschaftliche Veränderungen entwickeln und den damit einhergehenden Forderungen nach Sicherstellung der gegenwärtigen und zukünftigen Gesundheitsversorgung gezielt planen und steuern zu können.

ZusammenfassungVor dem Hintergrund der wissenschaftlichen Diskussion im Rahmen der Versorgungsforschung mangelt es nach wie vor an einer konkreten und einheitlichen Landarztdefinition. Diese wäre aber für die zukünftige Gestaltung der medizinischen Versorgungsstruktur in Deutschland dringend notwendig. Insbesondere die anhaltenden Diskussionen über den prognostizierten und bereits in Teilen Deutschlands gegenwärtigen Ärztemangel in ländlichen, zumeist strukturschwachen Regionen, stützen die Forderung nach einer Präzisierung des Landarztbegriffs. Nur auf Basis einer einheitlichen Definition erscheint es möglich, effiziente Lösungen regionsübergreifend entwickeln, diskutieren und zielgerichtet einsetzen zu können. Die Vielzahl bereits existierender Lösungsansätze wie z. B. die Telemedizin, Gesundheitszentren, Gemeindeschwestern, Übernahme ambulanter Versorgungsleistungen durch Krankenhäuser, Nachwuchsförderung usw., müssen evaluiert und dem tatsächlichen Bedarf entsprechend angepasst werden. Der zugrunde liegende Artikel stellt einen neu entwickelten Stufenplan zur Differenzierung zwischen Land- und Stadtärzten vor, welcher die Definition „Landarzt“ regionsadaptiert ermöglicht. Unter zur Hilfenahme der Definition kann dann eine Überprüfung und Weiterentwicklung der zuvor genannten Lösungsansätze stattfinden. Darüber hinaus besteht durch die Anwendung der Abgrenzungskonzeption die Chance, völlig neue Ideen und Lösungen im Rahmen der Versorgungsforschung zu kreieren. Die Grundlage der neuen Konzeption zur Land- und Stadtarztabgrenzung besteht im Wesentlichen aus den Abgrenzungsschritten: Grundzentrum (Schritt I), ländliche Besiedelung (Schritt II) sowie räumlich zentrale Lage (Schritt III). Diese 3 aufeinander aufbauenden Abgrenzungsschritte werden im Folgenden zunächst einzeln theoretisch hergeleitet. Im Anschluss erfolgt die praktische Anwendung der vorgestellten Konzeption an der Beispielregion Westfalen/Lippe. Das entwickelte Modell bietet zusammenfassend eine standardisierte Vorgehensweise, die unter zeitlichen und finanziellen Aspekten als realisierbar gilt. Ziel des vorliegenden Papiers ist vor allem ein Beitrag zur anhaltenden Diskussion der ambulanten Versorgungsforschung und insbesondere der Definition Landarzt zu leisten, die mit Hilfe des hier vorgestellten Modellansatzes auch Vergleiche zwischen verschiedenen Regionen Deutschlands ermöglicht.

In the context of the scientific discussions on health care research, a concrete and uniform definition of a country practitioner is still lacking. This would be essential, however, for the future design of the medical care structure in Germany. In particular, the ongoing discussions on the predicted shortage of physicians in rural and mostly economically undeveloped regions - a shortage that is already affecting parts of Germany - suggest the need for clarification of the concept of a country practitioner. Only on the basis of a uniform definition does it seem possible to develop and discuss effective solutions across regions and to be able to use them in a targeted manner. The multitude of existing approaches to solutions, which include, among others, telemedicine, health centres, community nurses, outpatient care services being undertaken by hospitals, and youth development, must be evaluated and adapted to actual needs. The article presents a newly developed multi-stage plan for the differentiation between rural and urban doctors, which enables the definition of "country practitioner" to be adapted according to the region. With the aid of the definition, a review and further development of the aforementioned approaches to solutions can take place. Moreover, by applying the concept of delineation, there is an opportunity to create completely new ideas and solutions in the context of health services research. The basis of the new approach to rural and urban medical delineation essentially consists of the following delineation steps: basic centre (Step I), rural settlement (Step II) and central geographic location (Step III). In the following, these 3 successive delineation steps are first separately and theoretically derived. Thereafter, the presented concept is applied to the region of Westphalia-Lippe. The developed model collectively offers a standardized approach that is feasible from a temporal and financial perspective. The primary aim of this paper is to contribute to the ongoing discussion on outpatient care research and, in particular, to the definition of the country practitioner. Using the model approach presented here, this definition also enables comparisons to be made between different regions of Germany.

Background: Most persons with dementia live at home and are treated in the primary care. However, the ambulatory health care system in Germany contains a lot of "interface problems" and is not optimized for the future challenges. Innovative concepts like regional networks in dementia care exist on a project level and need to be tested for efficacy to encourage implementation. The goal of the study is the scientific evaluation of an already existing regional dementia network. Methods: Prospective randomized controlled trial of 235 community-living elderly with dementia and their family caregivers of network treatment (n=117) compared to usual care (n=118) in a predominantly rural region. The allocation to intervention or control group was based on network membership of their General Practitioner. Intervention patients received diagnostic evaluation and subsequent treatment according to network guidelines. Main outcome measures were the early contact with a neurologic or psychiatric specialist and dementia-specific medication as well as quality of life of the patients, and as secondary outcomes caregiver burden and caregiver health-related quality of life. Results: Network patients were more likely to receive antidementive drugs (50.5 % vs. 35.8 %; p=0.035) and had more often contact to a neurologist (18.6 % vs. 2.8 %; p<0.001). No group differences were found on patient's quality of life nor overall effects or treatment by time effects. Intervention caregivers reported no significant improvements in health related quality of life measured by SF-36 and EQ-5D. Conclusion: The management of dementia patients in an interdisciplinary regional network solelyprovides measurable advantages with respect to the provision of dementia-specific medication and utilization of medical treatment i.e. referral rates to specialists. Further evaluation research is needed to identify relevant mechanisms of collaborative processes with respect to their impact on patient and caregiver related outcomes.

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.

Hintergrund Dem wachsenden Anteil von Betagten und Hochbetagten an der Gesellschaft mit entsprechendem Pflegebedarf stehen alter werdende Belegschaften und Personalabbau im Pflegebereich gegenuber, in dem Beschaftigte hohen beruflichen Belastungsfaktoren ausgesetzt sind. Masnahmen der Betrieblichen Gesundheitsforderung (BGF) stellen eine Moglichkeit zur Verbesserung von Verhaltnissen und Verhaltensweisen dar. Methoden In 32 Datenbanken wird eine systematische Literaturrecherche nach englisch- und deutschsprachigen Publikationen seit 1990 durchgefuhrt. Daruber hinaus erfolgen eine Internetrecherche und Sichtung der Referenzlisten identifizierter Publikationen. Die Literaturauswahl wird entsprechend der Ein- und Ausschlusskriterien von zwei unabhangigen Gutachtern getroffen. Datenextraktion und Evidenztabellen werden von einem Zweitgutachter uberpruft sowie die Bewertung des Verzerrungspotenzials anhand des Risk of bias tool der Cochrane Collaboration. Ergebnisse Durch die Recherchen werden elf Interventionsstudien und zwei systematische Ubersichtsarbeiten identifiziert. In drei randomisierten kontrollierten Studien (RCT) und einer kontrollierten klinische Studie (CCT) ohne Randomisierung werden Masnahmen zur Verbesserung der physischen Gesundheit untersucht, in vier RCT und zwei CCT Masnahmen zur Verbesserung der psychischen Gesundheit sowie in einem RCT Masnahmen zu physischer und psychischer Gesundheit. Die Dauer der Studien reicht von vier Wochen bis zu zwei Jahren und die Anzahl eingeschlossener Teilnehmer von 20 bis 345, im Median 56. Interventionen und Studienpopulationen sind uberwiegend heterogen. Masnahmen zur Verbesserung der korperlichen Gesundheit fuhren in drei Studien hinsichtlich von Beschwerden sowie Kraft und Beweglichkeit zu Veranderungen mit statistisch signifikanten Gruppenunterschieden. Aktive Teilnehmer an Interventionen zur Verbesserung der psychischen Gesundheit konnen mit statistisch signifikanten Gruppenunterschieden von einer geringeren Einnahme von Analgetika, besserem Umgang mit beruflich bedingtem Stress und Arbeitsbelastungen, einer verbesserten Kommunikationsfahigkeit sowie beruflicher Weiterbildung profitieren. Diskussion Die uberwiegend kleinen bis sehr kleinen Populationen, methodische Fehler mit einem hohen Verzerrungspotenzial und eine schlechte Berichtsqualitat schranken die Aussagekraft der Studienergebnisse stark ein. Ein Vergleich der Resultate ist sowohl aufgrund der Heterogenitat der Interventionsmasnahmen und Studienpopulationen mit verschiedensten Spezialisierungen als auch infolge der unterschiedlich langen Studiendauern und Nachbeobachtungsphasen wenig sinnvoll. Schlussfolgerungen Weitere Forschungsarbeiten mit groseren Stichproben, ausreichend langen Studiendauern und Nachbeobachtungsphasen, einem geringeren Verzerrungspotenzial durch die Einhaltung relevanter Qualitatskriterien und mit einer besseren Berichtsqualitat sind notwendig.

BACKGROUND:The increasing proportion of elderly people with respective care requirements and within the total population stands against aging personnel and staff reduction in the field of health care where employees are exposed to high load factors. Health promotion interventions may be a possibility to improve work situations and behavior.METHODS:A systematic literature search is conducted in 32 databases limited to English and German publications since 1990. Moreover, internet-searches are performed and the reference lists of identified articles are scanned. The selection of literature was done by two reviewers independently according to inclusion and exclusion criteria. Data extraction and tables of evidence are verified by a second expert just like the assessment of risk of bias by means of the Cochrane Collaboration's tool.RESULTS:We identified eleven intervention studies and two systematic reviews. There were three randomized controlled trials (RCT) and one controlled trial without randomization (CCT) on the improvement of physical health, four RCT and two CCT on the improvement of psychological health and one RCT on both. Study duration ranged from four weeks to two years and the number of participants included from 20 to 345, with a median of 56. Interventions and populations were predominantly heterogeneous. In three studies intervention for the improvement of physical health resulted in less complaints and increased strength and flexibility with statistically significant differences between groups. Regarding psychological health interventions lead to significantly decreased intake of analgesics, better stress management, coping with workload, communication skills and advanced training.DISCUSSION:Taking into consideration the small to very small sample sizes, other methodological flaws like a high potential of bias and poor quality of reporting the validity of the results has to be considered as limited. Due to the heterogeneity of health interventions, study populations with differing job specializations and different lengths of study durations and follow-up periods, the comparison of results would not make sense.CONCLUSIONS:Further research is necessary with larger sample sizes, with a sufficient study duration and follow-up, with a lower risk of bias, by considering of relevant quality criteria and with better reporting in publications.

Hintergrund: Kenntnisse über Einflussfaktoren auf die Lebens- und medizinische Versorgungssituation von Demenzkranken und deren Angehörigen sind eine Voraussetzung für die rationale Planung von versorgungsepidemiologischen Interventionen. Das Ziel dieser Studie ist es daher, die Inanspruchnahme medizinischer Leistungen von an Demenz Erkrankten und deren betreuenden Angehörigen im Vergleich zu einer bevölkerungsbezogenen Stichprobe zu analysieren sowie Einflussfaktoren auf die Inanspruchnahme zu ermitteln. Methoden: Datengrundlage bildet die IDemUck-Studie, bei der 241 in der (eigenen) Häuslichkeit lebende Demenzerkrankte sowie deren 190 betreuende Angehörige mit einem standardisierten Interview u.a. zur Inanspruchnahme medizinischer Leistungen (niedergelassene Ärzte, stationäre Aufenthalte) und zur Lebenssituation (z.B. Soziodemografie, gesundheitsbezogene Lebensqualität [SF 36], Angehörigenbelastung [BIZA-D]) befragt worden sind. Bei den Demenzerkrankten wurde außerdem ihre kognitive Leistungsfähigkeit (CERAD) erhoben. Für den Vergleich von Inanspruchnahmeprävalenzen werden Daten des ersten 5-Jahres follow-ups der Study of Health in Pomerania (SHIP-I) genutzt. An SHIP-I nahmen 3300 Probanden (Response: 83,5%; Alter: 25–88 Jahre) teil, bei denen in einem medizinischen Interview u.a. Daten zu Soziodemografie, Inanspruchnahme medizinischer Leistungen und Gesundheitszustand erhoben wurden[1]. Ergebnisse: Von den hinsichtlich Demenz positiv gescreenten Probanden der IDemUck-Studie (DemTect≤8 und GDS≤10), nahmen 241 Demenzerkrankte (Response: 84,6%, Alter: 55–100 Jahre) sowie 190 betreuende Angehörige (Alter: 21–87 Jahre) an der Studie teil. Der Anteil derjenigen, der in den letzten vier Wochen mindestens einen Arztkontakt aufwies, unterscheidet sich in der Altersgruppe >65 Jahre zwischen Demenzerkrankten (68,9%), Angehörigen (64,0%) und SHIP-Probanden (73,8%). Gleichzeitig schätzen jedoch 44,0% der >65-jährigen Angehörigen von Demenzerkrankten ihren Gesundheitszustand als schlecht oder sehr schlecht ein, hingegen nur 25,4% der SHIP-Probanden. Ergebnisse: der Regressionsanalysen zu den Einflussfaktoren kognitiver Status des Demenzerkrankten, selbst eingeschätzter Gesundheitszustand, Angehörigenbelastung sowie soziodemographische Daten auf die Inanspruchnahme medizinischer Leistungen bei Demenzerkrankten und Angehörigen werden vorgestellt. Literatur: [1] John U., Greiner B., Hensel E., et al. (2001). Study of Health In Pomerania (SHIP): a health examination survey in an east German region: objectives and design. Soz. Präventivmed., 46(3):186–194.

Korrespondenzadresse Dr. rer. med. N. van den Berg Institut f ü r Community Medicine Abt. Versorgungsepidemiologie und Community Health Klinikum der Ernst-Moritz-Arndt Universit ä t Greifswald A ö R Ellernholzstra ß e 1 / 2 17487 Greifswald neeltje.vandenberg@ uni-greifswald.de Schl ü sselw ö rter ● ▶ AGnES ● ▶ Delegation ä rztlicher T ä tigkeiten ● ▶ Hausbesuche ● ▶ Gesetzes ä nderung § 87 Absatz 2b SGB V ● ▶ AGnES-Curriculum

BACKGROUND:Against the background of a decreasing number of general practitioners (GPs) in rural regions in Germany, the AGnES-concept (AGnES = GP-supporting, community-based, e-health-assisted, systemic intervention) supports the delegation of regular GP-home visits to qualified practice assistants. The concept was implemented and evaluated in different model projects in Germany. To explore the economic effects of this concept, the development of the number of home visits in an ambulatory healthcare centre was analysed and compared with the number of home visits in the surrounding county.METHODS:Information about GP-home visits was derived from reimbursement data of the ambulatory healthcare centre and a statutory health insurance. Information about home visits conducted by AGnES-practice assistants was collected from the project documentation over a time period of 12 consecutive quarter years, four quarter years before the beginning of the project and 8 quarter years while the project was implemented, considering background temporal trends on the population level in the study region.RESULTS:Within the ambulatory healthcare centre, the home visits by the GPs significantly decreased, especially the number of medically urgent home visits. However, the overall rate of home visits (conducted by the GPs and the AGnES-practice assistants together) did not change significantly after implementation of the AGnES-concept. In the surrounding county, the home visit rates of the GPs were continuous; the temporal patterns were approximately equal for both usual and urgent home visits.CONCLUSION:The results of the analyses show that the support by AGnES-practice assistants led to a decrease of GP-home visits rather than an induction of additional home visits by the AGnES-practice assistants. The most extended effect is related to the medically urgent home visits rather than to the usual home visits.

Das Deutsche Netzwerk Versorgungsforschung e. V. (DNVF e. V.) hat am 30.08.2010 getragen von den genannten im DNVF organisierten Fachgesellschaften und Organisationen, das Memorandum III "Methoden für die Versorgungsforschung" Teil 2 verabschiedet, das in dieser Zeitschrift publiziert wurde [Gesundheitswesen 2010; 72: 739–748]. Die vorliegende Publikation fokussiert auf die Methodik der ökonomischen Evaluation der Gesundheitstechnologien bzw. Interventionen und stellt eine Vertiefung zu dem Memorandum III "Methoden für die Versorgungsforschung" Teil 2 dar. Zunächst werden allgemeine methodische Standards gesundheitsökonomischer Evaluationen, d. h. Studien, die die Kosten-Nutzen Relation (Wirtschaftlichkeit) von Interventionen untersuchen, kurz dargestellt. Um Versorgungsrealität adäquat zu reflektieren, müssen zur Ermittlung der Interventionskosten und -effekte oft mehrere Datenquellen, z. B. Wirksamkeitsstudien, Register, administrative Quellen usw., verwendet werden. Daher werden für die gesundheitsökonomischen Evaluationen im Rahmen der Versorgungsforschung potenziell geeignete Datenquellen vorgestellt, ihre Vorteile und Limitationen genannt. Anschließend wird der Weiterentwicklungsbedarf der Methodik im Hinblick auf die Datenerhebung, und -auswertung sowie die Kommunikation und Dissemination der Ergebnisse diskutiert.

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

Background In many rural regions in Germany, the proportion of the elderly population increases rapidly. Simultaneously, about one-third of the presently active GPs will retire until 2010. Often it is difficult to find successors for vacant GP-practices. These regions require innovative concepts to avoid the imminent shortage in primary health care. The AGnES-concept comprises the delegation of GP-home visits to qualified AGnES-practice assistants (AGnES: GP-supporting, community-based, e-health-assisted, systemic intervention). Main objectives were the assessment of the acceptance of the AGnES-concept by the participating GPs, patients, and AGnES-practice assistants, the kind of delegated tasks, and the feasibility of home telecare in a GP-practice. Methods In this paper, we report first results of the implementation of this concept in regular GP-practices, conducted November 2005 – March 2007 on the Island of Rügen, Mecklenburg-Western Pomerania, Germany. This study was meant as a proof of concept. The GP delegated routine home-visits to qualified practice employees (here: registered nurses). Eligible patients were provided with telecare-devices to monitor disease-related physiological values. All delegated tasks, modules conducted and questionnaire responses were documented. The participating patients were asked for their acceptance based on standardized questionnaires. The GPs and AGnES-practice assistants were asked for their judgement about different project components, the quality of health care provision and the competences of the AGnES-practice assistants. Results 550 home visits were conducted. 105 patients, two GPs and three AGnES-practice assistants (all registered nurses) participated in the project. 48 patients used telecare-devices to monitor health parameters. 87.4% of the patients accepted AGnES-care as comparable to common GP-care. In the course of the project, the GPs delegated an increasing number of both monitoring and interventional tasks to the AGnES-practice assistants. The GPs agreed that delegating tasks to a qualified practice assistant relieves them in their daily work. Conclusion A part of the GPs home visits can be delegated to AGnES-practice assistants to support GPs in regions with an imminent or already existing undersupply in primary care. The project triggered discussions among the institutions involved in the German healthcare system and supported a reconciliation of the respective competences of physicians and other medical professions.

Background: This study examines and compares the frequency of home visits by general practitioners in regions with a lower population density and regions with a higher population density. The discussion centres on the hypothesis whether the number of home visits in rural and remote areas with a low population density is, in fact, higher than in urbanised areas with a higher population density. The average age of the population has been considered in both cases.Methodology: The communities of Mecklenburg West-Pomerania were aggregated into postal code regions. The analysis is based on these postal code regions. The average frequency of home visits per 100 inhabitants/km(2) has been calculated via a bivariate, linear regression model with the population density and the average age for the postal code region as independent variables. The results are based on billing data of the year 2006 as provided by the Association of Statutory Health Insurance Physicians of Mecklenburg-Western Pomerania. In a second step a variable which clustered the postal codes of urbanised areas was added to a multivariate model.Results: The hypothesis of a negative correlation between the frequency of home visits and the population density of the areas examined cannot be confirmed for Mecklenburg-Western Pomerania. Following the dichotomisation of the postal code regions into sparsely and densely populated areas, only the very sparsely populated postal code regions (less than 100 inhabitants/km(2)) show a tendency towards a higher frequency of home visits. Overall, the frequency of home visits in sparsely populated postal code regions is 28.9% higher than in the densely populated postal code regions (more than 100 inhabitants/km(2)), although the number of general practitioners is approximately the same in both groups. In part this association seems to be confirmed by a positive correlation between the average age in the individual postal code regions and the number of home visits carried out in the area. As calculated on the basis of the data at hand, only the very sparsely populated areas with a still gradually decreasing population show a tendency towards a higher frequency of home visits.Conclusion: According to the data of 2006, the number of home visits remains high in sparsely populated areas. It may increase in the near future as the number of general practitioners in these areas will gradually decrease while the number of immobile and older inhabitants will increase.

INTRODUCTION:According to an amendment of German social security legislation, the AGnES concept of delegation of certain tasks of medical care, especially house calls, by general practitioners (GPs) to qualified practice employees (AGnES employees), will be transferred into the regular German health care system from January 2009 onward. The concept was developed to support GPs in regions with imminent gaps in primary care.METHODS:Patient data, the specifically delegated and all other activities carried out by the AGnES employees in the AGnES projects were digitally documented. Additionally, the participating GPs, AGnES employees and patients underwent a set of standardised interviews. A curriculum to qualify the AGnES employees and to define the requirements needed was developed. A legal assessment of all delegated activities was carried out, and an economical model to calculate the necessary allowance was calculated.RESULTS:In seven model projects in four federal states in Germany, 11,228 house calls were carried out involving 1,424, mostly multimorbid, patients (mean age: 78.6 years). A modular structured curriculum, considering the basic education and acquired competences, was developed. It allows for an individual qualification of the AGnES employees. The result of the legal assessment was the central relevance of the qualification of the practice employees according to the AGnES curriculum as the essential condition for carrying out the entire range of activities of the AGnES concept. The economic model revealed euro 21.58 for a house call by an AGnES employee. The underlying model referred to underserved regions.CONCLUSION:A successful transfer of the AGnES concept with a high standard of quality into regular health-care depends on several factors. Of particular importance is the specific qualification of the practice employees, which is a central legal condition for the delegation of medical tasks from GPs to AGnEs employees. A second determining factor is also an adequate reimbursement within the catalogus of the statutory health insurances.

BACKGROUND:The German AGnES (community-based, e-health-assisted systemic support for primary care) project allows general practitioners (GPs) to delegate certain elements of medical care, including house calls, to qualified AGnES employees and thereby provide primary care to a larger number of patients. AGnES projects of various types have been carried out in a number of German federal states from 2005 onward. In this article, an evaluation of the AGnES projects to date is presented.METHODS:Patient data (age, sex, diagnoses, level of care, mobility, etc.) and each of the specific activities carried out in the AGnES framework were documented with standardized computer-based instruments. The GPs, AGnES employees, and patients also underwent standardized interviews. The acceptance of the AGnES project, competence of the AGnES employees, and quality of medical care within the projects were evaluated. The participating GPs themselves assessed the quality of medical care.RESULTS:By July 8, 2008, 8386 house calls on a total of 1486 patients had been made within the framework of the AGnES projects. The evaluation revealed a high degree of acceptance of the project among the participating GPs, AGnES employees, and patients. The GPs considered the quality of medical care within the AGnES project to be good for the vast majority of patients.CONCLUSION:Structural redundancy is avoided by directly placing the AGnES employees in the general practitioners' practices. Based on the results of the AGnES projects, the law in Germany has now been amended to enable implementation of the AGnES project in the regular health care system from January 2009 onward. The next steps to be taken are the establishment of adequate reimbursement within the catalog of the statutory health insurance scheme and a detailed definition of the required qualifications.