Achim Hochlehnert

Psychiatric comorbidity in cardiovascular inpatients: costs, net gain, and length of hospitalization.

OBJECTIVE Although psychiatric comorbidity often goes undetected and untreated in cardiovascular patients, it is not clear whether the costs for a special treatment of psychiatric comorbidity are appropriately reflected in the reimbursement system. To investigate the economic impact of psychiatric comorbidity, we compared costs, returns, net gain, and duration of hospitalization in cardiovascular inpatients with and without psychiatric comorbidity. METHODS For a period of 2 years, we analyzed costs, net gain, and other outcome variables according to the diagnosis-related group (DRG) system for cardiovascular inpatients of a German university department (n = 940). Psychiatric disorders were diagnosed by the treating physicians based on clinical criteria and results from the Patient Health Questionnaire (PHQ). With respect to the outcome variables, we compared patients with and without a psychiatric disorder, controlling for sociodemographic characteristics. RESULTS The average total costs of hospitalization (mean ± S.E.) for cardiovascular patients without psychiatric comorbidity and for patients with psychiatric comorbidity differed significantly (€5142 ± 210 vs. €7663 ± 571; d = 0.39). The increased costs for patients with psychiatric comorbidity were related to elevated returns, but the net gain for patients without psychiatric comorbidity was €277 ± 119. In contrast, the treatment of internal medicine patients with psychiatric disorders resulted in a net loss of -€624 ± 324 (overall group difference, d = -0.25). CONCLUSION Psychiatric comorbidity in cardiovascular inpatients leads to higher costs that are not reflected in the current reimbursement system in Germany. The inappropriate reimbursement of psychiatric comorbidity in cardiovascular inpatients may result in a serious undertreatment of these patients.

Spontaneous pneumomediastinum in anorexia nervosa: A case report and review of the literature on pneumomediastinum and pneumothorax

We report a case of a 20-year-old white woman with the history of anorexia nervosa presenting with spontaneous pneumomediastinum (SPM). On admission, her body mass index (BMI) was 9.9 kg/m(2). Physical examination revealed subcutaneous crepitation especially in the axillae, the intercostal spaces, between the scapulae and along the spine. A chest X-ray showed extensive tissue emphysema, especially in the upper mediastinum. In a computed tomography (CT) scan, additional air was found in the upper retroperitoneal space adjacent to the stomach and to the left of the aorta. The patient recovered clinically within three weeks, and a CT scan showed a complete remission of the pneumomediastinum and subcutaneous emphysema. Based on this, case review of the literature about the frequency of pneumomediastinum in young patients with low weight is presented concerning epidemiology, etiology, symptoms, diagnosis, treatment, time to recovery and prognosis.

Partizipative Entscheidungsfindung PEF) mit chronischen Schmerzpatienten

ZusammenfassungDas Fibromyalgie-Syndrom (FMS) gilt als besonders schwer beherrschbare chronische Schmerzerkrankung, bei der es häufig zu einer belasteten Arzt-Patienten-Beziehung kommt. Einen möglichen Lösungsansatz für die Herausforderungen bei der Behandlung von FMS-Patienten könnte das Vorgehen nach dem Modell der Partizipativen Entscheidungsfindung (PEF) darstellen. Bei diesem medizinischen Konsultationsstil treffen Arzt und Patient nach wechselseitigem Informationsaustausch als gleichberechtigte Partner medizinische Therapieentscheidungen. In der dargestellten Studie wurde überprüft, inwieweit eine Behandlung im Einklang mit PEF die Therapieentscheidungen bei FMS-Patienten beeinflusst. Hierzu wurde ein Kommunikationstraining mit Ärzten durchgeführt, um diese zum Umsetzen von PEF zu befähigen. Für Patienten wurde ein computerbasiertes Informationsprogramm zu FMS entwickelt. 133 FMS-Patienten wurden in eine 3-armige Interventionsstudie eingeschlossen. Interventionsgruppe I (IG I) wurde von kommunikationsgeschulten Ärzten behandelt und hatte Zugang zum Informationsprogramm. Interventionsgruppe II (IG II) wurde von nicht speziell geschulten Ärzten behandelt, sah aber das Informationsprogramm. Die Vergleichsgruppe (VG) wurde ebenfalls von nicht speziell geschulten Ärzten behandelt und bekam kein Informationsprogramm. Alle 3 Gruppen konnten zwischen den gleichen evidenzbasierten Therapieoptionen wählen. Die Patienten der beiden IG entschieden sich häufiger für das Durchführen sportlicher Aktivitäten und Gymnastik, nahmen häufiger an der Integrierten Gruppentherapie für FMS-Patienten (IGTF) teil und neigten eher zur Einnahme von Analgetika. Diese Effekte waren in der IG I teilweise noch deutlicher ausgeprägt als in der IG II. Patienten der VG entschieden sich häufiger für die Einnahme von Antidepressiva. Mehr Patienten aus IG I und VG entschieden sich für Ent-spannungsverfahren als in IG II. Die Patienten der beiden IG wählten deutlich mehr Therapieoptionen als die Patienten der VG. PEF und hierbei insbesondere das Element der medizinischen Informationsvermittlung erhöhen die Behandlungsbereitschaft bei FMS-Patienten. Insbesondere die Bereitschaft zu sportlicher Aktivität, zu Analgetikaeinnahme sowie für psychotherapeutische Elemente steigt.AbstractFibromyalgia syndrome (FMS) is an exemplary condition of chronic widespread pain that is difficult to control and often leads to frustration and resignation on the part of both the patient and the doctor. Shared decision making (SDM) could be a means to facilitate doctor-patient interaction and might therefore influence therapeutic decisions taken. We conducted a prospective study to evaluate the effects of SDM with FMS patients. We developed a communication training program for physicians and a computer-based information tool on FMS for patients. The study included 133 FMS patients. Intervention group I (IG I) was treated by communication-trained doctors and had access to a computer-based information tool on FMS, intervention group II (IG II) was treated by standard doctors and received the information tool, and the control group (CG) was treated by standard doctors and got no additional information. All three groups were offered the same evidence-based treatment options for FMS. Patients of the IGs were more willing to become involved in exercise, to enroll in integrated group therapy for FMS patients (IGTF), and to take analgesics. Patients of the CG preferred antidepressants. More patients from IG II and CG opted for relaxation techniques. Patients in IG I and IG II choose significantly more therapeutic options than patients in the CG. SDM is one means to increase FMS patients’ readiness for treatment. Especially the element of providing sufficient medical information seems to account for this effect. The readiness to enroll in physical activities, to take analgesics, and to participate in psychotherapeutic elements was most likely to be raised through SDM.

Assessing the Prognoses on Health Care in the Information Society 2013 - Thirteen Years After

Health care and information technology in health care is advancing at tremendous speed. We analysed whether the prognoses by Haux et al. - first presented in 2000 and published in 2002 [1] - have been fulfilled in 2013 and which might be the reasons for match or mismatch. Twenty international experts in biomedical and health informatics met in May 2013 in a workshop to discuss match or mismatch of each of the 71 prognoses. After this meeting a web-based survey among workshop participants took place. Thirty-three prognoses were assessed matching; they reflect e.g. that there is good progress in storing patient data electronically in health care institutions. Twenty-three prognoses were assessed mismatching; they reflect e.g. that telemedicine and home monitoring as well as electronic exchange of patient data between institutions is not established as widespread as expected. Fifteen prognoses were assessed neither matching nor mismatching. ICT tools have considerably influenced health care in the last decade, but in many cases not as far as it was expected by Haux et al. in 2002. In most cases this is not a matter of the availability of technical solutions but of organizational and ethical issues. We need innovative and modern information system architectures which support multiple use of data for patient care as well as for research and reporting and which are able to integrate data from home monitoring into a patient centered health record. Since innovative technology is available the efficient and wide-spread use in health care has to be enabled by systematic information management.

Good exams made easy: The item management system for multiple examination formats

BackgroundThe development, implementation and evaluation of assessments require considerable resources and often cannot be carried out by a single faculty/institution. Therefore some medical faculties have founded cooperation projects which mainly focus on the exchange of multiple choice questions (MCQs).MethodsSince these cooperation projects do not entirely support all relevant processes in terms of preparation, implementation and evaluation of assessment, in 2006 the Medical Assessment Alliance (MAA) was founded for mutual support. In addition to MCQs the MAA started to develop innovative assessment formats and facilitate content through a coordinated exchange of experiences. To support cooperation within this network, the web-based Item Management System (IMS) was developed which supports all processes of the assessment workflow as an all-in-one working platform.ResultsAt present, the Alliance has 28 partner faculties in Europe. More than 2.800 users in 750 working groups are collaborating. Currently 90.000 questions have been stored in the IMS. Since 2007, nearly 4.600 examinations have been successfully conducted.ConclusionThis article describes in detail the unique features of the IMS and contrasts it with the item management systems of other associations.

[Normative-empirical determination of personnel requirements in psychosomatic medicine and psychotherapy].

OBJECTIVES There is a high degree of misallocated medical care for patients with somatoform disorders and patients with concomitant mental diseases. This complex of problems could be reduced remarkably by integrating psychosomatic departments into hospitals with maximum medical care. Admitting a few big psychosomatic specialist clinics into the calculation basis decreased the Day-Mix Index (DMI). The massive reduction of the calculated costs per day leads to a gap in funding resulting in a loss of the necessary personnel requirements - at least in university psychosomatic departments. The objective of this article is therefore to empirically verify the reference numbers of personnel resources calculated on the basis of the new German lump-sum reimbursement system in psychiatry and psychosomatics (PEPP). METHODS The minute values of the reference numbers of Heuft (1999) are contrasted with the minute values of the PEPP reimbursement system in the years 2013 and 2014, as calculated by the Institute for Payment Systems in Hospitals (InEK). RESULTS The minute values derived from the PEPP data show a remarkable convergence with the minute values of Heufts reference numbers (1999). CONCLUSIONS A pure pricing system like the PEPP reimbursement system as designed so far threatens empirically verifiable and qualified personnel requirements of psychosomatic departments. In order to ensure the necessary therapy dosage and display it in minute values according to the valid OPS procedure codes, the minimum limit of the reference numbers is mandatory to maintain the substance of psychosomatic care. Based on the present calculation, a base rate of at least 285 e has to be politically demanded. Future developments in personnel costs have to be refinanced at 100 %.

Electronic acquisition of OSCE performance using tablets.

Background: Objective Structured Clinical Examinations (OSCEs) often involve a considerable amount of resources in terms of materials and organization since the scores are often recorded on paper. Computer-assisted administration is an alternative with which the need for material resources can be reduced. In particular, the use of tablets seems sensible because these are easy to transport and flexible to use. Aim: User acceptance concerning the use of tablets during OSCEs has not yet been extensively investigated. The aim of this study was to evaluate tablet-based OSCEs from the perspective of the user (examiner) and the student examinee. Method: For two OSCEs in Internal Medicine at the University of Heidelberg, user acceptance was analyzed regarding tablet-based administration (satisfaction with functionality) and the subjective amount of effort as perceived by the examiners. Standardized questionnaires and semi-standardized interviews were conducted (complete survey of all participating examiners). In addition, for one OSCE, the subjective evaluation of this mode of assessment was gathered from a random sample of participating students in semi-standardized interviews. Results: Overall, the examiners were very satisfied with using tablets during the assessment. The subjective amount of effort to use the tablet was found on average to be “hardly difficult”. The examiners identified the advantages of this mode of administration as being in particular the ease of use and low rate of error. During the interviews of the examinees, acceptance for the use of tablets during the assessment was also detected. Discussion: Overall, it was found that the use of tablets during OSCEs was well accepted by both examiners and examinees. We expect that this mode of assessment also offers advantages regarding assessment documentation, use of resources, and rate of error in comparison with paper-based assessments; all of these aspects should be followed up on in further studies.

Anwendung der Mehrebenenmodellierung zur Auswertung von Tagebuchdaten adipöser Patienten mit und ohne Binge Eating Disorder

Fitting multilevel models to diary data allows the analysis of development trends, group differences, and breakpoints in time trends. The aim of this study is the application of multilevel modelling to determine time trends in the diary data of a group of obese patients with and without binge eating disorder (BED). Throughout the course of a four-month multi-modal intervention program, the patients answered questions daily on handheld computers about their eating behaviour as well as their psychological and physical states. Multilevel analysis of the diary data shows that initially the trend of the eating behaviour over time decreases but increases towards the end of the therapy. Results of the application of a relatively new method to identify break points in linear trends indicate that the 85 th day of the therapy is a break point in the trend over time of the eating behaviour. Significant differences in the development of the eating behaviour over time were found for the subgroups of patients with and without BED.