[Demographic change : challenges to ophthalmological patient-centered care]. / Demografischer Wandel : Herausforderungen für die ophthalmologische Versorgung.

BACKGROUND: Demographic change not only affects patients with ophthalmological diseases but also ophthalmologists. OBJECTIVES: The aim of this article is to evaluate the consequences of an aging society on health care provision. How can these challenges be overcome? MATERIAL AND METHODS: Evaluation of publications from the German Federal Statistical Office about the current and projected population, analysis of own studies about health care provision, utilization, and delivery as well as the presentation and discussion of regulatory and organizational conditions. RESULTS: There is a continuous increase in chronic and age-related diseases. At the same time the prevalence of multimorbidity and the number of patients dependent on long-term care is rising, leading to an increase in the demand for ophthalmological care. Regarding health care providers we observed a cutback in qualified ophthalmological personnel, especially for remote areas thus causing difficulties in providing adequate eye care to the population. CONCLUSION: To deliver health care to a growing number of patients with a decreasing number of medical professionals is the major challenge of demographic change. This will have an enormous impact on ophthalmological health care in terms of maintaining high quality health services covering a nationwide area.

[Morbidity developments in the demographic change: availability of medical services in regional care]. / Morbiditätsentwicklung im demographischen Wandel: Verfügbarkeit medizinischer Leistungen in der regionalen Versorgung.

The proportion of older people will increase strongly in Germany in the coming years. A consequence is an increase in patient numbers particularly for age-associated diseases and multimorbidity. Higher numbers of patients mean greater use of medical services and a higher demand for home visits with older patients. Although the total population is declining, the need for doctors will increase in certain medical areas, for example in the primary care sector. In many rural areas the reoccupation of vacant practices is already becoming a problem. Innovative, flexible and regionally organized healthcare concepts are necessary to ensure adequate medical care. Duties and responsibilities must be transferred between health professions and across sector boundaries, for example on the basis of delegation concepts, telemedicine and better cooperation between the outpatient and inpatient settings.

[Time required and associated costs for implementation of home medication review with associated pharmaceutical and medical evaluation in the ambulatory health care sector]. / Zeitbedarf und Kosten für die Umsetzung eines Medikamentenreviews und assoziierter pharmazeutischer und medizinischer Evaluation im ambulanten Versorgungssektor.

INTRODUCTION: We aimed to estimate the time which is needed to conduct a home medication review (HMR) in the context of the AGnES implementation studies (AGnES=GP-supporting, community-based, e-health-assisted, systemic intervention). In a subsequent step associated costs were calculated. METHODS: IT-supported HMR were conducted by specially qualified AGnES-practice assistants to detect selected drug-related problems (DRP). The patient received pharmaceutical care by their local pharmacist and medical evaluation by their GP, respectively. RESULTS: The data from 471 patients (w: 339; m: 132) were evaluated (median age: w=81; m=78). The interview to detect selected DRP was 6 min (median) long. The subsequent drug record took 14.4 min. There was an additional effort for documentation of 5 min. The local pharmacist needed a median time of 15 min for pharmaceutical evaluation, whereas the GP needed 8 min. The estimated costs accounted for: AGnES-practice assistant: 9.12 €; pharmacist: 11.05 €; GP: 6.30 €. The overall estimated costs were 26.47 €. CONCLUSION: For the first time we present objective costs which were associated with the implementation of HMR. Due to high DRP-induced costs the HMR should be mandatory for groups with a high risk like for the occurrence of DRP.

[Demographic change: demands on the health care system and solutions using the example of Mecklenburg-Western Pomerania]. / Demografischer Wandel: Anforderungen an das Versorgungssystem und Lösungsansätze am Beispiel Mecklenburg-Vorpommern.

The growing absolute number of the elderly causes an increase in the number of patients suffering from not only chronic diseases and multimorbidity, but also higher usage of the health care system. In the German Federal State of Mecklenburg-Western Pomerania (MW), the effects of demographic change will be more pronounced than in other regions. The objective of this article is to show the consequences of the changing population structure for the health care system. Using examples from MW, innovative models to secure high quality health care at the population level are presented. Examples include the establishment of subsidiary practices, multidisciplinary ambulatory health care centers, delegation models, ambulatory health care managers, telemedicine, and intensified and improved interdisciplinary networking. In the context of the demographic change, assisted care, adequate symptom control, maintaining personnel competence, preservation of an independent lifestyle with a high quality of life, and stimulation of social participation become priority objectives of medical care. Besides the effectiveness and the quality of results with regard to these objectives, innovative health care models should be economically evaluated at the population level under real life practice conditions.

[Transfer of the AGnES concept to the regular German health-care system: legal evaluation, reimbursement, qualification]. / Uberführung des AGnES-Konzeptes in die Regelversorgung: Juristische Bewertung, Vergütung, Qualifizierung.

INTRODUCTION: According to an amendment of German social security legislation, the AGnES concept of delegation of certain tasks of medical care, especially house calls, by general practitioners (GPs) to qualified practice employees (AGnES employees), will be transferred into the regular German health care system from January 2009 onward. The concept was developed to support GPs in regions with imminent gaps in primary care. METHODS: Patient data, the specifically delegated and all other activities carried out by the AGnES employees in the AGnES projects were digitally documented. Additionally, the participating GPs, AGnES employees and patients underwent a set of standardised interviews. A curriculum to qualify the AGnES employees and to define the requirements needed was developed. A legal assessment of all delegated activities was carried out, and an economical model to calculate the necessary allowance was calculated. RESULTS: In seven model projects in four federal states in Germany, 11,228 house calls were carried out involving 1,424, mostly multimorbid, patients (mean age: 78.6 years). A modular structured curriculum, considering the basic education and acquired competences, was developed. It allows for an individual qualification of the AGnES employees. The result of the legal assessment was the central relevance of the qualification of the practice employees according to the AGnES curriculum as the essential condition for carrying out the entire range of activities of the AGnES concept. The economic model revealed euro 21.58 for a house call by an AGnES employee. The underlying model referred to underserved regions. CONCLUSION: A successful transfer of the AGnES concept with a high standard of quality into regular health-care depends on several factors. Of particular importance is the specific qualification of the practice employees, which is a central legal condition for the delegation of medical tasks from GPs to AGnEs employees. A second determining factor is also an adequate reimbursement within the catalogus of the statutory health insurances.

A comparison between 1.36% and 3.86% glucose dialysis solution for the assessment of peritoneal membrane function.

OBJECTIVE: To assess peritoneal membrane function with respect to fluid transport, parameters of low molecular weight solute transport, and estimations of the function of peritoneal water channels, comparing the results from a 1.36%/1.5% glucose solution with those from a 3.86%/4.25% solution in standardized peritoneal function tests. DESIGN: The study was performed in 40 stable continuous ambulatory peritoneal dialysis (CAPD) patients [median age 50 years (range: 22-74 years); duration of CAPD 9 months (range: 2-45 months)] who underwent two standard peritoneal permeability analyses (SPAs) within 1 month. One SPA used 1.36% glucose; the other, 3.86% glucose. Mass transfer area coefficients (MTACs) and dialysate-to-plasma (D/P) ratios were compared for the two solutions. Also, two different methods of estimating aquaporin-mediated water transport were compared: the sieving of sodium (3.86% glucose) and the difference in net ultrafiltration (deltaNUF), calculated as NUF 3.86% SPA - NUF 1.36% SPA. RESULTS: Median NUF in the 1.36% glucose SPA was -46 mL (range: -582 mL to 238 mL); in the 3.86% SPA, it was 554 mL (range: -274 mL to 1126 mL). The median difference in NUF for the two SPAs was 597 mL (range: 90-1320 mL). No difference between the two solutions was seen for the MTAC of creatinine (11.4 mL/min for 1.36% vs 12.0 mL/min for 3.86%) and absorption of glucose (64% vs 65%, respectively). Also, D/P creatinine was not different: 0.77 (1.36%) and 0.78 (3.86%). However, the ratio of dialysate glucose at 240 minutes and at 0 minutes (Dt/D0) was 0.34 (1.36%) and 0.24 (3.86%), p < 0.01. Values of D/P creatinine from the two glucose solutions were strongly correlated. The intra-individual differences were small and showed a random distribution. Patient transport category was minimally influenced by the tonicity of the dialysate. The minimum D/P Na+ (3.86%) was 0.884, and it was reached after 60 minutes. After correction for Na+ diffusion, D/P Na+ decreased to 0.849 after 120 minutes. The correlation coefficient between the diffusion-corrected D/P Na+ and the deltaNUF was 0.49, p < 0.01. An inverse relationship was present between MTAC creatinine and D/P Na+ (p < 0.01) This correlation can be explained by the rapid disappearance of the osmotic gradient owing to a large vascular surface area. Such a correlation was not present between MTAC creatinine and deltaNUF. CONCLUSIONS: We conclude that a standardized 4-hour peritoneal permeability test using 3.86%/4.25% glucose is the preferred method to assess peritoneal membrane function, including aquaporin-mediated water transport. The D/P Na+ after correction for Na+ diffusion is probably more useful for the assessment of aquaporin-mediated water transport than is deltaNUF obtained with 3.86%/4.25% and 1.36%/1.5% glucose-based dialysis solutions.