Using a contribution margin system to manage medical centers in Berlin.

After German reunification, the Charité-Universitätsmedizin Berlin was restructured from three existing Berlin university hospitals. More than a too departments were reorganized into 17 centers. Professional management was necessary to improve the overall balance. A contribution margin-orientated management system was introduced in 2008 by using German benchmarks. All sectors help to improve the results continuously. In 2011, and for the first time, the balance showed a profit of 8.2 million Euros.

The effect of computerized tailored brief advice on at-risk drinking in subcritically injured trauma patients.

BACKGROUND: One-third of injured patients treated in the emergency department (ED) have an alcohol use disorder (AUD). Few are screened and receive counseling because ED staff have little time for additional tasks. We hypothesized that computer technology can screen and provide an intervention that reduces at-risk drinking (British Medical Association criteria) in injured ED patients. METHODS: In all, 3,026 subcritically injured patients admitted to an ED were screened for an AUD using a laptop computer that administered the AUD Identification Test (AUDIT) and assessed motivation to reduce drinking. Patients with a positive AUDIT (n = 1,139) were randomized to an intervention (n = 563) or control (n = 576) condition. The computer generated a customized printout based on the patient's own alcohol use pattern, level of motivation, and personal factors, which was provided in the form of feedback and advice. RESULTS: Most patients (85%) used the computer with minimal assistance. At study entry, a similar proportion in each group met criteria for at-risk drinking (49.6% versus 46.8%, p = 0.355). At 6 months, 21.7% of intervention and 30.4% of control patients met criteria for at-risk drinking (p = 0.008). Intervention patients also had a 35.7% decrease in alcohol intake, compared with a 20.5% decrease in controls (p = 0.006). At 12 months, alcohol intake decreased by 22.8% in the intervention group versus 10.9% in controls (p = 0.023), but the proportion of at-risk drinkers did not significantly differ (37.3% versus 42.6%, p = 0.168). CONCLUSIONS: The computer-generated intervention was associated with a significant decrease in alcohol use and at-risk drinking. Research is needed to further evaluate and adapt information technology to provide preventive clinical services in the ED.

Gender differences in the performance of a computerized version of the alcohol use disorders identification test in subcritically injured patients who are admitted to the emergency department.

OBJECTIVE: The Alcohol Use Disorder Identification Test (AUDIT) has been recommended as a screening tool to detect patients who are appropriate candidates for brief, preventive alcohol interventions. Lower AUDIT cutoff scores have been proposed for women; however, the appropriate value remains unknown. The primary purpose of this study was to determine the optimal AUDIT cutpoint for detecting alcohol problems in subcritically injured male and female patients who are treated in the emergency department (ED). An additional purpose of the study was to determine whether computerized screening for alcohol problems is feasible in this setting. METHODS: The study was performed in the ED of a large, urban university teaching hospital. During an 8-month period, 1205 male and 722 female injured patients were screened using an interactive computerized lifestyle assessment that included the AUDIT as an embedded component. World Health Organization criteria were used to define alcohol dependence and harmful drinking. World Health Organization criteria for excessive consumption were used to define high-risk drinking. The ability of the AUDIT to classify appropriately male and female patients as having one of these three conditions was the primary outcome measure. RESULTS: Criteria for any alcohol use disorder were present in 17.5% of men and 6.8% of women. The overall accuracy of the AUDIT was good to excellent. At a specificity >0.80, sensitivity was 0.75 for men using a cutoff of 8 points and 0.84 for women using a cutoff of 5 points. Eighty-five percent of patients completed computerized screening without the need for additional help. CONCLUSIONS: Different AUDIT scoring thresholds for men and women are required to achieve comparable sensitivity and specificity when using the AUDIT to screen injured patients in the ED. Computerized AUDIT administration is feasible and may help to overcome time limitations that may compromise screening in this busy clinical environment.

High and low response in relation to nitric oxide formation but not to lipid peroxidation in patients with sepsis.

OBJECTIVES: Nitric oxide overproduction in sepsis syndrome was suspected to be responsible for hemodynamic derangement and, by induction of lipid peroxidation, for tissue damage. Therefore, nitric oxide formation and lipid peroxidation were quantified in septic patients (SP) vs. patients with localized infection (IF) or without inflammation (C). Nitric oxide formation in sepsis was additionally compared with data for clinical status. DESIGN: Prospective study with consecutive sampling of patients. SETTING: A university hospital intensive care unit and research laboratories. PATIENTS: SP, 24 patients; IP, 7; and C, 13. INTERVENTIONS: Plasma measurement of nitrate, lipid peroxides (primary endpoints), and N-hydroxy-L-arginine (secondary end point) MEASUREMENTS AND MAIN RESULTS: For nitrate, there was a sequence of C < IP = SP. Among SP, one group with significantly higher nitrate (high-responders for nitric oxide; SP-HR) vs. IP and C and a second group (low-responders; SP-LR) with increased concentration only vs. C could be identified. For SP-HR vs. IP, a strong time kinetics in nitric oxide formation was obvious, indicated by significant nitrate increase already 1 day before sepsis started, tripling up to the peak concentration, and then a lowering but still increased value on the first day after sepsis. N-hydroxy-L-arginine was significantly increased in SP-HR vs. C. For lipid peroxides, the concentrations were comparable in SP and IP, but both significantly increased vs. C. Clustering and coincident kinetics of lipid peroxidation related to nitric oxide were not obvious. Furthermore, there was no strong correlation of clinical data and nitric oxide clustering in sepsis. CONCLUSIONS: High- and low-responders for nitric oxide were identified among septic patients. This finding was not associated with significant differences in lipid peroxidation or clinical data.