[What motivates patients with atopic diseases to search the internet-a focus group study on expectations and demands]. / Was motiviert Patienten mit atopischen Erkrankungen zur Suche nach Informationen im Internet? Ergebnisse einer Fokusgruppenstudie zu Erwartungen und Anforderungen.

BACKGROUND: People affected by allergies with mild-to-moderate symptoms are often not treated adequately, despite the availability of prevention and self-therapy measures. Given their good and quick accessibility when seeking information, evidence- and web-based services that are user-friendly may strengthen a more independent way of handling an allergy and may also increase health literacy. In order for such services to be found and read, developers and providers need to know about information needs, demands and users' behavior. OBJECTIVES: On which occasions does the target group search for allergy-specific information? Which preferences and demands do affected persons have regarding a web-based service? MATERIALS AND METHODS: Three individual interviews and four focus groups with 37 participants (19-81 years; hay fever, n = 30; asthma, n = 17; eczema, n = 15) were conducted in four German cities. These were recorded and transcribed verbatim. A multiprofessional team developed a system for coding the texts (two independent encoders, MAXQDA analysis software). RESULTS: Those who are affected usually seek information only in case of a concrete need for action. Impulses are, among others, symptoms, suggestions from the social environment, the beginning of the allergy season or an allergy-related contact with the health system. A web-based service should primarily include information about treatment options, provide individualized support for everyday life action strategies, and promote adequate self-management skills. DISCUSSION: In order to promote self-management skills, a web-based service should focus on allergy symptoms, treatment options and day-to-day help.

A Consensus German Reporting Standard for Secondary Data Analyses, Version 2 (STROSA-STandardisierte BerichtsROutine für SekundärdatenAnalysen).

Although secondary data analyses have been established in recent years in health research, explicit recommendations for standardized, transparent and complete reporting of secondary data analyses do not exist as yet. Therefore, between 2009 and 2014, a first proposal for a specific reporting standard for secondary data analysis was developed (STROSA 1). Parallel to this national process in Germany, an international reporting standard for routine data analysis was initiated in 2013 (RECORD). Nevertheless, because of the specific characteristics of the German health care system as well as specific data protection requirements, the need for a specific German reporting standard for secondary data analyses became evident. Therefore, STROSA was revised and tested by a task force of 15 experts from the working group Collection and Use of Secondary Data (AGENS) of the German Society for Social Medicine and Prevention (DGSMP) and the German Society for Epidemiology (DGEpi) as well as from the working group Validation and Linkage of Secondary Data of the German Network for Health Services Research (DNVF). The consensus STROSA-2 checklist includes 27 criteria, which should be met in the reporting of secondary data analysis from Germany. The criteria have been illustrated and clarified with specific explanations and examples of good practice. The STROSA reporting standard aims at stimulating a wider scientific discussion on the practicability and completeness of the checklist. After further discussions and possibly resulting modifications, STROSA shall be implemented as a reporting standard for secondary data analyses from Germany. This will guarantee standardized and complete information on secondary data analyses enabling assessment of their internal and external validity.

[Linking claims data and beneficiary survey information to report on the quality of health care: potential, pitfalls, and perspectives]. / Routinedaten der gesetzlichen Krankenversicherung und Versichertenbefragungen in der Qualitätsberichterstattung - Potenzial, Probleme und Perspektiven.

Reports on the quality of care aim at health and patient-reported outcomes in routine clinical care. To achieve meaningful information the study designs must be robust against bias through highly selected patient populations or health care providers but also allow for adequate control of confounding. The article describes the potential and pitfalls of administrative claims data and surveys of beneficiaries. The large potential of using both sources is illustrated in the primary inpatient treatment for prostate cancer. However, linking claims data and patient survey data still leaves some problems to be addressed in the final section. Linking claims data and beneficiary survey information on patient reported outcomes overcomes sectoral barriers and allows for an integrated evaluation of pathways of care in the short-, mid- and long-term. It is economical and well suited for a variety, but not all health care problems. Future efforts might be directed towards more collaboration among sickness funds.

[Prostate cancer in routine healthcare: health-related quality of life after inpatient treatment]. / Prostatakarzinom in der Routineversorgung : Gesundheitsbezogene Lebensqualität nach stationärer Behandlung.

BACKGROUND: Prostate cancer (PCA) is the most common form of neoplasm in men and various treatment options are available. Knowledge of health-related quality of life (HRQL) can provide information to support informed decision-making. In addition, information on factors influencing HRQL can provide indications for the further development of medical treatment. The aim of the study was to obtain data on HRQL after inpatient treatment of PCA and the identification of determinants of HRQL after PCA in routine healthcare. MATERIALS AND METHODS: In this study a total of 1165 beneficiaries of a German health insurance with a hospital stay due to prostate cancer (ICD C61) were surveyed on their health-related quality of life using the European Organization for Research and Treatment of Cancer quality of life questionnaire version 3 (EORTC QLQ-C30 V3.0) and disease-specific symptoms using the perceived sensitivity to medicine (PSM) scale 14 months after discharge. Survey data were linked with pseudonymous claims data of the health insurance provider. Determinants of HRQL were examined by logistic regression. RESULTS: Responses from 825 men (mean age 67.6 years and 80% treated with radical prostatectomy) were available for analysis (response 70.8%). Compared to the reference population impairments in HRQL were reported especially in terms of the roles and social functionality. The prostate-specific symptoms varied depending on the treatment strategy. A nerve-sparing surgical technique reduced the likelihood of erectile dysfunction. Other protective factors were no pre-existing comorbidities and younger age. DISCUSSION: The effects of PCA on the HRQOL varied by age, comorbidities and treatment modality which should be considered in healthcare information and counseling of patients.

[Leaflets and websites on colorectal cancer screening and their quality assessment from experts' views]. / Printmedien- und Internetangebote mit Informationen zur Darmkrebsfrüherkennung und ihre kriteriengestützte Bewertung aus Expertensicht.

In Germany, individuals who have statutory health insurance have free access to colorectal cancer (CRC) screening tests, and can choose between a fecal occult blood test and a screening colonoscopy. Evidence-based health information may support informed choices regarding whether or not to undergo CRC screening. The aim of this study was to assess whether the available German information materials on CRC screening meet evidence-based health information standards. A systematic search was made for print media and websites on CRC screening addressed to German people with average CRC risk (search period for print media August 2010, for websites January-March 2012). The identified information was assessed with a newly developed comprehensive list of criteria. In all, 41 print media, including 28 flyers and 13 brochures, and 36 websites were identified and assessed. These materials reported more often the benefits than the risks of CRC screening, and quantified presentations of benefits and risks were less frequently given. Most of the materials called for participation and did not indicate the option to decide whether or not to attend CRC screening. This bias in favor of screening was increased by fear-provoking or downplayed wording. Most materials included false and misleading information. The requirements for evidence-based patient information were currently not met by most of the leaflets and websites in Germany. Feedback was given to the producers of the leaflets including a discussion of the findings. The results may be used to revise existing leaflets or to develop new health information on CRC screening.

[Empirically derived recommendations for measuring patient-reported change in rehabilitation studies]. / Empirisch gestützte Empfehlungen für die patientenberichtete Veränderungsmessung in der medizinischen Rehabilitation.

Diverse methods are available for evaluation of (medical) interventions. In each case one has to decide on a specific method. Our aim was to analyze typical problems involved in the measurement of change. Different methods are delineated, and their specific pros and cons are set out. Subsequently, empirically derived recommendations are outlined on which method should be employed for which problem and under which circumstances. A characteristic of rehab treatment is that as a rule a multitude of problems are addressed, and accordingly, treatment goals are heterogenic. Straightforward recommendations for one or the other method cannot be given.

[Satisfaction with dental care from the patient's perspective - the dental-ZAP-V1]. / Zufriedenheit mit der zahnärztlichen Versorgung aus Perspektive der Patienten - Der Zahn-ZAP-V1.

BACKGROUND: Patient satisfaction is a central topic in quality management in outpatient dental care. The ZAP questionnaire was validated to explore patient satisfaction in general and specialist outpatient settings. This study aims at assessing the psychometric properties of the ZAP in dental care. METHODS: A minimally modified version of the ZAP consisting of 4 domains (office organisation, cooperation, interaction, information) was administered in personal interviews to a population-based sample. Descriptive, exploratory and confirmatory psychometric analyses were conducted with random subsets of the study sample. RESULTS: The study population comprised 1 773 subjects with at least one dental visit during their lifetime (mean age=50 years, female=51.6%). The exploratory factor analysis identified 3 subscales (office organisation, interaction, information). Based on these results, items of the subscale "cooperation" were excluded from further analyses. The remaining items had a medium difficulty of 0.75, all item-total-correlations were above 0.4. Missing values ranged between 2.3% and 28.7%. Cronbach's alpha ranged between 0.79 and 0.95. After introduction of 3 residual correlations, the confirmatory factor analyses reached a good model fit (TLI: 0.97; CFI: 0.97, RMSEA: 0.06). Partial standardised factor loadings ranged between 0.77 and 0.87. The 3 latent factors were highly correlated. There was a positive correlation between the 3 subscales and global patient satisfaction with the dentist. CONCLUSION: The psychometric assessment can be used in the 3 modified subscales (office organisation, interaction, and information) to assess patient satisfaction with dental care. To assess dentist's competence in relation to dental anxiety and pain as well as shared decision making new scales specific to dental care should be explored.

[Mammography and cervical cancer screening--a systematic review about women's knowledge, attitudes and participation in Germany]. / Früherkennung von Brust- und Gebärmutterhalskrebs--ein systematischer Review zu Wissen, Einstellungen und Inanspruchnahmeverhalten der Frauen in Deutschland.

INTRODUCTION: In the German statutory health insurance system, women can take part in free mammography and cervical cancer screening. The aim of this study is to investigate women's knowledge of, attitudes to and participation in these screening measures as well as the determinants of eligible women living in Germany. METHODS: We conducted a systematic literature search, supplemented by an Internet search, of Medline and other German and English databases for the period 2000-2010. Data extraction and quality assessment were carried out by 2 independent reviewers. Data synthesis was qualitative. RESULTS: We identified 12 studies on mammography and cervical cancer screening. Most women were found to be aware of the option of free screening. The majority of women were able to name risk factors for breast cancer correctly. This was not the case in cervical cancer, where women said they were insufficiently informed. To a significant extent, they were also uninformed about the benefits of screening and incidence of false-positive and false-negative test results in mammography. In 2007, 54% of the invited women took part in the organised mammography screening program with large variations in participation rate among the Federal states. It appears that better educated women or those with a private health insurance participate in the programme less frequently. However, one third of the non-participants attend a mammography outside the screening program. Data for participation in cervical cancer screening are inconsistent. There is some evidence that younger women, married women and those with higher education are more likely to participate in the screening. CONCLUSIONS: The interviewees' substantial lack of knowledge underscores the need for optimising communication on the aims, benefits and risks of screening tests to enable women to make an informed decision. It is desirable to continuously monitor women's knowledge about and participation in screening and determinants thereof with a view to laying the foundations for target group-specific information strategies.

[Empowerment and health literacy in medical rehabilitation - recommendations for strengthening patient education]. / Teilhabebefähigung und Gesundheitskompetenz in der medizinischen Rehabilitation - Empfehlungen zur Stärkung von Patientenschulungen.

UNLABELLED: The recommendations aim to increase patient participation and health literacy by strengthening the role of patient education in medical rehabilitation. Research shows patient education to be effective and efficient; making the implementation of high quality patient education a top priority. To strengthen the role of patient education it is important to address known obstacles, identify potential for improvement, and define future demands for rehabilitative care. Led by the German Society for Medical Rehabilitation (DEGEMED), the Centre for Patient Education at the Würzburg University, and the Institute for Quality Management and Clinical Audit in Medical Rehabilitation (IQEM) an inter- and multidisciplinary panel of 28 experts from research and practice developed recommendations to further patient education in medical rehabilitation. The recommendations address topics such as the implementation of legal requirements under book IX of the German Social Code, SGB 9, structural and organisational prerequisites to promote the importance of patient education in rehabilitation units, the incorporation of quality criteria for patient education in quality assurance, quality management, and certification, as well as networking between medical rehabilitation and other health care sectors. CONCLUSION: Providers of medical rehabilitation hold the power to strengthen patient education: by implementing patient education programmes that are well-evaluated, manual-based, and standardised, by providing sufficient resources within their institutions, and by placing patient education in the centre of their quality policy, i.e. by nomination of a patient education representative. Stakeholders need to acknowledge these activities by incorporating quality criteria for patient education in clinical audit, and last but not least by adequate funding of medical rehabilitation.

Abortion care training framework for nurses within the context of higher education in the Western Cape.

The high morbidity and mortality rate due to illegal abortions in South Africa necessitated the implementation of abortion legislation in February 1997. Abortion legislation stipulates that registered nurses who had undergone the proposed abortion care training--certified nurses--may carry out abortions within the first 12 weeks of pregnancy. Currently it seems that an inadequate number of nurses are being trained in the Western Cape to provide pregnant women with counselling, to perform abortions and/or refer problem cases. No real attempts have since been made by higher education institutions in the Western Cape to offer abortion care training for nurses. This case study explores the situation of certified nurses and the context in which they provide abortion care in different regions of the Western Cape. The sampling included a random, stratified (non-proportional) number of designated state health care facilities in the Western Cape, a non-probability purposive sampling of nurses who provided abortion care, a non-probability convenience sample of women who had received abortion care, and a non-probability purposive sampling of final-year pre-registration nursing students. Data was generated by means of questionnaires, a checklist and semi-structured interviews. The main findings of this study indicate that the necessary infrastructure required for legal abortion is in place. However, the ongoing shortage of trained health care practitioners hampers abortion care services. Deficiencies were identified in the existing provincial protocol as some of the guidelines were either not in use or had become obsolete. Certified midwives who had been trained by the regional offices of the Department of Health: Western Cape were skilled in carrying out the abortion procedure, but other aspects of abortion care mainly carried out by other categories of nurses required more attention. This article suggests a training framework that should provide focus for the development of a formal programme or programmes for the training of nurses in abortion care at higher education institutions in the Western Cape.

Patient-reported outcomes in hernia repair.

BACKGROUND: The project aimed at testing the feasibility of a quality improvement system based on patient-reported outcomes in short-stay surgery for groin hernia repair. METHODS: In two centres for short-stay surgery all patients referred for hernia repair were surveyed between August 1999 and January 2002. Patients reported on health-related quality of life (SF-36), symptoms (Hernia Symptom Checklist, HSCL) and other indicators pre-operatively (T0) and 14 days (T1) and 6 months post-operatively (T2). Three of the eight SF-36 subscales (physical functioning, bodily pain, and role physical) and the HSCL at T2 were considered as main outcome indicators. The main outcomes were analysed by generalized linear models with regard to predictors. RESULTS: At T0 a total of 342 hernia patients were included. The response rate at T2 was 54.1% (92.4% males, 58.6 years of age). At T2 only 21.1% did not report complaints (i.e. haematoma, pain, numbness) post-operatively. The overall positive course is reflected by the HSCL: from 32.4% pre-operatively, it rises slightly to 38.5% at T1 and decreases to 10.6% at T2 (T0-T2: P < 0.001). The SF-36 subscales "physical functioning", "bodily pain", and "role physical" showed the same course over time (slight decrease of health-related quality of life at T1 and large increase at T2). The main patient-reported outcomes were mainly influenced by the pre-operative level, age, and self-reported post-operative complaints. CONCLUSION: The low response rate was mainly due to non-delivery of questionnaires at T1 during the regular post-operative visit by the operating physician. Though non-response occurs under conditions of routine care, meaningful information was gained which should be used for quality improvement activities. Because the pre-operative level is a major determinant of the post-operative health outcomes, the prospective pre-post measurement should be standard, in case institutional comparisons are intended.

[Acceptance and practicability of a guideline for rehabilitation in coronary artery disease]. / Akzeptanz und Praktikabilität der Leitlinie für die Rehabilitation bei koronarer Herzkrankheit.

BACKGROUND: Developed within the German Pension Insurance scheme's Guidelines programme, the Guideline for Rehabilitation in Coronary Artery Disease has been publicly available since January 2005. Pension Insurance routine data on the therapeutic benefits and services provided (based on the Classification of Therapeutic Procedures, KTL) were analyzed to assess the extent to which rehabilitation facilities had complied with Guideline requirements already in 2004. In January 2005, the results were disseminated together with the Guideline to the rehabilitation facilities which had participated in Pension Insurance rehabilitation of patients with coronary artery disease in 2004. In an accompanying survey information was requested concerning acceptability and applicability of the Guideline, of the presentation of KTL data, as well as reasons for non-adherence to Guideline requirements. METHODS: In February 2005 a written, anonymous survey was conducted among 72 clinical directors of rehabilitation facilities. The survey instrument contained three standardized questionnaires covering the aspects cited above. The response rate was 73.6 % (n = 53). Descriptive analyses were performed. RESULTS: Views of the Guideline: The Guideline fulfils most of the seven quality attributes surveyed (completely fulfilled: 11.3-32.7 %, basically fulfilled: 49.1-64.2 %). Volume, structure and clarity of the guideline are judged to be "very good" by 62.3 %, 50.9 % and 36.5 % of the respondents. The KTL-procedure codes forming part of the Guideline to be used to assess guideline adherence, were considered appropriate by 88.5 % to 98 %. Consent to Guideline requirements varies between 80.8 and 34.6 %. Views of the audit feedback based on KTL-data: Depending on the various data table types, 37.7 % to 20.0 % of the respondents stated that the tables should remain unchanged in future evaluations. 28.0 % to 39.0 % consider the tables to be very useful for quality management. Reasons for non-adherence to Guideline recommendations: according to the clinicians, the most important reason for deviation from Guideline requirements is incomplete or incorrect coding of therapeutic procedures. DISCUSSION: The Guideline for Rehabilitation in Coronary Artery Disease basically fulfils the formal, methodological and content-related quality criteria considered to be most relevant by the clinical directors. As expected, the greatest need for discussion is focussed on the actual Guideline requirements. Form and content of the KTL-feedback are well accepted, and the feedback itself is considered relevant for everyday practice. The main reason given for non-adherence to guideline requirements (i. e., inaccurate coding) should not be overstated as the KTL-analyses was based on data from 2004, when the guideline had not yet been published. CONCLUSION: The Guideline for Rehabilitation in Coronary Artery Disease is acceptable and practicable, and it is moreover tied in with external quality assurance activities in place (i. e., the quality assurance programme of the statutory Pension Insurance scheme). The audit feedback given in this framework provides rehabilitation facilities participating in the programme not only with comparative analyses but also with input for their internal quality management actions. Future activities within the external quality assurance programme should inter alia focus on more targeted implementation activities and repeated KTL-based appraisals.

[Developing an evidence based clinical guideline on cardiac rehabilitation--Phase 2: comparative analysis of the present level of service provision in cardiac rehabilitation based on the KTL statistics]. / Entwicklung einer evidenzbasierten Leitlinie zur kardiologischen Rehabilitation--Phase 2: Vergleichende Analyse des Ist-Zustandes der in der kardiologischen Rehabilitation erbrachten Leistungen auf der Basis der KTL-Statistik.

BACKGROUND: This project aims to develop an evidence based clinical guideline for the rehabilitation of cardiac patients considering recent scientific literature (stage 1), procedures received by cardiac patients undergoing rehabilitation carried by the German Federal Insurance Institute for Salaried Employees (BfA) based on the Classification of Therapeutic Procedures (KTL) (stage 2), and expert agreement of the professionals involved (stage 3). This study presents the results of stage 2. The analysis of the KTL-statistics was carried out to determine whether it is essentially necessary to implement a guideline and to define "critical" aspects, i. e. aspects that require high priority implementation. The project is part of a research programme funded by the BfA. METHODS: 317 out of the 840 possible KTL-codes were attributed to one of twelve therapeutic modules that--according to the results of stage 1--are characteristics of cardiac rehabilitation. For these modules the number of people having received therapeutic procedures belonging to the respective module the duration per patient and per week were calculated. The influence of concomitant factors such as age, gender and indication were analysed multivariately. Furthermore, the hospitals involved were compared. The analyses are based on approximately 87,400 KTL-entries from 5,494 patients (indication: "myocardial infarction" or "coronary artery bypass surgery") treated in 2000. RESULTS: On average the patients receive therapeutic procedures "stemming" from 5.5 modules. More than 90 % receive procedures assigned to the modules "endurance training" or "motivation", respectively, and almost 70 % from "nutrition training". The other modules are rendered not consistently and occasionally to a relatively small degree. Younger patients following a myocardial infarction receive therapeutic procedures more frequently and longer while older patients after bypass surgery are treated less frequently and for a shorter duration. There is substantial variability between individual clinics. DISCUSSION: It appears to be necessary to implement clinical practice guidelines in all evaluated therapeutic modules but "endurance training" and "motivation". An evidence based clinical practice guideline for the rehabilitation of cardiac patients should detail the kind and extent of procedure(s) required. It should also inform about the lack of evidence for variations in treatment with respect to age, gender, or indication. To facilitate monitoring of the degree of implementation of the guideline precise instructions for the documentation using the KTL should be developed and implemented. As a next step towards an evidence based, empirically proven and acceptable guideline this project's results will be discussed with experts from science and clinical practice.

[Developing evidence based guidelines on cardiac rehabilitation - phase 1: a qualitative review]. / Entwicklung einer evidenzbasierten Leitlinie zur kardiologischen Rehabilitation - Phase 1: Bewertende Literaturanalyse.

BACKGROUND: Guidelines are a means to support effective clinical practice and can be used to implement evidence-based medicine in rehabilitative practice. In 1998 a study on cardiac rehabilitation, funded by Bundesversicherungsanstalt für Angestellte, BfA, concluded that the AHCPR's Guideline on Cardiac Rehabilitation published in 1995 could be used as a reference guideline for the rehabilitation of coronary patients. The AHCPR Guideline and other systematic reviews showed cardiac rehabilitation to be an effective means in coronary care. However, no detailed information is given with regard to the structural and processual details that are required for a multidimensional and comprehensive cardiac rehabilitation scheme. To define those central characteristics, therapeutic interventions that had been proven to be effective for cardiac rehabilitation were analysed. The information derived from these analyses will then be used to develop a more detailed evidence-based guideline. METHODS: The analysis was based on the research cited in the AHCPR Guideline. Additionally, a systematic search of the literature identified (randomised) controlled studies published after 1995 for the analysis. Using criteria that had been developed prior to our review, one third (n = 53) of the 159 studies identified were considered suitable for further analysis. Characteristics of the study design, the interventions and the outcomes reported were extracted on a standardised data sheet. In order to facilitate comparisons, studies were arranged according to main intervention and target groups. As it is not possible to present the results in their entirety, this publication focuses on the main aspects which illustrate the method applied. RESULTS: 32 of the 53 studies included dealt with patients after myocardial infarction (MI). In these 32 studies a total of 40 interventions (in 2,912 patients) were investigated. 28 of these interventions dealt with exercise training or exercise training combined with other physical training (i. e. strength training). 7 interventions dealt with counselling only, and 5 interventions had exercise training and counselling as integral parts. Exercise training starts mainly three to four weeks after MI, for 30 - 60 minutes three to 5 times a week. Usually, training intensity is set at 65 - 80 % of the maximum heart rate (or 70 % of the maximum oxygen consumption) reached in standardised exercise testing. All interventions lead to gains in exercise tolerance. Compared to untreated control groups the net benefit ranges from + 11 % to + 30 %. The higher the intensity of the training, the larger the net benefit. The majority of the studies on the effectiveness of exercise training after MI do not report outcomes like psychological well-being, return to work or modification of risk factors. DISCUSSION: Despite limitations in report quality and methodology in some of the studies included, a detailed analysis of the interventions investigated can be used to substantiate optimal cardiac rehabilitation. It is possible to quantify important characteristics of the main elements and to define lower and upper limits of treatment. While formulating these limits, it is intended to maintain compatibility with the BfA Classification of therapeutic measures in medical rehabilitation (KTL). As a next step the data from the KTL statistics will be used to assess the scope of German rehabilitative care to define areas which do not comply with the limits defined in the guideline. The results will be consented with experts from science and clinical practice in order to develop an evidence-based, empirically founded, practicable and acceptable guideline for cardiac rehabilitation.

[Effects of rehabilitation after hip replacement surgery on postoperative complaints regarding the disease and limitation of function]. / Effekte der Rehabilitation nach Hüftgelenkoperationen auf indikationsspezifische Beschwerden und Funktionseinschränkungen.

BACKGROUND: The study was conducted in co-operation with a German health insurance fund (Gmünder Ersatzkasse, GEK) to identify determinants of outcomes of hip surgery from the patient's perspective. METHODS: In September 1997 all beneficiaries (age 40-75 yrs.) who had been treated in hospital for osteoarthrosis of the hip (ICD-715/820) (n = 1352) were sent a questionnaire on average 5.2 months (T1) postoperatively. The standardized questionnaire contained, among others, items about pre- and postoperative subjective assessment of disease specific symptoms (Lequesne Index), complications, comorbidity (Katz-Index), health related quality of life (SF-36) and discharge (home or for inpatient rehabilitation). The response rate at T1 was 67.8%. Patients with hip surgery (n = 390) were sent a second questionnaire 17.2 months (T2) postoperatively. After the two mailings, data from 293 patients were available for analysis. Descriptive and multivariate analyses (GSK model) were performed to reveal determinants of disease specific symptom alleviation. RESULTS: Patients (57.6% male) were 61 years of age on average, and 61.2% reported no comorbidity. 88.4% had undergone total hip replacement. A third of the patients reported at least one complication. 70.6% were discharged for inpatient rehabilitation. Univariately, a substantial (and statistically highly significant) decrease was observed in the Lequesne Index over time: (recalled) preoperative: 14.2 points; postoperative T1: 5.6 pts.; postoperative T2: 4.4 pts. This result is confirmed by multivariate analyses (estimated values: pre = 13.8; T1 = 6.9; T2 = 5.7) although it is modified by an interaction effect between the variables "Lequesne Index" and "Discharge". In patients discharged home, the preoperative Lequesne Index is an estimated 13.3, at T1 = 6.9 and T2 = 6.2. The respective estimated values for patients discharged for inpatient rehabilitation are: preoperative 14.3; T1 = 6.9; T2 = 5.2. CONCLUSIONS: Patients receiving inpatient rehabilitation scored higher on the Lequesne Index (higher burden of disease) before hip surgery. In the short term, their improvements are higher than those of the patient group discharged home (-7.4 pts. versus -6.4 pts.) and continue to be higher in the medium term (-9.1 pts. versus -7.1 pts.). Inpatient rehabilitation after hip surgery leads to better disease specific health outcomes than direct discharge home.

[Hip joint operation in routine management--complications and their effect on indications-specific symptoms]. / Hüftgelenkoperationen in der Routineversorgung--Komplikationen und ihr Einfluss auf indikationsspezifische Beschwerden.

AIM: The study was conducted in co-operation with a German sickness fund to identify determinants of disease-specific health outcomes after hip surgery in routine health care. METHOD: In September 1997 all beneficiaries (age 40-75 yrs.), who were hospitalized for "osteoarthrosis" (ICD 9-715/820), were sent a disease-specific survey instrument on average 5.2 months (T1) after discharge. Survey content focused, among others, on pre- and postoperative symptoms and impairment (Lequesne index), postoperative complications, comorbidity (Katz Index) and health-related quality of life (SF-36). The response rate at T1 was 67.8%. Only patients undergoing hip surgery were sent a second survey instrument 17.2 months (T2) after discharge. After two mailings, data from 293 patients were available for analysis. Descriptive and multivariate analysis (GSK Model) were performed. RESULTS: Patients (57.6% male) were on average 61 yrs. of age and 61.2% reported no comorbidity. 88.4% received total hip replacement. A third of patients reported at least one complication. Univariate, a substantial (and highly significant) improvement was found for the Lequesne Index over time: (recalled) preoperative: 14.2 points; postoperative T1: 5.6 pts.; postoperative T2: 4.4 pts. This result is confirmed by multivariate analyses (estimated values: pre = 13.8, T1 = 6.9; T2 = 5.7), although it is modified by an interaction effect between the variables "Lequesne index" and "complication". The Lequesne Index in patients with complications is estimated preoperative 12.9, at T1 = 7.3 and T2 = 6.2. The respective estimated values for patients without complications are: preoperative 14.7, T1 = 6.5, T2 = 5.2. CONCLUSION: Patients with postoperative complications obtain lower scores on the Lequesne Index (higher burden of disease) before hip surgery. Their postoperative progress is slower in the short term (-5.6 pts. vs. -8.2 pts) and in the medium term (-6.7 pts. vs. -9.5 pts). Complications after hip surgery have a lasting negative effect on disease-specific health outcomes.

[The success of hernia surgery in routine care from the patient's perspective]. / Der Erfolg von Leistenbruchoperationen in der Routineversorgung aus der Sicht der Patienten.

BACKGROUND: The study was conducted in cooperation with a German sickness fund (Gmünder Ersatzkasse GEK) to determine the success of surgery for inguinal hernia from the patient's perspective. METHODS: We developed a standardized questionnaire containing, among other things, pre- and postoperative subjective assessment of disease-specific symptoms, complications, and health-related quality of life (SF-36). All beneficiaries (age 35-75 years), who were treated in the hospital for inguinal hernia repair (ICD-550) between November 1996 and January 1997 (n = 502) were sent the questionnaire at an average of 3 months (T1) and 14 months postoperatively. The response rate at T1 was 73%. At T2 data from 280 patients were available for analysis: 96% were male (mean age: 54 years). Descriptive and multivariate analysis (GSK model) were performed to reveal determinants of disease-specific symptom alleviation and health-related quality of life. RESULTS: Postoperative hematoma and genital swelling were reported by a quarter of the respondents, each. Pyogenic wound infection appeared in 4%. Compared to the (recalled) preoperative symptom level at T1 substantial and statistical significant improvements were apparent (P < 0.0001). These were maintained at T2 (disease-specific symptom checklist: preoperative: 10.7; T1: 2.8; T2: 2.5). Health-related quality of life reached the level of the German reference population in three of the eight subscales of the SF-36 at T1, and in five SF-36 subscales at T2. However, at T2 (still existing) deviations from the reference population in three of the SF-36 subscales were small. Bi- and multivariate analysis reveals that the appearance of complications from the patient's perspective has to be considered the main determinant of disease-specific symptom alleviation and health-related quality of life after hernia repair. CONCLUSION: Inguinal hernia repair leads to substantial improvements in disease-specific symptoms. Overall, health-related quality of life reaches the level of the reference population. The patient's perception of complications is the major determinant of health outcomes.

[Hip joint operations in routine patient management--determinants of quality of life]. / Hüftgelenkoperationen in der Routineversorgung--Determinanten der Lebensqualität.

The study was conducted in co-operation with a German sickness fund to identify determinants of health related quality of life (HRQL) after hip surgery in routine health care. In 9/97 all beneficiaries (age 40-75 years), which were treated in hospital for osteoarthrosis (n = 1352), were sent a questionnaire on average 5.2 months (t1), postoperatively. The standardized questionnaire contained a.o. items about pre- and postoperative subjective assessment of disease specific symptoms (Lequesne-Index), complications, comorbidity, health related quality of life (SF-36). The response rate at t1 was 67.8%. Patients with hip surgery (n = 390) were sent a second questionnaire 17.2 months (t2) postoperatively. At t2 data from 293 patients were available for analysis. Patients (57.6% male) were on average 61 years of age and 61.2% reported no co-morbidity. 88.4% received total hip replacement. 30.3% of patients reported at least one complication. HRQL in patients after hip surgery is significantly impaired in six of the eight SF-36 subscales compared to the German norms at t1 and t2. From t1 to t2 substantial improvements appear in the SF-36 subscales physical functioning, role physical and bodily pain (p < 0.001). Major determinants of HRQL are comorbidity (if yes: less improvement) and attendance of inpatient rehabilitation (if yes: more improvement). In routine healthcare HRQL after hip surgery is determined by patient characteristics and postoperative rehabilitation. Inspite of substantial improvements patients did not (yet) reach the level of the reference population.