Testicular cancer follow-up costs in Germany from 2000 to 2015.

PURPOSE: Advances in testicular cancer screening and therapy increased 10-year survival to 97% despite a rising incidence; eventually expanding the population of survivors requiring follow-up. We analyzed 10-year follow-up costs after testicular cancer treatment in Germany during 2000, 2008, and 2015. METHODS: Testicular cancer follow-up guidelines were extracted from the European Association of Urology. Per patient costs were estimated with a micro-costing approach considering direct and indirect medical expenses derived from expert interviews, literature research, and official scales of tariffs. Three perspectives covering costs for patients, providers, and insurers were included to estimate societal costs. Cost progression was compared across cancer histology, stage, stakeholders, resource use, and follow-up years. RESULTS: Mean 10-year follow-up costs per patient for stage I seminomatous germ-cell tumors (SGCT) on surveillance declined from EUR 11,995 in 2000 to EUR 4,430 in 2015 (p < 0.001). Advanced SGCT spending shrank from EUR 13,866 to EUR 9,724 (p < 0.001). In contrast, expenditure for stage II SGCT increased from EUR 7,159 to EUR 9,724 (p < 0.001). While insurers covered 32% of costs in 2000, only 13% of costs were reimbursed in 2015 (p < 0.001). 70% of SGCT follow-up resources were consumed by medical imaging (x-ray, CT, ultrasound, FDG-PET). Spending was unevenly distributed across follow-up years (years 1-2: 50%, years 3-5: 39%, years 5-10: 11%). CONCLUSIONS: The increasing prevalence of testicular cancer survivors caused German statutory insurers to cut per patient cost by up to 80% by budgeting services and decreasing reimbursement rates. The economic burden was gradually redistributed to patients and providers.

A historical account of the governance of midwifery education in Australia and the evolution of the Continuity of Care Experience.

BACKGROUND: Midwifery programs leading to registration as a midwife in Australia have undergone significant change over the last 20 years. During this time accreditation and governance around midwifery education has been reviewed and refined, moving from state to national jurisdiction. A major change has been the mandated inclusion of Continuity of Care Experiences as a clinical practice-based learning component. AIM: The purpose of this discussion is to present the history of the governance and accreditation of Australian midwifery programs. With a particular focus on the evolution of the Continuity of Care Experience as a now mandated clinical practice based experience. METHODS: Historical and contemporary documents, research and grey literature, are drawn together to provide a historical account of midwifery programs in Australia. This will form the background to the inclusion of the Continuity of Care Experience and discuss research requirements to enhance the model to ensure it is educationally sound. DISCUSSION: The structure and processes for the Continuity of Care Experience vary between universities and there is currently no standard format across Australia. As such, how it is interpreted and conducted varies amongst students, childbearing women, academics and midwives. The Continuity of Care Experience has always been strongly advocated for; however there is scant evidence available in terms of its educational theory underpinnings. CONCLUSION: Research concerned with the intended learning objectives and outcomes for the Continuity of Care Experience will support the learning model and ensure it continues into the future as an educationally sound learning experience for midwifery students.

Relato de caso: acompanhamento cardiológico durante 26 anos de atleta de alto nível / Case report: 26-year cardiological follow-up of a high-level athlete

O coração do atleta engloba um conjunto de alterações adaptativas resultantes da prática de exercício físico intenso e prolongado, promovendo alterações clínicas, eletrocardiográficas e ecocardiográficas. As alterações mais relevantes são a hipertrofia miocárdica, o alargamento das cavidades cardíacas e o aumento da massa cardíaca. Em alguns casos, essas alterações podem ser consideradas extremas, exigindo que as condições patológicas sejam eliminadas. Por meio de um relato de caso de um atleta de basquetebol de alto nível cuja única alteração no exame físico era a presença de bradicardia sinusal, persistente ao longo de 26 anos de acompanhamento clínico, investigada através de ecocardiograma, Holter e teste de esforço, demonstrando caráter benigno e fisiológico, apresentamos e discutimos a importância da avaliação cardiovascular por médico com experiência na análise de atletas, capaz de distinguir as condições patológicas das adaptações fisiológicas frente ao exercício de alta intensidade ao qual o atleta é submetido, evitando exames invasivos ou tratamento do coração do atleta.

The athlete's heart performs a set of adaptive changes resulting from the practice of intense and prolonged physical exercise, resulting in clinical, electrocardiographic and echocardiographic alterations. The most relevant changes are myocardial hypertrophy, enlargement of the cardiac cavities, and an increase in cardiac mass. In some cases, these changes can be considered extreme, requiring the elimination of pathological con - ditions. Through a case report of a high-level basketball player, whose only change in the physical examination was the presence of sinus bradycardia, persistent over 26 years of clinical follow-up, which was investigated through echocardiogram, Holter test and stress test, demonstrating benign and physiological characteristics, we present and discuss the importance of cardiovascular evaluation by a physician with experience in analyzing athletes, capable of distinguishing pathological conditions from physiological adaptations to the high-intensity exercise to which the athlete is subjected, avoiding invasive examinations or treatment of the athlete's heart

CE: Nursing's Evolving Role in Patient Safety.

: Background: In its 1999 report To Err Is Human: Building a Safer Health System, the Institute of Medicine (IOM) suggested that between 44,000 and 98,000 Americans die annually as a result of medical errors. The report urged health care institutions to break the silence surrounding such errors and to implement changes that would promote a culture of safety. OBJECTIVE: Our aim in conducting this content analysis of AJN articles was to explore the nurse's historical and contemporary role in promoting patient safety. We chose to focus on AJN because, as the oldest continuously published nursing journal, it provided a unique opportunity for us to view trends in nursing practice over more than 100 years. METHODS: We reviewed all AJN tables of contents from 1900 through 2015, identifying for inclusion articles with titles that suggested a focus on nursing care, patient safety, or clinical content. We then read and analyzed each of the final 1,086 articles over a period of nine months. FINDINGS: Our content analysis indicates that the early articles (from 1900 through 1920) focused on such safety measures as asepsis and the newly understood germ theory. In the 1930s, articles proposed methods for preventing medication errors and encouraged the development of written procedures to standardize care. During World War II, nurse authors identified improved patient survival rates with the use of "shock wards" and recovery rooms. The 1950s saw the emergence of progressive patient care initiatives, through which patients were assigned to various levels of care (intensive, intermediate, self, long-term, or home care) based on patient acuity. The 1960s brought increasingly complex equipment and medication regimens, which created safety problems. Hospital-acquired infections were recognized. Unit-dose medication was instituted in the 1970s. In the next two decades, medication and nursing-procedure safety were emphasized. From 2000 to 2015, articles looked beyond human performance as causes of health care errors to systemic factors, such as poor communication, patient-nurse ratios, provider skill mix, disruptive or inappropriate provider behavior, shift work, and long working hours. CONCLUSIONS: Emphasis on patient safety increased as patient care became more complex. As nurses developed a professional identity, they often put a spotlight on safety concerns and solutions. The IOM report, which encouraged research focused on systemic solutions to errors, was instrumental in furthering the very culture of safety that the nursing profession had championed.

The quintessential nursing population.

A past nursing model for 'chronically critically ill' patients provides lessons for health care today.As part of its Raise the Voice campaign to showcase nurses who are key players in transforming health care, the American Academy of Nursing has identified nurses they call edge runners-"practical innovators who have led the way in bringing new thinking and new methods to a wide range of health care challenges." This is the fourth in AJN's series of profiles of these nursing innovators. Read and be proud of what nurses can accomplish.

On Lok: a pioneering long-term care organization for the elderly (1971-2008).

On Lok is a pioneering nonprofit organization that has delivered services to the frail and elderly since its founding in 1971. The agency began as a grassroots effort focused on improving the health care available to older adults living independently in the community. Over its 40-year history, On Lok has evolved into a $70 million nonprofit human service organization with a national reputation for innovation as a leading provider of care to frail elderly. The agency has developed its own model of care that has been replicated in cities around the country. The history of On Lok represents the important impact that donor and community support plays in an organization's long-term success.

Patient-based continuum of care in nephrology: why read Thomas Addis' "Glomerular Nephritis" in 2010?

The name of Thomas Addis (1881-1949) is linked to several aspects of nephrological practice: from the "Addis count" of urinary elements, to the history of diet in chronic kidney diseases. He was accustomed to working with limited funds, and developed his theories with relatively simple means, combined with the careful, long-term observation of single cases. His political ideas were progressive; his outlook on life was optimistic. This is deeply reflected in his Glomerular Nephritis: Diagnosis and Treatment, a book worth reading in the era of chronic kidney disease (CKD), as it contains sharp analyses of the organizational aspects, and accurate comments on the role of the physician - all subjects of interest for the present times and challenges. One of Addis' ingenious ideas was to follow his patients throughout their lifelong disease, thus anticipating the theories of continuum of care and of therapeutic alliance between patients and physicians. He used to tailor his prescriptions and frequency of controls to each patient and phase of the disease, thus anticipating the tailored therapies and the patient empowerment presently considered as fundamental in chronic diseases. Furthermore, he suggested that physicians should work outside the hospital in small coordinated teams, in which volunteers, dietitians and laboratory technicians would play a crucial role. Patient-centered care and the importance of nonmedical team members are clear from the first lines of his book. As far as we know, he was the first physician to stress the role of volunteers in CKD, anticipating by decades nonprofit organizations such as the National Kidney Foundation.

The traumatic brain injury model systems: history and contributions to clinical service and research.

The model systems (MSs) of care for traumatic brain injury (TBI) is a demonstration program started by the National Institute on Disability and Rehabilitation Research in 1987 to improve care and outcomes for individuals with TBI, from emergency services through life-long follow-up. Over the next 20 years, the program increased in size, and the emphasis shifted from demonstration to research. The focal point of that research is the National Data Base, a longitudinal database including nearly 9000 individuals who were admitted for inpatient acute TBI rehabilitation. In addition to preinjury, injury, acute care, and rehabilitation information, the database includes reports of outcomes at 1, 2, 5, 10, 15, etc, years postinjury. The National Data Base criteria, main contents, and mechanisms used to improve data quantity and quality are described. The MSs' other research is described: local (site-specific), module, and collaborative, with illustrative glimpses of the content. The impact of the TBI MSs program, through dissemination, knowledge translation, training of clinicians and researchers, as well as consulting with policy makers, administrators, clinicians, and researchers is discussed.

[History of the German antenatal record ("mutterpass") and its need for updating]. / Zur Historie des Mutterpasses und seines Aktualisierungsbedarfs.

BACKGROUND: The German antenatal record, the "Mutterpass", is the most important document in German antenatal care. Following its introduction in 1968, subsequent editions were adapted to take account of successive revisions of the German maternity guidelines ("Mutterschaftsrichtlinien"). Before 1995, however, no details giving evidence for or explaining the reasons for the modifications to the maternity guidelines were included. While the maternity guidelines have been regularly updated, particularly with regard to serological findings and ultrasound examinations, the risk catalogue included in the "Mutterpass" has not, but has remained unchanged since 1986. Just one risk factor out of the 52 items listed suffices to define a pregnant woman as being at high risk during childbirth. DISCUSSION AND CONCLUSION: The history of the risk catalogue shows that its revision is essential to meet current health science requirements. Likewise, arguments for an evidence-based revision of the items of the risk catalogue are to be found in current literature.

On the uniqueness of surgery.

BACKGROUND: As the divergence between medicine and surgery increases, the author traces its beginnings not to the recent past, but as far back as the Middle Ages and the Renaissance. Even at that time, physicians rarely came in physical contact with the patients and made their diagnoses from looking at flasks of urine from the patients. Skilled physicians allegedly could make approximately 1000 diagnoses from examining a flask of urine. On the other hand, barber surgeons were relatively unskilled and unrewarded, at a much lower class in society, and laid hands on the patient by draining abscesses, cauterizing, dealing with bladder stones, etc. METHODS: Despite the Quincentenary of the Royal College of Surgeons of Edinburgh this year and the rendering of the first guild to the barber surgeons, this schism between medical and surgical practice has remained. The author attempts to fit this schism into medicine today by addressing continuity of care and the 80-hour workweek, stating that this schism is not a new development but has existed for many years. CONCLUSIONS: The proposal is made that medicine and surgery should work together as much as they can. However, if surgical patients are not well served by the lack of emphasis on continuity of care brought forth by the leadership of medicine in this country, who the author claims of intentionally distancing themselves from patient care, then surgery may need to go its own way. The patient comes first.

History and measurement of continuity of care in mental health services and evidence of its role in outcomes.

OBJECTIVES: The objective of this study was to provide a brief history of the concept of continuity of care, to update evidence of its association with patient outcomes, and to identify optimal characteristics of a continuity-of-care instrument. METHODS: Articles describing recent (1990 to 2002) empirical work on continuity of care were drawn from a broader set of 305 articles about continuity of care that were obtained from a systematic literature search. RESULTS AND DISCUSSION: The literature shows that ideas about continuity of care have changed in concert with general service delivery changes over the decades. Since 1997, only eight studies have used operationally defined measures either to describe continuity of care in mental health services or to examine the association of continuity of care with outcomes for adults with severe and persistent mental illness. Only three groups of researchers have published articles on development of continuity-of-care measures. CONCLUSIONS: There is little evidence that continuity of care results in better client outcomes, which may be primarily attributable to the underdevelopment of measures. Measurement of continuity of care must become more sophisticated before key questions about the association of continuity of care with outcomes can be examined and before the effectiveness of interventions designed to improve continuity of care can be rigorously evaluated.

Finance issue brief: continuity of care.

When a health care provider disenrolls or is terminated by a managed care plan, how long can that provider's patients continue to receive covered treatment for a life-threatening condition, pregnancy, disability or other circumstance that requires continuous medical care? Lawmakers in twenty-seven states have answered that question.

[Continuity--adjustment--autonomy--physician--patient--an overview of medical cultural philosophy in former East Germany]. / Kontinuität--Anpassung--Autonomie--Arzt--Patient--eine Betrachtung zur medizinischen Denkkultur in der ehemaligen DDR.

The author probes into the "culture" of medical thinking in the former GDR in respect of the interlinking of socialisation of the doctor, within the framework of socialism, with the fate of the patient; the fundamentals of the development of science and of the pattern of cultural life; and the development of moral consciousness and health policy under the influence of Marxist-Leninist teachings. (One should not neglect the difference made by the author between "official Marxism-Leninism as decreed by the state" and "Marxist theory" as well as "public level of consciousness".) Errors of judgment, illusions, so-called "noble" ideals of the medical profession such as ambitiousness, engagedness, and readiness to shoulder responsibilities, were interwoven with the trend to functionalism, to keep the party bureaucracy of the SED in power. One of the thematic points of emphasis was the "changing of paradigms in medicine", such as the hostility to psychology as a feature of GDR socialism, or the sociopolitically dictated condemnation of non-institutional or "alternative" medicine. The author sees a basic trend to technocracy in GDR medicine. He shows up trends to "moral remote control" of the doctor, to a deliberately practised illusionment, a systematically engineered demounting of decisions based on moral constraints--such demounting being promoted both in the doctor's mind and in actual practice--and to eliminating emotional obstacles officially construed as "interfering" with a strictly objectified doctor-patient relationship. Nothing in this context can be soft-pedalled and excused. The author points specifically to the officially promoted vision of a "successful repair and construction of a New Man". Within the context of socialist ideal views and actual socialisation of the doctor there are similarities between the balance-sheets of 1945 and 1989 in Germany without attempting to suggest that this amounts to a comparison on the same level with the genocide and war guilt of the National Socialist era. Guilt is a burden on the mind, but non-assessed guilt and lack of a possibility of redemption destroys humans. The article is a plea against an increasing tendency to criminalize the former GDR citizen and the doctors. "It will be necessary to honestly review the past history embodying my own errors, mistaken concepts and illusions." All this is only a first approximation to an important and complex subject. It is the author's aim to promote a better understanding between the former GDR citizens and those of West Germany.