Cost evaluation of an innovative outreach clinic across social insurance codes in rural Northern Germany - A routine data analysis.

A community outreach clinic was established in 2013 in a rural part of Germany to counsel and better integrate patients with mental health disorders or clients with psychosocial problems into the healthcare and complementary social assistance system. In a pilot study, we aimed to evaluate the costs of the integration assistance system after the outreach clinic was opened, the number of visits and the trend in the costs of the social assistance system of the federal state. Anonymised secondary cost data were used to evaluate the costs associated with the integration assistance receivers before (2010-2012) and after the establishment of the outreach clinic (2013-2015). Total costs were descriptively compared between the intervention group (consultation in the outreach clinic), the non-referral group, and a propensity score-matched control group for the years 2013-2015. To monitor the counselling activity, we used anonymised data on visits to the outreach clinic between 2013 and 2015. Data from 50 clients in the outreach clinic and 678 non-referral clients were analysed. The total costs of the integration assistance for the years 2013-2015 amounted to EUR 21,516 (95% CI 14,513-28,518) and EUR 28,464 (25,789-31,140) respectively. Propensity score matching of the controls resulted in equalised total costs for the years 2013 through 2015 for clients (n = 50, EUR 21,516 (14,513-28,518)) and controls (n = 250, EUR 21,725 (18,214-25,234)). The total number of integration assistance receivers in the district was lower than the average for the federal state. The number of consultations at the outpatient clinic steadily increased from 146 in 2013 to 1,090 in 2015. Counselling in the outreach clinic might help reduce the placement of clients into integration assistance, including supported housing, and slow the expected cost trend. However, counselling failed to lower total costs in the integration assistance service, possibly due to the selection of more severe cases.

Descriptive Cost-Effectiveness Analysis of a Counseling and Coordination Model in Psychosocial Care. Integration of Health Care and Social Rehabilitation.

INTRODUCTION: A psychosocial outreach clinic was established to offer counseling and coordination of healthcare and complementary services for persons with psychosocial and mental problems. The cost-effectiveness of these services was measured based on a pre-post comparison. METHODS: A prospective observational study was conducted with clients of the outreach clinic. Data on resource consumption and quality of life were collected at baseline and follow-up after 3, 6, and 12 months using the Client Sociodemographic and Service Receipt Inventory to assess service utilization, and the 12-Item Short Form Health Survey to assess quality of life. The objective of the present analysis was to estimate the relation between monetary expenditure and QALYs (quality-adjusted life-years), before and after the outreach clinic was established, descriptively. The analysis was constructed from payer's perspective and was supplemented by a sensitivity analysis. RESULTS: A total of 85 participants were included. Total annual expenditures before the intervention were 5,832 € per client for all service segments. During the 12-months study duration expenditures decreased to 4,350 € including the costs associated with outreach clinic services. QALYs for the 12-month study period were 0.6618 and increased about 0.0568 compared to the period before. DISCUSSION: Despite methodological limitations due to small sample size, a pre-post comparison and the retrospective cost data collection, this study suggests acceptability of the outreach clinic as cost-effective. CONCLUSION: The activities of the outreach clinic as an integrated care model seem to be cost-effective regarding the relation between monetary expenditures and clients' quality of life.

Treatment of children and adolescents with Hodgkin lymphoma without radiotherapy for patients in complete remission after chemotherapy: final results of the multinational trial GPOH-HD95.

UNLABELLED: PURPOSE To minimize the risk of late effects in pediatric Hodgkin lymphoma (HL) by omitting radiotherapy (RT) in patients in complete remission (CR) after chemotherapy and reducing the standard radiation dose to 20 Gy in patients in incomplete remission. PATIENTS AND METHODS: Between 1995 and 2001, 925 patients with classical HL (cHL) were registered from seven European countries in German Society of Pediatric Oncology and Hematology Hodgkin Lymphoma Trial 95. Patients in treatment group 1 (TG1; early stages) received two cycles of vincristine, prednisone, procarbazine, and doxorubicin or vincristine, prednisone, etoposide, and doxorubicin chemotherapy; additional two or four cycles of cyclophosphamide, vincristine, prednisone, and procarbazine were added in TG2 (intermediate stages) or TG3 (advanced stages), respectively. Patients in CR (assessed by computed tomography or magnetic resonance imaging) did not undergo RT. Those with tumor volume reduction more than 75% received reduced involved-field RT with 20 Gy and an additional 10- or 15-Gy boost only for larger residuals. RESULTS: Rates of overall survival, progression-free survival (PFS), and event-free survival at 10 years were (± SE) 96.3% ± 0.6%, 88.2% ± 1.1%, and 85.4% ± 1.3%, respectively. PFS for TG1 patients without or with RT was 97.0% ± 2.1% versus 92.2% ± 1.7% (P = .214) but was unsatisfactory for nonirradiated patients in TG2 (68.5% ± 7.4% v 91.4% ± 1.9%; P < .0001), with similar but not significant results in TG3 (82.6% ± 5.4% v 88.7% ± 2.0%, P = .259). Reduction of the standard radiation dose from 25 to 20 Gy did not increase failure rate. CONCLUSION: RT can be omitted in early stage HL in so defined CR following this chemotherapy. RT with 20(-35) Gy proved to be sufficient in patients with incomplete remission following chemotherapy.

Hot or not? Thermal reactions to social contact.

Previous studies using thermal imaging have suggested that face and body temperature increase during periods of sexual arousal. Additionally, facial skin temperature changes are associated with other forms of emotional arousal, including fear and stress. This study investigated whether interpersonal social contact can elicit facial temperature changes. Study 1: infrared images were taken during a standardized interaction with a same- and opposite-sex experimenter using skin contact in a number of potentially high-intimate (face and chest) and low-intimate (arm and palm) locations. Facial skin temperatures significantly increased from baseline during the face and chest contact, and these temperature shifts were larger when contact was made by an opposite-sex experimenter. Study 2: the topography of facial temperature change was investigated in five regions: forehead, periorbital, nose, mouth and cheeks. Increased temperature in the periorbital, nose and mouth regions predicted overall facial temperature shifts to social contact. Our findings demonstrate skin temperature changes are a sensitive index of arousal during interpersonal interactions.

Long-term outcome after polychemotherapy and intensive local radiation therapy of high-grade osteosarcoma.

BACKGROUND: Current standard therapy for high-grade osteosarcoma is neoadjuvant chemotherapy and complete resection of the primary tumour. Irradiation can improve local control if complete tumour resection is not possible or refused, but data on long-term outcome are not available. PATIENTS AND METHODS: We report on long-term results for overall survival, occurrence of local recurrence and metastasis, joint function and side-effects in 13 patients with high-grade osteosarcoma having been treated with a combination of local irradiation and polychemotherapy (median follow-up of 13.5 years). RESULTS: Ten of the 13 patients were alive 4-23 years after diagnosis. Three patients suffered local recurrence, in 2 of them tumour control and long-term survival could be achieved by secondary salvage surgery and polychemotherapy. In 5 patients pathological fractures of the irradiated bones occurred, none of them was associated with local recurrence. In 7 of the 10 long-term survivors good or fair joint function was achieved. CONCLUSIONS: We conclude that combination of chemotherapy and intensive local irradiation can achieve long-term local control and even cure in high-grade osteosarcoma. Thus radiation therapy may represent an alternative to definite surgery in selected patients, in particular in those with good response to chemotherapy, when surgery is not feasible or refused.

Gonadal and erectile dysfunction in diabetics.

The high prevalence of erectile dysfunction in patients with diabetes is caused mainly by vascular and neurological conditions;nevertheless, hypogonadism may also contribute to erectile dysfunction and to changes in mood, libido, body composition, and bone density. Age, obesity, and the assay used to measure testosterone will affect the diagnosis of hypogonadism. This article focuses on the interaction of these conditions and attempts to explain possible mechanisms for observations reported in the literature.

[Dissection or irradiation of the axilla in postmenopausal patients with breast cancer? Long-term results and long-term effects in 655 patients]. / Axilladissektion oder Axillabestrahlung bei postmenopausalen Patientinnen mit Mammakarzinom? Langzeitergebnisse und Langzeitfolgen bei 655 Patientinnen.

BACKGROUND: Until 1993 postmenopausal women with breast cancer did not receive adjuvant chemotherapy in our institution even if axillary nodes were involved. So in these patients axillary dissection had no diagnostic value for further treatment. Therefore we started a prospective study in which dissection of axillary nodes was replaced by irradiation in postmenopausal cN0 patients. PATIENTS AND METHODS: From 1986 to 1993 we irradiated 655 patients with breast cancer after breast conserving surgery (BET). In all 144 cN1- and all 209 premenopausal cN0-patients axillary dissection was recommended. Of 302 postmenopausal cN0 patients 129 had breast surgery in our institution. In a total of 129 patients axillary dissection was replaced by irradiation (AxRT-group). They were compared with all 173 patients referred from other hospitals for irradiation after both breast conserving surgery and axillary dissection (AxOP-group). Dissected patients with gross tumor involvement of the axilla or less than eight nodes removed had additional axillary irradiation. Patients age, tumor size, vessel-, muscle- or skin invasion and grading were similar in both groups (Table 1). However, in the AxRT-group there were more patients with negative hormone receptors, multifocal and medial sited tumors. Late complications after dissection and/or irradiation of the axilla were evaluated in 502 patients free of locoregional relapse and with a minimal follow up of 3 years (median 9.5 years). RESULTS: After 5, 10 and 15 years tumor free survival rates were 90%, 82% and 79% in the AxOP-group vs 91%, 82% and 80% in the AxRT-group, respectively (p = 0.95) (Figure 1). Overall survival (p = 0.98) (Figure 2), local (p = 0.47) and axillary control (p = 0.12) were equal in both groups (Figures 3 and 4). However, serious problems like lymphedema of the arm, pain, mobility impairment occurred in 26% patients following axillary dissection but only in 1% after axillary irradiation. No difference in late sequelae after axillary dissection with or without irradiation could be detected (26 vs 27%) (Table 2). CONCLUSION: In postmenopausal cN0-patients axillary dissection should be replaced by axillary irradiation, since it offers the same chance for cure with much lower morbidity.