Christian E. Schmidt

In various studies, type of surgery, age, and gender had different impact on sexuality and quality of life in patients with rectal cancer. This study was designed to investigate how sexuality and quality of life are affected by age, gender, and type of surgery. A total of 516 patients who had undergone surgery for rectal cancer in our department from 1992 to 2002 were included. Within one year after the operation, 117 patients died. Questionnaires were sent to 373 patients 12 to 18 months after surgery. We received quality of life data from 261 patients. Comparisons were made after adjusting age, gender, and type of surgical procedure. For patients receiving abdominoperineal resection sexuality was most impaired. Significant differences were seen in symptom and function scales between males and females. Females reported more distress from the medical treatment insomnia, fatigue, and constipation. Both genders had impaired sexual life; however, males had significantly higher values and felt more distressed by this impairment. Younger females felt more distress through impaired sexuality. In males sexuality was impaired independent of age. Adjuvant therapy had no influence on sexuality but on quality of life one year after surgery. Assessing quality of life with general and specific instruments is helpful to determine whether patients improved through the treatment. The study showed that gender, age, and type of surgery influence sexuality and that quality of life after surgery for rectal cancer is impacted. Because quality of life is a predictor for complications and survival, availability of such data may help to direct supportive treatment to improve outcome.

Background Study results on quality of life (QoL) between patients receiving an anterior resection (AR) or abdominoperineal resection (APR) for rectal cancer vary greatly. A main reason is grounded in...

Some studies indicate that age at the time of surgery has a general effect on outcomes. The impact of age on the quality of life (QOL) of patients with rectal cancer, however, has not been investigated. The present study was conducted to address this issue. Over a 5‐year period the European Organization for Research and Treatment of Cancer (EORTC)‐QLQ‐C‐30 and a tumor‐specific module were prospectively administered to patients before surgery, at discharge, and at 3, 6, 12, and 24 months postoperatively. Comparisons were made between age groups. A total of 519 patients participated in the study. QOL data were available for 253 patients. Significant differences were observed only between patients aged 69 years and younger (≤69 years) (169/253) and those aged 70 years and older (≥70 years) (85/253). Physical and role functioning was better for patients ≤69 years; patients ≥70 years suffered from increased pain and fatigue. Younger patients had more difficulty with sexual enjoyment, and over time sexual strain was worse for patients aged ≥70 years during the early postoperative period but improved, whereas patients aged ≤69 years had increasing levels of strain over time. The findings in this study confirmed that QOL is dynamic over time and that age has an impact on QOL and sexuality. Patients aged ≥70 years are affected by impaired physical functioning, global health, and fatigue, whereas increased treatment strain during the early postoperative period improves over time. Patients aged ≤69 years experience increased strain because of impaired sexual function.

Postoperative survival and complication rates have traditionally been the standard parameters of outcome after oncologic surgery. In tumors with poor patient survival, such as esophageal cancer, studies about quality of life are rare. The objectives of this study were to assess outcomes in terms of quality of life in patients with esophageal cancer when investigating differences between two surgical reconstructive procedures: intrathoracic anastomosis and collar anastomosis. A total of 108 patients with esophageal cancer had undergone surgery for esophageal cancer in our department from 1992 to 2000. Median survival was 36 months with no significant differences between patients undergoing collar or intrathoracic anastomosis. After determining the survival status, questionnaires on quality of life were sent to all patients 1 to 2 years after surgery. We received data from 46 patients. The responders were divided into groups of intrathoracic anastomosis (n = 24) and collar anastomosis (n = 22). Patients with the collar anastomosis showed significantly better physical and social functioning and global health status. From the viewpoint of postoperative quality of life, reflux‐related symptoms were the major problem for patients with an intrathoracic anastomosis. These symptoms cause significant insomnia and impair social and physical function. The study showed that assessing quality of life with specific and general instruments is helpful for determining the differences between surgical procedures where standard parameters such as survival have their limitations.

Ziele: Darstellung des Einsparungspotenzials, welches einer effizienten Nutzung von Radiologieleistungen in einer Health-Maintenance-Organisation (HMO) innewohnt, und der zur Realisierung verwendeten Managed-Care-Techniken. Material und Methoden: Im Rahmen eines Projektes zur Kostenreduktion an einer HMO in den USA wurden die Ursachen für gestiegene Ausgaben im Bereich Radiologie („Radiology-Utilisation-Line”) untersucht. Durch umfassende Datenanalysen, Überprüfungen der Kodierlogik, Interviews mit Angestellten sowie kritische Beleuchtung der Vertragsbeziehungen zu Leistungserbringern konnte das Einsparpotenzial beziffert werden. Sämtliche Daten wurden in Microsoft Excel® dokumentiert und unter Verwendung von SPSS 8.0 (Statistical package for the social sciences) für Windows® mithilfe nicht-parametrischer Tests ausgewertet. Ergebnisse: Hauptursache war eine verstärkte Verordnung von Radiologieleistungen pro versichertem Patienten, wobei die Kosten pro Untersuchung annähernd gleich blieben. Ein wesentlicher Kostenhebel lag in der Verbesserung des elektronischen Abrechnungssystems, welches für eine Überbezahlung von Leistungen verantwortlich war. Die Gestaltung der vertraglichen Risikovereinbarungen zwischen Versicherer und Leistungserbringer sowie die Qualität der Managementstrukturen innerhalb der radiologischen Einrichtungen hatten einen signifikanten Einfluss auf deren Wirtschaftlichkeit. Ferner konnte nachgewiesen werden, dass Ärzte mit eigenen Röntgenanlagen bis zu 4 - 5-mal mehr Untersuchungen veranlassen als Ärzte ohne eigene Röntgenausstattung und so einen erheblichen Kostentreiber darstellen. Schlussfolgerungen: Die gefundenen Verbesserungspotenziale konnten innerhalb eines Jahres umgesetzt werden und führten zu Einsparungen von etwa 5,5 Millionen Dollar. Einige der eingeführten Kostenhebel werden derzeit schon in Deutschland im Rahmen von Modellvorhaben oder Strukturverträgen umgesetzt und sind Bestandteil der aktuellen Planungen der Bundesregierung. Purpose: A large regional health plan in the Northeastern United States noted that its radiology costs were increasing more than it anticipated in its pricing, and noted further that other similar health plans in markets with high managed care penetration had significantly lower expenses for radiology services. This study describes the potential areas of improvement and managed care techniques that were implemented to reduce costs and reform processes. Materials and Methods: We performed an in-depth analysis of financial data, claims logic, contracting with provider units and conducted interviews with employees, to identify potential areas of improvement and cost reduction. A detailed market analysis of the environment, competitors and vendors was accompanied by extensive literature, Internet and Medline search for comparable projects. All data were docu-mented in Microsoft Excel® and analyzed by non-parametric tests using SPSS® 8.0 (Statistical Package for the Social Sciences) for Windows®. Results: The main factors driving the cost increases in radiology were divided into those internal or external to the HMO. Among the internal factors, the claims logic was allowing overpayment due to limitations of the IT system. Risk arrangements between insurer and provider units (PU) as well as the extent of provider unit management and administration showed a significant correlation with financial performance in terms of variance from budget. Among the external factors, shared risk arrangements between HMO and provider unit were associated with more efficient radiology utilization and overall improvement in financial performance. PU with full-time management had significantly less variance from their budget than those without. Finally, physicians with imaging equipment in their offices ordered up to 4 to 5 times more imaging procedures than physicians who did not perform imaging studies themselves. Conclusion: We identified initiatives with estimated potential savings of approximately $ 5.5 million. Some of these initiatives are similar to the reforms to reduce cost and improve quality that are already implemented or proposed within the German healthcare system.

Numerous methods of assessing quality in health care have been presented over the last years. Since the German health care reform of 2000 introduced a legal obligation to quality assurance, hospitals have to meet that condition. However, no specific system of quality assurance was implicated. Therefore, many potential users search for systems suiting their own needs. However, German hospitals can benefit from international experience in quality management. Accreditation, visitation, excellence schemes, and certification seem to be the dominant methods. Every method is worthy of hospital evaluation. Certifications illustrate the quality system view without regard to profession, while excellence schemes evaluate the development of quality management in hospitals. Accreditation portrays a specific hospital as a whole, while visitations follow the professional perspective of quality assurance. Depending on the perspective and aims, there are advantages and disadvantages in each method. Finally, a combination of two may also be helpful. Indeed, no "role model" exists yet for assessing quality in health care. These methods of quality management are applicable especially in surgery, because a variety of standard outcome parameters such as length of stay, duration of procedure, and complication and relapse rates are already available.

Die Veränderungen im deutschen Gesundheitssystem haben zu marktähnlichen Strukturen mit einem Konkurrenzkampf zwischen Kliniken geführt. Obwohl der Wettbewerb durch verschiedene Rahmenbedingungen und vor allem fehlende Patientensouveränität eingeschränkt wird, muss davon ausgegangen werden, dass Patientenzufriedenheit zu einem wichtigen Erfolgsfaktor für Kliniken wird [ 25 ] [ 37 ] [ 38 ] [ 41 ] . Letztlich entscheiden in erster Linie Patienten mit der Wahl einer bestimmten Klinik über den Erfolg derselben. Diese Entscheidung wird durch eigene Erlebnisse, jedoch auch durch von anderen Patienten mitgeteilte Erfahrungen beeinflusst, wie eine von der DAK in Auftrag gegebene Studie 1996 zeigen konnte [ 8 ]. Darüber hinaus berichten die Patienten auch den Krankenkassen und vor allem dem Hausarzt über die erlebte Qualität in einer Klinik. Schließlich werden mittlerweile auch in den Printmedien, ähnlich wie in den USA, Qualitätsvergleiche von Kliniken (so genannte „league tables” oder „rankings”) unter anderem auf Basis von Patientenzufriedenheit vorgenommen [ 11 ] [ 13 ]. Beispielhaft sind hier noch die Bemühungen der Kollegen aus der Schweiz zu nennen, Patientenzufriedenheitsmessungen für den routinemäßigen Klinikvergleich zu verwenden [ 19 ]. Somit wird Patientenzufriedenheit einen starken Einfluss auf die zukünftige Bedeutung und Position einer Klinik haben und auf diese Weise über den Patientenstrom die Nachfrage beeinflussen [ 14 ]. Der vorliegende Beitrag liefert deswegen einen aktuellen Überblick über Messinstrumente zur Patientenzufriedenheit. Patientenzufriedenheit wird in vielen Studien als Teil der Ergebnisqualität bzw. „Outcome Indikator” medizinischer Dienstleistungen behandelt [ 3 ] [ 4 ] [ 37 ] . Diese Sichtweise stützt sich im Wesentlichen auf die Überlegungen von Donabedian, der die Trias der Struktur-, Prozess- und Ergebnisqualität eingeführt hat [ 10 ]. Diese Ansicht steht im Gegensatz zu den Definitionen und Erkenntnissen der Wirtschafts- und Sozialforschung wonach Zufriedenheitswerte Resultat aller drei Bereiche der Qualität sind [ 32 ]. Um diesen Widerspruch aufzulösen und für klinische Studien nutzbar zu machen, wird in der folgenden Übersicht das Konzept der Zufriedenheit im Allgemeinen und später auch der Patientenzufriedenheit im Speziellen vorgestellt und diskutiert.

Die abdominelle Tuberkulose ist eine seltene Erkrankung, deren Therapie in der Regel konservativ ist. Ausnahmen stellen Komplikationen dar. Ein 75-jähriger Patient stellte sich uns mit den klinischen und radiologischen Zeichen des Ileus vor. Begleitend bestanden Gewichtsverlust und eine B-Symptomatik. In der Vorgeschichte befand sich der Patient wegen einer Hals- und Pharynxtuberkulose seit 4 Wochen in internistischer Behandlung. Intraoperativ imponierte ein stenosierender Zökaltumor mit Verdacht auf diffuse Peritonealkarzinose. Die makroskopisch maligne erscheinende Raumforderung wurde durch eine Hemikolektomie rechts entfernt. Die histologische Aufarbeitung ergab jedoch eine chronisch granulomatöse Entzündung mit Epitheloidzellgranulomen. Eine Peritonealkarzinose ließ sich nicht nachweisen. Der postoperative Verlauf gestaltete sich unter tuberkulostatischer Therapie problemlos, der Patient konnte nach 14 Tagen beschwerdefrei entlassen werden. Auch unter spezifischer Therapie kann eine Lymphknotentuberkulose progrediente Symptome bis zum abdominellen Befall zeigen. Abdominal tuberculosis is a rare disease. Therapy usually consists in drug treatment while surgery is only performed in complicated cases. We report on a 75 year-old man who presented with clinical and radiologic signs of bowel obstruction. The patient complained of weight loss and B-symptoms. There was a history of drug treatment for tuberculosis of the neck and throat in the medical department four weeks prior to admission. Intraoperatively a coecum stenosis was found due to a large tumor that macroscopically appeared with a diffuse carcinomatosis of the peritoneum. A right hemicolectomy was performed. Histopathology findings revealed a granulomatous inflammation with epithelioid cells. Signs of peritoneal carcinomatosis were not seen. The patient recovered well after an additional tuberculostatic treatment and was discharged after 14 days. At present he is free of symptoms. Even after tuberculostatic treatment lymphatic tuberculosis might show signs of progression that can lead to an abdominal presentation.