Labia Minora Repair.

BACKGROUND: Labia minora reduction has become part of the treatment spectrum offered by most plastic surgeons. The author has performed many corrective procedures involving the outer female genital region, most of which involved reducing the labia minora of approximately 4300 women. Over the years, the number of corrective procedures to rectify poorly performed initial operations increased significantly at the author's practice. The most common iatrogenic deformity is the overresection of the labia minora below the clitoris, leaving behind excess tissue in the area around and above the clitoral hood (small penis deformity). METHODS: Two basic procedures may be used to reconstruct the labia minora below the clitoris: reconstructing the labia minora by redundant labial tissue above the clitoris to form bilateral preputial flaps being rotated downward into the defect and reconstructing the labia minora by vaginal skin advancement. Other reconstructions depend on the deformity itself. The postoperative outcome was assessed in an anonymous questionnaire answered by 544 patients. RESULTS: The outcome showed a significant improvement in functional and psychological impairment as a result of the deformities caused by the initial operation. Even if the reconstruction of the labia minora did not produce the desired initial result, overall satisfaction with the corrective surgery was very satisfactory. CONCLUSION: The increase of iatrogenic deformities after the initial labia reductions is alarming. The causes of this growth are manifold: underestimation of the procedure, misjudgment and a lack of detailed knowledge. This has a heavy psychological and physical impact on patients. Reconstruction of excessively shortened labia minora is often not easy and not always satisfactory. Training and the establishment of surgical standards should be used to avoid errors and achieve the best result. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Are people's health care needs better met when primary care is strong? A synthesis of the results of the QUALICOPC study in 34 countries.

AIM: This article synthesises the results of a large international study on primary care (PC), the QUALICOPC study. BACKGROUND: Since the Alma Ata Declaration, strengthening PC has been high on the policy agenda. PC is associated with positive health outcomes, but it is unclear how care processes and structures relate to patient experiences. METHODS: Survey data were collected during 2011-2013 from approximately 7000 PC physicians and 70 000 patients in 34, mainly European, countries. The data on the patients are linked to data on the PC physicians within each country and analysed using multilevel modelling. FINDINGS: Patients had more positive experiences when their PC physician provided a broader range of services. However, a broader range of services is also associated with higher rates of hospitalisations for uncontrolled diabetes, but rates of avoidable diabetes-related hospitalisations were lower in countries where patients had a continuous relationship with PC physicians. Additionally, patients with a long-term relationship with their PC physician were less likely to attend the emergency department. Capitation payment was associated with more positive patient experiences. Mono- and multidisciplinary co-location was related to improved processes in PC, but the experiences of patients visiting multidisciplinary practices were less positive. A stronger national PC structure and higher overall health care expenditures are related to more favourable patient experiences for continuity and comprehensiveness. The study also revealed inequities: patients with a migration background reported less positive experiences. People with lower incomes more often postponed PC visits for financial reasons. Comprehensive and accessible care processes are related to less postponement of care. CONCLUSIONS: The study revealed room for improvement related to patient-reported experiences and highlighted the importance of core PC characteristics including a continuous doctor-patient relationship as well as a broad range of services offered by PC physicians.

Patients' Financially Driven Delay of GP Visits: Is It Less Likely to Occur in Stronger Primary Care Systems?

Available evidence has suggested that strong primary care (PC) systems are associated with better outcomes. This study aims to investigate whether PC strength is specifically related to the prevalence of patients' financially driven postponement of general practitioner (GP) care. Therefore, data from a cross-sectional multicountry study in 33 countries among GPs and their patients were analyzed using multilevel logistic regression modelling. According to the results, the variation between countries in the levels of patients' postponement of seeking GP care for financial reasons was large. More than one third of these cross-country differences could be explained by characteristics of the health care system and the GP practices. In particular, PC systems with good accessibility and those systems that offer comprehensive care were associated with lower levels of financially driven delay. Consequently, we can conclude that well-organized PC systems can compensate for the negative influence of individual characteristics (socioeconomic position) on the care-seeking behaviors of patients.

General Practitioners' Participation in a Large, Multicountry Combined General Practitioner-Patient Survey: Recruitment Procedures and Participation Rate.

Background. The participation of general practitioners (GPs) is essential in research on the performance of primary care. This paper describes the implementation of a large, multicountry study in primary care that combines a survey among GPs and a linked survey among patients that visited their practice (the QUALICOPC study). The aim is to describe the recruitment procedure and explore differences between countries in the participation rate of the GPs. Methods. Descriptive analyses were used to document recruitment procedures and to assess hypotheses potentially explaining variation in participation rates between countries. Results. The survey was implemented in 31 European countries. GPs were mainly selected through random sampling. The actual implementation of the study differed between countries. The median participation rate was 30%. Both material (such as the payment system of GPs in a country) and immaterial influences (such as estimated survey pressure) are related to differences between countries. Conclusion. This study shows that the participation of GPs may indeed be influenced by the context of the country. The implementation of complex data collection is difficult to realize in a completely uniform way. Procedures have to be tuned to the context of the country.

Primary care practice composition in 34 countries.

Health care needs in the population change through ageing and increasing multimorbidity. Primary health care might accommodate to this through the composition of practices in terms of the professionals working in them. The aim of this article is to describe the composition of primary care practices in 34 countries and to analyse its relationship to practice circumstances and the organization of the primary care system. The data were collected through a survey among samples of general practitioners (n=7183) in 34 countries. In some countries, primary care is mainly provided in single-handed practices. Other countries which have larger practices with multiple professional groups. There is no overall relationship between the professional groups in the practice and practice location. Practices that are located further from other primary care practices have more different professions. Practices with a more than average share of socially disadvantaged people and/or ethnic minorities have more different professions. In countries with a stronger pro-primary care workforce development and more comprehensive primary care delivery the number of different professions is higher. In conclusion, primary care practice composition varies strongly. The organizational scale of primary care is largely country dependent, but this is only partly explained by system characteristics.

Strengthening weak primary care systems: steps towards stronger primary care in selected Western and Eastern European countries.

European health care systems are facing diverse challenges. In health policy, strong primary care is seen as key to deal with these challenges. European countries differ in how strong their primary care systems are. Two groups of traditionally weak primary care systems are distinguished. First a number of social health insurance systems in Western Europe. In these systems we identified policies to strengthen primary care by small steps, characterized by weak incentives and a voluntary basis for primary care providers and patients. Secondly, transitional countries in Central and Eastern Europe (CCEE) that transformed their state-run, polyclinic based systems to general practice based systems to a varying extent. In this policy review article we describe the policies to strengthen primary care. For Western Europe, Germany, Belgium and France are described. The CCEE transformed their systems in a completely different context and urgency of problems. For this group, we describe the situation in Estonia and Lithuania, as former states of the Soviet Union that are now members of the EU, and Belarus which is not. We discuss the usefulness of voluntary approaches in the context of acceptability of such policies and in the context of (absence of) European policies.

Composite reduction labiaplasty.

BACKGROUND: The demand for surgery to treat the external female genital area has increased significantly in recent years. Since 2001, the author and his colleagues have performed more than 2,100 surgical procedures to enhance the shape and function of the female genital area. The majority of these procedures were aimed at reduction of the labia minora. Drawing on the technique for labia minora reduction (labiaplasty) that the author first described in 2007 (Gress S, Gynäkologisch-Geburtshilfliche Rundschau 47:23-32, 2007), the technique was advanced such that in addition to an even reduction of the labia over their entire length (i.e., not only the part below the clitoris but also the part of the clitoral hood and above), it currently is possible to achieve further tightening of the clitoral hood and correction of a protruding clitoris (clitoral protrusion). This technique creates separate labial segments, the composition of which allows for an optimal shaping and reduction of the labia minora. Since 2006, the author and his colleagues have managed 812 cases using this technique, which has been named "composite reduction labiaplasty." METHODS: After removal of the excessive tissue in an S-shaped line along the internal and external aspects of the labium minus and after cutting of a cranial pedicle flap approximately 2-3 cm long (seen as the caudal extension of the clitoral hood), a crescent-shaped skin segment below the clitoris and a centrally pointed rectangular skin segment above the clitoral hood are removed. By joining the wound margins, a tightening and balanced reduction of the labia minora as well as a correction for the protruding tip of the clitoris (clitoral protrusion) is achieved. RESULTS: All the patients received postoperative care and follow-up assessments during a period of 6 months. Except for a few cases of wound dehiscence requiring surgical correction, wound healing was without complications, and the outcomes were both aesthetically and functionally very satisfactory. CONCLUSION: In contrast to most techniques published to date, the "composite reduction labiaplasty" technique ensures a balanced reduction and a tightening of all parts of the labia minora, especially in the region of the clitoral hood. In addition, this technique results in an optimal correction of clitoris positioning in cases of clitoral protrusion. Concerns regarding impairment of sexual sensation or the ability to be sexually stimulated are unfounded. Approximately 35 % of the patients even reported a postoperative increase in their ability to be sexually stimulated. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Measures of quality, costs and equity in primary health care instruments developed to analyse and compare primary care in 35 countries.

BACKGROUND: The Quality and Costs of Primary Care in Europe (QUALICOPC) study aims to analyse and compare how primary health care systems in 35 countries perform in terms of quality, costs and equity. This article answers the question 'How can the organisation and delivery of primary health care and its outcomes be measured through surveys of general practitioners (GPs) and patients?' It will also deal with the process of pooling questions and the subsequent development and application of exclusion criteria to arrive at a set of appropriate questions for a broad international comparative study. METHODS: The development of the questionnaires consisted of four phases: a search for existing validated questionnaires, the classification and selection of relevant questions, shortening of the questionnaires in three consensus rounds and the pilot survey. Consensus was reached on the basis of exclusion criteria (e.g. the applicability for international comparison). Based on the pilot survey, comprehensibility increased and the number of questions was further restricted, as the questionnaires were too long. RESULTS: Four questionnaires were developed: one for GPs, one for patients about their experiences with their GP, another for patients about what they consider important, and a practice questionnaire. The GP questionnaire mainly focused on the structural aspects (e.g. economic conditions) and care processes (e.g. comprehensiveness of services of primary care). The patient experiences questionnaire focused on the care processes and outcomes (e.g. how do patients experience access to care?). The questionnaire about what patients consider important was complementary to the experiences questionnaire, as it enabled weighing the answers from the latter. Finally, the practice questionnaire included questions on practice characteristics. DISCUSSION: The QUALICOPC researchers have developed four questionnaires to characterise the organisation and delivery of primary health care and to compare and analyse the outcomes. Data collected with these instruments will allow us not only to show in detail the variation in process and outcomes of primary health care, but also to explain the differences from features of the (primary) health care system.

Managed competition in the Netherlands-a qualitative study.

BACKGROUND: In 2006, the Health Insurance Act changed Dutch health insurance by implementing managed competition, whereby the health insurance market is strongly regulated by the government. The aim of the study is to investigate key stakeholders' opinions about effects of recent changes in Dutch healthcare policy, focussing upon three important requirements for successful managed competition: risk-adjustment, consumer choice and instruments for managed care. METHOD: Expert interviews with 12 key stakeholders were performed (October/November 2009), transcribed and analyzed in a four-step qualitative process. RESULTS: The Dutch risk-adjustment scheme is very advanced but incentives for health insurers to select risks remain. The Health Insurance Act has given insurers new incentives to focus upon consumer needs and preferences, whereby large group contracts have replaced individual consumer choice with collective decision-making. Managed care concepts are slow in developing. Patient organizations and insurers report taking part in such efforts, but other stakeholders do not perceive that progress has been made. CONCLUSIONS: The pre-requisites for successful managed competition in the Netherlands are not yet entirely in place: risk-adjustment schemes cannot yet counteract all incentives to select risks, consumer preferences are just beginning to influence insurer policies and managed care elements are currently in the development stage.

QUALICOPC, a multi-country study evaluating quality, costs and equity in primary care.

BACKGROUND: The QUALICOPC (Quality and Costs of Primary Care in Europe) study aims to evaluate the performance of primary care systems in Europe in terms of quality, equity and costs. The study will provide an answer to the question what strong primary care systems entail and which effects primary care systems have on the performance of health care systems. QUALICOPC is funded by the European Commission under the "Seventh Framework Programme". In this article the background and design of the QUALICOPC study is described. METHODS/DESIGN: QUALICOPC started in 2010 and will run until 2013. Data will be collected in 31 European countries (27 EU countries, Iceland, Norway, Switzerland and Turkey) and in Australia, Israel and New Zealand. This study uses a three level approach of data collection: the system, practice and patient. Surveys will be held among general practitioners (GPs) and their patients, providing evidence at the process and outcome level of primary care. These surveys aim to gain insight in the professional behaviour of GPs and the expectations and actions of their patients. An important aspect of this study is that each patient's questionnaire can be linked to their own GP's questionnaire. To gather data at the structure or national level, the study will use existing data sources such as the System of Health Accounts and the Primary Health Care Activity Monitor Europe (PHAMEU) database. Analyses of the data will be performed using multilevel models. DISCUSSION: By its design, in which different data sources are combined for comprehensive analyses, QUALICOPC will advance the state of the art in primary care research and contribute to the discussion on the merit of strengthening primary care systems and to evidence based health policy development.

Health care system change and the cross-border transfer of ideas: influence of the Dutch model on the 2007 German health reform.

To increase understanding of the cross-border transfer of ideas through a case study of the 2007 German health reform, this article draws on Kingdon's approach of streams and follows two main objectives: first, to understand the extent to which the German health reform was actually influenced by the Dutch model and, second, in theoretical terms, to inform inductively on how ideas from abroad enter government agendas. The results show that the streams of problem recognition and policy proposals have not been predominantly influenced by the cross-border transfer of ideas from the Netherlands to Germany. The Dutch experience was taken into consideration only after a policy window opened by a shift in politics in the third, the political, stream: the change of government in 2005. In many respects, the way Germany learned from the Netherlands in this case sharply contrasts with an image of solving policy problems by either lesson drawing or transnational deliberation. Instead, the process was dominated by problem solving in the sphere of politics, that is, finding a way to prove the grand coalition was capable of acting.

Co-ordination and management of chronic conditions in Europe: the role of primary care--position paper of the European Forum for Primary Care.

Healthcare systems in Europe struggle with inadequate co-ordination of care for people with chronic conditions. Moreover, there is a considerable evidence gap in the treatment of chronic conditions, lack of self-management, variation in quality of care, lack of preventive care, increasing costs for chronic care, and inefficient use of resources. In order to overcome these problems, several approaches to improve the management and co-ordination of chronic conditions have been developed in European healthcare systems. These approaches endeavour to improve self-management support for patients, develop clinical information systems and change the organisation of health care. Changes in the delivery system design and the development of decision support systems are less common. Almost as a rule, the link between healthcare services and community resources and policies is missing. Most importantly, the integration between the six components of the chronic care model remains an important challenge for the future. We find that the position of primary care in healthcare systems is an important factor for the development and implementation of new approaches to manage and coordinate chronic conditions. Our analysis supports the notion that countries with a strong primary care system tend to develop more comprehensive models to manage and co-ordinate chronic conditions.

Effects of the German reference drug program on ex-factory prices of prescription drugs: a panel data approach.

This paper examines effects of the German social health insurance system's reference drug program (RDP) for prescription drugs on ex-factory prices. Moreover, we analyze whether manufacturers adapt prices of their products that are not subject to reference pricing as a consequence of changes in reference prices of their products that are subject to reference pricing. We use econometric panel data methods based on a large panel data set of nearly all German prescription drugs on a monthly basis between October 1994 and July 2005. They provide information on ex-factory prices, reference prices, manufacturers, type of prescription drug, and market entries and exits. Our results show that there is no full price adjustment: A 1%-change in reference prices leads to a 0.3%-change in market prices. Price adjustment, however, is fast - it mostly happens in the first month. Furthermore, the first introduction of a reference price reduces market prices of the affected products by approximately 7%. Finally, we observe a significant time effect that is positive in the market without reference prices and negative in the market with reference prices.

Reform of prescription drug reimbursement and pricing in the German social health insurance market: a comparison of three scenarios.

We review regulation of two important parameters for third-party payers and manufacturers of prescription drugs: regulation of reimbursement and pricing. We find that centralised regulation of reimbursement and pricing prevails in the 15 original EU member countries (EU-15) and in European Free Trade Association (EFTA) countries. Compared with countries such as Switzerland, The Netherlands, France and England, regulation in the German social health insurance system is rather unique. First, market approval is nearly always equivalent to reimbursement. Second, manufacturers are free to determine prices but internal reference prices restrict them from actually doing so for generics and therapeutic substitutes. In order to contain rising expenditures for prescription drugs in Germany, and to set incentives for physicians to consider the costs as well as the benefits of prescriptions, three reform scenarios are feasible. The first scenario maintains centralised reimbursement and centralised pricing; the second maintains centralised reimbursement but switches to decentralised pricing (similar to social health insurance in Israel and Medicare in the US). Third-party payers would be able to negotiate with manufacturers about discounts and market shares for genetic and therapeutic substitutes. In the third scenario, pricing and reimbursement would be decentralised (similar to private health insurance in the US). We suggest that the second scenario is a viable compromise between consumer protection and a more competitive and cost-effective market for prescription drugs in German social health insurance and other similar markets for prescription drugs.

[Aesthetic and functional corrections of the female genital area]. / Asthetische und funktionelle Korrekturen im weiblichen Genitalbereich.

In the last few years, we have performed an increasing number of genital reshaping procedures in females. Most frequently we carried out corrections of the labia, followed by operations to reduce the size of the clitoris and the pubic area. Psychological as well as functional complaints were the reasons for the decision to undergo a surgical correction. After a large number of operations we have gained great experience and developed specific operation techniques. The results are functionally reliable and aesthetically pleasing with a very low rate of complications and a high level of patient satisfaction.

Elasticities of market shares and social health insurance choice in Germany: a dynamic panel data approach.

In 1996, free choice of health insurers was introduced to the German social health insurance system. One objective was to increase efficiency through competition. A crucial precondition for effective competition among health insurers is that consumers search for lower-priced health insurers. We test this hypothesis by estimating the price elasticities of insurers' market shares. We use unique panel data and specify a dynamic panel model to explain changes in market shares. Estimation results suggest that short-run price elasticities are smaller than previously found by other studies. In the long-run, however, estimation results suggest substantial price effects.

Private health insurance in Germany: consequences of a dual system.

A variety of financial and non-financial incentives has resulted in a considerable degree of adverse selection against social health insurance in Germany. Enrollees in private health insurance are healthier, have higher incomes and have fewer dependents than enrollees in social health insurance. Adverse selection decreases average premium income and at the same time increases average healthcare expenditures in social health insurance. As a consequence, financial sustainability of the public system declines. Moreover, financial incentives for healthcare providers have led to preferential treatment for privately insured patients in outpatient care. The dual health insurance system in Germany is therefore inequitable as well as inefficient, and cannot be considered a role model for post-Chaoulli Canada.

Supplementary health insurance as a tool for risk-selection in mandatory basic health insurance markets.

As the share of supplementary health insurance (SI) in health care finance is likely to grow, SI may become an increasingly attractive tool for risk-selection in basic health insurance (BI). In this paper, we develop a conceptual framework to assess the probability that insurers will use SI for favourable risk-selection in BI. We apply our framework to five countries in which risk-selection via SI is feasible: Belgium, Germany, Israel, the Netherlands, and Switzerland. For each country, we review the available evidence of SI being used as selection device. We find that the probability that SI is and will be used for risk-selection substantially varies across countries. Finally, we discuss several strategies for policy makers to reduce the chance that SI will be used for risk-selection in BI markets.

Criteria and procedures for determining benefit packages in health care. A comparative perspective.

The legitimacy of procedures and criteria for determining benefit packages depends crucially on the representation of stakeholders in decision-making bodies, the transparency of procedures and the consistency of benefit decisions. Moreover, the assessment of the costs of healthcare services and its application as a decision criterion can be an important policy instrument in order to increase the overall efficiency of healthcare systems. Our analysis of procedures and criteria for determining benefit packages in England, Germany and Switzerland established potential for developing more legitimate procedures and criteria for benefits decisions. In Germany, representation of stakeholders and transparency of procedures can be improved. Consistency of decision-making is hindered by the veto positions of selected stakeholders. Moreover, benefit decisions are made for different healthcare sectors separately. In Switzerland, transparency of procedures is virtually non-existent at the moment. Thus, it is impossible to assess the consistency of decision-making. Only in England the costs of healthcare services influence the decision to include or exclude them.