[The problems of compliance and adherence, using the example of chronic inflammatory bowel disease]. / Das Problem von Compliance und Adhärenz am Beispiel der chronisch entzündlichen Darmerkrankungen.

To what extent do patients comply with their doctor's treatment recommendation, i.e. show "compliance" and "adherence" ?. The treatment of chronic diseases in particular is associated with enormous problems of adherence. Patients often take only 40 to 80% of their prescribed dosage of medication. This issue affects not only the course of the disease in the particular patient, but also has considerable impact on the health care system. Great difficulties still exist in recognizing poor adherence, because doctors depend on the information given by their patients. The reasons for adherence problems can be attributed to disease-related, treatment-related or patient-related factors, as well as to the quality of the doctor-patient relationship. Improving adherence is difficult due to its numerous and individually different causes. This has been emphasized by a recent Cochrane review, in which only 5 out of 21 randomized and controlled studies concerning the improvement of adherence demonstrated significant success. However, half of the studies displayed methodological errors that weakened the statistical detection of improvement because of the low numbers patients. Overall, enormous efforts will be required of doctors, patients and health care policies to achieve substantial alterations in the problems associated with adherence.

Evaluation of urolithiasis: a link between stone formation and diabetes mellitus?

INTRODUCTION: The pathogenesis of calcium oxalate stone formation is not completely understood. Recently, an influence of vascular phenomena like arteriosclerosis on the crystallization process was hypothesized. Thus, stone formation should be more common in patients with diabetes mellitus (DM) who are at risk of developing angiopathy. The aim of the study was to determine the prevalence of urolithiasis (UL) in patients with DM and to identify specific risk factors. MATERIAL AND METHODS: 350 patients with DM were evaluated with respect to DM-related history, and a total of 179 patients was included (83 female, 96 male; age 23-84 years). All patients were interviewed to assess the history of stone formation. These data were compared to epidemiological data in Germany. RESULTS: The overall prevalence of UL in the diabetic group was 7.82% (vs. 4.73% in Germany, p = 0.0485; binominal test). The prevalence was significantly higher in patients with coronary heart disease (25%; p < 0.0001; Fisher's exact test). We could not demonstrate an increased prevalence of UL for patients with occlusive arterial disease or arterial hypertension as diabetic nephropathy was not a risk factor for developing urinary lithiasis (p = 0.7184, p = 1.000, p = 0.6266, respectively; Fisher's exact test). Thiazide medication lowered the prevalence of stone formation (p = 0.0399; Fisher's test). Calcium or magnesium supplementation did not influence stone formation significantly (p = 0.5279; p = 1.000; respectively; Fisher's test). CONCLUSIONS: In Germany, patients with DM are at higher risk of UL compared with patients without diabetes. We demonstrated a significantly higher prevalence of urinary stones in patients with coronary heart disease. These findings are consistent with the hypothesis that urinary stone formation has a vascular pathogenesis in part.

Medical prevention and treatment of acute and chronic radiation induced enteritis--is there any proven therapy? a short review.

BACKGROUND: Radiation enteritis is a severe problem in patients receiving irradiation of the abdomen or pelvis in the course of cancer treatment. Nevertheless, there is a lack of standardised strategies for medical prevention and therapy. MATERIALS AND METHODS: A PubMed based literature search was performed to address the available data on the prevention of and therapy for acute and chronic radiation enteritis. RESULTS: Four double-blind and placebo-controlled studies used 5-aminosalycilates in the prevention of acute radiation enteritis. Only for sulphasalzine 2 g/d was a positive effect proven. Prophylactic administration of probiotics reduced the incidence of acute radiation enteritis in a large placebo-controlled trial. If acute radiation enteritis was present octreotide ameliorated radiation-induced diarrhoea in a randomised study. Two investigations, only one of them randomised, described the effectiveness of loperamide in the treatment of acute radiation enteritis. If diarrhoea was also the main symptom of chronic radiation enteritis, loperamide reduced stool frequency in a double-blind and placebo-controlled study. A retrospective analysis of severe cases of chronic radiation enteritis with obstruction and fistula indicated that parenteral nutrition at home was more effective than surgery. CONCLUSION: Reduction of radiation dose and field size are still the most important factors in the prevention of acute and chronic radiation enteritis. Valid data particularly on the treatment of chronic radiation enteritis are lacking. A better understanding of the pathopysiology especially in chronic radiation enteritis might offer new therapeutic perspectives. Inhibition of TGF-beta, for example, might be a new promising therapy approach.

Overcoming barriers to effectiveness in a health care operational environment: building on the lessons of American industry.

Several of the manufacturing-based philosophies, techniques and tools, such as Total Quality Management (TQM), Continuous Improvement (CI), Business Process Reengineering (BPR) and Time-based Competition (TBC) have been successfully adapted for use within the service sector. Diverse service industries including airlines, insurance, food services and hospitality have increased customer satisfaction and performance through the use of the quality driven, manufacturing-based philosophies. This article explores the reasons for the limited success of TQM/CI, BPR, TBC and benchmarking within the health care industry. Sixteen barriers to change are identified, possible counter-measures to these barriers are outlined and two conceptual frameworks are offered as possible facilitators of change for the health care industry.

Adapting a strategic management model to hospital operating strategies. A model development and justification.

Industrial organizations have employed the process of strategic management in their attempts to cope effectively with global competitive pressures, while attempting to build and maintain competitive advantage. With health-care organizations presently trying to cope with an increasingly turbulent environment created by the uncertainty as to pending legislation and anticipated reform, the need for such organizational strategic planning is apparent. Presents and discusses a methodology for adapting a business-oriented model of strategic planning to health care.

The impact of environmental turbulence on American hospital strategies.

It is clear that dramatic changes are taking place in the way health care organizations are being managed. Health care executives are having to make the transition from managing with a "pass the cost along to the consumer" perspective to one of extreme competitive pressure to reduce costs while maintaining appropriate levels of quality. Reports the results of a survey of 135 American hospitals' executives. Uses factor analysis to uncover four distinct strategies being operationalized. Classifies hospitals' strategies as: strategic analysers, externally focused and offensively proactive; quality providers, internally-focused and defensive reactors; price negotiators, externally-focused and offensively reactive; or cost efficiency providers, internally focused and defensively proactive.