[Regional and sex-specific differences in fulfillment of patient rights: results of a representative population survey in Munich, Dresden, Vienna and Bern]

OBJECTIVES

The European Office of the World Health Organization formulated the Amsterdam Declaration in 1994, demanding thereby the realisation of the principles of a humane health care. These principles relate to the protection of dignity of personhood, to self-determination, the right of information, and the right of quality, continuity and equality in health care. The present study aims at a gender-specific analysis of the fulfillment of these rights.

METHODS

Computer-assisted telephone interviews were conducted during the months February and March 2000 in four German speaking European cities (Munich, Dresden, Vienna and Berne). A paragraph of the Declaration on the Promotion of Patients' Rights was regarded as fulfilled if there was at least 80% agreement.

RESULTS

Deficiencies were most pronounced for the provision of community and domiciliary services after hospital treatment and for the right concerning humane terminal care and death in dignity. Moreover, regional differences were found between Munich, Dresden and Vienna on one side and Berne on the other side, with degrees of fulfillment being higher in Berne.

CONCLUSIONS

In summary, these regional differences are more pronounced than single gender-specific differences, which may be due to chance. Areas with potential for improvement could be identified and can be actively restructured, e.g., in the context of the setting of health targets. An evaluation of the influence of the managed care system which has been established only sporadically in Berne requires more data.

[Methods of comparative economic evaluations of therapies and for rational allocation of resources across sectors of health care systems - introduction, advantages, risks]

Because of scarcity of resources, diagnostic and therapeutic procedures in medicine increasingly have to be examined not only with regard to effectiveness but also with regard to cost-effectiveness, which means with regard to the relation between resources used and resulting outcome (however this outcome is measured). Primarily, this is true for treatment methods for one and the same medical condition. However, economists also consider to evaluate medical interventions across heterogeneous medical conditions, in order to rank them with regard to their cost-effectiveness. Using quality-adjusted life-years (QALYs) as outcome variable, all medical interventions examined can be ranked in QALY-League-Tables, which could serve as a basis for resource allocation decisions by health policy makers or other payers. However, there are methodological as well as ethical objections with such an approach.

[Venous thrombosis following severe multiple trauma]

The incidence of thromboembolic complications in patients with multiple injuries was reviewed as well with respect to our own prospective investigation (141 patients with a mean injury severity score of 37 points). The rate of deep venous thrombosis (DVT) in severely injured patients is reported to vary from 20 to 90% if invasive diagnostic procedures are used, whereas the rate of clinically relevant manifestations of DVT seems to be much lower. Although 96% of the patient population in our study were thought to be at high risk of having DVT (applying generally accepted risk factors), only 1.4% of the subjects actually developed clinically relevant DVT. The analysis of several parameters of the coagulation and fibrinolytic systems (platelet count, prothrombin time, partial thromboplastin time, antithrombin III, prothrombin, plasminogen, tissue-plasminogen-activator and its inhibitor) showed simultaneous activation of both systems in these severely injured patients. Thus, increased coagulation seems to be counteracted by increased fibrinolysis. In addition, fluid resuscitation with crystalloid and colloid infusions in the prehospital period (1970 ml and 573 ml, respectively) can be viewed as early prophylaxis of thromboembolic complications. Thus, the low DVT rate in a high-risk patient group with multiple injuries might be at least partially explained.

[Trauma scores: reproducibility and reliability]

The inter-rater reliability of the Injury Severity Score (ISS) and the Polytraumaschlüssel (PTS) [multiple trauma code] was studied using diagnosis sheets filled in for 107 multiple injured patients. The scoring was performed by eight physicians with different levels of qualification. The scores for individual patients varied widely depending on the scorer, with extremes differing from the mean by about 80% and 70% for the ISS and PTS, respectively. The mean ISS and PTS for the whole study population also varied significantly between the scorers (P less than 0.0001, one-way analysis of variance). Raters with experience in trauma scoring calculated significantly higher scores (P less than 0.01, t-test) Neither the ISS nor the PTS seem reliable enough to describe injury severity in an individual patient. Treatment decisions must not be based on such grounds. Even for larger groups, caution must be exercised in comparison of different populations of multiple traumatized patients.