Organisational Health Services Research in Germany: A Scoping Review of Conference Abstracts

Keywords

Health Services Research - Organisation studies - Health Care - Organisational Behaviour in Health Care - Organisational Health Services Research

Introduction

Health Services Research (HSR) in Germany

In Germany, health services research (HSR) is a growing interdisciplinary research field that began to develop in the late 1990s as a niche area within the health sciences. Within the last 15 years, HSR has increasingly been acknowledged as an important pillar of health research in Germany that is expected to aid understanding and improve routine health care. Through the increasingly acknowledged importance and increase of national research funding for HSR, the field has grown substantially and strong research groups have developed throughout Germany. Having developed mostly from the fields of evidence-based medicine, medical sociology and medical psychology, HSR in Germany was and is to a great extent institutionalised at medical faculties and is thereby expected to deliver meaningful evidence and solutions to challenges and phenomena close to clinical practice [1]. The institutionalisation at medical faculties let to close collaboration with clinical fields, which can be regarded as beneficial in terms of application-oriented research and practice translation. On the other hand, this proximity might keep HSR in Germany from being able to thoroughly and critically analyse health services [1] and from utilizing the full potential of methods and theories from other relevant disciplines.

The German Network of Health Services Research (DNVF)

The German Network for Health Services Research (DNVF) was founded in 2006 as an interdisciplinary academic network and currently comprises more than 80 institutional members (professional societies, health authorities and industry), more than 50 scientific institutions (scientific institutes and research groups) and 354 individual members from research and health care institutions (as of November 2023). The network’s aim is to connect health services researchers in Germany and German speaking countries, health care practitioners and policy-makers in order to facilitate the exchange of ideas and approaches for designing health care. The 22^th annual conference of the DNVF in 2023 was attended by more than 1,000 mostly national experts from research, health care and health policy.

Organisational Health Services Research (OHSR) in Germany

The relevance of health care organisations in HSR was acknowledged at an early stage of the HSR development in Germany. The working group ‘Organisational Health Services Research’ (OHSR) – which the authors of this article are part of – was founded as one of the first of currently 26 working groups within the DNVF. In 2009, the working group published a first consensus paper (‘memorandum’) on the concept and methods of organisation-focused HSR [2], which was updated and extended in 2019 [3] [4] [5]. In this conceptual paper [3] the research sphere of what we term organisational HSR includes the following areas:

• the environment (macro-level) in which health care organisations act and their interactions with the individual (micro-level) and organisational level (meso-level)

• structures, processes and cultures in health care organisations

• interactions within and between health care organisations

• impact of the aforementioned factors on (patient-related) outcomes and on the delivery of health care [3]

Links to Organisational Behaviour in Health Care (OBHC)

The terms OHSR and OBHC are sometimes used interchangeably in the German HSR community, but the term OHSR is more commonly used [6]. Our understanding of OHSR might be somewhat broader than what is usually defined as organisational behaviour, which according to Borkowski is “the study of individual and group dynamics within an organisational setting” [6]. Both examine the meso-level of health care organisations, but also their interactions with the micro-level (e. g., health care professionals, managers, patients, relatives) and the macro-level (e. g., society, health care system, labour market, regional networks) and therefore overlap in some topics. However, as the term OHSR is commonly used in Germany, we use the term in the following.

Motivation for conducting this study

Literature research in the course of writing the latest consensus paper [3] revealed that OHSR in Germany can be regarded as very heterogeneous in terms of research objects studied and as conceptually fuzzy [7]. It was observed that existing HSR studies deal with organisations, teams and individuals in organisations, but only rarely formulate research questions with an explicit organisational reference. Thereby, there is the impression that health care organisations are in many cases seen as a study setting only, without theoretically and methodologically acknowledging the organisational nature of their research. The main motivation for this study is to refine these preliminary hypotheses and to provide an overview of the field of OHSR in Germany that can inform the further conceptual development of the field.

Aims and research questions

The aims of this study are two-fold:

• to provide an overview on the field of OHSR in Germany

• to systematically map original contributions on OHSR from Germany

  Primary research questions are:

• What is the scope of OHSR in Germany?

• How many original contributions explicitly formulate the organisational nature of their research?

• How many original contributions implicitly do OHSR without referring to it?

  Secondary research questions are:

• Which organisational forms are objects of research?

• What is the main health care context that the research addresses?

• Which research designs including which methods and methods mixes are being used?

• What is the purpose and objective of the research?

• What level of primary outcomes or central variables of interest does the research address?

• Does the research explicitly have a theoretical basis?

Methods

We conducted a scoping review of the conference abstracts of the 19th German Conference on Health Services Research, held in October 2020 [8] [9] [10]. With regard to the PRISMA-ScR Reporting Guideline [11], the methodological steps with reference to the search context, inclusion criteria, screening and extraction of data are described below ([Fig. 1]).

Fig. 1 Methodological approach to the review including the steps of screening, data extraction and mapping.

Information Sources, Search and Data Preparation

The German Medical Science-Portal (GMS) abstract database was searched for all published conference abstracts [12]. The identified abstracts and data were imported into the literature management software Citavi and were checked for completeness and correctness. For screening, all complete abstracts were automatically imported into the screening software Rayyan (https://www.rayyan.ai/) [13].

Inclusion criteria

Inclusion criteria were designed based on the conceptual definition of OHSR described above [3]. Accordingly, an abstract was included if it met at least one criterion for each of the following two lists.

• A health care organisation as an institution OR

• subunits of a health care organisation (e. g., departments, teams, nursing stations) OR

• organisational processes in an explicitly named health care organisation

  were formulated as a focus of research within the research question, objective, analysis, or reported results AND if at least one of the five research perspectives in the conceptual definition of OHSR is addressed:

• the environment and conditions under which health care organisations act OR

• the interdependence between individual and organisational levels OR

• the organisational structures, processes, and cultures of health care organisations OR

• the interactions within and between health care organisations OR

• the impact of these factors on (patient related) outcomes and the organisation of health care delivery

Screening the conference abstracts

First, a pilot run was conducted with a random sample of abstracts. From the alphabetically sorted abstracts, every tenth abstract was selected and independently reviewed by two reviewers. Disagreements and suggestions for improvement were then discussed by the research group, after which the final screening procedure was defined and the inclusion criteria were slightly modified. Secondly, all identified conference abstracts were independently reviewed by three reviewers each. Disagreements were discussed between the reviewers and resolved by consensus.

Data extraction and mapping

Following Krippendorf [14], a content analytic approach was conceptualised to enable categorical extraction and data presentation of the scope of OHSR within the conference abstracts. Data were extracted from all included abstracts using a self-developed and consented detailed coding scheme. Given the research questions, the main dimensions of the coding scheme were first created deductively. Based on this, the data extraction was piloted in two rounds on a sample of the conference abstracts to refine subcategories inductively and to test the extraction procedure. A hierarchical coding tree including dimensions, categories, and sub-categories was created (see [Tab. 1]), and a coding manual was formulated (Online Supplement 1). Finally, the data were coded by four researchers. The categorical data extraction was organised in Excel spreadsheets and the data were analysed descriptively.

Tab. 1 Data extracted from the abstracts by content analysis (N=138).

ORGANISATIONAL SETTING
Organisational form	N	%
Hospital	48	34.8
Inpatient rehabilitation clinic	5	3.6
Outpatient medical practice	26	18.8
Outpatient (therapeutic) non-medical practice	2	1.4
Practice networks	2	1.4
Ambulatory health care centre (MVZ)	1	0.7
Inpatient care facilities	15	10.9
Outpatient care services	3	2.2
Other organisational forms	10	7.2
Several organisational forms	16	11.6
Not clearly assessable	10	7.2
Main context of health care	N	%
Health promotion	5	3.6
Preventive health care	6	4.3
Curative care	39	28.3
Rehabilitation	6	4.3
Nursing	17	12.3
Palliation	13	9.4
Several of the above-mentioned care contexts	14	10.1
Not clearly assessable	38	27.5
RESEARCH DESIGN
Study type	N	%
Literature study	8	5.8
Conceptual-theoretical contributions	2	1.4
Observational study	82	59.4
Intervention study	31	22.5
Other study types	2	1.4
Several study types mentioned	11	8.0
Not clearly assessable	2	1.4
Data source	N	%
Primary data	96	69.6
Secondary data	22	15.9
Combination of primary and secondary data	14	10.1
Not clearly assessable	6	4.3
Research methods	N	%
Qualitative methods	34	24.6
Quantitative methods	45	32.6
Scoping review	3	2.2
Systematic review	3	2.2
Narrative review	2	1.4
Other methods	3	2.2
Combination of different methods	44	31.9
Not clearly assessable	4	2.9
RESEARCH OBJECTIVES
Research purpose and objective	N	%
Description/Explanation	68	49.3
Concept development	24	17.4
Evaluation	32	23.2
Implementation	2	1.4
Combination of above-mentioned research purposes	8	5.8
Not clearly assessable	4	2.8
Level of the reported primary outcome	N	%
Patient level	24	17.4
Employee level	26	18.8
Organisation level	44	31.9
Health system level	4	2.9
Multiple outcomes reported at different levels	34	24.6
Not clearly assessable	6	4.3
THEORETICAL FRAMEWORK
Explicit reference to theory	N	%
Yes	10	7.2
No	128	92.8
Organisational health services research	N	%
Explicit “Organisation”	24	17.4
Implicit	114	82.6

Note. Due to rounding, percentages might not add up to exactly 100%.

Results

Overall, 468 abstracts were identified for screening, all of which were written in either German (n=393; 84.0%) or English (n=75; 16.0%). A total of 330 abstracts (70.5%) were excluded because either the research question or objective was not related to an OHSR topic (n=222; 67.3%) or because no OHSR topics were investigated according to the inclusion criteria (n=108; 32.7%). After screening 29.5% (n=138) of these abstracts were ultimately included in the scoping review ([Fig. 2]).

Fig. 2 Flowchart for the inclusion and exclusion of abstracts in the screening process.

The included abstracts were analysed with regard to the organisational setting, the research design, the research objectives, and the theoretical framework. The results are shown in [Table 1].

Organisational setting

The majority of identified abstracts reported on studies undertaken in hospitals (acute care: n=48 (34.8%)), followed by studies focusing on outpatient medical practices (n=26; 18.8%). The main body of identified studies in the nursing setting revealed a strong focus on inpatient health care facilities (n=15; 10.9%) rather than outpatient health care services (n=3; 2.2%). Interestingly, a considerable share of studies was based on an inter-organisational context (n=16; 11.6%), i. e., studies investigated different organisational settings. Other organisational settings such as outpatient therapeutic practices (e. g., physiotherapy and speech therapy) were barely considered. Although in 27.5% (n=38) of the abstracts it was not possible to identify the main context of care, the remaining abstracts focussed mostly on curative health care settings (n=39; 28.3%). Notably, nursing care (n=17; 12.3%), palliative care (n=13; 9.4%) as well as studies, where more than one main care context is studied, (n=14; 10.1%) were identified in a considerable part of included studies. Studies on health promotion (n=5; 3.6%), prevention (n=6; 4.3%) or rehabilitation (n=6; 4.3%) were rarely the main context of health care studied.

Research design

The majority of included abstracts (59.4%; n=82) were based on observational studies, and 22.5% (n=31) had an interventional study design. The main body of studies used primary data (n=96; 69.6%), whereas secondary data was used in 15.9% (n=22) of the abstracts. Some abstracts drew on a combination of primary and secondary data (n=14; 10.1%). Regarding the research methods, there was a slightly higher use of quantitative (n=45; 32.6%) than qualitative (n=34; 24.6%) research methods. A considerable part of studies combined different methods (n=44; 31.9%). Hardly any abstract provided an indication of a ‘scoping review’ (n=3; 2.2%), ‘systematic review’ (n=3; 2.2%) or ‘narrative review’ (n=2; 1.4%).

Research objectives

Almost half of the abstracts reviewed were descriptive or explanatory (n=68; 49.3%). Other clearly classifiable abstracts focused on concept development (n=24; 17.4%, e. g., developing an intervention) and evaluation (n=32; 23.2%) rather than questions of implementation (n=2; 1.4%). Considering the studies where the primary research objective was deducible from the included abstracts, 31.9% (n=44) had their research focus on a primary endpoint at the organisational level, whereas research objectives at patient (17.4%) and employee level (18.8%) and especially at the health system level (2.9%) were less represented. Around a quarter, 24,6% (n=34) of the abstracts reported several research objectives at different levels.

Theoretical framework

An explicit reference to theory was applied in 7.2% (n=10) of the included abstracts, citing different theoretical approaches and not only organisational theories. A total of 24 abstracts (17.4%) mentioned the term ‘organisation’ or related terms (organiz* or organis*) explicitly.

Discussion

The results of the study provide a systematic but preliminary overview of the scope to which HSR in Germany is currently addressing organisational research and also highlight several theoretical and methodological challenges. The analyses support the view that most organisational research within HSR is conducted in hospitals. The most common context of health care was curing diseases. Most frequently used study types were observational studies based on primary data, with a slight trend towards quantitative empirical methods. However, we also found an increasing use of qualitative and mixed-methods procedures to depict the complex contextual conditions in OHSR. The most commonly cited research objectives were description and explanation at the meso- and micro-level. The term “organisational health services research” was never used, and the term “organization” or related terms appeared only occasionally.

However, the reasons for a number of these findings remain unclear. Whether and to what extent the results are due to conceptual reasons, such as the vagueness of our underlying concept and the OHSR field as a whole? Do the results possibly reflect preferences of researchers in dealing with the research funding system, especially with the Innovation Fund (Innovationsfonds) as the largest funding program of HSR in Germany? Or do they reflect the strong institutionalization of HSR at medical faculties in Germany and the associated research culture that is shaped by the paradigm of evidence-based medicine rather than the social sciences? In addition to the conceptual and methodological foundations provided by the consensus paper, the next step in light of these ambiguous results is to conceptually sharpen the research field of OHSR, raise awareness of organisational topics in HSR and develop a research agenda that directs future research.

Based on our conceptual definition, most abstracts addressed OHSR issues only implicitly and largely without reference to theory. A reflective use of organisational theories was virtually absent in the abstracts we evaluated, although a number of German and international textbooks on organisational theories are available from the reference sciences of sociology, management, and psychology, among others [15] [16] [17] [18]. If the lack of theory is not only due to the abstracts’ word limit, but reflects the lack of theory use in the respective studies, then this would hint at a low explanatory power of OHSR studies. In this light, the goal should be to encourage health services researchers to make greater use of organisational theory to advance knowledge in the field [19]. In this discussion, however, it should also be noted that, firstly, the instruments of evidence-based medicine are in principle capable of providing reliable results on effectiveness even without explicit reference to a theory and, secondly, that this phenomenon generally prevails in HSR as an implicit socialised guiding principle. However, since HSR is expected to provide innovative solutions for health care problems, it would be advisable to promote the consideration of theories and qualitative methods [20] in intervention studies to understand and explain the occurrence of outcomes in a specific organisational context [21]. Particularly under the condition of an uncertain environment characterized by rapidly changing situations, such as recently experienced in the COVID-19 pandemic, Pfaff et al. recommend supplementing the EbM approach with theoretical evidence to be able to inform politics in urgent situations, where clear evidence in terms of EbM is lacking [22]. Due to their systemic nature, modern social science organisational theories such as systems theories [23] , behavioural theories [24] or sociological neo-institutionalism [25] can play a crucial role in understanding and explaining the implications of the organisational context for the effectiveness and, in particular, the effectiveness gap of a medical or health-related intervention.

Due to a lack of clarity in the conference abstracts, both ambiguity and vagueness in the use of the term “organization” are evident, reflected in a lack of distinction between ‘health care processes’ and ‘organisational processes’. For example, although some abstracts on intervention studies conclude that the organisational context had an influence on implementation, organisational determinants were not explicitly and a priori covered in the study design. This ambiguity was not explored further in this scoping review using a theoretical, epistemological lens [26] but it should rather be the subject of a future sharpening of the conceptual and methodological foundations of OHSR in Germany.

This leads to another challenge of OHSR in the German HSR context: there are few tools that can help health services researchers that are not deep into organisation studies to conceptualize organisational context and organisational determinants in their studies. Developing a core set of organisational factors or determinants could help researchers to explicitly consider “organization” when designing studies. However, the risk that it leads to over-standardization and homogenization of the HSR field needs to be considered and reflected upon [27].

Strengths of this scoping review are the robust evaluation and consensual exchange among the reviewers, the systematic methodological approach [11], a pilot screening performed to create a common understanding of inclusion and exclusion criteria and the use of structured coding scheme for data extraction. However, the results of this paper are limited to a review of published abstracts from the 19^th German Conference on Health Services Research 2020, and as such provide only a ‘snapshot’ with limited information. However, they provide a useful baseline for follow-up studies. We did not evaluate the study quality and we did not review further materials and publications on individual projects summarized in the abstracts. The limited information summarized in abstracts led to missing information on some of the categories of interest and it has to be considered that an extraction of full papers of the presented studies would probably alter our results. Thus, it is possible that OHSR has been considered in research projects, but has not been identified through the screening procedure. It is also possible that our broad definition of OHSR, on which we relied for inclusion and exclusion criteria, led to oversampling of abstracts. It would therefore be desirable to validate the presented results by an extended systematic review based on full texts of the original papers. However, the availability of original research papers would have to be systematically researched or the authors interviewed directly after publication, as these were not available for the conference.

Conclusions

The results of this scoping review indicate that the theoretical and methodological foundations of the OHSR concept in Germany need to be further researched and developed (see Ansmann et al., 2024, in this issue https://doi.org/10.1055/ a-2326-6768). The refinement of the conceptual basis needs the involvement of researchers from related disciplines beyond HSR that study health care organisations from their respective fields (e. g., organisational sociology, health care management). This also includes a critical review of terminology, especially in relation to OBHC. Within the HSR community in Germany and among research funders, it is important to create an awareness of the organisational nature of many pressing problems in health care and, building on this, to sharpen and conceptually develop the research field of OHSR in Germany.

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