[Methods of health economic evaluation for health services research]. / Methoden der gesundheitsökonomischen Evaluation in der Versorgungsforschung.

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

[The role of university medicine in the development of clinical guidelines]. / Die Rolle der Hochschulmedizin bei der Entwicklung von Leitlinien.

Clinical guidelines are bridges between clinical research and patient care. In Germany, medical societies and university medicine are the main bodies responsible for the development, dissemination, and updating of high quality guidelines. The high demand on these to be based on evidence, clinical judgement, and structured consensus requires considerable resources. Currently, there is an inequality between the resources available to university hospitals and the incentives they receive. Financial and scientific recognition of the professionals, who develop and disseminate these guidelines, should be improved.

[Statutory ambulatory medical care through the eyes of the health insurance beneficiaries--methods and results of the 2006 NASHIP Health Insurance Beneficiary survey: care utilisation, primary care, and emergency medical services]. / Die ambulante vertragsärztliche Versorgung aus der Perspektive der Versicherten--Methodik und Ergebnisse der KBV-Versichertenbefragung 2006: Inanspruchnahme, Versorgung beim Hausarzt, Bereitschafts- und Notdienstpraxen.

OBJECTIVE: The aim of this study was to obtain valid information on the delivery of ambulatory medical care from the point of view of the health insurance beneficiaries. The National Association of Statutory Health Insurance Physicians (NASHIP) conducted in 2006 for the first time a nationally representative telephone survey. The survey set out to gather information on health care utilisation, patients' experiences and satisfaction with care delivery, and to provide an indication for the further development of the services offered. METHODS: Between 22 May and 8 June 2006, a random sample of 4 315 inhabitants from 18 to 79 years of age was interviewed using a computer-assisted telephone interview (CATI). The questionnaire included 51 questions relating to six topics, and consisted of a core set of questions and supplementary questions dealing with further details or special issues. One section of the 2006 survey focused on emergency medical services. In the analysis, samples were weighted to reflect the distribution of the population by age and sex. RESULTS: 82% of survey participants have visited a doctor's office in the last 12 months, and 93% indicated to have a regular general practitioner (GP) they consult for medical problems or health advice. Referring to all respondents, the mean number of consultations in a doctor's office was about 5 per year. Over 90% of respondents having a regular GP arrive at the office within 20 min, and for 61% home visits by their regular doctor are very important or important. 90% of respondents having seen the GP during the last 12 months assess the medical care received as very good or good. The places contacted when the regular office is closed are clearly varying by region and respondent's age. Whereas younger people primarily consult the hospital emergency department, the importance of the general practitioner in the case of an emergency increases with age. Overall, 29% preferentially turn to a hospital or hospital emergency department, another 25% to outpatient emergency medical services, and scarcely 16% to their regular GP. 61% of survey participants or their close relatives have already utilised emergency medical services (EMS). Regarding the last case of a medical emergency, in 3 out of 5 cases patients went themselves to the emergency service. A total of 74% of patients assess the care received by the emergency medical service as very good or good. Evaluations are less favourable in the event of prolonged waiting time for the emergency medical doctor at home or in the EMS office. CONCLUSION: The NASHIP health insurance beneficiary survey reflects a broadening patient and service orientation and provides valid information on ambulatory medical care through the eyes of the insurance beneficiaries. The survey depicts high overall satisfaction with primary care, a high degree of trust in the doctor's medical competence, and easily accessible services. Patient evaluations of outpatient emergency medical care are mainly positive, but still show room for improvement.

[Diagnosis and therapy of carpal tunnel syndrome--guideline of the German Societies of Handsurgery, Neurosurgery, Neurology, Orthopaedics, Clinical Neurophysiology and Functional Imaging, Plastic, Reconstructive and Aesthetic Surgery, and Surgery for Traumatology]. / Diagnostik und Therapie des Karpaltunnelsyndroms--Leitlinie der Deutschen Gesellschaften für Handchirurgie, Neurochirurgie, Neurologie, Orthopädie unter Mitbeteiligung der Gesellschaften für Unfallchirurgie, Klinische Neurophysiologie und Funktionelle Bildgebung sowie Plastiche, Rekonstruktive und Asthetische Chirurgie.

Evidence-based supradisciplinary guideline that deals with the epidemiology, pathogenesis, symptoms, clinical and electrophysiological diagnosis, supplementary imaging investigations, differential diagnosis, conservative and surgical treatments, prognosis and course along with complications and revision surgery. The recommendations on investigation and treatment are based on a comprehensive literature search with critical evaluation and two consensus methods (expert group and Delphi technique) within the participating specialist societies. Besides this long version, a short version and a patient version can be viewed through the AWMF platform. The development of the guideline and the methodological foundations are documented in a method report. MAIN STATEMENTS: Apart from an accurate history and clinical neurological examination (including clinical tests), electrophysiological investigations (distal motor latency and sensory neurography) are particularly important. Radiography, MRI, high-resolution ultrasonography can be regarded as optional supplementary investigations. Among conservative treatment methods, treatment with a nocturnal splint and local infiltration of a corticosteroid preparation are effective. Oral steroids, splinting and ultrasound showed only short-term benefit. Surgical treatment is clearly superior to all other methods. Open and endoscopic procedures (when the endoscopic surgeon has sufficient experience) are equivalent. A routine epineurotomy and interfascicular neurolysis cannot be recommended. Early functional treatment postoperatively is important.

[Development and implementation of the guideline "Diagnosis of and Therapy for Carpal Tunnel Syndrome"]. / Zur Entstehung und Implementierung der Leitlinie "Diagnostik und Therapie des Karpaltunnelsyndroms".

In the period from July 2005 through November 2006, the evidence-based guidelines were developed by a steering committee consisting of three members from each of the societies involved (German Society for Hand Surgery, German Society of Neurosurgery, German Society of Neurology and German Society of Orthopaedics), coordinated by one member each from the DGH and the DGNC, under the methodological guidance of Prof. Selbmann of the German Association of the Scientific Medical Societies (AWMF). Six all-day working sessions and one proceeding to build a consensus (modified Delphi process) were held within the seven specialised societies involved. Degrees of recommendation, based upon the degree of evidence of the underlying literature studies, modified, if necessary, by the expert opinion of the steering committee's members and the external evaluators of the Delphi round, were established for the most important diagnostic and therapeutic methods. In addition to the long version, a short version and a patient information bulletin were prepared as well, and the ways, means, and considerations surrounding their realisation and implementation, and other potential developments were also pursued.

[Assessment and certification of hospital care in Germany]. / Bewertung und Zertifizierung von Akut-Krankenhäusern in Deutschland.

The increasing call for evaluating and certifying the quality of hospital care is to be seen in connection with the need for more transparency in the German health care system. Hospitals can have themselves evaluated or compared on four levels of quality: the level of medical, nursing, and organizational core services, the level of the quality system of the hospital, the level of the internal quality management, and the level of business excellence. The external comparisons of hospitals legally established in Germany deal with the evaluation of core services of hospitals. All the other levels are covered by holistic evaluation and certification procedures following the models of the EFQM and the ISO, the genuine medical certification systems (KTQ and JCI), or peer reviewing. Each of them has different objectives and all are applied in German acute care hospitals. However, their methods are not yet fully developed and certainly will have to be further optimized in view of the forthcoming changes in the German health care system.

[Methods in evidence-based medicine consensus findings--a case study in trauma surgery]. / Methoden zur evidenzbasierten Konsensfindung--ein Fallbeispiel aus der Unfallchirurgie.

The methods and processes of a guideline development programme including a structured consensus conference for the employment of Diagnostic Imaging in Trauma Surgery are presented and critically reviewed. International standards and methodical concepts described in the Guideline Manual by the Agency for Quality in Medicine (AQuMed) and the Association of the Scientific Medical Societies in Germany (AWMF) have been implemented. Experiences with this project reveal that even a small multidisciplinary panel group is potentially able to cope with the comprehensive panel work if they are methodologically supported. The establishment of an internal quality management proved to be a useful tool for the production of high-quality results in the face of limited project resources. As expected, for most sub-questions knowledge of evidence and medical experience correlated well. However, the lack of a method for ensuring that consensus recommendations finally obtained by panel work and discussions during the conference were always based on evidence was the weak spot of this evidence-based consensus conference.

[Effects of a regional intervention to promote asthma guidelines implementation]. / Effekte einer regionalen Intervention zur Förderung der Implementierung von Asthma-Leitlinien.

AIM: Despite of asthma guidelines existing for years, secondary data analysis shows insufficient medical care of asthmatics in Germany. The aim of the present study was to improve asthma guideline adherence by promoting guidelines implementation. METHOD: We analyzed prospectively pre- and post-interventional medical care of a sample of 127 asthmatics who were recruited by physicians working in ambulatory care and in hospitals of the Region Neckar-Alb, Germany. Data came primarily from patient interviews by phone. Our intervention to promote guidelines implementation consisted of following methods: 1. analyzing regional asthma care followed by a feedback performance report to physicians; 2. delivering asthma patient diaries and peak flow meters to study patients; 3. developing and adapting regionally asthma guidelines for adult asthmatics in the Region of Neckar-Alb; 4. promoting guidelines utilization by publishing the adapted guidelines in a scientific journal, direct mailing of a short version to the practitioners, and boosting the guidelines at regional CE meetings; 5. reanalyzing asthma care of the study cohort and the implementation of the guidelines 13 months after the beginning of the intervention. We studied the effect of the intervention using a qualitative model comprising 18 quality indicators measuring the proportion of patients who were treated in accordance to the guidelines. To compare pre- and post-interventional proportions we used the McNemar test for statistical analysis. RESULTS: The proportion of asthmatics treated in accordance to the guidelines improved significantly from 48 % to 57 %. The increase was mainly due to an improvement of guidelines adherence within the field of promoting asthma self-management and continuous monitoring of patients (42 % pre- and 57 % post-intervention), whereas guidelines adherence in pharmacotherapy improved only from 53 % to 56 %. CONCLUSION: The proportion of asthmatics treated in accordance to guidelines can be improved by using a multifaceted regional approach to promote guidelines implementation.

[HYGEA (Hygiene in gastroenterology--endoscope reprocessing): Study on quality of reprocessing flexible endoscopes in hospitals and in the practice setting]. / HYGEA (Hygiene in der Gastroenterologie - Endoskop-Aufbereitung): Studie zur Qualität der Aufbereitung von flexiblen Endoskopen in Klinik und Praxis*

The quality of reprocessing gastroscopes, colonoscopes and duodenoscopes in daily routine of 25 endoscopy departments in hospitals and 30 doctors with their own practices was evaluated by microbiological testing in the HYGEA interventional study. In 2 test periods, endoscopes ready for use in patients were found contaminated at high rates (period 1: 49 % of 152 endoscopes; period 2: 39 % of 154 endoscopes). Culture of bacterial fecal flora (E. coli, coliform enterobacteriaceae, enterococci) was interpreted indicating failure of cleaning procedure and disinfection of endoscopes. Detection of Pseudomonas spp. (especially P. aeruginosa) and other non-fermenting rods - indicating microbially insufficient final rinsing and incomplete drying of the endoscope or a contaminated flushing equipment for the air/water-channel - pointed out endoscope recontamination during reprocessing or afterwards. Cause for complaint was found in more than 50 % of endoscopy facilities tested (period 2: 5 in hospitals, 25 practices). Reprocessing endoscopes in fully automatic chemo-thermally decontaminating washer-disinfectors with disinfection of final rinsing water led to much better results than manual or semi-automatic procedures (failure rate of endoscopy facilities in period 2 : 3 of 28 with fully automatic, 8 of 12 with manual, 9 of 15 with semi-automatic reprocessing). The study results give evidence for the following recommendations: 1. Manual brushing of all accessible endoscope channels has to be performed even before further automatic reprocessing; 2. For final endoscope rinsing, water or aqua dest. should only be used disinfected or sterile-filtered; 3. Endoscopes have to be dried thoroughly using compressed air prior to storage; 4. Bottle and tube for air/water-channel flushing have to be reprocessed daily by disinfection or sterilization, and in use, the bottle have to be filled exclusively with sterile water. The HYGEA study shows that microbiological testing of endoscopes is useful for detection of insufficient reprocessing and should be performed for quality assurance in doctors' practices, too. The study put recommendations for reprocessing procedures in more concrete terms.

[Not Available]. / Umfassendes Qualitätsmanagement in Klinikverbünden Bericht aus dem Demonstrationsprojekt "Qualitätsmanagement im Krankenhaus" (DemoProQM) : Bericht aus dem Demonstrationsprojekt "Qualitätsmanagement im Krankenhaus" (DemoProQM).

Within the demonstration project "Quality Management in Hospitals" (DemoProQM), 44 hospitals, organised in ten collaborative project groups, were supported by the German Ministry of Health from 1998 to 2001 in their methods for implementing total quality management. Their activities were monitored and evaluated by a staff of scientists and experts in the field. The main intention of the DemoProQM project was the implementation of quality management with special attention to patients and staff concerns, including all professions, hierarchies and hospital units. The second objective was to show other hospitals successful methods of implementing quality management and to demonstrate its benefits with special regards to the aspects of quality, economy and competition. To achieve these aims, the participating hospitals created adequate quality management structures and defined a quality policy as well as quality goals. In quality improvement projects, interprofessional teams tried to achieve these quality goals using the well-known methods of quality management. The successes and problems experienced by the participating hospitals are reported below.