Claudia Hübner

Regional One Health antimicrobial stewardship networks require coordinated, adaptive strategies across sectors. This conceptual article combines strategic fit theory with the Ansoff matrix to identify key determinants of sustainable network performance and proposes strategic development pathways to strengthen governance, data integration, cross-sectoral collaboration and long-term network development.

Background: Antimicrobial resistance (AMR), as an original One Health problem, combines inextricable interactions between the human, animal and environmental dimensions. Addressing this challenge requires systemic thinking and coordinated networking between different levels of society and regional institutions. Knowledge of causal relationships, their mutual influence and the ability to assess the impact of possible interventions are prerequisites for coherent action to combat the further spread of antimicrobial resistance in a region. An integrated regional approach has not yet been addressed in One Health research on antimicrobial resistance. Methods: This study is based on a systems thinking approach and uses a causal loop diagram to visualise the relationships between human, animal and ecological components in a circular AMR system map for a One Health model region. The participatory approach actively involved regional stakeholders in the data collection and modelling process through surveys, semi structured interviews and interactive workshops. Based on the developed causal loop diagram, leverage point analysis is applied to estimate which types of interventions would have the greatest ability to address antimicrobial resistance in the One Health region. Results: Our results show that the system mapping tool is suitable for demonstrating the relationships regarding AMR in the One Health context for a defined region. It provides an opportunity to identify and visualise important risk factors that are direct or indirect drivers of AMR. Specifically, two amplifying and two balancing loops have been constructed in the model, covering antibiotic stewardship, public awareness, regional data management and environmental impact. Interdisciplinary and intersectoral collaboration, homogeneity of data and public awareness were identified as important leverage points. The graphical illustration of the causal loop diagram enables political and economic decision-makers to develop a deeper understanding of regional resistance patterns and the rational use of antibiotics from a One Health perspective. Conclusion: This study is one of the first applications of a participatory systems thinking approach to the topic of AMR in the context of a One Health region. Trail registration: Not applicable.

Strategic management is becoming increasingly important for sustainable management in healthcare. The reasons for this can be seen in the increasing complexity, dynamics and uncertainty of the system’s regimes and the resulting need for strategic thinking in a long-term period. The scientific discussion of this issue is the aim of the present analytical framework. The starting point is the definition of the term strategic management itself, followed by a reflection on the requirements resulting from the changes in the political, social and economic value systems of our post-industrial society. In this context, Dynaxity Zone III is used to explain the long-term perspective, the high levels of complexity and uncertainty and the responsibility of strategic management as important parameters. For a practical illustration, we demonstrate two selected applications (German hospital financing systems and development process of implants) and how the implementation of strategic management in the health care system shows success.

Innovations are the source of all human development and improvement of quality of life. At the same time, they challenge existing standards, solutions and societal patterns. In health care in particular, innovations enable us to treat previously incurable diseases or to make better use of scarce resources. However, they also make existing health care technologies obsolete, force specialists to learn completely new methods and require high investments. Consequently, in this paper we develop a conceptual framework model for the development, adoption and diffusion of innovations in health care. We analyse barriers and promoters of innovations, in particular meta-stability, costs, innovative ability and leadership and apply the framework to three innovations: personalized medicine, digital health, and implants. We conclude that strategic innovation management in healthcare is a prerequisite of the rapid development and adoption of innovations and the improvement of quality of life of the (aging) population.

The concept of opportunity cost can be applied to the utilization of hospital beds with special focus on patients colonized or infected with multidrug-resistant organisms. Blocked beds due to isolation measures or increased length of stay may result in opportunity costs if newly arriving patients have to be rejected and the hospital is confronted with revenue foregone. However, the amount of these costs is unclear, since different approaches are used in the literature to determine the respective costs. Our paper develops a concept to assess opportunity costs from the perspective of a hospital.

Der Methicillin-resistente Staphylococcus aureus (MRSA) tritt in Deutschland sektorenübergreifend auf. Der deutsche Gesetzgeber hat die Vergütung für ärztliche Leistungen bei Trägern von MRSA im niedergelassenen Bereich erstmalig zum 01.04.2012 geregelt und nach einem 2-jährigen Erprobungszeitraum in die Regelversorgung aufgenommen. Die vorliegende retrospektive Arbeit soll einerseits einen Überblick über die MRSA-bezogene Leistungs- und Erstattungssituation geben und andererseits die MRSA-Patienten und deren Behandlung im ambulanten Sektor beschreiben. Mit dieser Zielrichtung wurden Sekundärdaten – standardmäßig erfasste Leistungsabrechnungsdaten – der Kassenärztlichen Bundesvereinigung (KBV) und der Kassenärztlichen Vereinigung (KV) Mecklenburg-Vorpommern analysiert und ausgewertet. Die Analyse bezieht sich auf den Zeitraum 01.04.2012 bis 31.03.2014. Die Ergebnisse zeigen, dass bundesweit MRSA-Leistungen in Höhe von 3 235 870,18 € vergütet werden und die Diagnostikkosten die Behandlungskosten übersteigen. In Deutschland rechnen 5 627 Ärzte Leistungen im Zusammenhang mit MRSA ab. Davon sind 51,56% Allgemeinmediziner und 21,25% hausärztlich tätige Internisten. In der KV Mecklenburg-Vorpommern sind die Patienten älter (Altersmittelwert 69,13 Jahre), die Leistungen kosten im Durchschnitt 27,76 € und 76,85% der Patienten werden innerhalb eines Quartals behandelt. Insgesamt ist festzustellen, dass sich die Identifikation von MRSA-Trägern und deren ambulante Sanierung regional unterschiedlich darstellen. Um weitere Grundlagen für eine effizientere Ressourcenverteilung im Gesundheitswesen zu schaffen ist es notwendig, die ambulante MRSA-Eradikation nicht nur medizinisch detaillierter zu analysieren, sondern auch die Nahtstellen des sektorenübergreifenden Patientenstroms und die Ökonomie zu betrachten. Infection with methicillin-resistant Staphylococcus aureus (MRSA) occurs in both the inpatient and outpatient sector. The reimbursement for diagnostic services and eradication therapy in the outpatient sector was regulated for the first time on 01.04.2012 and after a 2-year test period, has been adopted into the standard range of care services. The aim of this retrospective study was to give an overview of the current situation in services and reimbursement in Germany and describe MRSA patients and their treatment in the outpatient sector. Secondary data, namely reimbursement data of the National Association of Statutory Health Insurance Physicians (KBV) und the Physicians’ Association (KV) Mecklenburg-West Pomerania for the period 01/04/2012–31/03/2014 were analyzed. Results show that on the federal level, MRSA services amounting to € 3,235,870.18 have been reimbursed and that diagnostic costs exceed treatment costs. In Germany, 5,627 doctors invoiced services related to MRSA; 51,56% of these were general practitioners and 21,25% specialists in internal medicine working in general practice. In the KV Mecklenburg-Western Pomerania, patients were elderly (average age 69,13), cost for services were on average 27,76 €, and 76,85% of the patients were treated within one quarter. On the whole, there were regional differences in the identification and eradication of MRSA in the outpatient setting. In order to provide an extended base for a more efficient resource allocation in the health care sector, in addition to analysis of MRSA eradication from the medical point of view, attention needs to be paid to patient flow between the out- and inpatient sectors, as well as economic aspects.

Objectives Infections and colonisations with multidrug-resistant organisms (MDROs) increasingly affect different types of healthcare facilities worldwide. So far, little is known about additional costs attributable to MDROs outside hospitals. The aim of this study was to analysis the economic burden of multidrug-resistant bacteria in nursing homes in Germany. Setting The cost analysis is performed from a microeconomic perspective of the healthcare facilities. Study took place in six long-term care facilities in north-eastern Germany. Participants Data of 71 residents with a positive MDRO status were included. Primary and secondary outcome measures The study analysed MDRO surveillance data from 2011 to 2013. It was supplemented by an empirical analysis to determine the burden on staff capacity and materials consumption. Results 11 793 days with a positive multidrug-resistant pathogen diagnosis could be included in the analysis. On average, 11.8 (SD±6.3) MDRO cases occurred per nursing home. Mean duration per case was 163.3 days (SD±97.1). The annual MDRO-related costs varied in nursing homes between €2449.72 and €153 263.74 on an average €12 682.23 per case. Main cost drivers were staff capacity (€43.95 per day and €7177.04 per case) and isolation materials (€24.70 per day and €4033.51 per case). Conclusions The importance of MDROs in nursing homes could be confirmed. MDRO-related cost data in this specific healthcare sector were collected for the first time. Knowledge about the burden of MDROs will enable to assess the efficiency of hygiene intervention measures in nursing homes in the future.

Hospital infections with multiresistant bacteria, e.g., Methicillin-resistant Staphylococcus aureus (MRSA), cause heavy financial burden worldwide. Rapid and precise identification of MRSA carriage in combination with targeted hygienic management are proven to be effective but incur relevant extra costs. Therefore, health care providers have to decide which MRSA screening strategy and which diagnostic technology should be applied according to economic criteria. The aim of this study was to determine which MRSA admission screening and infection control management strategy causes the lowest expected cost for a hospital. Focus was set on the Point-of-Care Testing (PoC). A decision tree analytic cost model was developed, primarily based on data from peer-reviewed literature. In addition, univariate sensitivity analyses of the different input parameters were conducted to study the robustness of the results. In the basic analysis, risk-based PoC screening showed the highest mean cost savings with 14.98 € per admission in comparison to no screening. Rapid universal screening methods became favorable at high MRSA prevalence, while in situations with low MRSA transmission rates omission of screening may be favorable. Early detection of MRSA by rapid PoC or PCR technologies and consistent implementation of appropriate hygienic measures lead to high economic efficiency of MRSA management. Whether general or targeted screening is more efficient depends mainly on epidemiological and infrastructural parameters.

Nosocomial infections are the most common complication during inpatient hospital care. An increasing proportion of these infections are caused by multidrug-resistant organisms (MDROs). This report describes an intervention study which was designed to address the practical problems encountered in trying to avoid and treat infections caused by MDROs. The aim of the HARMONIC (Harmonized Approach to avert Multidrug-resistant Organisms and Nosocomial Infections) study is to provide comprehensive support to hospitals in a defined study area in north-east Germany, to meet statutory requirements. To this end, a multimodal system of hygiene management was implemented in the participating hospitals. HARMONIC is a controlled intervention study conducted in eight acute care hospitals in the ‘Health Region Baltic Sea Coast’ in Germany. The intervention measures include the provision of written recommendations on methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE) and multi-resistant Gram-negative bacteria (MRGN), supplemented by regional recommendations for antibiotic prescriptions. In addition, there is theoretical and practical training of health care workers (HCWs) in the prevention and handling of MDROs, as well as targeted and critically gauged applications of antibiotics. The main outcomes of the implementation and analysis of the HARMONIC study are: (i) screening rates for MRSA, VRE and MRGN in high-risk patients, (ii) the frequency of MRSA decolonization, (iii) the level of knowledge of HCWs concerning MDROs, and (iv) specific types and amounts of antibiotics used. The data are predominantly obtained by paper-based questionnaires and documentation sheets. A computer-assisted workflow-based documentation system was developed in order to provide support to the participating facilities. The investigation includes three nested studies on risk profiles of MDROs, health-related quality of life, and cost analysis. A six-month follow-up study investigates the quality of life after discharge, the long-term costs of the treatment of infections caused by MDROs, and the sustainability of MRSA eradication. The aim of this study is to implement and evaluate an area-wide harmonized hygiene program to control the nosocomial spreading of MDROs. Comparability between the intervention and control group is ensured by matching the hospitals according to size (number of discharges per year / number of beds) and level of care (standard or maximum). The results of the study may provide important indications for the implementation of regional MDRO management programs.