Convergent Evolution of Boats with Sails.

This article unveils the geometric characteristics of boats with sails of many sizes, covering the range 102-105 kg. Data from one hundred boat models are collected and tabulated. The data show distinct trends of convergent evolution across the entire range of sizes, namely: (i) the proportionality between beam and draft, (ii) the proportionality between overall boat length and beam, and (iii) the proportionality between mast height and overall boat length. The review shows that the geometric aspect ratios (i)-(iii) are predictable from the physics of evolution toward architectures that offer greater flow access through the medium.

Medical costs of diabetic complications total costs and excess costs by age and type of treatment results of the German CoDiM Study.

AIMS: This study examined the medical costs of diabetic complications by age, type of treatment, and type of complication and researched the relationship between total and excess costs with respect to type of complications. METHODS: Patients with diabetes (n=26,971) were identified from a German statutory health insurance database by glucose-lowering drug prescriptions and ICD-10 diagnoses. Diabetes complications were defined as microvascular (eye and kidney diseases), foot complications (peripheral neuropathy, peripheral vascular disease), macrovascular (cardio- and cerebrovascular diseases), and uncontrolled glucose metabolism (glycaemic complications). Estimates of frequency and medical costs of complications were calculated for diabetic patients and an age- and sex-matched control group of persons without diabetes. RESULTS: Half (53%) of the medical costs per diabetes patient in 2001 (euro4,457) were spent for management of complications (euro2,380). In the control group, costs of these diseases were euro761 per person. Consequently excess costs of complication due to diabetes were estimated at euro1,619 (36%) and were caused for treatment of macrovascular (euro643, 14%), microvascular (euro458, 10%), foot complications (euro430, 10%) and glycaemic complications (euro88, 2%). Furthermore 12% were spent for management of hyperglycaemia (euro542). Excess costs for complications per diabetic patient were higher for insulin (euro4,395) versus non-insulin treated patients (euro587). Eye, kidney and foot complications were encountered 3 - 4 times more often in diabetic patients than in non-diabetic controls, whereas macrovascular diseases were only 1.6 times more frequent. Therefore the proportion of diabetes dependent excess costs of microvascular and foot complications was high (78%), and was considerably lower (56%) for macrovascular complications. CONCLUSIONS: A close relationship exists between diabetes related excess costs and the presence of microvascular and foot complications. It is important to identify these patients early in order to incorporate them into diabetes management programs. A better care of diabetes patients and subsequent prevention of these late complications promises not only to improve quality of life but also to be highly cost-effective.

Lung transplantation from dialysis dependent donors.

Lung transplantation from a donor with chronic renal failure has never been reported. This paper reports our successful experience with 2 transplants from donors with end-stage renal disease who were on chronic hemodialysis, and reviews the relevant literature on the effects of renal failure on pulmonary function and on the use of marginal donors.

Induction therapy in lung transplantation: a prospective, controlled clinical trial comparing OKT3, anti-thymocyte globulin, and daclizumab.

BACKGROUND: Because acute rejection is associated with inferior outcomes in lung transplantation, we have routinely employed OKT3, anti-thymocyte globulin (ATG), or daclizumab as adjuncts to reduce rejection. METHOD: We performed a 4-year prospective, controlled clinical trial of these 3 therapies to determine differences in post-operative infection, rejection, survival, and bronchiolitis obliterans syndrome (BOS). Eighty-seven consecutive lung transplant patients received OKT3 (n = 30), ATG (n = 34), and daclizumab (n = 23) as induction agents. The groups had similar demographics and immunosuppression protocols differing only in induction agents used. RESULTS: No differences were observed in immediate post-operative outcomes such as length of hospitalization, ICU stay, or time on ventilators. Twelve months post-transplant, OKT3 had more infections per patient than the other agents, a difference that only became significant 2 months post-operatively (p = 0.009). The most common infection was bacterial and OKT3 had more bacterial infections than any other agent. Daclizumab had more patients remain infection free in the first year (p = 0.02), having no fungal infections and a low rate of viral infections. No patient receiving daclizumab developed drug specific side-effects. Only those patients with episodes of acute rejection developed BOS. There were no significant differences in the freedom from acute rejection or BOS between the groups. The 2-year survival for the entire cohort was 68%, with no differences observed in patient survival. CONCLUSIONS: This study again reveals the importance of acute rejection in the subsequent development of BOS. Although daclizumab offers a low risk of post-transplant infection and drug specific side-effects, no drug is superior in delaying rejection or BOS or in prolonging long-term survival.

Pharmacotherapeutic circles. Results of an 18-month peer-review prescribing-improvement programme for general practitioners.

OBJECTIVE: To assess the effectiveness of the pharmacotherapeutic circle (PTC), a general practitioner (GP) prescribing-improvement programme to enhance prescribing quality and reduce drug costs. DESIGN: Combined pre- and post-intervention time-series design using an internal comparison of subgroups and an external comparative control. SETTING: Small discussion groups meeting 8 times over 18 months. PARTICIPANTS: 79 GPs exceeding the mean drug costs/patient of all Hessian physicians by > or = 40%; 10 moderators. INTERVENTIONS: Peer-review feedback of prescription patterns based on guidelines targeting 3 suboptimal prescribing areas: drug prescriptions lacking evidence-based efficacy (target A); presumptive prescribing habits (target B); and underprescribing of new, effective therapies (target C). MAIN OUTCOME MEASURES AND RESULTS: Significant decreases in prescription rates for target A drugs were recorded for varicose vein medications (p = 0.006), peripheral vasodilators (p = 0.0001) and topical antirheumatics (p = 0.0145), but not for prokinetics/enzymes/digestives. Prescribing of target B drugs such as benzodiazepines and nonsteroidal anti-inflammatory drugs declined markedly (p = 0.0019 and 0.0014, respectively). Target C drug prescriptions such as for opioids and proton pump inhibitors were not significantly increased. Highly significant reductions in prescription costs were observed for target A and B drugs, irrespective of whether GPs were stratified into high, medium or low prescribers. When mean prescribing costs for PTC participants were compared with those of a control group comprising 8000 GPs over a 21-month period, PTC GPs decreased their costs by 2%, whereas drug costs for all Hessian physicians rose by 10%. CONCLUSIONS: PTCs appear to be an effective method to optimise the quality of drug prescribing and reduce drug costs.

Type, scope und quality of drug utilization.

Drug utilization research examines the quantitative and qualitative aspects of drug utilization. These include the medical, social and psychological factors and consequences of drug use in relation to specific patient groups and specific population groups, as well as the population in general (EURO-DURG-Resolution 1997). The present article puts particular emphasis on the methodological aspects and the public health perspectives involved in this search. A major goal of drug utilization research is the improvement of drug therapy as administered by physicians and pharmacists and the assessment of drug use in the population as a whole, encompassing both prescription-based and self-administer medication. In addition, drug utilization research also fulfills an important public health role in a welfare state by monitoring and controlling drug expenditure, by providing data that serve to answer health policy questions and by contributing to the management and planning of public health politics. Drug search makes use of 2 data sources. On the one hand, case-related (prescription-related) mass data (e.g. drug index) or prescriptions and medical records for patient groups held by specific institutions (e.g. IMS data, utilization observations), on the other hand, personal but anonymous prescription information and medical records taken from unselected natural populations (e.g. survey data from statutory health insurance institutions). Comparing drug utilization data for population groups in various regions, both national and international as well as between medical institutions, sociodemographic groups and diagnostic profiles will help to provide information on the medical, economical and social determinants of drug use and provide a base for health policies.

Development of indicators for assessing the quality of prescribing of lipid-lowering drugs: data from the pharmacotherapeutic quality circles in Hesse, Germany.

OBJECTIVE: To develop indicators based on prescription analysis in order to assess adherence using guidelines and to monitor prescribing behavior. SETTING AND MATERIAL: Eleven pharmacotherapeutic circles (PTC) of the Association of Statutory Health Insurance Physicians (KV Hesse; 10 PTCs including 155 GPs as participants, mostly high prescribers; one circle with 11 moderators trained in pharmacology). These provided a total of 183,997 drug prescriptions involving 54,970 patients (prescriptions reimbursed by the substitute fund--Ersatzkassen--II. quarter 2000); claims form from 151 GPs. On average, 5.1% of the patients with prescriptions received lipid-lowering drugs. METHOD: Development and application of indicators based on the guideline for the treatment of hypercholesterolemia developed by a GP's guideline group of the quality circles in Hesse (Hausärztliche Leitliniengruppe Hessen). The ratio of prescribing for primary and secondary prevention was chosen as a top indicator for measuring adherence to the guideline. Prescribing for secondary prevention was assessed by a set of special diagnoses. The second indicator relates to patient groups (here: older than 75 years) where the benefit of prescribing is not clear. Further indicators measure the prescribing of first choice drugs, avoidance of risk combinations and costconscious prescribing. The indicators are presented in the prescription analysis and will be discussed during the circle meeting. RESULTS: On average, the moderators prescribed 34% of the lipid-lowering drugs for primary prevention, the GP circle participants 36.7%. On average, moderators and GP participants prescribed lipid-lowering drugs for 4.9% and 7.5% of patients older than 75 years, respectively (6% and 22% in primary prevention). Approximately, 28% of all lipid-lowering drugs issued by the participants involved simvastatin and pravastatin as first-choice drugs compared to 36.5% in the case of the moderators. The prescribing of statins with fibrates or macrolides in combination is seldom. Cost-conscious prescribing can be assessed for each GP by the percentage of generic prescribing and the number of different brands per active agent. Both, moderators and participants used generics when prescribing fibrates, bile acid sequestrants or other types of lipid-lowering drugs (moderators 53.8% and GP participants 78.5%). Three months is too short a period for assessing compliance of lipid-lowering drug prescribing. CONCLUSION: It is possible to derive indicators from the guidelines and to integrate them into prescription analysis. The indicators reveal prescribing problems. The evaluation of PTCs in 2002 will involve the use of indicators as an instrument to assess the success in the implementation of guidelines.

[Prevalence and distribution of stroke and transient ischemic insults: secondary data analysis of a representative sample of insured members of the General Local Insurance Dortmund]. / Häufigkeit und Verteilung von Apoplexie und transitorischer ischämischer Attacke: Sekundäranalyse der Verwaltungsdaten von Versicherten der AOK-Dortmund.

Apoplexia is not only one of the leading causes of death, but also a major contributor to disability in the aged. Population based prevalence rates, though being of basic importance for describing and planning health care structures, are sparse in the Federal Republic of Germany. We estimated the prevalence of apoplexia and transient ischemic attack (TIA). Data were gathered from a 5% representative random sample of insured of the local statuatory health insurance (AOK) in Dortmund, Germany (n = 7447). Cases were identified by the diagnosis on medical certificates, being further validated internally by other patient data. The rough prevalence rate was 0.86% (m 0.79%, f 0.93%) for apoplexia and 0.6% (m 0.4%, f 0.78%) for TIA. Adjusted for age and sex to the whole population of the FRG (excluding the former German Democratic Republic) the prevalence rate was 0.75% (m 0.8%, f 0.7%) for apoplexia and 0.52% (m 0.41%, f 0.63%) for TIA. 65% of the insured with apoplexia were 70 years and older; their average age was 71.7 years. The average age of the insured with TIA was 65.4 years. Prevalence rates for apoplexia increased continuously by age and were higher for men than for women in all age groups. Prevalence rates for TIA also increased with age, but under men only to the age of 70; after that-simultaneous to a steep rise of apoplexia prevalence-no more TIAs were noticed.

[General practitioners and internists prescribe psychopharmaceutic drugs]. / Allgemeinärzte und Internisten verschreiben Psychopharmaka.

An epidemiological study using data from a local German health insurance fund on the psychotropic drug prescription of physicians and the drug utilisation of their patients is presented. Taking a sample of 280 out-patients, descriptive methods are presented (defined daily dose (DDD), prescribed daily dose (PDD), active-agent-oriented classification of drugs, therapy-oriented classification of diagnoses). The following questions are answered by this study: Which patients with which indication received which dosage of which psychotropic drug for how long from which physicians? The patient-based structure of the data, taking into account the prescriptions of all physicians allows the course of therapies and the study of overall psychotropic medication. Prevalences estimates concerning the patients are also possible. Our results are compared with those of similar pharmaco-epidemiological studies; the difference in prevalence estimates, as well as advantages and possible disadvantages arising from the use of such secondary data base, are discussed.

[Drug therapy courses for family physicians--advanced education in pharmacotherapy]. / Pharmakotherapiezirkel für Hausärzte--Fortbildung in Pharmakotherapie.

UNLABELLED: General practitioners (GPs) are responsible for 70% (or roughly 30 billion DM) of the entire medication prescribed by practising doctors. Pharmacotherapy circles (PTC) are a further education, which focuses on the optimisation of prescription behaviour (best therapy possible in clinical pharmacology, the translatability into daily practice and guides the concept and contents of the further education. The concept of further education in pharmacotherapy circles developed by us follows the rules of quality assurance in medical care: ASSESSMENT: Recording prescriptions in one quarter for evaluation of prescription problems. Problem selection: Medicine groups, whose prescription frequency give an indication of prescription quality, i.e. vein and rheumatism ointments (as little as possible) and proton pump inhibitors and lipid reducers (as many as necessary). The problem analysis takes place as peer review by a group of physicians from the same field, and under the moderation of two doctors from the same field, who have been for at last one year, carefully instructed, in pharmacology and the moderations of groups. The formulation of guidelines shall be shown for an indication area, for which there is no robust therapy (e.g. venous medicaments). The purpose of theses guidelines shall be to optimise the treatment, strengthen the health consciousness of the patient and reduce the prescription of medicaments, whose efficacy has not been proven. The evaluation proves that these goals have been reached. The total reduction in costs is different for individual physicians depending on the original prescription level of the underlying medicament costs. Only the third of "high prescribers" showed economy reserves. There were savings in medicaments with non-proven efficacy among the lower and middle prescribers, however, there were increased expenditures and therapy improvements in other areas.

[Direct costs of ambulatory treatment of diabetes mellitus. Comparison of observed costs with estimated costs of adherence to the treatment standard]. / Die direkten Kosten der ambulanten Behandlung des Diabetes mellitus. Vergleich der beobachteten Kosten mit den Aufwendungen bei Einhaltung des Behandlungsstandards.

BACKGROUND: The aim of this investigation was to record the observed direct costs of the outpatient treatment and therapy control of diabetic patients based on patient-related analysis of health care expenses in a population-based sample and to compare these costs with those generated if the minimum requirements of the European IDDM and NIDDM Policy Groups are fulfilled. Up to now there are only few studies on this topic. PATIENTS AND METHOD: Medical records of a 5% random sample of all insured members of the AOK Dortmund (n = 6085) in 1990 provided the data basis. The direct diabetes-specific therapy and care costs were compiled per patient and year. RESULTS: The annual costs for antidiabetic drugs, monitoring of blood glucose and glycated hemoglobin, test strips for self-monitoring, checking serum cholesterol, triglycerides and creatinine as well as for fundoscopy amounted to a mean of DM 1218.-per each insulin-treated patient (n = 65), DM 211.-per patient on oral antidiabetic drugs (OAD, n = 177), and DM 42.-per patient treated by diet alone (n = 108). Provided that the minimal recommendations of the European IDDM and NIDDM Policy Groups were followed the calculated costs would be DM 1758.-, DM 287.- and DM 198.-, respectively. CONCLUSION: Fulfilling the minimum standards for diabetes care of the European IDDM and NIDDM Policy Groups, respectively, would cause additional costs per patient and year of DM 540.-for insulin-treated. of DM 76.-for OAD-treated and of DM 156.-for patients treated by diet alone. On the other hand adherence to the recommendations would reduce the annual costs for oral antidiabetic drugs by 40%. Improved care of diabetic patients would result in significantly higher costs, but these extra expenses would be probably compensated by a reduction or delay of late complication.

[Heterogeneity of costs of diabetic patients: the Cost of Diabetes Mellitus Study]. / Heterogenität der Kosten bei Patienten mit Diabetes mellitus: Die KoDiM-Studie.

BACKGROUND AND OBJECTIVE: Health economic studies in patients with diabetes mellitus have demonstrated that a large proportion of the excess cost is caused by the treatment of specific complications. It was the aim of this study to analyse the distribution of per capita cost of a large cohort of diabetic patients in order to develop new strategies for a better identification and care of high-risk patients. METHODS: The analysis was based on anonymous data on patients with diabetes and an age-matched control group from a large cohort of subjects insured by a large statutory health insurance fund (AOK Hesse) (n=305736). Costs were fully assessed and related to the state of complications and other criteria. RESULTS: The average cost was 5262 euros per diabetic patient and year. Excess costs due to the diabetes were estimated at 2507 euros. Costs were unevenly distributed, depending on the presence of complications. The average excess cost of patients with at least one complication was i 3730 euros (469 for patients without complication). In particular, patients on hemodialysis, after kidney transplantation or with lower leg amputation, stroke or with gangrene or foot ulcer incurred great costs. 5.3% of all diabetic patients incurred costs of > or = 20000 euros per year, totalling up to 33.6% of all costs of diabetic patients. Another 9.5% of patients incurred costs of between 10000 euros and 20000 euros per year. Both groups were responsible for 59.6% of total costs. In contrast, 55% of the patients incurred costs of < 2500 euros per year, amounting to 11.8% of all costs. CONCLUSIONS: There is a considerable variation of cost incurred in the management of diabetic patients, as demonstrated in a large population-based cohort of diabetics. This increased cost was largely due to the presence of complications. High-risk patients should be identified as early as possible so that they can receive intensive care to avoid the expensive complications of the disease.

Cost of illness of malignant lymphoma in Germany.

Cancer causes a high economic burden. The purpose of this study is to determine and compare the direct, indirect and societal costs of illness for Hodgkin's Disease (HD), Non-Hodgkin's Lymphoma (NHL), Plasmocytoma and Chronic Lymphatic Lymphoma (CLL). We used a database of 1.9 million individuals enrolled in a statutory sickness fund in Germany to identify 4,172 patients treated for malignant lymphoma in 2000. Direct, indirect and societal costs were calculated using a case-control design and the human capital approach. Direct cost (in Euro) for patients with HD was 3604, for NHL patients 6,149, for Plasmocytoma 8,400, and for CLL patients 3,226. Total indirect cost for HD was 69 million, for NHL patients 404 million, for Plasmocytoma 144 million, and for CLL patients 52 million. Totalling 1.7 billion Euro in economic cost for Germany in 2000, with 44,000 productive years lost, malignant lymphomas are a relatively costly disease group. As life expectancy increases, costs for malignant lymphoma are likely to rise due to the high prevalence among the elderly. Further research employing disaggregated, incidence-based cost is needed.

The cost burden of diabetes mellitus: the evidence from Germany--the CoDiM study.

AIMS/HYPOTHESIS: The aim of this study was to identify the health care costs of diabetic patients in Germany in 2001, focusing on the influence of age, sex, and type of treatment. SUBJECTS AND METHODS: Annual direct costs of medical care and indirect costs of inability to work and early retirement in diabetic subjects were compared with costs of age- and sex-matched non-diabetic control subjects. The analysis was based on routine health care data from a random sample (18.75%) taken from a database of 1.9 million insured persons. Incremental differences in medical and national expenditure between subjects with and without diabetes were calculated. RESULTS: Annual direct mean costs per diabetic patient were 5,262 Euro, and indirect costs were 5,019 Euro. In the control group, mean direct and indirect costs were 2,755 Euro and 3,691 Euro, respectively. Analysis of cost components revealed that the high costs associated with the care of diabetic patients could be largely attributed to inpatient care and overall medication costs. Hypoglycaemic drugs amounted to only one-quarter of the medication costs. The total health care costs were correlated with the type of treatment. Direct excess costs increased with increasing age in insulin-treated patients, but were unaffected by age in patients receiving other types of treatment. CONCLUSIONS/INTERPRETATION: The Costs of Diabetes Mellitus (CoDiM) study is the first comprehensive study to provide estimates of costs associated with diabetes care in Germany. Direct costs of diabetic patients account for 14.2% of total health care costs, which includes the proportion that specifically accounts for diabetes-related costs (6.8%).