[Minimum Caseload Requirements and In-hospital Mortality: Observational Study using Nationwide Hospital Discharge Data from 2006 to 2013]. / Mindestmengen und Krankenhaussterblichkeit ­ Beobachtungsstudie mit deutschlandweiten Krankenhausabrechnungsdaten von 2006 bis 2013.

Background: In order to improve hospital care, minimum caseload requirements for certain elective hospital treatments have been defined by law in Germany. This study analyses retrospectively if adherence to this regulation is associated with the outcome of hospital treatment. Differences in in-hospital mortality were analyzed for complex esophageal and pancreatic surgery, liver and kidney transplantation, stem cell transplantation and total knee replacement. Methods: Within individual inpatient data of the nationwide German hospital discharge data (DRG statistics) all inpatient episodes subject to the minimum volume requirements were identified and annual caseloads per hospital were calculated. Inpatient episodes were assigned to 2 groups: Patients treated in hospitals with a caseload equal to or greater than the minimum caseload (≥ MC) and patients treated in hospitals with a caseload below the minimum caseload (< MC). Logistic regression was used to calculate adjusted in-hospital mortality. Results: In total, 28 931 esophageal surgeries, 78 879 pancreatic surgeries, 7 984 liver transplantations, 21 773 kidney transplantations, 51 064 stem cell transplantations and 1 093 296 total knee replacements were analyzed. Adjusted in-hospital mortality in hospitals with a caseload≥MC was significantly lower than in hospitals with a caseload

[Complication rates and secondary interventions after coronary procedures in clinical routine: 1-year follow-up based on routine data of a German health insurance company]. / Komplikationen und Folgeeingriffe nach koronaren Prozeduren in der klinischen Routine.

BACKGROUND: Data on 1-year complication and follow-up intervention rates after coronary angiography (CA) and percutaneous coronary intervention (PCI) in German clinical routine are sparse. This analysis aims to determine these rates. METHODS: The analysis uses 2009 AOK claims data. Patients were divided into 3 groups (CA, without cardiac surgery and without acute myocardial infarction (AMI) n=116.071; PCI with stenting, without AMI: n=36.685; PCI with stenting and with AMI: n=32.707). The frequency of the endpoints MACCE (mortality, AMI, stroke, TIA), CABG, PCI and CA was recorded for up to one year. RESULTS: 1-year MACCE rates were 8.1 % (CA), 9.9 % (PCI without AMI) and 17.9 % (PCI with AMI). Quality-relevant follow-up intervention rates in the CA group were 2.5 % for CABG (after 31-365 days), 1.7 % for PCI within 90 days and 3.5 % for follow-up CA within 1 year. In the PCI groups, the frequencies were 1.6 % (without AMI) and 2.7 % (with AMI) for CABG (after 31-365 days), and 10.2 % (without AMI) and 10.1 % (with AMI) for PCI after 91-365 days. CONCLUSION: This is the first cross-sectoral routine analysis of cardiac catheters and sequential events up to one year in Germany. The actual medical care situation revealed information particularly with regard to the second and follow-up inventions, which cannot be derived directly from medical guidelines. Beyond clinical trials, knowledge can be gained which is important both for medicine as well as the politics of health services.

[Disease-specific patterns of hospital care in Germany analyzed via the German Inpatient Quality Indicators (G-IQI)]. / Krankheitsspezifische Versorgungsmerkmale in Deutschland: Analyse anhand der Bundesauswertung der German Inpatient Quality Indicators (G-IQI).

OBJECTIVE: Using the categories of the German Inpatient Quality indicators (G-IQI) important characteristics of inpatient care were analyzed on the national level in Germany. The evaluation gives an overview of total national case numbers and number of hospitals involved in the treatment of important diseases. METHOD: The analysis was based on the national so called 'DRG database' for the year 2010, which covers all German inpatient DRG cases (all patient / all payer database). With the major exception of psychiatric and psychosomatic cases this database covers 17.43 of the 18.49 million German inpatient cases. The coded diagnoses and procedures as well as demographic information were used to group cases into G-IQI disease categories. The respective total case numbers, number of hospitals providing the services, interquartile range of case distribution, in-hospital mortality and interquartile range of standardized mortality ratios were investigated. RESULTS: Especially for less frequent diseases and procedures it is shown, that many hospitals treat very low case numbers. For example for gastric resection the lower quartile is 4, for esophageal resection 1 and for cystectomy 5. Even for a more frequent disease like myocardial infarction the lower quartile is 36. Mortalities also show considerable variation. However, due to the low case numbers in many hospitals, the deviation of hospital mortality from the German average can only become significant for rather few hospitals. CONCLUSION: On the one hand this paper provides national reference values for the German Inpatient Quality Indicators, which cover 38.7 % of all inpatient cases and 50.8 % of in-hospital deaths. On the other hand it gives a first overview of the disease specific patterns of inpatient hospital care in Germany. Despite the high overall quality of the German health care system it suggests, that further improvement might be possible, if structural problems were addressed.

[Estimation for bugeting and evaluation of surgical procedures within the scope of comparative hospital administration. Value of LKA, PPR and DRG systems]. / Schätzverfahren zur Budgetfindung und Bewertung chirurgischer Leistungen im Rahmen eines Krankenhausbetriebsvergleiches. Wertigkeit von LKA-, PPR- und DRG-Systemen.

Comparison of costing and performances of individual departments or hospitals are required by the statute book of social affairs (Sozialgesetzbuch V; SGB V), but have not been fully introduced in Germany. LBK Hamburg, a trust of 8 hospitals with 17 surgical departments, evaluated the significance of performance and cost-accounting systems such as performance and cost-accounting (LKA), nursing staff regulation (PPR), and the diagnosis-related group system in order to distribute a three-year budget (1996-1998) and to compare, e.g., performance of surgical departments. The DRG system seems to be the best choice, since it weights all cases by means in 640 groups according to the degree of difficulty. With a given closed budget, the DRG system may compare the actual cost with the target figures.

[The development of drug utilization with special reference to demographic factors]. / Die Entwicklung des Arzneimittelverbrauchs unter besonderer Berücksichtigung demographischer Faktoren.

Possible influences of demographic changes in the Federal Republic of Germany on future expenditures for medication have been investigated using population models from the Federal Statistical Office and data concerning the structure of current drug expenditures of the health insurance system. In addition the former contribution of demographic changes to the development of drug expenditures has been estimated using retrospective analysis. The study demonstrates that a constant supply with medicines would require an increase of expenses of 0.6% per year until 2,000 AD due to demographic changes, assuming other conditions remain constant. Development since 1957, however, shows that demographic influences are of relatively low importance for the development of total drug expenditures. During the last decade the total growth of costs for medicines was 6 times higher than that which would have been expected due to demographic changes alone. Further comparisons with the growth rate of the gross national product (GNP) demonstrate that since 1975 growth of drug expenditures parallels growth of GNP. The price indices for pharmaceutical products and for cost of living developed in a parallel way during the same period of time.

Ultrasonography related to clinical and laboratory findings in lymphocytic thyroiditis.

The value of ultrasonography compared with established diagnostic procedures was investigated by reviewing medical records of 92 patients (88 women and 4 men, age 11-81 years, mean age 47) with lymphocytic thyroiditis. Clinical manifestations of the disease and serum antimicrosomal antibodies and TSH were determined in all patients. The thyroid was examined by ultrasound. Both lobes were aspirated by a fine needle under sonographic control and smears examined cytologically. A total of 27 (29.3%) patients had no clinical symptoms. Antimicrosomal antibodies were undetable in 12 (13%) patients, 16 (17.4%) had low titres 1:32-) 1:100, and 64 (69.6%) greater than or equal to 1:320. TSH (reference values 0.3-3.9 mU/1) was les than 0.3 in 4 (4.3%) 0.3-3.9 in 4) (44.6%) , 4-20 in 26 (28.3%), and greater than 20 in 21 (22.8%) patients. Ultrasound revealed a scattered sonolucent echo in 87 (94.6%) patients, and in 45 (48.9%) a normal thyroid volume (women less than 18, men less than 25 ml). Cytology alone was diagnostic in 84 (91.3%) patients, In conclusion, ultrasound can suggest lymphocytic thyroiditis. If antimicrosomal antibodies are undetectable or titres are not significant and/or clinical symptoms are uncertain, fine-needle aspiration can confirm the sonographic finding. Epidemiological studies including ultrasonography are necessary to obtain reliable data on the prevalence of lymphocytic thyroiditis.

[Effect of demographic changes on the case rate and days of care for hospitalized internal medicine patients]. / Einfluss demographischer Anderungen auf Fallzahlen und Pflegetage hospitalisierter internistischer Patienten.

Using case categories at the Center for Internal Medicine of the Medical University at Lübeck and predictions of future population trends by the German Federal Statistical Office, likely future numbers of inpatients and days of hospital stay were calculated. Assuming other conditions remaining constant, an annual rise of 0.9% of medical cases is to be expected until the year 2005. An increase above this average is expected for cases of cardiovascular and respiratory disease and of malignant neoplasms, while it will be below average for renal or gastrointestinal diseases. These data are similar to comparable projections made, on the basis of Federal statistics, of hospital cases registered with local health insurance schemes. In addition they indicate an increase of 3% for all non-paediatric admissions up to 2005.

[Therapy of pneumologic diseases in the aged]. / Zur Therapie pneumologischer Erkrankungen im Alter.

Chronic obstructive lung disease (COLD), especially obstructive bronchitis and obstructive lung emphysema, are the most common pulmonary diseases of the elderly. In around 10% of over 65's they cause the death of the individual. The aetiology of these phenomena is still not clear. In pathophysiological terms, a loss in lung function occurs during the natural process of aging, pulmonary and extrapulmonary disease and other environmental factors. Any reduction in function of other organ systems must be taken into consideration when ordering therapeutical measures in treating COLD. The following stepwise-orientated scheme can be recommended in the treatment of COLD in elderly patients: Theophylline, beta 2-adrenergic agents, Anticholinergic drugs, Corticoid therapy, Mucolytica and secretolytica, Physiotherapy, Measures to increase arterial pO2 - either with oxygen therapy at home or with Almitrin, Antibiotica.

Involvement of catecholamines and glutamate in GABAergic mechanism regulatory to luteinizing hormone and prolactin secretion.

There is some evidence that a population of estrogen-receptive neurons exists in the preoptic/anterior hypothalamic area which uses gamma-aminobutyric acid (GABA) as neurotransmitter and which is involved in mediating the negative feedback of estrogens on pituitary luteinizing hormone (LH) secretion. These neurons are proposed to be presynaptic inhibitors to norepinephrine (NE) release thereby inhibiting the stimulatory effect of NE on LHRH neurons. Muscimol, a potent GABA agonist, inhibits pituitary LH release in ovariectomized rats after intraventricular injection of 5 nmol. This treatment significantly increased prolactin levels. Catecholamine turnover rates in micropunches of various hypothalamic and mesolimbic structures following intraventricular treatment with muscimol were determined using the method of blocking the activity of tyrosine hydroxylase by alpha-methyl-p-tyrosine. Muscimol did not affect catecholamine, GABA and glutamate concentrations. Turnover rates of NE were significantly reduced in the medial preoptic/anterior hypothalamic area. In this structure as well as in the nucleus accumbens and in the anterior mediobasal hypothalamus turnover rates of dopamine (DA) were also reduced whereas DA turnover in mediocortical amygdalae was increased by muscimol. The selective reduction of NE turnover following muscimol may be explained by a direct or indirect action of the GABA-eric drug on NE axon terminals. The reduced NE and DA turnover in the medial preoptic area may be causally related to reduced serum LH levels whereas the reduced hypothalamic DA turnover may explain increased blood prolactin levels.

Hypothalamic and limbic GABA concentrations and turnover rates and glutamate concentrations following induction of hyperprolactinemia in ovariectomized rats.

Hyperprolactinemia was induced by transplantation of pituitaries of donor rats under the kidney capsule of ovariectomized recipient rats. This results in a permanently increased serum prolactin and temporarily suppressed luteinizing hormone (LH) levels. Concentrations of gamma-aminobutyric acid (GABA) and glutamate as well as turnover rates of GABA were determined in micropunches of the nucleus accumbens (ACB), medial preoptic area (MPO), anterior and posterior part of the mediobasal hypothalamus (AMBH and PMBH) and in the mediocortical amygdala (AMY). GABA concentration in the ACB and MPO were reduced in hyperprolactinemic rats. This was significant at day 8. At days 4 to 21 following pituitary transplantation glutamate concentrations were also significantly reduced in the AMY. The most conspicuous changes in GABA turnover rates were observed in the ACB and MPO. In the former structure hyperprolactinemia reduced GABA turnover, while in the latter high prolactin levels increased GABA turnover at day 4. It is concluded that the suppressive effect of hyperprolactinemia on blood LH levels may involve a preoptic GABAergic component and possibly a glutamatergic mechanism in the AMY. Alternatively, the AMY and the ACB may be involved in eliciting the many behavioral effects associated with hyperprolactinemia.

Glutamate in hypothalamic and limbic structures of diestrous, proestrous, ovariectomized and ovariectomized estrogen-treated rats.

Concentrations of glutamic acid were determined in the nucleus accumbens (ACB), medial preoptic area (MPO), anterior and posterior mediobasal hypothalamus (AMBH, PMBH) and mediocortical amygdala (AMY) of diestrous (D), proestrous (P), ovariectomized (OVX) and OVX rats treated with estradiol-benzoate (EB) 12 h and 24 h before decapitation. Significant changes of glutamate concentrations were found in the ACV and PMBH. Glutamate is reduced in OVX when compared to D, P and OVX-EB rats. No significant changes of glutamate concentrations could be detected in the MPO, AMBH, and AMY.

Involvement of preoptic-anterior hypothalamic GABA neurons in the regulation of pituitary LH and prolactin release.

The effects of intraventricular injections of the highly specific gamma-amino-butyric acid (GABA) agonist muscimol (5 nmol/animal) on blood LH and prolactin levels were measured in ovariectomized (ovx) and in ovx estrogen-progesterone (OEP) primed rats. While the drug stimulated pituitary prolactin release in both experimental groups, pituitary LH release was significantly inhibited in the ovx animals. Muscimol was without any effect on LH levels in ovx-OEP primed rats. Bilateral implantation of tubes containing a muscimol-mannitol mixture into the medial preoptic/anterior hypothalamic (MPO/AH) area abolished pulsatile LH release whereas blood prolactin values were elevated. The intraventricular injection of GABA (8 mumol) also reduced LH and increased prolactin levels in the blood. Measurements of catecholamine turnover rates in the MPO/AH and in the mediobasal hypothalamus (MBH) yielded reduced preoptic but unchanged hypothalamic norepinephrine (NE) and stimulated hypothalamic dopamine (DA) turnover. In view of the well known stimulatory involvement of the NE system in the mechanism of pulsatile LH release and the inhibitory effect of GABA and its agonist muscimol on pulsatile LH release, it is suggested that GABA inhibits NE release in the MPO/AH by the mechanism of presynaptic inhibition. The observation that muscimol is unable to suppress LH release in vox OEP-primed rats may indicate that those estrogen receptive neurons in the MPO/AH which mediate the negative feedback action of the steroid may use GABA as neurotransmitter and that they are the neurons which inhibit NE release. The inhibitory effect of locally implanted muscimol into the MPO/AH also supports this hypothesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Involvement of GABA in the feedback action of estradiol on gonadotropin and prolactin release: hypothalamic GABA and catecholamine turnover rates.

The concentrations and turnover rates of norepinephrine (NE), dopamine (DA) and gamma-aminobutyric acid (GABA) were measured in discrete brain areas of diestrous (D), proestrous (P), ovariectomized (OVX) and ovariectomized rats treated with estradiol-benzoate (EB) 12 or 24 h before decapitation. The turnover of NE in the medial preoptic area (MPO) correlates well with plasma LH levels under all endocrine conditions showing high NE turnover in P and OVX and low NE turnover in D and OVX-EB animals. The DA turnover shows no hormone-dependent changes in the MPO. In those animals where estrogens exert no (OVX) or a negative feedback action (D, OVX-EB) on LH the GABA turnover correlates inversely with LH and preoptic NE turnover showing low GABA turnover values in OVX and high values in D and OVX-EB. For P animals the inverse correlation cannot be confirmed. It is concluded that GABA mediates the negative feedback action of estrogens to LH-RH perikarya located in the MPO. GABA might act by presynaptic inhibition of NE axon terminals. This hypothesis is supported by morphological findings which indicate that axon terminals in the MPO are in close contact without separating glial lamellae. In the anterior mediobasal hypothalamus (AMBH) NE turnover correlates best with serum prolactin levels being high in P and OVX animals 24 h after EB treatment. The DA turnover is increased in OVX rats 24 h after EB. It is not yet clear if this increase might be a consequence of the elevated prolactin levels. GABA turnover in the AMBH shows no significant changes. GABA concentrations and turnover rates were also determined in the mediocortical amygdala where estrogen receptors have been reported and in the nucleus accumbens. No significant changes could be observed in these regions.

In vivo GABA release from the medial preoptic area of diestrous and ovariectomized rats.

The push-pull cannula technique was used to examine the endogenous release of GABA from the medial preoptic area (MPO) of unanesthetized rats. In diestrous females the mean resting release of GABA was 27.1 +/- 2.0 pmol/min. GABA release was significantly elevated by increasing the potassium concentration in the perfusion solution to 50 mM, whereas it was dramatically inhibited by mercaptoproprionic acid (1.0 mM), a glutamic acid decarboxylase inhibitor. A comparison between diestrous females and chronically castrated animals indicated that endogenous GABA release in OVX animals was only 60-70% of that in diestrous animals. A model for the presynaptic inhibition of NE by estrogen receptive GABAergic neurons in the MPO is proposed.