How do Chronically Ill Patients Rate Medical Care by their GPs and Specialists? Results of a Germany-wide Survey.

Introduction: The ability of health systems to respond to the legitimate expectations of the population regarding interpersonal and organizational aspects of healthcare - the so-called Health System Responsiveness - is considered a key competence of health systems. While various studies have assessed the responsiveness of ambulatory care, information on differences between care provided by general practitioners (GP) and specialists is still scarce. Methods: By means of a postal survey, 51 998 chronically ill persons (type 2 diabetes and/or coronary heart disease) insured by a statutory health insurance body (Techniker Krankenkasse) were surveyed regarding their experiences with GP and specialist care. An adapted version of the WHO Health System Responsiveness questionnaires was used for assessing data. Differences in the rating of specialist and GP care were analyzed using McNemar's test. Results: Responses from 13 685 patients were included in data analyses. Overall, ambulatory care was rated mostly as positive. Across all dimensions of health system responsiveness, GP care was rated statistically significantly as more positive than specialist care. Considerable differences were found in the evaluation of waiting times, involvement in decision-making and coordination of care. Conclusion: Overall, the surveyed persons were mostly satisfied with their GP and specialist care. However, some aspects of specialist care need to be optimized.

Treating the right patient at the right time: access to heart failure care.

Heart failure affects over 500,000 Canadians, and 50,000 new patients are diagnosed each year. The mortality remains staggering, with a five-year age-adjusted rate of 45%. Disease management programs for heart failure patients have been associated with improved outcomes, the use of evidence-based therapies, improved quality of care, and reduced costs, mortality and hospitalizations. Currently, national benchmarks and targets for access to care for cardiovascular procedures or office consultations do not exist. The present paper summarizes the currently available data, particularly focusing on the risk of adverse events as a function of waiting time, as well as on the identification of gaps in existing data on heart failure. Using best evidence and expert consensus, the present article also focuses on timely access to care for acute and chronic heart failure, including timely access to heart failure disease management programs and physician care (heart failure specialists, cardiologists, internists and general practitioners).

General commentary on access to cardiovascular care in Canada: universal access, but when? Treating the right patient at the right time.

In 2004, the Canadian Cardiovascular Society formed an Access to Care Working Group with a mandate to use the best science and information available to establish reasonable triage categories and safe wait times for common cardiovascular services and procedures through a series of commentaries. The present commentary is the first in the series and lays out issues regarding timely access to care that are common to all cardiovascular services and procedures. The commentary briefly describes the 'right' to timely access, wait lists as a health care system management tool, and the role of the physician as patient advocate and gatekeeper. It also provides advice to funders, administrators and providers who must monitor and manage wait times to improve access to cardiovascular care in Canada and restore the confidence of Canadians in their publicly funded health care system.

Treating the right patient at the right time: access to care in non-ST segment elevation acute coronary syndromes.

In 2004, the Canadian Cardiovascular Society formed an Access to Care Working Group with a mandate to use the best science and information available to establish reasonable triage categories and safe wait times for common cardiovascular services and procedures through a series of commentaries. The present commentary discusses the rationale for access benchmarks for urgent cardiac catheterization and revascularization, including hospital transfer in the setting of non-ST elevation acute coronary syndromes. The literature on standards of care, wait times, wait list management and clinical trials was reviewed. A survey of all cardiac catheterization directors in Canada was performed to develop an inventory of current practices in identifying and triaging patients. The Working Group recommended the following medically acceptable wait times for access to diagnostic catheterization and revascularization in patients presenting with acute coronary syndromes: for diagnostic catheterization and percutaneous coronary intervention, the target should be 24 h to 48 h for high-risk, three to five days for intermediate-risk and five to seven days for low-risk patients; for coronary artery bypass graft surgery, the target should be three to five days for high-risk, two to three weeks for intermediate-risk and six weeks for low-risk patients. All stakeholders must affirm the appropriateness of these standards and work continuously to achieve them. However, some questions remain around what are the best clinical risk markers to delineate the triage categories and the utility of clinical risk scores to assist clinicians in triaging patients for invasive therapies.

A modification of Charnley low-friction arthroplasty. Representative ten-year follow-up results of the St. Georg prosthesis.

From the stimulus offered by John Charnley in 1962, Hans Wilhelm Buchholz developed the St. Georg hip implant in Hamburg. The design differed from that of Charnley notably in the size of the femoral head. The results of early operations performed in Hamburg are confined largely to the most cogent form of failure, mechanical loosening of one or both components. Four representative years (1968-1971) were selected for this purpose, and survival curves were constructed for 1971 patients of different age and preoperative diagnosis. In conventional terms, the rate of mechanical loosening for the femoral component is 1.9%, for the acetabular component 2.4%, and for both components 7.5% for a ten or more year follow-up period. The principle annunciated by Charnley suggesting that total joint arthroplasty be performed in large units or special hospitals is strongly recommended.

[St. Georg knee endoprosthesis system (slide and hinge principle). Observations and results following 10 years' experience with over 3,700 operations]. / Die Knieendoprothesensysteme St. Georg (Schlitten- und Scharnierprinzip). Beobachtungen und Ergebnisse nach 10 Jahren Erfahrung mit über 3,700 Operationen.

Some 2000 total knee endoprostheses were inserted from 1970-1978 and about 1700 of these have been followed two different types of knee replacement were used, a surface replacement of a non-constrained design and a total hinge prosthesis. Serious complications, such as infection, loosening and fracture of the components were regarded as significant determinants in the evaluation of the durability of total and partial knee replacement. The highest and lowest incidence of complication were recorded. The longevity of knee arthroplasty and the survival rates were estimated by constructing survivorship tables. Patients with knee replacement having no complications were designated "survivals" while patients with an established complication were treated as "deaths". The success rates of total hinge prosthesis were compared with those of the sledge prosthesis. Failure rates of aseptic complications were assessed and compared with failure rates due to septic complications. A differentiation was also made between the sledge prosthesis and the total hinge prosthesis. Furthermore, significant differences in the indication for the insertion of the sledge or the total hinge were determined by group assessment (log-rank-test). Unlike the general trend to use a semiconstrained knee replacement the evaluation of this clinical trial has induced us to improve our hitherto used total knee prosthesis model rather than to develop a new surface replacement.

Management of deep infection of total hip replacement.

Exchange operation is recommended as the treatment of choice for most deep infections involving a total hip replacement. This revision arthroplasty comprises, in one stage, excision of soft tissue, removal of implant and cement, replacement with an appropriate implant using Palacos R acrylic cement loaded with an appropriate antibiotic and, more recently, systemic antibiotics. During our first 10 years without systemic antibiotics we have achieved an overall 77 per cent success rate from a first attempt in 583 patients and a 90 per cent success rate after subsequent exchange procedures. Morbidity is significant but acceptable. Success is defined as control of infection, no loosening, and useful function. The factors associated with failures include, in particular, specific infections (Pseudomonas group, Streptococcus group D, Proteus group, and Escherichia coli), delay in operation and inadequate antibiotic dosage in the cement.

[Experiences with the use of shoulder joint endoprosthesis]. / Erfahrungen mit der Anwendung von Schultergelenksendoprothesen.

Total shoulder replacement has been successful as treatment for patients with irreparably damaged and painful glenohumeral joints, though improvement of joint motion is limited. Our experiences with 101 alloplastic operations on the human shoulder are reported for further design and construction of total shoulder joint prostheses. The type of prosthesis chosen depends on the degree of joint damage. A dorsal approach is recommended, carefully preserving or restoring function of the musculo-tendinous cuff mechanism.

[Partial replacement of the humerus]. / Teilersatz des Oberarmknochens

Based on twelve cases, this paper reviews the possibilities of partial replacement of the humerus. In 6 cases an interpolation was successfully performed replacing a resected part of the humeral shaft while maintaining the shoulder and elbow joint. The interpolated material is polyethylene, centrally reinforced by metal. A resection of up to 17 cm was performed. The longest period of observation is more than 2 years. This operative procedure is preferred to the methods so far used in cases of extensive destruction of the humeral shaft. Primarily, osteolyses are an indication for this type of operation.

Statistics of total knee replacement: partial and total knee replacement, design St. Georg: a review of a 4-year observation.

Since 1969, we have used 2 different types of knee prostheses to reconstruct arthritic knees. The surface replacement prosthesis (sledge) is indicated where ligamentous stability is present and angular deformity is not severe. In addition, the sledge prosthesis may be implanted with good results in selected acute comminuted tibial plateau fractures. The total hinged prosthesis of metal design is recommended in knees which are severely deformed, and unstable, and therefore not suitable for the sledge prosthesis. Marked relief of pain was the most significant result in our patients. Residual knee pain was most frequently due to patello-femoral pain and, when severe, this was satisfactorily controlled by performing a patellectomy. Motion was usually maintained at the preoperative range or improved, mainly by reducing or eliminating the knee flexion contracture. In a high percentage, the unicompartmental sledge prosthesis has given excellent results. However, we tend to insert a bi-compartmental sledge prosthesis because experience has shown that even slight damage of the articular surfaces of the opposite side is likely to further deteriorate rapidly. Although a significant number of complications occurred, these have been minimized by further conservative and operative treatment. We anticipate a further reduction in complications based on our initial experience, and prosthetic revisions.