Entgeltvereinbarungen zwischen deutschen Krankenhäusern und Krankenkassen

Zeitschrift für Herz-,Thorax- und Gefäßchirurgie -     

Epidemiologie und Behandlung der PAVK und der akuten Extremitätenischämie in deutschen Krankenhäusern von 2005 bis 2012

Background

Due to the demographic changes an increase in peripheral arterial occlusive disease (PAOD) and acute ischemia of the extremities can be assumed. Simultaneously, the options for revascularization have been extended with the chance of a decreasing rate of amputation. It is unclear whether these developments can also be realized at a national level in Germany.

Material and methods

An analysis of the thoroughly categorized diagnosis data of hospital patients and the diagnosis-related groups (DRG) statistics of the Statistisches Bundesamt (StBA, Federal Statistical Office) from the years 2005 to 2012) was carried out. The numbers of cases, the incidence and mortality of chronic ischemia of the extremities and the main diagnoses (HD) 170 (atherosclerosis), E10.5–E14.5 (diabetes mellitus with peripheral vascular complications) and acute ischemia of the extremities (HD I74, arterial embolism and thrombosis) were analysed. All open and endovascular treatment modalities and major and minor amputations were assessed based on the DRG statistics of the StBA.

Results

The inhospital incidence of chronic and acute ischemia of the extremities increased from 199 to 241 and from 22 to 27 HDs per 100,000 inhabitants, respectively. The incidence of all cases of ischemia of the extremities showed a clear increase after the age of 70 years. The mortality associated with HD 170 has decreased since 2005 from 3.6?% to 2.7?%. The mortality over the age of 80 years is 5–10?%. The corresponding mortality associated with HD 174 was 9.7 % with an increase to 10-20 % in both sexes above 80 years old. The total number of all cases of peripheral balloon angioplasty increased from 73,000 in 2005 to approximately 130,000 in 2012. The number of peripheral bypass operations decreased from approximately 43,000 to 39,500 (?8.4 %). The number of cases of embolectomy and thrombectomy increased from approximately 38,000 to 60,000 and endovascular therapy of acute ischemia of the extremities increased from approximately 12,000 to 21,000. The number of major amputations could be reduced by 32 % since 2005.

Conclusion

The incidence of acute and chronic ischemia of the extremities is increasing. The mortality risk increases with age and is particularly high for acute ischemia of the extremities. Despite the increase in hospitalized cases with the threat of amputation due to ischemia, the number of major amputations has clearly decreased.     

Nachhaltigkeit in der Anästhesiologie

Die Anaesthesiologie -     

Voraussetzungen zur Anwendung von automatischen externen Defibrillatoren in deutschen Krankenhäusern

With an incidence of 130,000 per year, sudden cardiac death is one of the most frequent causes of death in Germany. Each day 350 patients die from cardiac arrest. Survival depends essentially on the time delay before professional help arrives and sufficient resuscitation measures have been started. At present, survival of sudden cardiac death is reported to be in the range of 5-8%. In preclinical conditions, many studies have already shown a successful use of automated external defibrillators (AED) by first responders even if they are lay persons. Even in large hospitals with maximum care facilities, delays before beginning resuscitation measures can occur which results in a dramatic reduction of the survival rate. Therefore, it seems reasonable to use AED in large hospitals. For implementation, training programmes and a nationally standardized documentation of resuscitation events should be promoted.     

Videoassistierte Patientenaufklärung in der Anästhesiologie

In video-assisted patient education (ViPa), patients watch an educational video about the process and the risks of anaesthesia in addition to the preanaesthetic interview with the anaesthesiologist. Used as a supplement to the preanaesthetic visit, the videos can increase patients' knowledge and satisfaction without having any negative effect on perioperative anxiety. Because the video graphically depicts the basic information, the preanaesthetic visit can then focus on specific aspects of the individual patient, i.e. high anxiety or specific questions. The redundant and monotonous explanations about the procedures and risks of anaesthesia by the interviewing anaesthesiologist are partly replaced by the video, but for medico-legal reasons the ViPa cannot totally replace the preanesthetic interview. It can be used in pediatric anaesthesia and reduces parental anxiety. Because of the lack of studies, the effects of the ViPa on perioperative patient compliance, especially for outpatient surgery, and on the economics of anaesthesia clinics are unclear.     

Dezentrale Arbeitsplätze in der Anästhesiologie

Die Anaesthesiologie - Anästhesieleistungen außerhalb zentraler OP-Bereiche („nonoperating room anesthesia“, NORA) haben stark an Bedeutung gewonnen. Nonoperating room...     

Zertifizierung von Krankenhäusern

Die Urologie - Die Ergebnisse der antegraden perkutanen endoluminalen Therapie bei Strikturen der ureterointestinalen Anastomose nach Harnableitung wurden evaluiert. Seit 1994 wurde die...     

Anästhesiologie als Pflichtfach in der neuen Approbationsordnung

BACKGROUND: Since October 2003 new regulations for qualifications to practice medicine in Germany now require compulsory courses in anaesthesiology. Therefore, existing curricular activities had to be changed from facultative courses for a small number of interested students to compulsory activities for all students. METHODS: Previous data of the department of anaesthesiology at the University Hospital Aachen (Germany) were collected and taken into consideration for the development of a new curriculum: The result was a course consisting of a tutorial with integrated "basic skill training", practical training in the operating theatre and a simulation-based session, in addition to two series of lectures. An evaluation by the students was carried out using EvaLuna as a tool for web-based on-line evaluation and faculty members had to fill out a standardized questionnaire. RESULTS: The different parts of the curriculum received the highest scores of all courses in the undergraduate medical school curriculum. Best results were achieved by the anaesthesia-simulation session followed by the tutorial and the practical training. CONCLUSION: The feedback of faculty members as well as the results of students' evaluation approved the developed concept of integrating anaesthesia-relevant issues into the formal medical school curriculum. Nevertheless, the on-line evaluation system EvaLuna provided additional suggestions for future improvements in the newly created curriculum.     

Die innerklinische Notfallversorgung in norddeutschen Krankenhäusern

Background

Emergency care of hospitalized patients is, in addition to the ward personnel, provided by certain teams which are called upon as a cardiac alarm team, resuscitation team or emergency care team. There is, however, little knowledge concerning numbers and causes of such in-hospital emergencies as well as management strategies and results.

Methods

The status quo of emergency care for hospitalized patients was assessed with a structured questionnaire which was sent to 58 hospitals in the Federal States of Mecklenburg-Western Pommerania (MWP; n=28) and Schleswig-Holstein (SH; n=30). The questionnaire was anonymous and consisted of 34 simple questions.

Results

Emergency teams are established in the majority of hospitals in both Federal States and response times are 2–3 min. Clearly defined criteria for emergency conditions and actions which would facilitate early identification of critical situations by the medical personnel are not standard in either Federal Sate. Emergency equipment is available on the wards in most instances and additionally provided by the emergency team. The requirement to have a defibrillator or AED available at the bedside within 3 min is not fulfilled. AEDs are used in only one hospital (MWP) included in this survey. The nursing staff receives basic cardiac life support (BCLS) training regularly in both Federal states. All physicians receive advanced cardiac life support (ACLS) training in 15 out of 20 hospitals in MWP and in 9 out of 20 hospitals in SH. Documentation of emergency management is in the patient chart only in 19 out of 20 hospitals in MWP and in 16 out of 25 hospitals in SH. Additional documents, such as the DIVI protocol (Deutsche Interdisziplinäre Vereinigung für Intensivmedizin/German Interdisciplinary Association of Critical Care Medicine) are rarely used. The reanimation register of the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin/German Society for Anaesthesiology and Intensive Care Medicine) is well known but hardly used.

Conclusions

In-hospital emergency care is largely well organized in MWP and SH. Emergency training of medical personnel, in particular physicians needs improvement and should be made mandatory, as in Anglo-American nations. A uniform, structured means of documentation of emergency management and statistical evaluation should be introduced; this would most likely contribute to identification of shortcomings of current in-hospital emergency management.     

Stress und Berufszufriedenheit im Fachgebiet der stationären Anästhesiologie

Background

How do physicians in the specialty of anesthesiology perceive the working conditions regarding stress and job satisfaction? The health system in Germany has been confronted with a rapidly changing framework over the last 20 years: For example, an increased influence of economic patterns on the workflow and the medical decision of physicians has been established forcing them to always take the economic aspects into account. Moreover, a new generation (generation Y) of physicians with other requirements of the work place, meaning mainly a demand for a better work-life balance, has gained a foothold in hospitals. These changes make it very important to investigate the status quo of current working conditions.

Aim

Working conditions in hospitals in the specialty of anesthesiology is the main issue investigated in this study.

Methods

For this study 1,321 completed online-questionnaires from physicians in hospitals with the specialty of anesthesiology were analyzed. The questionnaire was based on the stress theory, the effort-reward-imbalance model (ERI) and the job-demand-control model (JDC).The items used in the questionnaire were taken from the ERI questionnaire and the short questionnaire on work analysis (KFZA). By calculating a certain ratio of several items (according to the stress theory), the prevalence of distress could be measured. In addition the overall job satisfaction in the field of anesthesiology was measured and analyzed.

Results

In this study 47.0?% (95?%-CI: 44.3–49.7?%) of all respondents showed signs of distress. Simultaneously, 61.8?% (95?%-CI: 59.2–64.5 %) were very satisfied with the job situation. Regarding gender, female physicians perceived a lower control of the work situation whereas male physicians perceived a much higher decision level. This led to a higher prevalence of distress in the group of female physicians regarding the JDC model (odds ratio, OR: 1.54, 95?%-CI: 1.19–2.01). Regarding age, the prevalence of distress increased from 36.5?% in the respondents under 35 years old to 50.7?% in those 35–59 years old (OR: 1.79, 95?%-CI: 1.38–2.32). Looking at the different functional positions in the hospital, senior doctors showed a much higher prevalence of distress (52.8?%) than junior doctors (OR: 1.57, 95?%-CI: 1.21–2.05). Analyzing job satisfaction with respect to the functional position, the highest significant proportion was shown by senior doctors (65.8?%).

Consequences

This study revealed a high prevalence of unfavorable working conditions for anesthetists in hospitals. Taking the forthcoming shortage of qualified physicians in German hospitals into account, these results have to be considered as a cause for concern. Constant unfavorable working conditions have a negative effect on the mental and physical health of employees. Sooner or later a migration of qualified physicians abroad could be the consequence. To prevent a future shortage of qualified physicians and to make the hospital work place more appealing, working conditions have to be adapted to current needs and expectations of employees. The focus should be put on balanced working conditions according to stress models shown in this study.     

Rolle der Bewegungsanalyse in Orthopädie und Unfallchirurgie

Background

Instrumented 3D gait analysis was developed and standardised for treatment planning and therapy control of neuromuscular gait disorders in the early 1990s. Meanwhile, this functional examination is an established standard for the planning and outcome measure of soft tissue and bony procedures in the context of multilevel surgery. In contrast to other European countries and despite its diagnostic value, 3D gait analysis in Germany is still not reimbursed by the public health care system on a regular basis.

Use of gait analysis

In the last 20 years, multiple limitations associated with instrumented gait analysis have been resolved by methodological innovations and particularly by improved mathematical models. This has considerably broadened the use of gait analysis in orthopaedics and trauma surgery. Function and movement of the foot and its segments can nowadays be precisely analysed by detailed foot models. These foot models also enable a more detailed assessment of footwear and orthopaedic devices.

Perspective

Upper body models including arm and shoulder models allow for movement analysis during gait but also enable the assessment of upper extremity function during diverse activities of daily living.     

Nachwuchsförderung in der Anästhesiologie: attraktive Gestaltung der Famulatur

Die Anaesthesiologie - Praktische Erfahrungen in Famulaturen können die spätere Weiterbildungswahl prägen. Ziel der Untersuchung war es, Faktoren in der anästhesiologischen...     

Schmerz und An?sthesiologie

The connection between the development of anesthesiology and pain therapy in the twentieth century is close. The optimistic idea to overcome pain by using general anesthesia derives from the nineteenth century. Treatment of nonsurgical pain remained in the background for a long time and innovations in pain medicine did not improve the insufficient care for patients with postoperative pain. Therapy of chronic pain was mainly surgical and the extreme of this surgical approach was psychosurgery. In the years following World War?II leucotomy and lobotomy were established as methods to separate the psychological processing of pain from the experience of pain. Meanwhile, the French "pain surgeon" René Leriche elaborated a theory of pain where chronic pain was no longer seen as a symptom but as a "douleur-maladie", a pain disease. His theory was considered on various occasions but did not gain acceptance before the 1950s. Research in anesthesiology, such as that conducted by the American scientist Henry Beecher separated psyche and physiology with respect to pathological pain. This was contrasted by the approach of clinical anesthesia to pain therapy, which was based on regional anesthesia. The first "pain clinics" were "nerve block clinics". John Bonica, a regional anesthesiologist, extended the framework of pain therapy by introducing multidisciplinary teamwork into the therapy of chronic pain. From today's viewpoint his 1953 monograph The Management of Chronic Pain is a milestone in the development of modern pain therapy. However, Bonica's work did not attain major importance until 1960 when he was appointed to a newly established chair. Gradually, chronic pain was recognized as an independent illness and differentiated as such from acute pain. In 1965 the gate control theory by Melzack and Wall offered a possible explanation for the mechanisms of chronic pain. By the end of the 1970s the spectrum was extended to the biopsychosocial approach which was foremost developed by the American psychiatrist George Engel, defined chronic pain as an illness rather than a disease. Concurrently, the radical behaviorism of the late 1960s affected both the therapy of chronic and of acute pain. Based on this theory, patient-controlled analgesia (PCA) was introduced in the 1970s and 1980s. Acute pain services (APS) in hospitals, were developed beginning in the 1980s using the continuous release of opioids. Regional anesthesia played a greater role than general anesthesia in developing pain therapy in the twentieth century and paved the way for pain therapy. The restriction to nerve blocks in pain centers was overcome by the expansion of theoretical foundations beyond the framework of anesthesiology. Impulses from psychology and psychosomatic medicine were crucial. The evolution of cancer pain therapy was distinct from non-cancer pain therapy.     

Vernetzte Notfallversorgung von Krankenhäusern verschiedener Versorgungsstufen

Background

Comprehensive coverage for safe treatment of emergency patients is influenced by many factors. Irrespective of the current changes in demographics and hospital structures there is an obligation to provide definitive care for so-called tracer diagnoses, such as myocardial infarction, stroke, severe brain trauma and patients with multiple trauma as soon as possible. The key paper Eckpunktepapier zur notfallmedizinischen Versorgung der Bevölkerung postulates a distinct time corridor until an intervention or operative care has to be started. The human and technical resources have to be provided in a 24 h/365 days manner and are usually centralized in trauma centers or tertiary care facilities. Outside the normal working hours a reduction in treatment resources is frequently observed and a general shortage in intensive care capacity is evident.

Requirements

The emergency physician in the preclinical setting has to decide and select the adequate facility for the timely treatment of the specific diagnosis. In addition there is a requirement for specific rules and indications for the secondary transport of patients to hospitals with a higher level of care including the physician-staffed transfer services.

Solution

Following the demand for comprehensive networks for the treatment of acute critical diagnoses, several networks were created to meet the specific needs in the treatment of the tracer diagnoses. The common denominator of the networks is the integration of all stakeholders involved in the chain of treatment by signing a target agreement. The current status in Bavaria is used as an example to reflect on some open questions and future developments regarding the network structures.     

Publikationsleistungen der Universitätskliniken für Anästhesiologie

Aim

This study assessed the publication performance of university departments of anesthesiology in Austria, Germany and Switzerland. The number of publications, original articles, impact factors and citations were evaluated.

Material and methods

A search was performed in PubMed to identify publications related to anesthesiology from 2001 to 2010. All articles from anesthesiology journals listed in the fields of anesthesia/pain therapy, critical care and emergency medicine by the “journal citation report 2013” in Thomson Reuters ISI web of knowledge were included. Articles from non-anaesthesiology journals, where the stem of the word anesthesia (anes*, anaes*, anäst*, anast*) appears in the affiliation field of PubMed, were included as well. The time periods 2001–2005 and 2006–2010 were compared. Articles were allocated to university departments in Austria, Germany and Switzerland via the affiliation field.

Results

A total of 45 university departments in Austria, Germany and Switzerland and 125,979 publications from 2,863 journals (65 anesthesiology journals, 2,798 non-anesthesiology journals) were analyzed. Of the publications 23?% could not be allocated to a given university department of anesthesiology. In the observation period the university department of anesthesiology in Berlin achieved most publications (n?=?479) and impact points (1,384), whereas Vienna accumulated most original articles (n?=?156). Austria had the most publications per million inhabitants in 2006-2010 (n=50) followed by Switzerland (n=49) and Germany (n=35). The number of publications during the observation period decreased in Germany (0.5?%), Austria (7?%) and Switzerland (8?%). Tables 2 and 4–8 of this article are available at Springer Link under Supplemental.

Conclusions

The research performance varied among the university departments of anesthesiology in Germany, Austria and Switzerland whereby larger university departments, such as Berlin or Vienna published most. Publication output in Germany, Austria and Switzerland has decreased. Data processing in PubMed should be improved.