[Good and cost-effective palliative care in Westphalia-Lippe - but why? Results of a mixed-methods study].

Abstract

Background: The organization of palliative care in Germany varies from region to region. Previous studies show that palliative care in Westphalia-Lippe (WL) - measured by quality and cost indicators - performs better than in other regions. The Westphalian model for outpatient care emphasizes a close cooperation between general practitioners (GPs) and palliative care consultation services (PCS). The basis is a contractual regulation of general and specialized care within a joint outpatient palliative care contract according to Sect. 140a SGB V. The VESPAL study (on the Quality of care in outpatient palliative care based on the example of Westphalia-Lippe), which was funded by the Professional Association of Palliative Care Physicians in Westfalen-Lippe (Berufsverband der Palliativmediziner in Westfalen-Lippe e.V.) and the Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung Westfalen-Lippe e.V.), was conducted between 02/2022 and 07/2023 and examined which characteristics of outpatient palliative care in WL could be identified from the correlation of quantitative key figures with qualitative interview quotes that might contribute to high-quality care and cost-effectiveness.

Methods: A complex mixed-methods design was applied. Quantitative and qualitative data were collected and analyzed simultaneously, were used as a basis for further qualitative research, and then merged (QUAL+QUAN →QUAL). The quantitative data were derived from a routine data analysis on the utilization and quality of palliative care from data of deceased patients who had been covered by the BARMER health insurance, while qualitative data were obtained using five non-participant observations, interviews with 50 care providers (general practitioners, palliative care physicians, coordinators, nurses), and three focus groups. Both data sets were analyzed independently, with the quantitative results being complemented by qualitative insights to provide a more comprehensive understanding of the WL care model.

Results: The quantitative parameters used to measure the quality of care included, in particular: the hospital as place of death, the number of hospital cases, and the number of ambulance call-outs in the last 30 days of life. The qualitative study results show that these parameters can be improved by a close cooperation and specific arrangements with emergency services and nursing homes. According to the interviewees, the typical Westphalian organization of cooperation between doctors and PCS enables providers to respond quickly and provide care which is focused on the needs of patients and their relatives and can be flexibly "ramped up and down". Providers emphasized the flexibility of the model, the close cooperation, and the lack of competitive pressure from each other as reasons for the high quality of care perceived.

Conclusions: The results provide concrete indications of the potential mechanisms that are effective in the widespread WL outpatient model and which might explain the high quality of care and its cost-effectiveness. Future studies should address questions of transferability to other regions.