[Development and implementation of an integrated care pathway at the POLIKUM health centers using the example of anemia]. / Entwicklung und Umsetzung eines integrierten Behandlungspfads in den POLIKUM-Gesundheitszentren am Beispiel der Anämie.

BACKGROUND: Integrated treatment pathways are an appropriate means for increasing the quality of treatment and outcome via process optimization. Taking the POLIKUM Health Centers as an example, we intend to demonstrate how the implementation can be effected for the indication of anemia. METHOD: The development and implementation were executed by an interdisciplinary workgroup in several workshops. In addition, the diagnoses and hemoglobin values of all patients with requests for hemograms were obtained and analyzed at two locations. RESULTS: Developing the pathway required significantly greater efforts than initially planned. The biggest challenge was to adequately map the complexity of the different forms of anemia and, concomitantly, to design a pathway that can actually be realized in everyday life. Moreover, evaluation of the patient data demonstrated that there are a large number of cases where existing anemias are not reflected in the respective diagnoses. CONCLUSION: While the ultimate effects of the new pathway cannot yet be assessed conclusively, it was possible to obtain valuable findings for practical use even at this point. Despite the limitations of the sample, the surprisingly high number of undetected anemias should give physicians cause for taking diagnostic measures even in patients with mild anemia.

[Chemoprevention of prostate cancer - a plea]. / Chemoprävention des Prostatakarzinoms - Ein Plädoyer.

The high disease prevalence, the presentation in older age, a frequently slowly progressing course of disease, and high costs make the diagnosis of and therapy for prostate cancer a special challenge for urologists. Effective prevention of the disease may help to improve some of the problems mentioned above. Two randomised, controlled studies have proved that effective chemoprevention of prostate cancer is viable using 5α-reductase inhibitors (finasteride, dutasteride). Furthermore, there is increasing evidence that other compounds, e. g., selective oestrogen receptor modulators (SERMs), NSAIDs and statins might also be effective. This review investigates potential risks and benefits of chemoprevention including a consideration of health economical aspects. The authors conclude that the options of chemoprevention should be investigated in an open and unbiased way.

[Cost analysis of contrast-enhanced cranial MRI at a German university hospital]. / Kostenanalyse einer kontrastgestützten MRT des Schädels an einem Universitätsklinikum.

PURPOSE: Detailed evaluation and cost analysis of a cranial contrast-enhanced MRI (c-ceMRI) in outpatients, inpatients, patients in an intensive care unit and children under anesthesia. MATERIALS AND METHODS: Based on a detailed process-oriented model, we calculated the cost of a cranial MRI for the four situations mentioned above. A comprehensive evaluation of the overhead and personnel costs was performed. RESULTS: We performed 5108 MRI examinations on 2 scanners in the year 2008. 2150 examinations (42 %) were identified as c-ceMRI. For inpatients we calculated a total cost of € 242.46 per examination with a personnel cost of € 81.71 for the radiological department. In outpatients we calculated total costs of € 181.97 with radiological personnel costs of € 68.67. Patients coming from an intensive care unit were treated by an intensive care team, which resulted in total costs of € 416.58 with € 283 in costs for radiological personnel (32.8 %). MRI examinations of children under anesthesia resulted in costs of € 616.79 for the hospital, of which € 285.78 were radiological personnel costs (34.5 %). CONCLUSION: In this study we evaluated for the first time different radiological scenarios of a c-ceMRI at a university hospital. Considering the present reimbursement situation, all outpatients covered by statutory health insurance resulted in a deficit for the hospital. Particularly high costs for patients in intensive care units as well as for children under anesthesia have to be taken into account and are currently not adequately covered by care providers.

Whole-body MR imaging versus sequential multimodal diagnostic algorithm for staging patients with rectal cancer: cost analysis.

PURPOSE: To compare the direct costs of two diagnostic algorithms for pretherapeutic TNM staging of rectal cancer. MATERIALS AND METHODS: In a study including 33 patients (mean age: 62.5 years), the direct fixed and variable costs of a sequential multimodal algorithm (rectoscopy, endoscopic and abdominal ultrasound, chest X-ray, thoracic/abdominal CT in the case of positive findings in abdominal ultrasound or chest X-ray) were compared to those of a novel algorithm of rectoscopy followed by MRI using a whole-body scanner. MRI included T 2w sequences of the rectum, 3D T 1w sequences of the liver and chest after bolus injection of gadoxetic acid, and delayed phases of the liver. The personnel work times, material items, and work processes were tracked to the nearest minute by interviewing those responsible for the process (surgeon, gastroenterologist, two radiologists). The costs of labor and materials were determined from personnel reimbursement data and hospital accounting records. Fixed costs were determined from vendor pricing. RESULTS: The mean MRI time was 55 min. CT was performed in 19/33 patients (57%) causing an additional day of hospitalization (costs 374 euro). The costs for equipment and material were higher for MRI compared to sequential algorithm (equipment 116 vs. 30 euro; material 159 vs. 60 euro per patient). The personnel costs were markedly lower for MRI (436 vs. 732 euro per patient). Altogether, the absolute cost advantage of MRI was 31.3% (711 vs. 1035 euro for sequential algorithm). CONCLUSION: Substantial savings are achievable with the use of whole-body MRI for the preoperative TNM staging of patients with rectal cancer.

[Public reporting of the Californian "pay for performance" conducted by the Integrated Healthcare Association (IHA)]. / Public Reporting des kalifornischen "Pay for Performance" der Integrated Healthcare Association (IHA).

OBJECTIVE: In Germany, there is little transparency when it comes to quality of care of national health care providers. The population has hardly any opportunity to identify well-performing health-care providers. Therefore, the emerging quality improvement initiative "Pay for Performance (P4P)" developed in California, USA is examined with regard to an implementation into the German health care sector. This program wants to achieve higher levels of health care by setting both goal-oriented financial and non-financial incentives. Therefore, performance-based payment is combined with Public Reporting of the measured quality of care. As people can be influenced by the information provided, Public Reporting is supposed to have a positive effect on the quality of treatment. METHODOLOGY: Published data to the American population will be highlighted as well as indications and examinations included in the P4P program. Also, it will be shown how the performance of health care providers is determined. RESULTS: Since published performance results can be considered not only for a specific indication but also as a whole, patients have the opportunity to choose a well-performing health-care provider, according to their specific requirements. Thus, Public Reporting might be regarded as an effective method in order to improve the quality of care provided by health-care providers. CONCLUSION: Public Reporting in P4P is already conducted in a differentiated but also in a broad context. In the development of this key success element, many stakeholders have been involved, including health-care providers. So, the presented way of Public Reporting can be regarded as a business case to learn from with regard to more transparency in the German health-care sector.