[Polymyalgia rheumatica in 18-fluorodeoxyglucose-positron-emission-tomography/computed tomography : Improvement in diagnostic accuracy and differentiation from rheumatoid arthritis]. / Polymyalgia rheumatica in der 18-Fluordesoxyglukose-Positronenemissionstomographie/Computertomographie : Verbesserung diagnostischer Genauigkeit und Abgrenzung von rheumatoider Arthritis.

BACKGROUND: The diagnosis of patients with polymyalgia rheumatica (PMR) has relied upon the clinical examination of symptoms and laboratory parameters of inflammation until now. Currently, the use of different imaging modalities is being explored, including ultrasound, MRI and PET. OBJECTIVES: The aim was to evaluate the diagnostic value of 18-fluorodeoxyglucose-positron-emission-tomography/computed tomography (18F-FDG-PET/CT) for PMR, in order to improve the sensitivity and specificity of diagnosing PMR and to improve the differential diagnosis of rheumatoid arthritis (RA). MATERIALS AND METHODS: Examinations using 18F-FDG-PET/CT of 284 rheumatological patients, including 97 patients with PMR, were retrospectively evaluated over a 44-month period. Furthermore, 13 regions changed by inflammation were analysed via a three-dimensional region of interest (ROI) measurement with determination of maximum standardized uptake values (SUVmax), followed by statistical analyses. RESULTS AND DISCUSSION: Patients with PMR presented significantly elevated uptake in all regions examined (p < 0.001), compared with a control group treated for rheumatological diseases. The method with the highest diagnostic relevance was represented by the combination of four SUVmax values of both anterolateral hip capsules and both ischial tuberosities, reaching a sensitivity of 91.3% and a specificity of 97.6% with a cut-off of 11.0 SUV at the initial diagnosis of PMR patients who had not yet received any immunosuppressive therapy. Patients with RA could be significantly distinguished from those with PMR at initial diagnosis in the same anatomical regions (p < 0.001).

[Development of quality standards for patients with rheumatoid arthritis for use in Germany]. / Entwicklung von Qualitätsstandards für die Versorgung von Patient*innen mit rheumatoider Arthritis zur Anwendung in Deutschland.

Despite a qualitatively and structurally good care of patients with rheumatoid arthritis (RA) in Germany, there are still potentially amendable deficits in the quality of care. For this reason, the German Society for Rheumatology (DGRh) has therefore decided to ask a group of experts including various stakeholders to develop quality standards (QS) for the care of patients with RA in order to improve the quality of care. The QS are used to determine and quantitatively measure the quality of care, subject to relevance and feasibility. The recently published NICE and ASAS standards and a systematic literature search were used as the basis for development. A total of 8 QS, now published for the first time, were approved with the intention to measure and further optimize the quality of care for patients with RA in Germany.

[Development of quality standards for patients with axial spondyloarthritis for use in Germany]. / Entwicklung von Qualitätsstandards für Patient*innen mit axialer Spondyloarthritis zum Einsatz in Deutschland.

Quality standards (QS) are measurable constructs designed to quantify gaps in care and subsequently to improve quality of care. The Assessment of SpondyloArthritis International Society (ASAS) recently generated and published international QS for the management of patients with axial spondyloarthritis (axSpA) for the first time. The German Society of Rheumatology (DGRh) then decided to translate, review and possibly adopt these standards by a group of experts from different care settings. Against this background, national QS for the management of patients with axSpA for Germany were developed for the first time. The main focus was on feasibility and practical relevance. Ultimately, nine QS were defined with which the quality of care in Germany can and should be measured and improved.

[Quality in acute inpatient rheumatology 2021 : Current aspects of the KOBRA quality label of the Association of Rheumatological Acute Care Clinics]. / Qualität in der akutstationären Rheumatologie 2021 : Aktuelle Aspekte zum KOBRA-Qualitätslabel des Verbandes Rheumatologischer Akutkliniken (VRA e.V.).

A comprehensive health policy quality campaign launched in 2021 aims to improve the quality and transparency of hospital care for people with diseases in Germany. Legal requirements for minimum volumes and the expansion of quality contracts between cost units and hospitals as well as the use of quality indicators relevant to planning for demand-oriented and quality-oriented further development of inpatient care will increase competition in the quality of care between hospitals. The topic of development and definition of quality in medicine was also comprehensively addressed by the Association of Rheumatological Acute Care Clinics (VRA) shortly after its foundation in 1998. At the center of acute inpatient quality management are binding structural criteria linked to the continuous outcome benchmarking in acute rheumatology care (KOBRA) project launched in 2003 in rheumatology (and continuously implemented to date) measuring process and outcome quality. Based on this framework (fulfillment of the structural quality and participation in the KOBRA project) successfully participating rheumatology units can acquire the KOBRA seal of approval for 2 years at a time, which is awarded by the project management, the aQua Institute. The outstanding position of the project is exemplified by data evaluation on treatment change in active rheumatoid arthritis, diagnosis confirmation of connective tissue diseases and vasculitis during the inpatient stay as well as on participatory decision-making processes concerning rheumatoid arthritis (referring to the results of the data collection period 2018). By anchoring projects for structural, process and outcome quality acute inpatient rheumatology is well prepared for the paradigm shift demanded by health policies. Additionally, the KOBRA project is a good prerequisite to meet the requirements concerning quality management fixed in the Federal Joint Committee (G-BA) guidelines for recognition as a rheumatology center.

[Future of acute inpatient rheumatology in Germany : Statement of the Boards of the German Society for Rheumatology and the Association of Rheumatological Acute Clinics on hospital planning North-Rhine/Westphalia 2019 for the discipline rheumatology]. / Zukunft der akutstationären Rheumatologie in Deutschland : Stellungnahme der DGRh- und VRA-Vorstände zur Krankenhausplanung NRW 2019 für den Leistungsbereich Rheumatologie.

In September 2019 the Ministry of Labor, Health and Welfare (MAGS) of North-Rhine/Westphalia (NRW) published an expert report on hospital planning. In this report a fundamental reform of hospital planning was recommended, in that a requirements planning should be carried out in the future on the basis of a detailed designation of disciplines and organizational groups. At the request of the MAGS NRW, the German Society for Rheumatology (DGRh) with the support of the Association of Rheumatological Acute Clinics (VRA) has also commented on this issue.

[Evaluation of a basic educational program for patients with rheumatoid arthritis]. / Evaluation einer Basisschulung für Patienten mit rheumatoider Arthritis.

BACKGROUND: A new conceptual framework has enabled the flexible development of rheumatological patient educational programs for different healthcare settings. On this basis, a 5­h basic training program for patients with rheumatoid arthritis (RA) was developed to be used in specialized centers. Rheumatologists and psychologists were first trained and then the efficacy of the patient training program was evaluated based on the causal model of patient education. METHODS: The externally randomized waiting control group study with 249 RA patients included 3 measurement points. The impact of the 5­h basic training on disease and treatment-related knowledge as well as health competence of RA patients was examined. Secondary questions included attitudinal parameters, communication competence, effects on the disease and satisfaction with the educational program. Data were analyzed on an intention to treat basis by means of covariance analyses for the main target variables, adjusted for baseline values. RESULTS: The analyses showed that the training program was effective. Even 3 months after training, participants reported more knowledge and health competence than the waiting control group, with small to medium-sized effects (d = 0.37 and 0.38, respectively). With the exception of disease communication, no other effects of training were observed in the secondary objectives. CONCLUSION: The basic training program provides a good foundation to develop further interventions to improve attitudinal and disease parameters. It can serve as a central component for rheumatological healthcare for patients with RA at various levels.

[Flexible programs and advanced training for rheumatological patient education]. / Flexible Programme und Fortbildungen für die rheumatologische Patientenschulung.

In two research projects, rheumatological patient education programmes were updated. The first step was to develop an expert consented framework for all rheumatological patient education programmes. From this, curricula and working materials for rheumatoid arthritis (RA) and axial spondyloarthritis (AS) were derived and two exemplary patient education manuals developed. A randomized controlled trail was designed for the five-hour RA basic education program. Finally, existing train-the-trainer training courses were adapted for these patient education programmes.

[Outpatient specialist medical treatment (ASV)-a new treatment level in rheumatology]. / Ambulante spezialfachärztliche Versorgung (ASV) ­ eine neue Versorgungsebene in der Rheumatologie.

Since April 2018, the new third level care model of outpatient specialist care (ASV) according to §116b of the Social Code Book V (SGBV) has been available for patients with chronic inflammatory rheumatic diseases in Germany. Not only is a multiprofessional cooperation between the disciplines involved in treating rheumatic diseases promoted but also the cooperation between specialized rheumatologists and other specialists in private practice and in hospitals is encouraged. As budget capping limiting services and number of cases do not apply in ASV, a significant improvement of patient care in rheumatology is expected due to an increase in provider capacity. At the end of May 2019, 72 rheumatologists in the first 9 newly approved ASV teams had qualified for this new care concept. Bureaucratic obstacles have so far delayed the implementation of ASV. Difficulties arose in building a team with different specialties, in the process of registration of the teams and the assessment of the registration by certain regional boards responsible for access control. The national associations of rheumatologists, the Professional Association of German Rheumatologists (BDRh), the VRA (Verband der Rheumatologischen Akutkliniken e. V.) and the German Society of Rheumatology (DGRh) campaign for an easier admission of providers to the ASV and for adequate financing of all specialties involved in the ASV. The aim is to realize the chance of the ASV for better rheumatological care nationwide with shorter waiting times for a medical appointment and a better cooperation between specialists.

[Complex treatments in rheumatology and geriatrics - Challenges - Differences - Chances]. / Komplextherapien in der Rheumatologie und Geriatrie ­ Herausforderungen ­ Unterschiede ­ Chancen.

With the introduction of the German diagnostic-related groups (G-DRG) system in 2003, remuneration according to DRG was also implemented for the disciplines of rheumatology and geriatrics. For acute inpatient treatment in the field of rheumatology the specialized complex rheumatological treatment (OPS code 8-983) and the related DRG-I97Z (rheumatological complex treatment for diseases and disorders of the musculoskeletal system and connective tissue) were assigned to the DRG system in 2005 and 2006, respectively. The early complex geriatric rehabilitation (OPS code 8-550) is a tool in the treatment of older patients affected by rheumatism. In this article the challenges of realizing complex therapies are described using the examples of OPS code 8-983 and 8-550 and their structural and procedural differences are outlined. Acute inpatient treatment of patients severely affected by a rheumatic disease as well as of multimorbid geriatric patients with rheumatism is supported by the implementation of the respective complex therapy.

[Characteristics of pharmacotherapy in older patients with rheumatism]. / Besonderheiten der Pharmakotherapie des älteren Rheumapatienten.

Due to medical advances and the availability of efficient immunosuppressive therapies, the life-expectancy of people suffering from inflammatory rheumatic diseases is continuously increasing. In Germany, geriatric patients (definition: age older than 70 years combined with geriatric multimorbidity) affected, e. g. by rheumatoid arthritis (RA) frequently receive corticosteroids and less often biologic disease-modifying antirheumatic drugs (bDMARDs) and conventional DMARDs (cDMARDs), which is justified by additionally existing comorbidities and polypharmacy. Using geriatric typical assessments as well as detailed medication regimens the treatment risk of bDMARD and cDMARD administration can be properly evaluated. Current data on biological therapy in older patients with rheumatism support this recommendation. Following the "choosing wisely" initiative of the German Association of Internal Medicine the authors listed 5 positive and 5 negative recommendations concerning the pharmacotherapy of older patients suffering from rheumatism (e. g. RA) as practical guidance towards safer bDMARD and cDMARD treatment for geriatric RA patients.

[Memorandum of the German Society for Rheumatology on the quality of treatment in rheumatology - Update 2016]. / Memorandum der Deutschen Gesellschaft für Rheumatologie zur Versorgungsqualität in der Rheumatologie ­ Update 2016.

On behalf of the Steering Committee of the German Society for Rheumatology, in 2016 the Interdisciplinary Commission on Healthcare Quality updated the 2008 memorandum on rheumatological healthcare in Germany. The update considers changes in therapeutic strategies, treatment targets as well as current structures in healthcare and the political framework. It concentrates on examination of the need for rheumatologists with a background in internal medicine and determines the gap between needs and supply. The internist rheumatologist is responsible for the care of patients with inflammatory rheumatic diseases and contributes to the care of patients with severe forms of other musculoskeletal diseases. At least 2 internist rheumatologists are needed for the outpatient care of 100,000 adult inhabitants, equivalent to 1350 rheumatologists in Germany. With currently 776 rheumatologists, we have little more than half of what we need. The German Society for Rheumatology calls for specific requirements planning for rheumatologists in outpatient care in order to decrease the deficit. In acute inpatient care we need specialized hospitals and wards that ensure a high quality of treatment for patients with complex diseases. We need up to 50 beds per 1 million inhabitants. At least 2 full-time internist rheumatologists and 3 further physicians are needed per 30 beds. In inpatient and outpatient rehabilitation we need 40 beds or outpatient places per 1 million inhabitants with at least 1 full-time rheumatologist and 1 further physician. In order to reduce the existing deficits and to cover the increasing future need for rheumatologists, more emphasis has to be laid on primary and secondary education. Chairs for internal rheumatology are needed at each medical university and more positions for postgraduate training in rheumatology should be provided. In all segments of healthcare the treatment aims should be jointly defined between patients and physicians. The patients should be treated in an interdisciplinary network, comprising other medical specialties, health professionals as well as patient organizations.

[Cornerstones of quality assurance in medicine in Germany. Important impulse for the situation in treatment of rheumatism]. / Eckpfeiler der Qualitätssicherung in der Medizin in Deutschland. Wichtige Impulse für die rheumatologische Versorgungssituation.

The recently passed German hospital structure act (Krankenhausstrukturgesetz) stresses the immense importance of quality for the medical care of the population. How can inpatient and outpatient treatment in the field of rheumatology be improved and how can this be assessed? A very important basis for such measurement approaches are quality indicators, i.e. parameters that indicate to what degree a certain level of quality has already been reached or is planned to be reached in the future. The work performed by the German Rheumatism Research Center (DRFZ) and the Association of Rheumatological Acute Clinics (VRA) in Germany has already used certain quality indicators and this topic has been recently described elsewhere. International quality indicators have also been published in recent years, all for rheumatoid arthritis (RA), the most prevalent inflammatory rheumatic disease and are the central subject of this article. This overview of proposed instruments for quality assessment in rheumatology is intended to initiate a broad discussion on the subject of quality of rheumatological care in Germany.

[International quality indicators in rheumatology. Suggestions for rheumatoid arthritis]. / Internationale Qualitätsindikatoren in der Rheumatologie. Vorschläge für die rheumatoide Arthritis.

Quality measurement of medical care has become increasingly important in Germany in recent years. Essentially, three areas can be distinguished: the quality of structure, process and outcome. For the measurement of quality, quality indicators are necessary. The Federal Joint Committee has recently been responsible for defining such quality indicators. Because proposals for quality indicators for the indication for rheumatoid arthritis in have already been published in international rheumatology, we selected and translated the three most important European publications in order to present them to the rheumatology community. The ultimate aim is the initiation of a process for the joint development of quality indicators within the professional association and the two associations in Germany in order to then be able to adequately discuss these with policy-makers.

[Hospital financing in 2016. Relevant changes for rheumatology]. / Krankenhausfinanzierung 2016. Relevantes für die internistische Rheumatologie.

Hospital financing 2016 will be influenced by the prospects of the approaching considerable changes. It is assumed that the following years will lead to a considerable reallocation of financial resources between hospitals. While not directly targeted by new regulations, reallocations always also affect specialties like rheumatology. Compared to the alterations in the legislative framework the financial effects of the yearly adaptation of the German diagnosis-related groups system are subordinate. Only by comprehensive consideration of current and expected changes a forward-looking and sustainable strategy can be developed. The following article presents the relevant changes and discusses the consequences for hospitals specialized in rheumatology.

[Quality of German medical services: a review]. / Qualität in der Medizin in Deutschland - eine Bestandsaufnahme.

In the current draft of the law on the reform of the support structures of hospital provision (German Hospital Structure Law) the future quality of provision is highly significant. Quality assurance measures are mandatory for hospitals. The Federal General Committee was legally charged with developing the relevant quality indicators for structural, procedural and outcome quality that are designed to form the criteria and the basis for planning decisions in the federal states. This involves a paradigm shift in quality assurance measures in hospitals. In the future, subject to the verified quality, this should have an influence on hospital planning, and the funding or regulation of hospital departments should also adhere to this prescribed quality. This review reveals the course of quality or quality assurance measures in medical services in Germany. The status of the institutions responsible for the quality of care in hospitals and the significance of quality indicators are explained.

[Hospital financing in 2015. Relevant changes for rheumatology]. / Krankenhausfinanzierung 2015. Relevantes für die internistische Rheumatologie.

The announced major reforms will most probably not have an impact on hospital financing before 2016. Nevertheless, the numerous minor changes in the legislative framework and the new version of the German diagnosis-related groups (G-DRG) system can be important for hospitals specialized in rheumatology. The following article presents the relevant changes and discusses the consequences for hospitals specialized in rheumatology.