Health-related quality of life (HRQoL) in German early benefit assessment: The importance of disease-specific instruments

INTRODUCTION

Health-Related Quality of Life (HRQoL) data is frequently requested in early benefit assessment in Germany. To test the hypothesis that the importance of HRQoL in general and the significance of disease-specific instruments in particular has increased since the introduction of AMNOG in Germany, we analysed all early benefit assessments between 2011 and 2022.

METHODS

All 793 early benefit assessments completed between 01/01/2011 and 03/11/2022 were systematically analysed. The HRQoL instruments featured in the dossier submissions were extracted for all assessments and categorized into generic and specific instruments. All G-BA resolutions were likewise assessed for consideration and acceptance of generic and specific HRQoL instruments. In addition, it was examined whether there was an association between HRQoL data and the extent of additional benefit.

RESULTS

Since 2014 HRQoL data have continuously been submitted in 70% to 80% of assessments per year with the exception of 2022 (63%). Generally, disease-specific instruments are favoured, regarding submissions by industry but especially with higher acceptance by the G-BA in the resolution. Subgroup analyses revealed oncology as a major contributor to the submission and acceptance rates of disease-specific instruments. Disease-specific instruments were submitted in 81% of all oncology assessments and accepted in 53% of assessments. Overall, assessments with accepted HRQoL data tend to reach a higher overall benefit. Procedures with accepted HRQoL were most likely to receive a considerable benefit (31%), while for procedures in which HRQoL data were not accepted, a benefit was most often (65%) not proven.

DISCUSSION

Industry has followed the request for submission of specific HRQoL instruments early on. Higher submission rates of specific instruments over time which at the same time meet the methodological requirements indicate that industry has learned from early assessments. A potential reason for the high submission- and acceptance rates of specific HRQoL instruments in oncology might be the particularly high relevance of HRQoL in this indication. Possible effects of changes in legislature on the future development of submission and acceptance of HRQoL data need to be monitored.

CONCLUSION

In Germany, HRQoL has gained a relevant position in early benefit assessment over time. Overall specific instruments are favoured, regarding submissions by industry but especially through consideration by the G-BA in the resolution. Furthermore, HRQoL data can be supportive for benefit assessments, in particular to show that advantages in morbidity and/or mortality are reflected in HRQoL and not at the expense of HRQoL.

Hospitalisation costs and health related quality of life in delirious patients: a scoping review

INTRODUCTION

Delirium is a common condition of a global disturbance of cognition, triggered by underlying diseases. The objective of this study is to review the current evidence in the literature on direct healthcare costs and health-related quality of life (HRQOL) associated with delirium.

METHODS

A systematic search was conducted in PubMed and Embase for relevant studies published between January 1, 2010 and November 4, 2021. Studies for inclusion reported estimates on healthcare costs or HRQOL, adjusted for relevant confounding factors.

RESULTS

Fourteen studies on healthcare costs and eleven studies on HRQOL were included. Delirium resulted in (adjusted) increased costs ranging from $1,532 to $22,269 depending on included cost categories, the country and the type of hospital department. Increased length of stay for delirious patients ranged from 2.5 days to 10.4 days and had the largest contribution to overall, direct incremental costs. Heterogeneity was observed in HRQOL outcomes.

CONCLUSION

The analysis indicates that the presence of a delirium episode may lead to increased costs of hospitalisation. Changes in HRQOL due to delirium are not well demonstrated and more research is needed to determine the effect of delirium on HRQOL.

[Enjoying Sports and Movement in Mental Illness]

Enjoying Sports and Movement in Mental Illness Abstract. Sports and exercise therapy is an effective complemant in the treatment of major depression. The recommendations of at least 150 minutes of moderate or 75 minutes of intensive physical activity per week should be met to achieve positive effects of physical activity. In addition, individual needs and the physical health conditions must be considered in the planning and implementation, so that exercise will be enjoyed in the long term.

Problematic Gaming in Youth and Its Association with Different Dimensions of Quality of Life

Objective: The problematic use of computer games was included in the DSM-5 and in the ICD-11. Initial research revealed associations between problematic gaming (PG) and quality of life (QoL). However, clarification is needed concerning which dimensions of the multidimensional construct QoL are particularly relevant for PG. Method: To answer this question empirically, we asked 503 parents (mean age: 47.63 years) to rate their 503 children (average age: 14.60 years) regarding QoL and PG, using validated questionnaires on parental assessments of adolescent PG and health-related QoL to collect the data. Correlation analyses were calculated to determine bivariate relations, and a multiple linear regression was used to conduct a multivariable analysis. Results: In the bivariate analyses, a higher severity of PG was associated with a lower health-related QoL in all five surveyed dimensions. In the multivariable model (corrected R² = 0.35), we observed statistically significant associations between higher severity of PG and male sex and lower age of the adolescent as well as lower QoL in the dimensions of physical well-being and school environment. Conclusions: According to the findings of the present study, physical well-being and school environment should be especially focused on in preventive approaches against the development of PG in youth.

[Development of a screening workflow to identify patient needs in an interdisciplinary oncological day clinic]

INTRODUCTION

The diagnosis of cancer leads to high levels of emotional distress in many patients. Quality of life is an important therapeutic goal in this context. A quality-of-life guide was implemented in the oncological day clinic (ICT) at the University Hospital of Regensburg (UKR) in order to individually support outpatients, help them with their questions and needs and improve their quality of life.

METHODS

A screening tool is necessary for the structured assessment of quality of life/needs in the routine of tumor therapy and follow-up. As part of a mixed-methods study, focus groups with health professionals/patients were organized to specify the needs of cancer patients. On this basis, the literature was searched for questionnaires covering these needs in order to adapt an ICT-specific questionnaire and integrate it with the help of a workflow.

RESULTS

A total of 333 individual aspects were brought up by the participants in focus groups on the needs of cancer patients in various phases of treatment/with various tumor entities. Since none of the questionnaires identified in the literature met our requirements, a new screening tool containing elements from different standardized forms and the results of the focus groups was developed and a new workflow created to integrate the questionnaire into the ICT routine.

DISCUSSION

By interviewing health experts from different areas and patients with different tumor entities, the needs of cancer patients over different stages of the disease and additional possible differences between the cancer entities were identified and recorded. Through the implementation of a quality-of-life guide in the ICT, a structured assessment of the quality of life and an analysis of patient needs can take place with the help of the screening. A workflow was created to integrate screening into routine care. In addition, the questionnaire was designed in such a way that it can be used repeatedly at various points in time. In order to cover important stages in the course of therapy and to determine how patient needs change over the course, patients should be asked to complete the questionnaire several times after specified time intervals.

CONCLUSION

The questionnaire is intended to assess the needs of cancer patients receiving outpatient treatment in a structured manner. Now it needs to be explored how the new screening tool and workflow interact and perform in clinical practice and how they help to improve patients' quality of life. It is also interesting to analyze which patients accept the advice offered by the quality-of-life guide and which needs are expressed most frequently.

Return to Work and Quality of Life in Disease-Free Adult Patients with Soft-Tissue and Bone Sarcoma of the Extremity

Treatment of extremital sarcoma patients may be associated with significant functional disabilities and psychosocial distress affecting return to work (RtW) and quality of life (QoL). In this exploratory study we prospectively investigated the RtW rate, explored biomedical and psychosocial predictors of RtW, and compared generic QoL with Swiss population norms. Forty people (89 %) returned to work. Full-time employment before sarcoma diagnosis, high educational level, and low tumor grade showed an increased probability of RtW. The median age was lower in patients who returned to work, and they reported less fear of progression. Generic QoL (SF-36) was reduced in almost all dimensions when compared to a normative Swiss population. Physical functioning and fear of progression have to be addressed in the rehabilitation process.

[Mental Stress and Health-Related Quality of Life in Adolescents with Gender Dysphoria]

Mental Stress and Health-Related Quality of Life in Adolescents with Gender Dysphoria Although the level of mental stress in adolescents with gender dysphoria is found to be generally high in many studies, differences have been shown between samples of gender dysphoria clinics for adolescents in different countries. However, a comparison within the German speaking area is lacking. In this article we compared samples of gender dysphoria clinics from Munster (Germany) and Zurich (Switzerland) and tested potential correlates of mental stress using quantitative methods. Subsequently, we interviewed clients from both clinics regarding mental stressors and protective factors. There were no quantitative differences in the level of mental stress of clients between Munster and Zurich, whereas health-related quality of life was significantly higher in Munster. Problems in physical well-being and school environment were the strongest correlates of mental stress. This reflects in the interviews, too, in addition to further related factors reported. We conclude that physical well-being and inclusion at school should be addressed with special emphasis in counseling or treatment of adolescents with gender dysphoria to counter the in average high levels of mental stress.

[The Zurich Specialist Clinic for Adolescent with Gender Dysphoria - Preliminary Follow-up Results]

The Zurich Specialist Clinic for Adolescent with Gender Dysphoria - Preliminary Follow-up Results The specialist clinic for children and adolescents with gender dysphoria (GD) of the Psychiatric University Hospital of Zurich shows an increasing number of referrals since its foundation in 2009. Since 2014 we started an observational study including adolescents aged 13 years and older. At the time of the first appointment (T0) N = 77 participants completed a battery of questionnaires assessing demographic factors, general psychopathology, quality of life as well as gender identity, social transitioning and GD treatment modalities. Few of the adolescents were socially transitioned and had hormone therapy but 77.9 % wished to get hormone therapy. Follow up assessment T1 was performed after at least one year of treatment in our specialist clinic. 51 adolescents completed an online follow-up examination including the same questionnaires and baseline parameters as well as a scale measuring treatment satisfaction. At T0, 77.3 % of the adolescents scored in the clinical range of the Youth Self Report (YSR) total score, which did not decrease significantly until T1 in our preliminary follow up sample. Puberty blocking before T0 correlated negatively with the YSR score, indicating less psychopathology in treated patients. Preliminary longitudinal analysis suggests that social transitioning influences quality of life (Kidscreen subscale autonomy and parental relationship). At T1, 52 % of the adolescents were socially transitioned in all contexts and 70 % received gender affirming hormonal treatment. Gender identity changed between T0 and T1 in about 18 % of the cases. Treatment satisfaction in most cases was high.

Health status, comorbidities and cost-of-illness in females with stress urinary incontinence living in the Canton of Bern

INTRODUCTION

Two thirds of women suffering from stress urinary incontinence (SUI) reported a negative impact on quality of life (QoL). SUI can also lead to less physical activity and more comorbidities. SUI may result in a substantial economic burden on health care services but numbers are not clear. Therefore, the aim of this study was to estimate the health status, the comorbidities and the health costs of women with SUI living in the Canton of Bern (Switzerland).

METHODS

This cost-of-illness (COI) study was embedded in an RCT (n=96) exploring the effect of two pelvic floor muscle training protocols in women with SUI. A prevalence-based COI study with a societal perspective and a bottom-up approach was applied. Baseline demographics, comorbidities and cost data were collected prospectively during 16 weeks. Descriptive statistics, a frequency and a one-way sensitivity analysis were performed.

RESULTS

Thirty-seven participants volunteered in this COI study. About 95 % had at least one comorbidity. The most commonly reported problem was back pain (47.6 %). Fifty-one percent consulted a medical doctor, the prevalence of drug consumption was 70 %, 11 % reported less efficiency whilst working and 30 % less physical activity. Mental stress was mentioned by 59.5 % of the participants. The average health costs were CHF 2256.

DISCUSSION

This COI study provided data on health status, comorbidities, QoL, health care use, productivity losses and costs of SUI. The high prevalence of comorbidities observed in this study was comparable to obese females of a similar age group. The high economic burden of SUI requires cost-effective preventive actions and clinical treatment concepts.

[Quality of Life and Behavioral Problems of Unaccompanied Minor Refugees in Child Care Facilities]

Quality of Life and Behavioral Problems of Unaccompanied Minor Refugees in Child Care Facilities Unaccompanied minor refugees (UMR) who arrive in Germany are generally placed in institutional child care facilities. UMR are a very burdened group, however other children and adolescents in institutional care are burdened as well, and their quality of life is often reduced. The aim of the current study was thus to compare quality of life and behavioral problems of UMR in child care facilities with those of other resident adolescents. For a total of 50 UMR, data regarding behavioral problems was available, for 41 UMR ratings on quality of life, both from external assessments. Two parallel comparison samples of other adolescents in the same institutional care facilities were drawn with adolescents with and without a migration background. Results show that in general, UMR show fewer behavioral problems than the other two groups, especially in externalizing behavior. For internalizing behavior, no differences were evident. For quality of life, no differences could be found between the three groups of inhabitants in institutional care. This indicates that the same factors determining quality of life are present in all three groups, but that the underlying mental problems are different in UMR than in other adolescents. Thus, staff in institutional care should possibly work differently with these group of adolescents than with other inhabitants and should be educated respectively.

[Quality of Life in Children with Down Syndrome from Parental Point of View]

Quality of Life in Children with Down Syndrome from Parental Point of View Parents of 42 children with Down syndrome (mean age 9 years) report on their child's quality of life (physical, emotional and social domain). The KINDL-R was used as a proxy-report measure. Quality of life correlated negatively with behavioral symptoms (SDQ), but did not vary between children in mainstreamed or special schools. Regression analysis identified the child's behavioral symptoms and parental stress - assessed when the children had reached the age of five - as significant predictors of quality of life assessed four years later.

Interne Konsistenz und Konstruktvalidität des demenzspezifischen Lebensqualitätsinstruments QUALIDEM - Eine Sekundärdatenanalyse einer Querschnittserhebung

Internal consistency and construct validity of the Quality of Life measurement in dementia QUALIDEM - a secondary data analysis of cross-sectional data Abstract. Background: Maintaining and improving the Quality of Life (QoL) of people with dementia is the principal aim of nursing and medical care. The QUALIDEM is a theory-based, dementia-specific QoL instrument in the German language. Until now, however, there are hardly any findings on the construct validity.

OBJECTIVE

Evaluation of the item difficulty, internal consistency, discriminant and convergent validity of the German QUALIDEM.

METHOD

The evaluation of the construct validity is based on a Multi-Trait-One-Method approach, using a sample of 167 people with mild to severe dementia and 71 people with very severe dementia.

RESULTS

The correlation between the QUALIDEM subscales and the comparative constructs agitation, depression, anxiety, aberrant motoric behavior, apathy, pain and QoL, measured with the Alzheimer's Disease Related Quality of Life instrument, was confirmed in the expected direction in 82 % of the predefined hypotheses. The correlation coefficients range between 0.04 and -0.60 (discriminant validity) and -0.21 and 0.71 (convergent validity). For the majority of QUALIDEM subscales a good internal consistency could be demonstrated.

CONCLUSION

The results indicate first indications for the construct validity of the QUALIDEM subscales and for the further development of the instrument. In future studies, the validity of the German QUALIDEM should be further investigated.

[HeiMeKOM (Heidelberg Milestones Communication): development of an interprofessional intervention for improvement of communication in patients with limited prognosis]

BACKGROUND

The care for patients with advanced disease and limited prognosis and their relatives is complex and characterized by insufficient communication and lack of coordination and continuity.

AIM

Development of an interprofessional, practice-guided concept of longitudinally structured communication with the goal of fostering communication, improving quality of life and facilitating early integration of palliative care.

METHODS

Multi-level process starting from a draft with discussion and approval within the multiprofessional team and correlation with interviews with patients and relatives. Preparation of a comprehensive concept with review of the literature, problem analysis, theoretical foundation, goal setting and intervention components. Discussion of suitability for daily use, adaptation and further development of the concept.

RESULTS AND CONCLUSIONS

Concept with the following components: interprofessional communication training, structured conversations at defined moments in a tandem of physician and nurse with patient and relative, follow-up conversations conducted by the nurse, and respective instruments (conversation protocol, question prompt list, memory cards). Only iterative discussion with and the approval of patients, relatives and the multiprofessional team and their approval will put the concept into practice.

[Verbesserung der Lebensqualität durch integrative onkologische Rehabilitation]

Hintergrund: Die onkologische Rehabilitation ist integraler Bestandteil der Versorgung krebskranker Menschen. Nach einer dreiwöchigen stationären Rehabilitation mit multimodalem und integrativem Ansatz wurden die Effekte auf Belastungen und Lebensqualität der Patienten überprüft. Patienten und Methoden: 74 Krebspatienten erhielten ein komplexes Therapieprogramm, das Therapien zur Verbesserung der funktionalen Gesundheit, zur Reduktion psychosozialer Belastungen und komplementäre Massnahmen beinhaltete. Der Erfolg der Therapie wurde mit validierten Fragebögen am Abschluss der Rehabilitation (T2) und 3 Monate danach (T3) bestimmt. Ergebnisse: Es zeigte sich eine signifikante Besserung von Distress, Angst, Depression, Fatigue und Lebensqualitätsfunktionsskalen zum Zeitpunkt T2 und T3. Von T2 nach T3 war der Therapieeffekt rückläufig, ohne die Werte von T1 zu erreichen. Schlussfolgerungen: Eine multimodale, integrative onkologische Rehabilitation führt zu einer über 3 Monate anhaltenden Besserung des subjektiven Befindens der Patienten. Dieses Therapiekonzept sollte in einer Folgestudie mit einer Standardrehabilitation verglichen werden.

BACKGROUND

Oncological rehabilitation is an integral part in the care of cancer patients. Following an inpatient rehabilitation of 3 weeks’ duration with multidimensional and integrative components, the effects on distress and quality of life were measured.

PATIENTS AND METHODS

74 cancer patients received a complex treatment program, including treatments for improvement of functional health, reduction of psychosocial distress and complementary therapies. The treatment outcome was evaluated with validated questionnaires at the end of the rehabilitation (T2) and 3 months thereafter (T3).

RESULTS

We observed significant improvement of distress, anxiety, depression, fatigue and quality of life at T2 and T3. In the interval from T2 to T3, the treatment effect was declining, without reaching the values of T1.

CONCLUSIONS

A multidimensional integrative oncological rehabilitation improves the subjective condition of the patients over a 3-month period. This treatment concept should be tested in a comparative study against standard rehabilitation.

[Patient perspective of the importance of asthma- and COPD-specific rehabilitation components: A secondary data analysis]

Little is known about the importance that patients attribute to individual rehabilitation components (RCs) and about which factors influence the patients' perspective and the impact of this judgment on the perceived success of the rehabilitation process. To address these questions, the data of 759 patients with chronic obstructive pulmonary disease (COPD) or bronchial asthma, who were interviewed at the end of their rehabilitation about the subjective importance of various RCs, were analysed retrospectively. The patients were pooled from our previous studies "Prospektive Katamnesestudie zur Asthma-Rehabilitation" (ProKAR) and "Routinemäßiges Inspirationsmuskeltraining in der COPD-Rehabilitation" (RIMTCORE). Asthma patients and COPD patients differed in their assessments. Their evaluation was also affected by personal parameters such as sex, comorbidities, quality of life and the perceived effectiveness of the "rehabilitation as a whole". Patients considered all RCs to be essential, with minor differences. However, the patients' assessment of the importance of the RCs was in the closest possible agreement with the evidence available for the effectivity of multimodal rehabilitation. The added value of the proposed study is to generate further insight into the upcoming scientific field of personal rating of therapy components.

[First results of a German second opinion program show high patient satisfaction and large discrepancies between initial therapy recommendations and second opinion]

BACKGROUND AND OBJECTIVES

Although legally anchored, there are no empirical results from German second opinion programs. In this study, various aspects within a population of a second opinion program are examined.

METHODS

In this study patients were analyzed who sought a second opinion in the period from August 2011 to December 2016. Differences in patient characteristics, differentiated by agreement of first and second opinion, were analyzed using multivariate logistic regression. Patients' satisfaction and quality of life were examined one, three and six months after obtaining the second opinion.

RESULTS

In total, 1,414 patients sought a second opinion. Most frequently, second opinions were sought on knee (38.7 %), back (26.8 %), hip (11.7 %), and shoulder (10.2 %) complaints. Except for the indication (p=0.035), no patient characteristic had influence on the conformation of the second opinion. Approximately two out of three initial recommendations were not confirmed by the specialists. 89 % of the patients were satisfied or very satisfied with the second opinion and the service offered.

CONCLUSIONS

The second opinion offers patients the opportunity to seek an additional independent medical opinion and thus provides support for decision making. Further research is needed to examine the reasons for the high discrepancies between the first and second opinions.

[Microscopic Colitis]

Microscopic colitis (MC) is still an underestimated cause of chronic, non-bloody watery diarrhea. It is typically manifested in elderly patients with a female predominance. The incidence of microscopic colitis has been increasing. The aetiology and pathophysiology remain unclear. Conditions associated with it include autoimmune diseases. There may be a genetic predisposition, as familial cases have been described. As implicated by the name microscopic colitis, the diagnosis is found by histological examination. There are mainly two subtypes, the lymphocytic colitis (LC) and the collagenous colitis (CC). Even if the condition's long-term course is benign, a chronic recurrent course of the symptoms is frequent. Due to the symptoms, there is an impairment of patient's health-related quality of life. A correct diagnosis and therapy is therefore mandatory. The aim of this paper is to create awareness for microscopic colitis.

[Healthy Siblings of Children with Autism Spectrum Disorders. A Mixed-methods Pilot Study]

Healthy Siblings of Children with Autism Spectrum Disorders. A Mixed-methods Pilot Study Healthy siblings of chronically ill and/or disabled children may have an increased risk of developing behavioral problems; this is particularly given for siblings of children with Autism Spectrum Disorders (ASD). Quality of life and distress of five siblings (12-15 years) of children with ASD were examined using self- and parent-proxy-reports. Guideline-based interviews were conducted with the siblings and their parents and analyzed according to Mayring. Quality of life described by the children resembled the KINDLR´s standardized range of scores, but parents described a decreased quality of life. Both siblings and parents reported low to medium distress. Interviews revealed healthy children are asked by their parents to take responsibility for their siblings with ASD. Parents assumed their healthy children are less affected by the ASD of the sibling. The healthy siblings described being "annoyed" by ASD-associated behavior and partly feeling "treated unfairly". They wished their sibling no longer "suffered" from ASD or behaved "normally". The results of this pilot study, albeit with a small sample, show siblings do experience low to medium burden. This burden is often caused by the sibling relationship or the ASD-associated behavior. Suggestions for supporting the healthy siblings are given.

[Not Available]

Zusammenfassung. Zusammenfassung: Die Komplikationsrate nach Osteosynthese von proximalen Humerusfrakturen ist trotz neu entwickelten Implantaten hoch. Wir sind der Meinung, dass die hohe Individualität der Patienten auch einen möglichst individuellen Therapieansatz benötigt. Somit definierten wir einen evidenzbasierten Behandlungsalgorithmus, der die Patientenindividualität und das ganze Behandlungsspektrum beinhalten sollte. Wir suchten dabei nach einem optimalen Weg zwischen Risiko (Komplikationen) und Ertrag (Schulterfunktion). Vor allem die Lebensqualität sollte nach der Frakturbehandlung wieder möglichst gut sein. Die ersten Resultate unserer prospektiven Untersuchung sind vielversprechend. Die konservativen Wege im Algorithmus scheinen gut zu funktionieren, nur sehr selten musste davon abgewichen werden. Es zeigt sich jedoch, dass vor allem die Osteosynthesen noch immer komplikationsbelastet sind. Diesbezüglich gilt es, den Algorithmus und die chirurgische Technik in Zukunft noch zu verbessern.

Implementation and first results of a tablet-based assessment referring to patient-reported outcomes in an inpatient cancer care unit

BACKGROUND

Inclusion of patient-reported outcomes (PROs) in routine cancer care is of key importance for individualized treatment, shared decision making and patient satisfaction.

OBJECTIVE

To describe the implementation under routine conditions of an electronic self-administered PRO assessment and comparison of PROs before and after inpatient treatment in oncologic care.

METHODS

In a tablet-based survey PROs on symptom burden, global health status/ quality of life (QoL) and health utility were collected twice (at hospital admission and discharge) in an inpatient oncological setting over a 17-month period using the EORTC QLQ-C30 and EQ-5D questionnaires. Data were linked to the hospital information system (HIS). Patient acceptability, recruitment rates, symptom burden, and clinically meaningful changes in PROs over time were analyzed.

RESULTS

From a total of 384 hospitalized patients invited to participate at admission 371 (96.6 %) participated. At discharge, 195 patients were approached for a follow-up assessment, and 192 patients (98.5 %) participated. Despite strong acceptance among patients, recruitment rates were decreasing over time. During the hospital stay clinically meaningful improvements were observed for health utility (33.3 %, n = 64) and global health status/QoL (43.2 %, n = 83). Patients reported a variety of symptoms at admission and discharge.

CONCLUSIONS

Implementation of PRO assessment in routine care and data integration into the HIS provides valuable information for the entire medical staff as symptom burden is present during the entire hospital stay.

IMPLICATIONS FOR PRACTICE

Long-term maintenance of PRO assessment in a clinical setting as a prerequisite of value-based healthcare requires continuous involvement of the nursing team, which can only be achieved by allocating resources to this task.

[Not Available]

Zusammenfassung. Die tumorassoziierte Fatigue ist ein häufig auftretendes und ernstzunehmendes Beschwerdebild mit belastenden körperlichen, psychischen und sozialen Auswirkungen, das im Verlauf einer Brustkrebserkrankung zu jedem Zeitpunkt auftreten kann. Das Erscheinungsbild der tumorassoziierten Fatigue ist in der klinischen Symptomatik wie auch in den pathophysiologischen Mechanismen sehr heterogen und komplex. Sowohl die Abklärung von Ursachen als auch die Behandlung erfordert ein differenziertes Vorgehen. Eine frühzeitige Therapie der tumorassoziierten Fatigue ist wichtig, um einer möglichen Chronifizierung entgegenzuwirken. Die Behandlung der Fatigue-Symptomatik erfolgt mittels medikamentöser und nicht-medikamentöser Therapieansätze. Während pharmakologische Interventionen mit Psychostimulanzien in der Behandlung der Fatigue-Symptomatik inkonsistente Resultate zeigen, können die Beschwerden der Fatigue-Symptomatik durch nicht-pharmakologische Interventionen, besonders körperliches Training, kognitiv-behaviorale Therapie, Psychoedukation, komplementärmedizinische Behandlungen (Akupunktur, Yoga, phytotherapeutische Verfahren mit Ginseng) deutlich gemindert werden.

[Not Available]

Zusammenfassung. Ziel der onkoplastischen Chirurgie ist es, durch Verbindung von onkologisch sicherer Chirurgie und rekonstruktiven plastisch chirurgischen Techniken auch grössere Tumoren brusterhaltend operieren zu können. Durch innovative Techniken wird der ästhetische Outcome verbessert mit dem Ziel die Patientinnenzufriedenheit und Lebensqualität hoch zu halten, möglichst ohne deformierende Resultate als Folge der Brustkrebsbehandlung. Gemäss Patientinnenwunsch kann in der selben Operation die Gegenseite symmetrisierend angeglichen werden, ohne dass für die Patientinnen Kosten entstehen. Onkoplastik ist genauso sicher wie konventionelle brusterhaltende Chirurgie. Es gibt jedoch Hinweise für häufigere postoperative Komplikationen, am ehesten zurückzuführen auf anspruchsvollere Techniken und längere Operationszeit. Letztere führen jedoch nicht zu einer Verzögerung der adjuvanten Therapie. Um die vielfältigen neuen Techniken zu standardisieren, wurde Anfang 2017 in Basel ein sehr erfolgreiches internationales Expertentreffen abgehalten, dessen Resultate hier ebenfalls erläutert werden sollen.

Predictors and determinants for weight reduction in overweight and obese children and adolescents

INTRODUCTION

Worldwide, overweight and obesity are known as posing serious health risks. Successful methods for weight reduction have remained elusive. This multicenter non-randomised trial aimed to identify parameters and determinants of long-term weight reduction.

PATIENTS AND METHODS

A total of 143/159 overweight and obese children and adolescents (90 %) completed the prospective multicenter trial (age 13.9±2.4 years, BMI 31.2±5.4kg/m², BMI-SDS 2.51±0.57). During a 6-week rehabilitation period the patients participated in a structured treatment and teaching program (STTP). Following in-patient treatment the children and adolescents were monitored over a period of 24 months (physical examination, measurements of BMI, BMI-SDS, body composition, carotid intima-media thickness, laboratory parameters, blood pressure, standardized questionnaires to assess socio-demographic and socio-economic parameters, eating behavior, well-being, quality of life, intelligence, intrafamilial conflicts, self-efficacy, resilience, sense of coherence, stress management, social support, actual body shape).

RESULTS

66% of the children and adolescents had abnormal laboratory parameters as well as higher blood pressure and/or an increased carotid intima-media thickness. The mean carotid intima-media thickness was 0.53±0.09mm (range 0.40 to 0.80); 15% of the patients showed normal range values (< 0.45mm), 40% a slightly elevated (≥ 0.45 to ≤ 0.50mm) and 45% an elevated (> 0.50mm) thickness. After the inpatient treatment lasting 40.4±4.1 (range 28 to 49) days, children and adolescents reached a mean weight reduction of 5.52±3.94 (0.4 to 13.3) kg (p<0.01) that was accompanied by a reduction in body fat mass. Using multivariate analyses, the most important psychological factors associated with long-term weight reduction were identified (R-square=0.53): well-being (β=-0.543), resilience (β=0.434), and sense of coherence (β=0.315).

CONCLUSION

The different parameters (i. e., well-being, resilience, sense of coherence) have demonstrated their utility, and strategies should be developed allowing an adaption of these into the STTPs.

[Living with achondroplasia- how do young persons with disproportional short stature rate their quality of life and which factors are associated with quality of life?]

OBJECTIVE

Presently, little is known aqout the quality of life (QoL) as well as the strengths and difficulties of young people with achondroplasia. This study describes these patient-reported indicators and identifies possible correlates.

METHOD

At the invitation of a patient organization, a total of 89 short-statured patients aged 8 to 28 years and their parents participated in this study. QoL was assessed cross-sectionally with both generic and disease-specific instruments and the Strengths and Difficulties Questionnaire (SDQ) as a brief behavioral screening. In addition to descriptive analyses, patient data were compared with a reference population. Hierarchical regression analyses reflecting sociodemographic, clinical, and psychological variables were conducted to identify correlates of QoL.

RESULTS

QoL and the strengths and difficulties of young patients with achondroplasia did not differ substantially from a healthy norm sample. However, the participants reported more behavioral problems and limitations in their physical and social QoL compared to patients with another short stature diagnosis. Strengths and difficulties, height-related beliefs, and social support correlated significantly with QoL. Adding psychological variables to the regression model increased the proportion of variance explained in QoL.

CONCLUSIONS

Young persons with achondroplasia did not differ in their QoL and strengths and difficulties from healthy controls. Characteristics such as height appear less important for the self-perceived QoL than are strengths and difficulties and protective psychosocia~factors.

[Not Available]

Zusammenfassung. Schmerzen erkennen, diagnostizieren und interpretieren sind unabdingbare Voraussetzungen für eine potente Therapie. Die Art, die Form und die anatomische Korrespondenz des Schmerzes sowie der Schmerzentstehung, -modulation und -fortleitung sind zur Erstellung des Behandlungskonzeptes zu beachten. In den meisten Fällen geht es bei chronischen Schmerzerkrankungen nicht mehr um Schmerzfreiheit, sondern um Lebensqualität und Aktivität. Durch Kenntnis der zu erläuternden Schmerzmechanismen sollte es prinzipiell theoretisch möglich sein, eine «Schmerzkarriere» zu vermeiden.

[Trans-sectoral care for patients with colorectal cancer: Design of a prospective randomized controlled multi-center trial (FKZ 01GY1143)]

BACKGROUND

Health-related quality of life (HrQoL) is an increasingly focused aim in the care for patients with colorectal cancer that are treated with curative intent. Achieving this aim partly depends on the quality of the transsectoral management of these patients throughout the entire treatment course. However, recent population-based surveys have shown that HrQoL in patients with colorectal cancer is significantly impaired over a long time following initial diagnosis. This also applies to patients for whom adjuncant chemotherapy is not indicated according to the German medical S3 guideline. In addition, the patients' need for medical and psychosocial support has repeatedly been reported to persist at a significantly increased level - despite the extensive establishment of certified cancer centres which has apparently failed to solve this problem sufficiently.

AIM

The SCAN intervention aims to increase the percentage of patients reaching an enhancement of their HrQoL by at least 12 points (range: 0-100 pts.) within eight weeks after hospital discharge by 15 percent compared to standard care.

DESIGN AND METHODS

The SCAN intervention is carried out as a randomised controlled multicentre trial in seven large- and middle-sized hospitals all over Saxony-Anhalt. 370 patients have been enrolled, 185 of whom are offered additional nurse-led outpatient counselling.

INTERVENTION

Patients in the intervention group are offered transitional guidance and support consisting of routine symptom assessment and patient counselling regarding self-management, informed therapy-related decision-making and psychosocial support.

ENDPOINTS

The primary endpoint of the study is the patients' global health-related quality of life (HrQoL), assessed by the EORTC Quality of Life Questionnaire QLQ C-30 V3.0, item 30. Disease-free survival within eight months, the utilisation of indicated adjuvant chemotherapies as well as therapy-related side effects, e. g., anxiety and depression and the patients' symptom burden are monitored as secondary endpoints.

EXPECTED RESULTS

We assume that the SCAN intervention will be effective in increasing the percentage of patients reaching a clinically relevant enhancement of their HrQoL within eight weeks after hospital discharge by 15 percent compared to standard care.

[Methodology for analysing quality-of-life data in the benefit assessment of pharmaceuticals]

Early benefit assessment aims to prove a benefit of a new pharmaceutical over the appropriate comparator based on patient-relevant endpoints. In addition to mortality and morbidity, quality of life is a patient-relevant endpoint. Thus, phase III clinical trials are the basis of evidence. But HTA and health authorities attach different importance to quality of life. Using the example of oncology, the challenges with study design and analysis will be discussed. A particular challenge to the analysis of quality-of-life data is varying observation times in treatment arms with different effectiveness. Based on the example of Crizotinib possible solutions will be presented.

[The significance of quality of life--an ethical approach]

Quality of life is highly appreciated as an evaluation criterion and a goal of interventions in medicine, but it is insufficiently applied. There is no unanimous definition of "quality of life". From a philosophical point of view, subjectivistic concepts can be differentiated from objectivistic ones. In medicine there are the three concepts of general, health-related and disease-specific quality of life. In this paper it is argued that a general and subjectivistic account of quality of life is of prevailing ethical significance, due to patient orientation and patient autonomy reasons. The normative function of quality of life should be given much more consideration by the responsible players in clinical research, healthcare and allocation decisions within the healthcare system.

[The relevance of quality of life for the work of the Federal Joint Committee]

As the highest decision-making body of the joint self-government of physicians, dentists, hospitals and health insurance funds in Germany, the Federal Joint Committee (G-BA) is responsible for determining the catalogue of benefits for those insured by statutory health insurance (SHI) funds. The G-BA uses patient-relevant, health-related quality of life outcomes as a decision criterion in the assessment of new examination or treatment methods, the benefit assessment of new pharmaceuticals, the quality assurance of services, and in determining treatment goals for disease management programmes and special forms of care. But the data generally available on quality of life are considered insufficient by the G-BA. Studies submitted for methods assessments or the benefit assessments of pharmaceuticals often lack findings on quality of life, or the data are of limited value due to methodological shortcomings. Because the burden of disease is shifting more and more towards chronic and oncological diseases due to demographic changes, the G-BA considers an improvement in the data available on health-related quality of life to be urgently necessary.

[The significance of quality of life from a socio-legal perspective]

Only rarely is the term quality of life explicitly mentioned in the Social Security Code (Sozialgesetzbuch, SGB). In the statutory health insurance law (Book V of the Social Security Code, SGB V), the term is explicitly regulated within the context of the entitlement to pharmaceuticals. While there are pharmaceuticals that have the priority to increase the quality of life but are excluded from the provision of healthcare (Section 34 (1) Sentence 7 SGB V), the improvement of the quality of life has to be taken into account for the cost-benefit assessment (Section 35b SGB V) as well as for the early pharmaceutical benefit assessment (Section 35a SGB V) and for the formation of reference price groups (Section 35 SGB V) for and in the case of an entitlement to benefits in the event of illness.

[Quality of life and the healthcare system: do we know what we are doing? On the importance of quality of life from the perspective of patients]

"Healthcare" is not an exact term but an abstract representation of a system which itself is unable to create quality of life. The term "quality of life" is a general term. Every human being is part of the world he or she lives in (his or her "lifeworld", "Lebenswelt"). Health and disease have a direct and, through individual system components, significantly different effect. Is there a healthcare system? Which resources are available to this healthcare system and the individual persons themselves? There are numerous and quite different components influencing a patient's individual quality of life. These components also include the professional philosophy of physicians, their professional practice and their communication skills in dealing with their patients. The disease-related quality of life can be categorised into the groups "occasional diseases," "chronic, incurable diseases," "diseases leading to disability," or "fatal diseases". In each group, the factors influencing quality of life are subject to a different individual assessment. Disease does not stop at the doctor's office, but becomes an integral part of life, which is especially true of predestined, life-long chronic diseases such as, for example, psoriasis, a chronic skin condition. Diagnosis und limiting factors in treatment have an impact on the patient's quality of life, too, and must be conceived of as "indication-related". Also, support from outside the professional healthcare system, in particular from patient self-help organisations, contributes to assisting patients with maintaining a high level of individual quality of life. Self-help is not only effective, but useful as well, as has been demonstrated by initial studies in Germany.

[Is it quality of life that patients really want? Assessment from a general practitioner's perspective]

The multidimensional, complex construct of 'quality of life' as a patient-reported outcome is used in medicine as a measurable indicator of health and illness. But do we know what we do when we measure 'quality of life'? Can we grasp how the patient with his individual concept of disease really feels when we use instruments that were designed, administered and analysed by professionals? Do we know the meaning of what we have measured? Is it not shortsighted to focus on health-related quality of life? And is it really quality of life that patients actually want? From a general practitioner's perspective, these questions will be asked of three patients.

[Aspects of quality of life of residents of a nursing oasis from the perspectives of relatives and nurses- qualitative results of an evaluation study]

A nursing oasis (NO) can be understood as a version of special care units. The focus is on a constantly living arrangement for people with severe dementia in nursing homes (multiple person room). Nurses are permanently present during the day shift. The question has to be raised which characteristics of quality of life (QoL) are mentioned and how nurses and relatives do assess this concept. Qualitative Results of a two-year evaluation study of 15 people living in NOs are presented. Data were collected during four (five) group discussions with 8 nurses (15 relatives). Additionally problem-based interviews were realized. Data evaluation was oriented to the grounded theory. The findings show that primarily the focus of QoL in NOs was on psychophysical well-being. Assessments of relatives and nurses were prevailing positive and could be interpreted in the light of the Festingers' social-psychological "Theory of Cognitive Dissonance". Comparisons between the situation before and after the implementation of the NOs were shown to be relevant for the overall assessments. All in all we have to deal with the construction of "care worlds of everyday life" in long term care institutions.