Impact of New Shift Models for Doctors Working at a German University Hospital for Gynaecology and Obstetrics Four Years After Implementation. Can They Meet the European Working Time Directive Without Increasing Costs?

Background: The impact of the European Working Time Directive and subsequent collective wage agreements for doctors from 2006 onwards were substantial. So far, no systematic evaluation of their application in Germany has been performed. We evaluated the impact four years after implementation of new shift models in a University Hospital for Gynaecology and Obstetrics (UHGO). Methods: A new shift model was created together with doctors of Tübingen UHOG in 2007 and implemented in 2008. Documentation of working hours has hence been done electronically. Adherence to the average weekly working time limit (AWTL) and the maximum of 10 h daily working time (10 h-dwt) was evaluated, as well as staffing costs in relation to case-weight points gathered within the German DRG (diagnosis related groups) System. Results: Staff increased from a mean of 44.7 full time equivalent (FTE) doctors in 2007 to 52.5 FTE in 2009, 50.8 in 2010, and 54.5 in 2011. There was no statistically significant difference of the monthly staff expenditures per case-weight between the years 2009 or 2010 vs. 2007. 2011, however, was significantly more expensive than 2007 (p = 0.02). The internal control group (five other departments of the university hospital) did not show an increase during the same period. AWTL were respected by 90, 96, and 98 % in 2009, 2010, and 2011, respectively. Of all shifts 10 h-dwt was exceeded by 7.4 % in 2009, 1.3 % in 2010, and 2.6 % in 2011, with significant differences between 2009 and both, 2010 and 2011 (p < 0.001), and between 2010 and 2011 (p = 0.02). Discussion: AWTL and 10 h-dwt could be continuously respected quite well after implementation of the new shift model without increasing the cost/earnings ratio for the first two years. However, in 2011 the ratio increased significantly (p = 0.02).

[A new working shift model for anesthesiologists: an analysis 3 years after implementation]. / Neues Dienstzeitenmodell für Ärzte in der Anästhesie : Eine Analyse 3 Jahre nach Implementierung.

OBJECTIVE: The aim of this study was to assess the efficacy, appropriateness and cost-effectiveness of a new working shift model for anesthesiologists complying with the European working time directive (EWTD) at the University Hospital of Tübingen (UKT), Germany 3 years after implementation BACKGROUND: Applying the standards of the EWTD is challenging for university hospitals as doctors must comply with the challenge of combining patient care, research and teaching. So far there have been no data available for German university hospitals on how these requirements can be met. As the department of anesthesiology is also a service-providing department it is essential not to increase staffing costs with a new shift model. METHODS: In 2007 a new working shift model for the department of anesthesiology was designed and introduced in 2008. Shift planning and documentation of working hours were implemented electronically. The calculated number of doctors to run this model was 87.6 full time equivalents (FTE). For 2009 and 2010 the compliance with the EWTD parameters was checked for 1) average weekly working time limit (AWWTL) and 2) compliance to the maximum daily working time limit of 10 h (10 h DWTL). Furthermore, staffing costs for doctors in 2010 were compared to 2007. To check for the time spent in patient care the period of anesthetic attendance (PAA) was chosen, i.e. the total time of patient contact by anesthesiology staff. Data were analyzed descriptively for AWWTL and for 10 h DWTL. FTE, staff costs and PAA were evaluated by one-way ANOVA. RESULTS: The new shift model allowed 84.4 % of all doctors to comply with the individual AWWT limits of 54 h and 48 h in 2009 (81/96) and 76.0 % in 2010 (79/104). In 2009 61.5 % of anesthesiologists voted for opt-out (59/96) and 53.8 % did so in 2010 (56/104). The 10 h DWTL was respected by 84.0 % in 2009 and by 85.9 % in 2010. The mean number of anesthesiologists rose significantly from 78.4 FTE in 2007 to 82.5 FTE in 2009 and 84.6 FTE in 2010 (p < 0.001 for 2010 vs. 2007, p = 0.004 for 2009 vs. 2007 and was not significant for 2010 vs. 2009). Staff costs per FTE increased from 7,524.79 /month to 7,800.66 /month and 7,966.11 /month in 2007, 2009 and 2010, respectively with the differences being non-significant. The PAA increased significantly from a mean of 6,124 h/month in 2007 to 6,581 h/month in 2009 and 6,872 h/month in 2010 (p < 0.001 for 2010 vs. 2007, whereas 2009 vs. 2007 and 2010 vs. 2009 were not significant). Thus, labour costs increased from 96.59 /h PAA in 2007 to 98.53 /h in both 2009 and 2010, the differences being not significant. CONCLUSIONS: The newly designed shift model allowed a fair compliance with the EWTD in respect to AWTL and 10 h DWTL, although the calculated number of doctors to run the shift model could not be met in 2009 and 2010. Violations of the 10 h DWT limits were stable in 2009 and 2010; however the number of doctors exceeding the AWWT limits appeared to increase. The compliance with opt-out decreased from 2009 to 2010 and a high proportion of AWWTL violations resulted from the group of non-opt-out voters. The staff costs per hour PAA after implementation of the new shift model did not differ significantly from the year before although staffing costs increased by 7.2 % between 2007 and 2010. Costs increased by 162,454 /year for all PAA hours in 2010. Further evaluation of staff satisfaction with the new shift models is needed and already under way.

Assessment of the ductus venosus, tricuspid blood flow and the nasal bone in second-trimester screening for trisomy 21.

OBJECTIVE: To examine the prevalence of reversed a-wave in the ductus venosus, tricuspid regurgitation and absent nasal bone, in a second-trimester population undergoing amniocentesis, after exclusion of major fetal defects and to estimate the performance in screening for trisomy 21 based on maternal age and these markers in a general population. METHODS: This was a retrospective study involving pregnancies undergoing amniocentesis due to increased risk for trisomy 21, mainly because of advanced maternal age. Before the invasive procedure, an ultrasound examination was carried out to exclude major fetal defects and to examine the ductus venosus, tricuspid blood flow and the presence of the fetal nasal bone. Modeling techniques were used based on 20 000 euploid pregnancies and 20 000 pregnancies with trisomy 21 to assess the screening performance in a general population. RESULTS: The study population consisted of 3613 euploid pregnancies and 35 cases with trisomy 21. In the euploid group, reversed flow in the ductus venosus, tricuspid regurgitation and an absent nasal bone was observed in 1.7%, 1.5% and 0.1% of cases, respectively. In the trisomic group, these markers were found in 14.3%, 11.4% and 14.3% of cases, respectively. For a 5% false-positive rate, the detection rate in screening for trisomy 21, based on maternal age and either ductus venosus, tricuspid blood flow or nasal bone would be 33.8%, 32.4% or 31.4%, respectively. Screening by maternal age alone would detect 29.0% of the fetuses with trisomy 21. Receiver-operating characteristics curve analysis showed a slight but significant improvement in screening performance for trisomy 21 based on the inclusion of these markers. CONCLUSION: Second-trimester ultrasound screening for trisomy 21 based on maternal age with additional assessment of the ductus venosus, tricuspid blood flow and the fetal nasal bone in otherwise normal-appearing fetuses is only marginally better than is screening by maternal age alone.

Cutaneous microcirculatory assessment of the burn wound is associated with depth of injury and predicts healing time.

RATIONALE: Current trends for the treatment of deep partial thickness and full-thickness burns include early excision and skin grafting. In this study we retrospectively evaluated the ability of Laser Doppler Flowmetry (LDF), taken within 24h of the burn to predict: (1) burn wound depth and (2) wounds which would heal in less than 21 days. METHOD: The Laser Doppler Flowmeter (O2C, LEA Medizintechnik, Germany) was employed to non-invasively measure the cutaneous microcirculation of 173 selected areas on 28 patients who suffered burns. RESULTS: A distinct association between initial flow (<24h after burn injury) and the clinical assessment of depth of burn wounds was observed. Wounds demonstrating an initial blood flow of >100 AU were, in 93.1% of cases, correctly (positively) predicted for spontaneous healing within 21 days. A blood flow of <100 AU (negatively) predicted in 88.2%, those wounds which would not go on to heal within 21 days. Sequential measurement analysis (<24h, 3 days after injury and 6 days after injury) revealed no significant decrease in skin perfusion velocity or flow rate. CONCLUSION: LDF can provide immediate results for early determination of burn wound depth and is useful in selecting patients for conservative treatment of their burn wounds.

[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.

Assessment of coronary artery bypass grafts by magnetic resonance imaging.

This study evaluated graft patency and flow at rest/stress in patients with coronary artery bypass grafts using MR flow measurements and MR angiography (MRA). 45 symptomatic patients with 86 grafts (46 arterial, 40 venous) were examined 5.5 years after surgery. MRA was used to assess bypass patency. Flow measurements were performed at rest and after stress induction with dipyridamole. All graft segments were evaluated at MRA for stenosis, and were additionally evaluated by the combination of flow measurements and MRA. Conventional coronary angiography or multidetector computed tomography was regarded as a reference standard. No significant stenosis was observed in 49 grafts (Group A), whereas significant stenosis was observed in 37 grafts (Group B). Sensitivity, specificity, and positive and negative predictive values for stenosis in arterial grafts were 95.2%, 96.8%, 80% and 99.4%, respectively, and in venous grafts were 100%, 97.8%, 87.5% and 100%, respectively. The mean blood flow rate at baseline/stress in Group B was significantly lower than that in Group A (p<0.002/p<0.001). With the combined MR method, 84 of 86 (97%) grafts could be correctly classified. In conclusion, MRI allows a combined assessment of graft status, including bypass patency and flow, in symptomatic patients after revascularization.

[Chronic rhinosinusitis. Subjective assessment of benefit 1 year after functional endonasal sinus surgery]. / Chronische Rhinosinusitis. Subjektive Nutzenbewertung 1 Jahr nach funktioneller endonasaler Nasennebenhöhlenoperation.

BACKGROUND: Against the background of constantly intensifying economic pressure in the healthcare sector, in the future confirmation of subjective and economic benefit of different forms of therapy will be the criterion applied by the health insurance companies to decide whether to reimburse the costs they involve. The aim of this study was to provide confirmation that patients with chronic rhinosinusitis (CRS) do benefit from functional endonasal sinus surgery (FESS). PATIENTS AND METHODS: One year after undergoing FESS for the treatment of CRS, 82 patients completed various questionnaires. The Glasgow Benefit Inventory (GBI) was used, as it is a validated instrument for the assessment of benefit. In addition, the patients were asked to complete questionnaires relating to pre- and postoperative use of resources (use of antibiotics, visits to their doctors and time unfit for work) and also to give an overall rating of their satisfaction with the outcome, the difference in their symptoms after FESS and the likelihood that they would recommend this treatment to friends or relatives. RESULTS: Three out of four GBI scales [total score (+22.6), general benefit (+26.8), physical functioning (+23.7)] indicated that patients experienced significant benefit. The frequency of visiting their doctors, their intake of antibiotics and the amount of time off work were all significantly reduced. The vast majority of patients were satisfied with the overall result and the level of symptom relief achieved and would recommend FESS to friends and relatives. CONCLUSION: The vast majority of these patients with CRS experienced FESS as highly beneficial. A significant reduction of resource usage was reported after the operation.

Compliance of German pediatric patients with oral antibiotic therapy: results of a nationwide survey.

BACKGROUND: Noncompliance with a prescribed therapy is a common problem in ambulatory pediatrics. OBJECTIVE: To establish a nationwide status quo of compliance of German ambulatory pediatric patients with oral antibiotics prescribed for various bacterial infections. PATIENTS AND METHODS: In this study, organized and financed by the German Society for Pediatric Infectious Diseases, 42 pediatricians in private practice who were selected to represent the 3 main regions of Germany and residence in large cities or small towns, respectively, enrolled consecutive patients who had bacterial infections that required therapy with oral antibiotics. Choice of agent and duration of treatment were left to the study physicians. Compliance was measured by a standardized telephone interview on the penultimate day and a urine bioassay for antibacterial activity on the last day of the planned treatment period. Parents did not know the true purpose of the study. RESULTS: Five hundred eight-four patients were fully evaluable. The most frequent diagnoses included tonsillopharyngitis (n = 231), otitis media (n = 170) and lower respiratory tract infections (n = 114). Most frequently prescribed antibiotics included amoxicillin (n = 102), potassium penicillin V (n = 81) and clarithromycin (n = 67). Overall compliance (positive urine test) on the last day of therapy was 69.5% (406 of 584 patients). Compliance was not significantly influenced by the region of residence or the underlying bacterial infection. It was significantly associated with the antibiotic used (macrolides, 89.0%; penicillins, 62.2%; cephalosporins, 66.4%; P = 0.0001 for macrolides vs. the others). Best compliance was found with clarithromycin (94.0%) and erythromycin estolate (89.8%). Compliance was also significantly better in patients > or =6 years old (77.7%; P = 0.016); with a treatment duration of < or =7 days (77.6%; P = 0.014); when the drug package contained a dose-taking reminder (79.7%; P = 0.003); and when the pediatrician's behavior toward the patient was assessed by the parents as "very sympathetic" or "sympathetic" (72.6%; P = 0.017). Subjecting all variables to logistic regression analysis, we found 3 variables to be significant predictors of treatment compliance: choice of antibiotic (P = 0.0001); patient age (P = 0.0008); and residence in town or city (P = 0.03). CONCLUSIONS: A noncompliance rate of >30% is unsatisfactory. Whereas some variables significantly associated with compliance cannot be influenced (patient age; place of residence in town or city), others are amenable to modifications. These include the physician-patient interaction and the choice of antibiotic. Agents should be preferred that are well-accepted by patients, that enable short-term therapy with few daily doses and with a package that contains a dose-taking reminder.