[Decision criteria for the appropriateness of inpatient treatment in patients with peripheral angiopathy]. / MDK - Prüfungen zur primären und sekundären Fehlbelegung am Beispiel der Angiologie.

In various medical subspecialties like angiology, invasive diagnostic procedures and elective therapy, which under certain conditions may be carried out on outpatients, represent a large proportion of all inpatient medical treatment. As regulations for the statutory health insurance in Germany demand that medical procedures should be preferentially carried out in outpatient facilities, there is a high potential for conflicting views with respect to the question whether hospitalisation of an individual patient is mandatory for medical reasons. Explicit criteria may be useful to prevent conflicting views and to increase truth and fairness in the proceedings of hospitals on one hand and the medical service of the statutory health insurance on the other hand. With respect to this problem we present decision criteria which were compiled by a hospital (Hochrhein-Eggberg-Klinik Bad Säckingen) and the medical service of the statutory health insurance in the state of Baden-Württemberg (MDK-Baden-Württemberg). Our model has proven to be of value in our practical experience. It seems to be transferable to medical subspecialties with similar problems.

[Elzach concept and intervention catalogue of nursing therapy in postacute neurological rehabilitation within the German DRG System]. / Elzacher Konzept und Leistungskatalog der therapeutischen Pflege in der neurologischen Frührehabilitation (Phase B).

The German DRG system defines specialized treatments through a set of minimal requirements, the documentation of which and its assessment by external specialists of the medical service of the statutory health insurance causing frictions between rehabilitation hospitals and the medical service. It is especially problematic to make a clear distinction between nursing care and treatment. To reduce frictions and interface problems, a catalogue of acts of therapy performed by nurses was agreed for neurological early rehabilitation in Baden-Württemberg. This Elzach concept and catalogue describe therapeutic nursing in neurological rehabilitation and increase transparency and accountability both for providers and cost carriers.

[Case payments in hospital psychiatry in the USA. The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)]. / Fallpauschalen in der Krankenhaus-Psychiatrie der USA. Das Inpatient Psychiatric Facility Prospective Payment System (IPF PPS).

OBJECTIVE: In Germany the introduction of a prospective payment system (PPS) is intended for inpatients hospitalised in psychiatric facilities. We investigate the various elements of the Prospective Payment System for Inpatient Psychiatric Facilities (IFP PPS) which was established in the USA in 2005 with respect to their potential to be incorporated into a german PPS. RESULTS: The most important elements of IFP PPS (impact of diagnosis, comorbidity, patient age, per diem adjustment for length of stay, various other adjustment factors like facility characteristics and geographical factors) are presented. The IFP PPS was especially designed for the requirements of psychiatric inpatient facilities in the USA. Complexity of the individual elements of the PPS appears to be manageable. However, various elements, e. g. the facility based adjustments including wage index or rural location and cost of living adjustments will not be applicable to countries other than the US. The 15 diagnosis related groups of the IFP PPS system refer to ICD-9 which is less differentiated than the ICD-10 which is in use in Germany, thus these psychiatric DRG will not be compatible under conditions of a german PPS. The per diem adjustment for length of stay is the predominating element of the IFP PPS, relation to effort/performance is insufficiently represented. CONCLUSION: Some elements of the IFP PPS may be applicable to a german prospective payment system for psychiatric inpatient facilities, especially with respect to the rules for per diem adjustment for length of stay and for handling of cases with frequent discharge and readmission of patients. Altogether a stronger representation of elements of performance of inpatient facilities seems to be desirable.

[DRG evaluation results--state comparisons: MDK Baden-Württemberg versus MDK Westfalen-Lippe]. / DRG-Prüfergebnisse im Ländervergleich: MDK Baden-Württemberg und MDK Westfalen-Lippe.

We report on the first detailed comparison of evaluation results regarding the correct billing in the G-DRG (German diagnosis-related group) system. For two Medical Review Boards of the Statutory Health Insurance Funds of comparable size (MDK Baden-Württemberg and MDK Westfalen-Lippe), we analysed consecutive expertises regarding correct billing according to section sign 275 SGB V, and the results were compared in terms of the frequency of DRG-relevant error codes, their relevance to revenue, and the question of error clustering (specific DRGs, primary diagnoses, etc.). The analysis comprised 51,010 individual expertises pertaining to billings of the year 2005 (admittance to hospital from January 1 to December 31, 2005). The proportion of disapproved cases was 38.5% in Baden-Württemberg and 44.6% in Westfalen-Lippe. Among these, errors to the disadvantage of the Health Insurance (incorrectly high) were 33.9% and 39.3%, respectively, and errors to the disadvantage of the hospitals (incorrectly low) were 4.6% and 5.3%, respectively. The resulting ratio (incorrectly high vs. low) was an identical 7.4 in both cases. Not only the most commonly rejected DRGs but also the primary and secondary diagnoses were similar in both cases, while the disapproved procedure codes showed a significant variability (analysis based on the respective 10 most common objections). We discuss the similarities and differences in these results and their possible causes, and demonstrate the cost relevance of this audit segment. Result comparisons of this type can yield insights into streamlining of the review practice of Medical Review Boards, as well as increase the efficiency and effectiveness of the selection of cases.

[Integrated case fees in cardiosurgery--a pilot project for fast-track rehabilitation]. / Komplexfallpauschalen in der Herzchirurgie--ein Modellprojekt zur Frührehabilitation.

BACKGROUND: Lengthy recovery and treatment times following cardiosurgical interventions were the motivation for introducing a pilot procedure to integrate acute and rehabilitative treatment structures. The advantage of such a pilot procedure is the medico-economic link between direct transition from acute care to rehabilitation treatment and cutting average case costs. With this in mind, shared case fees for patients following cardiosurgery are being agreed in a pilot project between health insurance companies, acute-care hospitals and rehabilitation clinics. The aim of this study was thus to investigate whether rehabilitation directly after cardiosurgery without prior transferral to an acute-care hospital is comparable with the conventional procedure involving acute care. METHODS: A total of 221 patients were included in the investigation. The pilot project group comprised 159 patients (mean age 70 +/- 6 yrs, 117 men and 42 women) who were transferred directly to rehabilitation following cardiosurgery. The control group, comprising 62 patients (mean age = 71 +/- 6 yrs, 42 men and 20 women), was transferred to an acute-care hospital following cardiosurgery before commencing rehabilitation. Sociodemographic and clinical data were comparable between the two groups. RESULTS: At the end of rehabilitation, the mean maximum ergometric performance in the pilot group was 96 +/- 33 W, significantly higher than the control group's performance of 81 +/- 31 W. One difference between the two groups related to complications. During rehabilitation, complications occurred more frequently within the pilot group. In the pilot group, compared to the control group, postcardiotomy syndrome occurred in 45.3 versus 25.8% and impaired wound healing in 10.1 versus 4.8% of cases. Despite these results, the pilot group demonstrated a significantly shorter overall hospital stay of 39.5 +/- 7.5 days compared to the control group stay of 45.7 +/- 9.7 days. CONCLUSION: Compared to the control group, the pilot group was at no disadvantage with regard to clinical or performance data by the end of rehabilitation. Cardiac complications occur more often during rehabilitation taking place directly after cardiosurgery than with the conventional procedure. These can be viewed, however, as complications occurring directly in temporal conjunction with the operation and as to be expected. Complications attributed directly to fast-track rehabilitation can be excluded. In the pilot group the overall hospital stay was thus shortened. In an environment of legislative restructuring within the healthcare sector, this shows that adequate treatment of cardiosurgical patients is still guaranteed with fast-track rehabilitation.

Systolic blood pressure as a predictor for cardiovascular disease in diabetes. A 5-year longitudinal study.

Diabetic patients suffer from atherosclerotic diseases more often and at an earlier stage than nondiabetic persons. The factors predisposing those with diabetes to premature arteriosclerosis are not fully clarified. Data from a 5-year follow-up of 615 diabetic outpatients of the Schwabing Study are reported. Forty-six (8.5%) died from a cardiovascular cause of death, 13 (2.4%) suffered from stroke, 68 (12.5%) showed electrocardiographic changes indicative of significant coronary heart disease, and 11 (2.0%) exhibited an ischemic foot lesion. Univariate and multiple logistic analyses of baseline variables revealed systolic blood pressure as the most consistent risk factor for these events. The frequency of major cardiovascular events was as high in men as in women. It is concluded that systolic blood pressure has been seriously underestimated as a predictor for macrovascular events.

Determinants and prognoses of locoregional and distant progression in breast cancer.

PURPOSE: To describe locoregional and distant progression in a population-based breast cancer sample. METHODS AND MATERIALS: Between 1978 and 1998, the Munich Cancer Registry evaluated 14,429 patients. The mean follow-up of survivors was 8.3 years. Metastases (MET), local recurrence (LR), and lymph node recurrence (LNR) were considered as outcome measures. The prognostic factor for, and effects of, LR and MET were assessed multivariately by the Cox and dynamic Aalen models. RESULTS: The LR and MET rate increased with increasing tumor size, with the latter described by pT category. Distant MET occurred earlier than local progression. MET was recorded even earlier for MET alone. The mean time from diagnosis to MET for MET and LR was 54.9, 43.4, 29.4, and 24.7 months and for MET only was 36.5, 31.0, 22.6, and 12.9 months for pT1, pT2, pT3, and pT4, respectively. After MET, survival varied only slightly by pT stage; after LR, a more favorable prognosis, especially for pT1 and pT2, was evident. The prognosis after MET depended mainly on the MET location; 50% of patients with cerebral or nervous system MET survived <1 year and 50% of those with skeletal MET survived >2 years. In the Cox model, the relative risk of LR for MET was 3.0. In the Aalen model, after 30 months, when the hazard rates of MET began to decline, there was still an excess risk of MET after LR. CONCLUSION: This disease description highlights the importance of long-term observational studies. Empiric evidence that LR is both an indicator for, and in part a cause of, MET has been provided. In the future, the MET location should be reported. Variations in guidelines or health care systems that influence the time to MET and survival after MET through different diagnostic procedures should also be considered.

Monitoring immunocompetent cells in the peripheral blood of stomach cancer patients after splenectomy and gastrectomy.

The status of lymphocyte subpopulations in splenectomized (Sx) stomach cancer patients (SCa-patients), assessed by monoclonal antibodies, has not been evaluated so far. Therefore subsets of peripheral white blood cells were monitored prior to and following surgical treatment in gastrectomized (Gx) and Sx (n = 64) as well as in non-Sx patients (n = 39). Postoperative surgical complications were more frequent in the Sx group. However, the 2-year survival rate of this group was higher than in non-Sx patients. Lymphocytes were significantly decreased in both groups of patients during the early postoperative period. Monocytes and polymorphonuclear cells (PMN) increased correspondingly. A significant loss of lymphocytes and their subsets in Sx patients was observed during the 1st-3rd postoperative days as compared to the Gx only patients. The OKT4/OKT8 ratios did not differ in either group of patients, whereas the OKT3+anti-B-Ly2 ratio was significantly increased in Sx patients 1 to 3 days postoperatively.

Procalcitonin: a new marker for diagnosis of acute rejection and bacterial infection in patients after heart and lung transplantation.

UNLABELLED: The aim of the study was to investigate the reliability of procalcitonin (PCT), a new potential marker for detection of bacterial, fungal and protozoal infections, in order to differentiate these from viral infections and early rejections in heart, heart-lung and lung transplanted patients. PCT is a propeptide of calcitonin with unknown origin which is not detectable in plasma of healthy subjects. It increases rapidly and significantly under severe microbial infections. METHODS: PCT plasma levels were measured using an immuno-luminescence assay. C-reactive protein and white blood cells were quantified to validate the PCT values. RESULTS: Increased levels of PCT were found in all transplant patients with bacterial, fungal and protozoal infections. The magnitude of the values were clearly associated with the severity of the infection. Trauma of operation or inflammatory events such as viral infections and rejections did not trigger PCT-production. The release of PCT did not depend on the type of pathogens even though Aspergillum resulted in the highest levels measured. Sensitivity, specificity and prognostic value of PCT for systemic infections were higher than of the other parameters investigated. CONCLUSION: PCT is a highly specific analyte which shows significant diagnostic validities when nonviral infections are compared with rejection episodes. PCT discriminates between inflammatory events such as rejection or viral infections and nonviral-infections including bacterial, fungal and protozoal infections. The half-life of PCT is 24 h indicating clearly a competent antibiotic treatment. Unnecessary antibiotic therapy can be avoided due to the early exclusion of bacterial and fungal infections.

Influence of the shock wave application mode on the growth of A-Mel 3 and SSK2 tumors in vivo.

We examined the influence of different shock wave application modes with a Dornier XL1 electrohydraulic lithotripter on the growth of A-Mel 3 and SSK2 tumors implanted under the dorsal skin of hamsters or mice. In a basic protocol, 500 shock waves a day on 4 consecutive days were administered at a discharge rate of 100 waves per minute and focused to the tumor center. This did not affect A-Mel 3 growth. A similar result was obtained with the basic protocol modified to 1000 shock waves a day and a wave application rate of 100 shock waves per second. Growth of A-Mel 3 and SSK2 tumors was significantly delayed, when the basic protocol was used, but the 500 shock waves a day were distributed over four points at the tumor edges and the tumor center. With the same shock wave protocol, lowering the water level over the tumor from 10 cm to 1 cm induced temporary regressions of SSK2 tumors. This was not due to the higher energy applied to the tumor, since twice the number of shock waves (1000 a day instead of 500 a day) was applied at a high water level and did not induce regressions. Four consecutive treatments with intervals between treatments shortened to 3 h and an additional treatment 12 h later at a low water level completely controlled tumor growth in 8 out of 12 SSK2 tumors for more than 150 days. The result showed that addition of a reflected wave from the water surface was most important for the shock wave effect, and suggested that shock wave devices generating similar wave forms should be applied for tumor therapy.

Embryonic heart rate in dated human embryos.

Using simultaneous B-mode and time-motion transvaginal ultrasonography we measured embryonic heart rate (EHR) in dated human embryos during the first trimester in a prospective study. In 160 pregnant women who had undergone assisted reproductive procedures, 139 singleton embryos and 46 embryos from 21 multiple pregnancies were studied between the 37th and 98th postmenstrual day. Because multiple measurements in one embryo at different ages were possible, a total of 348 measurements were taken. EHR in dated human embryos shows an increase up to 63 postmenstrual days or 22 mm greatest length. Thereafter a steady decrease of EHR was noted. Maximal EHR is reached when morphological development of the embryonic heart is completed. Furthermore, we examined 27 embryos with low EHR compared with greatest embryonic length. All of these ended in missed abortion within the embryonic period. According to our data the increase of EHR parallels the morphological development of the embryonic heart. Decline of EHR afterwards is interpreted as a functional adaption to muscular development of the heart.

[Quality project in invasive/interventional cardiology]. / Qualitätsprojekt Invasive/Interventionelle Kardiologie.

With installing a new catheterization laboratory, a quality project with focus on indications for invasive/interventional procedures was implemented. Health insurance companies as budget holders were involved in the project, external control is accomplished by their medical service (MDK). The focus on indications is new, since most approaches in this area deal with structure and/or process quality. The actual concept of this quality project makes medical performance transparent with regard to adequate indication as the first and important step to excellent quality of results. Further, the concept contains a rational approach to the controversial discussion about the increasing frequency of catheter-based coronary interventions.

Volume loading of the heart by "leg up" position and head down tilting (-6 degrees) (HDT).

Head down tilting is widely used to increase preload and to induce intrathoracic blood pooling similar to microgravity. During daily routine, this venous pooling is performed by raising the legs up. In this study, both these approaches have been compared by invasive measurement using a right heart catheter. In patients with moderate coronary artery disease, diagnostic right heart catheterization was performed by the Swan-Genz-techniques. All measurements were performed with head down tilting (-6 degrees) and with "leg up" position. Patients then received Nitroglycerin to countermeasure the preload changes. Pressures in the pulmonary artery as well as in the wedge position increased significantly during leg up and HDT. However, changes were significantly more pronounced in the "leg up" position than during HDT. No changes were observed for arterial blood pressure, cardiac output, stroke volume and resistances. Nitroglycerin during HDT lowered blood pressure and pressures in the pulmonary artery and in PCW-position and reduced cardiac output significantly. Both approaches of volume loading of the heart induced significant changes and increases of preload. However, changes were more pronounced during the "leg up" position than during HDT. It is questioned whether HDT with -6 degrees is appropriate to truly reflect hemodynamic alterations during simulated weightlessness.

Cardiac factors in orthostatic hypotension.

Cardiac function is determined by preload, afterload, heart rate and contractility. During orthostatic stress, the footward blood shift is compensated for by an increase of afterload. LBNP is widely used to analyze effects of volume displacement during orthostatic stress. Comparisons of invasive (right heart catheterization) and non-invasive approach (echocardiography) yielded similar changes. Preload and afterload change with graded LBNP, heart rate increases, and stroke volume and cardiac output decrease. Thus, the working point on the left ventricular function curve is shifted to the left and downward, similar to hypovolemia. However, position on the Frank-Starling curve, the unchanged ejection fraction, and the constant Vcf indicate a normal contractile state during LBNP. A decrease of arterial oxygen partial pressure during LBNP shows impaired ventilation/ perfusion ratio. Finally, LBNP induced cardiac and hemodynamic changes can be effectively countermeasured by dihydroergotamine, a potent venoconstrictor. Comparison of floating catheter data with that of echocardiography resulted in close correlation for cardiac output and stroke volume. In addition, cardiac dimensions changed in a similar way during LBNP. From our findings, echocardiography as a non-invasive procedure can reliably used in LBNP and orthostatic stress tests. Some information can be obtained on borderline values indicating collapse or orthostatic syncope. Early fainters can be differentiated from late fainters by stroke volume changes.

Long-term follow-up after eradication of Helicobacter pylori with a combination of omeprazole and amoxycillin.

Early studies have suggested that omeprazole may facilitate the eradication of Helicobacter pylori. Sixty patients with duodenal ulcer and H. pylori colonization were randomly assigned to receive either omeprazole monotherapy (n = 30) or combination therapy with omeprazole and amoxycillin (n = 30) for a total duration of 6 weeks. Four patients receiving monotherapy and three receiving combination therapy had to be withdrawn from the study. All (100%) duodenal ulcers healed in patients receiving combination therapy, and 25 out of 26 (96%) healed in the group receiving monotherapy. H. pylori was eradicated in 22 out of 27 (82%) patients receiving combination therapy; only two ulcer relapses (9%) occurred within 18 months in these 22 patients. Of the five patients who remained H. pylori-positive after combination therapy, two relapsed during the 18-month follow-up. In the monotherapy group, all patients remained H. pylori-positive after treatment, and duodenal ulcer relapsed in 16 out of 25 (64%) patients within the median follow-up of 18 months. Adverse events were not reported in the group treated with combination therapy; one patient receiving monotherapy reported severe headache. These results lend further support to existing data that H. pylori eradication prevents duodenal ulcer relapse and show that combination therapy with omeprazole and amoxycillin is effective and well tolerated.

[Complication rates and secondary interventions after coronary procedures in clinical routine: 1-year follow-up based on routine data of a German health insurance company]. / Komplikationen und Folgeeingriffe nach koronaren Prozeduren in der klinischen Routine.

BACKGROUND: Data on 1-year complication and follow-up intervention rates after coronary angiography (CA) and percutaneous coronary intervention (PCI) in German clinical routine are sparse. This analysis aims to determine these rates. METHODS: The analysis uses 2009 AOK claims data. Patients were divided into 3 groups (CA, without cardiac surgery and without acute myocardial infarction (AMI) n=116.071; PCI with stenting, without AMI: n=36.685; PCI with stenting and with AMI: n=32.707). The frequency of the endpoints MACCE (mortality, AMI, stroke, TIA), CABG, PCI and CA was recorded for up to one year. RESULTS: 1-year MACCE rates were 8.1 % (CA), 9.9 % (PCI without AMI) and 17.9 % (PCI with AMI). Quality-relevant follow-up intervention rates in the CA group were 2.5 % for CABG (after 31-365 days), 1.7 % for PCI within 90 days and 3.5 % for follow-up CA within 1 year. In the PCI groups, the frequencies were 1.6 % (without AMI) and 2.7 % (with AMI) for CABG (after 31-365 days), and 10.2 % (without AMI) and 10.1 % (with AMI) for PCI after 91-365 days. CONCLUSION: This is the first cross-sectoral routine analysis of cardiac catheters and sequential events up to one year in Germany. The actual medical care situation revealed information particularly with regard to the second and follow-up inventions, which cannot be derived directly from medical guidelines. Beyond clinical trials, knowledge can be gained which is important both for medicine as well as the politics of health services.