[The quality of the German health-care system in an international comparison - a systematic review].
OBJECTIVE
Studies assessing the quality of the German health-care system in an international comparison come to different results. Therefore, this review aims to investigate how the German health-care system is evaluated in comparison to other health-care systems by reviewing international publications. Results show starting points for ways to improve the German health-care system, to maintain and expand its strengths as well as to derive strategies for solving identified problems.


METHODS
A systematic review searching different databases [library catalogues, WorldCat (including MEDLINE and OAIster-search), German National Library, Google Scholar and others]. Search requests were addressed to English or German language publications for the time period 2000-2010 (an informal search was conducted in October 2011 for an update). Results of the identified studies were aggregated and main statements derived.


RESULTS
In total, 13 publications assessing the German health-care system in an international comparison were identified. These comparisons are based on 377 measures. After aggregation, 244 substantially different indicators remained, which were dedicated to 14 categories. It became apparent that the German health-care system can be characterised by a high level of expenses, a well-developed health-care infrastructure as well as a high availability of personal and material resources. Outcome measures demonstrate heterogeneous results. It can be stated that, particularly in this field, there is potential for further improvement. The utilisation of health-care services is high, the access is mostly not regulated and out of pocket payments can pose a barrier for patients. Waiting times are not regarded as a major weakness. Although civic satisfaction seems to be acceptable, a large portion of the citizens calls for elementary modifications. Especially, more patient-centred health-care delivery should be addressed as well as management of information and the adoption of meaningful electronic assistance systems.


CONCLUSIONS
The presented results show starting points on the way to further improve the German health-care system. It is necessary to maintain and expand its strengths as well as to derive strategies for solving identified weaknesses. This can be done with confidence since, according to Donabedian, a high structural quality represents an important fundament to improve outcome and process measures.
Institut für Medizinmanagement und Gesundheitswissenschaften, Universität Bayreuth.
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M
Lauerer
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M
Emmert
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O
Schöffski
D003695:Delivery of Health Care / Q000145:classification / Q000592:standards* / Q000706:statistics & numerical data*; D005858:Germany; D038622:Internationality; D009313:National Health Programs / Q000145:classification / Q000592:standards / Q000706:statistics & numerical data*; D010506:Periodicals as Topic / Q000706:statistics & numerical data*; D011785:Quality Assurance, Health Care / Q000592:standards / Q000706:statistics & numerical data*; D011787:Quality of Health Care / Q000145:classification / Q000592:standards / Q000706:statistics & numerical data*