Intensive care unit resources and patient-centred outcomes in severe COVID-19: a prospective single-centre economic evaluation.

During the COVID-19 pandemic, ICU bed shortages sparked a discussion about resource allocation. We aimed to analyse the value of ICU treatment of COVID-19 from a patient-centred health economic perspective. We prospectively included 49 patients with severe COVID-19 and calculated direct medical treatment costs. Quality of life was converted into aggregated quality-adjusted life years using the statistical remaining life expectancy. Costs for non-treatment as the comparator were estimated using the value of statistical life year approach. We used multivariable linear or logistic regression to identify predictors of treatment costs, quality of life and survival. Mean (SD) direct medical treatment costs were higher in patients in ICU with COVID-19 compared with those without (£60,866 (£42,533) vs. £8282 (£14,870), respectively; p < 0.001). This was not solely attributable to prolonged ICU length of stay, as costs per day were also higher (£3115 (£1374) vs. £1490 (£713), respectively; p < 0.001), independent of overall disease severity. We observed a beneficial cost-utility value of £7511 per quality-adjusted life-year gained, even with a more pessimistic assumption towards the remaining life expectancy. Extracorporeal membrane oxygenation therapy provided no additional quality-adjusted life-year benefit. Compared with non-treatment (costs per lost life year, £106,085), ICU treatment (costs per quality-adjusted life-year, £7511) was economically preferable, even with a pessimistic interpretation of patient preferences for survival (sensitivity analysis of the value of statistical life year, £48,848). Length of ICU stay was a positive and extracorporeal membrane oxygenation a negative predictor for quality of life, whereas costs per day were a positive predictor for mortality. These data suggest that despite high costs, ICU treatment for severe COVID-19 may be cost-effective for quality-adjusted life-years gained.

[Can quality assurance in medical care be practically implemented?]. / Qualitätssicherung in der medizinischen Versorgung praktisch umsetzbar?

The German discussion on the necessity and form of quality assurance in health care was promoted through legal changes. The objective of quality assurance is to control to assure and to improve quality in health care. For this reason a desired level of quality has to be determined and compared with the actually achieved level. If a deviation of quality is observed, actions for quality improvement are instituted. There are some problems in this context since the level of quality is a result of a patient's individual perception it is very difficult to set a common level. Furthermore the theoretical value of an analysis of deviations is restricted in those areas of health care, in which the relevant data are deeply distorted by statistical outliers caused by a heterogeneous structure of patients and a small number of cases. Therefore, quality assurance is only possible in such areas of medical care, in which numerous identical and non-complex services are provided to patients with a similar morbidity structure.

[Quality assurance in medical care]. / Qualitätssicherung in der medizinischen Versorgung.

The demand for quality assurance in Germany's health care system has been on the increase since promulgation of the Germany Statutory Health Service Reform law. To control, to assure and to improve quality a vast array of different systems is used by health care providers. All these systems work in a similar manner. The desired level of quality is determined and compared with the actually achieved level. If a deviation of quality is observed, actions for quality improvement are instituted. However, there are some problems that make quality assurance a difficult problem. Since the level of quality is a result of a patient's individual evaluation it is very difficult to set a common level. Another problem is to find valid criteria to measure the degree of quality. Finally, further research is necessary to analyse benefits and costs of introducing a quality assurance system.

[Aviation and space flight ophthalmology]. / Luft- und Raumfahrtophthalmologie.

So far it has not been possible to adapt man genetically to the specific environmental conditions of flying. A variety of disturbing factors act on the human body and affect its vital as well as sensory functions, vision being considered the most important sense for providing information. The effects of oxygen deficiency caused by increasing altitude, acceleration and centrifugal force affecting visual function, ocular motility, and pupillary reactions are well known. Like visual illusions, vibrations, high accelerative forces, high illuminance and glare at high altitudes impair the visual perception of the environment. In space flight further problems ensue from weightlessness and short-wave radiation. The high medical standards that must be met by the eyes of flying personnel, as will as for air-traffic controllers, result in the enhancement of flight safety. After operations on the cornea or retina or cataract operations in pilote, the retinal findings and DOP must be monitored closely. Special attention must be paid to means of visual aids, corrective lenses, contact lenses, and intraocular lenses. Ophthalmology is a very important element of aviation and aerospace medicine.

[Peripheral fundus changes in subjects with healthy eyes (pilots)]. / Periphere Fundusveränderungen bei "Augengesunden" (Piloten).

Over a period of one year in 1980 2451 pilots between 25 and 41 years of age and 674 pilot recruits between 18 and 24 years of age were examined ophthalmologically. All the subjects tested had a visual acuity of 20/20 or better. Of this population, 16% wore glasses with refractive powers ranging up to +4.0 to -1.5 D. Fundus examination revealed microaneurysms in 8%, chorioretinal scars in 6%, paving-stones in 5%, pigmented nevi of the choroid in 4.2% and hypertrophies of the retinal pigment epithelium in 1.3%. White without pressure was seen in 11%. The incidence of formations predisposing to retinal breaks (lattice degeneration and snail tracks 9.1%, round retinal holes 1.5%) was comparable to that of other populations examined by other authors.