Assessing European national health information systems in peer review format: lessons learnt

BACKGROUND

Systematic assessments of a country's health information system (HIS) help identify strengths and weaknesses and may stimulate actions for improvement. They represent a capacity-building process for the country assessed as well as for the assessor. The joint action on HISs (InfAct) developed a peer-to-peer assessment methodology adapting an established WHO support tool. The aim of this study is to identify lessons learnt and the added value of the InfAct peer assessment for the assessors.

METHODS

A qualitative evaluation of the peer HIS assessment was performed based on 12 semi-structured interviews: nine interviews were carried out with assessors from nine participating countries, and three with an observer (present during assessments). The interviews were carried out between May 2019 and January 2020. Interviews were analysed using qualitative content analysis.

RESULTS

The interviews revealed the experiences of the assessors mainly occurred in five areas: assessors strengthened their understanding of what a population-based HIS is; they strengthened their understanding of how a HIS operates in different countries; they learnt how to carry out a HIS assessment; they strengthened their organization, communication, negotiation and reporting skills and they strengthened the networks in health information within and between countries.

CONCLUSION

Since the assessors are key personnel in their respective national health systems, the impact of the assessment is not limited to the assessor alone but may extend to stakeholders in their country. The deployment of the InfAct HIS peer assessment, anchored in systematic HIS capacity building across European countries, is recommended.

Impact of COVID-19 on hospitalisation for diverse conditions in European countries

Background

The COVID-19 pandemic has had an unprecedented impact on Europe. Health systems came under strain, with non-urgent treatments postponed and resources reserved for treatment of COVID-19 patients. Delayed care seeking has been reported, for fear of infection with SARS-CoV2. Yet, the scale of this impact remains under researched. This study aims to compare indirect effects of the pandemic in a European cross-country study aiming to highlight the potential of Population Health Information Research Infrastructures (www.phiri.eu).

Methods

Focusing on (i) major vascular events (MVE) and (ii) elective surgery for joint replacements (ESJR) as well as (iii) serious trauma this study analyses individual level hospital data in a standardised harmonised data model. We compared pre-pandemic incidence rates (2018-2019) with rates for 2020 and 2021. Analyses are systematically contrasted with SARS CoV2 incidence rates, and policy measures taken based on the OxCGRT index.

Results

A drop in hospital discharge rates was observed during the pandemic in all countries but differing by condition and month. Socio-economic differences also varied by condition. Our evidence suggests that periods of more severe policy measures also correlated with more dramatic drops in regular hospital activities.

Conclusions

Our findings provide new insights on the dramatic level of de-prioritisation of essential services faced by non-COVID-19 patients in Europe. From a public health perspective, hospital escalation plans should be developed early on to avoid negative mid and long-term health and financial consequences of indirect effects. The study demonstrates the tremendous potential in exploiting health information systems in a systematic way across countries and the value of the PHIRI system. Further research should investigate policy trade-offs involved in severe lockdown measures during a pandemic and variations in health service resilience for future pandemic preparedness.

A crisis like no other? Unmet needs in healthcare during the first wave of the COVID-19 crisis in Austria

Background

Many patients experienced restricted access to healthcare during the Coronavirus Disease 2019 (COVID-19) pandemic. This study is among the first to provide systematic evidence on the existence of subjective unmet needs (SUN) in different population groups during the pandemic.

Methods

Using data on individuals aged 20–64 and living in Austria from the AKCOVID survey (June 2020) and the ‘European Social Survey’ (2015), SUN were compared between 2015 and 2020, either related to the pandemic (fear of infection, provider closed or treatment postponed) or not (barriers related to knowledge, affordability, time and reachability). Multinomial logistic regression models identified determinants of SUN during the pandemic, adjusting for socio-demographics, socio-economic status and self-reported health.

Results

Shares of the population with SUN in 2020 substantially exceeded SUN in 2015. Excess unmet needs were mostly attributable to the pandemic. Postponed treatments and closed providers were the most important reasons for SUN in June 2020. Older age groups (50–64 years), inactive and retired people were most likely to report pandemic-related SUN. We did not find socio-economic differences in pandemic-related SUN.

Conclusions

The pandemic resulted in a supply-side shock to healthcare, with vulnerabilities emerging especially among older people, people with poor health and/or people no longer active on the labour market. Further research could focus on health system resilience and the possibilities to improve management of healthcare services during pandemics without widening inequalities while maintaining population health.

Barriers to accessing health care for people with chronic conditions: a qualitative interview study

BACKGROUND

There is a growing interest in redesigning healthcare systems to increase access to and coordination across care settings for people with chronic conditions. We aim to gain a better understanding of the barriers faced by (1) children with chronic bronchial asthma, (2) adults with non-specific chronic back pain, and (3) older people with pre-existing mental illness/es in Austria's fragmented social health insurance system.

METHODS

Using a qualitative design, we conducted semi-structured interviews face-to-face and by telephone with health service providers, researchers, experts by experience (persons with lived/ personal experience, i.e., service users, patient advocates or family members/carers), and employees in public health administration between July and October 2019. The analysis and interpretation of data were guided by Levesque's model of access, a conceptual framework used to evaluate access broadly according to different dimensions of accessibility to care: approachability, acceptability, availability and accommodation, affordability, and appropriateness.

RESULTS

The findings from the 25 expert interviews were organised within Levesque's conceptual framework. They highlight a lack of coordination and defined patient pathways, particularly at the onset of the condition, when seeking a diagnosis, and throughout the care process. On the supply side, patterns of poor patient-provider communication, lack of a holistic therapeutic approach, an urban-rural divide, strict separation between social care and the healthcare system and limited consultation time were among the barriers identified. On the demand side, patients' ability to perceive a need and to subsequently seek and reach healthcare services was an important barrier, closely linked to a patient's socio-economic status, health literacy and ability to pay.

CONCLUSIONS

While studies on unmet needs suggest a very low level of barriers to accessing health care in the Austrian context, our study highlights potential 'invisible' barriers. Barriers to healthcare access are of concern for patients with chronic conditions, underlining existing findings about the need to improve health services according to patients' specific needs. Research on how to structure timely and integrated care independent of social and economic resources, continuity of care, and significant improvements in patient-centred communication and coordination of care would be paramount.

Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe☆

Countries with social health insurance (SHI) systems display some common defining characteristics - pluralism of actors and strong medical associations - that, in dealing with crisis times, may allow for common learnings. This paper analyses health system responses during the COVID-19 pandemic in eight countries representative of SHI systems in Europe (Austria, Belgium, France, Germany, Luxembourg, the Netherlands, Slovenia and Switzerland). Data collection and analysis builds on the methodology and content in the COVID-19 Health System Response Monitor (HSRM) up to November 2020. We find that SHI funds were, in general, neither foreseen as major stakeholders in crisis management, nor were they represented in crisis management teams. Further, responsibilities in some countries shifted from SHI funds to federal governments. The overall organisation and governance of SHI systems shaped how countries responded to the challenges of the pandemic. For instance, coordinated ambulatory care often helped avoid overburdening hospitals. Decentralisation among local authorities may however represent challenges with the coordination of policies, i.e. coordination costs. At the same time, bottom-up self-organisation of ambulatory care providers is supported by decentralised structures. Providers also increasingly used teleconsultations, which may remain part of standard practice. It is recommended to involve SHI funds actively in crisis management and in preparing for future crisis to increase health system resilience.

Care in times of COVID-19: the impact of the pandemic on informal caregiving in Austria

Much attention has been paid to the effects of the COVID-19 pandemic on long-term care but the impact on informal caregivers has remained speculative. In Austria, like in other European countries, informal care is carried out overwhelmingly by (non-cohabiting) relatives. Limited care services available during the pandemic, social-distancing, increased unemployment and competing care needs within households (e.g. due to school closures) may have changed the prevalence and intensity of informal caregiving. Moreover, these changes may have increased the psychological strain experienced by caregivers. Focusing on Austria, this study aims to empirically analyse the following research questions: how have the prevalence and intensity of informal care changed due to the pandemic? How has the psychological well-being of informal caregivers been affected? We use a pre- and post-onset of the pandemic research design based on a representative survey carried out in Austria in June 2020 (N = 2000) in combination with comparable 2015 data from the European Social Survey. Findings suggest that neither prevalence nor intensity of informal care changed significantly due to the pandemic. However, the psychological well-being gap between carers and non-carers increased with the start of the pandemic, especially among men. Findings are discussed in relation to the policy measures implemented and possible policy implications for the future.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10433-021-00611-z.

Making the case for strong health information systems during a pandemic and beyond

BACKGROUND

The Sars-CoV-2 pandemic exacerbates existing inequalities across health care systems globally, both within countries and between countries. It also highlights, like no other crisis before, existing weaknesses in health information systems (HIS). This article summarizes these key challenges for HIS in times of a pandemic and beyond, with a focus on European countries. It builds on the experiences of a large consortium representing HIS experts in key positions in national public health or similar institutes across Europe.

METHODS

Data were collected in bi-weekly conference calls organized by the InfAct project between February and June 2020. Emerging themes were clustered and analysed around a WHO framework for health information systems (HIS). We analyse strengths of HIS at two levels: (i) dealing with health information directly, and (ii) dealing with other parts of information systems that allow for a holistic assessment of the pandemic (including health-related aspects).

RESULTS

The analysis highlights the need for capacity-building in HIS before a pandemic hits, the relevance of going beyond health information only related to health care but taking a broader perspective (e.g. on vulnerable groups), the need for strong reporting systems on staffing numbers and in primary care. Further, data linkage emerges as a crucial precondition to identify unmet needs for essential health care services in a timely manner. Finally, room for innovation and digitalisation is key to be able to react flexibly in times of crisis. Trust for health information stakeholders is another important factor to create strong HIS.

CONCLUSIONS

The strengths and shortcomings of European HIS that have been observed during the COVID-19 crisis highlight the need for strong HIS beyond the crisis. The experiences reported leave as a central message that successful reactions to the pandemic are (also) grounded in strong HIS that ultimately not only benefit the health of the population but also create a number of economic and psycho-social benefits. Strong data reporting schemes may also support fine-tuning of containment measures during a pandemic as well as transition phases.

Mapping variability in allocation of Long-Term Care funds across payer agencies in OECD countries

Background

Long-term care (LTC) is organized in a fragmented manner. Payer agencies (PA) receive LTC funds from the agency collecting funds, and commission services. Yet, distributional equity (DE) across PAs, a precondition to geographical equity of access to LTC, has received limited attention. We conceptualize that LTC systems promote DE when they are designed to set eligibility criteria nationally (vs. locally); and to distribute funds among PAs based on needs-formula (vs. past-budgets or government decisions). The objectives of this cross-country study is to highlight to what extent different LTC systems are designed to promote DE across PAs, and the parameters used in allocation formulae.

Methods

Qualitative data were collected through a questionnaire filled by experts from 17 OECD countries.

Results

11 out of 25 LTC systems analyzed, fully meet DE as we defined. 5 systems which give high autonomy to PAs have designs with low levels of DE; while nine systems partially promote DE. Allocation formulae vary in their complexity as some systems use simple demographic parameters while others apply socio-economic status, disability, and LTC cost variations.

Conclusions

A minority of LTC systems fully meet DE, which is only one of the criteria in allocation of LTC resources. Some systems prefer local priority-setting and governance over DE. Countries that value DE should harmonize the eligibility criteria at the national level and allocate funds according to needs across regions.

Key messages

A minority of LTC systems in OECD countries fully meet distributional equity in allocation of resources across payer agencies. Countries that value distributional equity should harmonize the eligibility criteria to LTC at the national level and allocate funds according to needs across regions.

Mapping variability in allocation of Long-Term Care funds across payer agencies in OECD countries

INTRODUCTION

Long-term care (LTC) is organized in a fragmented manner. Payer agencies (PA) receive LTC funds from the agency collecting funds, and commission services. Yet, distributional equity (DE) across PAs, a precondition to geographical equity of access to LTC, has received limited attention. We conceptualize that LTC systems promote DE when they are designed to set eligibility criteria nationally (vs. locally); and to distribute funds among PAs based on needs-formula (vs. past-budgets or government decisions).

OBJECTIVES

This cross-country study highlights to what extent different LTC systems are designed to promote DE across PAs, and the parameters used in allocation formulae.

METHODS

Qualitative data were collected through a questionnaire filled by experts from 17 OECD countries.

RESULTS

11 out of 25 LTC systems analyzed, fully meet DE as we defined. 5 systems which give high autonomy to PAs have designs with low levels of DE; while nine systems partially promote DE. Allocation formulae vary in their complexity as some systems use simple demographic parameters while others apply socio-economic status, disability, and LTC cost variations.

DISCUSSION AND CONCLUSIONS

A minority of LTC systems fully meet DE, which is only one of the criteria in allocation of LTC resources. Some systems prefer local priority-setting and governance over DE. Countries that value DE should harmonize the eligibility criteria at the national level and allocate funds according to needs across regions.

Austria: Health System Review

This analysis of the Austrian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Two major reforms implemented in 2013 and 2017 are among the main issues today. The central aim of the reforms that put in place a new governance system was to strengthen coordination and cooperation between different levels of government and self-governing bodies by promoting joint planning, decision-making and financing. Yet despite these efforts, the Austrian health system remains complex and fragmented in its organizational and financial structure. The Austrian population has a good level of health. Life expectancy at birth is above the EU average and low amenable mortality rates indicate that health care is more effective than in most EU countries. Yet, the number of people dying from cardiovascular diseases and cancer is high compared to the EU-28 average. Tobacco and alcohol represent the major health risk factors. Tobacco consumption has not declined over the last decade like in most other EU countries and lies well above the EU-28 average. In terms of performance, the Austrian health system provides good access to health care services. Austrias residents report the lowest levels of unmet needs for medical care across the EU. Virtually all the population is covered by social health insurances and enjoys a broad benefit basket. Yet, rising imbalances between the numbers of contracted and non-contracted physicians may contribute to social and regional inequalities in accessing care. The Austrian health system is relatively costly. It has a strong focus on inpatient care as characterized by high hospital utilization and imbalances in resource allocation between the hospital and ambulatory care sector. The ongoing reforms therefore aim to bring down publicly financed health expenditure growth with a global budget cap and reduce overutilization of hospital care. Efficiency of inpatient care has improved over the reform period but the fragmented financing between the inpatient and ambulatory sector remain a challenge. Current reforms to strengthen primary health care are an important step to further shift activities out of the large and costly hospital sector and improve skill mix within the health workforce.

Income-rich and wealth-poor? The impact of measures of socio-economic status in the analysis of the distribution of long-term care use among older people

This article aims to investigate the impact of using 2 measures of socio-economic status on the analysis of how informal care and home care use are distributed among older people living in the community. Using data from the Survey of Health, Ageing and Retirement in Europe for 14 European countries, we estimate differences in corrected concentration indices for use of informal care and home care, using equivalised household net income and equivalised net worth (as a proxy for wealth). We also calculate horizontal inequity indices using both measures of socio-economic status and accounting for differences in need. The findings show that using wealth as a ranking variable results, as a rule, in a less pro-poor inequality of use for both informal and home care. Once differences in need are controlled for (horizontal inequity), wealth still results in a less pro-poor distribution for informal care, in comparison with income, whereas the opposite is observed for home care. Possible explanations for these differences and research and policy implications are discussed.

Fairness and Eligibility to Long-Term Care: An Analysis of the Factors Driving Inequality and Inequity in the Use of Home Care for Older Europeans

In contrast with the case of health care, distributional fairness of long-term care (LTC) services in Europe has received limited attention. Given the increased relevance of LTC in the social policy agenda it is timely to evaluate the evidence on inequality and horizontal inequity by socio-economic status (SES) in the use of LTC and to identify the socio-economic factors that drive them. We address both aspects and reflect on the sensitivity of inequity estimates to adopting different definitions of legitimate drivers of care need. Using Survey of Health, Ageing and Retirement in Europe (SHARE)data collected in 2013, we analyse differences in home care utilization between community-dwelling Europeans in nine countries. We present concentration indexes and horizontal inequity indexes for each country and results from a decomposition analysis across income, care needs, household structures, education achievement and regional characteristics. We find pro-poor inequality in home care utilization but little evidence of inequity when accounting for differential care needs. Household characteristics are an important contributor to inequality, while education and geographic locations hold less explanatory power. We discuss the findings in light of the normative assumptions surrounding different definitions of need in LTC and the possible regressive implications of policies that make household structures an eligibility criterion to access services.

Communicating the Risk of MRSA: The Role of Clinical Practice, Regulation and Other Policies in Five European Countries

BACKGROUND

The threat posed by Meticillin-resistant Staphylococcus aureus (MRSA) has taken on an increasingly pan-European dimension. This article aims to provide an overview of the different approaches to the control of MRSA adopted in five European countries (Austria, Germany, Netherlands, Spain, and the UK) and discusses data and reporting mechanisms, regulations, guidelines, and health policy approaches with a focus on risk communication. Our hypothesis is that current infection control practices in different European countries are implicit messages that contribute to the health-related risk communication and subsequently to the public perception of risk posed by MRSA. A reporting template was used to systematically collect information from each country.

DISCUSSION

Large variation in approaches was observed between countries. However, there were a number of consistent themes relevant to the communication of key information regarding MRSA, including misleading messages, inconsistencies in content and application of published guidelines, and frictions between the official communication and their adoption on provider level.

SUMMARY

The variability of recommendations within, and across, countries could be contributing to the perception of inconsistency. Having inconsistent guidelines and practices in place may also be affecting the level at which recommended behaviors are adopted. The discrepancy between the official, explicit health messages around MRSA and the implicit messages stemming from the performance of infection control measures should, therefore, be a key target for those wishing to improve risk communication.

Analysing the importance of older people's resources for the use of home care in a cash-for-care scheme: evidence from Vienna

Older people of lower socioeconomic status (SES) are disproportionately affected by chronic conditions, yet less able to compensate health limitations through use of formal long-term care (LTC) at home, a preferred type of care for most. Some, like older women and single people, are particularly vulnerable. Under the Austrian public cash-for-care scheme, which aims to incentivise care at home and empowerment of LTC users, this study analyses: (i) interdependencies between SES, gender and 'informal' or family care, and (ii) how these factors associate with the use of old age formal home care in Vienna. An adaptation of Arber and Ginn's theory is used to identify material resources (income), health resources (care needs) and informal caring resources (co-residence and/or availability of family care). Gender aspects are also considered as a persistent source of inequalities. Administrative and survey data, collected by public authorities between 2010 and 2012 in Vienna, serve to compare home care use in old age (60+) to other support forms (residential and informal care) using logistic regression analysis. Results show a pro-rich bias in home care use among single-living people, with high-income single people being less likely to move to a care home, while there are no significant income differences present for non-singles. Second, traditional gender roles are salient: female care recipients co-residing with a partner are more likely to use formal care than men, reflecting that men's traditional gender roles involve less unpaid care work than women's. In conclusion, in an urban setting, the Austrian cash-for-care scheme is likely to reinforce stratifications along gender and class, thus implementing the general policy objective of care at home, but more likely for those with higher income. A support mechanism promoting empowerment among all older people might contribute to unequal degrees of choice, especially for those with fewer resources to manage their way through a fragmented system of LTC delivery.

Predictors of social leisure activities in older Europeans with and without multimorbidity

Older people spend much time participating in leisure activities, such as taking part in organized activities and going out, but the extent of participation may differ according to both individual and environmental resources available. Chronic health problems become more prevalent at higher ages and likely necessitate tapping different resources to maintain social participation. This paper compares predictors of participation in social leisure activities between older people with and those without multimorbidity. The European Project on Osteoarthritis (EPOSA) was conducted in Germany, UK, Italy, The Netherlands, Spain and Sweden (N = 2942, mean age 74.2 (5.2)). Multivariate regression was used to predict social leisure participation and degree of participation in people with and without multimorbidity. Fewer older people with multimorbidity participated in social leisure activities (90.6 %), compared to those without multimorbidity (93.9 %). The frequency of participation was also lower compared to people without multimorbidity. Higher socioeconomic status, widowhood, a larger network of friends, volunteering, transportation possibilities and having fewer depressive symptoms were important for (the degree of) social leisure participation. Statistically significant differences between the multimorbidity groups were observed for volunteering and driving a car, which were more important predictors of participation in those with multimorbidity. In contrast, self-reported income appeared more important for those without multimorbidity, compared to those who had multimorbidity. Policies focusing on social (network of friends), physical (physical performance) and psychological factors (depressive symptoms) and on transportation possibilities are recommended to enable all older people to participate in social leisure activities.

Fit for caring: factors associated with informal care provision by older caregivers with and without multimorbidity

Due to an increased prevalence of chronic diseases, older individuals may experience a deterioration of their health condition in older ages, limiting their capacity for social engagement and in turn their well-being in later life. Focusing on care provision to grandchildren and (older) relatives ('informal care') as forms of engagement, this paper aims to identify which individual characteristics may compensate for health deficits and enable individuals with multimorbidity to provide informal care. We use data from the SHARE survey (2004-2012) for individuals aged 60 years and above in 10 European countries. Logistic regression estimates for the impact of different sets of characteristics on the decision to provide care are presented separately for people with and without multimorbidity. Adapting Arber and Ginn's resource theory, we expected that older caregivers' resources (e.g., income or having a spouse) would facilitate informal care provision to a greater extent for people with multimorbidity compared to those without multimorbidity, but this result was not confirmed. While care provision rates are lower among individuals suffering from chronic conditions, the factors associated with caregiving for the most part do not differ significantly between the two groups. Results, however, hint at reciprocal intergenerational support patterns within families, as the very old with multimorbidity are more likely to provide care than those without multimorbidity. Also, traditional gender roles for women are likely to be weakened in the presence of health problems, as highlighted by a lack of gender differences in care provision among people with multimorbidity.

Licensing procedures and registration of medical doctors in the European Union

The current proposals to update the European Union (EU) directive on professional qualifications will have potentially important implications for health professions. Yet those discussing it will struggle to find basic information on key issues such as licensing and registration of physicians in different countries. A survey was conducted among national experts in 14 EU member states, supplemented by literature and independent expert review. The questionnaire covered five components of licensing and registration: (1) definitions, (2) regulatory basis, (3) governance, (4) the process of registration and (5) flow and quantity of applications. We identify seven areas of concern: (1) the meaning of terminology, which is inconsistent; (2) the role of language assessments and the responsibility for them; (3) whether approval to practise should be lifelong or time limited, subject to periodic assessment; (4) the need for improved systems to identify those deemed no longer fit to practise in one member state; (5) the complexity of processes for graduates from non-EU/European Economic Area (EAA) countries; (6) public access to registers; and (7) transparency of systems of governance. The systems of licensing and registration of doctors in Europe have developed within specific national contexts and vary widely. This creates inevitable problems in the context of free movement of professionals and increasing mobility.

The public gets what the public wants: experiences of public reporting in long-term care in Europe

INTRODUCTION

Public reporting of quality in long-term care is advocated on the basis of allowing providers to improve their performance by benchmarking and supporting users to choose the best providers. Both mechanisms are intended to drive improvements in quality. However, there is relatively scarce comparative research on the experiences and impact of public reporting on quality in long-term care in Europe.

METHODS

Using information gathered from key informants by means of a structured questionnaire and country profiles, this paper discusses experiences with public reporting mechanisms in seven European countries and available information on their impact on quality in long-term care.

RESULTS

Countries surveyed included a variety of public reporting schemes, ranging from pilot programmes to statutory mechanisms. Public reporting mechanisms more often focus on institutional care. Inspections carried out as part of a legal quality assurance framework are the main source of information gathering, supplemented by provider self-assessments in the context of internal quality management and user satisfaction surveys. Information on quality goes well beyond structural indicators to also include indicators on quality of life of users. Information is displayed using numerical scores (percentages), but also measures such as ratings (similar to school grades) and ticks and crosses. Only one country corrects for case-mix. The internet is the preferred medium of displaying information.

DISCUSSION

There was little evidence to show whether public reporting has a significant impact on driving users' choices of provider. Studies reported low awareness of quality indicators among potential end users and information was not always displayed in a convenient format, e.g. through complicated numerical scores. There is scarce evidence of public reporting directly causing improved quality, although the relative youth and the pilot characteristics of some of the schemes covered here could also have contributed to downplay their impact. The establishment of public reporting mechanisms did however contribute to shaping the discussion on quality measurement in several of the countries surveyed.

CONCLUSIONS

The findings presented in this paper highlight the need to consider some factors in the discussion of the impact of public reporting in long-term care, namely, the organisation of care markets, frequently characterised by limited competition; the circumstances under which user choice takes place, often made under conditions of duress; and the leadership conditions needed to bring about improvements in quality in different care settings.

[Caught between economic pressure and work-life balance--perspectives on emigration of German health professionals to Austria]

OBJECTIVE

Given the increasing lack of medical doctors in Germany, this study aimed to investigate the professional situation and the push and pull factors of German medical specialists working in Austrian hospitals.

METHODS

This explorative study is based on semi-structured interviews with 14 specialists working in Austria, who completed their education partly or fully in Germany. The material has been interpreted using qualitative content analysis.

RESULTS

Better work-life balance, higher quality of life and more favourable working conditions represent major reasons for German specialists to stay in Austria. Moreover, the higher density of medical doctors in Austrian hospitals can have an impact on the distribution of responsibilities among health-care personnel, and on hospital performance.

CONCLUSIONS

In the light of recent reforms in the German health-care system, the study underlines the importance of qualitative factors for the satisfaction of German medical doctors. These factors should be further analysed in order to avoid a brain drain of high-qualified health care staff in the future.

Factor IXa:factor VIIIa interaction. helix 330-338 of factor ixa interacts with residues 558-565 and spatially adjacent regions of the a2 subunit of factor VIIIa

The physiologic activator of factor X consists of a complex of factor IXa, factor VIIIa, Ca(2+) and a suitable phospholipid surface. In one study, helix 330 (162 in chymotrypsin) of the protease domain of factor IXa was implicated in binding to factor VIIIa. In another study, residues 558-565 of the A2 subunit of factor VIIIa were implicated in binding to factor IXa. We now provide data, which indicate that the helix 330 of factor IXa interacts with the 558-565 region of the A2 subunit. Thus, the ability of the isolated A2 subunit was severely impaired in potentiating factor X activation by IXa(R333Q) and by a helix replacement mutant (IXa(helixVII) in which helix 330-338 is replaced by that of factor VII) but it was normal for an epidermal growth factor 1 replacement mutant (IXa(PCEGF1) in which epidermal growth factor 1 domain is replaced by that of protein C). Further, affinity of each 5-dimethylaminonaphthalene-1-sulfonyl (dansyl)-Glu-Gly-Arg-IXa (dEGR-IXa) with the A2 subunit was determined from its ability to inhibit wild-type IXa in the tenase assay and from the changes in dansyl fluorescence emission signal upon its binding to the A2 subunit. Apparent K(d(A2)) values are: dEGR-IXa(WT) or dEGR-IXa(PCEGF1) approximately 100 nm, dEGR-IXa(R333Q) approximately 1.8 micrometer, and dEGR-IXa(helixVII) >10 micrometer. In additional experiments, we measured the affinities of these factor IXa molecules for a peptide comprising residues 558-565 of the A2 subunit. Apparent K(d(peptide)) values are: dEGR-IXa(WT) or dEGR-IXa(PCEGF1) approximately 4 micrometer, and dEGR-IXa(R333Q) approximately 62 micrometer. Thus as compared with the wild-type or PCEGF1 mutant, the affinity of the R333Q mutant for the A2 subunit or the A2 558-565 peptide is similarly reduced. These data support a conclusion that the helix 330 of factor IXa interacts with the A2 558-565 sequence. This information was used to model the interface between the IXa protease domain and the A2 subunit, which is also provided herein.

In vitro testing of the bond between soft materials used for maxillofacial prostheses and cast titanium

STATEMENT OF PROBLEM

The choice of soft materials for maxillofacial prostheses is important for covering extraoral defects after tumor surgery or radiation therapy. The use of cast commercially pure titanium as reinforcement seems to be a suitable option.

PURPOSE

Making use of the advantages of titanium frameworks for maxillofacial prostheses requires exploring ways of combining it with soft materials. This study investigated such combinations and evaluated discoloration of the soft material to determine whether it was attributable to the titanium reinforcement.

MATERIAL AND METHODS

Five soft materials used for maxillofacial prostheses and their bond strengths to cast titanium were tested. Different ways of conditioning the titanium surface and different adhesives were used. Plain mechanical retention was also studied. The Gretag SPM 100 was used to determine the potential effects on coloring after 24 hours of radiation in the Suntest rapid exposure unit.

RESULTS

Suitable material combinations for bonding soft materials to titanium were found for all soft materials studied. Bond strength varied depending on the chemical basis of the soft material. Results indicated that maximal bond strengths were obtained by the combinations Supersoft with Super-Bond, Supersoft with subsequent silicoating, and bonding with Dentacolor connector. Few color shifts attributable to the titanium reinforcement were evident in the 2-mm layers of the soft materials applied.

CONCLUSION

The results of this study showed that it is possible to combine a titanium framework and soft silicone materials.

Plaque, gingival health and post-operative sensitivity in titanium inlays and onlays: a randomized controlled clinical trial

OBJECTIVES

Few clinical data on the use of titanium for restorative appliances are available. The aim of this study was to clinically evaluate titanium restorations compared to gold alloy restorations with regard to plaque, gingival health and post-operative sensitivity.

METHODS

In 54 patients, 99 titanium restorations were placed. The control group comprised 56 patients with 96 high gold alloy restorations. The material was chosen by random. Each patient received one or two Class II restorations. Plaque Index (Silness and Löe, 0-3), Gingival Index (Löe and Silness, 0-3), and post-operative sensitivity (1-4, 1=none) were rated at 2 weeks, 3 months, 6 months, 12 months, and 18 months, post-operatively.

RESULTS

The mean plaque scores ranged from 0.89 to 0.99 in the titanium group, and from 0.88 to 1.04 in the gold group. The mean gingival scores ranged from 0.91 to 1.07 in the titanium group, and from 0.82 to 0.99 in the gold group. The mean plaque and gingival scores of the titanium and gold group did not differ significantly at any visit (P>0.05). To evaluate post-operative sensitivity, patients with one MOD restoration each were included, resulting in 46 titanium and 44 high gold restored teeth. Mean values of the post-operative sensitivity scores in the titanium group were significantly higher than in the gold group (P<0.05). The restoration material was found to be the dominating variable with regard to post-operative sensitivity, which was not influenced by age, sex and the application of calcium hydroxide liner.

CONCLUSIONS

It is concluded that neither higher plaque scores nor adverse effects on gingival health are to be expected in titanium restorations.

Clinical fit of Procera AllCeram crowns

STATEMENT OF PROBLEM

Color stability, strength, and accuracy of fit are the main requirements for complete-ceramic crowns. The Procera AllCeram crown system is a CAD/CAM system used to fabricate individual complete-ceramic crowns that have a dry sintered, aluminum oxide core and appear to match clinical requirements. However, there are few articles about the clinical fit of all-ceramic crowns.

PURPOSE

This in vivo study measured the accuracy of fit of Procera AllCeram crowns in anterior and posterior teeth.

MATERIAL AND METHODS

The clinical fit of 80 anterior and posterior Procera AllCeram crowns was evaluated by a replica technique with a light body silicone to fill space between crown and tooth and a heavy body silicone to stabilize the light body film. After removal from the artificial crowns, the replicas were segmented, and measurements of the film thickness were performed with a light microscope.

RESULTS

Medians of mean marginal gap widths were between 80 and 95 microm in anterior teeth and between 90 and 145 microm in posterior teeth. Medians of maximal marginal gap widths ranged from 80 to 180 microm in anterior teeth and from 115 to 245 microm in posterior teeth.

CONCLUSION

The accuracy of fit achieved by Procera AllCeram was comparable to other conventional and innovative systems.

Cloning and characterization of the EAP30 subunit of the ELL complex that confers derepression of transcription by RNA polymerase II

The product of the human oncogene ELL encodes an RNA polymerase II transcription factor that undergoes frequent translocation in acute myeloid leukemia (AML). In addition to its elongation activity, ELL contains a novel type of RNA polymerase II interaction domain that is capable of repressing polymerase activity in promoter-specific transcription. Remarkably, the ELL translocation that is found in patients with AML results in the deletion of exactly this functional domain. Here we report that the EAP30 subunit of the ELL complex has sequence homology to the Saccharomyces cerevisiae SNF8, whose genetic analysis suggests its involvement in the derepression of gene expression. Remarkably, EAP30 can interact with ELL and derepress ELL's inhibitory activity in vitro. This finding may reveal a key role for EAP30 in the pathogenesis of human leukemia.

Margin quality of titanium and high-gold inlays and onlays--a clinical study

OBJECTIVES

Unalloyed titanium may be an economical substitute for gold alloys. The purpose of this study was to evaluate the suitability of unalloyed titanium as an alternative to gold alloys for posterior inlay and onlay restorations.

METHODS

Fifty-four patients received 99 titanium restorations, 56 patients 96 gold alloy restorations. All titanium restorations were cast in a vacuum-pressure casting machine. Two weeks after insertion the clinical margin integrity was evaluated by replica technique. The maximum marginal gaps were assessed under the optical measuring microscope. The two tailed t-test for independent samples was used for statistical analysis.

RESULTS

Accuracy of fit was significantly better in gold alloy than in titanium restorations. Mean maximum marginal gap between restoration margin and tooth structure were 72 +/- 18 microns (mean +/- S.D.) for titanium and 64 +/- 18 microns (mean +/- S.D.) for gold restorations.

SIGNIFICANCE

Though marginal gap widths in titanium restorations did not yet match the gold standard, the data justify the use of titanium as an alternative to gold alloy for inlay and onlay restorations.

[Production of slides using a microdatamat]

For production of dias for presentation of scientific data, a personal computer, a dias programme and a camera are necessary. A microdatamat with a 80286 precessor, 20 MB hard disc and an EGA colour screen are the minimum configurations which can be recommended. A hard disc between 40 and 85 MB and a VGA screen provide a better solution. Out of the numerous dias programmes, Harvard Graphics appears to be suitable for production of dias for scientific use. In this programme, it is easy to combine text, graphic and hand drawing. Many other excellent programmes such as 35 mm Express and Mirage are also available. In the choice of camera, a solution of at least 4,000 x 4,000 lines is required and the camera concerned must be capable of working with recognized statistical and graphic parcels as more special graphs cannot be produced in ordinary dias programmes. Among the numerous cameras, the following may be mentioned: Montage which costs of 70,000 Danish crowns (approximately 6,000 pounds), Matrix PCR at 100,000 Danish crowns (approximately 9,000 pounds), Matrix QCR-Z at 200,000 Danish crowns (approximately 18,000 pounds) and Lasergraphic's two models at 60,000 and 120,000 Danish crowns, respectively (approximately 5,000 pounds and 10,000 pounds). In the price class of about 100,000 Danish crowns, Matrix PCR can be recommended particularly as this camera has an excellent optic and advanced self calibrating system. Among the cheaper cameras. Montage is recommended which e.g. functions well with Harvard Graphics.(ABSTRACT TRUNCATED AT 250 WORDS)

Ovarian steroid secretion changes after hCG stimulation in early pregnant pigs

Administration of human chorionic gonadotropin (hCG) to promote ovarian steroid secretion near the time of recognition of pregnancy was evaluated. Neither 500 or 1000 IU of hCG caused a significant increase in luteal function as determined by progesterone (P(4)) concentrations in peripheral blood following treatment on Day 12. Estradiol concentrations were elevated (P<0.01) for the 500 IU hCG group on Days 13, 14, 15 and 16 versus the control group. The 1000 IU of hCG group had three-to five-fold greater (P<0.01) estradiol concentrations than controls on Days 14, 15 and 16 post mating. Treatment with hCG also reduced (P<0.05) the number of resorbed embryos. The results suggest that hCG treatment on Day 12 of pregnancy reduced embryo loss and influenced peripheral estradiol secretion patterns.