[From "medicinal policy" to public health sciences: on the relationship between health experts and the state].
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Germany↗
Biomedical subjects
F W Schwartz
Publications and source records attributed to F W Schwartz.
[Performance and costs of outpatient clinics of university hospitals for medical care, teaching, research activities].
BACKGROUND: Outpatient clinics of university hospitals (Hochschulambulanzen) play a significant role in the German health care system. Universities have in contrast to other hospitals the right to implement an outpatient clinic, but the health care services they can render are restricted to clinical research and teaching activities. The university outpatient clinic study evaluates the intensity of medical care, teaching, research activities, and the related costs. METHOD AND DATABASE: 6 university hospitals with 51 outpatient departments in Germany were included. The prospective documentation of consultations was restricted to 800 visits per department. A total of 26,312 consultations with approximately 40,000 diagnoses and 150,000 services were documented. Furthermore, data concerning costs, teaching activities and research facilities were documented. RESULTS: Clinical treatment without any correlation to research or teaching activities amounted to about 81 % of the working time in the outpatient department (research 11 %; teaching 8 %). The primary task of the university outpatient clinics takes up less than 20 % of the working time. The physicians documented that the disease of every fourth visit was in accordance with their main field of research. 6.9 % of the visits were asked to take part in clinical trials, of these 1.25 % were included for the first time, 3.7 % were already included. 6.5 % of the visits were addressed to participate in specific teaching activities. The average total costs per case added up to 149 Euro. No outpatient clinic could cover the total per case costs with the lump sum payments. On the average 31 % of these costs were covered by lump sum payments (without cases concerning research and teaching). CONCLUSION: Treatment in outpatient departments of university clinics is far beyond research and teaching activities required by law. However, the ability of outpatient departments of universities to provide excellent outpatient services should have a more dominant role in the health care system. Therefore access to care should be deregulated for the patients and reimbursement schemes should be adjusted to adjust for the present losses.
Biomedical Research↗
[Exercise. Prevention and health promotion--pathways to innovation in public health?].
Besides appropriate nutrition, adequate exercise is the universal remedy. Regular endurance training elicits positive effects in numerous organs and tissue systems in the sense of primary prevention. Nevertheless, a lack of exercise and obesity are widespread among the German population. In addition to the individual's own responsibility, measures for disease-oriented prevention as well as for preserving health should be improved based on broad social consensus. To begin with, improved research on treatment and prevention should be required. This national challenge should not only be financed by health insurance funds but also by taxes and levies (e.g., tobacco tax). Only then can the constantly spiralling costs of public health be met.
Adolescent↗
Modeling the fate and transport of organic and nitrogen species in soil aquifer treatment process.
Soil aquifer treatment (SAT) is a promising technique for wastewater reclamation and reuse. This treatment strategy takes advantage of physicochemical and biological processes in the subsurface. The model employed in this study is based on MODFLOW-SURFACT (HydroGeoLogic, Inc.), a three-dimensional model for variably saturated flow and reactive mass transport. The model accounts for reactions including the nitrification of ammonium, the denitrification of nitrate, and the oxidation of organic carbon. Concentration of dissolved oxygen and biomasses involved in aerobic and anaerobic biological reactions forms the basis for estimates of nonlinear reaction rates formulated using a multiple-Monod expression. Illustrative simulations were conducted in a two-dimensional cross-sectional domain, with unsaturated and saturated zones. They examine the effects that site and operational conditions have on the performance of a SAT system. The parameters and conditions of concern included length of the wet/dry cycle, ground surface condition, and infiltration rate. From the simulations, we found that organic carbon was effectively removed in all cases. The availability of oxygen was a key factor in predicting the production and removal of nitrate. Overall, the model successfully described the fate and transport of the key constituents during the wet/dry operational periods in both unsaturated and saturated subsurface.
Conservation of Natural Resources↗
[Insurance medicine and ethics].
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Curriculum↗
Use of acute hospital beds does not increase as the population ages: results from a seven year cohort study in Germany.
OBJECTIVES: (1) To compare the number of hospital days used by survivors with those by persons in their last, second last, and third last year of life in relation to age; (2) to analyse lifelong hospital utilisation in relation to life expectancy. DESIGN: Cohort study using a 10% sample (stratified by age and sex) of persons insured by one sickness fund. SETTING: Germany, 1989-1995. SUBJECTS: 69,847 survivors (with a minimum of three more years to live), 1385 persons in last, 1368 in second last, and 1333 in third last year of life. RESULTS: The number of days spent in hospital in the last year of life was lowest for the young (24.2 days under age 25) and the old (23.2 days at age 85+) and was greatest at ages 55-64 (40.6 days). The ratio of days to survivors was highest at age 35-44 (31.0) and fell continuously thereafter to 4.3 at age 85+. Similar patterns were seen for hospital days in the second and third year before death, except that peaks were at 35-44 years (22.5 and 13.7 days respectively). Calculated lifelong number of hospital days increased with age from 54.8 (death at age 20) to 201.0 (age 90). Numbers of hospital days per year of life, averaged over the entire lifespan, were stable at 2.0-2.2 for deaths between age 50 and 90 (and up to 2.7 at age 20). CONCLUSIONS: Lifelong hospital utilisation for persons who die at 50 or later is directly proportional to the number of years lived. These data contradict results from cross sectional studies that suggest an exponential rise in health care costs as longevity increases. They have important implications for projections of future health care expenditure.
Acute Disease↗
[Prevention in medical care: potentials, effectiveness and conversion].
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Adult↗
[Effect of a back education program by the Lower Saxony AOK in response to the development of health related quality of life and occupational disability].
The statutory sickness fund AOK Lower Saxony developed a specific course program for a target group of up to 55-year old employees with common back pain in the early satge of chronification. Comparative evaluation of effects in study participants and controls was achieved by quality of life and performance data, i.e. days of sick leave (DSL). Medium and long-term change inquality of life (6 and 12 months after the course) was assessed by means of the SF-36 dimensions for cases and controls and compared in bivariate and multivariate test. 92 of 197 baseline participants (or 127 participants who completed the programme) and 483 controls were included in the medium term effect analysis. Significant medium and long-term net efffects could only be shown for pain dimensions. Anonymised DSL data for all 5409 insured persons who were initially selected as potiential participants for the regionally restricted course programme in the second quarter of 1997 were available for the period from 01-01-1996 to 30-06-1999. For controlling any selection bias and potential regional differences, the initial DSL trends of the 197 baseline course participants were compared with two control groups, namely other insured from the programme region and control regions. DSL trends in the three groups prior to the course program were identical. Subsequently DSL due to ICD-9 Codes 710-739 were reduced more substantially in course participants than in controls: 25.5 versus 33 or 32 days respectively. A covariance analysis model that also considered socio-economic factors and pre-intervention DSL levels yeilded a 14-day reduction in DSL (p value 0.023). This is a clear effect on DSL trends taht may be utilised for net savings for AOK. This is also the first proof of a backpain programme outside company settings taht permits net savings.
Curriculum↗
[Effects of rehabilitation after hip replacement surgery on postoperative complaints regarding the disease and limitation of function].
BACKGROUND: The study was conducted in co-operation with a German health insurance fund (Gmünder Ersatzkasse, GEK) to identify determinants of outcomes of hip surgery from the patient's perspective. METHODS: In September 1997 all beneficiaries (age 40-75 yrs.) who had been treated in hospital for osteoarthrosis of the hip (ICD-715/820) (n = 1352) were sent a questionnaire on average 5.2 months (T1) postoperatively. The standardized questionnaire contained, among others, items about pre- and postoperative subjective assessment of disease specific symptoms (Lequesne Index), complications, comorbidity (Katz-Index), health related quality of life (SF-36) and discharge (home or for inpatient rehabilitation). The response rate at T1 was 67.8%. Patients with hip surgery (n = 390) were sent a second questionnaire 17.2 months (T2) postoperatively. After the two mailings, data from 293 patients were available for analysis. Descriptive and multivariate analyses (GSK model) were performed to reveal determinants of disease specific symptom alleviation. RESULTS: Patients (57.6% male) were 61 years of age on average, and 61.2% reported no comorbidity. 88.4% had undergone total hip replacement. A third of the patients reported at least one complication. 70.6% were discharged for inpatient rehabilitation. Univariately, a substantial (and statistically highly significant) decrease was observed in the Lequesne Index over time: (recalled) preoperative: 14.2 points; postoperative T1: 5.6 pts.; postoperative T2: 4.4 pts. This result is confirmed by multivariate analyses (estimated values: pre = 13.8; T1 = 6.9; T2 = 5.7) although it is modified by an interaction effect between the variables "Lequesne Index" and "Discharge". In patients discharged home, the preoperative Lequesne Index is an estimated 13.3, at T1 = 6.9 and T2 = 6.2. The respective estimated values for patients discharged for inpatient rehabilitation are: preoperative 14.3; T1 = 6.9; T2 = 5.2. CONCLUSIONS: Patients receiving inpatient rehabilitation scored higher on the Lequesne Index (higher burden of disease) before hip surgery. In the short term, their improvements are higher than those of the patient group discharged home (-7.4 pts. versus -6.4 pts.) and continue to be higher in the medium term (-9.1 pts. versus -7.1 pts.). Inpatient rehabilitation after hip surgery leads to better disease specific health outcomes than direct discharge home.
Adult↗
The impact of maternal education on intrauterine growth: a comparison of former West and East Germany.
BACKGROUND: Objective of this re-analysis of datasets from former East and West Germany was to examine the influence of maternal education on intrauterine growth in two different political and social systems. METHODS: Information on socio-demographic or lifestyle factors and pregnancy outcome was available for 3374 liveborn singletons from West Germany (1987/88) and 3070 from East Germany (1990/91). Multiple logistic regression was used to estimate the association between maternal education and the risk of delivering a small-for-gestational-age (SGA) newborn below the 10th percentile of birthweight. RESULTS: Women with the lowest education had a significantly elevated risk of SGA newborns compared to women with the highest education in West (odds ratio [OR] = 2.58, 95% CI : 1.17-5.67) and East Germany (OR = 2.77, 95% CI : 1.54- 5.00). The distribution of factors known to influence intrauterine growth varied with education in both states. After adjusting for these factors, women with the lowest educational level still had a higher risk of SGA birth: OR (West) = 2.02, 95% CI : 0.87-4.72; OR (East) = 1.95, 95% CI : 1.02-3.74. CONCLUSIONS: Our findings support the assumption that in former socialist countries health inequalities as a result of social inequalities existed.
Body Mass Index↗
[Hip joint operations in routine patient management--determinants of quality of life].
The study was conducted in co-operation with a German sickness fund to identify determinants of health related quality of life (HRQL) after hip surgery in routine health care. In 9/97 all beneficiaries (age 40-75 years), which were treated in hospital for osteoarthrosis (n = 1352), were sent a questionnaire on average 5.2 months (t1), postoperatively. The standardized questionnaire contained a.o. items about pre- and postoperative subjective assessment of disease specific symptoms (Lequesne-Index), complications, comorbidity, health related quality of life (SF-36). The response rate at t1 was 67.8%. Patients with hip surgery (n = 390) were sent a second questionnaire 17.2 months (t2) postoperatively. At t2 data from 293 patients were available for analysis. Patients (57.6% male) were on average 61 years of age and 61.2% reported no co-morbidity. 88.4% received total hip replacement. 30.3% of patients reported at least one complication. HRQL in patients after hip surgery is significantly impaired in six of the eight SF-36 subscales compared to the German norms at t1 and t2. From t1 to t2 substantial improvements appear in the SF-36 subscales physical functioning, role physical and bodily pain (p < 0.001). Major determinants of HRQL are comorbidity (if yes: less improvement) and attendance of inpatient rehabilitation (if yes: more improvement). In routine healthcare HRQL after hip surgery is determined by patient characteristics and postoperative rehabilitation. Inspite of substantial improvements patients did not (yet) reach the level of the reference population.
Adult↗
[The success of hernia surgery in routine care from the patient's perspective].
BACKGROUND: The study was conducted in cooperation with a German sickness fund (Gmünder Ersatzkasse GEK) to determine the success of surgery for inguinal hernia from the patient's perspective. METHODS: We developed a standardized questionnaire containing, among other things, pre- and postoperative subjective assessment of disease-specific symptoms, complications, and health-related quality of life (SF-36). All beneficiaries (age 35-75 years), who were treated in the hospital for inguinal hernia repair (ICD-550) between November 1996 and January 1997 (n = 502) were sent the questionnaire at an average of 3 months (T1) and 14 months postoperatively. The response rate at T1 was 73%. At T2 data from 280 patients were available for analysis: 96% were male (mean age: 54 years). Descriptive and multivariate analysis (GSK model) were performed to reveal determinants of disease-specific symptom alleviation and health-related quality of life. RESULTS: Postoperative hematoma and genital swelling were reported by a quarter of the respondents, each. Pyogenic wound infection appeared in 4%. Compared to the (recalled) preoperative symptom level at T1 substantial and statistical significant improvements were apparent (P < 0.0001). These were maintained at T2 (disease-specific symptom checklist: preoperative: 10.7; T1: 2.8; T2: 2.5). Health-related quality of life reached the level of the German reference population in three of the eight subscales of the SF-36 at T1, and in five SF-36 subscales at T2. However, at T2 (still existing) deviations from the reference population in three of the SF-36 subscales were small. Bi- and multivariate analysis reveals that the appearance of complications from the patient's perspective has to be considered the main determinant of disease-specific symptom alleviation and health-related quality of life after hernia repair. CONCLUSION: Inguinal hernia repair leads to substantial improvements in disease-specific symptoms. Overall, health-related quality of life reaches the level of the reference population. The patient's perception of complications is the major determinant of health outcomes.
Adult↗
[Concept for a health care economic evaluation of short- and long-term costs and effectiveness parameters of an expanded ambulatory psychosomatic rehabilitation program].
There are only few ambulatory rehabilitation concepts for mothers with psychosomatic disorders (prevalence 5%). Also, only little is known about the evaluation of these programmes. This study compares the socioeconomic evaluations of an ambulatory rehabilitation programme with a post-assistance programme and one without a post-assistance programme. The superior programme should be determined by weighing all relevant costs and benefits. The intensive phase of the ambulatory rehabilitation programme consists of an eight-week treatment with group, single, body and art therapy. The post-assistance programme spans a period of nine-months with 36 sessions of psychoanalytic group therapy. The evaluation of both programme alternatives is made by with the evaluation tool of socioeconomic analyses. For consideration and pricing of costs all direct medical costs, direct non-medical costs and indirect costs are being monitored. Outcomes assessment is realised by cost-effectiveness analysis, cost-utility analysis and cost-benefit analysis. Utilisation of the health care system is being assessed with questionnaires. Measurements are being performed at the beginning and the end of the rehabilitation programme and three, six, nine and twelve months later. Mothers with children aged six years and younger and suffering from various psychosomatic disorders were included in this study. The costs identified for the rehabilitation programme are DM 5571.10 (intensive care and post-assistance programme) and DM 1512.40 (intensive care) per patient. Further progress of the study will show if future cost will differ between the two alternatives. For the comparison of both alternatives all costs will be linked with outcomes. It remains to be seen that additional costs of the post-assistance programme will be compensated with positive outcomes. A sensitivity analysis will show if variation of assumptions will influence the cost-benefit-ratio of the different alternatives.
Adult↗
[Determining priorities in the development of medical guidelines. 1: Criteria, procedures and actors: a methodological review of international experiences].
Setting priorities for the development of clinical practice guidelines has--similar to other decision-making procedures in health care--as much a political as a scientific component. Prioritizing guidelines aims to allocate resources to those health problems likely to maximize medical, social and economic outcomes associated with the use of these guidelines. This is a review and critical appraisal of international initiatives of systematically setting priorities for the development of clinical practice guidelines. Priority-setting criteria, both quantitative and qualitative methods as well as participation by relevant stakeholders will be discussed. This review provides possible decision-makers with an information basis which may assist in the development of concepts for setting priorities in a given context.
Forecasting↗
[Methodological standards of the evidence-based approach of clinical guidelines development in Germany. Consensus between the scientific community, self-governed bodies and practice].
The most appropriate method of clinical guidelines development has been the subject of controversial debates in Germany during the last few years. The German Guidelines Clearinghouse at the Society for Quality in Medicine (Cologne) provided a discussion forum where clinicians, methodologists, the Association of the Scientific Medical Societies, and the corporate self-governed bodies (the health insurances, physicians' associations, and the hospital associations) agreed on the most important methods of an evidence-based approach for guidelines development. It was generally agreed that rigorous methodological standards should be followed to ensure both the scientific quality and the consensus quality in the development or revision of clinical practice guidelines. The agreement draws on the following topics: Scientifically valid guidelines: (1) are based on a comprehensive and systematic review of the best available evidence, (2) derive the recommendations from the best available evidence, and (3) demonstrate explicitly how the recommendations are linked to the evidence. The quality of consensus is ensured through (1) the participation of all relevant stakeholders in the guideline panel and (2) the application of formal consensus development methods. This type of an "evidence-based consensus guideline" is assumed to possess the highest level of scientific and political legitimacy.
Evidence-Based Medicine↗
[Surveys on patient satisfaction in ambulatory care. Practicability, acceptance and relevance from the physician's perspective].
Surveys on patient satisfaction have become an integral part in quality management. Adequate survey conduction and appropriate feed back of survey results are essential prerequisites for a successful transfer of survey results into practice. During the validation of a new instrument to assess patient satisfaction in ambulatory care, we assessed the practicability, acceptance and relevance of the procedure used in this study (distribution and return of questionnaires, preparation of results and comparative feed back) from the perspective of the participating physicians (N = 60). Our results confirm, that physicians gain a considerable amount of information on quality of care from the patient's perspective, provided that results are fed back appropriately. Two thirds of the participating physicians (65%) obtained ideas and suggestions for quality management and improvement. Most of the ideas were realised at the time the physician survey took place. Recommendations for conducting patient surveys in ambulatory care and feed back of survey results for participating physicians are presented.
Ambulatory Care↗
Prevalence and determinants of prone sleeping position in infants: results from two cross-sectional studies on risk factors for SIDS in Germany.
The authors investigated whether there was a decline in infants sleeping prone and other modifiable risk factors for sudden infant death syndrome (SIDS) in Germany, where, as in some other countries, no nationwide intervention campaign against the prone sleeping position had been initiated. Data were obtained from parents by mailed questionnaires in two cross-sectional studies in 1991 (n = 3,330) and 1995 (n = 3,124). Prevalence of prone sleeping decreased from 37.6% to 8.7% (p < 0.05) in the German population and from 44.1% to 32.0% (p < 0.05) in the Turkish immigrant population. Parents who laid their infants prone in 1995 were less likely to follow advice from physicians, public media, and other parents (relative risks < 0.5, p < 0.05) and were more likely to have a low educational level, to be <20 years old, to be single parents, to have two or more children, to be raised in West Germany, or to be of Turkish ethnicity. Although the information on prone sleeping being a risk factor for SIDS became known among the population, these data suggest that subgroup-specific public intervention campaigns may be needed to reduce the prevalence of prone sleeping even further in those countries where no nationwide campaign has been initiated.
Adult↗