Search PubMed⌕ Search

Biomedical subjects

B Birkner

Publications and source records attributed to B Birkner.

At least 19 recordsLinked to original sources
PubMed2006

[Problems with the implementation of medical guidelines].

Neither today nor tomorrow will medicine be completely encompassed within guidelines. Those who have been concerned with developing guidelines in the past years are well aware of the limitations involved. At present, the most important task is to review the flood of current guidelines to check their compliance with the criteria quoted here, as has already been done for English guidelines in the internet. In the future, too, other "paths of knowledge" besides guidelines will continue to be taken to improve the quality of medical care in Germany. Quality management as a whole offers many as yet unused possibilities for making such improvements. Academic research and the teaching of quality management would give a new impetus to the spreading of guidelines, and achieve greater acceptance. These points are necessary, if we are to produce the evidence for the efficacy of quality management.

Germany↗
PubMed2005

[Clinical gastroenterology--luxury or standard of service in gastroenterology?].

Gastroenterology is one of the important specialities in internal medicine. The reform of the training curriculum for internal medicine and the reimbursement for inpatient and outpatient services in gastroenterology threatens the existence of internal medicine and gastroenterology in Germany, too. The capacity for training in internal medicine and gastroenterology is reduced by a decrease in the number of hospital beds in academic and community training centres. The concentration on gastrointestinal endoscopy in outpatient gastroenterology will be a result of an increasing demand for gastrointestinal endoscopy services and the decreasing number of gastroenterology clinics, respectively. Therefore, clinical gastroenterology as a core service in gastroenterology will be steadily eliminated. This development will diminish clinical gastroenterology to gastrointestinal endoscopy by eliminating the clinical services for chronic gastroenterological conditions such as, e.g., IBD, chronic hepatitis, reflux disease, IBS and functional dyspepsia. In this way gastroenterology looses its central role in health care services in specialised internal medicine. In 2003 the American Gastroenterological Association position paper: "Training the Gastroenterologist of the Future: the Gastroenterology Core Curriculum" was published. It has emphasised the role of clinical gastroenterology in medical training and medical services, too. Clinical gastroenterology consists of an array of several disciplines, e.g., GI physiology, GI research, infectious diseases, hepatology, oncology and gastrointestinal endoscopy, which all contribute to the effectiveness and efficiency in health care service. Financial incentives and better prospects of leading positions for young gastroenterologists in clinical gastroenterology have to be accomplished in order to nourish clinical gastroenterology in Germany. The German Association of Gastroenterology should negotiate with the responsible authorities for the addition of clinical gastroenterological services to the reimbursement by the EBM2000plus. The section of Gastroenterology of the German Association of Internists will provide sustained support to the achievement of this goal.

Delivery of Health Care↗
PubMed2005

The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies.

BACKGROUND AND STUDY AIMS: Screening colonoscopy with polypectomy has been shown to reduce the morbidity and mortality associated with colorectal cancer. However, there is a lack of large and systematic prospective studies of the complications of polypectomy. PATIENTS AND METHODS: Data on all snare polypectomies performed in 13 institutions (six hospitals and seven gastroenterology offices) were recorded prospectively during a 20-month period, including data on a 30-day follow-up period. The primary end points of the study were polypectomy complications, which were classed as "major" or "minor". Risk factors for complications were analyzed for both patient characteristics and polyp parameters. RESULTS: A total of 3976 snare polypectomies in 2257 patients (mean age 64.5 years) were included in the study. The mean polyp size was 1.1 cm, and 72% were sessile. Complications occurred in 9.7% of patients (6.1% of polyps); 75% of these complications were minor; and the mortality rate was zero. Multivariate regression analysis revealed polyp size as the main risk factor, both for complications overall (odds ratio 6.56, 95%CI 4.45-9.67) and for major complications (odds ratio 31.01, 95%CI 7.53-128.1). Right-sided polyp location was a significant risk factor for major complications (odds ratio 2.40, 95%CI 1.34-4.28). Setting a cut-off value of 3% as an acceptable rate for major complications, polyps larger than 1 cm in the right colon or 2 cm in the left colon, and multiple polyps carried an increased risk. CONCLUSIONS: Colonoscopic polypectomy is associated with a 10% rate of complications, but three-quarters of these are of minor clinical significance. More than 90% of the complications can be managed conservatively if adequate endoscopic expertise is available. Guidelines for intensified follow-up after polypectomy should be based on the size, location, and number of a patient's polyps.

Adult↗
PubMed2003

A prospective randomized comparison of unsedated ultrathin versus standard esophagogastroduodenoscopy in routine outpatient gastroenterology practice: does it work better through the nose?

BACKGROUND AND STUDY AIMS: In an outpatient gastroenterological practice setting, highly effective diagnostic procedures and patient satisfaction play an important role. Ultrathin endoscopy in unsedated patients has been shown to be more cost-effective and time-efficient in comparison with standard endoscopy. A prospective randomized study was carried out in unsedated patients to compare performance, feasibility, safety, and patient tolerance between ultrathin transnasal (UT), ultrathin oral (UO), and standard (SO) esophagogastroduodenoscopy (EGD). PATIENTS AND METHODS: A total of 200 of 600 eligible patients consented to participate in the study, and were randomly assigned to undergo UT, UO, or SO. Patients reported their tolerance of the procedure (anxiety, pain, gagging, and overall satisfaction; Likert scale 1-10), and the endoscopists reported the effectiveness of the procedure (handling, picture quality, and overall performance; Likert scale 1-10). Statistics were calculated using the Kruskal-Wallis test. RESULTS: After randomization, 65, 67, and 68 patients were allocated to the UT, UO, and SO groups, respectively. Failure to achieve complete EGD by the intended route occurred in 14 patients (22 %) in the UT group. Compared to the SO group, patients in the UT and UO groups rated anxiety before the procedure as being more intense - median score (10 % quantile estimate; 90 % quantile estimate): UT, 2.0 (1.0; 4.0); UO, 2.0 (1.0; 4.0); SO, 0.0 (0.0; 2.0); p < 0.0001), whereas SO patients experienced a higher level of anxiety during the procedure ( P < 0.0001). Pain during insertion of the endoscope was the least intense in the UO group: UT, 2.0 (1.0; 5.0); UO, 1.0 (1.0; 3.0); SO, 2.0 (1.0; 4.0); P < 0.001). Gagging during insertion was more pronounced in the UO group: UT, 2.0 (1.0; 4.0); UO, 3.0 (1.0; 7.0); SO, 2.0 (1.0; 5.0); P < 0.01). The patients' score for the overall assessment was better in the SO group ( P < 0.0001). The endoscopists' overall assessment for ultrathin EGD was poorer than for standard EGD: UT, 3.0 (2.0; 5.0); UO, 3.0 (2.0; 5.0); SO, 2.0 (1.0; 3.0); P < 0.0001). CONCLUSIONS: Ultrathin endoscopy through both the transnasal and oral routes has limited use in routine outpatient practice. Techniques for reducing pain and gagging may improve patient tolerance. Further technical improvements are needed to allow routine implementation.

Adult↗
PubMed2003

[The German Quality Management System for Outpatient Care (Q-M-A) Checklist--an instrument for assessing quality management systems in outpatient care].

Quality management systems had originally been designed for industrial purposes and were hardly applicable for small enterprises, there have been adjustments to the two main applications EFQM and ISO enabling utilisation also in ambulatory care. There are also different approaches like the Dutch Visitatiae concept which reflects the needs of GP's and is based on peer exchange. The presented paper gives an overview of existing quality management and certification systems and presents an instrument for evaluation. This checklist was developed by an interdisciplinary expert panel of the Agency for Quality in Medicine and serves as an aid for users and graders of quality management systems with regard to the feasibility of these systems.

Ambulatory Care↗
PubMed2002

[HYGEA (Hygiene in gastroenterology--endoscope reprocessing): Study on quality of reprocessing flexible endoscopes in hospitals and in the practice setting].

The quality of reprocessing gastroscopes, colonoscopes and duodenoscopes in daily routine of 25 endoscopy departments in hospitals and 30 doctors with their own practices was evaluated by microbiological testing in the HYGEA interventional study. In 2 test periods, endoscopes ready for use in patients were found contaminated at high rates (period 1: 49 % of 152 endoscopes; period 2: 39 % of 154 endoscopes). Culture of bacterial fecal flora (E. coli, coliform enterobacteriaceae, enterococci) was interpreted indicating failure of cleaning procedure and disinfection of endoscopes. Detection of Pseudomonas spp. (especially P. aeruginosa) and other non-fermenting rods - indicating microbially insufficient final rinsing and incomplete drying of the endoscope or a contaminated flushing equipment for the air/water-channel - pointed out endoscope recontamination during reprocessing or afterwards. Cause for complaint was found in more than 50 % of endoscopy facilities tested (period 2: 5 in hospitals, 25 practices). Reprocessing endoscopes in fully automatic chemo-thermally decontaminating washer-disinfectors with disinfection of final rinsing water led to much better results than manual or semi-automatic procedures (failure rate of endoscopy facilities in period 2 : 3 of 28 with fully automatic, 8 of 12 with manual, 9 of 15 with semi-automatic reprocessing). The study results give evidence for the following recommendations: 1. Manual brushing of all accessible endoscope channels has to be performed even before further automatic reprocessing; 2. For final endoscope rinsing, water or aqua dest. should only be used disinfected or sterile-filtered; 3. Endoscopes have to be dried thoroughly using compressed air prior to storage; 4. Bottle and tube for air/water-channel flushing have to be reprocessed daily by disinfection or sterilization, and in use, the bottle have to be filled exclusively with sterile water. The HYGEA study shows that microbiological testing of endoscopes is useful for detection of insufficient reprocessing and should be performed for quality assurance in doctors' practices, too. The study put recommendations for reprocessing procedures in more concrete terms.

Colony Count, Microbial↗
PubMed2001

[Compliance with terminology standards in reflux, ulcers, and gastritis: A study of 881 consecutive upper gastrointestinal endoscopy reports].

BACKGROUND: The German version of the Minimal Standard Terminology document for endoscopy was discussed in 1997 and 1998, and finally published at the end of 1999 as one of the German Gastroenterology Society guidelines. The diagnoses and descriptive terms included in this standard terminology are based on the consensus views of a large number of German endoscopists (20 endoscopists based in Munich and 20 elsewhere in Germany). The aim of the present study was to investigate how much spontaneous compliance there is with the descriptive terms included in the standard terminology - both among the members of the consensus discussions, and among colleagues not involved in this project. METHODS: A total of 881 endoscopy reports with the diagnoses of reflux, ulcer, and gastritis were collected from 11 centers (2 hospitals and 9 private offices, with a total of 26 examiners) over a one-month period. Nine of the 26 examiners were actively involved in the terminology consensus discussion. The rate of occurrence of the descriptive terms contained in the standard terminology was assessed for the diagnoses listed above. RESULTS: Compliance with the descriptive terms was high (> 90 %) only for basic parameters such as the Savary classification of reflux and the area in which gastroduodenal ulcers were located. Other important parameters, such as the extent (length) of Barrett's esophagus, ulcer size, and circumferential location, were reported in only three-quarters of cases or less. The descriptions of gastritis were inconsistent. There was no difference in the degree of compliance either between endoscopists using free dictation and those using computerized text blocks, or between members of the terminology group and those not involved in preparing the terminology. CONCLUSIONS: Adherence to standard terminology and its descriptive parameters is poor even among specialized gastroenterologists who have been involved in terminology consensus discussions. Compliance needs to be improved by providing suitable software programs with automatic reporting functions.

Barrett Esophagus↗
PubMed2000

Are guidelines followed in Helicobacter pylori diagnosis and therapy? An inquiry among gastroenterologists, referring physicians and patients in Munich.

BACKGROUND AND STUDY AIMS: Attempts to standardize Helicobacter pylori (Hp) diagnosis and therapy have led to the publication of guidelines by various national gastroenterological societies in Europe and the USA. However, little information is available either regarding the compliance of gastroenterologists and referring physicians with these guidelines, or regarding the patients' perspective. PATIENTS AND METHODS: A retrospective analysis was conducted of all outpatient upper gastrointestinal endoscopy reports for a one-month period in eleven different centers (two university hospitals and nine private practice gastroenterology offices) with a total of 24 gastroenterologists. Endoscopy reports from patients wit the indications of reflux, diarrhea, and tumors were excluded. Diagnoses and treatment recommendations given by gastroenterologists were recorded. Questionnaires concerning Hp diagnosis, treatment indications and performance, and follow-up were sent to referring physicians and patients. RESULTS: A total of 772 endoscopy reports were included in the study; analyzable questionnaires were returned by 287 referring physicians (47%) and by 265 patients (59%). Gastroenterologists recommended Hp eradication in all ulcers and in 29% of gastritis/nonulcer dyspepsia (NUD) cases. Referring physicians thought that 94% of ulcers should be treated by Hp eradication, which was also considered to be an absolute and relative indication in NUD by 15% and 53% of the referring physicians, respectively. Among the patients who replied, 52% had received Hp eradication regimens; ulcers were found in 22% of the total patient group. Check-up examinations after Hp therapy were considered necessary by 75% of the referring physicians, but only 22% of the responding patients actually underwent some form of check-up (upper gastrointestinal endoscopy in 91%). CONCLUSIONS: Gastroenterologists and (to a somewhat lesser extent) referring physician appear to be following the current guidelines for Hp treatment. As expected, two thirds of referring physicians consider NUD to be absolute or relative indication for Hp eradication. Check-up examinations are apparently being performed less frequently than recommended.

Adolescent↗
PubMed2000

[Certification of an ambulatory gastroenterologic service fulfilling ISO Law 9001--criteria and national guidelines of the Gastroenterologic Association].

The objectives of certification and accreditation are the deployment and examination of quality improvement measures in health care services. The quality management system of the ISO 9001 is created to install measures and tools leading to assured and improved quality in health care. Only some experiences with certification fulfilling ISO 9001 criteria exist in the German health care system. Evidence-based clinical guidelines can serve as references for the development of standards in quality measurement. Only little data exists on the implementation strategy of guidelines and evaluation, respectively. A pilot quality management system in consistence with ISO 9001 criteria was developed for ambulatory, gastroenterological services. National guidelines of the German Society of Gastroenterology and Metabolism and the recommendations of the German Association of Physicians for quality assurance of gastrointestinal endoscopy were included in the documentation and internal auditing. This pilot quality management system is suitable for the first steps in the introduction of quality management in ambulatory health care. This system shows validity for accreditation and certification of gastrointestinal health care units as well.

Ambulatory Care↗
PubMed1997

Clinical response to dietary fiber treatment of chronic constipation.

OBJECTIVES: To determine the clinical outcome of dietary fiber therapy in patients with chronic constipation. METHODS: One hundred, forty-nine patients with chronic constipation (age 53 yr, range 18-81 yr, 84% women) at two gastroenterology departments in Munich, Germany, were treated with Plantago ovata seeds, 15-30 g/day, for a period of at least 6 wk. Repeated symptom evaluation, oroanal transit time measurement (radiopaque markers), and functional rectoanal evaluation (proctoscopy, manometry, defecography) were performed. Patients were classified on the basis of the result of dietary fiber treatment: no effect, n = 84; improved, n = 33; and symptom free, n = 32. RESULTS: Eighty percent of patients with slow transit and 63% of patients with a disorder of defecation did not respond to dietary fiber treatment, whereas 85% of patients without a pathological finding improved or became symptom free. CONCLUSION: Slow GI transit and/or a disorder of defecation may explain a poor outcome of dietary fiber therapy in patients with chronic constipation. A dietary fiber trial should be conducted before technical investigations, which are indicated only if the dietary fiber trial fails.

Adolescent↗
PubMed1997

[Harmonization of the assessment of outcomes, predictors and costs as well as testing for gender-specific differences in rehabilitation research].

The scientific program "Rehabilitation Research in Germany" includes as a priority topic the evaluation of the effectiveness of rehabilitation regarding return to work. Controlled intervention studies with randomized allocation to treatment and a minimum follow-up of six to twelve months after rehabilitation are of primary importance. It is also recommended that the studies should include economic aspects and consider gender differences. Another request is harmonization of studies with respect to methods, assessment tools, and implementation to improve the relevance of the studies and to allow for combining the results. The authors respond to this request. They make proposals for harmonizing the assessment of outcomes, predictors, and costs as well as for testing gender differences in intervention studies. The proposals address the rehabilitation research networks and aim to provide a basis of discussion and to initiate the necessary consensus finding between the networks. Proposals include (1) a taxonomy of outcomes and predictors for rehabilitation and recommendations for generic assessment tools which allow for data-pooling of studies; (2) a concept for the pre-post and follow-up measurement and recommendations concerning the time interval on which evaluation of the effectiveness and efficiency of rehabilitation or treatment modalities should be based; (3) descriptions of the content and interpretation of the self assessment instruments which are recommended for cross study comparisons; (4) a procedure to assess the direct and indirect costs, i.e. costs of treatments and costs of disease consequences, which considers especially the assessment of rehabilitative services and their monetary evaluation; (5) provisions for ensuring representativeness of women in intervention studies and procedures for testing differences in treatment outcomes between women and men; (6) a procedure to reach harmonization by establishing a coordination committee including representatives of the research networks, and by using well-established methods such as consensus conferences.

Cost-Benefit Analysis↗
PubMed1996

[Quality assurance in coloscopy in private practice and the hospital. The Gastroenterology Quality Circle (GEQC) Munich].

OBJECTIVE: As quality control in medicine is part of a doctor's professional duty, the "Munich Quality Circle" conducted a prospective feasibility study in which ten, previously defined, quality indicators were to be assessed. PATIENTS AND METHODS: Six specialised private practice groups and three specialised hospitals centers took part. Data on 2928 consecutive patients were collected by questionnaire and ten quality indicators assessed: concordance with the indication list; intestinal cleansing; premedication; duration and completeness of the study; sensation of pain; use of radiology; complications; diagnosis; and therapeutic intervention. RESULTS: Concordance with the indication list was present in 97.8% (range 93-100), premedication was given to 94.6% (77-100), midazolam to 77%. The proportion of patients who recorded no or only moderate pain correlated with the dose but not with the duration of advancing the coloscope. Mean time of advancing the instrument to the caecum was 8.0 min, the duration directly depending on the experience of the examiner. A mean time of less than 10 minutes was achieved only after more than 1200 examinations. The more a centre used fluoroscopic control the shorter the time of coloscopy. The examination was completed in 97.6% (92-99). There was no correlation between experience (assuming supervision) and dose of midazolam or frequency of fluoroscopy. CONCLUSIONS: Nowadays total coloscopy is a primary diagnostic method, but it needs an intensive learning phase. In clinical centers consequent supervision of less experienced examiners achieved comparable results to those with experience. Informative quality indicators for coloscopy can be documented with little cost.

Anesthetics, Intravenous↗