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"Evaluation of Complex Interventions in Hard to Serve Regions - Lessons Learned from a German Innovation Fund Project"


Volker Amelung

inav - Institute For Applied Health Services Research, DE
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An introduction:

The German health care landscape is dominated by a fragmented system and an insufficient cooperation between service providers, which causes misallocations. Demographic change and scarce resources (especially human resources) cause a need for new structures.

Due to the gap between in- and outpatient care, the German health care legislation implemented appropriate reforms. With the Statutory Health Insurance Care Provision Strengthening Act (GKV-VSG) coming into force in 2015, the Federal Joint Committee (G-BA) received the mandate to fund new forms of health care going beyond standard care by integrating interdisciplinary and/or cross-sectoral health care services.

One of the projects, funded for 4 years, is called “IGiB StimMT”. It comprehensively deals with the outlined problems of the silo-structured health care system and focuses on maintaining basic health care provision in hard to serve regions. The goal of IGiB StimMT is to restructure the concerned rural health care system in such a way that it becomes demand-oriented and responds to the regional problems of an aging and multimorbid population. This is implemented by new ways of task sharing of in- and outpatient care service providers and a series of innovative care components.


Evaluation becomes increasingly challenging as interventions move along the spectrum from simple towards complex interventions like IGiB StimMT. To evaluate complex interventions, the evaluation concept and study design should include an effectiveness, a cost-effectiveness and a process evaluation, using both quantitative and qualitative methods.


First results from outcome and process evaluation have already been analysed and show interesting insights in the complex and challenging task of maintaining health service provision in hard to serve regions.


Regarding the shape of complex interventions, regional capacities like the available human resources have to be considered. Pragmatic solutions for today’s demographic challenges and their impact on health care services are imperative.

As to the evaluation of complex interventions, randomised controlled trials (RCTs) often cannot be implemented due to the real-life circumstances of the health care system. Scholarly debate should focus more on other study designs for complex interventions, like cluster randomised studies or natural experiments. 


IGiB StimMT has already had an impact on misallocated medical treatment by reducing the number of emergency ambulance deployments, by allocating patients to a newly established on-call medical service instead.

Lessons learned:

Three years ahead of the project IGiB StimMT, a series of lessons have been learned that apply to innovative and complex interventions in general. The scope of an intervention should be considered carefully. To prevent a project of overcharging regional capacities, it is advisable to roll out one project component after another. As agile project management is a recommendable method for complex interventions, the evaluation design has to be adopted accordingly.


Regions are different in population and geographic structure. Therefore, the generalizability of the insights from the project have to be considered.

Suggestions for future research:

Future research could shed light on the evaluation of complex interventions with a gradual rollout.

How to Cite: Amelung V. \"Evaluation of Complex Interventions in Hard to Serve Regions - Lessons Learned from a German Innovation Fund Project\". International Journal of Integrated Care. 2021;21(S1):113. DOI:
Published on 01 Sep 2021.


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