[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.

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.

[Changes in the quality of life after organ transplantations]. / Veränderungen der Lebensqualität nach Organtransplantationen.

138 patients with end-stage kidney disease and 118 patients with end-stage liver disease were included in an observational cohort study regarding their quality of life. Instruments used were the Nottingham Health Profile (NHP), a scale for Activities of Daily Life (ADL), a Symptom Check List (SCL-90-R), and the Center of Epidemiology and Statistics Depression Scale (CES-D), all for self rating, as well as the indices of Spitzer and Karnofsky for foreign rating of life quality. Apart from the early postoperative period in both groups there was significant and persistent improvement in quality of life already three months after transplantation. In some dimensions, patients after kidney transplantation presented even lower trouble scores than a population sample. In addition, semistructured interviews showed clearly the need for psychotherapeutic support to guarantee the success for specific cases. The present investigation demonstrates, that systematic registration of the patients perception of illness and treatment is possible even in extreme situations and leads to a differentiated evaluation of medical procedures. Thereby the study also contributes to the development of modern evaluation research according to the spirit of evidence based medicine.

[Methodological quality of clinical practice guidelines in Germany: results of a systemic assessment of guidelines presented on the Internet]. / Methodische Qualität ärztlicher Leitlinien in Deutschland. Ergebnisse einer systematischen Untersuchung deutscher Leitlinienberichte im Internet

Critics claim that most of the German clinical practice guidelines are of poor quality having produced by informal ad hoc methodologies without a rigorous approach. This paper reports on the systematic appraisal of 329 guidelines published online by the Association of the Scientific Medical Societies (AWMF) in Germany. The results of this study suggest that most of the guidelines presented in Internet do not meet internationally recognised criteria for quality. Proposals are offered how to enhance the methodological quality of future guidelines.

Hospital outcomes research in Germany: results from a retrospective survey among sickness fund beneficiaries.

OBJECTIVES: The authors assess the feasibility of using retrospective, indication-specific patient surveys to conduct hospital outcomes research in Germany. Surgical outcome and patient satisfaction were examined in patients who underwent common elective surgical procedures. METHODS: Using the International Classification of Diseases Ninth Revision coding available in the Schwäbisch Gmünd health insurance data base, all patients for a defined period of time with one of the three following diagnoses were selected and questioned retrospectively using an indication-specific survey instrument: (1) varicose veins of the lower extremity; (2) nasal septum deviation; and (3) inner knee joint damage limited to patients undergoing arthroscopic meniscus repair. Survey content focused on preoperative conditions, pre- and postoperative symptoms, postoperative complications, the nature and duration of postoperative follow-up, and satisfaction with surgical outcome. RESULTS: Significant postoperative improvement of preoperative symptoms was found for all three groups. Complete freedom from symptoms was found in 29.7% of patients treated for varicose veins, 24.1% of patients with meniscus repair, and in only 10.6% of patients with nasal septum deviation. Multivariate analyses indicated that postoperative impairment was the decisive variable governing patient satisfaction for all three groups. CONCLUSIONS: The use of retrospective, indication-specific patient surveys constitutes a time-efficient, cost-effective, and patient-focused option for the systematic acquisition and evaluation of health outcomes in Germany. This methodology holds promise for international and domestic efforts to demonstrate the consequences of restructuring activities in the inpatient sector.

[Determinants of the quality of life in chronic renal failure]. / Determinanten der Lebensqualität bei chronischer Niereninsuffizienz.

Dialysis patients, waiting for kidney transplantation, were asked about their quality of life. Data from 1027 persons have been collected. Compared to a population sample by the "Nottingham Health Profile" (NHP), dialysis patients showed double the frequency of symptoms--only for the subscale "pain" no significant difference could be recognised. Duration of dialysis treatment reduces the quality of life considerably: increasing troubles have been observed through different quality of life scales. Age shows less important influence concerning "pain" and "physical mobility", even a decrease of symptoms in elder patients has been demonstrated by NHP-subscales for "emotional reaction" and "social isolation". Gender, education, kind of disease and dialysis treatment, and the fact of former transplantations had only marginal influence on some different dimensions of life quality. The study demonstrates in which way the patients perception of life quality could be operational and integrated in analysis and evaluation of therapeutic procedures.

[Clinical success of surgical correction of the nasal septum]. / Der klinische Erfolg der operativen Korrektur der Nasenscheidewand.

BACKGROUND: We conducted a retrospective survey on patient's evaluation of the outcomes of surgery for a deviated nasal septum. MATERIAL AND METHODS: In January 1995 all working members of a German health insurance plan who were hospitalized between March and September 1994 for ICD-470 (n = 392) were surveyed using a self-administered pretested questionnaire. The response rate was 85.2% (n = 334, 88.8% male; medium age: 35.2 years, average length of stay: 6.5 days). Descriptive and multivariate analysis (GSK model) were preformed. Relative alleviation of symptoms was taken as an indicator for clinical outcome. RESULTS: The most important reasons for undergoing septal surgery from the patient's point of view were nasal obstruction (52%), headache (8.7%) and snoring (7.8%). Ten point six percent of the study population reported complete disappearance of preoperative symptoms (100% relative improvement), whereas in 7.9% no symptom alleviation of nasal related symptoms was described. Postoperative complications were reported by 29.9% of the respondents (i.e., adhesions: 5.7%; perforations; 2.1%). Multivariate analysis revealed that the relative improvement of symptoms increases if no nasal packing is administered, if the patients report minor postoperative discomfort only, and if no postoperative complications appear. CONCLUSION: The clinical outcome of septal surgery is similar compared to that of other studies, but may be improved by not applying postoperative nasal packings. For some of the surgical complications we found higher rates than those that have been reported so far. The results may offer opportunities for clinical audit and quality management.

[Patient satisfaction as health care outcome--the example of surgical correction of the nasal septum]. / Patientenzufriedenheit als Health Care Outcome--das Beispiel der operativen Korrektur der Nasenscheidewand.

BACKGROUND: Presented is a study, that investigates the relevance of patient satisfaction as evaluative criteria for effectiveness of medical measures exemplary in patients who underwent surgery for a deviated nasal septum. MATERIAL AND METHODS: A standardised Instrument was specifically developed and pretested (n = 30). In January 1995 all working members of a German sickness fund hospitalised between March and September 1994 for ICD-470 (deviated nasal septum) were surveyed retrospectively by means of a written questionnaire. The response rate was 85.2% (n = 334, 88.8% male; medium age: 35.2 years, average length of stay: 6.5 days). Descriptive and multivariate analysis were performed. RESULTS: 10.6% of the study population reported a complete decrease of preoperative symptoms (100% relative improvement), whereas in 7.9% no alleviation of nasal related symptoms was reported. 45.2% of the patients are satisfied with the outcome of septal surgery, 35.6% are satisfied to a limited extent, 19.2% express their "dissatisfaction". Multivariate analysis was performed to investigate the main determinants of patient satisfaction. It can be seen that the percentage of satisfied patients increases if there is a large alleviation of that symptom cited as main reason for undergoing nasal surgery, if the discomfort caused by nasal packings is small and if the overall burden of nasal associated symptoms is low postoperatively. CONCLUSION: Patient criteria for evaluating the surgical outcome are plausible and include dimensions also relevant from the clinician's perspective. Therefore, the integration of systematic patient-oriented assessments into the evaluation of medical care seems to be a promising approach. It might be used i.e. to identify high priority areas in the context of quality management.

[Longitudinal analysis of utilization of inpatient treatment based on insurance data of mandatory health insurance]. / Längsschnittanalyse der Inanspruchnahme stationärer Krankenhausbehandlungen auf der Basis von Versichertendaten der gesetzlichen Krankenversicherung.

AIM: To investigate which of the routinely collected claims data from the German "Legal sickness funds" on hospital utilisation may be used, in addition to that prescribed by the legislator. DESIGN: We used claims data to study a cohort of sickness fund beneficiaries who were insured during the complete year 1992 (n = 81,309). Six utilisation parameters, using the number of cases and in hospital days overall as well as diseases specific (i.e. readmission rates, in-hospital days per person with [at least] one hospital stay) were calculated. RESULTS: There are 88 persons with (at least) one hospital stay, 116 hospital cases and a total of 1306 in-hospital days per 1000 insured persons in the study cohort. The average hospital days per person (14.8 days) are ca. 30% higher than the average length of stay (11.2 days). Hospital utilisation increases with age. Hospital stays associated with ICD-239 (neoplasms of unknown origin) resulted in a higher than average number of hospital days in total although the mean length of stay is not above the average. This is due to a high readmission rate. Hospital stays associated with elective surgical procedures have a high prevalence rate but a low readmission ratio and short length of stay. CONCLUSION: The parameters related to insured persons, cases and specifically personal parameters of hospital utilisation allow a detailed analysis of hospital care; different utilisation and user patterns can be investigated and possible determinants of utilisation can be identified. After technical transformation, routine data of the sickness funds can be used to obtain information relevant for health care planners as well as for quality management.