137 research outputs found
Geographic variations in ambulatory care: Extent, root causes and need for reform with regard to inequities in physician distribution
Die Gewährleistung einer "bedarfsgerechten und gleichmäßigen Versorgung" (§ 70 Abs. 1 SGB V) ist Zielsetzung und Auftrag an die Akteure des deutschen Gesundheitssystems. An dieser normativen Grundlage muss sich im besonderen Maße die ambulante Versorgung messen lassen, die als erster Kontaktpunkt des Patienten mit dem Gesundheitssystem einen wohnortnahen Zugang zur gesundheitlichen Versorgung bieten sollte. Ziel dieser Arbeit ist es daher, das Ausmaß regionaler, nicht bedarfsgerechter Unterschiede in der ambulanten Versorgung, insbesondere in der Ärzteverteilung, zu bemessen, deren Ursachen und Folgen zu analysieren und Lösungsansätze für eine bedarfsgerechtere regionale Ärzteverteilung aufzuzeigen. Der erste Artikel untersucht die Bedarfsgerechtigkeit der derzeitigen Ärzteverteilung. Dabei zeigt sich, dass eine erhebliche regionale Ungleichverteilung zwischen Ärzten einerseits und dem (approximierten) Versorgungsbedarf andererseits vorliegt – insbesondere mit zunehmender Spezialisierung der Fachgruppe. Eine Verbesserung dieser Verteilung mittels der geltenden Regulierung, der Bedarfsplanung, ist nicht zu erwarten, da diese die Fehlverteilung lediglich fortschreibt. Unterschiede in der Angebotsdichte der Versorgungsstrukturen sind auch ein maßgeblicher Grund für regionale, nicht durch den Bedarf zu erklärende Unterschiede in der Inanspruchnahme von Versorgung. Dies zeigt ein zweiter Artikel, der Erklärungsfaktoren für regionale Abweichungen von der erwarteten ambulanten Leistungsmenge, gemessen anhand der ambulanten, kreisspezifischen Morbi-RSA-Zuweisungen, untersucht. Auch die Soziökonomie, (Sozio-)Geografie und die Verlagerung eigentlich ambulanter Fälle in den stationären Sektor sind nachweisbar mit einer nicht bedarfsgerechten Inanspruchnahme assoziiert. Die Analyse möglicher Lösungsansätze wird durch eine dritte Studie eingeleitet, die die Maßnahmen des Versorgungsstrukturgesetzes von 2011 kritisch bewertet. So enthält dieses Gesetzespaket zwar erste Ansätze zu einer Reform der Bedarfsplanung – insbesondere durch die Flexibilisierung der räumlichen Planungsebene und die Anreize zur Erhöhung der Attraktivität der Landarzttätigkeit. Andererseits bleiben jedoch die Mechanismen zum Abbau von Über- und Unterversorgung schwach und eine echte Neuordnung der Bedarfsplanung fraglich. Der vierte Artikel widmet sich der Frage, welche (Politik-)Mechanismen effektiv sind, um eine bedarfsgerechte räumliche Verteilung von Hausärzten zu erreichen. Mithilfe einer international vergleichenden Untersuchung erweisen sich eine regional begrenzte Zulassung der Ärzte sowie Capitation-basierte Vergütungsmodelle als besonders wirksam, während finanzielle Anreize und Mechanismen, die während der ärztlichen Ausbildung ansetzen, keine nachweisbare systemrelevante Wirkung erzielen können. Auf Grundlage dieser Evidenz werden im letzten Kapitel die Problemstellungen für eine Neuordnung der Bedarfsplanung anhand eines 10-Punkte-Katalogs abgesteckt und jeweilige Lösungsansätze aufgezeigt. Die Eckpunkte einer Lösung umfassen insbesondere die Aufspaltung der Bedarfsplanung in eine separate Kapazitäts- und Verteilungsplanung, eine (methodische) Angleichung der Verteilungsplanung an bereits bestehende Verteilungsmechanismen, eine Auswahl geeigneter Bedarfsprädiktoren sowie eine präzisere Berücksichtigung interregionaler Mitversorgungseffekte.Ensuring "needs-based and evenly distributed health care" (Section 70 para 1 German Social Code V) is an objective and task faced by stakeholders of the German health care system. This normative principle is particularly applicable to ambulatory care which is the first contact point for patients with the health care system and should thus be locally accessible. Therefore, this dissertation aims to assess geographical inequities in ambulatory care, mainly in the distribution of physicians, analyze its underlying causes and resulting consequences, and provide solutions for a more equitable distribution of physicians. The first article concerns the degree of equity in the current distribution of physicians. It shows the existence of considerable geographical disparities between physicians, on the one hand, and patients' needs, on the other hand. This is especially true for highly specialized physicians. An improvement of this maldistribution through the current regulation, the 'need-based planning mechanism' is not to be expected as the latter only conserves current inequities. One implication of these geographical supply disparities are non-needs-based variations in health care utilization. This is demonstrated by the second article which focuses on explanatory factors for geographical inequities in ambulatory care utilization. These are measured by comparing needs-based allocations from the risk structure adjustment scheme against actual health care expenditures by district. Socio-economic and (socio-)geographic factors as well as a shift of ambulatory care-sensitive cases to the hospital care sector also prove to be valid predictors of inequitable utilization. The following section probes into possible approaches to combat these inequities: The third article provides a critical analysis of the Care Structures Act of 2011. This act included a reform of the needs-based planning mechanism, namely by allowing for more flexibility in the selection of the appropriate spatial planning level and providing incentives to increase the attractiveness of medical practice in rural areas. Nonetheless, it remains questionable whether the mechanisms aiming to reduce over- and undersupply are forceful enough and whether the modifications to the planning mechanism are sufficient. The fourth article regards the effectiveness of different policy mechanisms in achieving a more equitable geographical distribution of general practitioners. In a comparative analysis across several countries, regional quotas limiting the number of accredited physicians and capitation-based payments prove most effective while financial incentives and mechanisms aimed at increasing medical students' rural affinity do not have a measurable system-wide effect. Based on this evidence the last chapter of this work compiles a 10-points catalogue of primary issues to be resolved in a reform of the 'need-based planning mechanism' and provides a solution framework. Solutions include a separation of capacity and distribution planning, a new methodology for the calculation of the geographical allocation of physician seats, which converges towards already existing allocation mechanisms, a selection of appropriate needs predictor variables, and a more precise consideration of care provision occurring across planning areas
Perinatal and cardiovascular outcomes in a pregnant patient with Marfan syndrome
A 25-year-old primigravida with Marfan syndrome (MFS) was admitted at 36 weeks of gestation (WOG)
Intra-articular injections of high-molecular-weight hyaluronic acid have biphasic effects on joint inflammation and destruction in rat antigen-induced arthritis
To assess the potential use of hyaluronic acid (HA) as adjuvant therapy in rheumatoid arthritis, the anti-inflammatory and chondroprotective effects of HA were analysed in experimental rat antigen-induced arthritis (AIA). Lewis rats with AIA were subjected to short-term (days 1 and 8, n = 10) or long-term (days 1, 8, 15 and 22, n = 10) intra-articular treatment with microbially manufactured, high-molecular-weight HA (molecular weight, 1.7 × 10(6 )Da; 0.5 mg/dose). In both tests, 10 buffer-treated AIA rats served as arthritic controls and six healthy animals served as normal controls. Arthritis was monitored by weekly assessment of joint swelling and histological evaluation in the short-term test (day 8) and in the long-term test (day 29). Safranin O staining was employed to detect proteoglycan loss from the epiphyseal growth plate and the articular cartilage of the arthritic knee joint. Serum levels of IL-6, tumour necrosis factor alpha and glycosaminoglycans were measured by ELISA/kit systems (days 8 and 29). HA treatment did not significantly influence AIA in the short-term test (days 1 and 8) but did suppress early chronic AIA (day 15, P < 0.05); however, HA treatment tended to aggravate chronic AIA in the long-term test (day 29). HA completely prevented proteoglycan loss from the epiphyseal growth plate and articular cartilage on day 8, but induced proteoglycan loss from the epiphyseal growth plate on day 29. Similarly, HA inhibited the histological signs of acute inflammation and cartilage damage in the short-term test, but augmented acute and chronic inflammation as well as cartilage damage in the long-term test. Serum levels of IL-6, tumour necrosis factor alpha, and glycosaminoglycans were not influenced by HA. Local therapeutic effects of HA in AIA are clearly biphasic, with inhibition of inflammation and cartilage damage in the early chronic phase but with promotion of joint swelling, inflammation and cartilage damage in the late chronic phase
Bendamustine: Safety and Efficacy in the Management of Indolent Non-Hodgkins Lymphoma
Bendamustine (Treanda, Ribomustin) was recently approved by the US Food and Drug Administration (FDA) for treatment of patients with rituximab refractory indolent lymphoma and is expected to turn into a frontline therapy option for indolent lymphoma. This compound with amphoteric properties was designed in the former Germany Democratic Republic in 1960s and re-discovered in 1990s with multiple successive well-designed studies. Bendamustine possesses a unique mechanism of action with potential antimetabolite properties, and only partial cross-resistance with other alkylators. Used in combination with rituximab in vitro, bendamustine shows synergistic effects against various leukemia and lymphoma cell lines. In clinical studies, bendamustine plus rituximab is highly effective in patients with relapsed-refractory indolent lymphoma, inducing remissions in 90% or more and a median progression-free survival of 23–24 months. The optimal dosing and schedule of bendamustine administration is largely undecided and varies among studies. Results of ongoing trials and dose-finding studies will help to further help ascertain the optimal place of bendamustine in the management of indolent NHL
A review of ECG-based diagnosis support systems for obstructive sleep apnea
Humans need sleep. It is important for physical and psychological recreation. During sleep our consciousness is suspended or least altered. Hence, our ability to avoid or react to disturbances is reduced. These disturbances can come from external sources or from disorders within the body. Obstructive Sleep Apnea (OSA) is such a disorder. It is caused by obstruction of the upper airways which causes periods where the breathing ceases. In many cases, periods of reduced breathing, known as hypopnea, precede OSA events. The medical background of OSA is well understood, but the traditional diagnosis is expensive, as it requires sophisticated measurements and human interpretation of potentially large amounts of physiological data. Electrocardiogram (ECG) measurements have the potential to reduce the cost of OSA diagnosis by simplifying the measurement process. On the down side, detecting OSA events based on ECG data is a complex task which requires highly skilled practitioners. Computer algorithms can help to detect the subtle signal changes which indicate the presence of a disorder. That approach has the following advantages: computers never tire, processing resources are economical and progress, in the form of better algorithms, can be easily disseminated as updates over the internet. Furthermore, Computer-Aided Diagnosis (CAD) reduces intra- and inter-observer variability. In this review, we adopt and support the position that computer based ECG signal interpretation is able to diagnose OSA with a high degree of accuracy
A phase I study of bendamustine hydrochloride administered day 1+2 every 3 weeks in patients with solid tumours
The aim of the study was to determine the maximum tolerated dose (MTD), the dose limiting toxicity (DLT), and the pharmacokinetic profile (Pk) of bendamustine (BM) on a day 1 and 2 every 3 weeks schedule and to recommend a safe phase II dose for further testing. Patients with solid tumours beyond standard therapy were eligible. A 30-min intravenous infusion of BM was administered d1+d2 q 3 weeks. The starting dose was 120 mg m−2 per day and dose increments of 20 mg m−2 were used. Plasma and urine samples were analysed using validated high-performance liquid chromatography/fluorescence assays. Fifteen patients were enrolled. They received a median of two cycles (range 1–8). The MTD was reached at the fourth dose level. Thrombocytopaenia (grade 4) was dose limiting in two of three patients at 180 mg m−2. One patient also experienced febrile neutropaenia. Lymphocytopaenia (grade 4) was present in every patient. Nonhaematologic toxicity including cardiac toxicity was not dose limiting with this schedule. Mean plasma Pk values of BM were tmax 35 min, t1/2 49.1 min, Vd 18.3 l m−2, and clearance 265 ml min−1 m−2. The mean total amount of BM and its metabolites recovered in the first micturition was 8.3% (range 2.7–26%). The MTD of BM in the present dose schedule was 180 mg m−2 on day 1+2. Thrombocytopaenia was dose limiting. The recommended dose for future phase II trials with this schedule is 160 mg m−2 per day
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