[Reasons for the Non-Utilisation of an Oncological Rehabilitation. Results of a Written Survey with Patients of Oncological Healthcare Centers]. / Gründe für die Nichtinanspruchnahme einer onkologischen Rehabilitation. Ergebnisse einer schriftlichen Befragung von Patienten aus onkologischen Versorgungszentren.

BACKGROUND: Incidence and survival rates in patients with cancer are rising as well as the potential rehabilitation needs. In contrast, the numbers of rehabilitation treatments after cancer are decreasing. The reasons are not yet completely understood. METHODS: A written survey with patients of three cancer indications breast cancer, prostate cancer and colon cancer after acute medical treatment. 376 persons participated and were asked for rehabilitation utilisation, reasons against medical rehabilitation and subjective health status. Statistical analyses were mainly performed descriptively. RESULTS: Half of the participants used a medical rehabilitation. Those patients were more affected in subjective health and showed a higher level of disease severity. Participants who refused the utilisation of a medical rehabilitation mentioned primarily family, personal and private reasons. CONCLUSION: The written survey provided a variety of reasons why a medical rehabilitation is not used after cancer disease. From this data, suggestions for the optimization of rehabilitation and organizational arrangements can be derived.

Economic impact of epilepsy and the cost of nonadherence to antiepileptic drugs in older Medicare beneficiaries.

Epilepsy is most prevalent among older individuals, and its economic impact is substantial. The development of economic burden estimates that account for known confounders, and using percent incremental costs may provide meaningful comparison across time and different health systems. The first objective of the current study was to estimate the percent incremental healthcare costs and the odds ratio (OR) for inpatient utilization for older Medicare beneficiaries with epilepsy and without epilepsy. The second objective was to estimate the percent incremental healthcare costs and the OR for inpatient utilization associated with antiepileptic drug (AED) nonadherence among Medicare beneficiaries with epilepsy. The OR of inpatient utilization for cases compared with controls (i.e., non-cases) were 2.4 (95% CI 2.3 to 2.6, p-value<0.0001) for prevalent epilepsy and 3.6 (95% CI 3.2 to 4.0, p-value<0.0001) for incident epilepsy. With respect to total health care costs, prevalent cases incurred 61.8% (95% CI 56.6 to 67.1%, p-value<0.0001) higher costs than controls while incident cases incurred 71.2% (95% CI 63.2 to 79.5%, p-value <0.0001) higher costs than controls. The nonadherence rates were 33.6 and 32.9% for prevalent and incident cases, respectively. Compared to nonadherent cases, the OR of inpatient utilization for adherent prevalent cases was 0.66 (95% CI 0.55 to 0.81, p-value <0.0001). The cost saving for a prevalent case adherent to AEDs was 13.2% (95% CI 6.6 to 19.4%, p-value=0.0001) compared to a nonadherent case. An incident case adherent to AEDs spent 16.4% (95% CI 6.5 to 25.2%, p-value=0.002) less than a nonadherent incident case on health care. Epilepsy is associated with higher health care costs and utilization. Older Medicare beneficiaries with epilepsy incur higher total health care spending and have higher inpatient utilization than those without epilepsy. Total health care spending is less for older Medicare beneficiaries who have prevalent or incident epilepsy if they are adherent to AEDs.

Effects of the Mental Health Parity and Addiction Equity Act on Specialty Outpatient Behavioral Health Spending and Utilization.

BACKGROUND: For decades, insurance plans in the United States have applied more restrictive treatment limits and higher cost-sharing burdens for mental health and substance use treatments compared to physical health treatments. The Mental Health Parity and Addiction Equity Act (MHPAEA) required health plans that offer mental health and substance use benefits to offer them at parity with physical health benefits starting in January 2010. AIMS OF THE STUDY: To determine the effect of MHPAEA on out-of-pocket spending and utilization of outpatient specialty behavioral health services. METHODS: The proportion of individuals with at least one outpatient specialty behavioral health visit, the average number of visits among those with any behavioral health visit, and the proportion of behavioral health spending paid out-of-pocket were obtained from the nationally-representative Medical Expenditure Panel Survey (MEPS) for the years 2006 to 2013. Difference-in-differences models were estimated comparing individuals with employer-sponsored insurance to those with Medicaid, Medicare, or who were uninsured. RESULTS: Out-of-pocket share of spending was lowest among Medicaid (2.0%) and highest among the uninsured (22%), followed by the employer group (13%). Individuals in Medicaid had the highest proportion of any behavioral health visit (11%) and the uninsured had the lowest (2.4%). Among those with any behavioral health visits, the average number of visits was similar across groups. Our primary and sensitivity analyses suggest MHPAEA did not lead to changes in utilization or spending on specialty outpatient behavioral visits for individuals with employer-sponsored insurance compared to other groups. DISCUSSION: Potential reasons for MHPAEA's apparent lack of effect are that health plans were already at parity before the law's passage, that many health plans continue to be out of compliance with the law, that concurrent changes in plans' cost-sharing blunted the law's effects, and that other barriers to behavioral health service use continue to limit utilization. While our study cannot provide direct evidence of these mechanisms, we review existing evidence in support of each of them. Our study had several limitations. We cannot test definitively whether the difference-in-differences assumption was violated or fully control for time-varying differences between groups. We attempt to address this by using multiple control groups and presenting evidence of parallel trends before MHPAEA implementation. Second, because our data do not have state identifiers, we cannot control for which states had existing mental health parity laws. Third, a nationally representative analysis may mask substantial heterogeneity for affected subgroups. IMPLICATIONS FOR HEALTH POLICIES: We find no evidence MHPAEA substantially affected behavioral health utilization or out-of-pocket spending. Federal parity legislation alone is likely insufficient to address barriers to behavioral health affordability and access.

DECOMPOSING THE SOCIOECONOMIC INEQUALITY IN UTILIZATION OF MATERNAL HEALTH CARE SERVICES IN SELECTED COUNTRIES OF SOUTH ASIA AND SUB-SAHARAN AFRICA.

The gap in access to maternal health care services is a challenge of an unequal world. In 2015, each day about 830 women died due to complications of pregnancy and childbirth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented. This study quantified the contributions of the socioeconomic determinants of inequality to the utilization of maternal health care services in four countries in diverse geographical and cultural settings: Bangladesh, Ethiopia, Nepal and Zimbabwe. Data from the 2010-11 Demographic and Health Surveys of the four countries were used, and methods developed by Wagstaff and colleagues for decomposing socioeconomic inequalities in health were applied. The results showed that although the Concentration Index (CI) was negative for the selected indicators, meaning maternal health care was poorer among lower socioeconomic status groups, the level of CI varied across the different countries for the same outcome indicator: CI of -0.1147, -0.1146, -0.2859 and -0.0638 for <3 antenatal care visits; CI of -0.1338, -0.0925, -0.1960 and -0.2531 for non-institutional delivery; and CI of -0.1153, -0.0370, -0.1817 and -0.0577 for no postnatal care within 2 days of delivery for Bangladesh, Ethiopia, Nepal and Zimbabwe, respectively. The marginal effects suggested that the strength of the association between the outcome and explanatory factors varied across the different countries. Decomposition estimates revealed that the key contributing factors for socioeconomic inequalities in maternal health care varied across the selected countries. The findings are significant for a global understanding of the various determinants of maternal health care use in high-maternal-mortality settings in different geographical and socio-cultural contexts.

[Psycho-oncology care in rural areas : Results from a cross-sectional survey on the utilisation of community-based psychosocial support services]. / Psychoonkologische Versorgung im ländlichen Raum : Ergebnisse einer Querschnittsbefragung zur Inanspruchnahme ambulanter Unterstützungsangebote.

BACKGROUND: Clinically relevant distress and unmet psychosocial needs frequently occur in the course of cancer diseases. Particularly for thinly populated rural areas in Germany rates of distressed patients and uptake of community-based psycho-oncology services are unknown. OBJECTIVES: Determination of a) the proportion of cancer patients with psychosocial distress and unmet needs and b) the utilisation of community-based psycho-oncology services in thinly populated rural areas. MATERIALS AND METHODS: Prospective cross-sectional study of 229 cancer patients (colon, breast, prostate cancer) living in thinly populated rural areas. Indicators for clinically relevant distress and utilisation of psychosocial services were assessed by applying screening instruments. We conducted descriptive and multivariate analyses. RESULTS: More than one third of all cancer patients (39.3%) in thinly populated areas exhibited clinically relevant distress. However, only 15.6% of distressed patients consulted community-based psycho-oncology services. Most frequently, medical or psychological psychotherapists were contacted. Information deficits of patients and attending physicians alongside dispositional factors emerged as the main reasons for non-utilisation. DISCUSSION: This study presents first data on psycho-oncology care in rural areas in Germany stratifying the degree of urbanisation in line with the standards of the European Commission. Concerning limitations, we only accounted for structural service coverage, leaving aside other indicators for socio-spatial deprivation.

Usual Care for Maltreatment-Related Pediatric Posttraumatic Stress Disorder in Germany.

Child maltreatment represents a major risk factor for the development of emotional and behavioral problems, especially posttraumatic stress disorder (PTSD). While effective trauma-focused treatments are available, little is known about the usual mental healthcare for abused youths in Germany. The present study compared the utilization of mental healthcare in abused youths who had developed a PTSD (N = 95) with a group presenting other mental disorders (N = 146). Semistructured interviews were used to assess maltreatment histories, current mental health, and healthcare utilization. In addition, potential child factors associated with access to mental healthcare (age and level of functioning) were examined. Results showed that 65 % of both diagnostic groups currently fail to use any mental healthcare service. Of the participants with PTSD, 43 (45 %) had never received any mental healthcare intervention. Investigations on potential barriers are necessary to close the huge gap between clinical services and evidence-based, trauma-focused interventions.

Associations between Functional Milestones and Psychiatric Admissions in an Urban Area: Utility of a Cluster-Analytical Approach.

BACKGROUND: The purpose of the study was to identify homogenous subgroups, based upon achievement of two functional milestones (marriage and employment) and Global Assessment of Functioning (GAF) score in a sample of 848 acute patients admitted to the Psychiatric Emergency Service (PES) of the Città della Salute e della Scienza di Torino, during a 24-months period. SUBJECTS AND METHODS: A two-step cluster-analysis, using GAF total score and the achievements in the two milestones as input data was performed. In order to examine whether the identified subgroups differed in external variables that were not included in the clustering process, and consequently to validate the found functional profiles, chi-square tests for categorical variables and analyses of variance (ANOVA) for continuous variables were performed. RESULTS: Five clusters were found. Employed patients (Clusters 4 and 5) had more years of education, less illness chronicity (shorter duration of illness and lower proportion of previous voluntary hospitalizations), lower use of mental health resources in the last year yet higher treatment adherence, larger network size, and higher ordinary discharge. Married inpatients (Clusters 3 and 5) had lower frequencies of substance abuse. CONCLUSIONS: The remarkably high rate of unemployment in this inpatients' sample, and the evidence of associations between unemployment and poorer functioning, argue for further research and development of evidence-based supported employment programs, that put forth diligent effort in helping people obtain work quickly and sustain; they may also help to reduce health care service use among that clientele.

[One Size Fits All? Using Psychosocial Risk Assessments to Predict Service Use in Early Intervention and Prevention]. / One size fits all? Die Eignung von Risikoscreenings zur Prognose der Inanspruchnahme von Angeboten der Frühen Hilfen.

One Size Fits All? Using Psychosocial Risk Assessments to Predict Service Use in Early Intervention and Prevention Early intervention and prevention services offer a variety of programs. At the same time, program participants differ widely in their service use. This study aims at investigating the prognostic validity of psychosocial risk assessments in predicting the participants' service use. The psychosocial risk assessment "Heidelberg Stress Scale" is used to predict aspects of service use (dosage, attrition, intervention content, working relationship). Service use data of N = 1.514 participants of a home-visiting program will be analyzed via Machine-Learning-Algorithms. Dosage and intervention content can be predicted with psychosocial risk assessments. The classification strength is small. Global and continuous risk scales have a prognostic advantage over single categorical risk items. Financial burden has a significant influence on every aspect of service use. Psychosocial risk assessments provide additional information that can support intervention planning. Yet, these instruments should be supplemented by additional diagnostic information.

RSV in adult ED patients: Do emergency providers consider RSV as an admission diagnosis?

BACKGROUND: Respiratory Syncytial Virus (RSV) has been recognized for over half a century as a cause of morbidity in infants and children. Over the past 20years, data has emerged linking RSV as a cause of illness in adults resulting in 177,000 annual hospitalizations and up to 14,000 deaths among older adults. OBJECTIVE: Characterize clinical variables in a cohort of adult RSV patients. We hypothesize that emergency physicians do not routinely consider RSV in the differential diagnosis (DDx) of influenza like illness. METHODS: Observational study of all adult inpatients, age≥19, with a positive RSV swab ordered within 48h of their hospital visit, including their emergency department (ED) visit, and who initially presented to a university affiliated urban 100,000 annual visit emergency department from 2007 to 2014. A data collection form was created, and a single trained clinical research assistant abstracted demographic, clinical variables. ED providers were given credit for RSV DDx if an RSV swab was ordered as part of the diagnostic ED workup. RESULTS: 295 consecutive inpatients (mean age=66.5years, range, 19-97, 53% male) were RSV positive during the 7-year study period. 207 cases (70%) were age≥60. 76 (26%) had fever, 86 (29%) had O2sat <92% and 145 (49%) had wheezing. 279 patients required admission, 30 needed ICU stay and overall mortality was 12 patients (4%). Age≥60 was associated with overall mortality (p=0.09). There were 106 (36%) immunocompromised patients (23% transplant, 40% cancer, 33% steroid use) in the cohort. A diagnosis of RSV was considered in the ED in 105 (36%) of patients. Being immunocompromised, having COPD/asthma, O2sat <92, or wheezing did not alert the ED provider to order an RSV test. CONCLUSION: Adults can harbor RSV as this can lead to significant mobility and mortality, especially in individuals who are over the age of 60. RSV is not being considered in the DDx diagnosis, and this was especially surprising in the transplant/immunocompromised subgroups. Given antiviral treatment options, educational efforts should be undertaken to raise awareness of RSV in adults.

Quarterly Reporting of Computed Tomography Ordering History Reduces the Use of Imaging in an Emergency Department.

BACKGROUND: Computed tomography (CT) is a useful and necessary part of many emergency department (ED) assessments. However, the costs of imaging and the health risks associated with radiation exposure have sparked national efforts to reduce CT ordering in EDs. STUDY OBJECTIVE: We analyzed CT ordering habits prior to and following implementation of a feedback tool at a community hospital. METHODS: In this intervention study, we identified the CT-ordering habits of physicians and mid-level care providers (physician assistants and nurse practitioners) at baseline and after implementation of a system that sent quarterly feedback reports comparing their ordering habits with those of their peers. Variability in ordering and subgroup analyses by body region were included in these reports. RESULTS: We examined the records of 104,454 patients seen between October 1, 2013 and December 31, 2014. There were 5552 or 21.0% of patients seen during the baseline period that underwent CT imaging. We observed an absolute reduction in imaging of 2.3% (95% confidence interval 1.7-2.8%) after implementation, avoiding approximately $400,000 in costs, 22 days of scanning time, and radiation exposure equivalent to 33,000 chest films annually. These changes occurred across physicians and mid-level providers, regardless of the number years of practice or board certification. CONCLUSIONS: Implementation of a feedback mechanism reduced CT use by emergency medicine practitioners, with concomitant reductions in cost and radiation exposure. The change was similar across levels of medical care. Future studies will examine the effect of the feedback reporting system at other institutions in our hospital network.

[Urgency of GP Emergency Visits to Nursing Homes]. / Dringlichkeit von hausärztlichen Notfallbesuchen in Altenheimen.

Until now there are no uniform criteria or standards for classification of emergency home visits. Due to demographic changes, especially urgent visits to patients in nursing homes will increase. In the URGENT study, physicians and nurses rated the urgency of emergency visits to nursing home patients before and after the visit. This should help to see how many emergency house calls had been classified as less urgent and how often the assessment of physicians and nurses were in agreement with each other. In a prospective observational study, home visits were analyzed, which were classified as urgent at request by the physicians. After performing home visits, the physicians and the responsible nurse classified again the urgency of the home visit from 0 (not urgent) to 10 (highly urgent). In addition, the times of the home visit requests and the time for carrying out the visits, as well the reasons for the home visits were documented. A total of 75 urgent home visits were documented. The patients were on average 82 years old (65% female). The home visits were done on average 2.5 h after request. In retrospect, the physicians evaluated emergency home visits on average less urgent (5.7±2.7) than the nurses (7.2±2.2). In 20% of emergency home visits (15 cases), physicians and nurses agreed as to their being less urgent (0-5). Our data show that in the absence of a standardized urgent assessment scheme, a significant proportion of home visits is misclassified. In further studies it has to be investigated if a uniform score for urgent assessment could reduce the proportion of incorrect medical response operations so that the efficiency of emergency care for nursing home patients can be improved.

[Exploring Patient Motives to Use Emergency Departments for Non-urgent Conditions: A Qualitative Study]. / Inanspruchnahme zentraler Notaufnahmen: Qualitative Erhebung der Motivation von Patientinnen und Patienten mit nichtdringlichem Behandlungsbedarf.

Background: The increasing utilization of Emergency Departments (ED) by outpatients with acute but non-urgent conditions contributes to ED crowding. This study aims to explore the motives of patients categorized as non-urgent for visiting the ED. Methods: A qualitative study based on semi-structured interviews was conducted at 2 ED's at Charité Berlin. A total of 40 patients categorized as non-urgent were interviewed. Data were analyzed using Qualitative Content Analysis. Results: In addition to unavailable appointments or having to wait a long time for an appointment with general practitioners and specialists, patients stated better time-flexibility, the University Hospital's quality of care and the availability of multidisciplinary care as reasons to seek medical care in the ED. Because of the 24/7 availability of EDs, some patients seem to make little effort to seek an appointment with a GP or a specialist outside the hospital. Conclusion: Our interview data indicate an independent function of EDs in outpatient care. It must be assumed that even a full coverage of service guarantee by the association of statuary health insurance physicians would not reduce ED utilization to cases of medical urgency only. To ensure sustainable medical quality for urgent as well as non-urgent medical care seekers, EDs need appropriate resources to cover the demand.

[Calculating Ratios Based on Statutory Health Care Data at the District Level - An Empirical Estimation Based on the Microcensus]. / Ratenbildung bei KV-Daten mit GKV-Versicherten auf Kreisebene ­ ein empirisches Schätzmodell auf der Basis des Mikrozensus.

Background: In Germany, data of the statutory health insurance system are used, amongst others, in health monitoring and health care research at the district level. For the calculation of exact ratios, the number of those covered by statutory health insurance is needed as denominator. For some federal states, however, this number is not available on a district level. Therefore, ratios based on statutory health care data are calculated using a surrogate defined in terms of visits to the doctor. This leads to uncertainties that limit small area comparisons. Therefore, the aim of the present study was to develop a superior estimation model for the number of those covered by statutory health insurance on a district level. Methods: The proportion of those covered by statutory health insurance in the Bavarian districts is estimated by a multiple linear regression model. The model relates data on determinants of the insurance status (income, proportions of civil servants and of self-employed persons) available on district level to data on the number of those covered by statutory health insurance obtained from microcensus on a regional level. The proportion of those covered by statutory health insurance estimated by this model is compared to the surrogate. As an example for practical application, small area estimations for diabetes prevalence are compared to data provided by the Bavarian Association of Statutory Health Insurance Physicians. Results: The proportion of those covered by the statutory health insurance in the Bavarian districts as estimated by the regression model varies between 74.7 and 91.6%. The difference to the currently used surrogate reaches up to 18.6 percentage points. This is also reflected in treatment prevalence, shown here using the example of diabetes mellitus. Conclusion: The present analysis shows the uncertainties of ratios and consequences for small area comparisons based on statutory healthcare data. Providing valid data for the denominator in accordance with the data transparency regulation in the Social Insurance Code (SGB) V should be attempted.

[Utilization of Rehabilitation after Disk Surgery - A Cross-Sectoral Analysis of Claims Data from Statutory Health Insurance and German Federal Pension Fund]. / Inanspruchnahme der Anschlussrehabilitation nach einer Bandscheibenoperation.

The aim of this study was to identify relevant factors that influence utilization and interim period between hospitalization and postoperative rehabilitation after disk surgery. Logistic regression was performed for utilization of an early postoperative rehabilitation and for an interim period, when patients were going to a rehabilitation facility (directly after hospitalization or after a period at home) on claims data from statutory pension insurance and statutory health insurance. Increased utilization of postoperative rehabilitation was found in older and German patients. Moreover, adiposity and additional physiotherapy in hospital increased the utilization of postoperative rehabilitation, while blood transfusion during hospitalization was an inhibiting factor.Female gender, older age and additional physiotherapy in hospital decreased the probability for an interim period between hospitalization and postoperative rehabilitation. However, the probability for an interim period increased from 2005 to 2010. Utilization and interim period between hospitalization and postoperative rehabilitation meet patient's needs and seem adequate. Nevertheless, there are indications for under-utilization of certain patient groups (foreign citizens, unemployed persons, male patients).

[Determinants of psychotropic medication in adults with mild or moderate intellectual disabilities]. / Bedingungsfaktoren psychopharmakologischer Behandlung bei leichter oder mittelgradiger Intelligenzminderung.

BACKGROUND: During the past years the provision of mental healthcare for adults with intellectual disabilities (ID) has repeatedly been criticized; however, the number of relevant studies is still relatively few. OBJECTIVE: The aim of the present study was to identify determinants for utilization of mental healthcare services and prescription of psychotropic medication in adults with mild to moderate ID. MATERIAL AND METHODS: Analyses were based on data from 417 adults with mild to moderate ID, which had been collected within the cross-sectional MEMENTA study in three different regions of Germany. Logistic regression analyses were conducted to identify clinical and sociodemographic variables as predictors of utilization of mental healthcare services (n = 282) and psychotropic medication (n = 351). RESULTS: Utilization of healthcare services and psychotropic medication were both associated with mental disorders and problem behavior. In addition, the likelihood of being treated with psychotropic medication and antipsychotic drugs was higher in adults living in residential homes. CONCLUSION: The findings indicate a lack of adherence to existing guidelines in the treatment of adults with ID living in residential homes.

[Prospective Study of the Health Care Utilization of a Clinic by Outpatients in a Rural Region]. / Prospektive Untersuchung zur ambulanten Inanspruchnahme einer Klinik im ländlichen Bereich.

Background: Medical care of emergency cases is based primarily on the so called KV-emergency service in Germany. However, it seems that hospitals are more and more frequented in such cases, which was the focus of our study. Material and Methods: The prospective study started in April 2013 and ended in March 2014. All outpatients were analyzed according several items such as personal data, the reason, time and urgency for presentation. An emergency case was defined by the patient's need of acute ENT-care. Results: All in all 11 002 patients were enrolled in this study. There were 6 463 elective cases in the regular office hours, 2 438 emergencies were treated at our department. Evaluation of the acuteness of the emergencies according to the Manchester-Triage-System demonstrated that most of the patients did not require immediate treatment. This fact is also reflected by the small number of only 10% of admissions and 18% of surgical interventions. During office hours 38% patients presented themselves as emergency and 62% cases came after official service to our department. Discussion: Especially the emergency treatment was frequently used, however the medical reasons did not justify the presentation in the majority of cases.

[Impact of the Overlap Region Between Acoustic and Electric Stimulation]. / Einfluss des Überlappungsbereichs zwischen akustischer und elektrischer Stimulation.

Patients with residual hearing in the low frequencies and ski-slope hearing loss with partial deafness at medium and high frequencies receive a cochlear implant treatment with electric-acoustic stimulation (EAS, "hybrid" stimulation). In the border region between electric and acoustic stimulation a superposition of the 2 types of stimulation is expected. The area of overlap is determined by the insertion depth of the stimulating electrode and the lower starting point of signal transmission provided by the CI speech processor. The study examined the influence of the variation of the electric-acoustic overlap area on speech perception in noise, whereby the width of the "transmission gap" between the 2 different stimulus modalities was varied by 2 different methods. The results derived from 9 experienced users of the MED-EL Duet 2 speech processor show that the electric-acoustic overlapping area and with it the crossover frequency between the acoustic part and the CI should be adjusted individually. Overall, speech reception thresholds (SRT) showed a wide variation of results in between subjects. Further studies shall investigate whether generalized procedures about the setting of the overlap between electric and acoustic stimulation are reasonable, whereby an increased number of subjects and a longer period of acclimatization prior to the conduction of hearing tests deemed necessary.

[Data on palliative care in Germany : Which data sources are available and what do they tell?] / Daten zur Palliativversorgung in Deutschland : Welche Datenquellen gibt es, und was sagen sie aus?

Palliative care is more and more in the focus of politics and the public. Although provision and utilization of palliative care have increased considerably in recent years, there is still a great need for palliative services and a comprehensive supply has not yet been achieved. Reliable and continually available data are indispensable to describe developments in Germany, to identify existing gaps in palliative care provision, and to assess the impact of relevant policies. In this article, we present a systematic outline of publicly available data sources on palliative care in Germany and point out their potentials and limitations. We show that mainly data on palliative care provision are available. Data on utilization are basically limited to inpatient and specialized outpatient palliative care ("spezialisierte ambulante Palliativversorgung", SAPV). Periodical analyses of routine data, e. g. from statutory health insurances or from the Association of Statutory Health Insurance Physicians, would be helpful to fill these data gaps. Monitoring the sociodemographic characteristics of users of palliative care could also be of major interest. Another important indicator is the place of death. The difference between the places where people die and where they wish to die indicates that there is a continuous need to strengthen outpatient structures of palliative care.

[TraumaNetwork, Trauma Registry of the DGU®, Whitebook, S3 Guideline on Treatment of Polytrauma/Severe Injuries - An Approach for Validation by a Retrospective Analysis of 2304 Patients (2002-2011) of a Level 1 Trauma Centre]. / Traumanetzwerk, TraumaRegister der DGU®, Weißbuch, S3-Leitlinie Polytrauma ­ ein Versuch der Validierung durch eine retrospektive Analyse von 2304 Patienten (2002­2011) an einem überregionalen (Level 1) Traumazentrum.

Background: In the last decades, a reduction in mortality in severely injured patients with an ISS ≥ 16 could be observed. Some authors report a death rate of about 22 %. Moreover, there were some new insights in the last years such as the reduction in mortality by use of whole-body CT and the introduction of the S3 guideline of the German Society of Trauma Surgery "Treatment of Patients with Severe and Multiple Injuries" have supported the evidence-based treatment of severely injured patients. Methods: A retrospective analysis of 2304 patients was performed between 2002 and 2011. The data of the authors' clinic for the trauma registry of the DGU® were used. After applying the inclusion criteria, ISS ≥ 16 and primary transfer from the accident site, 968 patients remained. Results: In the study population, a mean ISS of 29.81 and a mean GCS of 9.42 were found. The average age was 46.04 years. The mortality rate was 28.7 %. A significant difference between decedents and survivors was found at the ISS, GCS, RTS, new ISS, TRISS, RISC, AIS head, AIS skin, RR pre-clinical, pre-clinical heart rate and age. To test whether the lethality was reduced by the increased use of whole-body CT, a division into a group prior to and from 2009 was performed. Results revealed a significant increase in the whole-body CT rate from 56.96 to 71.7 %. The mortality rate declined from 32.3 to 24.5 %. In the same way it was verified whether the S3 guideline had an impact on mortality. Therefore, a division into groups before and from 2011 was conducted. Here, the mortality rate decreased from 30.4 to 18.4 %. In addition, a comparison between 2010 and 2011 was performed. Overall, there were statistically significant differences in the trauma room time, the surgical time, the volume infused, the rate of multiple organ failure and the rate of whole-body CTs performed. Conclusion: In the period from 2002 to 2011 a mortality rate of 28.7 % was found. The higher rate in comparison to published data is most likely explained by the high rate of serious and severe head injuries. The increased use of whole-body CT and the introduction of the S3 guideline led to a significant decrease in mortality in the authors' patient population. This is due particularly to the accelerating of the treatment of severely injured patients, the reduction of the infused volume, shortened surgical phase within the first 24 hours and the increased use of whole-body CT.

[The proportion of unaccompanied refugee minors suffering from psychiatric disorders in Germany]. / Häufigkeit psychischer Störungen bei unbegleiteten minderjährigen Flüchtlingen in Deutschland.

Objective: This article is the first investigation into the proportion of unaccompanied refugee minors suffering from psychiatric disorders in Germany. Method: In a retrospective study done between 2013 and 2015, any refugees showing symptoms of a psychiatric disorder during their stay in a residential refugee center were referred to an Outpatient Department of Child and Adolescent Psychiatry for diagnostic assessment. To this end, special consultation hours were arranged. Besides the diagnoses, the number of emergency consultations occurring before and after the implementation of the special consultation hours was recorded. Results: Of the 75 refugee minors (75 %) referred, 56 were suffering from a psychiatric disorder, with posttraumatic stress disorder and depression being the most common diagnoses. Following implementation of the consultation hours, the number of refugee patients initially admitted in the Child and Adolescent Psychiatry on an emergency basis fell. Conclusions: Unaccompanied refugee minors are a highly vulnerable group that poses great challenges to clinical care. The implementation of special consultation hours is a constructive option for meeting these challenges. In particular, this special offer enables improvement of crisis management in the case of emergency consultations.