Michael Mueller
email: michael.mueller@umit.at436765446929

Prof. Dr Harald Meyer

Harald Stummer

Michael Müller

Behaviour in therapeutic medical care -evidence from general practitioners in

Keywords: general practitioner, supplier-induced demand, therapeutic medical care Blinded

Aim The present study examines monetary effects of general practioners' behaviour in therapeutic medical care to identify sample characteristics that allow differentiating between the individual general practitioner and the basic population. Subjects and methods Medical services, provided by 3919 general practitioners in Austria, were operationalized by means of the dependent variable "costs per patient". Statistical outliers were identified using Chebyshev's inequality and categorized by investigating bivariate correlations between the dependent variable and the personal characteristics of each physician. Results Variables that relate to the size of the customer base, such as number of consultations (r = 0.385) and office days (r = 0.376), correlate positively with the costs for medical services. By analyzing the portfolio of the general practitioners, we found a correlation of 0.451 between this coefficient and the costs. Statistical outliers feature an average portfolio of 44.5 different services, compared to 30.45 among non-outliers. Especially laboratory services were identified as cost drivers (r = 0.408). Statistical outliers generate at least one laboratory parameter for 44.34% of their patients, opposed to 27.2 % within the rest of the sample. Consequently outliers produce higher laboratory costs than their counterparts. Conclusion We found some evidence that physicians have influence in the provision of their services. Considering entrepreneurial objectives the extension of the portfolio can increase their profit. Our findings indicate supplier-induced demand for several groups of services. We assume that the effect is consolidated by the fee for service system and could be compensated by adequate reform.

Introduction

In primary care, general practitioners (GPs) represent the first point of contact for people with illness issues, who determine the diagnosis and advise their clients regarding the adequate treatment (Statistik Austria 2006;[START_REF] Britt | The contribution of demographic and morbidity factors to self-reported visit frequency of patients: A cross-sectional study of general practice patients in Australia[END_REF][START_REF] Smits | Epidemiology of frequent attenders: A 3-year historic cohort study comparing attendance, morbidity and prescriptions of one-year and persistent frequent attenders[END_REF]). Because of their steering function in the health care system, GPs are often referred to as gatekeepers who regulate and control the demand for medical services [START_REF] Toon | Justice for gatekeepers[END_REF].

They decide whether the service of another colleague or discipline is inevitable or if their portfolio is sufficient enough to induce the recovery of the patient. The personal portfolio can basically be classified into the prescription of pharmaceuticals and the autonomous delivery of medical services, where the latter represents the doctor's income. As e.g. in Germany and Austria outpatient therapeutical medical care is financed by social insurance institutions and therefore consumers rarely control the generated quantities, health economists assume that doctors have the ability to create demand for their services [START_REF] Peacock | Supplier-induced demand: Re-examining identification and misspecification in cross-sectional analysis[END_REF][START_REF] Fuchs | The supply of surgeons and the demand for operations[END_REF]). This phenomenon is referred to as supplier-induced demand (SID), which implies that the producer of medical services defines the degree of his capacity utilization according to his own preferences -including his salary requirements -without the basic market forces regulating the transaction [START_REF] Richardson | Supply and demand for medical care: Or, is the health care market perverse?[END_REF]Freebairn 2001).

The model is based on a study by [START_REF] Evans | Supplier induced demand: Some empirical evidence and implications[END_REF], who analyzed the financial situation of physicians in outpatient therapeutic medical care under the assumption that the income not only depends on the actual demand for medical services, but also on the providers' preferences. One of the most recognized publications in this field was presented by [START_REF] Fuchs | The supply of surgeons and the demand for operations[END_REF] He reported direct association between the physician density per capita and the number of therapeutic medical services (TMS) performed.

In his sample a 10% rise in surgeon positions increased the demand for surgeries by 3%. In absolute numbers each additional position in the particular region would imply an increase of between 40-60 surgeries per year [START_REF] Fuchs | The supply of surgeons and the demand for operations[END_REF].

Other studies since the late 1970s have advanced the theoretical and empirical knowledge of SID, which in the USA is also referred to as physician-induced demand PID [START_REF] Green | Physician-induced demand for medical care[END_REF][START_REF] Auster | Identification of supplier induced demand in the health care sector[END_REF]Freebairn 2001). Most of the research refers to the fact that the personal income is an important determinant in the physician's utility function and a shift in doctor's advice to more expensive medical treatment can be autonomously induced by the providers.

However, the monetary effect of SID was discussed by Stano, who assumes that SID could only occur in monopolistic markets, since the effect can never compensate for the loss in earnings if the market is saturated [START_REF] Stano | A clarification of theories and evidence on supplier-inducement demand for physicians' services[END_REF].

There is a controversial debate on the view if SID is a phenomenon of self-interest of the physicians, emphasizing the doctor's role as an agent who has to preserve the patient's interests [START_REF] Rossiter | Standesmeldung Österreichische Ärztekammer Juni[END_REF]. In this context the dual capacity of the GPs causes some reason for doubt. On the one hand they represent trusted advisers in health matters of their clients, but on the other hand they operate as entrepreneurs who can benefit from excessive supply [START_REF] Breyer | Gesundheitsökonomik[END_REF]. This antagonism is enhanced by the information asymmetry between the protagonists, with the less informed patients delegating health care desicions to the doctors. This behaviour remains unproblematic as long as the latter serve as perfect agents, without pursuing opportunistic interests.

Based on the present state of research in the field of SID and under the assumption that physicians who operate in a social health care system have to economize when choosing the adequate treatment for their patients, the main objective of the present study is to analyze the behaviour in outpatient therapeutic medical care.

According to the above-discussed literature, the aim of the present study is to answer the question if GPs providing excessive medical services can be identified. It will be evaluated to what extent miscellaneous individual characteristics of physicians have an impact on their behaviour by using the example of Austrian GPs and the medical services they generated during the year of 2008.

Methodology

The present study uses data from an national social insurance institution from 3,919 GPs nationwide in the year 2008. The cooperating institution represents the social insurance company for the self-employed in Austria, with a customer base of 461,301 insurants. In Austria approximately 6,400 GPs work in private practice, with 4,367 GPs being under contract with the cooperating social insurance institution. 1 The dataset only includes doctors who provide medical attendance during the entire year, excluding those who went out of business or started operations during that period.

During the observation period 2,903,820 consultations were conducted that accounted for € 59,477,598.

After the selection of the outliers their personal characteristics are to be detected.

The objectives require the identification of all statistical outliers in the following category, which also represents the dependent variable (DV):

DV = Total expenditure per patient for TMS provided

In calculating the outliers, we take into account that there is a strong linear relationship between the costs for medical services and the number of patients treated. The graph which describes the relationship runs through the zero point and has an inclination that represents the proportionality constant. The proportionality constant equates to the average costs per TMS, calculated over the total sample of 3,919 GPs.

b = total costs / total number of patients

With the proportionality constant the estimated costs for each GP are calculated by the formula:

estimated costs = b * number of patients

We use the distribution of the deviations of the actual costs per patient from the estimated costs to define a statistical outlier:

An outlier is a physician, whose discrepancy between actual and estimated costs for medical services exceeds the 90 % percentile of the distribution of the discrepancies of all physicians with the same number of patients.

To determine the limit that has to be exceeded in order to be identified as an statistical outlier we apply Chebyshev's inequality, which reads as follows [START_REF] Fisz | Wahrscheinlichkeitsrechnung und mathematische Statistik. 1 st edn. Berlin, VEB Deutscher Verlag der Wissenschaften Freebairn J[END_REF]):

If X is a random variable X with a second order finite moment E(X 2 ) < ∞, then for every constant c>0 holds: P(IXI c)  E(X 2 ) /c 2 . In our case X represents the deviation of the actual costs from the estimated costs. +++insert figure 1+++

Fig. 1 Chebyshev's inequality

This inequality has the advantage to be a very conservative method to determine outliers, since it only identifies outliers whose actual costs deviate dramatically from the estimated cost. Moreover no estimation for the special kind of the distribution (e.g. normal distribution) is needed for the calculation, since the method only requires an estimation for the second order finite moment of the distribution, which can be calculated from the empirical data. After determination of the numerical value of P(IXI  c) the inequality can be resolved to c.

Typology of the outliers

In the attempt to categorize outliers according to their behaviour in therapeutic medical care we investigate bivariate correlations between the statistical outliers and

Results

The primary focus of this study is to evaluate the role of the GP in the demand for medical services by statistically analyzing his behaviour irrespective of the patient's health status. Table 1 presents an overview of the correlation between the relevant variables. The strong correlation between the patient quantity and the costs (r=.71) confirms our decision to use the average costs per patient as the dependent variable to identify statistical outliers.

+++insert table 1+++

Table 1 Overview of the relevant variables Within the sample a total of 437,532 patients were treated, who consulted their GPs 2,903,820 times during the year 2008 and received a total number of 6,576,830 services, which amounted to € 59,477,598. Based on the numerical value per patient (€ 135.94), the anticipated cost for each physician and the deviation from the actual costs can be calculated. The application of Chebyshev's inequality shows a significant deviation from the estimate in 148 cases. In other words, the treatment expenses of 148 GPs, measured by the deviation of the actual costs per patient from the estimated costs, exceed the rest of the sample significantly. In this subsample of 148 statistical outliers the total sum of costs above the extimated costs amounts to € 2,238,777.90. Now we intend to contain the statistical outliers by explaining their behaviour in therapeutic medical care with criteria or a combination of criteria that are characteristic for the physician.

We found correlations between the dependent variable (costs per patient) and all variables that relate to the patient frequency (office days, number of consultations).

The correlations vary between 0.376 (office days) and 0.385 (consultations). This indicates that the doctor's income is dependent on the size of his customer base and the magnitude of the demand for his services. That assumption is confirmed by the following findings: Outliers have significantly more office days and a larger number of consultations than subjects that do not exhibit these attributes (Tab. 2). The probability that an outlier is identified within group 2 is nine times higher that within the group with less capacity. In this and all following contingency tables "group 2" contains the physicians whose value in the independent variable exceeds the upper limit of the so-called 2-sigma-range. Group 1 contains the rest of the sample. Between the criterion "population" and the dependent variable we found a negative correlation of -0.241, indicating that physicians who produce more quantity are likely to be located in regions with a smaller population. Additionally, we compare physicians from the two biggest municipal regions (Vienna and Graz) with the rest of the sample (Tab 3).

+++insert table 2+++

+++insert table 4+++

Table 4 Population As expected we found significantly more outliers outside the two municipal areas.

The probability to identify an outlier in a rural region is twice as high as finding one in a municipal area. In contrast the physician density, which represents a common feature of many SID studies, could not be detected as a variable of relevant influence within the sample.

When analyzing the quantity of medical services, the data provides evidence for an appreciable correlation between the number of medical services produced by the physician and the costs (r = 0.425). The outliers show an average of 2098.39 therapeutic services annually, compared to 1131.09 services for the rest of the sample. The dichotomous analysis verifies the results, since the group of physicians that produces more quantity contains 7 times more outliers than the other group (Tab 4).

+++insert table 5+++

Table 5 Number of services

Considering the fee structure for medical services, the findings seem to be trivial, since prices are fixed and basically the quantity regulates the costs. However, we decided to assess the subject more extensively by focusing on the physicians' individual portfolio. In this context we define the GP's portfolio as the range of medical services, measured by the number of different services according to the current fee structure. The correlation between the dependent variable and the criterion "portfolio" is 0.451. The mean comparison indicates that outliers (44.51 different services) have a greater portfolio than their peers (30.45 different services).

The dichotomous analysis is highly significant and supports the results (Tab 8).

+++insert table 6+++

Table 6 Portfolio

We continued by investigating if a group of services might induce this trend exceptionally and found a positive correlation (r = 0.408) between the number of laboratory services and the dependent variable.

On average statistical outliers provide 433.96 laboratory services compared to 148.32 services by their peers. The evaluation of the laboratory costs featured a corresponding result (Tab. 6, 7). Finally we focused on the criterion "laboratory services" to investigate possible differences between the statistical outliers and non-outliers in this area:

+++insert table 7+++

The mean value of the annual costs for laboratory services per physician within the group of outliers is € 4,013.46 (standard deviation 3,516) compared to € 1,453,20 (standard deviation 1,834.27) with non-outliers. The costs for laboratory services per patient reveal a similar result. In the group of outliers the annual costs per patient average € 90.75 (standard deviation 57.64) compared to € 40.21 (standard deviation 34.28) with non outliers.

+++insert table 9+++

Table 9 Key data for laboratory services

The laboratory quota represents the percentage of patients who receive a laboratory test during the consultation of their GP. Outliers perform at least one or more tests per year for 44.34% (standard deviation 14.13%) of their patients, opposed to 27.82% (standard deviation 11.68%) among their counterparts. Since every laboratory parameter contributes to the GP's income we calculated the share of laboratory revenue of the total revenue. The percentage of the physician's income that can be attributed directly to laboratory services is on average 14.24% (standard deviation 9.31%) in the group of outliers and 9.16% (standard deviation 12.08%) amongst other providers.

Considering the final two criteria of our study, neither the variable age of the physician nor gender had a significant influence on the costs per patient.

Discussion

In Austria, outpatient therapeutic medical care is disbursed on a "fee for service" basis ( § 28 Honorarordung). With the exception of a few capped positions, the doctor's income correlates positively with the number of services provided for his clients and consequently with the number of consultations. This type of remuneration system does not use the medical output in terms of "production of health" to determine the net income of the provider. Therefore, an economical and considerate use of the resources is not necessarily required. Through its monetary incentives the modality of payment for medical attendance determines not only the costs of health care but also the effectiveness of the system. In general, effectiveness can be described by the capability of the selected procedure to achieve the objectivein our case the recovery of the patient.

Accordingly, GPs are expected to (Devlin and Sarma 2008;[START_REF] Newhouse | Reimbursing health plans and health providers: Efficiency in production versus selection[END_REF]:

supply as many patients as possible with TMS and to be continuously available for their clients offer a wide range of medical services to meet the individual requirements of their patients establish a personal doctor-patient relationship with all customers without discriminating against high-risk groups

The "fee for service" system meets these requirements [START_REF] Rice | Physician payment policies: Impacts and implications[END_REF]Devlin and Sarma 2008). Physicians who provide a sizable clientele with a maximum of services are rewarded, sanctioning those who accomplish less quantity [START_REF] Robinson | Theory and practice in the design of physician payment incentives[END_REF]. Our study supports the assumption that the size of the customer base and the frequency they demand for doctor's advice is the biggest cost driver in therapeutic medical care.

The findings are comprehensible and inherent to the current remuneration system. In this context a few drawbacks of the fee for service approach should be mentioned:

Neither the adequacy of the supplied services nor the enhancement of the population's health status represent criteria for success [START_REF] Hickson | Physician reimbursement by salary or fee for service. Effect on physician practice behaviour in a randomized prospective study[END_REF]. Also interdisciplinary collaboration between the different groups of health care professionals is not promoted. Most of these shortfalls could be balanced by implementing alternative remuneration mechanisms such as "pay for perfomance" or "capitation", which presently are not established in the Austrian health care system [START_REF] Levaggi | Optimal payment schemes for physicians[END_REF].

Under the assumption that the behaviour of GPs in therapeutic medical care is also determined by personal requirements of the care provider, the theory of SID becomes a popular research area for health economics. As stated above, to be considered an inducement, the medical services should be of questionable value to the patient and primarily initiated for profit and not medical reasons [START_REF] Bradford | Supplier-induced demand and quality competition: An empirical investigation[END_REF]. Eventually there also is a strong coherence between the system of remuneration for medical services and the likelihood of SID. Physicians who derive their income in a "fee for service" system have a 30% higher probability to initiate further consultations than their peers in "capitation" or "pay for performance" settings [START_REF] Phelps | Health Economics[END_REF]. The interdependency between SID and health care costs appears to be reasonable, since our current system measures the GP's income in achieved quantities, whereas alternative approaches emphasize the outcome of the medical intervention. Against this background the steering function of the remuneration system becomes apparent.

The results of our study provide some insight into the GP's latitude when providing medical treatment. The tendency that physicians with extensive portfolios frequently exceed the costs indicates the occurence of SID within the sample. Statistical outliers feature on average 14 more services within their portfolio than physicians with a more economic behaviour. We assume that most of the effect can be attributed to the possibility to provide laboratory services. Considering the average laboratory costs per patient, the identified statistical outliers exceed the rest of the sample by 125%. Also the mean laboratory quota of 44.34% within the outlier group appears to be rather excessive, especially if you consider the GP to be more of a generalist and not necessarily a specialist for laboratory diagnostics. It is highly improbable that the disparities in the magnitude of conducted laboratory services can exclusively be attributed to the health status or active demand on behalf of the patients. Rather the qualification of the physician -and his opportunity to allocate activities -increases the supply. Consequently if a physician is permitted to procure a certain product range, he is capable of providing TMS irrespective of the actual demand.

Our findings indicate the existence of SIDnot necessarily for the occupational group collectively, not even for the individual GP's full range of services, but more probably for several types of services. It seems appropiate that, especially in the field of laboratory medicine, tests can be generated by the bulk using technical equipment without exceptionally affecting the scarce time resources of the physician.

Considering the entrepreneurial objectives in a fee for service system, the expansion of the portfolio of TMS seems to be a common method to increase profit [START_REF] Carrin | An empirical model of the demand for health care in Belgium[END_REF]. The effect is however consolidated by the prevailing system of remuneration and could be absorbed by adequate reform. Reflecting the opening statement about the GP's core competences and his particular importance to the health care system, alternative forms of payment that inhibit SID by compensating the GP ad valorem are inevitable.

The following limitations of this study should be mentioned:

The behaviour of the GPs was analyzed based on the available data. Since only the billing data of the national health insurance was accessible, the diagnoses of the patients and the form of therapy could not be evaluated. Therefore the study was conducted without consideration of the clients' health status. Another critical point is the absent comprehensive survey reflecting on the interdependency between the medical services and the pharmaceuticals prescribed by the physicians. We assume that these factors are mutually dependent and would like to focus on that assumption in a follow-up study. -Author's comment: The study does not include privately financed services of GPs. Within the group of GPs, who are under contract of a social insurance company, the vast majority of services are financed by the social insurance institutions. To some extent legal restrictions even prohibit this group of physicians to invoice private bills.

In contrast within the group of GPs who are not under contract of a social insurance institution (Wahlärzte) all medical services are paid on the patient's own accountand only if the patient files the invoice to his social insurance company, they reimburse 80% of the costs. However this group of GPs is not included in the sample. The financing of GP services through private insurance institutions is not a common method of remuneration on the Austrian market, since they predominantly focus on financing hospital services. 4. Page 3, I.53: Maybe better: "It will be evaluated to what extent…" -Revision p.3: was adopted in the text 5. Page 4, I.12/13: Sentence "According to the above-questioned literature, the aim…" fits better on page 3 between I.51 and 52/53 -Revision p.3: was adopted in the text 6. Question: Page 4, I.2: What kind of health insurance institution cooperated with you in order to conduct the study? In Germany, different health insurances exist with more or less different groups of insured people (differ for instance in age, socio-economic status, chronic diseases…) -Revision p.3/4: The cooperating institution represents the social insurance company for the self-employed, with a customer base of 461,301 insurants. 7. Acknowledgment -Revision p. 12: The authors would like to express their appreciation to the SVA der gewerblichen Wirtschaft for providing us with the data used in the study.

  densitynumber of GPs per community c. Gender of the physician d. Age of the physician e. Dimensions of the medical practice measured by the patient frequency (office days, number of consultations) f. Number of medical services g. Portfolio of medical services h. Quantity of services and costs in the field of laboratory medicine These tested variables have no obvious relationship with the health status of the physician's patients.

Table 2

 2 Office Days +++insert table 3+++

Table 3 Consultations

 3

Table 7

 7 Number of laboratory services +++insert table 8+++

Table 8

 8 Costs of laboratory services

Table 1

 1 Overview of the relevant variables

	Tables 1-9
		patient quantity	office days consultations	medical services quantity	medical services costs	laboratory services costs
	patient quantity		.61	.86	.79	.71	.50
	office days	.61		.72	.69	.61	.43
	consultations	.86	.72		.95	.84	.65
	medical services quantity	.79	.69	.95		.86	.81
	medical services costs	.71	.61	.84	.86		.66
	laboratory services costs	.50	.43	.65	.81	.66

Table 2

 2 Office Days

		non-outliers outliers total
	group 1	3636	127
	group 2	135	21
	total	3771	148
	chi square	41.94
	mean	536.54 882.22

Table 3

 3

	Consultations

Table 4

 4

	Population

Table 5

 5 Number of services

		non-outliers outliers total
	group 1	3668	130
	group 2	103	18
	total	3771	148
	chi square	42.33
	mean	30.45	44.51

Table 6

 6

	Portfolio

Table 7

 7 Number of laboratory services

		non-outliers outliers total
	group 1	3629	110 3739
	group 2	142	38 180
	total	3771	148 3919
	chi square	156.01
	mean	827.43 2434.46

Table 8

 8 Costs of laboratory services

			outliers		non outliers
		mean	standard deviation	mean	standard deviation
	total laboratory costs	4,013.46	3,516.00 1,453.20	1,834.27
	total laboratory services	707.53	602.47	259.87	325.56
	laboratory costs per patient	90.75	57.64	40.21	34.28
	laboratory quota	44.34%	14.13% 27.82%	11.68%
	income quota	14.24%	9.31%	9.16%	12.08%

Table 9

 9 Key data for laboratory services The present study uses data from an Austrian national health insurance institution from 3919 GPs nationwide in the year 2008. In Austria approximately 6400 GPs work in private practice, with 4367 GPs being under contract with the social insurance institution. Physicians who did not provide services for the cooperating social insurance institution during the entire year of 2008 were excluded from the sample.3. Page 2 (Introduction), I.3: In Germany, medical services are predominantly paid by social insurance institutions but there are other resources like private health insurances and others. In fact, remuneration by private health insurances constitutes a very important source of income for GPs.

	Figure 1
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Standesmeldung Österr. Ärztekammer, Juni

Authors' Response to Reviewers' Comments

Acknowledgments

The authors would like to express their appreciation to the SVA der gewerblichen Wirtschaft for providing us with the data used in the study.

Abbreviations

supplier-induced demand (SID), general practitioner (GP), therapeutic medical services (TMS)

Conflict of interest

The authors declare that they hove no conflict of interest.


Keywords: Workplace, Health promotion, effect, benefit, employee perspective

Aim: The aims of the present study were to investigate the potential of worksite health promotion to improve individual well-being from the employees' perspective, analyze benefit categories and develop suggestions for future worksite health promotion program designs. Subject and Methods: A questionnaire based on a qualitative study was distributed in four Austrian organizations to cover state-owned, private, and non-profit organizations. A total of 237 white-collar employees participated in the survey.

Results: Workplace health promotion does improve individual well-being from the employees' perspective. A factor analysis of the changes in well-being reported yields a three factor solution with a physical/cognitive element, a social component, and an emotional factor. In the sample tested, the physical-cognitive and emotional elements of perceived benefits were felt the most.

Conclusion:

The current theoretical grouping of potential WHP effects requires further testing and might profit from being differentiated into more categories. Research on WHP could gain from a consideration of the employee's perspective by showing which program elements to focus on. Strengthening the emotional components of WHP information and offer design is proposed to increase participation rates and subsequent individual benefits derived.

Introduction

What determines individual well-being? How can it be achieved and then maintained?

Researchers have so far explained the concept of well-being in different ways and according to Huppert et al. (2009) there is still no definition widely agreed on. A vast variety of factors regarding the personal disposition and the situational context influence how people perceive and evaluate how they feel or should feel, compared to others. While achieving personal wellbeing is thought to play an important role when individuals rate and choose options and behaviours [START_REF] Rodogno | On the Importance of Well-being[END_REF], personal and situational issues influence these decisional processes, as well [START_REF] Heckhausen | Motivation und Handeln[END_REF]. The outcome then has an effect on well-being, creating a dynamic interdependency, which on the one hand is sure to make any scientific model on the topic of well-being rather complex, but on the other hand it also makes clear that there are various possibilities to influence and improve well-being. These may in the long term also serve to even fluctuations of well-being. The present paper addresses this idea by investigating which potential worksite health promotion (WHP) shows in improving individual well-being from the employees' perspective, which is an underrepresented research topic [START_REF] Bödeker | IGA-Barometer 2[END_REF]. Moreover, there is no instrument available for analyzing employee perceived effects apart from medical criteria, which is why a quantitative questionnaire was developed based on available, mostly qualitative research, to find out which effects of WHP are felt by a larger number of employees.

Background

WHP is one of the most prominent approaches to improve individual well-being in the work setting [START_REF] Breucker | Gesundheitsförderung -Zum Wohle von Unternehmen und Mitarbeitern[END_REF] and following the European Network for Workplace Health Promotion (ENWHP) is defined as "the combined efforts of employers, employees and society to improve the health and well-being of people at work" (ENWHP 2007, p. 1). It is a holistic concept incorporating (1) the improvement of the work organisation and the working environment, (2) the promotion of active participation of all stakeholders in the process, plus

(3) the encouragement of personal development (ENWHP 2007). By doing so, WHP is expected to bring about positive changes in employee well-being over time, and to result in them achieving a higher general level of well-being so that even fluctuations of well-being do not reach as low a point as before. This outcome seems especially appealing since fluctuations in well-being may have a tendency to happen too quickly for any situational approach to take effect.

So far, experts assumed that positive effects of WHP for individuals can occur on the physical, mental, and social level [START_REF] Westermayer | Evaluation betrieblicher Stressprävention[END_REF]. An alternative grouping is provided by De Greef and Van den Broek (2001) who present the findings of their review using headings referring to (1) awareness and motivation, (2) health and quality of life, plus (3) job satisfaction. For describing potential benefits also including effects not referring (solely) to the individual, [START_REF] Breucker | International Union for Health Promotion and Education (ed) The Evidence of Health Promotion Effectiveness[END_REF] group into direct, intermediate, and long-term health and social effects. [START_REF] Anderson | Conceptual Framework, Critical Questions, and Practical Challenges in Conducting Research on the Financial Impact of Worksite Health Promotion[END_REF] provide a conceptual model differentiating between process, impact, and outcome. The impact, they state, can be cognitive/emotional and behavioural. The outcome categories regarding the individuals' health comprise (changes in) health risks, health status and well being.

Organizational outcomes are subdivided into direct, indirect, and other.

General cognitive and affective outcomes were already reported in various studies (De Greef and Van den Broek 2001;Kreis and Bödeker 2003;[START_REF] Sockoll | IGA Report 13. Wirksamkeit und Nutzen betrieblicher Gesundheitsförderung und Prävention. Zusammenstellung der wissenschaftlichen Evidenz[END_REF]. [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF] propose to add these as a discrete effect category to the currently used model of [START_REF] Westermayer | Evaluation betrieblicher Stressprävention[END_REF] and to further enlarge the systematisation of effects by adding the facilitation of prevention. Drawing on these ideas, a basis for a quantitative investigation of employee perceived WHP benefits is created in the next sections. This is done by reviewing recent articles and reviews on effects of WHP using a concept of now five potential effect categories (physical, mental, social, general cognitive/affective, facilitation of prevention).

As for physical outcomes, depending on what WHP programs target, various results have been reported. Investigations in this area typically focus on the prevention of negative influences on physical health by tackling risk factors and indicate the reduction of health risk factor levels (Kreis and Bödeker 2003), illnesses and sick-days, occupational accidents, and disabilities (De Greef and Van den Broeck 2004). Research on behavioural changes [START_REF] Breucker | International Union for Health Promotion and Education (ed) The Evidence of Health Promotion Effectiveness[END_REF] and very specific interventions or health related outcomes (cholesterol level changes, etc) form the bulk of available studies (Helmenstein et al. 2004). Taken together, they imply a positive impact of WHP [START_REF] Breucker | International Union for Health Promotion and Education (ed) The Evidence of Health Promotion Effectiveness[END_REF]Kreis and Bödeker 2003).

Research on the effects of increased physical activity due to health promotion on (1) a reduction in as well as (2) prevention of the emergence of health risk factors like overweight, plus (3) a diminished likelihood of chronic diseases is already substantial on a general [START_REF] Who | Global strategy on diet, physical activity and health[END_REF]) and at least indicative on the WHP specific level [START_REF] Breucker | International Union for Health Promotion and Education (ed) The Evidence of Health Promotion Effectiveness[END_REF][START_REF] Sockoll | IGA Report 13. Wirksamkeit und Nutzen betrieblicher Gesundheitsförderung und Prävention. Zusammenstellung der wissenschaftlichen Evidenz[END_REF][START_REF] Goldgruber | Effectiveness of workplace health promotion and primary prevention interventions: a review[END_REF]. Moreover, it could be shown that physical activity decreases exhaustion and tiredness levels [START_REF] Sockoll | IGA Report 13. Wirksamkeit und Nutzen betrieblicher Gesundheitsförderung und Prävention. Zusammenstellung der wissenschaftlichen Evidenz[END_REF]) and improves mental health [START_REF] Who | Global strategy on diet, physical activity and health[END_REF], which in turn positively influences the body.

Programs consisting of an assessment of health risks with subsequent individual feedback lead to behaviour change (reduced tobacco use, fat intake and heavy alcohol consumption, increased seat belt use and physical activity levels), improvements in blood test results (cholesterol level, blood pressure), a decrease in days of sick-leave, plus increased levels of well-being and health [START_REF] Goetzel | Worksite Health Promotion. How Much Do We Really Know About What Works?[END_REF]. Similar tendencies are also reported in reviews (see for example De Greef and Van den Broeck 2004) and studies of best practice WHP programs [START_REF] Grossmeier | Best Practices in Evaluating Worksite Health Promotion Programs[END_REF]. According to Kreis and Bödeker (2003) and [START_REF] Sockoll | IGA Report 13. Wirksamkeit und Nutzen betrieblicher Gesundheitsförderung und Prävention. Zusammenstellung der wissenschaftlichen Evidenz[END_REF] however, the results even of holistic programs can be considered as equivocal.

Analyzing high-quality WHP interventions including environmental modifications, [START_REF] Engbers | Worksite Health Promotion Programs with Environmental Changes. A Systematic Review[END_REF] state strong evidence concerning the intake of fruit, vegetables, and fat, inconclusive evidence regarding physical activity levels, and no evidence regarding health risk indicators. [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF] report that employees highlighted the general positive effects of WHP on their health status, the reduction or prevention of health problems, and changes in specific behaviours (nutrition, etc.) due to WHP interventions. Experts interviewed focused on the value of behavioural prevention, the maintenance or improvement of the current health status as well as early diagnoses of health risks [START_REF] Nöhammer | Nutzenpotenziale von betrieblicher Gesundheitsförderung für die MitarbeiterInnen -Gestaltungsansätze für das zielgruppenoptimierte Angebot betrieblicher Gesundheitsförderung[END_REF].

Regarding mental effects, [START_REF] Breucker | Gesundheitsförderung -Zum Wohle von Unternehmen und Mitarbeitern[END_REF] suggests WHP generally improves well-being by promoting more positive emotions at the workplace and by reducing work related strains.

While psychological outcomes were of rather limited relevance in earlier WHP evaluation studies, the interest is growing now and focuses particularly on interventions targeted at stress [START_REF] Sockoll | IGA Report 13. Wirksamkeit und Nutzen betrieblicher Gesundheitsförderung und Prävention. Zusammenstellung der wissenschaftlichen Evidenz[END_REF]). These are reported to have a "significant medium to large effect" (Goldgruber and Ahrens 2010. p. 77), but for achieving this seem to have to be very holistic and integrative [START_REF] Sockoll | IGA Report 13. Wirksamkeit und Nutzen betrieblicher Gesundheitsförderung und Prävention. Zusammenstellung der wissenschaftlichen Evidenz[END_REF]. Stress management training can, for instance, result in fewer somatic problems and can improve the results of various blood tests [START_REF] Ganster | Workplace Interventions To Prevent Stress-Related Illness: Lessons From Research And Practice[END_REF]. Adding enhanced self-esteem [START_REF] Badura | Betriebliche Gesundheitspolitik. Der Weg zur gesunden Organisation[END_REF]Birgmann 2006), satisfaction with the job (Birgmann 2006) and increased perceived meaning of one's work [START_REF] Badura | Betriebliche Gesundheitspolitik. Der Weg zur gesunden Organisation[END_REF] to potential psychological benefits, experts have high expectations of WHP. However, according to employees interviewed by [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF], positive psychological outcomes are no automatic result of WHP. Nevertheless, employees as well as experts said the workforce felt appreciated by the company's commitment to WHP and stated the possibility of a potential positive effect regarding mental hygiene, motivation and satisfaction [START_REF] Nöhammer | Nutzenpotenziale von betrieblicher Gesundheitsförderung für die MitarbeiterInnen -Gestaltungsansätze für das zielgruppenoptimierte Angebot betrieblicher Gesundheitsförderung[END_REF][START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF]. There is evidence of an increase of motivation and satisfaction levels due to WHP offers and/or the individual's participation in them (De Greef and Van den Broek 2004). As [START_REF] Anderson | Conceptual Framework, Critical Questions, and Practical Challenges in Conducting Research on the Financial Impact of Worksite Health Promotion[END_REF] note, higher satisfaction levels may not only lead to a better health status, but also a higher likelihood of remaining with the organization. According to De Greef/ Van den Broeck (2004), this may also be due to an enhanced corporate image derived from the company's commitment to WHP.

A higher retention rate due to increased satisfaction also has a social impact because of its stabilizing and potentially facilitating effect on the emergence of trust in the company. Not only for this reason, is WHP thought to be an investment in the company's overall social capital [START_REF] Breucker | International Union for Health Promotion and Education (ed) The Evidence of Health Promotion Effectiveness[END_REF]. [START_REF] Badura | Betriebliche Gesundheitspolitik. Der Weg zur gesunden Organisation[END_REF] suggest salutogenetic potentials of WHP in the social realm especially regarding better flow of information and facilitated team work, which is also mentioned by [START_REF] Breucker | Gesundheitsförderung -Zum Wohle von Unternehmen und Mitarbeitern[END_REF] and Birgmann (2006).

Health experts interview by [START_REF] Nöhammer | Nutzenpotenziale von betrieblicher Gesundheitsförderung für die MitarbeiterInnen -Gestaltungsansätze für das zielgruppenoptimierte Angebot betrieblicher Gesundheitsförderung[END_REF] observed improvements in the internal climate and the relationships between superiors and subordinates as well as between colleagues. With regard to that, [START_REF] Breucker | International Union for Health Promotion and Education (ed) The Evidence of Health Promotion Effectiveness[END_REF] refer to support derived by WHP for management functions and in creating a positive internal value balance. Moreover, positive changes were described regarding the internal communication and conflict solving processes [START_REF] Breucker | International Union for Health Promotion and Education (ed) The Evidence of Health Promotion Effectiveness[END_REF][START_REF] Nöhammer | Nutzenpotenziale von betrieblicher Gesundheitsförderung für die MitarbeiterInnen -Gestaltungsansätze für das zielgruppenoptimierte Angebot betrieblicher Gesundheitsförderung[END_REF]). When referring to social effects, employees underline the opportunities of getting to know other people within the organisation during various WHP activities [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF], which may also contributes to better communication lines.

Increased individual health awareness is either implicitly expected (De Greef/ [START_REF] De Greef | Making the Case for Workplace Health Promotion[END_REF] or observed to be a result of WHP programs and trigger behavioural changes [START_REF] Breucker | International Union for Health Promotion and Education (ed) The Evidence of Health Promotion Effectiveness[END_REF]. General effects are described by [START_REF] Nöhammer | Nutzenpotenziale von betrieblicher Gesundheitsförderung für die MitarbeiterInnen -Gestaltungsansätze für das zielgruppenoptimierte Angebot betrieblicher Gesundheitsförderung[END_REF] and [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF] regarding cognitive and affective outcomes: potential positive changes concerning health attitudes and behaviour along with a better health awareness. The employees interviewed observed that their knowledge about health is enlarged, which was already hypothesized in the literature before (Birgmann 2006). Moreover, they stated feeling more productive, which was also reported by De Greef and [START_REF] De Greef | Making the Case for Workplace Health Promotion[END_REF] and [START_REF] Grossmeier | Best Practices in Evaluating Worksite Health Promotion Programs[END_REF]. Just as [START_REF] Anderson | Conceptual Framework, Critical Questions, and Practical Challenges in Conducting Research on the Financial Impact of Worksite Health Promotion[END_REF] found WHP programs to be popular with employees, [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF] report that they enjoyed participating in WHP activities.

The former reflects so far not completely substantiated hopes of managers as well as health experts, but may be caused by a general feeling of being healthier or be connected to social desirability. The latter might be connected to expert's expectations of positive emotions, which so far were rather described in line with organizational changes and improvements in the internal climate, but not enjoyment derived form WHP in itself.

The facilitation of preventive activities has already been reported in qualitative results, for example by Willams and Bruno (2007), but without labelling these as a potential effect category. The employees interviewed by [START_REF] Williams | Worksite Wellness Programs -What Is Working[END_REF] and [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF] mentioned and substantiated facilitations regarding time, finances, medical and psychosocial aspects. Having access to health promoting activities at the workplace was also described as more convenient. Another factor might be that WHP offers tend to be cheaper than having to organize similar possibilities by oneself [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF].

As stated above, employees underlined that effects of WHP were not always perceivable.

However, they never mentioned negative aspects of WHP except of (1) feeling annoyed by the company not focussing primarily on improving general working conditions or (2) being tired of internal changes. Experts, nevertheless, do report negative effects of WHP, for example in case the changes due to WHP (like improving the work hours, making the working environment healthier by having machines perform the risky tasks, etc.) result in people loosing risk payments (which are perceived as part of the income) or even their jobs. [START_REF] Nöhammer | Nutzenpotenziale von betrieblicher Gesundheitsförderung für die MitarbeiterInnen -Gestaltungsansätze für das zielgruppenoptimierte Angebot betrieblicher Gesundheitsförderung[END_REF] This has already been very well described as health detrimental in the literature [START_REF] Jahoda | Die Arbeitslosen von Marienthal[END_REF][START_REF] Elkeles | Arbeitslosigkeit und Gesundheitszustand[END_REF][START_REF] Lange | Die Gesundheit arbeitsloser Frauen und Männer. Erste Auswertungen des telefonischen Gesundheitssurveys[END_REF]. Further negative consequences of WHP are described by [START_REF] Haunschild | Humanziation Through Discipline? Focault and the Goodness of Employee Health Programmes[END_REF] who suggests programs could lead to an intra-organizational obligation to be healthy and potential health related privacy violations.

Drawing on the results reported above, it can be assumed that employees experience more potential effects of WHP that typically considered in research based on concepts so far available. Moreover, it remains unclear which outcomes of WHP perceived by the individual are genuine experiences and not prompted by research questions (i.e. effects that would otherwise not have been noted are checked in questionnaires because the items make the individual realize this outcome). As this effect cannot be reconstructed for most studies and reviews referred to above, the present investigation quantitatively tested the results obtained by [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF] who exploratively interviewed employees about effects of WHP.

In total, [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF] conducted 19 problem-centred interviews with employees of three organizations -one non-profit, one public, and one privately owned. These were chosen based on the quality and duration of their WHP program. Moreover, the four people responsible for the programs at the organizations were interviewed. The interviews lasted for about 30 minutes each; questions posed were for example "Did your health status change due to participating in WHP programs? If yes, how? Positively or negatively?", "Did you note further effects of WHP on your health, or other changes? In which areas? Were these changes rather positive or negative?" [translation by the authors]. The interviews were transcribed, communicatively validated, and the results were clustered according to the resulting categories of effects of WHP mentioned by the employees [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF].

Focussing on changes in well-being perceived by the workforce, these results were tested here in order to (1) explore their occurrence in a larger sample, (2) discover possible patterns to test the necessity of an extension of present effect categorizations, and (3) develop a ranking of effects to determine the potential of WHP in improving individual well-being.

Methods

In order to investigate employee perceptions of changes in well-being through WHP, the results of a qualitative study [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF] were transformed into statements for use in a quantitative questionnaire. The latter was distributed in four companies to cover stateowned, private, and non-profit organizations. Participation in the study was voluntary; the participants were informed about the aims of the investigation and knew about their employer's agreement to provide time for answering the questionnaire. Absolute anonymity was granted by providing centralized distribution as well as several possibilities for collection.

In total, 26 items referring to effects of WHP were generated. Of these, 15 statements reflect changes in well-being due to WHP and were thus used for the paper at hand. Response possibilities were presented in a Likert-type format ranging from 1 (disagree) to 4 (agree completely), without giving the option of a neutral category. Examples for the items are:

• I feel more motivated because the company offers WHP programs.

• By participating in WHP programs I can moderate beginning health problems.

The data obtained were analyzed using frequency, correlation and, factor analyses.

Results

In the following sections, the results of the analyses we conducted are presented.

Demographic sample description

In total, 237 people filled in the questionnaire. Of these, 55.3% were female and 42.2% male (rest: no indication of sex), with a mean age of 43.64 years (SD = 8.935). The educational level was rather high with 43.5% holding a university entrance degree and almost 14% holding a university degree. This is due to the sample including only white-collar employees.

As can be seen in Figure 1, satisfaction with the current health status correlates with active participation in WHP programs. While at this stage of research we do not want to imply any causality in either direction, it is nevertheless quite interesting to note that the higher the satisfaction with the current health status is, the more do people actively participate in WHP over a longer period of time.

Insert Figure 1 about here

Factor analysis

To test the requirement of a new conceptual grouping of WHP effects regarding changes in well-being, a factor analysis was conducted. In a first step, we did an exploratory factor analysis (principal axis analysis) with Oblimin rotation, treating the ordinal values obtained as pseudo-metric. Missing values were excluded pair-wise. With a Kaiser-Meyer-Olkin Criterion of 0.894 and 0.000 significance according to the Bartlett test, we have a good model fit explaining 66.47% of variance. A subsequent confirmatory analysis yielded no deviations. As can be seen in Table 1, a three factor solution emerges with a physical/cognitive element, a social component, and an emotional factor.

Insert Table 1 about here

The physical/cognitive factor comprises seven items referring to feeling healthier -in general as well as physically, paying more attention to health related issues and knowing more about these, feeling more productive and also noticing a reduction or prevention of current and/ or potential future health problems. Cronbach's alpha, testing internal consistency, is at 0.918 for this subscale, the item mean is at 2.858 with a variance of 0.058 (range: 2.634-3.347). The second factor, labeled social, consists of three items concerning improved contacts to co-workers as well as a better basis of conversation with the supervisor. Cronbach's alpha is at 0.868 for this subscale, the item mean is at 2.729 with a variance of 0.107 (range: 2.352-2.930). The emotional factor comprises five items considering satisfaction and motivation, feeling appreciated, having better stress related coping abilities and having a higher capacity of distancing oneself from the job and relax after working hours. Cronbach's alpha is at 0.880 for this subscale, the item mean is at 2.836 with a variance of 0.176 (range: 2.491-3.551).

An overview of the statistical values of the items the factors consist of is shown in Table 2.

Insert Table 2 about here

It is surprising to note that in case the cognitive elements are not included, a two-factor structure results with a physical-emotional and a social component. When potential beneficial effects of WHP reported by [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF] that refer to other issues than changes in well-being are also included into the analysis, a four component model is obtained.

Nevertheless, a confirmatory analysis trying to find four factors also for items concerning changes in well-being only does not lead to better results than the original three factor solution.

Effect ranking

To determine the potential of WHP in improving individual well-being, the agreement rates were analyzed. The agreement was grouped into five segments labelled as very high with an agreement rate of over 50%, high refers to 40-49.9% of agreement, mediocre to 20-39.9%, low to 10-19.9%, and very low to values below 10%. In Table 3, these results are shown together with the factor the items refer to based on the factor analysis described above.

Insert Table 3 about here

The highest values are achieved by an item of the emotional component of the model, feeling appreciated by the company, followed by a physical health related item that also results in getting the mind at ease: the prevention of beginning health problems. The subsequent values range in a category labelled mediocre regarding agreement, lie close and have no clear structure regarding factors. This is why means were calculated by adding the "agree completely/agree" score per factor and dividing it by the number of items included as shown in Table 4.

Insert Table 4 about here

The results show that physical, cognitive and emotional effects are perceived the most, but still only by about a quarter of the employees. However, single items differ clearly from the mean score, as for example feeling appreciated.

Implications and Conclusions

The investigation reported in the paper at hand was designed to analyze the potential that WHP programs show in creating positive changes in employee well-being from their point of view, which has so far been underrepresented in research. To date, academics as well as practitioners in the field were mostly drawing on expert's opinions assuming beneficial outcomes of WHP for the workforce on the physical, mental and social level [START_REF] Westermayer | Evaluation betrieblicher Stressprävention[END_REF]. Our results confirm that WHP has a positive impact on employee wellbeing in three areas also from the employee's perspective. Nevertheless, a factor analysis of the changes in well-being suggests a divergent grouping of potential effects into physicalcognitive, emotional, and social effects. When more potential benefits are considered, including effects that do not imply changes in well-being, a four component model emerges, and in case cognitive effects are ignored, a two factor model results with a physical-emotional and a social component. This leads to the assumption that research on WHP could gain from a consideration of the employee's perspective and the current theoretical grouping of potential WHP effects should be revised. A further reason for this is that benefits in the emotional realm are not always clearly labelled, but referred to as mental, affective, emotional, or psychological. By providing the exact items used for labelling the category labelled as emotional above, we add to finding a common definition.

Combing the three factor solution of changes in well-being with a frequency analysis of perceived effects, it can be stated that in the sample tested the physical-cognitive and emotional elements of perceived benefits are felt the most. Also, the emotional component is strong for variables referring to various status oriented items (which are not referring to changes in wellbeing and thus not reported in detail here). Almost 50% of the respondents for example experience joy due to program participation and feel WHP helps them care better for their health. This outcome highlights the importance of emotions in the workplace and its relevance in the context of WHP. This combination has so far not been investigated in depth, which is why a consideration of the linkage is suggested for future research on health in the work setting. However, as we cannot exclude a potential bias of having especially those respond to the questionnaire that are already interested in WHP and enjoy taking part in related activities, the relevance of emotions may be lower when also potentially more indifferent employees are taken into account.

While positive changes can be expected to last especially due to sustainable effects by increased health related awareness and knowledge, which lead to increased self-efficacy and a dynamic cycle of well-being, benefits are not perceived by many. As mentioned above, only about a quarter of the interviewees stated perceiving changes in well-being on the physicalcognitive, emotional, and social level. In order to increase the amount of employees who state and also subjectively experience positive changes in well-being due to the WHP offer, one possibility is to increase the number of those participating actively. This could be done by considering the determinants of participation in WHP [START_REF] Nöhammer | Determinants of employee participation in workplace health promotion[END_REF] and might in turn lead to an increased satisfaction with the current health status of a larger proportion of the workforce due to the correlation of WHP participation and health satisfaction.

Current research mentions WHP related internal communication [START_REF] Stummer | Interne Kommunikation und betriebliche Gesundheitsförderung. Informationshemmnisse bei der Umsetzung von betrieblicher Gesundheitsförderung[END_REF]) and WHP offer design [START_REF] Nöhammer | Nutzenpotenziale und Effekte betrieblicher Gesundheitsförderung[END_REF]

  as barriers to active participation. By improving WHP information, awareness of and interest in the program can be achieved. Having offers targeted at employee needs and communicating this properly should create a desire to participate and result in action. In case what was communicated holds true and is confirmed, adherence probability is increased, creating a dynamic, motivational cycle of Awareness -Interest -Desire -Action -Confirmation -Adherence. As a starting point and drawing from the present research, we propose strengthening the emotional components of WHP information and offer design.

Fig. 1

 1 Fig. 1 Satisfaction with current health status and active participation in WHP; N= 237

Table 1 : Factor analysis Pattern matrix a

 1

	Factor
	Physical/
	Cognitive Social	Emotional

Table 2 : Item description

 2

			N				Standard
	Items/Effects	Valid	Missing Mean Median Mode	Deviation	Variance
	Feeling healthier due to participating in WHP program offers	221	16	2,76	3,00	3	,992	,983
	Feeling more productive due to participating in WHP program offers	218	19	2,68	3,00	3	,991	,982
	Paying more attention to health since participating in WHP offers	222	15	2,63	3,00	3	1,240	1,538
	Knowing more about a healthy lifestyle due to WHP program offers	226	11	2,77	3,00	3	1,192	1,420
	Feeling physically better due to participating in WHP program offers	222	15	2,93	3,00	3	1,035	1,072
	Reduction of physical problems are due to participating in WHP program offers	223	14	2,91	3,00	3	1,110	1,231
	Prevention of beginning health problems with WHP	219	18	3,35	4,00	4	1,100	1,211
	Contact with colleagues deepens due to participating in WHP program offers	217	20	2,96	3,00	3	1,103	1,216
	Getting more personal contacts within the company due to participating in WHP program offers	217	20	2,93	3,00	3	1,093	1,194
	Better basis of conversation with supervisor	216	21	2,35	3,00	3	1,027	1,056
	Feeling more satisfied with work	221	16	2,64	3,00	3	1,025	1,050
	Feeling more motivated because company offers WHP	222	15	2,84	3,00	3	1,104	1,219
	Better coping with stress and pressure due to participating in WHP program offers	218	19	2,67	3,00	3	1,031	1,062
	Feeling appreciated by the company due to WHP offer	221	16	3,54	4,00	4	1,169	1,367
	Better relaxing after work due to participating in WHP program offers	217	20	2,50	3,00	3	1,028	1,057

Table 3 : Effect ranking

 3

	Agreement	Potential Outcome	Disagree/ partly disagree	Neither/ nor	Agree completely/ partly agree	No answer	Factor
	VERY HIGH (≥50%)	Feeling appreciated by the company due to WHP offer	16.0	19.8	57.4	6.8	E
	HIGH (40%-49.9%)	Prevention of beginning health problems with WHP	17.3	26.6	48.5	7.6	P/C
		Getting more personal contacts within the
		company due to participating in WHP program	23.6	39.2	28.7	8.4	S
		offers
		Contact with colleagues deepens due to participating in WHP program offers	22.4	41.4	27.8	8.4	S
	MEDIOCRE 20% -39.9%	Reduction of physical problems are due to participating in WHP program offers Feeling physically better due to participating in WHP program offers	26.2 23.6	40.1 43.9	27.8 26.2	5.9 6.3	P/C P/C
		Knowing more about a healthy lifestyle due to WHP program offers	33.3	36.7	25.3	4.6	P/C
		Paying more attention to health since participating in WHP offers	38.4	30.8	24.5	6.3	P/C
		Feeling more motivated because company offers WHP	27.0	43.5	23.2	6.3	E
		Better coping with stress and pressure due to participating in WHP program offers	32.5	42.6	16.9	8.0	E
	LOW 10%-19.9 %	Feeling more satisfied with work because company offers WHP Feeling healthier better due to participating in WHP program offers	32.5 23.6	45.6 54.9	15.2 14.8	6.8 6.8	E P/C
		Feeling more productive due to participating in WHP program offers	26.2	52.3	13.5	8.0	P/C
		Better relaxing after work due to participating in WHP program offers	38.0	42.2	11.4	8.4	E
	VERY LOW Below 10%	Better basis of conversation with supervisor	38.0	47.4	5.5	8.9	S

Table 4 :

 4 Mean values of Agreement to Changes in Well-being

	Mean value

Conflict of interest statement

The authors declare that they have no conflict of interest.


Prenzler Anne

Mittendorf Thomas

Johann-Matthias Schulenburg

Theidel Ulrike

Montag Thomas

Müller-Busch Hans

Anne Prenzler

Aspects of outpatient palliative care in Germanya survey among office-based physicians

Keywords: Palliative care, Palliative medicine, constipation, Germany, reimbursement, SAPV -3-

Background: Currently, Palliative care is widely discussed. Aim of this study is to explore different aspects of the ambulatory treatment environment of palliative patients and its structure in Germany from the viewpoint of caring physicians.

Methods: A structured questionnaire was developed and sent to 1,003 office-based physicians in Germany. Topics were the delivery and effort of care, cooperation between health care providers, the perception of existing health care structures, the reimbursement system, as well as an assessment of future developments. Subgroups analyses were conducted.

Results: 314 questionnaires were included in the statistical analyses. 50% estimate the additional time and effort for palliative patients compared to non-palliative patient to be 50% and more. The best cooperation is seen with caregivers; however, cooperation with psycho-social care should be improved. 50% state the outpatient health care situation as (very) insufficient, but improvements are expected in future.

90% assess German reimbursement structures as (very) insufficient.

Conclusions:

This study gives an insight into the German outpatient health care setting for palliative patients. Palliative patients have a higher and more complex need with respect to health care than other patients. Further studies should focus on the collection of longitudinal patient data for a more comprehensive insight.

Background

In Germany as well as in other European countries, the demographic structure is characterized by an increasing number of elderly people. Today, about 20% of the German population is over 65 years old and will increase up to 33% by 2050 (Federal Institute for Population Research 2008). This change is accompanied by a rising incidence of specific diseases which follow at least partly by an increase in age.

Especially the rising number of cancer patients results from this demographical shift and reflects a major public health burden to society today and in the near future. For instance, according to German data the incidence of cancer indications in Germany is projected to increase from 461,000 in 2007 to 588,000 in the year 2050 (+27%) in absolute figures [START_REF] Beske | Morbiditätsprognose 2050. Ausgewählte Krankheiten für Deutschland[END_REF].

With regard to health services which are to be provided for such life-threatening diseases, the need for professional, extensive health care beyond acute phases of disease as well as the development and more importantly implementation of specific palliative structures became more and more apparent in the last years in Germany.

The World Health Organization defines palliative care as an "approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness…" (WHO 2002). Whereas palliative medicine focuses on medical care for the patients, palliative care is understood as a more holistic, multi-discipline approach, which involves for example caregivers, psychotherapists and spiritual guidance in addition to care provided by general practitioners (GPs) and specialized physicians (Pastrana et al. 2008).

According to the World Health Organization (WHO), the inpatient palliative sector is already well organized in Germany (Centeno et al. 2007). However, with respect to the outpatient sector improvements are necessary [START_REF] Radbruch | What is special in specialised palliative care?[END_REF]).

In the German outpatient health care sector, there is a differentiation between general ambulatory palliative care and specialized ambulatory palliative care (SAPV).

The SAPV differs from the general palliative care mainly by higher qualification requirements (e.g. additional training in palliative medicine) and by a need for special palliative care teams due to higher intensity or complexity of disease events and symptoms a patient might be confronted with.

Over the last years, the palliative care sector gained a higher attention in Germany [START_REF] Schneider | Problems and challenges for palliative care: what are the views of different stakeholders on the meso and macro level of the health system?[END_REF]). The German government and the Statutory Health Insurance (SHI) have tried to support the development of new palliative care structures e.g. via new regulations regarding SAPV. For instance, every person insured within the SHI who has a non-curable, progressive disease as well as limited life expectancy has the right to receive SAPV if needed. SAPV can then be prescribed by physicians with costs being covered by the SHI (Federal Joint Committee 2008).

However, even though efforts in this health care sector have been increased, there is a lack of scientific research in this field in Germany to date [START_REF] Schneider | High need for improvement and many open questions in health care for palliative patients[END_REF].

Therefore, the aim of this study is to explore different aspects of the ambulatory treatment environment of palliative patients and its structure in Germany from the viewpoint of caring physicians.

Methods

A structured questionnaire was developed and sent to 1,003 office-based physicians in Germany in January 2009 with a reminder sent in February. 50% of the contacted doctors were members of the German Association for Palliative Medicine, the other 50% were office-based GPs taken from an IMS-database. Several issues were addressed within the survey. Besides general information on the physicians' specialization, information on the proportion of palliative patients as well as the frequency and duration of visits either in the office or at home by palliative patients were addressed. Furthermore, since palliative care focuses on the improvement of quality of life, which includes pain relief by opioids, an additional focus was laid on side-effects which in turn are typically caused by opioids. Therefore, the physicians were asked to estimate frequencies of various side-effects due to opioid medication in palliative patients and to give information on the additional time needed for treatment of sideeffects, using the example of on opioid-induced constipation (OIC), which is known to be the most frequent side effect (Clemens et al. 2008).

Additionally, the physicians were asked to classify and rate the ongoing cooperation with other health care suppliers as well as the outpatient care situation for palliative patients in general. Finally, their satisfaction with the current German reimbursement system with regard to palliative care and their perceptions of future developments in this health care sector was evaluated.

The data was analyzed with SPSS, version 16. As relative differences between the responses of GPs and specialists as well as physicians with and without a special training in palliative care were of special interest various subgroup analyses were conducted. Values from descriptive statistics are given as mean values in absolute terms or percentage. To explore possible statistical significances, the Mann-Whitney-U-test as well as the Wilcoxon-test was applied.

Results

Questionnaires from 314 physicians (70.3% male) were included in the statistical analyses (response rate: 31.3%). Mean and median age was 50 years. 64% were GPs, the others specialists (e.g. hematologist/oncologist (13.7%); anesthetist (11.5%)). On average, they already practiced in their office for 13 years, whereas GPs were significantly (p<0.01) longer office-based than specialists (15 vs. 10 years). 67% of the physicians had special formal palliative medicine (PM) training. 57% of those were GPs.

Physicians overall have 9.6% palliative patients on average. PM-trained physicians (13%) and other specialists (18.5%) treat more patients with a palliative status (p<0.01) than physicians without PM-training and GPs, respectively. According to the survey, 80% of the palliative patients suffer from cancer as primary condition (specialists: 90%; GPs: 75%).

A specific point of interest of this survey was the duration of the palliative phase (from first palliative health care need till death). According to our results, the palliative period lasts for less than six months in 60% of all cases, with PM-trained physicians estimating this timeframe to be shorter than others (figure 1). No significant difference between GPs and specialists was identified.

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Every second physician estimated the additional time and effort needed for a palliative patient compared to a non-palliative patient with at least 50%. For a more detailed view of the additional required time, participants were asked to approximate the number of home visits and office consultations as well as the timeframe needed per visit for palliative patients vs. non-palliative patients with chronic health problems.

On average, GPs estimate to visit palliative patients 5.9 times per quarter at their home (non-palliative: 2.3; p<0.01). They also state to need more time per home visit (18 vs. 12 min; p<0.01). Palliative patients also have significantly (p<0.01) more office consultations per quarter in a specialist's practice (4.6 vs. 3.4) and need more time per visit (16 vs. 10 min).

As to the important treatment component, physicians were asked to estimate the frequency of various side effects due to opioid containing medications in palliative patients. The physicians should differentiate between patients who receive mild and strong opioids, respectively, whereas the WHO-pain ladder was used to distinguish between the opioid groups (WHO-2: mild opioids, i.e. codeine; WHO-3: strong opioids, i.e. morphine). According to the answers OIC is the most frequent sideeffect, followed by nausea / vomiting, and fatigue. On average, physicians estimated the occurrence of OIC in 60 % of the palliative patients, who received a WHO-3-opioid (figure 2). PM-trained physicians indicated significantly higher frequencies of OIC than physicians without this extra qualification (WHO-2 criteria: 32% vs. 26%; WHO-3 criteria: 63% vs. 54%). Specialists noted nausea / vomiting, dizziness and confusion as side-effects due to WHO-2-opioids significantly less often than GPs, whereas specialists significantly more often observe fatigue as a result of more potent formulations (WHO-3) (p<0.05). Since these side-effects might cause additional time in patient care, physicians were asked to estimate this additional time using the example of OIC. On average, physicians estimate the additional time to be 20%, whereas PM-trained physicians approximate slight less additional effort than others (18% vs. 21%).

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In the final part of the questionnaire, assessment of overall outpatient health care structure for palliative patients, reimbursement system, and cooperation between different groups of health care providers as well as perceptions on possible future developments were outlined.

Every second physician considers the outpatient health care structure as to be (very) insufficient. Furthermore, over 60% of the PM-trained doctors as well as specialists, independent of their knowledge in palliative medicine, assess the situation as (very) unsatisfactory (figure 3). A large discrepancy between statements of GPs could be observed: 51% of the PM-trained GPs describe the situation as insufficient (13%: very insufficient), whereas only 22% of the GPs without PM-training share this opinion (3%: very insufficient).

With respect to the reimbursement system in the outpatient care sector, 95% of the PM-trained physicians state that it is (very) insufficient (without PM-training: 87%).

However, 58% of the physicians who are informed about the current SAPVregulations believe that those will improve the health care structure in outpatient care in Germany. Yet, only 31% expect improvements with respect to the reimbursement situation. Specialists tend to be more optimistic than GPs in this question.

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A main issue for an efficient provision of health care to palliative patients is the cooperation between the different providers of health care. The results of this survey show that physicians assess the existing cooperation structures as quite good, as before, specialists being more optimistic than GPs in their assessment (figure 4).

The best cooperation is given with caregivers: Three in four participants describe this form of cooperation as to be (very) good. In contrast, the assessment of the cooperation with psychotherapists and parties providing spiritual guidance is heterogeneous: 42% of the GPs give (very) good ratings, 30% are neutral and 28% consider the situation as being (very) insufficient which is lower in values in comparison to the answers given by specialists (60% -22% -18%). These results are also reflected in the question in which field the cooperation should improve with respect to extent and quality. As a result, especially psycho-social care and its cooperation are seen as an area of future efforts.

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This German study sample was also asked if they would support changes in the treatment process with respect to the assignment of duties to other caregivers, as the spectrum of responsibilities of other groups is rather limited in comparison to other countries, e.g. the role of outpatient nurses in the UK [START_REF] Taylor | On the precipice of great things: The current state of UK nurse education[END_REF]). 71% of specialists with PM-training (85% without) indicate that they would be willing to share or transfer duties to caregivers (only 66% of the GPs with PM-training (57% without) would support this).

Looking into the future, 60% of palliative care specialists believe that the quality of outpatient palliative health care will develop positively within the next five years. Only 30% of the physicians without PM-training agree on this and 35% of this group even expects a deterioration of the quality of health care.

Discussion

This study gives an overview of the perceptions of physicians working in palliative care in Germany about the outpatient health care structure of this very special area.

Following the findings palliative patients have a higher and more complex need with respect to health care than other patients which results in more time and effort the physicians have to spend on this special patient group.

According to the German Remuneration Scheme (EBM) physicians receive a lumpsum payment per quarter for office consultations, irrespective of the number or length of visits or the morbidity or palliative status of a patient (National Association of Statutory Health Insurance Physicians 2010). GPs receive approximately EUR 35 per quarter and patient; specialists about EUR 31 (not including special procedures).

Furthermore, taking care of OIC, which was identified as the most common opioidinduced side-effect and very time-consuming, or any other complication, is also not reflected separately in the remuneration system. Regular home visits are reimbursed with approx. EUR 15. Hence, it is not surprising that 90% of the physicians consider the reimbursement regarding outpatient care of palliative patients as being insufficient. This inadequate compensation of the time-consuming services provided during palliative care was also recently explored via a series of expert interviews [START_REF] Brueckner | Palliative care for older peopleexploring the views of doctors and nurses from different fields in Germany[END_REF]. Following new regulations regarding SAPV, special palliative care teams, which need to fulfill certain requirements (Federal Joint Committee Other studies have already issued the cooperation between health care providers [START_REF] Schneider | Discrepancies in the Viewpoints of Different German Health Care Providers of Palliative Care[END_REF]. The results of the study indicate that especially the cooperation between psychotherapists and other health care providers involved in palliative care is in need of improvement. This cooperation is essential for providing a more holistic health care approach which is indicated in palliative care [START_REF] Schmidt & Klaunig | Pastoral care in palliative medicine[END_REF].

With respect to the assignment of duties to caregivers, GPs seem to be more skeptical than specialists. An explanation for this finding might be that disproportionately more GPs have to give up tasks than specialists and hence receive less payment. Since 2009, qualified assistant personnel of physicians are allowed to undertake home visits on behalf of the GP which is reimbursed with normally EUR 17 including time and cost for the journey (National Association of Statutory Health Insurance Physicians 2010). However, this possibility of altering treatment paradigms is connected to some requirements. For instance, the respective regional area needs to be under-supplied and the assistant has to do undergo qualified training. As a result it is not expected that this change has the potential to serve as a significant support for physicians.

The validity of findings from this survey might be limited due to different reasons.

First of all, it cannot be ruled out that the cohort has a selection bias. However, as the study sample with over 300 physicians is rather big for this kind of health care services research the results might at least be considered as giving trend indications.

If a selection bias was created by asking specialists with a background in palliative care in one subgroup of the study cohort, it is more likely that the results of the survey would be biased towards a more positive description of the average real world treatment environment.

Another important aspect are different definitions of palliative status (Pastrana et al. 2008). Hence, this might explain why the figures concerning the relative importance of palliative patient vs. patients in the outpatient setting in general are a bit higher than in earlier works [START_REF] Abholz | Palliativmedizinische Versorgung -eine hausärztliche Aufgabe? [Palliative Care -a task for the GP?[END_REF][START_REF] Buser | Gutachten: Palliativversorgung in Niedersachsen -Bestandsaufnahme und Empfehlungen zur Weiterentwicklung[END_REF]). Furthermore, it is important to emphasize that the information in this study is not directly based on clinical data from palliative patients files but rather on estimations from physicians who take part in the treatment process. Therefore, the reliability and validity of the information (e.g. on the proportion of side-effects as well as the length of a palliative period) might be limited.

An earlier study by Koch-Horn et al. (2002) analyzed in a prospective study setting, that GPs on average need 15 minutes per patient including journey time which is less than in the present study.

Summarizing, not only the results but also the limitations of the study call for a need of further studies that should focus on the collection of longitudinal patient data to get an even more comprehensive insight into the health care environment and the specific needs of palliative patients.

Conclusions

In comparison to non-palliative care there is a need for higher use of medical resources among palliative patientsa need that currently might not be adequately reflected in the remuneration system. Considering ongoing demographic developments and the resulting importance of palliative care further research has to identify room for improvement and corresponding strategies.

  2008), can make a special contract based on SAPV with individual sickness funds and receive additional remuneration. Started in April 2009, office-based physicians also might receive extra payments for prescribing SAPV which is connected with some bureaucratic effort (National Association of Statutory Health Insurance Physicians 2010). However, as the German health care system faces the challenge of an upcoming lack of practicing physicians (National Association of Statutory Health Insurance Physicians, German Medical Association 2007)especially in rural areas it still is highly indicated to further work on additional adjustments within the remuneration system. This might also improve the job satisfaction of German physicians which isaccording to the results in the present studyquite poor. The responsibility of adjustment should not be born solely by the Health Ministry, but rather should be shared with health insurances and the different physician associations in this field.

Figure1

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Funding / Conflict of interest

This work was supported by Wyeth Pharma GmbH, Germany, a company of the Pfizer Group. Apart from the funding, the authors declare to have no further conflict of interest.