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.

[Quality assurance in coding expertise of hospital cases in the German DRG system. Evaluation of inter-rater reliability in MDK expertise]. / Qualitätssicherung in der Kodierungsbegutachtung von Krankenhausfällen im G-DRG-System. Prüfung der Interrater-Reliabilität bei MDK-Gutachtern.

AIM: The purpose of this study was to evaluate differences in the D-DRG results of a hospital case by 2 independently coding MKD raters. Calculation of the 2-inter-rater reliability was performed by examination of the coding of individual hospital cases. The reasons for the non-agreement of the expert evaluations and suggestions to improve the process are discussed. METHODS: From the expert evaluation pool of the MDK-WL a random sample of 0.7% of the 57,375 expertises was taken. Distribution equality with the basic total was tested by the χ² test or, respectively, Fisher's exact test. For the total of 402 individual hospital cases, the G-DRG case sums of 2 experts of the MDK were determined independently and the results checked for each individual case for agreement or non-agreement. The corresponding confidence intervals with standard errors were analysed to test if certain major diagnosis categories (MDC) were statistically significantly more affected by differing expertise results than others. RESULTS: In 280 of the total 402 tested hospital cases, the 2 MDK raters independently reached the same G-DRG results; in 122 cases the G-DRG case sums determined by the 2 raters differed (agreement 70%; CI 65.2-74.1). Different DRG results between the 2 experts occurred regularly in the entire MDC spectrum. No MDC chapter in which significant differences between the 2 raters arose could be identified. CONCLUSION: The results of our study demonstrate an almost 70% agreement in the evaluation of hospital cost accounts by 2 independently operating MDK. This result leaves room for improvement. Optimisation potentials can be recognised on the basis of the results. Potential for improvement was established in combination with regular further training and the expansion of binding internal code recommendations as well as exchange of code-relevant information among experts in internal forums. The presented model is in principle suitable for cross-border examinations within the MDK system with the advantage that further trends could be uncovered by more variety and larger numbers of the randomly selected cases.

[Off-label therapy from the perspective of the medical insurance service]. / Off-Label-Therapie aus der Perspektive des MDK.

The assessment of off-label medications is one of the most common reasons for assessment of drugs for individual patients in the German medical services. Tension is not uncommon because of great expectations of patients and doctors on the one hand and the requirements of the law on the other. They often do not match. Even if there is a medically justified off-label use the road to drug approval is principally via the authorities with tested efficacy and safety in order not to deprive the patient of the protection of the Pharmaceuticals Act. The jurisdiction has approved criteria for reimbursement by the statutory health insurance only in clearly defined exception and one requirement is that there are no alternative forms of treatment. For serious diseases this is based on the evidence of drug approval; however, for immediately life-threatening situations a very low evidence level is sufficient.

[(Inter)national and regional health goals in academic social-medical education conception for teaching medical students at the Eberhard Karls University Tuebingen]. / (Inter)nationale und regionale Gesundheitsziele in der sozialmedizinischen LehreLehrkonzeption für Medizinstudierende an der Eberhard Karls Universität Tübingen.

BACKGROUND: Social medicine deals with the specific interactions between medicine and society within a constantly changing social environment. The Institute of Occupational and Social Medicine, University Hospital Tuebingen, focuses on this relationship within the academic teaching of the Medical Faculty. Many of the issues thus directly affect the national health objectives and especially the health targets of the state of Baden-Württemberg, summarised in the Health Strategy Baden-Wuerttemberg. MATERIAL AND METHODS: In addition to the recommendations of the German Society for Social Medicine and Prevention (DGSMP) for the social medicine curriculum and the specific definition of the content by the Tuebingen medical faculty, national and regional health-care goals are also taken into account in the teaching conception. RESULTS: Classes are increasingly offered as training courses in small groups (seminars, group work with practical training), instead of classic lectures. These teaching methods allow the students to take part more actively in social medicine issues and to think and act within a comprehensive understanding of health management based on societal goals and the needs of a good health system. The concept is supported by the curriculum design element "log-book skills" of the Medical Faculty of Tuebingen. Feedback elements for teachers and students shape the further development of the concept. In dealing with real system data, practical experience on site and case vignettes, the students experience the links between societal influences, political objectives and medical action as well as the importance of accessibility of medical services for equity in health chances. CONCLUSIONS: The fact that advice and expertise play a crucial role in accessibility is a component to which too little attention is paid and calls for emphasis in the teaching concept. This teaching approach will deepen the understanding of the influence of psychosocial context factors and the conditions of the structural framework on the medical outcome. Furthermore there is a need for providing knowledge and special skills, which enable medical doctors to guide their patients optimally within the healthcare system and to make their contribution to a good system.

[Structured psychiatric assessment of risk for violent recidivism in juvenile offenders]. / Psychiatrische Beurteilung des Gewaltrisikos im Jugendalter.

The psychiatric assessment of violence in youth represents a critical and essential part of forensic expertise and clinical practice. New methodical approaches are offered by structured risk rating scales and checklists which encompass psychopathy. The recently translated German version of Structured Assessment of Violence Risk in Youth (SAVRY), which is based on the Historical, Clinical, Risk Management Scheme (HCR 20), was evaluated in a sample of forensically assessed youth (n=83) regarding the predictive validity for criminal recidivism. Receiver operating characteristic (ROC) analyses attested medium (general delinquency), moderate (violent reoffending) and high (serious violent reoffending) effect strength, depending of the type of offence. Survival analyses showed that juveniles rated as high risk for violence were significantly faster and in a higher proportion recidivistic than those with a moderate or low risk. The results indicate the applicability of risk assessment instruments for German juveniles. Approaches for preventive, therapeutic and reintegrating measures are demonstrated, taking relapse patterns and dynamic risk aspects into consideration.

[On the prognosis of hip fractures. Assessment of mortality after hip fractures by analyzing overlapping segments of longitudinal data]. / Zur Prognose der Schenkelhalsfraktur. Beurteilung der Mortalität nach Schenkelhalsfraktur durch sektorübergreifende Datenzusammenführung.

BACKGROUND: Data on the treatment of hip fractures in acute care settings have been collected in a report card system for quality assurance in Germany since the beginning of the 1990s. However, there are no data on the long-term outcome and long-term quality of care. MATERIAL AND METHOD: In a retrospective study, data on 1393 patients from 1999 were collected from different sources: from the department of quality assurance at the medical association of Westfalia-Lippe, the Statutory Health Insurance Funds (AOK), and the Medical Review Board of the Statutory Health Insurance Funds (Medizinischer Dienst der Krankenkasse, MDK). Statistical analyses were performed by the Center for Clinical Studies of the University of Düsseldorf. RESULTS: Uni- and multivariate analyses reveal the following prognostic parameters for survival after hip fracture: sex, age, nursing care dependency, living in a nursing home, risk stratification according to ASA, and postoperative complications. Timing of the operation had no affect on survival. CONCLUSIONS: Prognostic factors for the outcome after hip fracture can only be obtained by analyzing data from the hospital stay and the post-hospital setting as well. Chances of survival can be significantly improved by rehabilitative care.

[High-resolution computed tomography (HRCT) of the pediatric lung]. / Hochauflösende Computertomographie der Lunge bei Kindern und Jugendlichen.

High-resolution computed tomography (HRCT) of the lung is a very valuable method in the evaluation of children with acute and chronic lung disease due to the high spatial resolution and precise display of anatomy and pathology without superposition. The following publication will describe an optimized HRCT technique in order to reduce dose, explain various HRCT pattern and explain typical pediatric lung diseases.

Hospital and physician partnership in the acquisition and use of high-cost niche technology.

The addition of the ventricular assist device to the compliment of interventions within a high-quality cardiovascular program can be justified based on the potential reduction in ICU days for patients with right ventricular failure and/or left ventricular failure following open heart surgery. The improved outcomes associated with appropriate patient selection further serves to strengthen the justification. Close cooperation among physicians, administrators, manufacturers, and competing centers can make even highly specialized technology a valuable and cost-effective addition to the community.

The respirative breakdown of glucose by Saccharomyces cerevisiae: an assessment of a physiological state.

Cells of Saccharomyces cerevisiae exhibiting respirative glucose metabolism in continuous culture were able to use ethanol as a co-substrate. The ethanol uptake rate was dependent on the residual respirative capacity of the cells. The activities of gluconeogenic enzymes and of malate dehydrogenase were higher in cells degrading glucose respiratively than in cells metabolizing glucose respiro-fermentatively, but were lower than in cells growing on ethanol only. The pattern of distribution of the mitochondrial cytochromes was similar but the differences were less distinct. In synchronously growing cells, the activities of gluconeogenic enzymes and of malate dehydrogenase oscillated, with activities increasing during the budding phase. The increase was preceded by the appearance of ethanol in the culture medium.