National Initiatives Germany

In this section, national initiatives which have been set up in Germany can be found.

Sep 2017: 3.4 million pain patients not adequately treated in Germany

September 2017

3.4 million pain patients not adequately treated in Germany

Prof. Dr. Dr. Joachim Nadstawek, President of the German BVSD (Berufsverband der Ärzte und Psychologischen Psychotherapeuten in der Schmerz- und Palliativmedizin in Deutschland e.V.), calls for a restructured pain therapy within the German health care system. In Germany, a pain patient usually would have to wait about two years before being diagnosed correctly and another two years before being treated adequately. Only 350.000 out of 3.4 million patients suffering from chronic pain in Germany would have access to a pain specialist working in one of the 1.173 health care centres.

During this year’s congress, Nadstawek underlines the necessity of a new specialized pain management system (SASV) within the statutory health insurance and asks the German Health Minister Hermann Gröhe for political support. Interdisciplinary, qualified teams should be established in order to make sure that pain patients receive adequate treatment. Action would have to be taken soon, otherwise the lack of young doctors would aggravate the Situation.

The BVSD president asks the German health authorities to clear the way for the introduction of such a system. The intensive co-operation between GPs, specialists, psychotherapists, physiotherapists and pain nurses would allow a greater efficiency in pain management and enable patients to reintegrate into the workforce.

UVSD SchmerzLOS e.V. supports this initiative. 

 Read the original article here

 

August 2017: Open Letter to the Directors of KBV and GKV about issues in Palliative Care

August 2017

Neue EBM-Ziffern zur Versorgung Sterbender – kommt es zum Streit um die Palliativpatienten?

Open Letter to the Directors of KBV and GKV about issues in Palliative Care

In his open letter Ulrich Weigeldt, President of the German Association for General Practitioners (Deutscher Hausärzteverband), criticizes recent decisions of the Evaluation Committee (Bewertungsausschuss) which have been integrated into the EBM. These new regulations concern GPs and their responsabilities in palliative care. In future, a considerable number of medical services will only be remunerated if approved by the ‚Kassenärztliche Vereinigung‘. The approval will be given if the GP participates in additional trainings and qualifications. But how should a GP take part in a 14 days training in a centre for palliative care if he has to run the practice at the same time? And how should he take care of his patients when he is obliged to participate in seminars? Representatives of the German Association for GPs had pointed out these contradictions before the new regulations have been put into practice. However, nobody seems to have listened.

Weigeldt is convinced that the new regulations have mainly got one aim which is to exclude the GP from palliative care. According to Weigeldt, the patient is the one who has to bear the consequences. The doctor he might know for a lifetime is not allowed to accompany him during his last months or years. Instead, he will have to see a number of different specialists.

Weigeldt asks the addressees of his letter to reconsider the decisions. In his opinion, it does not make sense to break with established structures that proved to be effective and, furthermore, to ignore a GPs expertise completely. The Association for GPs would certainly be glad to support a professional exchange of information and ideas with its expertise.

Read the original articles here and here

Sep 2017: Kompass Sonderausgabe zu SIP 2017

Special Edition of Kompass - SIP 2017 Symposium

September 2017

Please find here the Special Edition of the Kompass with the summary of the presentations and discussions at the SIP 2017 Symposium in Malta in German language.

2016: Lower back pain as a significant factor in work related disability

The main topic of the German disability report from 2016 was “Company culture and health – challenges and opportunities”. Experts from different disciplines evaluated these topics and provided guidance for health management in business and how to create a positive company culture.

Furthermore, the report published current data and analyses about disease related loss of working days in Germany. The basis for these analyses are data from about 12 million employees from more than 1.5 million businesses in 2015 which have been provided by the public insurance institution AOK.

Development of Disabilities

According to these data the amount of disabilities in 2015 compared to the previous year has increased by 0.1%, now totaling 5.3%. The regions of North Rhine-Westphalia (5.9%), Saarland (6.4%) and Rhineland-Palatinate (5.9%) show the highest rates in Germany whereas in Bavaria (4.7%) and Baden-Württemberg (5.1%) they are comparatively somewhat lower.

On average, the employees insured by AOK were on sick leave for 19.5 calendar days within the reporting year. 54.9% of employees were recorded by their doctors at least once per year for their inability to work.

Overall, the level of disability has been slightly increased by 0.1% since the previous year up to the new level of 5.3%.

The following six disease areas are the major causes for lost working days:

  • Muscular skeletal diseases (21.8%)

  • Respiratory diseases (13.0%)

  • General injuries (10.8%)

  • Psychological disorders (10.5%)

  • Cardiovascular diseases (6.1%)

  • Gastrointestinal disorders (5.2%)

Back pain is the most prevalent diagnosis

The disability report 2016 evaluated 12 different industries, these were: the building industry, energy/water/refuse/mining, the manufacturing industry, metal, transportation, agriculture and forestry, tertiary service sector, trading, public administration and social insurance, health and social area, education as well as banking/insurance companies.

Out of the 40 most frequently reported single diagnoses, back pain is the most common cause for registered disability within the observed industries. Back pain is overall one of the three mostly reported single diagnoses. Acute infections have been the most frequent cause in 2015 for sick notes with 9.3 % of reported cases and 5.7 % of lost working days. Back pain is the next most frequent with 6.0% of cases and 5.7% of lost working days.

Proportion of back pain disability by industry in 2015

Below there are some examples listed by industry with the position of back pain related to the 40 most frequent reported single diagnosis (% cases / % of work loss days):

Banking/insurance: Top 3 (3.4% / 3.3%)
Building industry: Top 2 (7.0% / 6.2%)
Service: Top 2 (6.2% / 5.9%)
Energy/water/disposal: Top 2 (6.7% / 6.1%)
Education: Top 3 (4.1% / 3.8%)
Trading: Top 2 (5.6% / 5.4%)

 

Supporting conclusions from other health studies

In addition to the disability report 2016 there are other study results available which report that back pain counts for a large proportion of lost working days. SpiegelOnline has reported on October 19th 2016 with the headline “These 10 disorders affect the most Germans” which relates to a health study where the authors conclude that back pain is the number 2 of main complaints from the German population. Besides these surveys the authors refer also to data from the health insurance companies Techniker Krankenkasse and Barmer GEK. Both insurers have allocated a high proportion of lost working days to back pain as well.

References:

Fehlzeiten-Report 2016 „Unternehmenskultur und Gesundheit – Herausforderung und Chancen“, Hrsg. Badura, Ducki, Schröder, Klose, Meyer, 2016, Springer Verlag

SpiegelOnline, Gesundheitsstudie „Diese zehn Leiden plagen die Deutschen am ärgsten“, 19. Oktober 2016, Hrsg. Irene Berres und Nina Weber

Krankenhaus-Report 2015, Barmer GEK

Gesundheitsreport 2014, Techniker Krankenkasse

Nov 2015: "Societal disease" pain - deficient care in Germany

Oberursel (ots).

In November 2015 the German Pain League (Deutschen Schmerzliga e.V. (DSL)), the German Society of Pain Medicine (Deutsche Gesellschaft für Schmerzmedizin DGS) and the Professional Association of Physicians and Psychological Psychotherapists in Pain and Palliative Care in Germany (und Palliativmedizin in Deutschland e.V. (BVSD)) invited to the National Care Forum Pain, where Pain Physicians, Member of the German Parliament, Representatives of Insurance Companies, Associations of Statutory Health Insurance Physicians, and Patients discussed concepts for an improved pain care in Germany.

The unanimous consent among the participants: Current pain care is deficient.

More information you can find on the homepage of the German Society for Pain Medicine e.V.

Aug 2015: 88th Conference of Health Ministers

Care for pain patients in Germany has to improve. The 88th Conference of Health Ministers (GMK) chaired by the Rhineland-Palatinate Health Minister Sabine Bätzing-Lichtenthäler supported this.

“Despite all medical progress chronic pain is one of the largest health problems in Germany,” Cornelia Prüfer-Storcks, Hamburg's Health Senator, explains. The GMK demands that every hospital guarantees qualified and interdisciplinary care of pain patients. The aim of the Federal Joint Committee (G-BA) is to prepare quality criteria for pain therapy. In hospice and palliative care it must be ensured according to GMK that it is possible for all patients and inhabitants of care institutions also to actually have access to these specialised offers. When planning the new nursing training palliative care must be taken into account.

The German Pain Society hopes for concrete steps to be taken following the GMK's decision. From Professor Michael Schäfer's (President of the German Pain Society) point of view it is for example necessary to work out and implement pain quality indicators in hospital care. Schäfer also advises on a certification procedure. According to the Pain Society about 23 million Germans report chronic pain, 5 percent attributed to cancer.

In a further resolution the GMK  promotes the improvement of hygiene quality in medical institutions. The aim of the G-BA is to develop quality indicators. The conference has also agreed together with other European countries to make provisions for an influenza pandemic with severe diseases. Specifically vaccines should be ordered for the whole of Europe in the near future. Per federatl state a care key of 30 percent of the populaiton is planned.

Aug 2015: Day of Action against Pain

“Pain” must become a top priority in healthcare policy. Professor Michael Schäfer, President of the German Pain Society, demanded this on the occasion of the “Day of Action against Pain”. He urges hospitals to make pain care a quality criterion.

Schäfer emphasises that it is a question of raising awareness of key opinion leaders - policy,  health insurance companies and Regional Associations of SHI-accredited Physicians. The aim must now be to improve the care of both chronic and acute pain patients and to eliminate existing deficits. The specialist points out that the care of chronic pain patients in urban areas is good, but in rural areas such as Brandenburg rather poor. However, there are no exact statistics on the subject. The German Pain Society therefore wants to examine supply and demand broken down over 600 regions in Germany. The results, where supply and demand deviate from one another are to be summarised in a pain atlas.

Schäfer describes pain management and acute pain therapy in many hospitals as “not the best”. “In some cases this is neglected due to economic reasons,” he said. The expert calls upon hospitals to recognise pain care as a quality criterion. Franz Wagner, Vice President of the German Nursing Council,  picks out staff downsizing as one of the causes of the problems. “We have precarious staffing in nursing but also in other hospital professions,” Wagner explains. This leads to longer reaction times and in addition deterioration in patient care, if they have pain. Wagner's demands include expert nursing staff having to be available in every institution specialised in pain care.

This would ensure both excellent care and advice from colleagues in specialised questions. Both Wagner and Schäfer would like closer cooperation of all professions in the care of pain patients. Physicians, psychologists, physiotherapists, specialised nursing staff, pharmacists and the patients themselves have to work well and intensively together for effective pain therapy.  Schäfer emphasises that no single therapist can “know everything and comprehensively combine correct therapy”. The national “Action Day against Pain” is organised by the German Pain Society together with partner organisations annually on the first Tuesday in June.

July 2013: Best Practice from German Thuringia University Hospital Jena

Following the SIP platfrom news request from 27 July 2013, two German best pain practice projects were submitted by the Thuringia University Hospital Jena. Please find here more information on the following two projects:

  • QUIPS - Quality improvement in postoperative pain management
  • PAIN OUT - Improvement in postoperative Pain Outcome
Oct 2012: "Pain Nurses" - A new profession in the struggle against pain

 

ZDF_Report_Pain_NursesOn the 24 October 2012 the German TV station “ZDF” broadcasted a segment on “Nurses fighting against Pain”, a healthcare project that was initiated in 2010. This report dealt with the improvement of pain management in German Hospitals. In order to enhance the treatment of patients who suffer from severe or acute pain, e.g. after a surgery, a totally new profession was created in Münster, Germany, the so called “Pain Nurses”.

The segment is about one of the new skilled Nurses, Martina Rettig. By her example the benefits of a Pain Nurse are described:  alleviate acute pain and thereby prevent pain of becoming chronic. According to her opinion an improved pain management is only possible if doctors, physiotherapists and nurses exchange their experiences mutually.

Prof. Jürgen Osterbrink consents with her point of view and states that “Origin and outset of our effort is to prevent acute pain from proceeding into chronic pain. This is only possible through a convenient interaction of doctors, nurses and the patients themselves.”

Another benefit of this new treatment is that healthcare costs decrease because patients recover sooner and therefore regain a higher quality of life.

Meanwhile, all hospitals employ “Pain Nurses" and several cities intend to optimize their pain management according to this model.

In case you would like to read the full english transcription, please click the previous link.
If you'd like to see the full german ZDF heute report of the ZDF heute click the previous link: 

Oct 2012: Guidebook for Palliative Care

"Deutsche Palliativ Stiftung" publishes guidebook on "Palliative Care"

The 42-page booklet "Palliative Care" published by Thomas Sitte gives ideas and practical advice for caretakers as well as family members how to care for a dying person.

Furthermore it deals with topics like grief-management, pain relief and clinical or hospice inhabitation.

Read the full guidebook "Palliative Care"

Oct 2012: “Nurses fighting against pain”

National Care Forum Pain: Patients and Pain Medicine Professionals request improved pain care

„The quality of medical pain care in in-patient, as well as out-patient settings is negatively impacted by the lack of sufficient structures and by deficites in the training of doctors", states the German Pain Society (Deutsche Gesellschaft für Schmerzmedizin e.V. (DGS)) and the patients advocacy group German Pain League (Deutsche Schmerzliga e.V. (DSL)). The one who suffers is the patient him/herself.

Read the full press article (German) by the German Pain Society (Deutsche Gesellschaft für Schmerzmedizin e.V.).

Oct 2012: Informative guidebook "Dementia & Pain"

"Deutsche Palliativ Stiftung" publishes giudebook on "Dementia and Pain"

The practical booklet " Dementia and Pain", written by the pain therapists Magdalene Roth-Brons and Dr. Christoph Roth deals with patients who do not only suffer from chronic pain but also from dementia. Furthermore, it gives advice to family members and nursing staff how to treat someone affected by these diseases.

In addition this guidebook provides possibilities and options for relatives and caretakers to improve the exposure to dementia sufferers.

On the occasion of this improved treatment the guidebook includes a "sheet for pain evaluation for dementia sufferers" ("Bogen zur Beurteilung von Schmerzen bei Demenz", in short BESD).

Read the full guidebook "Dementia and Pain"

August 2012 : Special "Kompass"-issue on SIP 2012

SIP "Special Compass" : Chronic Pain challenges Health Care Systems

This special eight padeg paper sums up the outcomes and key results of this year's Symposium, taking place in Copenhagen on the 29-31 May 2012. Furthermore it displays current news from healthcarepolicies.

It is made up of 4 main topics:

- Chronic Pain challenges the Health Care System
- Chronic Pain is beeing underdiagnosed worldwide
- Policy needs to increase pressure on Doctors' self-government
- Interview: Possible savings not yet recognized by politicians with Dr. Hans Kress 

Read the full "Special Compass"[GER]
Here you can find the English "Special Compass" [EN]

August 2012: German Charta: Sign now!

Cross-Border support for “German Charta for Care of severely-ill and palliative patients”

Until today the Charta has been signed by almost 500 organisations and  850 individuals; now the health minister of the German-speaking community of Belgium has also given his signature. Please click here to sign the Charta.

The Charta for Care of severely-ill and palliative patients was published in autumn 2010 describing the current status quo of the management of severely-ill and palliative patients in Germany and giving suggestions for improvement for future actions. About 200 Experts from 50 societal and health political institutions had participated in the 2-year-development process of the Charta.

Responsible bodies are the German Society for Palliative Medicine (“Deutsche Gesellschaft für Palliativmedizin”, DGP), the German Hospice- and Palliative Association (“Deutsche Hospiz- und PalliativVerband”, DHPV) and the German Medical Association (“Bundesärztekammer”, BÄK).

During the 90th Aachen Hospice Day (“90. Aachener Hospizgespräch”) on 22 June 2012 signatures were given different representatives of the city of Aachen as well as the communities and (cross-border) regions, e.g. by Städteregionsrat Helmut Etschenberg, state secretary of the ministry of health, emancipation, care and age of the German region of Northrheine-Westphalia (NRW), Mr Marlis Bredehorst, and minister for family, health and social affairs of the government of the German-speaking community of Belgium, Harald Mollers (ProDG). Here you can find the speech of Harald Mollers.  Due to the  “Servicestelle Hospiz”, one of the endorsing organisations of the scientific aims of SIP, the region of Aachen & its communities (“Städteregion Aachen”) was mentioned as national best-practice example for its engagement and management of palliative care patients.

More information you can find at the Charta-Website.

June 2012: Kompass Newsletter

Pain is a key factor for the quality of life and a challenge for health care systems. Around 80 million people in Europe suffer from chronic pain. Prof. Dr. Hans-Georg Kress, the president of the European Federation of IASP Chapters (EFIC), pointed this out during the Pain Conference "Societal Impact of Pain" (SIP) in Copenhagen and requests political support.tl_files/redakteur-bereich/National Initiatives/Germany/June2012KompassNewsletter.jpg

In the June 2012 Kompass Newsletter, an interview with Prof. Kress regarding problems and progress in pain care and an article on for example pain education (amongst others) can be found.

Please read here the June 2012 Kompass Newsletter (German). The English version will be placed online soon.

June 2012: German Pain Society - "Action Day Against Pain"

Deutsche Schmerzgesellschaft - "Aktiv gegen den Schmerz"

17 % of Germans suffer from non-tumor related chronic pain. According to recent estimations, 50% of these patients are receiving inadequate pain treatment. For this reason, the Deutsche Schmerzgesellschaft e.V. is implementing reconsiderations in their “national action plan against pain” concerning politics and science.

On the 5th of June the Deutsche Schmerzgesellschaft will organize a nationwide “Action Day Against Pain”. By organizing this nationwide day, pain as an important subject will be made public even more. Under this year’s motto of “creating awareness”, people who are affected by pain can inform themselves by over 20 clinics that are participating. Through a cost free hotline, patients (and others) are given the opportunity to ask questions to pain specialist from all over Germany.

On 24 April a press conference was held about this subject. Please find here all materials related to this press conference. Please also find here the full announcement.

March 2012: German Pain Society: 26th Pain Research Award

Deadline for submission: 31 May 2012

This year for the 26th time the German Pain Society will hand out the Pain Research Award. With this prize for executing pain research, doctors, psychologists and scientists are encouraged to do work in the field of applied and basic research on acute and chronic pain.

A first as well as a second prize will be handed out in the categories "clinical research" and "basic research". A jury will determine the decide to whom the prizes will be handed out. Entries can be received until the 31st of May.

More information about this award, procedures and how to apply can be found here in the Pain Research Award 2012 flyer.

March 2012: Gesellschaftspolitischer Kommentar

“A matter of human rights”

 In March 2012 the article “Insufficient Paint Therapy – A matter of human rights” written by Rolf-Detlef Treede and Norbert van Rooij appeared in the „Gesellschaftpolitische Kommentare“ No 3/12.

 The article discusses that pain is one of the major health problems in Germany. Several initiatives to make access to the treatment of pain as a right have already passed the revue. In terms of the degree to which an appropriate pain therapy concept has been implemented, Germany is at the lower end of the scale. For Germany, the DGSS has established a national action plan to combat pain. Now the European Parliament (EP) may soon also actively take up the issue of pain after a number EP members called for a “Road Map for Action” in the course of SIP.

Please click here for the English GPK Article.
Please click here for the German GPK Article.

March 2012: Brochure "Chronischen Schmerzen im Alter"

German Senior League - "Chronic Pain in the Elderly"

In March 2012 the Deutsche Seniorenliga produced an informative brochure about pain in cooperation with Grünenthal. The title of the brochure is "Chronischen Schmerzen im Alter" and it focuses on elderly people. The brochure contains information about what pain is, diagnosing pain, the treatment of pain and tips for elderly people who suffer from pain.

Please find here the full brochure "Chronischen Schmerzen im Alter".

2011: Managed Care Programme: "Second opinion" / "Back to Work"

Cooperation of German health insurance and pain specialist society

1) "Second opinion for back pain patients" (Zweitmeinung)

In April 2010, German health care insurer (TK Krankenkasse) in cooperation with one of the German pain specialist societies started a project called "second opinion for back pain". According to a press release by the TK Krankenkasse insurance in Germany, every year about 230.000 patients are operated due to back pain.

Frequently, the original complaint - back pain - remains or returns. Patients often complain that after the back operation the pain became worse.
According to data provided by the insurance about 80% of these back operations (intervertebral discs) are not needed as they could have been cared of with conventional (pain) care.

For patients referred for a back operation, the insurance offers the possibility to get a very fast second opinion with a specialized pain care team without waiting time (within 2 days). In case the pain specialist and patient agree upon an pain therapy alternative to the back surgery the pain therapy is reimbursed. The pain treatment will then be performed by a cross-functional team where pharmaceutical treatment is only one of the available instruments. In case the pain treatment is unsuccessful the back surgery still can take place.

For the healthcare insurance the costs of a back surgery are much higher than pain care; for the patient the risk is much lower. For pain specialists the advantage is that they get to see the patient while measures still can be taken. The only ones losing in this managed care program seem to be the surgeons. Due to the long waiting lists they have not complained.

According to a 2011 German press article 85% of the patients within this programme were not confirmed for their back surgery.

Article on Ärzte Zeitung

2) "Back to Work"

The same cooperation initiated a project to bring back patients back to work. Patients unable to work due to back problems the insurance offers a managed-entry pain care program (medical doctors, psychologists and physiotherapists). This project was presented at the symposium on the Societal Impact of Pain (SIP) 2010 by the CEO of this insurance Prof. Norbert Klusen.

From over 3.700 patients included in this program in a 4 - 8 week therapy program 49% was free of pain after 4 weeks and 84% returned to work after 8 weeks. Six month later still over 90% of the former patients was still working. Modest calculations show the insurance saves at least 5000€ per patient (see "Informationsdienst Wissenschaft").

December 2011: Summary "Future of Pain Therapy"

The summary of "Future of Pain Therapy", an interdisciplinary symposium that took place in Düsseldorf on 2 and 3 December 2011 for the 7th time, is now available online. The summary is being complimented by the supplement "Der Schmerz über den fehlenden Schmerz" focusing on a dinner speech by Dr. Wolfgang Klitzsch, manager of the Ärztekammer Nordrhein.

Here you can find the summary of the dinner speech "Der Schmerz über den fehlenden Schmerz", held during the 7th workshop. Furthermore, summaries and previous programs of previous workshops organised by Grünenthal focussing on the Future of Pain (2005 - 2011) can also be found on the Grünenthal website.

November 2011: Publication Versorgungsatlas Schmerz
November 2011: Publication Deutsche Seniorenliga e.V.

German Senior Citizens League

Magazine Aktiv "Chronic Pain", Nov-Dec 2011

More information on the Deutsche Seniorenliga is available on the official website.

July 2011: Kompass Newsletter - SIP Special Edition
February 2011: Publication in "Der Schmerz"

"Epidemiology of chronic non-malignant pain in Germany"

The journal article "Epidemiology of chronic non-malignant pain in Germany", written by R. Wolff et al, was published in the German medical magazine "Der Schmerz" Volume 25, number 1, with the aim of presenting information on chronic, non-malignant pain in Germany.

Article in Der Schmerz

Full Epidemiology Report

Chronic Non-Malignant Pain in Germany

Please find below the full report of "Epidemiology of chronic non-malignant pain in Germany", written by Christine Clar, Christian Lerch, Robert Wolff and Jos Kleijnen.

Full Report "Epidemiology of chronic non-malignant pain in Germany"

Specialised Outpatient Palliative Care

Specialised Outpatient Palliative Care in Germany

(SAPV - Spezialisierte ambulante Palliativversorgung)

About 25 years ago the “hospice movement” started - arising from a situation characterized by tabooing death and isolating deceasing persons. Since then a dynamic development has taken place in Germany. The hospice movement particularly actuated the societal change in awareness and attitude in dealing with severely ill patients. These changes were mainly driven by a citizens' movement and smoothed to way for palliative medicine.

Palliative care has the goal of maintaining, enhancing and improving the quality of life and self-determination of severely ill patients with an incurable very advanced disease and to allow them a dignified life up to death.

Since 1 April 2007, in accordance with the Social Code Book V (SGB V), patients with statutory legal insurance are entitled to specialised outpatient palliative care (SAPV).

Today there are about 1500 outpatient hospice services, 180 inpatient hospices and 230 palliative departments in hospitals. More than 80000 people get voluntary involved in hospice work. 

At this all severely ill and deceasing persons must benefit from progress in pain therapy and alleviation of severe physical symptoms.

The German Parliament decided in a sitting on June 18th 2009 the substantial changes in the Social Code Book V (SGB V) regarding hospice care within the context of the amendment of German pharmaceutical law (AMG Novelle). The German hospice and palliative society (DHPV) had started the corresponding legislative initiative after having evaluated the current situation of outpatient and inpatient palliative services in a considerable study in 2008.

To implement the new range of benefits, the statutory health insurance funds first have to make contracts with suitable facilities or persons (service providers), in so far as they are necessary for adequate care. 

More information available at the Bundesministerium für Gesundheit (German Ministry of Health). 
Report of the German Ministry of Health on the Specialised Outpatient Palliative Care in Germany
Additional information at www.dgpalliativmedizin.de or at www.dhpv.de.