[Redirection of patients from the emergency department to ambulatory care: a feasibility study]

BACKGROUND

§ 120 para. 3b SGB V mandates the Federal Joint Committee to define guidelines for the initial assessment of self-referred walk-in patients as well as for the redirection of patients who can be treated by office-based physicians. A corresponding streaming and redirection process was tested in a feasibility study at the RoMed Clinic Rosenheim.

MATERIALS AND METHODS

For the duration of the study, triage nurses of the emergency department (ED) first assessed self-referred walk-in patients with the Manchester Triage System (MTS). Patients in categories green and blue who did not obviously need the ED's resources were additionally assessed by health professionals of the Association of Statutory Health Insurance Physicians of Bavaria using the software Structured Initial Medical Assessment in Germany (SmED). Patients with a recommendation for non-hospital medical treatment were streamed to the out-of-hours practice on campus or were redirected to a physician office after video consultation with an office-based physician. Patient pathways were documented and a qualitative survey using semistructured guided interviews of all stakeholder groups was carried out.

RESULTS

1,091 self-referred walk-in patients were included. Direct streaming to the ED occurred in 525 cases,13 refused to participate. Based on SmED, 24 additional patients were referred to the ED, 514 patients were streamed to the out-of-hours practice, 23 received a video consultation and five left the ED. After video consultation, eight patients were redirected to a physician's office, 10 were discharged, and five referred to the ED of which one did not want an office-based physician. No returnees from practices to the ED were identified. Generally, the redirection process was evaluated positively in the interviews (n=18). In particular, potential for technical improvement was identified.

CONCLUSION

Overall, the results indicate the feasibility of the redirection process and high acceptance levels. Using SmED in addition to MTS appeared useful before redirection but not necessary for streaming on campus. Redirection to physician offices can help reduce strain on the ED when the out-of-hours practice is not operating. In addition to arranging acute care appointments, video consultations offer an additional potential to treat patients. In a follow-up study, a broader range of patients should be included and appropriateness of redirection decisions should be evaluated.

Model-Based Economic Evaluations of Interventions for Dementia: An Updated Systematic Review and Quality Assessment

BACKGROUND

There has been an increase in model-based economic evaluations of interventions for dementia. The most recent systematic review of economic evaluations for dementia highlighted weaknesses in studies, including lack of justification for model assumptions and data inputs.

OBJECTIVE

This study aimed to update the last published systematic review of model-based economic evaluations of interventions for dementia, including Alzheimer's disease, with a focus on any methodological improvements and quality assessment of the studies.

METHODS

Systematic searches in eight databases, including PubMed, Cochrane, Embase, CINAHL, PsycINFO, EconLit, international HTA database, and the Tufts Cost-Effectiveness Analysis Registry were undertaken from February 2018 until August 2022. The quality of the included studies was assessed using the Philips checklist and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist. The findings were summarized through narrative analysis.

RESULTS

This review included 23 studies, comprising cost-utility analyses (87%), cost-benefit analyses (9%) and cost-effectiveness analyses (4%). The studies covered various interventions, including pharmacological (n = 10, 43%), non-pharmacological (n = 4, 17%), prevention (n = 4, 17%), diagnostic (n = 4, 17%) and integrated (n = 1, 4%) [diagnostics-pharmacologic] strategies. Markov transition models were commonly employed (65%), followed by decision trees (13%) and discrete-event simulation (9%). Several interventions from all categories were reported as being cost effective. The quality of reporting was suboptimal for the Methods and Results sections in almost all studies, although the majority of studies adequately addressed the decision problem, scope, and model-type selection in their economic evaluations. Regarding the quality of methodology, only a minority of studies addressed competing theories or clearly explained the rationale for model structure. Furthermore, few studies systematically identified key parameters or assessed data quality, and uncertainty was mostly addressed partially.

CONCLUSIONS

This review informs future research and resource allocation by providing insights into model-based economic evaluations for dementia interventions and highlighting areas for improvement.

Referring physicians' intention to use hospital report cards for hospital referral purposes in the presence or absence of patient-reported outcomes: a randomized trial

PURPOSE

This study aims to determine the intention to use hospital report cards (HRCs) for hospital referral purposes in the presence or absence of patient-reported outcomes (PROs) as well as to explore the relevance of publicly available hospital performance information from the perspective of referring physicians.

METHODS

We identified the most relevant information for hospital referral purposes based on a literature review and qualitative research. Primary survey data were collected (May-June 2021) on a sample of 591 referring orthopedists in Germany and analyzed using structural equation modeling. Participating orthopedists were recruited using a sequential mixed-mode strategy and randomly allocated to work with HRCs in the presence (intervention) or absence (control) of PROs.

RESULTS

Overall, 420 orthopedists (mean age 53.48, SD 8.04) were included in the analysis. The presence of PROs on HRCs was not associated with an increased intention to use HRCs (p = 0.316). Performance expectancy was shown to be the most important determinant for using HRCs (path coefficient: 0.387, p < .001). However, referring physicians have doubts as to whether HRCs can help them. We identified "complication rate" and "the number of cases treated" as most important for the hospital referral decision making; PROs were rated slightly less important.

CONCLUSIONS

This study underpins the purpose of HRCs, namely to support referring physicians in searching for a hospital. Nevertheless, only a minority would support the use of HRCs for the next hospital search in its current form. We showed that presenting relevant information on HRCs did not increase their use intention.

[Working Time of Physicians in Germany: Results of the Micro-Census with a Focus on Established Practitioners]

Medical practitioners are considered to be an occupational group with a high workload. However, findings on working hours are incomplete. Therefore, we investigated data on "normal" working hours and corresponding preferences in the course of an analysis of the Microcensus 2017. Established physicians reported an average working time of 48,8 h per week for full-time employment, 46,2 h as dependent employees. Dependent employees working part-time, reported about 4 h more than established doctors. Male doctors reported about 4 h more than female doctors when working full-time, and 5 h less when working part-time. The proportion of part-time work was significantly higher for female physicians than for male physicians (28% vs. 10%). The specific analysis for established doctors also showed an inverse discrepancy: if part-time, female physicians worked 4 h more than male physicians; if full-time, male physicians worked 4 h more than female physicians. Established doctors worked less than employees when working part-time. Here, too, the rate was higher for female physicians (19,5% vs. 10,6%). Overall, 14% worked part-time (just under 20 h per week), 86% full-time (just under 49 h). Dentists reported slightly lower working hours, while general practitioners and specialists were about the same at 45 hours. This difference was due to differences in full-time work, which is about 50 h for general practitioners and specialists and 46 h for dentists. In contrast, part-time dentists worked longer hours (24 vs. 18 h). Only a few physicians, especially those working part-time (6,5%), stated that they would like to work more. Most of them would like to work slightly more hours. The majority of women cited family obligations (68%) as the reason for part-time work, while men mostly cited "other" reasons (76%) and less often childcare or personal/family obligations (15%). A total of 13% of those working full-time would like to work fewer hours, women slightly more often. This analysis complements sources such as the Zi Practice Panel. At the overall level, the microcensus average was 5 h lower than the ZiPP (50 h/week). The limitations for survey data known from methodology are countered by the very high sample quality.

The elicitation of patient and physician preferences for calculating consumer-based composite measures on hospital report cards: results of two discrete choice experiments

PURPOSE

The calculation of aggregated composite measures is a widely used strategy to reduce the amount of data on hospital report cards. Therefore, this study aims to elicit and compare preferences of both patients as well as referring physicians regarding publicly available hospital quality information METHODS: Based on systematic literature reviews as well as qualitative analysis, two discrete choice experiments (DCEs) were applied to elicit patients' and referring physicians' preferences. The DCEs were conducted using a fractional factorial design. Statistical data analysis was performed using multinomial logit models RESULTS: Apart from five identical attributes, one specific attribute was identified for each study group, respectively. Overall, 322 patients (mean age 68.99) and 187 referring physicians (mean age 53.60) were included. Our models displayed significant coefficients for all attributes (p < 0.001 each). Among patients, "Postoperative complication rate" (20.6%; level range of 1.164) was rated highest, followed by "Mobility at hospital discharge" (19.9%; level range of 1.127), and ''The number of cases treated" (18.5%; level range of 1.045). In contrast, referring physicians valued most the ''One-year revision surgery rate'' (30.4%; level range of 1.989), followed by "The number of cases treated" (21.0%; level range of 1.372), and "Postoperative complication rate" (17.2%; level range of 1.123) CONCLUSION: We determined considerable differences between both study groups when calculating the relative value of publicly available hospital quality information. This may have an impact when calculating aggregated composite measures based on consumer-based weighting.

[The presumed consent legislation - A success factor or a disruptive factor for tissue donation? A qualitative study based on multidisciplinary interviews with experts]

INTRODUCTION

Tissue transplantation can improve the quality of life of patients in a very wide range of applications. In 2021, around 900 people in Germany agreed to donate organs after death - the number of tissue donors was significantly higher. Nevertheless, there is a shortage of organs and tissues in Germany. In order to counteract this, the introduction of a presumed consent legislation has been discussed time and again. However, the debates focused on possible positive effects for organ donation, whereas potential consequences for tissue donation have so far not been considered in the political discourse or in research. Using an exploratory approach, this paper aims to contribute to closing this research gap: Multidisciplinary interviews with experts were conducted to investigate whether the presumed consent legislation is a key success factor for increasing the number of tissue donors in Germany and which other approaches might be promising.

METHODS

We conducted qualitative interviews with 14 experts who worked as employees in different positions in tissue banks/networks, ophthalmologists performing corneal transplantation, medical ethicists, lawyers or scientists. These interviews were evaluated using the structuring content analysis according to Mayring. In reporting, we followed the Standards for Reporting Qualitative Research (SQRQ).

RESULTS

The majority of experts did not consider presumed consent legislation to be a key factor in increasing the donation rate in Germany. Instead, an improvement of processes and structures in tissue donation was cited as the most important optimization potential. Furthermore, communication measures were postulated to create transparency about the characteristics of tissue donation as distinct from organ donation. These should address not only the general population, but also the professional groups involved in the tissue donation process.

CONCLUSION

The present study indicates that the presumed consent legislation is not a success factor for increasing the number of tissue donors in Germany. It would be far more effective to improve structures and processes in order to identify the large number of potential tissue donors and to be able to conduct informed conversations with their relatives. Information measures for the general public and professionals, which clearly differentiate between tissue donation and organ donation, are also more promising than fruitless debates about the introduction of the presumed consent legislation.

Digital health applications in the self-management of epilepsy-A survey on patients' perspective

OBJECTIVE

Digital health applications can be prescribed since 2019 in Germany, which is likely to facilitate a broad use of epilepsy self-management applications, possibly directly connected to clinical systems via telematics infrastructures. This article reports on patients' interest in digital support for epilepsy self-management, influencing factors and patients' knowledge about digitization of health care in Germany.

METHODS

This work is based on self-reported data from 115 people with epilepsy participating in an anonymous online survey with a total of 54 questions covering several topics, including sociodemographics and epilepsy manifestation, use of technology in general and for treatment support, training programs, affinity for technology, knowledge on the digital infrastructure in Germany, and self-efficacy in dealing with chronic illness. The self-constructed questionnaire uses existing instruments like TA-EG, SES6G, and Hoffmeyer-Zlotnik sociodemographic questionnaire. To analyze the knowledge about digitalization in health care, a combination of self-assessment and knowledge quiz was used. The analysis was performed using descriptive methods and inferential statistics (t-test, reliability analysis, and correlations).

RESULTS

Participants were most interested in seizure alerting and documentation with the possibility to share documentation with physicians. The analysis of technology affinity showed medium enthusiasm, with positively perceived consequences being rated higher than the negatively perceived consequences of technology use. Knowledge on national health infrastructures was mediocre and training on this was judged to be essential and desired. Furthermore, a significant correlation was found between interest in use and affinity for technology (enthusiasm for technology [r = 0.29; P = 0.00]) and positively perceived consequences of technology (r = 0.33; P = 0.00).

SIGNIFICANCE

Our results underline the high relevance of digital solutions for patients and the importance of individual training opportunities in digital health literacy, thereby enabling patients to decide competently for or against offered digital solutions.

[Income of physicians in private practice in Germany: Results of a micro census]

EINLEITUNG

Daten zum Einkommen von Ärzt:innen in Deutschland sind bisher nur teilweise verfügbar. Die Einkommen der niedergelassenen Ärzteschaft werden vor allem aus den Praxiserträgen abgeleitet, was aber große Interpretationsspielräume eröffnet. Ziel des Artikels ist es, diese Lücke zu schließen.

METHODIK

Hierfür werden die Einkommensangaben aus dem Mikrozensus 2017 ausgewertet - mit besonderem Fokus auf niedergelassene Ärzt:innen. Neben dem persönlichen Einkommen erfolgt eine Darstellung der Einkommenssituation auf Haushaltsebene. Die Einkommensziffern werden nach Tätigkeitsumfang, Tätigkeitsgruppe (Allgemein-/Fach-/Zahnärzte), Geschlecht und Stadt/Land differenziert.

ERGEBNISSE UND SCHLUSSFOLGERUNG

Das verfügbare persönliche Nettoeinkommen niedergelassener Ärzt:innen beträgt bei Vollzeittätigkeit im Mittel knapp 7.900 € pro Monat. Fachärzt:innen liegen bei 8.250 €, Allgemein- und Zahnärzt:innen bei ca. 7.700 €. Eine finanzielle Benachteiligung von Landärzt:innen lässt sich nicht feststellen, Allgemeinärzt:innen aus Gemeinden<5.000 Einwohnerinnen und Einwohner haben mit 8.700 € sogar das höchste Durchschnittseinkommen - bei einer mittleren Arbeitszeit von 51 Stunden pro Woche. Ärztinnen arbeiten häufiger in Teilzeit als Ärzte. Ein niedrigeres Einkommen resultiert überwiegend aus einem geringeren Tätigkeitsumfang.

INTRODUCTION

Data on the income of physicians in Germany are only partially available to date. The income of physicians in private practice is derived primarily from practice income, but this opens up considerable scope for interpretation. The aim of this article is to close this gap.

METHODOLOGY

For this purpose, the income data from the 2017 micro census were evaluated, with a special focus on physicians in private practice. In addition to personal income, the income situation was presented at the household level. The income figures were differentiated according to the scope of activity, activity group (general practitioners/specialists/dentists), gender and city/country.

RESULTS AND CONCLUSION

The disposable personal income of physicians in private practice was just under € 7,900 per month on average for full-time employment. Specialists earned € 8,250, while general practitioners and dentists earned about € 7,700. Rural physicians were not found to suffer from financial disadvantages; general practitioners from municipalities with<5,000 inhabitants even had the highest average income of € 8,700, with an average working time of 51 hours per week. Female physicians worked part-time more often than did male physicians. A lower income resulted primarily from a lower scope of activity.

How to further develop quality competition in the German healthcare system? Results of a Delphi expert study

INTRODUCTION

Many international healthcare systems use quality competition to improve the quality of care. The corresponding instruments include quality measurement, public reporting, selective contracting, and pay for performance. The German healthcare system clearly shows that the possibilities are often limited in the status quo. Therefore, a need for practicable and evidence-based proposals are necessary to further the development of quality competition.

METHODS

We conducted a national analysis and an international comparison (Switzerland, Netherlands and USA) as a pre-study to derive recommendations. On this basis, we designed a Delphi study with a consensus objective. Experts from relevant stakeholder groups in the German healthcare system were selected using purposive sampling for this study.

RESULTS

The experts saw potential for quality improvement in the further development of quality competition. Quality measurement and public reporting were rated as empowering tools. There was mostly disagreement on whether quality competition should be further developed in a more regulatory or entrepreneur-based manner. However, there was a clear consensus that further development must be coordinated between the stakeholders, step-by-step and scientifically supported. In addition, the impulse should be supported by a legislatively introduced reform.

CONCLUSIONS

Finally, these empirically based recommendations highlight the need for a coordinated coexistence of a top-down and a bottom-up approach. The developed blueprint proposal serves as an impetus for practical considerations of implementation.

[Terra incognita of tissue donation: A systematic literature review analyzing institutional factors influencing the willingness to donate tissue]

INTRODUCTION

Partly because of a lack of governmental commitment in educational work, tissue donation is largely unknown in the German population, although it has an increasing relevance for patient care. Due to the progress in research, the shortage of donor tissues in Germany is constantly increasing and has to be compensated by imports. In contrast, nations such as the USA are self-sufficient in donor tissue and can even export it. Since not only individual but also institutional factors (e.g., legal framework, allocation principles and the organization of tissue donation) can lead to these national differences in donor rates, the present systematic literature review will investigate how these factors influence the willingness to donate tissue.

METHODS

Relevant publications were systematically searched in seven databases. The search command consisted of English and German terms for the two search components "tissue donation" and "health care system". Papers published in English or German between 2004 and May 2021 and focusing on the analysis of institutional factors influencing the willingness to donate tissue post-mortem for transplantation were included (inclusion criteria); studies on blood and organ and living donation as well as publications not dealing with institutional factors influencing the willingness to donate tissue were excluded (exclusion criteria). In reporting, we followed the PRISMA 2020 statement.

RESULTS

Of 1,398 hits, seven were finally included after screening. Many of the remaining studies focused on organ donation or non-institutional aspects of tissue donation. Only two studies considered the central population perspective. Furthermore, five publications originate from an Australian research group and focus on the international allocation of tissues. The results highlight the inadequate state of research and at the same time suggest that both tissue bank organization and allocation principles may influence the willingness to donate tissue. At the same time, the publications indicate that tissue donors are often not informed about a potential commercial use or an international allocation of tissues, which represents an ethical-legal conflict.

CONCLUSION

The results indicate that institutional factors may influence people's willingness to donate. In particular, the lack of societal awareness of the issue results in various areas of tension for which recommendations for action have been developed. In order to prevent a slump in tissue donations because of socially unacceptable practices, further population-based studies should explore the institutional framework conditions that society demands for tissue donation.

Preferences of People Living with HIV for Long-Acting Antiretroviral Treatment in Germany: Evidence from a Discrete Choice Experiment

OBJECTIVE

This study aimed to elicit preferences for attributes of current and novel long-acting antiretroviral therapy for human immunodeficiency virus treatment.

METHODS

Primary survey data were collected (July-October 2022) on a sample of 333 people living with human immunodeficiency virus in Germany from a patient recruitment agency. Respondents were invited by e-mail to respond to a web-based questionnaire. After performing a systematic literature review, we conducted qualitative semi-structured interviews to identify and select the key attributes of drug therapy for patients' preferences for human immunodeficiency virus treatment. Based on this, a discrete choice experiment survey elicited preferences for long-acting antiretroviral therapy characteristics, including the type of medication, frequency of dosing, the location of treatment, the risk of both short-term and long-term side effects, as well as possible interactions with other medications or (party) drugs. A statistical data analysis was performed using multinomial logit models. An additional latent class multinomial logit was performed to evaluate subgroup differences.

RESULTS

Overall, 226 respondents (86% male, mean age 46.1 years) were included in the analysis. The frequency of dosing (36.1%) and the risk of long-term side effects (28.2%) had the greatest influence on preferences. The latent class analysis identified two patient groups. While the first class (n = 135; 87% male, mean age 44.4 years) found the frequency of dosing (44.1%) to be most important, the second class (n = 91; 85% male, mean age 48.6 years) focused on the risk of long-term side effects (50.3%). The evaluation of structural variables showed that male respondents, those living in small cities or villages, and those with better health status results were significantly more likely to be assigned to the second class (p < 0.05 each).

CONCLUSIONS

All attributes included in our survey were important to participants when choosing an antiretroviral therapy. We found evidence that the frequency of dosing as well as the risk of long-term side effects have a particular impact on the acceptance of novel therapy regimens and should be considered in order to optimize adherence and satisfaction.

[Surgery in the balance between humanity, ethics and economics]

BACKGROUND

The economic pressure in the healthcare system has noticeably increased in the past few years. The manifestation of an "economization in medicine" development raises questions about the compatibility of physicians' duties and economic incentives in the healthcare system.

OBJECTIVE

Against this background the article analyzes areas of conflict in the German healthcare system and surgery in particular. The main questions focus on: what lines of conflict can arise between ethical duties and economic requirements and what possibilities for conflict resolution can provide orientation on the macrolevel and microlevel?

MATERIAL AND METHODS

The article is based on the analysis of normative regulations, guidelines and statements from the self-administrative institutions and multidisciplinary literature from medicine, medical ethics and health economics. Core issues in the conflict area between "humanity-ethics-economics" are structured and recommendations for action are derived.

RESULTS AND DISCUSSION

Superordinate regulatory framework conditions and their subsequent incentives must not conflict with the ethical principles of medical care, especially the primary orientation to patient welfare. Institutional and individual healthcare providers have a responsibility towards patients first and only secondarily for an economically appropriate spending of public resources. The provision of medical care for people must enable an adequate livelihood. Institutional maximization of profits is to be avoided, especially concerning financial investors. In the corona pandemic, economic disincentives are becoming apparent and necessitate readjustments. Possible recommendations for action are the empowerment of the medical profession and management to engage in a qualified exchange.

[Heidelberg Milestones Communication (HeiMeKOM) - Experiences, Best Practice Examples and Recommendations from the Final Symposium on January 30 and 31 in 2020]

The National Cancer Plan emphasises the importance of medical communication and calls for its integration into medical education and training. In this context, the Milestone Communication Approach meets the communicative challenges in dealing with lung cancer patients. Interprofessional tandems, consisting of doctors and nurses, conduct structured conversations at defined moments with patients and their relatives. The concept aims at shared decision making, continuity in the care of lung cancer patients and the early integration of palliative care. During the symposium on the Heidelberg Milestone Communication in January 2020, recommendations on the care situation of lung cancer patients in advanced stages were developed. In addition, the further adaptability of HeiMeKOM to other settings and hospitals and to other diseases was discussed as well as the possibility of implementing such a concept in standard care. This article presents the experiences, best practice examples and recommendations discussed during the symposium in order to enable their extrapolation to other similarly oriented projects. The long-term goal is to transfer the milestone concept to other hospital, primarily certified lung cancer centers, and to ensure permanent funding. For further dissemination of the concept and, above all, to have it established in standard care, health policy awareness and support are required in addition to the integration of the concept in competence catalogues of continuing medical and nursing education.

Acute disseminated encephalomyelitis following Tdap vaccination and bacterial meningoencephalitis

INTRODUCTION

Association of Acute Disseminated Encephalomyelitis (ADEM) with both recent vaccination and viral infections is well described in current literature. However, the coincidence of ADEM and bacterial infections has been rarely documented. In this report, we present a case of ADEM which occurred after bacterial meningoencephalitis and prior vaccination against tetanus, diphtheria, and pertussis (Tdap).

CASE PRESENTATION

A 62-year old woman was hospitalized with an upper respiratory tract infection three weeks after Tdap triple vaccination. A few days after admission, she became somnolent and developed meningism. Cerebrospinal fluid (CSF) analysis revealed pleocytosis and increased protein/lactate levels compatible with bacterial meningoencephalitis. The patient was treated with intravenous antibacterial triple therapy in combination with dexamethasone leading to a significant improvement of clinical symptoms and improvement of CSF parameters. Five days later, the patient's condition worsened again, and she developed aphasia and right-sided hemiparesis. A magnetic resonance imaging (MRI) scan revealed distinct fluid-attenuated inversion recovery sequence (FLAIR)-hyperintense lesions in both hemispheres. Following brain biopsy, the diagnosis of ADEM was made and methylprednisolone pulse therapy was initiated for five days leading to a nearly complete remission of symptoms.

CONCLUSION

ADEM is a neurological syndrome which may be associated with bacterial infection of the central nervous system (CNS). We hypothesize that the preceding Tdap triple vaccination may have contributed to the development of ADEM.

[Health Care for Asylum Seekers in Germany according to Asylum Seekers' Benefits Act: Public Perceptions and Preferences]

OBJECTIVE

This study analyses public perceptions and preferences regarding scope, access and funding of health care for asylum seekers (AS).

METHODS

Standardized survey addressing the population >18 years, combined quota plan, descriptive and inferential statistics.

RESULTS

The sample (n=419) was rather badly informed about this topic. We found heterogeneous preferences. 47.0% preferred to maintain current regulations of the scope of health care, 22.7% wanted an expansion. 56.1% favored a health card. The EU, tax payers, countries of origin and AS were preferred as funders.

CONCLUSION

A consideration of preferences might strengthen the acceptance and legitimation of decisions. Our results indicate that this would lead to moderate changes in health care for AS. Since participants were not well informed subjectively, we suggest qualitative research.

[The Trade-Off between Chance of Success and Urgency in Organ Allocation: A Discrete Choice Experiment to Elicit Public Preferences]

OBJECTIVE

According to the German Organ Transplantation Act, donor organs must be allocated with particular regard to chance of success and urgency. However, the objectives of these guiding criteria - the efficient use of available organs and meeting the most urgent need - are in conflict with each other, as success rate of transplantation (TX) ordinarily diminishes when urgency increases. Current allocation guidelines balance these criteria differently depending on the organ. This is only justified in part by medical reasons. Thus, further considerations are essential to develop consistent allocation rules. Therefore, a discussion on the stated trade-off considering the far-reaching consequences of such allocation decisions is indispensable. This also implies taking account of public preferences.

METHODS

In this pilot study, preferences of 250 participants were assessed using a Discrete Choice Experiment. Choice-sets for the allocation of a donor organ included 2 patients, who were characterized by 3 success- and 2 urgency-based attributes. Data analysis was performed by Counting Analysis and Hierarchical Bayes estimation as well as Student's t-tests for subgroup analysis.

RESULTS

All attributes influenced allocation decisions significantly (p≤0.01). Both, patients with greater chance of success and higher urgency were preferred. As a whole, chance of success and urgency were equally important for the allocation of organs (53 and 47%, respectively). The importance of the success- and urgency-based criteria was quantified as follows: The post-TX 5-year probability of survival was weighted with 31%, the expected post-TX quality of life and the surgery survival rate with 11% each, the pre-TX 3-month mortality with 35% and the pre-TX quality of life with 12%. Subgroup analysis revealed significant differences.

CONCLUSION

The pilot study was successful in analyzing the balance of the guiding criteria chance of success and urgency without referring to a specific kind of organ. This type of results allows comparing current allocation rules and public preferences. These results could help decision makers to take into account public preferences developing organ-specific guidelines. A stronger involvement of citizens in decision making could gain confidence in transplantation medicine, increase the willingness to donate and potentially counteract the scarcity of organs and thereby the tragedy of the distributional conflict. Therefore the continuation of this project is advisable.

Organ Transplantation in the Face of Donor Shortage - Ethical Implications with a Focus on Liver Allocation

BACKGROUND

Transplantation medicine is associated with several ethical issues related to the lack of organs. Major questions concern the regulations for giving permission for organ removal, informing the public about organ donation, setting of organ allocation priorities, waiting list access, and strategies to counteract scarcity.

METHODS

This contribution is based on analyses of legal regulations, guidelines of self-regulatory bodies, administrative data, and literature from medical, normative, and empiric disciplines. It addresses the above-mentioned issues descriptively with a focus on Germany and liver transplantation.

RESULTS

The basic principle of beneficence justifies a shift from voluntariness towards an obligation to document one's decision regarding organ donation. Organ allocation is obviously tangent to fundamental values and concepts of justice. At that, there is no consistent agreement on whether to prioritize the sickest patient or to maximize the overall health benefit. Restrictions relating to waiting list access are the subject of controversies. The reasons for denial of access are largely related to high demands on the prospect of success. Strategies to counteract organ scarcity partly conflict with the respect for autonomy, non-maleficence, beneficence, or justice.

CONCLUSION

We propose to focus on recent most promising strategies to counteract scarcity in the short-term: demanding a documented decision on organ donation and an orientation towards the Spanish model of organization. Concepts for waiting list access should constantly be reviewed considering all medical evidence and must not be based on moralism. Moreover, we suggest to consider public preferences for organ allocation and strengthen the confidence in transplantation medicine.

[The quality of the German health-care system in an international comparison - a systematic review]

OBJECTIVES

Studies assessing the quality of the German health-care system in an international comparison come to different results. Therefore, this review aims to investigate how the German health-care system is evaluated in comparison to other health-care systems by reviewing international publications. Results show starting points for ways to improve the German health-care system, to maintain and expand its strengths as well as to derive strategies for solving identified problems.

METHODS

A systematic review searching different databases [library catalogues, WorldCat (including MEDLINE and OAIster-search), German National Library, Google Scholar and others]. Search requests were addressed to English or German language publications for the time period 2000-2010 (an informal search was conducted in October 2011 for an update). Results of the identified studies were aggregated and main statements derived.

RESULTS

In total, 13 publications assessing the German health-care system in an international comparison were identified. These comparisons are based on 377 measures. After aggregation, 244 substantially different indicators remained, which were dedicated to 14 categories. It became apparent that the German health-care system can be characterised by a high level of expenses, a well-developed health-care infrastructure as well as a high availability of personal and material resources. Outcome measures demonstrate heterogeneous results. It can be stated that, particularly in this field, there is potential for further improvement. The utilisation of health-care services is high, the access is mostly not regulated and out of pocket payments can pose a barrier for patients. Waiting times are not regarded as a major weakness. Although civic satisfaction seems to be acceptable, a large portion of the citizens calls for elementary modifications. Especially, more patient-centred health-care delivery should be addressed as well as management of information and the adoption of meaningful electronic assistance systems.

CONCLUSION

The presented results show starting points on the way to further improve the German health-care system. It is necessary to maintain and expand its strengths as well as to derive strategies for solving identified weaknesses. This can be done with confidence since, according to Donabedian, a high structural quality represents an important fundament to improve outcome and process measures.

Nitrate Acts as a Signal to Induce Organic Acid Metabolism and Repress Starch Metabolism in Tobacco

Nia30(145) transformants with very low nitrate reductase activity provide an in vivo screen to identify processes that are regulated by nitrate. Nia30(145) resembles nitrate-limited wild-type plants with respect to growth rate and protein and amino acid content but accumulates large amounts of nitrate when it is grown on high nitrate. The transcripts for nitrate reductase (NR), nitrite reductase, cytosolic glutamine synthetase, and glutamate synthase increased; NR and nitrite reductase activity increased in leaves and roots; and glutamine synthetase activity increased in roots. The transcripts for phosphoenolpyruvate carboxylase, cytosolic pyruvate kinase, citrate synthase, and NADP-isocitrate dehydrogenase increased; phosphoenolpyruvate carboxylase activity increased; and malate, citrate, isocitrate, and [alpha]-oxoglutarate accumulated in leaves and roots. There was a decrease of the ADP-glucose pyrophosphorylase transcript and activity, and starch decreased in the leaves and roots. After adding 12 mM nitrate to nitrate-limited Nia30(145), the transcripts for NR and phosphoenolpyruvate carboxylase increased, and the transcripts for ADP-glucose pyrophosphorylase decreased within 2 and 4 hr, respectively. Starch was remobilized at almost the same rate as in wild-type plants, even though growth was not stimulated in Nia30(145). It is proposed that nitrate acts as a signal to initiate coordinated changes in carbon and nitrogen metabolism.

Nitrate Acts as a Signal to Induce Organic Acid Metabolism and Repress Starch Metabolism in Tobacco

Nia30(145) transformants with very low nitrate reductase activity provide an in vivo screen to identify processes that are regulated by nitrate. Nia30(145) resembles nitrate-limited wild-type plants with respect to growth rate and protein and amino acid content but accumulates large amounts of nitrate when it is grown on high nitrate. The transcripts for nitrate reductase (NR), nitrite reductase, cytosolic glutamine synthetase, and glutamate synthase increased; NR and nitrite reductase activity increased in leaves and roots; and glutamine synthetase activity increased in roots. The transcripts for phosphoenolpyruvate carboxylase, cytosolic pyruvate kinase, citrate synthase, and NADP-isocitrate dehydrogenase increased; phosphoenolpyruvate carboxylase activity increased; and malate, citrate, isocitrate, and [alpha]-oxoglutarate accumulated in leaves and roots. There was a decrease of the ADP-glucose pyrophosphorylase transcript and activity, and starch decreased in the leaves and roots. After adding 12 mM nitrate to nitrate-limited Nia30(145), the transcripts for NR and phosphoenolpyruvate carboxylase increased, and the transcripts for ADP-glucose pyrophosphorylase decreased within 2 and 4 hr, respectively. Starch was remobilized at almost the same rate as in wild-type plants, even though growth was not stimulated in Nia30(145). It is proposed that nitrate acts as a signal to initiate coordinated changes in carbon and nitrogen metabolism.

Tobacco mutants with a decreased number of functional nia genes compensate by modifying the diurnal regulation of transcription, post-translational modification and turnover of nitrate reductase

Although nitrate reductase (NR. EC 1.6.6.1) is thought to control the rate of nitrate assimilation, mutants with 40-45% of wildtype (WT) NR activity (NRA) grow as fast as the WT. We have investigated how tobacco (Nicotiana tabacum L. cv. Gatersleben) mutants with one or two instead of four functional nia genes compensate. (i) The nia transcript was higher in the leaves of the mutants. However, the diurnal rhythm was retained in the mutants, with a maximum at the end of the night and a strong decline during the photoperiod. (ii) Nitrate reductase protein and NRA rose to a maximum after 3-4 h light in WT leaves, and then decreased by 50-60% during the second part of the photoperiod and the first part of the night. Leaves of mutants contained 40-60% less NR protein and NRA after 3-4 h illumination, but NR did not decrease during the photoperiod. At the end of the photoperiod the WT and the mutants contained similar levels of NR protein and NRA. (iii) Darkening led to a rapid inactivation of NR in the WT and the mutants. However, in the mutants, this inactivation was reversed after 1-3 h darkness. Calyculin A prevented this reversal. When magnesium was included in the assay to distinguish between the active and inactive forms of NR, mutants contained 50% more activity than the WT during the night. Conversion of [15N]-nitrate to organic compounds in leaves in the first 6 h of the night was 60% faster in the mutants than in the WT. (iv) Growth of WT plants in enhanced carbon dioxide prevented the decline of NRA during the second part of the photoperiod, and led to reactivation of NR in the dark. (v) Increased stability of NR in the light and reversal of dark-inactivation correlated with decreased levels of glutamine in the leaves. When glutamine was supplied to detached leaves it accelerated the breakdown of NR, and led to inactivation of NR, even in the light. (vi) Diurnal changes were also investigated in roots. In the WT, the amount of nia transcript rose to a maximum after 4 h illumination and then gradually decreased. The amplitude of the changes in transcript amount was smaller in roots than in leaves, and there were no diurnal changes in NRA. In mutants, nia transcript levels were high through the photoperiod and the first part of the night. The NRA was 50% lower during the day but rose during the night to an activity almost as high as in the WT. The rate of [15N]-nitrate assimilation in the roots of the mutants resembled that in the WT during the first 6 h of the night. (vii) Diurnal changes were also compared in Nia30(145) transformants with very low NRA, and in nitrate-deficient WT plants. Both sets of plants had similar low growth rates. Nitrate reductase did not show a diurnal rhythm in leaves or roots of Nia30(145), the leaves contained very low glutamine, and NR did not inactivate in the dark. Nitrate-deficient WT plants were watered each day with 0.2 mM nitrate. After watering, there was a small peak of nia transcript NR protein and NRA and, slightly later, a transient increase of glutamine and other amino acids in the leaves. During the night glutamine was low, and NR did not inactivate. In the roots, there was a very marked increase of nitrate, nia transcript and NRA 2-3 h after the daily watering with 0.2 mM nitrate. (viii) It is concluded that WT plants have excess capacity for nitrate assimilation. They only utilise this potential capacity for a short time each day, and then down-regulate nitrate assimilation in response, depending on the conditions, to accumulation of the products of nitrate assimilation or exhaustion of external nitrate. Genotypes with a lower capacity for nitrate assimilation compensate by increasing expression of NR and weakening the feedback regulation, to allow assimilation to continue for a longer period each day.