Can drones save lives and money? An economic evaluation of airborne delivery of automated external defibrillators

BACKGROUND

Out-of-hospital cardiac arrest is one of the most frequent causes of death in Europe. Emergency medical services often struggle to reach the patient in time, particularly in rural areas. To improve outcome, early defibrillation is required which significantly increases neurologically intact survival. Consequently, many countries place Automated External Defibrillators (AED) in accessible public locations. However, these stationary devices are frequently not available out of hours or too far away in emergencies. An innovative approach to mustering AED is the use of unmanned aerial systems (UAS), which deliver the device to the scene.

METHODS

This paper evaluates the economic implications of stationary AED versus airborne delivery using scenario-based cost analysis. As an example, we focus on the rural district of Vorpommern-Greifswald in Germany. Formulae are developed to calculate the cost of stationary and airborne AED networks. Scenarios include different catchment areas, delivery times and unit costs.

RESULTS

UAS-based delivery of AEDs is more cost-efficient than maintaining traditional stationary networks. The results show that equipping cardiac arrest hot spots in the district of Vorpommern-Greifswald with airborne AEDs with a response time < 4 min is an effective method to decrease the time to the first defibrillation The district of Vorpommern-Greifswald would require 45 airborne AEDs resulting in annual costs of at least 1,451,160 €.

CONCLUSION

In rural areas, implementing an UAS-based AED system is both more effective and cost-efficient than the conventional stationary solution. When regarding urban areas and hot spots of OHCA, complementing the airborne network with stationary AEDs is advisable.

Sustaining medical research - the role of trust and control

BACKGROUND

Medical research is increasingly interdisciplinary. However, not all projects are successful and cooperation is not always sustained beyond the end of funding. This study empirically assesses the effect of control and trust on the sustainability of interdisciplinary medical research in terms of its performance and satisfaction.

METHODS

The sample consists of 100 German publicly funded medical research collaborations with scientists from medicine, natural and social sciences (N = 364). We develop a system model to analyze the influence of trust and control on performance and satisfaction of the cooperation.

FINDINGS

Both control and trust are important prerequisites for sustainability, control mainly for the performance of the collaboration, and trust primarily for its satisfaction. While the level of interdisciplinarity is a positive moderator for performance, expectation of continuity is a negative intervening variable for the effect of trust and control on satisfaction. Moreover, trust principally adds to the positive impact of control on sustainability.

CONCLUSIONS

Interdisciplinary medical research requires a participative but systematic management of the respective consortium.

Direct cost of cochlear implants in Germany - a strategic simulation

BACKGROUND

Despite the current undersupply of cochlear implants (CIs) with simultaneously increasing indication, CI implantation numbers in Germany still are at a relatively low level.

METHODS

As there are hardly any solid forecasts available in the literature, we develop a System Dynamics model that forecasts the number and costs of CI implantations in adults for 40 years from a social health insurance (SHI) perspective.

RESULTS

CI demand will grow marginally by demographic changes causing average annual costs of about 538 million €. Medical-technical progress with following relaxed indication criteria and patients' increasing willingness for implantation will increase implantation numbers significantly with average annual costs of 765 million €.

CONCLUSION

CI demand by adults will increase in the future, thus will the costs for CI supply. Continuous research and development in CI technology and supply is crucial to ensure long-term financing of the growing CI demand through cost-reducing innovations.

Strengthening the occupational and social participation of multiple sclerosis patients - design of a multicenter, parallel-group randomized controlled trial (MSnetWork-study)

BACKGROUND

Multiple Sclerosis is an autoimmune inflammatory disease of the central nervous system that often leads to premature incapacity for work. Therefore, the MSnetWork project implements a new form of care and pursues the goal of maintaining or even improving the state of health of MS patients and having a positive influence on their ability to work as well as their participation in social life. A network of neurologists, occupational health and rehabilitation physicians, psychologists, and social insurance suppliers provide patients with targeted services that have not previously been part of standard care. According to the patient's needs treatment options will be identified and initiated.

METHODS

The MSnetWork study is designed as a multicenter randomized controlled trial, with two parallel groups (randomization at the patient level with 1:1 allocation ratio, planned N = 950, duration of study participation 24 months). After 12 months, the patients in the control group will also receive the interventions. The primary outcome is the number of sick leave days. Secondary outcomes are health-related quality of life, physical, affective and cognitive status, fatigue, costs of incapacity to work, treatment costs, out-of-pocket costs, self-efficacy, and patient satisfaction with therapy. Intervention effects are analyzed by a parallel-group comparison between the intervention and the control group. Furthermore, the long-term effects within the intervention group will be observed and a pre-post comparison of the control group, before and after receiving the intervention in MSnetWork, will be performed.

DISCUSSION

Due to the multiple approaches to patient-centered, multidisciplinary MS care, MSnetWork can be considered a complex intervention. The study design and linkage of comprehensive, patient-specific primary and secondary data in an outpatient setting enable the evaluation of this complex intervention, both on a qualitative and quantitative level. The basic assumption is a positive effect on the prevention or reduction of incapacity for work as well as on the patients' quality of life. If the project proves to be a success, MSnetWork could be adapted for the treatment of other chronic diseases with an impact on the ability to work and quality of life.

TRIAL REGISTRATION

The trial MSnetWork has been retrospectively registered in the German Clinical Trials Register (DRKS) since 08.07.2022 with the ID DRKS00025451 .

[Is a tele-emergency physician system a sensible addition in rural German regions?-An analysis from a medical and economic perspective]

Hintergrund und Ziel

Um die präklinische Notfallversorgung zu optimieren und aktuelle Herausforderungen zu bewältigen, wurde im Landkreis Vorpommern-Greifswald im Jahr 2017 ein Telenotarzt-System eingeführt. Es sollte aus medizinischer und ökonomischer Sicht geprüft werden, ob dies, insbesondere im ländlichen Raum, eine effiziente Ergänzung der präklinischen Notfallversorgung darstellt.

Methodik

Es wurden ca. 250.000 Einsatzdaten, vor und nach Einführung des Systems, über die Jahre 2015 bis 2020 ausgewertet und ein Prä-Post-Vergleich über die Einsatzstruktur erstellt. Die 3611 Einsätze der Telenotärztinnen und -ärzte (TNA) wurden nach medizinischen Indikationen und zeitlichen Faktoren analysiert sowie mit Einsätzen ohne TNA verglichen. Zusätzlich erfolgten eine Analyse der Gesamtkosten des neuen Versorgungskonzeptes sowie eine Kostenanalyse der prä- und innerklinischen Behandlungskosten ausgewählter Erkrankungen.

Ergebnisse

Das Einsatzspektrum des TNA umfasste alle Altersstufen mit verschiedenen Meldebildern, die zu 48,2 % eine mittlere Erkrankungsschwere (stationäre Behandlung erforderlich) hatten. Von Patient*innen und Mitarbeitenden wurde das System gut angenommen. Die Einsatzdaten zeigten einen signifikanten Rückgang der Notarztbeteiligung bei telenotarztfähigen Einsatzfahrzeugen um 20 %. Die jährlichen Kosten des Systems belaufen sich auf ca. 1,7 Mio. €.

Schlussfolgerung

Die Ergebnisse belegen die Vorteilhaftigkeit des TNA-Systems, sodass es über die Projektdauer hinaus implementiert wurde. Das System ist medizinisch sinnvoll, funktionsfähig sowie effizient und steht als Innovation für die Umsetzung in ganz Deutschland bereit.

Optimizing home-based long-term intensive care for neurological patients with neurorehabilitation outreach teams - protocol of a multicenter, parallel-group randomized controlled trial (OptiNIV-Study)

Background

Even with high standards of acute care and neurological early rehabilitation (NER) a substantial number of patients with neurological conditions still need mechanical ventilation and/or airway protection by tracheal cannulas when discharged and hence home-based specialised intensive care nursing (HSICN). It may be possible to improve the home care situation with structured specialized long-term neurorehabilitation support and following up patients with neurorehabilitation teams. Consequently, more people might recover over an extended period to a degree that they were no longer dependent on HSICN.

Methods

This healthcare project and clinical trial implements a new specialised neurorehabilitation outreach service for people being discharged from NER with the need for HSICN. The multicentre, open, parallel-group RCT compares the effects of one year post-discharge specialized outpatient follow-up to usual care in people receiving HSICN. Participants will randomly be assigned to receive the new form of healthcare (intervention) or the standard healthcare (control) on a 2:1 basis. Primary outcome is the rate of weaning from mechanical ventilation and/or decannulation (primary outcome) after one year, secondary outcomes include both clinical and economic measures. 173 participants are required to corroborate a difference of 30 vs. 10% weaning success rate statistically with 80% power at a 5% significance level allowing for 15% attrition.

Discussion

The OptiNIV-Study will implement a new specialised neurorehabilitation outreach service and will determine its weaning success rates, other clinical outcomes, and cost-effectiveness compared to usual care for people in need for mechanical ventilation and/or tracheal cannula and hence HSICN after discharge from NER.

Trial registration

The trial OptiNIV has been registered in the German Clinical Trials Register (DRKS) since 18.01.2022 with the ID DRKS00027326.

Prevalence of Low-Value Care and Its Associations with Patient-Centered Outcomes in Dementia

Background:

Low-value care (LvC) is defined as care unlikely to provide a benefit to the patient regarding the patient’s preferences, potential harms, costs, or available alternatives. Avoiding LvC and promoting recommended evidence-based treatments, referred to as high-value care (HvC), could improve patient-reported outcomes for people living with dementia (PwD).

Objective:

This study aims to determine the prevalence of LvC and HvC in dementia and the associations of LvC and HvC with patients’ quality of life and hospitalization.

Methods:

The analysis was based on data of the DelpHi trial and included 516 PwD. Dementia-specific guidelines, the “Choosing Wisely” campaign and the PRISCUS list were used to indicate LvC and HvC treatments, resulting in 347 LvC and HvC related recommendations. Of these, 77 recommendations (51 for LvC, 26 for HvC) were measured within the DelpHi-trial and finally used for this analysis. The association of LvC and HvC treatments with PwD health-related quality of life (HRQoL) and hospitalization was assessed using multiple regression models.

Results:

LvC was highly prevalent in PwD (31%). PwD receiving LvC had a significantly lower quality of life (b = –0.07; 95% CI –0.14 – –0.01) and were significantly more likely to be hospitalized (OR = 2.06; 95% CI 1.26–3.39). Different HvC treatments were associated with both positive and negative changes in HRQoL.

Conclusion:

LvC could cause adverse outcomes and should be identified as early as possible and tried to be replaced. Future research should examine innovative models of care or treatment pathways supporting the identification and replacement of LvC in dementia.

Overcoming COVID-19 in China despite shortcomings of the public health system: what can we learn?

BACKGROUND AND OBJECTIVE

The COVID-19 pandemic started in Wuhan, China, in December 2019. Although there are some doubts about the reporting of cases and deaths in China, it seems that this country was able to control the epidemic more effectively than many other countries. In this paper, we would like to analyze the measures taken in China and compare them with other countries in order to find out what they can learn from China.

METHODS

We develop a system dynamics model of the COVID-19 pandemic in Wuhan. Based on a number of simulations we analyze the impact of changing parameters, such as contact rates, on the development of a second wave.

RESULTS

Although China's health care system seems to be poorly financed and inefficient, the epidemic was brought under control in a comparably short period of time and no second wave was experienced in Wuhan until today. The measures to contain the epidemic do not differ from what was implemented in other countries, but China applied them very early and rigorously. For instance, the consequent implementation of health codes and contact-tracking technology contributed to contain the disease and effectively prevented the second and third waves.

CONCLUSIONS

China's success in fighting COVID-19 is based on a very strict implementation of a set of measures, including digital management. While other countries discuss relaxing the lock-down at a rate of 50 per 100,000 inhabitants, China started local lock-downs at a rate of 3 per 100,000. We call for a public debate whether this policy would be feasible for more liberal countries as well.

Telemedical emergency services: central or decentral coordination?

BACKGROUND AND OBJECTIVE

Teleemergency doctors support ambulance cars at the emergency site by means of telemedicine. Currently, each district has its own teleemergency doctor office (decentralized solution). This paper analyses the advantages and disadvantages of a centralized solution where several teleemergency doctors work in parallel in one office to support the ambulances in more districts.

METHODS

The service of incoming calls from ambulances to the teleemergency doctor office can be modelled as a queuing system. Based on the data of the district of Vorpommern-Greifswald in the Northeast of Germany, we assume that arrivals and services are Markov chains. The model has parallel channels proportionate to the number of teleemergency doctors working simultaneously and the number of calls which one doctor can handle in parallel. We develop a cost function with variable, fixed and step-fixed costs.

RESULTS

For the district of Greifswald, the likelihood that an incoming call has to be put on hold because the teleemergency doctor is already fully occupied is negligible. Centralization of several districts with a higher number of ambulances in one teleemergency doctor office will increase the likelihood of overburdening and require more doctors working simultaneously. The cost of the teleemergency doctor office per ambulance serviced strongly declines with the number of districts cooperating.

DISCUSSION

The calculations indicate that centralization is feasible and cost-effective. Other advantages (e.g. improved quality, higher flexibility) and disadvantages (lack of knowledge of the location and infrastructure) of centralization are discussed.

CONCLUSIONS

We recommend centralization of telemedical emergency services. However, the number of districts cooperating in one teleemergency doctor office should not be too high and the distance between the ambulance station and the telemedical station should not be too large.

Costing of helicopter emergency services- a strategic simulation based on the example of a German rural region

BACKGROUND

Helicopter emergency services (HEMS) are of increasing relevance for emergency medical services (EMS) of developed countries. Despite the known cost intensity of HEMS, there is only very limited knowledge of its cost dynamics and structures. This averts an efficient resource allocation of scarce EMS resources in an environment that is characterized by socio-political, medical and economic challenges. The objective of this study is the exemplary modeling of HEMS cost structures.

METHODS

We defined three scenarios with each five variations to illustrate different models of HEMS provision. Into these, we included varying availability times, technical features for off-shore or alpine rescue and differing numbers of operations. Cost data is based on a broad literature review and primary data from a German HEMS organization resulting in a cost function. We calculated average costs per primary missions and total costs, whilst differentiating between fixed, jump-fixed, variable and maintenance costs for every scenario variation. The costs were further used to evaluate the profitability of operations by executing a break-even analysis.

RESULTS

Average costs per HEMS operation decrease with increasing number of operations due to the digression of fixed costs. Depending on special equipment, availability times or other assumptions, total costs differ significantly with the different scenario variations. For the basic scenario (12 h of operations per day), the total costs per year of HEMS are 1,697,546.20 € and the unit costs are 763.41 € per primary mission at 1200 primary and 92 secondary operations. At an engine-runtime based revenue of 70 € per minute, global cost covering is possible after 728 missions (c.p.).

CONCLUSIONS

Considering a revenue of 70 € per minute of engine run-time, HEMS can be operated at a profit for companies. However, the necessary remuneration represents a high financial effort for the societal cost bearers of helicopter emergency services. This leads to the question of the cost-benefit ratio of HEMS, which could be approached in further researches by using this model. The valuation of mission costs also opens a new view to the framework of HEMS disposition procedures and criteria. This cost analysis enhances the necessity of better planning of HEMS networks to use available resources efficiently in order to improve social welfare.

[The Tele-Emergency Physician System as an Innovation in the Emergency Medical Service: Evaluation of Potentials by Employees of German Ambulance Control Centres]

BACKGROUND

One of the health policy challenges lies in guaranteeing comprehensive emergency care in Germany. Telemedical applications are assumed to be a potential solution to current problems. One of these innovations is the tele-emergency physician system, which changes the workflows of the various actors in prehospital emergency medicine. The aim of the study was to determine how the potentials of the tele-emergency physician system were evaluated by employees of the ambulance control centres in Germany.

METHOD

In the cross-sectional study, employees of ambulance control centres throughout Germany were interviewed using an online-based questionnaire. The results are illustrated in a sub-group analysis according to the state of knowledge on innovation, either (very) low or (very) high. Correlation analyses were carried out to determine significant differences between the subgroups. Data analysis was performed using Microsoft Excel 2013 and IBM SPSS Version 25.

RESULTS

The response rate was 69.04%. Of those surveyed, 76.23% expected that the tele-emergency physician system would save them a relevant amount of time. 57.38% believed that patients would be transported faster and 51.64% of the respondents did not see any chance of cost savings in the health care system. Significant evaluation differences resulted in expected time saving (p=0.004), shorter time to transport (p=0.009) and cost saving (p=0.0004). 64.71% thought that there would be a risk of increased documentation effort. 56.41% did not believe that patients would be sufficiently informed about the legal provisions on data protection during their tele-emergency physician treatment. The increase in documentation effort (p=0.02) and patients being sufficiently informed about data protection regulations (p=0.015) were evaluated significantly differently. 90.98% of the respondents rated the tele-emergency physician system as meaningful. The rural region was considered by 47.62% of the respondents as the primary region where the use of system would be necessary. 36.29% of the participants stated that a tele-emergency physician system should be implemented in their own area.

CONCLUSION

All in all, the tele-emergency physician system is considered useful in prehospital emergency medical service by the staff of the emergency control centres. However, the majority of participants do not assume that there is potential for implementation of this system in their own region.

Lifetime cost of unilateral cochlear implants in adults: a Monte Carlo simulation

BACKROUND/OBJECTIVE

Due to increasing prevalence of hearing loss and relaxation of candidacy criteria of cochlear implant (CI) supply, the number of implantations is likely to further increase. Statutory health insurances are facing ever more urgent financing challenges since CI treatment causes high life-long costs. Additionally, increasing life expectancy and earlier implantation may extend therapy time and cost. With every case being individual, this study aims to calculate the possible lifetime cost of unilateral CI treatment in adults including stochastic uncertainties.

METHODS

Taking a statutory health insurance perspective, relevant cost components of CI therapy and their values were identified. The Monte Carlo method was used to simulate lifetime cost considering age at first implantation and distributions of costrelevant variables. A sensitivity analysis was conducted to determine the most crucial variables impacting on lifetime cost.

RESULTS

Lifetime cost of CI treatment varies according to age at first implantation, respectively remaining lifetime; the earlier the implantation, the higher the overall cost. According to our simulation, the average lifetime cost for an adult patient first implanted between the age of 20-80 is at 53,030 € (present value). Cost of implantation and periodic speech processor exchanges show the highest impact on the total cost.

DISCUSSION

Health care systems could face rising expenses for CI supply by technical development. Innovative life-long CIs could achieve significant savings per case that could finance additional implant cost. Until then, further targeted research will be required.

CONCLUSION

CI-related cost for statutory health insurance crucially depends on the patient-side demand for cochlear implants. Therefore, cost forecasts must also consider the development of demand.

Der Telenotarzt als Innovation des Rettungsdienstes im ländlichen Raum – Kosten der Implementierung

Zielsetzung In der Notfallversorgung besteht insbesondere in ländlich geprägten Regionen ein Zielkonflikt zwischen hoher Versorgungsqualität und effizientem Mitteleinsatz. Eine mögliche Lösung könnte der Telenotarzt darstellen, der mittels Informations- und Kommunikationstechnologien noch vor Eintreffen des Notarztes oder diesen ersetzend mit der ärztlichen Behandlung beginnen kann.

Folgend werden die Kosten eines Telenotarzt-System dargestellt. Die Analyse basiert auf der Einführung eines Telenotarzt-Systems im Landkreis Vorpommern-Greifswald.

Methodik Als Datengrundlage dienten die im Rahmen der Einführung des Telenotarzt-Systems im Landkreis Vorpommern-Greifswald angefallenen Kosten. Sämtliche Kosten wurden zu den Positionen Sach- und immaterielle Investitionen sowie jährliche Betriebs- und Personalkosten zusammengefasst. Weiterhin wurden die Investitionskosten anteilig berücksichtigt, so dass eine Jahresbetrachtung möglich war. Abschließend wurden die Kosten zu einer Kostenfunktion summiert.

Ergebnisse Bei Zusammenführung aller angefallenen Kosten im Rahmen des Projektes Land|Rettung entstehen jährlich für jeden telenotarztfähigen Rettungswagen Kosten in Höhe von 20 842 €. Unter der Annahme eines betriebenen Telenotarzt-Arbeitsplatzes, belaufen sich die jährlichen Sach-, Personal- und Betriebskosten in dem Kreis insgesamt auf 1 049 466 €. Hierin enthalten sind die Investitions- und Betriebskosten des Telenotarzt-Arbeitsplatzes sowie allgemeine Komponenten des Telenotarzt-Systems (beispielsweise Netzwerk und Personalschulungen).

Schlussfolgerung Das Telenotarzt-System, so wie es im Kreis Vorpommern-Greifswald entwickelt wurde, ist grundsätzlich auch für andere ländliche Regionen eine sinnvolle Maßnahme zur Verbesserung der Notfallversorgung. Wie das Beispiel aus Nordostdeutschland zeigt, sind die Kosten jedoch nicht vernachlässigbar. Bei der Übertragung auf andere Regionen können die Kosten abweichen, denn die Größe, der Urbanisierungsgrad sowie die geographische Lage einer Region beeinflussen die Kostenfunktion. Die hier vorgelegte Analyse gibt jedoch einen ersten Ansatz, um diese Kosten abschätzen zu können und damit eine evidenzbasierte Entscheidung über den Einsatz eines Telenotarztes treffen zu können.

[The Calculated Physician's Fee in the Doctor's Fee Scale (EBM): A Normative Parameter for Medical Doctors in the Outpatient Sector]

The "calculated physician's fee" is important part of the ongoing discussion on health policies and the Doctor's fee scale (EBM). It is the fictional gross fee that a community doctor can receive when he selects employee relationship instead of being freelance. In order to determine the significance for real physician fees, the gross fees per minute for a community physician have been analysed in different ways: Version 1) Opportunity principle: The gross fee per minute is € 0.90. The basis is the senior physician salary plus the supplement shown in the "calculated physician's fee" (18.66% for entrepreneurial activity, 27.50% for additional work time). Version 2) Empirical value: The gross fee per minute in the outpatient sector is € 1.13 and, net of GKV, € 0.94. The fee for the calculated hospital sector is € 0.93. CONCLUSION: The value of the "calculated physician's fee" should be raised in accordance with the extra time worked. Considering senior physician's salary as an opportunity cost for community physicians appears to be correct, but the gross fees per minute for community doctors are only financially attractive when one provides services outside of the EBM. Also, the yearly adjustment of the benchmark influences the profits of community physicians. Further developments in calculating the EBM are complex, but provide an opportunity to counteract regional gaps in outpatient care.

[Effects of Depressive Comorbidities on Revenues of Somatic Inpatients in the G-DRG-System]

BACKGROUND

Depressive comorbidity is common with physically ill inpatients and is associated with many negative medical and economic effects (e. g., increased morbidity and mortality, increased length of stay, poorer quality of life and increased utilization of health services). The aim of this study is to clarify the question whether the additional costs caused by comorbid depressive diseases are recovered by additional G-DRG-specific revenues in order to finance necessary diagnostics and therapies of this comorbidity.

METHODS

We analysed the revenues generated by depressive secondary diagnoses. Consequently, we selected patients with relevant F-diagnoses according to ICD-10 from billing data of the University Hospital Greifswald between 2010 and 2014. We recoded each case without a comorbid depression, taking into account the specifications of the relevant accounting year. Subsequently, the revenues with and without coding the comorbidity were compared (n=6,563).

RESULTS

In 115 out of 6,563 patients (1.75%), mainly with unspecific recurrent depressions, the documentation and coding of a comorbid depression led to a change in the proceeds. Taking into account the applicable base rate between 2010 and 2014, the coding leads to an additional revenue of 216,737.01 Euro for the entire observation period. This corresponds to an increase of approximately 1,885 Euro per patient (n=115). In relation to the total number of patients with comorbid depressions (n=6,563) it is a surplus of 33.02 Euro. However, predominantly unspecific depressive diagnoses (e. g., F 32.8) are encoded, which do not increase the level of severity in the DRG system and, thus, have no effect on the proceeds.

DISCUSSION

In very few cases, the inclusion of depressive comorbidities leads to an increase in revenue. Only some depressive diagnoses have a CCL. Due to the relatively low CCL (1 or 2), depressive comorbidities often show no effect on PCCL of multimorbid patients. Currently there is no adequate financial incentive for the hospitals to recognize and treat depressions, since the additional costs do not lead to increased revenues. In the context of a systemic treatment, depression will have to be taken into account more strongly in the financing system, especially in view of the numerous negative effects of this comorbidity.

Integrating cross-border emergency medicine systems: Securing future preclinical medical workforce for remote medical services

The European Union intends to enable its citizens to interact across borders in relevant areas of society and culture to further integrate neighboring regions. Medicine has not been at the core of recent EU-funded efforts in central Europe, partially due to significant differences in health care administration, delivery, reimbursement, and culture. However, impeding changes in social structure and centralization of specialized care warrant changes in preclinical administration of medical care, which are already transforming practices across developed countries in central Europe. Moreover, demographic and social changes are transforming not only patients but also health care providers, thus leading to an increased need for specialized medical personnel, particularly in regions close to formerly secluding borders. The EU-funded cooperation project presented in this article is located in the Euroregion Pomerania, which consists of northeastern Germany and northwestern Poland. This project emerged because of the need to solve practical emergency medicine-related problems for many years, which brought partners together. Unfortunately, administrative and medical interaction has not become significantly easier with Poland joining the Schengen area in 2007 and, subsequently, initial international contracts regarding, among other things, emergency medicine being negotiated and signed thereafter. Three different interdependent areas of cooperation within the project deal with key aspects of an improved and eventually integrated cooperation. An accepted clarification of administrative and legal foundations - or the lack and thus the need thereof - needs to be defined. Specialized language and simulation-based education and practice sessions employing modern technology throughout will be introduced to the entire region. Finally, the pre-existing and developing acceptance and sustainability aspects of personnel involved in the aforementioned actions and stakeholders on both sides of the border will be evaluated. In essence, the project focuses on a multimodal improvement of professional cooperation of key providers of emergency medicine services in the Euroregion Pomerania. Thereby, it aims to improve infrastructure; interpersonal and professional skills of involved personnel, administrative, and cultural relations; and eventually identification of specialized personnel with their workplace and region to secure and retain important medical workforce in an otherwise remote area on both sides of a formerly secluded border.

[Young Academics in Neuropsychological Disciplines: Factors Affecting Career Aspiration in Psychiatry, Neurology and Psychosomatic Medicine]

OBJECTIVE

Students with specialization preferences in psychiatry, neurology, or psychosomatic medicine were retrospectively compared with regard to aspects of motivation to choose medicine as their field of study.

METHODS

To identify early predictors of specialization preferences, a nationwide online survey was conducted with 9079 medical students. The statements of those with a preference for neurology, psychiatry, or psychosomatic medicine were evaluated using analysis of variance (ANOVA).

RESULTS

Prospective neurologists were motivated by scientific interest variables and less by the aspects of life management. On the other hand, students with preferences for one of the psychological disciplines reported comparatively higher degrees of desire to actively provide help and of the importance of their own medical history. There were no significant differences between future psychiatrists and psychosomatic professionals.

CONCLUSION

The reported motives point to thematic orientations that might be useful in the subject-specific acquisition of young academics.

[Cost assessment for endoscopic procedures in the German diagnosis-related-group (DRG) system - 5 year cost data analysis of the German Society of Gastroenterology project]

Background In the German hospital reimbursement system (G-DRG) endoscopic procedures are listed in cost center 8. For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e. g. DKG-NT, GOÄ) have remained in use. We have assessed the cost for endoscopic procedures in the G-DRG-system. Methods To assess the cost of endoscopic procedures 74 hospitals, annual providers of cost-data to the Institute for the Hospital Remuneration System (InEK) made their data (2011 - 2015; § 21 KHEntgG) available to the German-Society-of-Gastroenterology (DGVS) in anonymized form (4873 809 case-data-sets). Using cases with exactly one endoscopic procedure (n = 274 186) average costs over 5 years were calculated for 46 endoscopic procedure-tiers. Results Robust mean endoscopy costs ranged from 230.56 € for gastroscopy (144 666 cases), 276.23 € (n = 32 294) for a simple colonoscopy, to 844.07 € (n = 10 150) for ERCP with papillotomy and plastic stent insertion and 1602.37 € (n = 967) for ERCP with a self-expanding metal stent. Higher costs, specifically for complex procedures, were identified for University Hospitals. Discussion For the first time this catalogue for endoscopic procedure-tiers, based on § 21 KHEntgG data-sets from 74 InEK-calculating hospitals, permits a realistic assessment of endoscopy costs in German hospitals. The higher costs in university hospitals are likely due to referral bias for complex cases and emergency interventions. For 46 endoscopic procedure-tiers an objective cost-allocation within the G-DRG system is now possible. By international comparison the costs of endoscopic procedures in Germany are low, due to either greater efficiency, lower personnel allocation or incomplete documentation of the real expenses.

[Regional Budgets in Psychiatry: An Alternative to Hospital per Diem Charges and the New Reimbursement System? - A Case Study from the District of Dithmarschen]

Objective The study looked at the impact that the switch from a reimbursement system with hospital per diem charges to a regional budget had on treatment. Methods Routine data from two clinics over a period of ten years were evaluated. Results Treatment took place in day clinics and on an outpatient basis to an increased extent after the change. Conclusion The change in reimbursement system was the cause of the change in treatment. Since similar effects can also be expected when switching from the new reimbursement system for psychiatry and psychosomatic medicine to a regional budget system, regional budgets are a reasonable alternative.

Systems Medicine: hype or revolution?

Research and innovation in healthcare can change existing practices aiming at constant improvement of diagnosis, treatment and prevention. As a new holistic approach Systems Medicine (SM) may revolutionize the healthcare system. This paper analyzes ethical and economic obstacles of SMs development from a niche innovation to a standard solution. We adapt a model of innovation theory to structure the barriers of adopting SM to become standard in the medical system. SM has the potential to change the medical system if barriers to this innovation can be overcome. The article discusses the potential of SM in becoming the future health paradigm considering these barriers and provides an overview of the current situation.

[Diagnostics and Eradication Therapy for MRSA Carriers in the Outpatient Sector: an Analysis of the Reimbursement Situation in the Light of Current Reimbursement Changes]

Infection with methicillin-resistant Staphylococcus aureus (MRSA) occurs in both the inpatient and outpatient sector. The reimbursement for diagnostic services and eradication therapy in the outpatient sector was regulated for the first time on 01.04.2012 and after a 2-year test period, has been adopted into the standard range of care services. The aim of this retrospective study was to give an overview of the current situation in services and reimbursement in Germany and describe MRSA patients and their treatment in the outpatient sector. Secondary data, namely reimbursement data of the National Association of Statutory Health Insurance Physicians (KBV) und the Physicians' Association (KV) Mecklenburg-West Pomerania for the period 01/04/2012-31/03/2014 were analyzed. Results show that on the federal level, MRSA services amounting to € 3,235,870.18 have been reimbursed and that diagnostic costs exceed treatment costs. In Germany, 5,627 doctors invoiced services related to MRSA; 51,56% of these were general practitioners and 21,25% specialists in internal medicine working in general practice. In the KV Mecklenburg-Western Pomerania, patients were elderly (average age 69,13), cost for services were on average 27,76 €, and 76,85% of the patients were treated within one quarter. On the whole, there were regional differences in the identification and eradication of MRSA in the outpatient setting. In order to provide an extended base for a more efficient resource allocation in the health care sector, in addition to analysis of MRSA eradication from the medical point of view, attention needs to be paid to patient flow between the out- and inpatient sectors, as well as economic aspects.

[Psychiatric Nursing Internship and Promotion of Specialized Training Interest]

Qualified personnel in the field of medical psychiatry are crucial to providing comprehensive care. The importance of a nursing internship as an access point to the psychiatric field is not considered by key players. A survey conducted across German medical schools in 2012 analyzed medical care internships as viewed by medical school students. From among students surveyed, those who participated in a nursing internship, and would consider taking part in further internships within the psychiatric department ("PFJ"), were separated from those who were not sure ("PFU") or who would not ("PFN") consider further study in the field of psychiatry. The survey's conclusion was that a comparably small number of students opted for a psychiatric nursing internship based upon practical aspects of content, satisfaction, and access to nursing internships. A potential solution to the low numbers of students selecting psychiatric internships is to restructure the initial contact program that psychiatric departments use to introduce prospective medical school students to the field of psychiatry.

[Financing Regional Dementia Networks in Germany: Determinants of Sustainable Healthcare Networks]

OBJECTIVES

Analysis of practice-based financing concepts in German dementia networks (DN); Provision of sustainable financing structures and their determinants in DN.

MATERIALS AND METHODS

Qualitative expert interviews with leaders of 13 DN were conducted. A semi-structured interview guide was used to analyse four main topics: Finance-related organization, cost, sources of funding and financial sustainability.

RESULTS

DN were primarily financed by membership fees, earnings of services provided, public funds and payments by municipalities or health care providers. 63% of the DN reported a financial sustainability. Funds to support the interpersonal expanding, a mix of internal and external financing sources and investments of the municipality were determinants of a sustainable financing. Overall, DN in rural areas seemed to be disadvantaged due to a lack of potential linkable service providers.

CONCLUSION

DN in urban regions are more likely able to gather sustainable funding resources. A minimum funding of 50.000 €/year for human resources coordinating the DN, seems to be a threshold for a sustainable DN.

Association of PNPLA3 rs738409 and TM6SF2 rs58542926 with health services utilization in a population-based study

Background

Hepatic steatosis confers an increased risk of metabolic and cardiovascular disease and higher health services use. Associations of the single nucleotide polymorphisms (SNP) PNPLA3 rs738409 and TM6SF2 rs58542926 with hepatic steatosis have recently been established. This study investigates the association between rs738409 and rs58542926 with health services utilization in a general population.

Methods

Data of 3759 participants from Study of Health in Pomerania (SHIP), a population-based study in Germany, were obtained. The annual number of outpatient visits, hospitalization and length of hospital stay was regressed on rs738409 and rs58542926 and adjusted for socio-economic factors, lifestyle habits, clinical factors, and health status.

Results

Minor allele homozygous subjects of rs738409 had an increased odds of hospitalization as compared to major allele homozygous subjects (odds ratio [OR] 1.51; 95 % confidence interval [CI], 1.02 to 2.15). Heterozygous subjects did not differ from major allele homozygous subjects with respect to their odds of hospitalization. The three genotype groups of rs738409 were similar with respect to the number of outpatient visits and inpatient days. Minor allele homozygous and heterozygous subjects of rs58542926 had higher outpatient utilization (+53.04 % and +67.56 %, p < 0.05, respectively) and inpatient days than major allele homozygous subjects.

Conclusions

After adjustment for several confounding factors, PNPLA3 rs738409 and TM6SF2 rs58542926 were associated with the number of outpatient visits, hospitalization, and inpatient days. Further studies are warranted to replicate our findings and to evaluate whether genetic data can be used to identify subjects with excess health services utilization.

The cost of dialysis in low and middle-income countries: a systematic review

Background

The cost of dialysis in low and middle-Income countries has not been systematically reviewed. The objective of this article is to systematically review peer-reviewed articles on the cost of dialysis across low and middle-income countries.

Methods

PubMed and Embase databases were searched for the year 1998 to March 2013, and additional studies were added from Google Scholar search. An article was included if two reviewers agreed that it had reported cost of dialysis from low and middle-Income countries.

Results

The annual cost per patient for hemodialysis (HD) ranged from Int$ 3,424 to Int$ 42,785, and peritoneal dialysis (PD) ranged from Int$ 7,974 to Int$ 47,971. Direct medical cost especially drugs and consumables for HD and dialysis solutions and tubing for PD were the main cost drivers.

Conclusion

The number of studies on the economics of dialysis in low and middle-income countries is limited. Few papers indicate that dialysis is an expensive form of treatment for the population of these countries and that the poorer countries have an over-proportional burden to finance dialysis services. Further research is needed to determine the cost of dialysis based on a standard methodology grounded on existing economic guidelines and to address the question whether dialysis should be an element of the essential package of health in resource-poor countries. Used data should be as complete as possible. In case of missing data, proxies can be used. In case of developing countries, expert interviews are often used for estimating missing information.

[Improvement of cost allocation in gastroenterology by introduction of a novel service catalogue covering the complete spectrum of endoscopic procedures]

BACKGROUND

The German hospital reimbursement system (G-DRG) is incomplete for endoscopic interventions and fails to differentiate between complex and simple procedures. This is caused by outdated methods of personnel-cost allocation.

METHODS

To establish an up-to-date service catalogue 50 hospitals made their anonymized expense-budget data available to the German-Society-of-Gastroenterology (DGVS). 2.499.900 patient-datasets (2011-2013) were used to classify operation-and-procedure codes (OPS) into procedure-tiers (e.g. colonoscopy with biopsy/colonoscopy with stent-insertion). An expert panel ranked these tiers according to complexity and assigned estimates of physician time. From June to November 2014 exact time tracking data for a total 38.288 individual procedures were collected in 119 hospitals to validate this service catalogue.

RESULTS

In this three-step process a catalogue of 97 procedure-tiers was established that covers 99% of endoscopic interventions performed in German hospitals and assigned validated mean personnel-costs using gastroscopy as standard. Previously, diagnostic colonoscopy had a relative personnel-cost value of 1.13 (compared to gastroscopy 1.0) and rose to 2.16, whereas diagnostic ERCP increased from 1.7 to 3.62, more appropriately reflecting complexity. Complex procedures previously not catalogued were now included (e.g. gastric endoscopic submucosal dissection: 16.74).

DISCUSSION

This novel service catalogue for GI-endoscopy almost completely covers all endoscopic procedures performed in German hospitals and assigns relative personnel-cost values based on actual physician time logs. It is to be included in the national coding recommendation and should replace all prior inventories for cost distribution. The catalogue will contribute to a more objective cost allocation and hospital reimbursement - at least until time tracking for endoscopy becomes mandatory.

[Outpatient Care of People with Dementia within Residential Communities in Germany--Care Potential and Cost]

BACKGROUND

Since the 1980s dementia residential communities (DRC) have been established as part of the health-care landscape and as an alternative to inpatient long-term nursing care. Information about (a) the residents (b) the care potential and (c) the cost of DRCs are still lacking.

METHODS

A nation-wide postal questionnaire was sent to n=332 DRCs managed by n=151 organizations. The sample was based on an internet search with various combinations of search terms such as "outpatient" and "residential care communities". The questionnaire contained questions about the resident's social-demography, nursing care level and the utilization, financing and cost structures of DRCs.

RESULTS

In total 81 organizations with n=88 DRCs replied to the questionnaire. Overall n=794 persons were living in these communities, most of the residents were female (80%, n=522), and 67% of the residents were older than 80 years. The nursing care level was high, 27% of the DRC residents reached the highest stage. Only 5% of the DRCs capacity was vacant. 86% of the communities stated to be able to provide nursing care for the residents until the end of their life. Almost half (48%) of the residents received money from the social welfare. The total average amount of cost per place per month was 3,265.08€ (excluding costs of services related to health insurance).

CONCLUSIONS

DRCs are caring for residents with high nursing care levels. Costs of these communities vary to a large extent but are in addition comparable to inpatient long-term nursing care. Thus, interested persons should obtain information about cost, financing and care concepts. The low level of vacant capacity demonstrates the demand for DRCs in Germany. Studies with the objective to evaluate quality of care, care concepts and suitable clients for those communities are needed to develop this living concept.

[Additional Costs for Care of Patients with Multi-Resistant Pathogens--An Analysis from the Perspective of a Statutory Health Insurance]

Aim of this study was to determine the additional expenditures for a German statutory health insurance which are induced by patients with multi-resistant bacteria. Therefore a nationwide cross-sectional data analysis using routine data of the health insurance "Techniker Krankenkasse" was conducted. In the consideration of costs we included expenditures for inpatient and outpatient care and on drugs in a time period of 12 months. A control group was matched by age, gender, basic disease, quarterly period and region. On average additional costs of 17,500 Euro per insured were calculated due to the presence of multi-resistant bacteria. The hypothesis was corroborated in that the level of these costs differ widely by age, gender and basic disease.

Societal cost-of-illness in patients with borderline personality disorder one year before, during and after dialectical behavior therapy in routine outpatient care

Societal cost-of-illness in a German sample of patients with borderline personality disorder (BPD) was calculated for 12 months prior to an outpatient Dialectical Behavior Therapy (DBT) program, during a year of DBT in routine outpatient care and during a follow-up year. We retrospectively assessed resource consumption and productivity loss by means of a structured interview. Direct costs were calculated as opportunity costs and indirect costs were calculated according to the Human Capital Approach. All costs were expressed in Euros for the year 2010. Total mean annual BPD-related societal cost-of-illness was €28026 (SD = €33081) during pre-treatment, €18758 (SD = €19450) during the DBT treatment year for the 47 DBT treatment completers, and €14750 (SD = €18592) during the follow-up year for the 33 patients who participated in the final assessment. Cost savings were mainly due to marked reductions in inpatient treatment costs, while indirect costs barely decreased. In conclusion, our findings provide evidence that the treatment of BPD patients with an outpatient DBT program is associated with substantial overall cost savings. Already during the DBT treatment year, these savings clearly exceed the additional treatment costs of DBT and are further extended during the follow-up year. Correspondingly, outpatient DBT has the potential to be a cost-effective treatment for BPD patients. Efforts promoting its implementation in routine care should be undertaken.

Krankheitskosten der Borderline Persönlichkeitsstörung aus gesellschaftlicher Perspektive

Hintergrund: Bislang liegen in Deutschland keine Befunde über die krankheitsbedingten Kosten von Patienten mit einer Borderline Persönlichkeitsstörung (BPS) aus der gesellschaftlichen Perspektive vor. Fragestellung: Wie hoch sind die jährlichen Krankheitskosten pro BPS-Patient? In welchen Bereichen entstehen die höchsten Kosten? Methodik: Auf der Grundlage aktueller gesundheitsökonomischer Empfehlungen wurden die krankheitsbedingten Kosten von N = 55 BPS-Patienten in Berlin für den Zeitraum von 12 Monaten vor Beginn einer ambulanten Psychotherapie aus der gesellschaftlichen Perspektive mit einem Interview erhoben und berechnet. Ergebnisse: Die Krankheitskosten in den 12 Monaten vor der Therapie betrugen insgesamt € 26.882 (SD = € 32.275) pro BPS-Patient. € 17.976 (SD = € 23.867) davon waren direkte Kosten, € 8.906 (SD = € 15.518) wurden für indirekte Kosten berechnet. Die höchsten Kosten entstanden durch stationäre und teilstationäre Aufenthalte (M = € 13.121; SD = € 19.808) sowie durch krankheitsbedingte Erwerbsunfähigkeit (M = € 7.020; SD = € 15.099). Schlussfolgerungen: Die BPS geht mit hohen gesellschaftlichen Kosten einher, die weitaus höher sind als die durch viele andere psychische und somatische Erkrankungen bedingten Kosten.

Cost comparison of MRSA screening and management - a decision tree analysis

Background

Methicillin-resistant Staphylococcus aureus (MRSA) infections represent a serious challenge for health-care institutions. Rapid and precise identification of MRSA carriers can help to reduce both nosocomial transmissions and unnecessary isolations and associated costs. The practical details of MRSA screenings (who, how, when and where to screen) remain a controversial issue.

Methods

Aim of this study was to determine which MRSA screening and management strategy causes the lowest expected cost for a hospital. For this cost analysis a decision analytic cost model was developed, primary based on data from peer-reviewed literature. Single and multiplex sensitivity analyses of the parameters “costs per MRSA case per day”, “costs for pre-emptive isolation per day”, “MRSA rate of transmission not in isolation per day” and “MRSA prevalence” were conducted.

Results

The omission of MRSA screening was identified as the alternative with the highest risk for the hospital. Universal MRSA screening strategies are by far more cost-intensive than targeted screening approaches. Culture confirmation of positive PCR results in combination with pre-emptive isolation generates the lowest costs for a hospital. This strategy minimizes the chance of false-positive results as well as the possibility of MRSA cross transmissions and therefore contains the costs for the hospital. These results were confirmed by multiplex and single sensitivity analyses. Single sensitivity analyses have shown that the parameters “MRSA prevalence” and the “rate of MRSA of transmission per day of non-isolated patients” exert the greatest influence on the choice of the favorite screening strategy.

Conclusions

It was shown that universal MRSA screening strategies are far more cost-intensive than the targeted screening approaches. In addition, it was demonstrated that all targeted screening strategies produce lower costs than not performing a screening at all.

[Quality features of German memory clinics: a cross-sectional study]

BACKGROUND

Although memory clinics have become an established institution for diagnosing and treating dementia in Germany over the years, little is known about their quality features. Considering the increasing societal relevance of dementia, memory clinics will most likely gain in importance in the future.

MATERIAL AND METHODS

Addresses of German memory clinics were obtained by an online search. All institutions were surveyed via questionnaire with items regarding structural characteristics (designation, affiliation, services offered, funding) and quality features (waiting times, disease severity at diagnosis).

RESULTS

The results of the inquiry of all institutions (n=153, response: 48%) show memory clinics as specialised institutions that have a low degree of standardisation, but basically have a high structural quality for diagnostic and therapeutic care.

CONCLUSION

The development of homogeneous structure and process standards could help to establish memory clinics in regular care and to establish sustainable funding. In order to achieve this, an even more intensive collaboration and consensus building of all German memory clinics would be needed as well as a coordinated representation of interests.

Marginal contribution of UKS- versus TKA in varus arthritis of the knee

BACKGROUND

In recent years, decisions regarding the treatment of individual patients have increasingly been affected by economic considerations. The G-DRG system reimburses sledge endoprosthetic implantations at a much lower rate than surface replacements and at significantly different cost weights (CW). Therefore, when only G-DRG payments are considered, TKA produces higher gains. Taking only these revenues alone into consideration, however, does not provide the basis of an economically sound decision-making process. The target of this research was to present a comparison between variable costs of the two procedures.

METHODS

The mean cost and performance data of 28 Endo-Modell (Link company) sledge implantations (UKS) and of 85 NexGen CR surface replacement total knee arthroplasties (TKA; Zimmer company) were compared in 2007.

RESULTS

From the perspective of the hospital, UKS treatment is of greater economic advantage when the medical indication is given. In preferring UKS marginal contribution can be improved, and although the relative weighting is comparatively low, the costs are significantly lower than in a comparative analysis of TKA. Based on the length of stay required for each procedure the average daily CW for UKS can be calculated as 0.1728, while being 0.1955 for TKA. The earlier release of the first patient results in another patient being admitted 1.5 days earlier and thus an increase in case mix. Meanwhile, the case-mix index and the costs of care per case decrease ceteris paribus.

CONCLUSION

Assuming the correct medical indication, the hospital seeking to maximize its marginal contribution would be wise to select sledge endoprosthesis implantation. Considering the economic perspective of gains and costs, the assumption that TKA is advantageous could not be confirmed in the present study.

Cost-analysis of PCR-guided pre-emptive antibiotic treatment of Staphylococcus aureus infections: an analytic decision model

The aim of this study is to examine whether rapid polymerase chain reaction (PCR)-based screening is a cost-efficient tool to optimize pre-emptive antibiotic therapy of methicillin-resistant and methicillin-sensitive Staphylococcus aureus (MRSA and MSSA, respectively) infections. A decision analytic cost model was developed, based on data from the peer-reviewed literature. Sensitivity analyses were undertaken to investigate the impact of variation in the MRSA rate, cost ratio of the cost of inappropriate antibiotic therapy to the cost of appropriate antibiotic therapy, PCR test cost, and total hospital costs per case. At a current MRSA rate of 24.5 % in Germany, PCR-guided treatment regimens are cost-efficient compared to empirical strategies. The costs of alternative treatment strategies differ, on average, up to 1,780 <euro> per case. An empirical MRSA treatment strategy is least costly when the cost ratio is less than 1.06. When the total hospital cost per MRSA case is increased, pre-emptive MSSA treatment with PCR tests achieves the lowest average cost. Early verification and adaptation of an initial pre-emptive antibiotic treatment of S. aureus infections using PCR-based tests are advantageous in Germany and other European countries. PCR tests, accordingly, should be considered as elements in antimicrobial stewardship programs.

Transmission rates, screening methods and costs of MRSA--a systematic literature review related to the prevalence in Germany

Methicillin-resistant Staphylococcus aureus (MRSA) infections represent a serious challenge for health care institutions, which is inherent in the combination of prevalence, transmission rates and costs. Furthermore, performing an MRSA screening requires information on the complex system of effectiveness, accuracy and costs of different screening methods. The purpose of this study was to give an overview of parameters with decisive significance for the burden of MRSA and the selection of a specific MRSA screening strategy. A systematic literature search for peer-reviewed health economic studies associated with MRSA was performed (from 1995 to the present). Eighty-seven different studies met all inclusion and exclusion criteria. Primary outcomes included the prevalence of MRSA, MRSA transmission rates, performance characteristics of MRSA screening methods, costs for pre-emptive isolation precautions and costs per MRSA case. The prevalence rates reported for all inpatients (1.2-5.3 %) as well as for inpatients with risk factors or patients in risk areas (3.85-20.6 %) vary greatly. The range of cross-transmission rates per day reported for patients with MRSA in isolation is 0.00081-0.009 and for carriers not in isolation is 0.00137-0.140, respectively. For polymerase chain reaction (PCR) methods, the mean sensitivity and specificity were 91.09 and 95.79 %, respectively. Culture methods show an average sensitivity of 89.01 % and an average specificity of 93.21 %. The turn-around time for PCR methods averages 15 h, while for the culture method, it can only be estimated as 48-72 h. This review filtered important parameters and cost drivers, and covered them with literature-based averages. These findings serve as an ideal evidence base for further health economic considerations of the cost-effectiveness of different MRSA screening methods.

Life- and person-centred help in Mecklenburg-Western Pomerania, Germany (DelpHi): study protocol for a randomised controlled trial

Background

The provision of appropriate medical and nursing care for people with dementia is a major challenge for the healthcare system in Germany. New models of healthcare provision need to be developed, tested and implemented on the population level. Trials in which collaborative care for dementia in the primary care setting were studied have demonstrated its effectiveness. These studies have been conducted in different healthcare systems, however, so it is unclear whether these results extend to the specific context of the German healthcare system.

The objective of this population-based intervention trial in the primary care setting is to test the efficacy and efficiency of implementing a subsidiary support system on a population level for persons with dementia who live at home.

Methods and study design

The study was designed to assemble a general physician-based epidemiological cohort of people above the age of 70 who live at home (DelpHi cohort). These people are screened for eligibility to participate in a trial of dementia care management (DelpHi trial). The trial is a cluster-randomised, controlled intervention trial with two arms (intervention and control) designed to test the efficacy and efficiency of implementing a subsidiary support system for persons with dementia who live at home. This subsidiary support system is initiated and coordinated by a dementia care manager: a nurse with dementia-specific qualifications who delivers the intervention according to a systematic, detailed protocol. The primary outcome is quality of life and healthcare for patients with dementia and their caregivers. This is a multidimensional outcome with a focus on four dimensions: (1) quality of life, (2) caregiver burden, (3) behavioural and psychological symptoms of dementia and (4) pharmacotherapy with an antidementia drug and prevention or suspension of potentially inappropriate medication. Secondary outcomes include the assessment of dementia syndromes, activities of daily living, social support health status, utilisation of health care resources and medication.

Discussion

The results will provide evidence for specific needs in ambulatory care for persons with dementia and will show effective ways to meet those needs. Qualification requirements will be evaluated, and the results will help to modify existing guidelines and treatment paths.

Trial registration

NCT01401582

Review of indicators for cross-sectoral optimization of nosocomial infection prophylaxis - a perspective from structurally- and process-oriented hygiene

In the care of patients, the prevention of nosocomial infections is crucial. For it to be successful, cross-sectoral, interface-oriented hygiene quality management is necessary. The goal is to apply the HACCP (Hazard Assessment and Critical Control Points) concept to hospital hygiene, in order to create a multi-dimensional hygiene control system based on hygiene indicators that will overcome the limitations of a procedurally non-integrated and non-cross-sectoral view of hygiene.

Three critical risk dimensions can be identified for the implementation of three-dimensional quality control of hygiene in clinical routine: the constitution of the person concerned, the surrounding physical structures and technical equipment, and the medical procedures. In these dimensions, the establishment of indicators and threshold values enables a comprehensive assessment of hygiene quality. Thus, the cross-sectoral evaluation of the quality of structure, processes and results is decisive for the success of integrated infection prophylaxis.

This study lays the foundation for hygiene indicator requirements and develops initial concepts for evaluating quality management in hygiene.

Can the Hazard Assessment and Critical Control Points (HACCP) system be used to design process-based hygiene concepts?

Recently, the HACCP (Hazard Analysis and Critical Control Points) concept was proposed as possible way to implement process-based hygiene concepts in clinical practice, but the extent to which this food safety concept can be transferred into the health care setting is unclear. We therefore discuss possible ways for a translation of the principles of the HACCP for health care settings. While a direct implementation of food processing concepts into health care is not very likely to be feasible and will probably not readily yield the intended results, the underlying principles of process-orientation, in-process safety control and hazard analysis based counter measures are transferable to clinical settings. In model projects the proposed concepts should be implemented, monitored, and evaluated under real world conditions.