Zum Vorschlag des Erlasses einer Richtlinie über die Ausübung der Patientenrechte in der grenzüberschreitenden Gesundheitsversorgung – Was ist neu?

Ohne Zusammenfassung     

The effect of case management on the costs of health care for enrollees in Medicare Plus Choice plans: a randomized trial

OBJECTIVE: To measure the effects of case management on an older population's costs of health care. DESIGN: A 1-year randomized controlled trial. SETTING: Multiple sites of care in San Francisco, California. PARTICIPANTS: Patients aged 65 or older of primary care physicians in a large provider organization bearing financial risk for their care (n = 6409). INTERVENTION: Screening for high risk and provision of social work-based case management. OUTCOME MEASURES: Volume and cost of hospital, physician, case management, and other health-related services. RESULTS: The experimental group used more case management services than the control group (0.09 vs. 0.02 months per person, P<.001). The experimental group's average total payments for health care were slightly lower ($3148 vs $3277, P = .40). CONCLUSIONS: This study provides no statistically significant evidence that social work-oriented case management reduces the use or the cost of health care for high-risk older people. Other potentially favorable effects of this type of case management need to be evaluated, as do the effects of other types of case management.     

Second malignant neoplasms following childhood Hodgkin's disease: treatment and splenectomy as risk factors

The risk of second malignant neoplasm (SMN) was evaluated in 979 children with Hodgkin's disease. This cohort was diagnosed between 1955 and 1979 at one of the institutions of the Late Effects Study Group. Solid tumors, non-lymphocytic leukemia, and non-Hodgkin's lymphoma (NHL) developed in 18, 17, and 3 patients, respectively. The estimated cumulative probability of developing any SMN was 2% at 5 years from diagnosis, 5% at 10 years, and 9% at 15 years. The incidence is ninefold greater than the risk of acquiring cancer in 19 year-olds, the median age at which the diagnosis of SMN was made in this study population. For leukemia and NHL the corresponding probabilities were 1%, 3%, and 4% for the group as a whole but were increased (2%, 6%, and 8%) in patients who had suffered one or more recurrences. In order to analyze the risk of leukemia and NHL associated with alkylating agent chemotherapy, each patient was assigned a score of one for each alkylating agent administered for a 6-month period. Scores of 2, 4, 6, and 8 were associated with probabilities of leukemia or NHL of 2%, 3%, 6%, and 10%, respectively. In a multivariate analysis for leukemia/lymphoma that included AAD score, stage, and splenectomy, the effect of AAD score and splenectomy did not change substantially compared to the univariate results. AAD score remained statistically significant (P = .0001), and splenectomy was of borderline significance (P = .09). Of the 18 solid tumor SMNs, 15 developed within the field of radiation, and one other developed in tissue irradiated 34 years earlier for hemangioma. This study of a large and unselected group of children with Hodgkin's disease who received a variety of therapies demonstrates that children are as likely as adults to develop acute leukemia after alkylating agents and solid tumors in the field of radiation therapy.     

An exploratory analysis of risk factors for childhood malignant germ-cell tumors: report from the Childrens Cancer Group (Canada,United States)

A study of 105 patients with childhood malignant germ-cell tumors (MGCT) and 639 community controls was conducted utilizing a large epidemiologic database collected by the Childrens Cancer Group from 25 member institutions in the United States and Canada. This study was designed to explore the risk factors of this malignancy whose etiology remains poorly understood. A structured, self-administered questionnaire was used to collect exposure information, and data were analyzed using an unconditional logistic regression model with adjustment for relevant confounders. Consistent with the findings from studies of adult MGCT, gestational age was associated inversely with risk of MGCT, with a 70 to 75 percent reduction in risk for children born at term compared with those born pre-term. Parental, particularly maternal, self-reported exposure to chemicals or solvents (odds ratio [OR]=4.6, 95 percent confidence interval [CI]=1.9–11.3) and OR=2.2, CI=1.1–4.7 for maternal and paternal exposure, respectively) and plastic or resin fumes (OR=12.0, CI=1.9–7.5.0 [maternal] and OR=2.5, CI=1.0–6.5 [paternal]) were associated with elevated risk of MGCT. New findings, not reported previously, include a positive relationship of MGCT risk with birthweight and prolonged breastfeeding, an inverse association between MGCT risk and number of cigarettes smoked by the mother during pregnancy, and a 3.1-fold increased risk (CI=1.5–6.6) associated with maternal urinary infections during index pregnancy. Although these findings need confirmation from future studies, they suggest a potential influence of in utero exposure to maternal endogenous hormones, parental environmental exposures, and maternal diseases during pregnancy in the development of childhood MGCT.Drs Shu, Nesbit, and Robison are affiliated with the Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, MN, USA. Drs Buckley and Krailo are affiliated with the Department of Preventive Medicine, University of Southern California School of Medicine, Los Angeles, CA, USA. Contributing Childrens Cancer Group Investigators, Institutions, and Grant Numbers are given in the Appendix. Address correspondence to Dr Shu, Childrens Cancer Group, P.O. Box 60012, Arcadia, CA 91066-6012, USA. Grant support is from the US National Cancer Institute and the US Department of Health and Human Services.     

Maternal exposure to potential inhibitors of DNA topoisomerase II and infant leukemia (United States): A report from the Children's Cancer Group

Nearly 80 percent of infant leukemias present with an abnormality involving the MLL gene at 11q23. Moreover, secondary acute myeloid leukemias (AML) that occur as the result of chemotherapy agents, which are known to inhibit DNA topoisomerase II, often manifest the same MLL abnormalities. It has been hypothesized that de novo infant leukemias may occur as a result of maternal exposure to agents in diet and medications that inhibit DNA topoisomerase II. Three epidemiologic studies of childhood leukemia with similar methodologies were conducted in the United States and Canada over the past 10 years by the Children's Cancer Group (CCG). Of the total 771 mothers of infants diagnosed at one year of age or less (<12.5 months) who originally were interviewed (303 infant cases and 468 matched controls) across the three studies, follow-up questionnaire data on maternal exposure to potential DNA topoisomerase II inhibitors during pregnancy were available on 84 cases and 97 matched controls in the US. For maternal diet, a composite variable was created that consisted of 10 foods identified a priori as containing DNA topoisomerase II inhibitors. There were no significant trends with increasing maternal consumption for either the overall group, or the acute lymphoblastic leukemia (ALL) stratum. However, within the AML stratum, there was a statistically significant positive association (P trend=0.04) with increasing consumption of DNA topoisomerase II-inhibitor containing foods (odds ratio [OR]=9.8, 95 percent confidence interval [CI]=1.1–84.8; OR=10.2, CI=1.1–96.4; for medium and high consumption, respectively). Other potential topoisomerase II inhibitors were explored; no significant findings were found. Results of this preliminary study, in combination with molecular data, should be used in future investigations of childhood leukemia (particularly, infant) to justify the incorporation of a detailed dietary history.Drs Ross and Robison are with the Division of Pediatric Epidemiology and Clinical Research, University of Minnesota, Minneapolis, MN, USA. Dr Potter is with the Cancer Prevention Research Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA. Dr Reaman is with the Department of Pediatric Hematology-Oncology, Children's National Medical Center, Washington, DC. Dr Pendergrass is with the Department of Pediatric Hematology-Oncology, Children's Hospital and Medical Center, Seattle, WA. Address correspondence to Dr Ross, Children's Cancer Group, P.O. Box 60012, Arcadia, CA 91066-6012, USA. This research was supported in part by the University of Minnesota Children's Cancer Research Fund, NIH training grant T32 09607, and NCI grants CA42479, CA49450, CA58051 from the United States Department of Health and Human Services. Participating Children's Cancer Group investigators, institutions, and grant numbers (Division of Cancer Treatment, National Cancer Institute) are provided in the appendix.     

Kidney size at diagnosis of childhood acute lymphocytic leukemia: lack of prognostic significance for outcome

The prognostic significance of kidney size at diagnosis of acute lymphoblastic leukemia (ALL) was assessed in a population of 142 children. Kidney size was determined using three different methodologies, and its significance was determined by univariate and multivariate life-table methods. Enlarged kidney size (as determined by any of the three methods used) was not associated with an overall poorer survival. These findings were consistent when kidney size at diagnosis was analyzed as a singled variable and when it was considered after adjustment for the known prognostic factors of age, sex, and initial WBC count. Assessment of renal size at the time of diagnosis of childhood ALL is not indicated for the purpose of predicting subsequent prognosis.