[Financial Influence on Medical Decisions in Germany - A Review of the Reasons and State of Research on Economization in Inpatient Care]. / Finanzielle Beeinflussung medizinischer Entscheidungen in Deutschland ­ Eine Übersichtsarbeit zu Ursachen und Forschungsstand von ökonomischen Einflüssen in der stationären Versorgung.

Increased economization in the German health care system may have an impact on medical decisions. A selective literature search presents an overview of the current evidence on the influence of financial incentives on inpatient healthcare in Germany. Due to the current economic pressure, physicians increasingly feel subjected to financial constraints concerning indication and treatment decisions. There is evidence for financially initiated upcoding and volume expansion. Little is known about the extent, the impact on quality of care, nor on vulnerable groups. The literature clearly documents effects of financial pressure on job satisfaction, perceived stress, and the health of attending physicians. The current discussion on the economization of physician practice is important, especially with regard to disincentives and job satisfaction. Little is known about the risks to patient health.

Systematic symptom screening in patients with advanced cancer treated in certified oncology centers: results of the prospective multicenter German KeSBa project.

PURPOSE: Guidelines recommend a structured symptom screening (SC) for especially advanced cancer patients (CPs). The aim of this multicenter German prospective quality assurance project KeSBa (Kennzahl Symptom- und Belastungserfassung) was to gain knowledge on SC procedures in Oncology Centers (OCs) for advanced cancer patients and a first impression on the consequences of SC. METHODS: The KeSBa project consisted of three phases: pilot, 3 months screening and feedback phase. Participating OCs decided to use either the Minimal Documentation System (MIDOS) or the Integrated Palliative care Outcome Scale (IPOS) and defined the cutoff values for positive screening results. RESULTS: Out of 172 certified German OCs, 40 (23%) participated in the KeSBa pilot phase, 29 (16.8%) in the 3 months screening phase using MIDOS (n = 18, 58.6%) or IPOS (n = 11, 41.3%) and in the feedback round. 25/29 performed paper-based screening (86.2%). 2.963 CPs were screened. Results were documented for 1255 (42.2%, SC +) positive and 874 (29.5%, SC-) negative screenings depending on the center´s schedules: 452 SC + CPs (28.4%) and 42 SC- CPs (2.6%) had contact to specialized palliative care or other supportive specialist teams afterwards, 458 SC + CPs (28.8%) and 605 SC- CPs (38.1%) remained in standard oncology care. In the feedback round missing resources (personal and IT) and improved communication were mentioned most often. CONCLUSION: Routine SC is feasible in advanced CPs treated in OCs but associated with considerable workload. In 42.2% of CPs SC was classified as positive, indicating the need of further diagnostics or professional judgment. SC requires staff and IT resources.

Administration of chemotherapy by an arteriovenous fistula in a patient with metastatic rectal cancer after life-threatening, port thrombosis-associated cava superior syndrome. An option for patients without possibility of peripheral or central venous access.

BACKGROUND: Patients with solid tumors have an increased risk of venous thromboembolism, potentially related to a venous port system. In case of catheter-related thrombosis despite full anticoagulation, further treatment administration is difficult. CASE REPORT: A 41-year-old female patient with a K-Ras wild-type adenocarcinoma of the rectum was diagnosed with systemic disease in June 2008 after several local recurrences treated with surgery and additive chemotherapy. To administer chemotherapy with FOLFIRI (folinic acid, 5-fluorouracil, irinotecan) and bevacizumab, a venous port system into the vena subclavia was implanted. In April 2009, the computed tomography (CT) scan revealed a portassociated thrombosis with cava superior syndrome, despite treatment with phenprocoumon and an international normalized ratio (INR) of 3.75 at the time of the event. The port system was explanted. According to the possible relationship to bevacizumab, treatment was discontinued, followed by rapid disease progression. Access to peripheral veins became virtually impossible. Therefore, a radiocephalic fistula was established. For 9 months, the patient has been receiving several therapeutic agents with 20 punctures of the fistula, revealing no locoregional events (e.g. arterial, venous or cutaneous). CONCLUSION: The application of current therapeutic agents by an arteriovenous fistula seems to be a feasible option for patients with restricted peripheral or central vein status and/or medical history of thrombotic events disabling the use of a port system.

Adjuvant therapy for early colon cancer: current status.

Adjuvant chemotherapy after resection of the primary tumour reduces the risk of death by an absolute 5% in UICC (Union Internationale Contre le Cancer) stage II colon cancer and about 15-20% in stage III. Adjuvant treatment has to be evaluated separately for each stage due to the different clinical situations: in stage II about 80% of patients are cured by surgery alone, whereas only about half of patients with stage III are cured by surgery. Decisions on adjuvant treatment need to be discussed with the patient on an individual basis, and take into account patient characteristics (performance status, age, co-morbidity and patient preference) as well as cancer features (pathological stage, grading and overall risk of relapse). Recently, capecitabine in combination with oxaliplatin has been approved for treatment of stage III colon cancer, providing the benefits of an oral fluoropyrimidine. Predictive markers for guidance of treatment have gained importance, particularly in stage II disease. Microsatellite instability, a well known prognostic factor, might be predictive for a lack of activity of fluorouracil treatment in some stage II patients. Furthermore, patients aged ≥70 years do not seem to obtain the same benefit from combination therapy compared with those aged <70 years. The impact of these current developments on daily clinical practice is discussed in this review.