Eva Maria Bitzer

Der Erfolg von Leistenbruchoperationen in der Routineversorgung aus der Sicht der Patienten

Abstract.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 patients 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 patients 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 patients perception of complications is the major determinant of health outcomes.Zusammenfassung.Hintergrund: Ziel des in Kooperation mit der Gmünder Ersatzkasse (GEK) durchgeführten Projekts ist es, den kurz- und mittelfristigen Erfolg von Leistenbruchoperationen in der Routineversorgung aus der Perspektive der Patienten zu beurteilen. Material und Methode: Ein standardisiertes Erhebungsinstrument wurde entwickelt, das unter anderem die Aspekte „prä- und postoperative subjektive Einschätzung des Beschwerdegrads“, „Komplikationen“ sowie „gesundheitsbezogene Lebensqualität“ (SF-36) umfaßt. Alle Versicherten der GEK (Alter: 35–75 Jahre), die sich zwischen November 1996 und Januar 1997 in stationärer Behandlung mit der Hauptdiagnose „Leistenbruch“ (ICD-550; n = 502) befanden, wurden durchschnittlich 3 Monate (T1) und 14 Monate (T2) postoperativ schriftlich befragt. Der Rücklauf zu T1 betrug 73 %, zu T2 56,8 %. Somit liegen 280 auswertbare Fragebögen vor. 96 % waren Männer, das durchschnittliche Alter betrug 54 Jahre. Ergebnisse: Bei jeweils einem Viertel der Befragten kommt es postoperativ zu einem Hämatom im Operationsgebiet bzw. zu einer postoperativen Schwellung des Hodens. Vier % der Patienten berichten über eine eitrige Entzündung der Operationswunde. In Bezug auf das (erinnerte) präoperative indikationsspezifische Beschwerdeniveau lassen sich postoperativ zu T1 substantielle Verbesserungen nachweisen (p < 0,0001), die im weiteren Verlauf (T2) erhalten bleiben (indikationsspezifischer Beschwerdewert präoperativ: 10,7; T1: 2,8; T2: 2,5). Zu T1 erreichen die Patienten in 3, zum zweiten Erhebungszeitpunkt in 5 der 8 SF-36-Subskalen das Niveau der Normalbevölkerung. Die in den 3 Lebensqualitätsdimensionen zu T2 (noch bestehenden) Abweichungen im Vergleich zur Normalbevölkerung sind dabei vergleichsweise gering. Multivariate Analysen belegen, daß das Auftreten von Komplikationen aus der Perspektive der Patienten die zentrale Determinante von Verbesserungen indikationsspezifischer Beschwerden und der gesundheitsbezogenen Lebensqualität ist. Schlußfolgerungen: Leistenbruchoperationen führen bereits relativ kurzfristig zu einer deutlichen Reduktion indikationsspezifischer Beeinträchtigungen, und auch die gesundheitsbezogene Lebensqualität erreicht im wesentlichen das Niveau der Normalbevölkerung. Patientenseitig wahrgenommene Komplikationen sind die wichtigste Determinante der postoperativen gesundheitsbezogenen Lebensqualität.

Zufriedenheit in der Arztpraxis aus Patientenperspektive

ZusammenfassungZiel der vorliegenden Untersuchung ist die Entwicklung eines standardisierten patientenzentrierten quantitativen Instrumentes zur Messung der prozeßbezogenen Patientenzufriedenheit, daß z.B. im Rahmen eines internen Qualitätsmanagements oder im Zusammenhang mit externen Qualitätssicherungsmaßnahmen eingesetzt werden kann. Die Auswahl der Items erfolgte auf der Basis einer umfangreichen qualitativen Untersuchung, eine vorläuflge Fragebogenversion (35 Items) wurde in einer Voruntersuchung mit 2.800 Patienten aus 56 Arztpraxen (auswertbare Antworten: n= 969) eingesetzt. Nach einer vorläufigen psychometrischen Prüfung wurde das optimierte Erhebungsinstrument an 3.000 Patienten aus 60 Praxen getestet. Antworten von 1.387 Patienten (Rücklaufquote: 46%, 62% weiblich, durchschnittliches Alter:52 Jahre) lagen zur Auswertung vor. Die psychometrische Prüfung umfaßte Analysen zur faktoriellen Validität (konfirmatorische Faktorenanalyse), konvergenten und diskriminanten Validität sowie zur Reliabilität (Interne Konsistenz, Cronbach’s alpha). Das optimierte Erhebungsinstrument umfaßt vier Dimensionen: „Arzt-Patient-Interaktion” (8 Items), „Information” (8 Items), „Praxisorganisation” (4 Items) und „Fachliche Kompetenz” (3 Items). Die konfirmatorische Faktorenanalyse bestätigt die Struktur gut (GFI: 0,997). Die Reliabilität der Subskalen liegt zwischen.73 und.95. Die Korrelationen der Subskalen untereinander liegen zwischen. 76 und. 47. Alle Subskalen korrelieren positiv mit der Globaleinschätzung zur Zufriedenheit mit dem Arzt. Zusammenfassend zeigt die Prüfung des Erhebungsinstrumentes gute psychometrische Eigenschaften hinsichtlich Reliabilitdt und Validität sowie der Diskriminationsfähigkeit.AbstractThe purpose of the study was to develop and to validate a standardized patient centered quantitative instrument to assess patient satisfaction in ambulatory care, to be used i.e. in quality management and benchmarking activities. Item selection for the instrument was based on an extensive qualitative pilot study. A pre-final version (containing 35 items) has been tested with 2.800 patients from 56 ambulatory care practices (bases for analysis: n= 969). After psychometric evaluation a modified version has been tested with 3.000 patients from 60 ambulatory care physicians. Answers from 1.387 patients (response rate: 46 %, 62 % female, mean age 52 yrs.) were available for analysis. The questionnaire was validated by testing for factorial validity (confirmatory factor analysis), convergent and divergent validity as well as reliability (internal consistency, cronbachäs alpha). The final version of the questionnaire contains four dimensions: patient-physician-interaction (8 items), information (8 items), office organization(4 items), professional competence (3 Items). Confirmatory factor analysis confirms the four hypothesized dimensions perfectly (GFI: 0.997). Reliability ranged from.75 and.95. The correlation’s between the sub-scales ranges from.76 to 47, indicating that the dimensions are not fully independent. All sub-scales correlate positively with global assessments of satisfaction with the physician. With satisfactory to good results for validity and reliability testing, the final questionnaire might be used fruitfully in quality management in primary care.

Familial risk and protective factors in alcohol intoxicated adolescents: psychometric evaluation of the family domain of the Communities That Care Youth Survey (CTC) and a new short version of the Childhood Trauma Questionnaire (CTQ)

BackgroundAlcohol intoxicated adolescents (AIA) in emergency department are an important target group for prevention and valid information on their familial risk and protective factors (RPF) is crucial for implementing customized family-based counseling in hospitals. We therefore, examined the psychometric characteristics of scales which assess familial RPF.MethodsWe used seven family scales from the Communities That Care Youth Survey Instrument (CTC-F7); four assess risk factors: family conflicts, poor family management, parental attitudes favorable towards drug use/antisocial behavior; three assess protective factors: family attachment, opportunities and rewards for prosocial involvement. To assess physical and emotional abuse and emotional neglect, we created a new scale composed of six items from the Childhood Trauma Questionnaire (CTQ-6). We tested these eight scales on 342 AIA aged 13-17. Based on the classical test theory we calculated descriptive item and scale statistics and internal consistency. We assessed construct validity by confirmatory factor analysis with Maximum Likelihood (ML) estimation in a sample with imputed missing values (EM-Algorithm). To check robustness, we repeated the analyses with complete cases, with multiple imputed data, and with methods suitable for categorical data. We used SPSS 21, AMOS 21 and R (randomForrest and lavaan package).ResultsThree of seven CTC-F scales showed poor psychometric properties in the descriptive analysis. A ML-confirmatory model with five latent factors fitted the remaining CTC-F scales best (CTC-F5). The latent structure of the CTQ-6 is characterized by three first-order factors (physical abuse, emotional abuse, emotional neglect) and one second-order factor. The global goodness-of-fit indices for the CTC-F5 and the CTQ-6 demonstrated acceptable fit (for both models: TLI and CFI>0.97, RMSEA<0.05). The confirmatory evaluation based on complete cases (n=266), on multiple imputed data, and with alternative estimation methods produces global and local model-fit indices that are comparable to those from the main analysis. The final subscales CTC-F5 and CTQ-6 show acceptable to good internal consistency (α>0.7).ConclusionsThe final CTC-F5 and the newly developed CTQ-6 demonstrate acceptable to good psychometric properties for the AIA sample. The CTC-F5 and the CTQ-6 facilitate a psychometrically sound assessment of familial RPF for this vulnerable and important target group for prevention.

Clinical effectiveness and cost-effectiveness of fissure sealants in children and adolescents with a high caries risk

In Germany, the application of resin-based pits and fissures sealants on the occlusal surfaces of permanent molars is part of individual prophylaxis for children and adolescents between six and 18 years. The individual prophylaxis is covered by the Statutory Health Insurance since 1993. The report addresses questions on medical effectiveness, cost-effectiveness, as well as ethical, social, and legal implications of pit and fissure sealants in preventing dental caries for children and adolescents at high caries risk. The results of the studies indicate a protective effect of pit and fissure sealants, particularly for children and adolescents at high caries risk. Additionally, the economic evaluation suggests a tendency for cost savings in this group. Nevertheless, a general expansion of the intervention cannot be recommended. All studies show a risk of bias in favour of pit and fissure sealing and a limited transferability to the German health care system. Studies included in the economic evaluation revealed methodological flaws. Both the economic models and primary studies do not provide reliable results.

Gesundheitskompetenz in der medizinischen Rehabilitation und die Bedeutung für die Patientenschulung

Medical rehabilitation in Germany has a long tradition. It is covered by the statutory sickness funds and pension schemes, and is aimed at the prevention of work disability and need for nursing care due to chronic conditions. Chronically ill but health-literate patients - patients capable of making good health-related decisions, or of participating strongly in this decision making - have better health outcomes. To enhance health literacy and participation, medical rehabilitation relies heavily on patient education. This article describes health literacy from the perspective of educational research, outlines the basics of learning principles, and draws conclusions for developing patient education programmes in medical rehabilitation. Implementing a constructivist learning paradigm promotes changes within the trainer team and within the rehabilitation institution - turning it into a health-literate health care organisation. Health literacy in medical rehabilitation is aimed at neither turning the patient into a physician nor replacing evidence-based recommendations through subjective preferences. Medical rehabilitation reaches patients best by using modern health education programmes based on findings from education research, theoretically founded and directed towards building competencies. Furthermore, an educationally qualified training team and a rehabilitation institution are essential in enabling formal and informal learning processes.

Evaluation of a standardized patient education program for inpatient asthma rehabilitation: Impact on patient-reported health outcomes up to one year

OBJECTIVES To modify and evaluate a patient education program for adult asthma patients in consideration of quality criteria for teaching. METHODS This was a prospective single-center controlled trial in an inpatient rehabilitation center. The control group (n=215) received the usual lecture-based education program, and the intervention group (n=209) the modified patient education program. Data were assessed at admission, discharge, 6 and 12 months post discharge. The primary outcome was asthma control, the secondary outcomes were asthma knowledge, quality of life, and program acceptance. Analysis of change was performed by ANCOVA for each follow-up, adjusting for baseline values. RESULTS Statistically significant increases in all health outcomes and in asthma control were maintained in both groups at 12 months: CG: +1.9 (95%-CI 1.3-2.6) IG: +1.6 (95%-CI 0.8-2.3). We observed no significant differences between the programs for asthma control and quality of life. Regarding practical asthma knowledge, after 12 months, a group*time interaction emerged with a small effect size (P=0.06, η2=0.01). CONCLUSION The modified program was not superior to traditional patient education concerning asthma control. It permanently increased self-management knowledge. PRACTICAL IMPLICATIONS Structured and behavioral patient education fosters patients disease management ability. Possible ways of improving asthma control need to be explored.

„Health Literacy“ im Kindes- und Jugendalter

ZusammenfassungHintergrundStudien belegen die gesundheitliche Relevanz von „Health Literacy“ (HL), etwa für die Inanspruchnahme von präventiven und kurativen Angeboten. Der Kindheits- und Jugendphase kommt hierbei für die gesundheitliche Entwicklung sowie für die Nachhaltigkeit von Angeboten der Prävention und Gesundheitsförderung eine zentrale Bedeutung zu. Die Befundlage zeigt jedoch, dass Kinder und Jugendlichen bislang nicht ausreichend adressiert sind.FragestellungIm Mittelpunkt steht die Entwicklung eines theoretischen Rahmens für die Förderung von HL im Kindes- und Jugendalter. Des Weiteren geht es um die Entwicklung, Erprobung und Evaluation von Maßnahmen zur Förderung von HL sowie von Prävention und Gesundheitsförderung am Beispiel von Mental HL und eHL. Es sind insgesamt 9 theoretisch und anwendungsorientiert ausgelegte Projekte geplant.Methode und MaterialDer Verbund wird Methoden zur Erfassung von HL bei Kindern und Jugendlichen entwickeln, testen und validieren. Hierbei werden sowohl quantitative als auch qualitative Methoden und Materialien zur Anwendung kommen.ErgebnisseDas Verbundvorhaben wird dazu beitragen, die Rahmenbedingungen für die bedarfsspezifische Gestaltung von Interventionen im Bereich Primärprävention und Gesundheitsförderung für Kinder und Jugendliche konzeptionell und methodisch weiter zu entwickeln.SchlussfolgerungDer HLCA-Verbund wird durch die theoretisch fundierte Konzeptualisierung des HL-Konzepts für die Zielgruppe „Kinder und Jugendliche“ die Entwicklung, Erprobung und den Praxistransfer von bedarfsspezifischen Maßnahmen der Gesundheitsförderung und Primärprävention fördern. Der vorliegende Artikel beschreibt kursorisch das Forschungsprogramm, die Verbundstruktur und die beteiligten Forschungseinrichtungen.AbstractBackgroundScientific research consistently confirms the relevance of health literacy (HL), e.g., utilization of preventive and curative services. Screening of the scientific literature, however, reveals that children and adolescents have poorly been included in HL research in the past. This is in contrast with the importance given to the phase of childhood and adolescence for the individual’s future health development and for sustainable health promotion and primary prevention.ObjectivesThe HLCA Consortium aims at contributing to the comprehensive understanding of HL in children and adolescents by developing, adjusting, implementing, and evaluating theoretical, conceptual, and methodological HL approaches. A total of nine projects focusing on basic research and applied research (mental HL, eHL) will offer a solid base to substantially contribute to the understanding of the topic.Materials and methodsA multidisciplinary approach has been adopted by the HLCA Consortium in order to develop, test, and validate methods of measurement and evaluation of HL in children and adolescents. Both quantitative and qualitative methods and materials will be utilized.ResultsThe HLCA Consortium will contribute to further develop the conceptional and methodological framework of HL in order to make the design of needs-based interventions for primary prevention and health promotion for children and adolescents possible.ConclusionsThe HLCA Consortium aims at contributing to a comprehensive understanding of HL in children and adolescents. This paper gives an overview of the HLCA Consortium, its research projects, and the participating research institutions.

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].

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.

Der Epilepsiehund – Traumtänzerei, Tierquälerei oder sinnvoller Einsatz?

ZusammenfassungImmer wieder wird berichtet, dass Hunde sehr gut in der Lage seien, epileptische Anfälle vorherzusagen oder nach einem Anfall zu helfen. Dies soll zu einer deutlichen Anfallsreduktion und auch zur Verbesserung der Lebensqualität der Betroffenen führen. Die vorgestellte systematische Literaturanalyse zeigt, dass es bislang nur wenige empirische Studien gibt, die sich mit diesem Thema befasst haben. Die Ergebnisse lassen sich wie folgt zusammenfassen: Vor allem spezifisch ausgebildete Anfallswarnhunde sind in der Lage, epileptische Anfälle vor ihrem klinischen Beginn anzuzeigen. Jedoch existieren keine validen Daten hinsichtlich der Zuverlässigkeit und der Spezifität des Warnverhaltens vor. Hunde zeigen auch Hilfeverhalten während oder nach einem Anfall. Jedoch variiert dieses Hilfeverhalten erheblich und scheint nicht immer zuverlässig zu sein. Das berichtete Hilfeverhalten ist in seiner Funktion medizinisch meist nicht nachvollziehbar und nicht sinnvoll. Aufgrund der Literatur ist anzunehmen, dass durch die Anwesenheit eines Hundes die Lebensqualität des Betroffenen steigt, Gefühle der Kontrolle und der Selbstwirksamkeit sich erhöhen und der erlebte Stress abnimmt. Dadurch scheint es möglich, dass die Zahl und die Schwere der Anfälle reduziert werden. Ob dieser Effekt jedoch überdauernd ist, bleibt unklar. Es gibt keine Hinweise, dass Hunde zwischen epileptischen oder pseudoepileptischen (nichtepileptischen) Anfällen unterscheiden können. Abschließend werden tierethische Überlegungen diskutiert.AbstractIt has been reported that dogs can be trained to recognize the specific changes preceding an epileptic seizure in humans or to assist during or after epileptic seizures. This should result in reducing seizures and improving quality of life. A systematic literature analysis was performed showing that there have been few empirical studies in this field. The findings can be summarized as follows: dogs that have been specifically trained can give humans warnings of their seizures; however, no rigorous data exist regarding whether seizure prediction by seizure alert dogs is better than chance or regarding the false positive and negative prediction rates. Dogs are also able to assist during or after a seizure but assistance behavior often seemed variable and unreliable and the function of assistance is difficult to understand from a medical point of view and not always appropriate. The findings of the literature review suggest that the presence of a dog can improve quality of life, give the feeling of being in control, improve self-efficacy and decrease stress. These mechanisms may reduce seizure frequency and severity but no data exist regarding whether this is a long-lasting effect. There is no evidence that dogs can distinguish between epileptic and non-epileptic seizures. Questions concerning animal welfare and animal ethics are also discussed.