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E Swart

Publications and source records attributed to E Swart.

At least 19 recordsLinked to original sources
PubMed2006

[Determinants of hospital admission--investigation by case vignettes].

Unexplained differences in the density of in-patient management in one federal state in Germany led to a regional survey of physicians in independent and hospital practice, which aimed to describe more precisely the determinants of referral and admission behaviour. Brief typical case descriptions (vignettes) were designed, as an instrument of data collection, dealing with two examples of management problems: upper and lower abdominal pain. The urgency of inpatient treatment was ranked using clinical scores and guidelines. Social characteristics for the patient (age, gender, social situation, preference for/against hospitalisation, day of the week on which the patient presented) were randomly assigned to the case vignettes. Each physician was asked by mail to decide on the management of 10 upper and 10 lower abdominal vignettes each. The physicians were also asked to provide additional information on the characteristics of their practice or hospital. The data were analysed using multivariate hierarchical models. A 28 % response rate meant that vignettes were available from 455 general practitioners and internal medicine specialists in independent practice, as well as 261 hospital surgeons and internal medicine specialists, together with responses from 31 physicians from the medical service of the German statutory health insurance (MDK). 7376 upper abdominal and 7335 lower abdominal vignettes were analysed. Admission rates reflected the graded severity of the symptoms built into the vignettes. Hospital physicians wanted to admit the vignette patients much more frequently than physicians in independent practice wished to refer them. Older patients, independent of symptoms, were more frequently referred or admitted than younger patients. In the case of acute symptoms it is the day of the week when the patient consulted the physician and in the case of elective surgery the patient's preference that are important for hospitalisation. The results show that medical decisions on case management are made using reasonable problem-specific preferences. The probability of actually instigating admission was, other things being equal, much higher in hospital physicians than in office-based physicians. As an instrument of comparative research into medical care, case vignettes have practical advantages in relation to medical audits and standardised patients. They can also be used for teaching, examining, documenting and quality assurance purposes.

Decision Making↗
PubMed2006

[Patient satisfaction with outpatient/short stay operations in a practice clinic].

BACKGROUND: In a pilot scheme for outpatient/short-stay surgery in a practice clinic in Magdeburg, Germany, as well as medical indicators patient satisfaction was evaluated as part of its research programme. Typically, the recovery phase is transferred to the home environment. For this reason the practice clinic has little opportunity to observe the patient's post-operative course. Patient satisfaction, therefore, is a particularly important indicator in evaluating the quality of patient care in outpatient, generally elective, surgery. This study assessed patient satisfaction with the services offered by the practice clinic. The analysis also identified which determinants had significant impact on patient satisfaction in order to obtain information about reasonable measures for improvement. METHODS: A questionnaire developed by Blum to evaluate patient satisfaction with outpatient surgery in a hospital setting was slightly modified. The questionnaire contained 77 items, which included overall satisfaction as well as the following attributes: information, participation in decision-making, care, health care processes and organisation, post-operative recovery and follow-up care at home. All 420 patients treated were surveyed during two data collection periods in autumn 2001 and summer 2002. RESULTS: Response rate was 55.7% (234/420). Overall satisfaction was very high. Only 3.6% of patients were dissatisfied. Of the individual attributes patients were most satisfied with care, follow-up care at home, and participation in decision-making. 19% of the patients had criticisms relating to "post-operative recovery". Three out of six items could be identified as determinants of overall satisfaction (R(2) = 0.4 in a forward stepwise multiple linear regression analysis): participation in decision-making, follow-up care at home and health care processes and organisation in the practice clinic. Patients expectations and needs explained 79% of variance in satisfaction with participation in decision-making. DISCUSSION: The very high satisfaction scores, however, include criticism of detail and indicate scope for improvement. Negative reaction to the particularly relevant attribute "participation in decision-making" can markedly impair overall satisfaction. Patients' participation in their care has a special place with regard to patient satisfaction. The practice clinic intends to repeat the study as a part of its quality assurance programme.

Adolescent↗
PubMed2005

[What do we conclude from re-admissions about quality of inpatient care?].

Quality assurance in hospital care increasingly focuses on evaluation of outcome. Problems arise with displaying results of medical care beyond discharge. In this context hospital readmissions are often used as outcome variable. But it is unclear whether readmissions are meaningful indices of quality of hospital care and if so, where to get valid data on readmissions. We used claims data of the regional health insurance fund in Saxony-Anhalt (AOK Saxony-Anhalt) from 2002 and 2003 (850,000 insured; nearly 300,000 cases per year). All hospital admissions of a insured person are identified by an anonymous id-number independent of the admitting hospital. By this way we can analyze readmissions individually. Readmission are frequent events in hospital care. Nearly one third of all patients were admitted at least a second time in 2003. 18 % of all hospital cases are readmissions within 30 days after discharge. Readmissions concentrated on chronically ill, oncological, or multimorbid patients. Many of the readmissions take place in the context of planned therapies or post-operative treatment. 'Revolving-door patients' with multiple readmissions point to problems in cooperation of ambulatory and hospital care. By defining tracer diagnoses and specific causes of readmissions unplanned readmissions may be identified as a quality indicator of suboptimal care. Readmissions don't express suboptimal care per se. But taking into account methodological aspects a tracer approach with defining specific unplanned readmissions may provide meaningful outcome indicators. These can be derived from claims data fast, routinely, and with low costs. Further validation of the approach is needed.

Delivery of Health Care↗
PubMed2005

[GPS--good practice secondary data analysis. Working Group for the Survey and Utilization of Secondary Data (AGENS) of the German Society for Social Medicine and Prevention (DGSMP)].

The scientific use of secondary data, especially of claims data from health insurance funds, has continuously increased in the last years. Therefore the Working Group "Collection and Use of Secondary Data" (AGENS) of the German Society of Social Medicine and Prevention (DGSMP) took the initiative to define quality standards for secondary data analysis. Starting with a review of the Good Epidemiologic Practice (GEP) AGENS adapted the GEP to the specific requirements of secondary data analysis by a multi-stage consensus process. The guideline Good Practice Secondary Date Analysis (GPS) was adopted on January 15 (th), 2005. GPS consists of 10 guidelines which are divided in explaining comments and recommendations. The GPS are targeted to set up standards for secondary data analysis, and they may also be used as a foundation of contracts between data owners and scientists. They are addressed to scientists from health services research and social medicine. AGENS commits itself to revise GPS continuously.

Benchmarking↗
PubMed2004

["Loss of perspective is my disease" -- subjective feelings of long-term unemployed].

BACKGROUND: Nowadays job loss implies the risk of long-term unemployment particularly in former East Germany. Many physical, psychological and social problems are associated with unemployment. However, health of long-term unemployed may not decrease continually, but may be subject to fluctuations according to different phases of unemployment and short-term work. METHODS: This expectation was examined by structured interviews with long-term unemployed (10 men and women) working in temporary job-creating-schemes (ABM). We asked for determinants of health and subjectively perceived associations between health and employment as well as for conditions of life and work. RESULTS: The employees were on average 55 years old and more than 7 years without work before joining the ABM. Psychosocial complaints such as depression, sleep disorders or nervousness appeared after approximately three months of unemployment. Subjective health improved during job-creating-schemes, depending on specific work conditions, but deteriorate at its end again. Most of the ABM-employees don't have any perspective of future employment. CONCLUSIONS: The well-known association between unemployment and health was confirmed. Furthermore, the study gave new insights into psychological strains of long-term unemployed and subjective work loads during ABM. Future prospects were proved to be an important determinant of health ('lack of perspective is my illness'). From this measures of health promotion for long-term unemployed within ABM companies and other institutions can be derived.

Attitude to Health↗
PubMed2003

[Social inequality and noise pollution by traffic in the living environment--an analysis by the German Federal Health Survey (Bundesgesundheitssurvey)].

AIM OF THE STUDY: The study deals with the relationship between socioeconomic status and the uneven distribution of noise pollution in residential areas. Based on the social indicators education, occupation, income and an index of socioeconomic status, the study investigates whether people of lower socioeconomic status are more likely to live in busier streets and to be more affected by traffic and noise pollution than others. MATERIAL: The German Federal Health Survey (Bundesgesundheitssurvey, BGS) is a representative survey of the health status of the adult population in Germany. The representative sample in question reflects the opinions of 6,644 individuals aged between 18 and 79 years who were asked to fill in a standardised questionnaire between autumn 1997 and spring 1999. RESULTS: People of lower socioeconomic status are more likely to live in busy to extremely busy main roads and through roads. They feel significantly more often affected by traffic noise pollution. People of higher socioeconomic status are more likely to live in quiet environments. Essentially, all four social indicators reflect the social gradient of noise pollution, but their impact is differently weighted. CONCLUSION: Noise pollution in environments is unevenly distributed, with people of lower socioeconomic status suffering more than others. In view of the increased social burden and assumed vulnerability experienced by lower socioeconomic groups, environmental objectives for protection from noise pollution should be developed which ensure a socially just distribution of environmental noise pollution in addition to avoiding danger to health.

Adult↗
PubMed2002

[Preparing for the G-DRG system: portfolio analysis of the hospitals in Saxony-Anhalt, Germany].

Diagnosis-Related Groups are scheduled for step-by-step introduction into the German hospital system. Initially DRG base rates will be specific to each hospital (i. e. in keeping with the present budget), but eventually (by 2007) a common base rate will be reached in each federal state. This development may have grave financial consequences for some hospitals where initial base rates are above average and hence likely to be reduced. Therefore, we grouped the remunerations paid by the AOK Saxony-Anhalt (i. e. the largest statutory health insurance company in this federal state) for a total of 308,495 hospital cases in fiscal year 2000 according to hospital and diagnoses, expressed them as a percentage difference from the average remuneration, and analysed them jointly with the average length of stay (LOS). We found considerable differences between hospitals in terms of the payments per case and the LOS, independent of the stratification of the cases. For example, Magdeburg University Clinical Centre registered hospitalisations that were short (below average) but expensive (well above average), hence there is less scope for further rationalization of the LOS in this hospital compared to others. Considerable adjustments will become necessary in due course when switching over from hospital-specific base rates to a common regional base rate.

Budgets↗
PubMed2002

[Self-exercised health care and consultation of medical aid by single-parent mothers or fathers - results of a federal health survey].

PURPOSE: Single parents are at high risk of economical poverty and social deprivation. In this study we investigated the association of single parenthood with self-reported health, self-perceived mental disorders and the use of medical services. METHODS: The public users file of the German Health Survey 1998 were used for secondary analysis. Single-parent mothers aged 18 to 45 with at least one child under the age of 18 (n = 81) were compared with two control groups of the same age: mothers living in traditional nuclear families (n = 104) and women living in partnership status without children (n = 140). RESULTS: Single-parent mothers report less frequently than controls of a very good or excellent health status and more frequently of mental complaints (differences of single items of 10 to 15 percent). Feelings of discouragement and sadness are more common in this group. Overall, single-parent mothers do not use medical services more frequently than the control groups, but there are differences in the use of some specialists, especially psychotherapists. CONSEQUENCES: In respect of health, psychological stress is at a high level whereas the value of subjective health seems lower. The emphasis on situational parameters provides an insight into positive coping strategies and shifts the focus on influences that support health in a positive manner.

Adolescent↗
PubMed2002

[Possibilities of utilising official statistics for health services research].

This report deals with the experiences and problems with using official statistics on a limited area level of Germany's 440 administrative districts. The data comprised health-related issues and were used for an ecological analysis of the determinants of hospital use. We obtained health statistics data from homepages of the German health report, the Federal statistics office, and the 16 statistics offices of the Federal states. We also made use of the data base of the joint regional statistics published by the Federal and regional statistics offices. Finally, there was a co-ordinated inquiry to the regional statistics offices about the supply of data on mortality, hospital discharges, structure of hospital care and several socio-economic indicators. The process of data collecting was mostly unproblematic. On the other hand, not all of the data were available on a limited area level in a satisfying form and quality. For reasons of data protection some information of small districts was transmitted incompletely. Additionally, there are procedural differences between regional statistics offices regarding the differentiation between some variables and in the exchange of data between the federal states. Finally, some problems were due to varying age classifications for different health indicators. For health services research the use of official statistics becomes increasingly comfortable via health reports and Internet. However, for specific questions of research some problems still remain, rising from missing standardised health indicators and deficient availability of limited area health data. Data collection is exacerbated by restrictive interpretation of data protection acts and the different handling of data inquiries in the regional statistics offices. Finally, there is a lack of data on morbidity and use of ambulatory care.

Data Collection↗
PubMed2000

Identification of a novel acidic mammalian chitinase distinct from chitotriosidase.

Chitinases are ubiquitous chitin-fragmenting hydrolases. Recently we discovered the first human chitinase, named chitotriosidase, that is specifically expressed by phagocytes. We here report the identification, purification, and subsequent cloning of a second mammalian chitinase. This enzyme is characterized by an acidic isoelectric point and therefore named acidic mammalian chitinase (AMCase). In rodents and man the enzyme is relatively abundant in the gastrointestinal tract and is found to a lesser extent in the lung. Like chitotriosidase, AMCase is synthesized as a 50-kDa protein containing a 39-kDa N-terminal catalytic domain, a hinge region, and a C-terminal chitin-binding domain. In contrast to chitotriosidase, the enzyme is extremely acid stable and shows a distinct second pH optimum around pH 2. AMCase is capable of cleaving artificial chitin-like substrates as well as crab shell chitin and chitin as present in the fungal cell wall. Our study has revealed the existence of a chitinolytic enzyme in the gastrointestinal tract and lung that may play a role in digestion and/or defense.

Amino Acid Sequence↗
PubMed2000

[Surgery rates and small area variations].

On the basis of the claims data of the statutory health insurance funds, surgery rates and small-area variations within the catchment area of the AOK Magdeburg were examined for the year 1997. Substantial variation can be constantly seen. The extremal quotient at the 30 most frequent ICPM groups ranged from 2 to 5. Generally, the extent of the variation was larger with elective procedures than with acute. Correlation analyses do not show clear associations with hospital bed supply and physician density in primary sectors. The extent of the small-area variation requires further research to evaluate possible determinants of surgery rates. Criteria for hospital admission and indications for surgery should be made explicit.

Data Interpretation, Statistical↗
PubMed2000

[Does health status improve after re-assumption of ABM employment?].

UNLABELLED: Due to structural problems of the East German economy the level of unemployment will probably remain high for the next ten years. Thus, thousands of health-employment-schemes are established to reduce negative social and financial consequences of unemployment for those groups that are most affected. In this study the effects of temporary re-employment on health within the bounds of a job-creating measure are examined. By questionnaire employees of two firms in Magdeburg that exclusively occupies former unemployed men and women were asked about their subjective health status and changes in health status since re-employment. 217 employees filled the questionnaire (response rate: 50%; mean age: 45 years, mean duration of former unemployment: 18 months). About one half of the employees (48%) report positive effects on health after re-employment. This percentage is highest in the age group 50 years and older. The frequency of health impairments remained unchanged for half of the workers, the rest mainly stated fewer impairments. Poor working conditions or physical overtaxing decreases the positive effects of re-employment. Employees who had a positive attitude towards their work report on positive effects on health and other aspects of life more than average. CONCLUSIONS: Negative consequences of unemployment on physical and psychological health are well understood. On the other hand, our study demonstrates positive effects on health and a reduction of health impairments by temporary job-creating measures. This is influenced by the working conditions and the social environment of the employees. Further investigation are needed for detailed medical evaluation of job-creating schemes.

Adult↗
PubMed1999

[Rationale of inpatient care--towards a new payment system].

German statutory health insurance is introducing a system of lump sum payments for hospital care in the framework of a sectorial budget. All hospital cases covered by a major regional health insurance fund (AOK Magdeburg) and completed in 1995 to 1997 (590,000 cases and 7.6 million hospital days, resp.) were analysed to find out changes in the main parameters of inpatient care. The number of hospital cases per 10,000 insured persons continues to increase even after age-adjustment. The increase was 3.1% from 1996 to 1997. Hence the objective "outpatient treatment ranks before inpatient treatment" has not been achieved. The number of hospital days per 10,000 insured patients also increased. Hence the concept of "controlled touch down" (i.e. reaching the prospectively negotiated number of hospital days exactly) has not succeeded. After taking age into account, the number of hospital days slightly and for the first time decreased in 1997 compared to 1996. The average level of hospital stay (LOS) is decreasing, but still high. The proportion of cases with hospital stays exceeding the "Length of Stay Guidelines" was more than 30% in 1997. The pattern of the three parameters (number of cases, hospital days, and LOS) indicate that hospitals manage bed occupancy rates in the first place and that the indications for inpatient treatment are getting softer. Between 1996 and 1997 there has been a 17.5% increase in the total number of cases reimbursed by lump sums. In some categories of the fee schedule the increase is considerably greater. Such changes in performance make it difficult for both contracting parties to assess the "necessary" amount of cases and procedures to be covered by lump sum payments. In a considerable proportion of cases covered by lump sum renumeration, the LOS is longer than the calculated average on which costing is based. In spite of this, however, most hospitals gain more income from lump sum payment than they would if their per diem rates were applied. The proportion of cases with the LOS exceeding the upper compensation limit is low. Between hospitals, the average LOS in the same categories of the fee schedule differs by a factor of 1.5 to 2. There is no consistent indication of adverse risk selection. If the present payment system is maintained until the end of 1999 (or even 2001 as preferred by some), German hospitals will have an opportunity to continue with their development of organisation and costing, to improve their structure of services as well as their negotiating power and- the full compensation scheme having been abandoned in favour of prospective budgets- to net rationalization profits.

Germany↗
PubMed1998

[Target agreements between insurance carriers and hospitals as instrument for modifying hospital length of stay].

In 1995 the statutory sickness fund (AOK) in Magdeburg arranged target agreements with 10 of 23 acute care hospitals in its district to exercise an influence on the development of the average length of hospital stay. With the aim of decreasing the length of stay as well as the administrative cost and effort, these agreements set upper limits on the average length of stay which were hospital-specific and period-specific. In return, with only a few exceptions, the AOK Magdeburg refrained from limiting the coverage of individual cases. Hospital cases discharged from 1994 and 1996 were analysed to determine whether the development of the length of stay in the ten hospitals with target agreements differed from that in the other 13 hospitals. Only some of the hospitals were successful in reaching their target agreements. The average length of stay dropped by 4.2% in the hospitals with target agreements and by 7.9% in those without target agreements. This must be considered in the context of the development of the case load and number of available hospital beds. For instance, in spite of a target agreement, one hospital showed a (compensatory) increase in the average length of stay in association with an increase in the number of authorized beds and a concurrent decrease in the number of cases. The number of days billed by AOK patients per authorized bed (as an indicator of hospital productivity) showed a more favourable development in the group of hospitals with target agreements than in the other group. This was not a controlled trial as far as the selection of the hospitals is concerned. The results suggest that there is no harm in incentives that induce hospitals to manage primarily on their own the average length of stay. The use of routine aggregate data in monitoring this development, rather than the current more expensive individual case approach, also seems reasonable. Well planned studies that further test the "tool" of target agreements can be recommended.

Cost Control↗
PubMed1997

[When are recommended breast biopsies carried out, and what information does the physician responsible for mammography receive? Experiences with 317 breast biopsy in a regional quality assurance project for screening mammography].

In a regional quality assurance project for screening mammography (German Mammography Study), 27,335 women were screened in 40 participating, office-based mammography units from 1990-1992. Screening led to 317 biopsies with a positive predictive value of 0.33. All biopsy documentation available to the mammography physicians was analysed with a view towards biopsy interval and completeness of information fed back to the Mx physicians. Biopsy recommendations were acted upon in 29% of cases within 2 weeks. With the exception of the dignity Mx physicians were incompletely informed about biopsy results. The surgical procedure was known in the doctors' offices in 62% of the cases. Specimen radiographies were not done regularly. A pathology report was available overall in 42 of 106 malignant cases, respectively. With the exception of the histological diagnosis itself, no variable mentioned in the reports was documented completely. Only one third of the physicians received such reports routinely. Fail-safe information are requested by Mx physicians and can help them to better target biopsy recommendations. A (regional) quality assurance center should be made responsible to analyse the flow of information in mammography screening, to fill in gaps and to speed up professional cooperation.

Biopsy↗
PubMed1997

Quantitative estimates of the impact of sensitivity and specificity in mammographic screening in Germany.

STUDY OBJECTIVE: To estimate quantitatively the impact of the quality of mammographic screening (in terms of sensitivity and specificity) on the effects and costs of nationwide breast cancer screening. DESIGN: Three plausible "quality" scenarios for a biennial breast cancer screening programme for women aged 50-69 in Germany were analysed in terms of costs and effects using the Microsimulation Screening Analysis model on breast cancer screening and the natural history of breast cancer. Firstly, sensitivity and specificity in the expected situation (or "baseline" scenario) were estimated from a model based analysis of empirical data from 35,000 screening examinations in two German pilot projects. In the second "high quality" scenario, these properties were based on the more favourable diagnostic results from breast cancer screening projects and the nationwide programme in The Netherlands. Thirdly, a worst case, "low quality" hypothetical scenario with a 25% lower sensitivity than that experienced in The Netherlands was analysed. SETTING: The epidemiological and social situation in Germany in relation to mass screening for breast cancer. RESULTS: In the "baseline" scenario, an 11% reduction in breast cancer mortality was expected in the total German female population, ie 2100 breast cancer deaths would be prevented per year. It was estimated that the "high quality" scenario, based on Dutch experience, would lead to the prevention of an additional 200 deaths per year and would also cut the number of false positive biopsy results by half. The cost per life year gained varied from Deutsche mark (DM) 15,000 on the "high quality" scenario to DM 21,000 in the "low quality" setting. CONCLUSIONS: Up to 20% of the total costs of a screening programme can be spent on quality improvement in order to achieve a substantially higher reduction in mortality and reduce undesirable side effects while retaining the same cost effectiveness ratio as that estimated from the German data.

Adult↗
PubMed1997

[Evaluation of Federal Health Insurance process data as instrument for structural and quality analysis of inpatient care].

Statistically based quality assurance, despite its advantages also has a few marked disadvantages. In particular, it is not proven that it promotes measures of internal quality assurance. Instead, processing data of the statutory health insurance bodies are shown as flexible and easily available data covering a defined population and region. Hence, these processing data may be the starting point for internal quality management in hospitals. As examples, from an analysis of hospitalised cases some questions were derived concerning the structure and quality of hospital care. These questions should be answered by common efforts of hospitals, health insurance bodies, and public institutions. This may guarantee good and efficient inpatient care.

Adult↗