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1.
BMC Musculoskelet Disord ; 22(1): 783, 2021 Sep 12.
Artigo em Inglês | MEDLINE | ID: mdl-34511058

RESUMO

BACKGROUND: Total knee replacement (TKR) is one of the most commonly performed routine procedures in the world. Prognostic studies indicate that the number of TKR will further increase constituting growing burden on healthcare systems. There is also substantial regional heterogeneity in TKR rates within and between countries. Despite the known therapeutic effects, a subset of patients undergoing TKR does not benefit from the procedure as intended. To improve the appropriateness of TKR indication, the EKIT initiative ("evidence and consensus based indication critera for total arthroplasty") developed a clinical guideline for Germany on the indication of TKR. This guideline is the basis for a digital medical decision aid (EKIT tool) to facilitate shared decision making (SDM) in order to improve decision quality for elective surgery. The aim of this cluster randomized trial is to investigate the effectiveness of the EKIT tool on decision quality. METHODS: The Value-based TKR study is a prospective pragmatic multi-center, stepped wedge, cluster randomized controlled trial (SW-RCT). The EKIT tool provides (1) a systematic presentation of individual patient and disease-specific information (symptoms, expectations), (2) the fulfillment of the indication criteria and (3) health information about safety and effectiveness of TKR. All study sites will follow routine care as control clusters until the start of the intervention. In total, there will be 10 clusters (study sites) and 6 sequential steps over 16 month, with clusters receiving the intervention with a minimum 2 months of standard routine care. The primary outcome is patients' decision quality measured with the Decision Quality Instrument (DQI)-Knee Osteoarthritis questionnaire. Furthermore, we will collect information on global patient satisfaction, patient reported outcome measures and the fulfilment of the individual expectations 12 months after SDM. The power calculation yielded an estimated power of 89% using robust Poisson regression under the following assumptions: 10 study sites with a total of N=1,080 patients (including a dropout rate of 11%), a 10% increase in decision quality due to the use of the EKIT tool, and a significance level of 5%. DISCUSSION: There is a high potential for transferring the intervention into routine practice if the evaluation is positive. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04837053 . Registered on 08/04/2021.


Assuntos
Artroplastia do Joelho , Osteoartrite do Joelho , Médicos , Artroplastia do Joelho/efeitos adversos , Técnicas de Apoio para a Decisão , Humanos , Estudos Multicêntricos como Assunto , Osteoartrite do Joelho/diagnóstico , Osteoartrite do Joelho/cirurgia , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto
2.
J Med Internet Res ; 2021 Sep 12.
Artigo em Inglês | MEDLINE | ID: mdl-34523604

RESUMO

BACKGROUND: With the rise of digital health technologies and telemedicine services, the need for evidence-based evaluation is growing. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are recommended as an essential part of comprehensive and multidisciplinary evaluation studies on telemedicine applications. For the first time, a systematic review has been conducted investigating the use of PROMs and PREMs in evaluation studies of telemedicine applications covering all application types and medical purposes. OBJECTIVE: Our review investigates the following research questions: • In which scenarios were PROMs and PREMs collected for evaluation purposes? • Which PROM/PREM outcome domains have been covered and how often? • Which outcome measurement instruments (OMIs) have been used and how often? • Did the selection and quantity of PROMs and PREMs differ between study types and application types? • Has the use of PROMs and PREMs in evaluation studies changed over time? METHODS: We conducted a systematic literature search in the MEDLINE and EMBASE databases and included studies published from inception until April 2, 2020. We included studies evaluating telemedicine applications with patients as main users; these studies reported PROMs and PREMs within randomized controlled trials (RCT), controlled trials, non-controlled trials and feasibility trials in English and German. RESULTS: Out of 2671 records identified, 303 studies were included with 22.1% (67/303) feasibility studies, 23.1% (70/303) non-controlled trials, 6.6% (20/303) controlled trials and 48.2% (146/303) RCTs. Health-related quality of life (HRQoL) (n=310, mean=1.02, SD=1.05), emotional function (n=244, mean=0.81, SD=1.18) and adherence (n=103, mean=0.34, SD=0.53) were the most frequently assessed outcome domains. Self-developed PROMs were used in 21.4% (65/303) of all studies, self-developed PREMs were used in 22.3% (68/303). PROMs (n=884) were assessed more frequently than PREMs (n=234). As the evidence level of the studies increased, the number of PROMs also increased (τ=-0.45) with the number of PREMs decreasing (τ=0.35) at the same time. Since 2000, not only has the number of evaluation studies using PROMs/PREMs increased - the level of evidence and the number of OMIs used have also increased, with the number of PREMs permanently remaining at a lower level compared to the number of PROMs. CONCLUSIONS: There have been increasingly more studies, particularly high-evidence studies, which use PROMs and PREMs to evaluate telemedicine applications. PROMs have been used more frequently than PREMs. With an increasing maturity stage of the telemedicine applications and higher evidence level, the use of PROMs increased in line with the recommendations of evaluation guidelines. HRQoL and emotional function were measured in almost all studies. Simultaneously, health literacy as a precondition for using the application adequately - alongside proper training and guidance - was rarely reported. Further efforts should be pursued for the standardization of PROM and PREM collection in evaluation studies of telemedicine applications.

3.
Z Evid Fortbild Qual Gesundhwes ; 165: 68-76, 2021 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-34483074

RESUMO

INTRODUCTION: Due to the high variability and, at the same time, rare occurrence of rare diseases, the diagnosis of these patients (approx. 4 million people in Germany) can turn into an odyssey. The large time interval between the appearance of symptoms and the final diagnosis of the rare disease leads to a delay in the appropriate treatment. The often long period of uncertainty about the cause of symptoms as well as non-specific or even wrong therapies can have negative effects on both the course of disease and the patients' quality of life. For a better understanding of the current care situation and IT landscape, the interdisciplinary care pathway for people with rare diseases will be modelled and the possible uses of IT applications identified that have the potential to improve diagnosis, treatment and therapy of rare diseases. METHODS: In order to achieve these goals, an initial care pathway was modelled on the basis of process descriptions which are commonly used in the literature, discussed in detail, and agreed upon in a first workshop with six experts from outpatient and inpatient care as well as employees of Centers for Rare Diseases. In a second workshop, ten experts analyzed the resulting care pathway with regard to the possible use of IT applications, and the identification was agreed upon. The experts included those involved in the process, in particular physicians, patients / patient representatives, health care researchers, and experts in hospital IT, IT security, and data protection. RESULTS: The two workshops resulted in process models including the specification of possible uses for IT applications. The most important steps in the care pathway for people with rare diseases in Germany include: neonatal screening, seeking medical advice, outpatient care by general practitioners, outpatient care by specialists, care by specialist outpatient clinic, care by clinic, care by a Center for Rare Diseases: case review and case conference and treatment and therapy. The discussion of the possible uses of IT applications resulted in a focus on registers (e. g. with regard to experts, treatment and therapy options) as well as on digital tools, such as "digital findings and findings platform" and "digital referral with referral tracking". DISCUSSION: Our results show that the care pathway is very heterogeneous and complex. Thus, the sub-processes show different variants with many branches and repetitions. They also illustrate that the care for people with rare diseases requires a high level of interdisciplinary collaboration; diagnosis as well as treatment and therapy often take place across sectors and in cooperation between different medical health care institutions and professions. When analyzing the current IT landscape, it becomes clear that IT applications can be used at many process steps in the care for people with rare diseases and have a high potential. Therefore, they must be used to inform decisions about the adequate diagnosis and treatment as well as communication about the clinical pictures and the patient's case between practitioners and medical care sectors. CONCLUSION: The interdisciplinary collaboration highlights the need for cooperation between the various parties involved in the process, which requires the identification and implementation of interfaces between the stakeholders and their systems. However, it is not enough to include the view of the processes; the data perspective is also required. Creating interoperability also enables the use of IT applications. The basis for this is the results obtained.


Assuntos
Qualidade de Vida , Doenças Raras , Atenção à Saúde , Alemanha , Humanos , Recém-Nascido , Planejamento de Assistência ao Paciente , Doenças Raras/diagnóstico , Doenças Raras/terapia
4.
PLoS One ; 16(9): e0256737, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34492045

RESUMO

Due to increasing demand and scarce financial resources for healthcare, health system efficiency has become a major topic in political and scientific debates. While previous studies investigating determinants of health system efficiency focused primarily on economic and social influence factors, the role of the political regime has been neglected. In addition, there is a lack of formal theoretical work on this specific topic, which ensures transparency and logical consistency of arguments and implications. Using a public choice approach, this paper provides a rigorous theoretical and empirical investigation of the relationships between health system efficiency and political institutions. We develop a simple principal-agent model describing the behavior of a government with respect to investments in population health under different political regimes. The main implication of the theoretical model is that governments under more democratic regimes put more effort in reducing embezzlement of health expenditure than non-democratic regimes. Accordingly, democratic countries are predicted to have more efficient health systems than non-democratic countries. We test this hypothesis based on a broad dataset including 158 countries over the period 1995-2015. The empirical results clearly support the implications of the theoretical model and withstand several robustness checks, including the use of alternative indicators for population health and democracy and estimations accounting for endogeneity. The empirical results also indicate that the effect of democracy on health system efficiency is more pronounced in countries with higher income levels. From a policy perspective, we discuss the implications of our findings in the context of health development assistance.

5.
PLoS One ; 16(9): e0257003, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34492062

RESUMO

BACKGROUND: The standardized mortality ratio (SMR) is often used to assess and compare hospital performance. While it has been recognized that hospitals may differ in their SMRs due to differences in patient composition, there is a lack of rigorous analysis of this and other-largely unrecognized-properties of the SMR. METHODS: This paper proposes five axiomatic requirements for adequate standardized mortality measures: strict monotonicity (monotone relation to actual mortality rates), case-mix insensitivity (independence of patient composition), scale insensitivity (independence of hospital size), equivalence principle (equal rating of hospitals with equal actual mortality rates in all patient groups), and dominance principle (better rating of unambiguously better performing hospitals). Given these axiomatic requirements, effects of variations in patient composition, hospital size, and actual and expected mortality rates on the SMR were examined using basic algebra and calculus. In this regard, we distinguished between standardization using expected mortality rates derived from a different dataset (external standardization) and standardization based on a dataset including the considered hospitals (internal standardization). The results were illustrated by hypothetical examples. RESULTS: Under external standardization, the SMR fulfills the axiomatic requirements of strict monotonicity and scale insensitivity but violates the requirement of case-mix insensitivity, the equivalence principle, and the dominance principle. All axiomatic requirements not fulfilled under external standardization are also not fulfilled under internal standardization. In addition, the SMR under internal standardization is scale sensitive and violates the axiomatic requirement of strict monotonicity. CONCLUSIONS: The SMR fulfills only two (none) out of the five proposed axiomatic requirements under external (internal) standardization. Generally, the SMRs of hospitals are differently affected by variations in case mix and actual and expected mortality rates unless the hospitals are identical in these characteristics. These properties hamper valid assessment and comparison of hospital performance based on the SMR.

6.
Artigo em Inglês | MEDLINE | ID: mdl-34342924

RESUMO

OBJECTIVE: We investigated the health-related quality of life (HRQoL) of patients with gastrointestinal stromal tumours (GIST). METHODS: In the multicentre PROSa study, the HRQoL of adult GIST patients was assessed between 2017 and 2019 using the European Organisation for Research and Treatment of Cancer HRQoL questionnaire (EORTC QLQ-C30). We performed group comparisons and multivariate linear regressions. RESULTS: Among 130 patients from 13 centres, the mean global HRQoL was 63.3 out of 100 points. Higher sores indicate better HRQoL. The highest restrictions were in emotional, social, role functioning, insomnia, fatigue, and pain. In multivariate linear regression, we found no significant differences between patients receiving tyrosine kinase inhibitor (TKI) treatment and those without TKI treatment as well as between patients treated with curative or with palliative intent. Patients who received multiple lines of TKI treatment had the most restrictions, notably in physical (unstandardized regression coefficient [B] = -15.7), role (B = -25.7), social (B = -18.4), and cognitive functioning (B = -19.7); fatigue (B = 15.93); general health (B = -14.23); and EORTC-sum score (B = -13.82) compared to all other patients. CONCLUSION: The highest HRQoL restrictions were in GIST patients receiving multiple lines of TKI therapy. Underlying causes need further investigation.

7.
Int J Cancer ; 149(10): 1744-1754, 2021 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-34213799

RESUMO

Hospital certification has become an important measure to improve cancer care quality, with the potential effect of prolonging patient survival and reducing medical spending. However, yet to be explored is the cost-effectiveness of cancer care provided in certified hospitals, considering significant additional costs incurred from certification requirements. We performed a cost-effectiveness analysis (CEA) using two colon cancer populations (N = 1909) treated in different levels of certified hospitals (CHs) vs noncertified hospitals (NCHs) from a healthcare system's perspective. We matched patient-level data of incident colon cancer cases, diagnosed between 2008 and 2013 from a large statutory health insurance in Saxony, Germany, to calculate net treatment costs by phase (initial, continuing and terminal phase). The costs were supplemented with extra costs from 31 additional services required for certification. Effectiveness measure was total survival time in life-years. Outcome of interest was incremental costs per additional life-year. The annualized net colon cancer treatment costs by phase showed a U shape with high costs in the initial (mean €26 855; 95% CI €25 058-€28 652) and the terminal phases (mean €30 096; 95% CI €26 199-€33 993). The base-case CEA results and all sensitivity analyses consistently demonstrated longer survival and lower costs for the colon cancer cohort treated in CHs vs NCHs. To conclude, we used administrative data to derive the first cost-effectiveness evidence supporting that colon cancer care delivered in the certified cancer centers in Germany improves survival outcomes and saves costs from a healthcare system's perspective. Generalization of the study results should be exercised with caution.

8.
BMC Pregnancy Childbirth ; 21(1): 531, 2021 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-34315416

RESUMO

BACKGROUND: There is convincing evidence that birth in hospitals with high birth volumes increases the chance of healthy survival in high-risk infants. However, it is unclear whether this is true also for low risk infants. The aim of this systematic review was to analyze effects of hospital's birth volume on mortality, mode of delivery, readmissions, complications and subsequent developmental delays in all births or predefined low risk birth cohorts. The search strategy included EMBASE and Medline supplemented by citing and cited literature of included studies and expert panel highlighting additional literature, published between January/2000 and February/2020. We included studies which were published in English or German language reporting effects of birth volumes on mortality in term or all births in countries with neonatal mortality < 5/1000. We undertook a double-independent title-abstract- and full-text screening and extraction of study characteristics, critical appraisal and outcomes in a qualitative evidence synthesis. RESULTS: 13 retrospective studies with mostly acceptable quality were included. Heterogeneous volume-thresholds, risk adjustments, outcomes and populations hindered a meta-analysis. Qualitatively, four of six studies reported significantly higher perinatal mortality in lower birth volume hospitals. Volume-outcome effects on neonatal mortality (n = 7), stillbirths (n = 3), maternal mortality (n = 1), caesarean sections (n = 2), maternal (n = 1) and neonatal complications (n = 1) were inconclusive. CONCLUSION: Analyzed studies indicate higher rates of perinatal mortality for low risk birth in hospitals with low birth volumes. Due to heterogeneity of studies, data synthesis was complicated and a meta-analysis was not possible. Therefore international core outcome sets should be defined and implemented in perinatal registries. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42018095289.

9.
Support Care Cancer ; 2021 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-34247310

RESUMO

PURPOSE: Cancer patients have been shown to frequently suffer from financial burden before, during, and after treatment. However, the financial toxicity of patients with sarcoma has seldom been assessed. Therefore, the aim of this study was to evaluate whether financial toxicity is a problem for sarcoma patients in Germany and identify associated risk factors. METHODS: Patients for this analysis were obtained from a multicenter prospective cohort study conducted in Germany. Using the financial difficulties scale of the EORTC QLQ-C30, financial toxicity was considered to be present if the score exceeded a pre-defined threshold for clinical importance. Comparisons to an age- and sex-matched norm population were performed. A multivariate logistic regression using stepwise backward selection was used to identify factors associated with financial toxicity. RESULTS: We included 1103 sarcoma patients treated in 39 centers and clinics; 498 (44.7%) patients reported financial toxicity. Sarcoma patients had 2.5 times the odds of reporting financial difficulties compared to an age- and sex-matched norm population. Patient age < 40 and > 52.5 years, higher education status, higher income, and disease progression (compared to patients with complete remission) were associated with lower odds of reporting financial toxicity. Receiving a disability pension, being currently on sick leave, and having a disability pass were statistically significantly associated with higher odds of reporting financial toxicity. CONCLUSION: Financial toxicity is present in about half of German sarcoma patients, making it a relevant quality of life topic for patients and decision-makers.

10.
Dtsch Arztebl Int ; 118(18): 313-319, 2021 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-34140080

RESUMO

BACKGROUND: In Germany, the 12-month prevalence of methamphetamine use among persons aged 15 to 34 is 1.9%. An increasing number of newborns are being born after a prenatal methamphetamine exposure (PME). In 2014, in the German state of Saxony, approximately four out of 1000 newborns were affected. METHODS: This systematic review (Prospero registration number CRD42017060536) includes publications that were published between January 1990 and November 2019. The purpose was to determine the effects of PME on the peri- and neonatal condition of the affected children and on their further long-term development. Observational studies with a control group were included in the review and examined for their methodological quality. RESULTS: 31 publications, which dealt with two prospective and six retrospective cohort studies, were included in the review. The studies involved a total of 4446 mother-child pairs with PME, compared with 43 778 pairs without PME. A metaanalysis revealed that PME was associated with, among other findings, lower birth weight (SMD = -0.348; 95% confidence interval [-0.777; 0.081]), shorter body length (SMD= -0.198 [-0.348; -0.047]), and smaller head circumference (SMD= -0.479 [-1.047; 0.089]). Some differences between the groups with and without PME persist into the toddler years. Moreover, children with PME much more commonly display psychological and neurocognitive abnormalities, which are more severe in children growing up in problematic surroundings (discord, violence, poverty, low educational level of the parent or caregiver). A limitation of this review is that not all studies employed an objective or quantitative measure of methamphet - amine use. CONCLUSION: The documented effects of PME on child development necessitate early treatment of the affected expectant mothers, children, and families. Emphasis should be placed on structured and interdisciplinary preventive measures for methamphetamine use.


Assuntos
Metanfetamina , Efeitos Tardios da Exposição Pré-Natal , Desenvolvimento Infantil , Feminino , Alemanha/epidemiologia , Humanos , Recém-Nascido , Metanfetamina/efeitos adversos , Gravidez , Efeitos Tardios da Exposição Pré-Natal/induzido quimicamente , Efeitos Tardios da Exposição Pré-Natal/epidemiologia , Estudos Prospectivos , Estudos Retrospectivos
13.
Qual Life Res ; 30(10): 2829-2841, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33983617

RESUMO

PURPOSE: Multimorbidity leads to decreasing health-related quality of life (HRQoL). Telemedicine may help to improve HRQoL. The present study was conducted to show (I) differences in HRQoL and changes in HRQoL over time in elderly, multimorbid individuals with and without depression and/or mild cognitive impairment (MCI) using a telemonitoring application (TMA) and (II) associations between engagement with measurements by study participants using a TMA and changes in their HRQoL. METHODS: The present feasibility study was part of a longitudinal intervention study. Recruited general practitioners (GPs) enrolled individuals and assigned them to risk groups according to absence/presence of depression and/or MCI. Depression was assessed using the Geriatric Depression Scale (GDS-15), MCI using the Mini-Mental State Examination (MMSE), and HRQoL using the SF-12. The TMA consisted of tablets, software, and measuring devices. Measured vital data were transferred to a care and case manager for monitoring and possible intervention. RESULTS: Nine GPs recruited 177 individuals, 97 of whom were included in the HRQoL analysis. Significantly lower physical and mental component summary (PCS/MCS) scores were revealed in study participants with depression, and with both depression and MCI, compared to participants with no mental disorders. PCS scores did not differ between study dates, but MCS scores had significantly increased over time. Participants' engagement with measurements was significantly associated with an increased MCS score, but not with the PCS score. DISCUSSION: Depression and/or MCI are negatively associated with the HRQoL of elderly, multimorbid people using a TMA. Engagement of individuals with vital data measurements via a TMA may increase their mental HRQoL. Mentally impaired people should be closely involved as co-designers and experts in development processes of TMAs to benefit from tailored solutions. An individual's increased mental HRQoL can be a decisive factor in their engagement with a GP treatment regimen and telemonitoring processes.

14.
Arch Dermatol Res ; 2021 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-34019133

RESUMO

Postinflammatory hyperpigmentation (PIH) is a disorder of pigmentation that is a common presenting complaint, especially in individuals with skin of color. It is associated with a significant psychological burden and decrement of quality of life. Management options include photoprotection, topical lightening agents, and lasers and energy devices. Clinical trials of melasma report a diversity of outcomes, which often impedes synthesis of results across trials, or comparison of results associated with different treatment modalities. This protocol describes the design of a consensus process that would culminate in the development of a core set of outcomes to be assessed in all clinical trials for PIH. A long list of candidate outcomes will be developed through a systematic review, combined with semi-structured interviews with various stakeholders, including patients, scientists, regulators, and health care professionals. This long list of outcomes will be reviewed and refined by a steering committee. Then two rounds of Delphi surveys of patient and physician groups, respectively, will be used to cull the list, with provisional inclusion of those items deemed "important" by 70% of the respondents. A consensus meeting will be held virtually or in person to vote on these items, and also to consider any changes necessary before acceptance of a final core outcome set. Development of a core outcome set for PIH is expected to improve and standardize outcomes reporting in current and future clinical trials. This, in turn, may facilitate aggregation of research results and permit comparison of outcomes across multiple studies.

15.
Gesundheitswesen ; 83(5): e20-e37, 2021 May.
Artigo em Alemão | MEDLINE | ID: mdl-34015857

RESUMO

This prospectively registered review characterizes 50 intervention studies from the 1st wave of the Innovation Fund based on study protocols or original articles, among other sources. The mainly (randomized) controlled intervention studies included predominantly adults/seniors in ambulatory care without a regional focus and analyzed treatment processes, clinical and patient outcomes as outcomes. The substantial lack of study protocols and methodological details (e. g., sample size planning) reveals (avoidable) methodological problems regarding the scientific quality of the funded studies.


Assuntos
Assistência Ambulatorial , Administração Financeira , Adulto , Protocolos Clínicos , Alemanha , Humanos
16.
Gesundheitswesen ; 83(6): 470-480, 2021 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-34020493

RESUMO

The evaluation of intervention effects is an important domain of health services research. The ad hoc commission for the use of routine practice data of the German Network for Health Services Research (DNVF) therefore provides this second part of its manual focusing on the use of routine practice data for the evaluation of intervention effects. First, we discuss definition issues and the importance of contextual factors. Subsequently, general requirements for planning, data collection and analysis as well as concrete examples for the evaluation of intervention effects for the 3 fields of application regarding pharmacotherapy, nonpharmaceutical interventions as well as complex interventions are elaborated. We consider scenarios in which no information from randomized controlled trials (RCTs) comparing the two groups directly is yet available or in which RCTs are already available but an extension of the research question is required. In all examples either with or without randomization, the first and foremost question is always whether the data source is suitable for the specific research question. Most of the examples chosen are from oncology trials, because the necessary data are already available for Germany, at least in some form. Finally, the manual discusses possible challenges for future use of these data.


Assuntos
Pesquisa sobre Serviços de Saúde , Armazenamento e Recuperação da Informação , Coleta de Dados , Alemanha
17.
Z Evid Fortbild Qual Gesundhwes ; 163: 1-12, 2021 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-34023246

RESUMO

INTRODUCTION: The quality indicators of the Initiative Qualitätsmedizin e. V. (IQM) have been developed as triggers to examine treatment processes for opportunities for improvement. Published quality results have partly been used for external quality comparisons in the media. Therefore, member hospitals of IQM demanded to investigate if methods of risk adjustment should be applied in the calculation of the quality indicators. After a hearing of experts had been held, a task force was founded to conduct test calculations on risk adjustment methods. METHODS: Specific risk adjustment models for mortality in myocardial infarction, heart failure, stroke, pneumonia, and colectomy in colorectal cancer were developed in the database of national German DRG data of the year 2016. These models were used to calculate standardized mortality ratios (SMR) per indicator in a sample of 172 member hospitals of IQM based on the data of the year 2018. Median SMR per indicator were compared to median SMR based on a standardization by age and gender, which is the standard procedure in IQM. Correlations between the different SMR were calculated. Quality of care was judged by two different approaches: a) a descriptive discrepancy of |0.1| from the SMR value of 1, and b) a significant discrepancy from 1 using the 95% confidence limits. The effect of using the specific risk adjustment in relation to the standard procedure was investigated for both approaches (a and b). RESULTS: The specific risk adjustment methods showed an area under the curve between 0.72 and 0.84. The median differences between the SMR based on standardization by age and gender and the SMR based on specific risk adjustment were small (between 0 and 0.4); Spearman's correlations were between 0.90 and 0.99. Changes in the judgement of quality of care in comparison to the national average occurred in 3.9% (mortality from pneumonia) to 20.6% of the hospitals (mortality from heart failure) in descriptive comparisons. When the judgement was based on confidence limits changes were observed in 1.6% (mortality after colectomy) to 17.4% of the hospitals (mortality from heart failure). DISCUSSION: Implementing specific risk adjustment models had only minor effects on the distribution of risk-adjusted mortality compared to the standard procedure, but the judgement of quality of care could change for a fifth of the hospitals in individual indicators. Concerning methodological and practical reasons, the task force recommends further development of risk adjustment methods for selected indicators. This should be accompanied by studies on the validity of inpatient administrative data for quality management as well as by efforts to improve the usefulness of these data for such purposes.


Assuntos
Indicadores de Qualidade em Assistência à Saúde , Risco Ajustado , Alemanha , Mortalidade Hospitalar , Humanos , Pacientes Internados
18.
Oncol Res Treat ; 44(6): 301-312, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33887740

RESUMO

BACKGROUND: Data on institutional structures of sarcoma care in Germany are scarce. The utilization of an interdisciplinary tumor board (IDTB) is an essential part of modern cancer care. We investigated to which extent and when IDTB are used in sarcoma care. We hypothesized that IDTB before treatment initiation were used more often at certified cancer centers and at high-volume centers and that IDTB utilization increased over time. METHODS: From 2017 to 2020 we conducted a prospective cohort study, undertaking major efforts to include the whole spectrum of sarcoma treatment facilities. To analyze potential predictors of IDTB utilization, we calculated multivariable logistic regressions. RESULTS: Patients and survivors (n = 1,309) from 39 study centers (22 tertiary referral hospitals, 9 other hospitals, and 8 office-based practices) participated; 88.3% of the patients were discussed at some stage of their disease in an IDTB (56.1% before treatment, 78% after therapy, and 85.9% in metastatic disease). Hypotheses were confirmed regarding the utilization of IDTB in certified cancer centers (vs. all others: OR = 5.39; 95% CI 3.28-8.85) and the time of diagnosis (2018/2019 vs. until 2013: OR = 4.95; 95% CI 2.67-9.21). CONCLUSION: Our study adds to the evidence regarding the institutional structures of sarcoma care in Germany. Utilization of a tumor board before therapy seems to be in an implementation process that is making progress but is far from complete. Certification is a possible tool to accelerate this development.


Assuntos
Sarcoma , Neoplasias de Tecidos Moles , Certificação , Alemanha , Humanos , Estudos Prospectivos
20.
Orthopade ; 50(4): 278-286, 2021 Apr.
Artigo em Alemão | MEDLINE | ID: mdl-33666675

RESUMO

BACKGROUND: The decision for total hip arthroplasty (THA) is based on pain, loss of function, radiological changes and failed conservative therapy. These criteria are rarely based on systematic research and have not been integrated in generally accepted treatment guidelines. Aim of our study was, therefore, to analyse which decision criteria German orthopaedic and trauma surgeons use in order to recommend THA for patients with hip osteoarthritis. MATERIALS AND METHODS: From 10/2019 to 07/2020 we conducted a nation-wide survey among 218 orthopaedic and trauma surgeons about their criteria for and against THA surgery, as well as their treatment objectives. RESULTS: 147 fully completed questionnaires were analysed. Pain (99%), limitation of movement (99%), as well as impairment of walking distance (97%), and the subjective burden (97%) were the most frequent criteria. 97% and 96% of surgeons consider prescription of analgesics and physical therapy, as well as a lack of their effectiveness, as criteria for THA. 87% see radiological changes grade Kellgren & Lawrence III as threshold. A recommendation against surgery is triggered by obesity (BMI ≥ 40 kg/m2) in 48% and by the presence of an active infection in 96%. CONCLUSIONS: Current surgeons' practice criteria of recommendations for THA in Germany seem to reflect widely nationally and internationally discussed recommendations. Particular attention is given to patient factors like pain, loss of function and subjective burden, as well as previous conservative treatment and contraindications, like poorly controlled diabetes or an active infection, whereas morbid obesity is not seen as contraindication by all surgeons.


Assuntos
Artroplastia de Quadril , Ortopedia , Osteoartrite do Quadril , Cirurgiões , Alemanha/epidemiologia , Humanos , Osteoartrite do Quadril/cirurgia
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