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Biomedical subjects

F W Schwartz

Publications and source records attributed to F W Schwartz.

At least 37 records · Page 2Linked to original sources
PubMed1999

Maternal occupational exposure to chemical substances and the risk of infants small-for-gestational-age.

BACKGROUND: The association between maternal occupational exposure to specific chemical substances (organic solvents, carbon tetrachloride, herbicides, chlorophenols, polychlorinated biphenyls, aromatic amines, lead and lead compounds, mercury and mercury compounds) and birth of small-for-gestational-age (SGA) infants was evaluated using data from a prospective cohort study of 3,946 pregnant women in West Germany from 1987 to 1988. METHODS: Occupational, medical, and psychosocial information was gathered through a questionnaire from pregnant women who were recruited between 15 and 28 gestational weeks. Exposure to chemical substances at the current workplace was assessed by a job-exposure matrix constructed by Pannett in 1985 and weighted for the number of working hours per week. Women not working at the time of the interview, women with multiple births, and women with stillbirths were excluded from analysis. Data were analyzed using dichotomous and polytomous logistic regression to control for age, smoking status, alcohol consumption, body mass index, and number of former births. RESULTS: The results of the dichotomous logistic regression analysis suggest that leather work might be associated with the birth of infants small-for-gestational-age through exposure to chlorophenols (P = 0.02) and aromatic amines (P = 0.05). In the polytomous logistic regression analysis, only the association between exposure to mercury and growth retardation reached statistical significance (P = 0.02); however, the power of the study is limited. Further adjustment for income, shift work, and heavy physical work had no substantial effect on the results. CONCLUSIONS: These findings suggest that maternal exposure to specific chemicals at work may be a risk factor for the birth of SGA infants.

Adolescent↗
PubMed1999

Regulation of health-related technologies in Germany.

Against the background of a financial crisis and supposed inefficiencies due to inappropriate use or the use of ineffective technologies in the German health care system, increasing awareness of the role of coverage decisions and the use of health technologies has stimulated interest in the regulation of health technologies. A systematic analysis of the decision processes at the levels of licensing/market admission, coverage by statutory health insurance and steering of diffusion and usage reveals considerable inconsistencies in different health care sectors. With regard to different types of technology, an explicit licensing procedure conforming to international standards is required for drugs and medical devices. Concerning coverage decisions, the ambulatory sector appears to be much more regulated than the in-hospital sector. This applies also to diffusion and usage of technologies. However, steering of usage of health related technologies is generally weak in Germany since only non-binding guidelines are in place.

Delivery of Health Care↗
PubMed1999

Two types of health care systems and their influence on the introduction of perinatal care: an epidemiological twin model in Berlin from 1950 to 1990.

OBJECTIVES: When perinatal medicine emerged as a new medical discipline in the 1960s, Berlin was as one of the world's leading centers. During that time, the city was separated into two parts, each fostering its own health care system. After the destruction of the Berlin Wall, it was possible to speak with the citizens of East Berlin and to access their database systems. This created the singular opportunity to objectively compare the development of perinatal care in both parts of Berlin. METHODS: Rates of maternal, perinatal, and infant mortality as well as the rate of preterm deliveries were evaluated over time and between East and West Berlin. The timing of introduction of 20 specific perinatal interventions was evaluated across 18 hospitals with more than 500 deliveries (11 in West Berlin and 7 in East Berlin). Interviews were conducted with 100 gynecologists, 100 midwives, and 100 women who had recently delivered their first child from each side of the city regarding their opinions of the importance of these interventions for the quality of perinatal medicine and how they would distribute a budget to improve maternity care. RESULTS: Maternal, perinatal, and infant mortality decreased in both parts of Berlin until 1990 (p < 0.0001), without significant differences between East and West Berlin, though the preterm delivery rate was slightly lower in East Berlin compared with West Berlin (p < 0.06). Some new clinical techniques and treatments--such as cardiotocography, ultrasound, tocolytic therapy, and peridural anesthesia--were introduced earlier in West Berlin. In contrast, certain public health measures--such as maternal transport, screening programs for diabetes, and support of breastfeeding--were introduced much earlier in East Berlin. There were significant differences between the beliefs of gynecologists, midwives, and mothers in East and West Berlin. In general, citizens of East Berlin were more enthusiastic about technological medical advances, whereas citizens of West Berlin were more supportive of public health and alternative methods. In addition, there were significant differences between female and male physicians in their beliefs about how to improve health care, regardless of whether they resided in East or West Berlin. CONCLUSIONS: The results of this study may serve as a basis for reflection on how different social circumstances and health care policies can influence the improvement of maternal and child health care.

Attitude of Health Personnel↗
PubMed1999

Which factors determine the use of diagnostic imaging technologies for gastrointestinal complaints in general medical practice?

OBJECTIVE: Even though gastrointestinal complaints are among the most frequent reasons to contact general medical practitioners, little is known about the actual care of these patients, especially the use of diagnostic imaging technologies. METHODS: In a network of 57 family practitioners and 29 general internists in Lower Saxony, Germany, 1,217 contacts with patients with gastrointestinal diseases (16%, gastritis; 12%, gastroenteritis; 6%, cholelithiasis; 5% each, ulcus ventriculi and duodeni, and 14%, no final diagnosis) were documented. The effects of patient and physician/practice side factors on the use of ultrasonography and radiography were modeled using multivariate logistic regression. RESULTS: For ultrasonography, diagnosis and ownership of an ultrasound unit (odds ratio [OR] = 3.33) were highly significant predictors (p < .0001), followed by unknown diagnosis at beginning of contact (OR = 1.92; p = .0019), physician specialty (OR for internists = 1.89; p = .0025), and severity (p = .0085). For radiography, ownership of an ultrasound unit was the most significant factor (OR = 0.34; p < .0001), followed by severity (p < .0009), ownership of x-ray apparatus (OR = 2.56; p = .0025), physician specialty (OR for internists = 1.98; p = .0358), and unknown diagnosis at beginning of contact (OR = 1.79; p = .0451). Not significant were age and sex of patient and diagnosis for radiography. CONCLUSIONS: Physicians use diagnostic imaging technologies for patients with gastrointestinal complaints according to severity and knowledge about the diagnosis, but ownership of technology is the most predictive factor.

Adult↗
PubMed1999

Cardiac catheterization in Germany. Diffusion and utilization from 1984 to 1996.

OBJECTIVE: To describe the diffusion of cardiac catheterization technologies and time trends of their use according to setting and geographic region in Germany during a 13-year period. It is hypothesized that the cardiac catheterization technology has matured from an experimental state to a broadly accepted technology. METHODS: Data come from the annual survey of the German Society for Cardiovascular Research. All German cardiac catheterization units are requested to provide data on volume and type of catheterization procedures. Data are available from 1984 to 1996. Number and type of procedure, type of unit, diagnoses, and complications are all recorded. The overall response rate is 90%, on average. RESULTS: The total number of catheterization units was 324 in 1996, or an average of 3.69 units per 1 million population. In 1996, all of the East German Länder and districts were below average. Utilization of cardiac catheterization procedures increased exponentially during the study period. The number of angiographies rose from about 45,000 in 1984 to more than 450,000 in 1996; the number of angioplasties increased almost by a factor of 50 to 125,000 procedures in 1996. Inverse correlations between the rates per million population of either coronary angiographies or PTCAs and mortality rates from ischemic heart disease were observed at the level of the German Länder. CONCLUSION: Further studies taking patient characteristics, long-term outcomes, and other factors in account are necessary to clarify the large geographic variations and the negative relationship between utilization rates and coronary heart disease mortality found in this study.

Adult↗
PubMed1998

[Cost-benefit principle and cost containment].

Benefits-in-kind and co-payment are often regarded as instruments to support self-responsible demand of the insured and to generate effective cost control. Economic theory however assumes that benefits-in-kind alone (without co-payment) will not have a great influence on the demand decision of the insured, because with rational behaviour price is not a determinant of demand. Also the control effects of (limited) co-payment are to be regarded as rather low. According to the hypothesis of supplier induced demand the major influence on demand is generated by those providing health care services, as soon as the patient has made up the decision to visit a doctor. But co-payment determines the decision and the timing of the initial contact, resulting in potentially negative effects on medical outcome. This is especially true, if co-payment ist not moderated by social policy. These theoretical considerations are supported by empirical evidence provided by the example of the French ambulatory care sector.

Cost-Benefit Analysis↗
PubMed1998

[MORBUS: the Sentinel Practice Network. Report on a study in South Oldenbury].

There has been considerable public concern that emissions from intensive livestock farming may have hazardous effects on human health, particularly on the respiratory system. From October 1991 to September 1992, data on consultations of asthmatic children (up to 8 years) were obtained by a network of 25 GP and paediatric practices in South Oldenburg, a region with one of the highest livestock densities in Germany. Comparable data from a similar network of 75 practices in 3 adjacent regions (Brunswick, Hanover, Verden) with average livestock density served as a reference. In South Oldenberg, 2084 consultations of 542 asthmatic children were observed, with asthma being the reason for visit in 734 of the contacts (36%). The boy-girl ratio was 2.1:1 among index patients and 1.9:1 among consultations. Consultation rate was 25.2 contacts by asthmatic children per 1,000 total consultations of children up to 8 years in South Oldenburg, compared to 17.8 per 1,000 in Hanover, 15.7 per 1,000 in Brunswick and 13.6 per 1,000 in Verden. Consultations due to asthma scored 11.2/1,000 in South Oldenburg, 10.8/1,000 in Hanover, 7.2/1,000 in Brunswick and 6.5/1,000 in Verden. Asthmatic patients in South Oldenburg were younger (mean age 38 vs. 42 months) than those observed in the reference regions. There were no regional patterns in sex ratio, severity of asthma, respiratory allergies or atopic dermatitis. As this is an ecological study design, inferences concerning the cause of the observed regional differences can only be weak. We therefore propose a case-control study in order to obtain exposure and health data on an individual level.

Air Pollutants, Occupational↗
PubMed1998

[Methodological quality of clinical practice guidelines in Germany: results of a systemic assessment of guidelines presented on the Internet].

Critics claim that most of the German clinical practice guidelines are of poor quality having produced by informal ad hoc methodologies without a rigorous approach. This paper reports on the systematic appraisal of 329 guidelines published online by the Association of the Scientific Medical Societies (AWMF) in Germany. The results of this study suggest that most of the guidelines presented in Internet do not meet internationally recognised criteria for quality. Proposals are offered how to enhance the methodological quality of future guidelines.

Humans↗
PubMed1998

[Determinants for diagnostic and therapeutic co-operation between general practitioners].

In the light of new opportunities for structural arrangements in Germany calling for higher co-operation between physicians in private practice, determinants for diagnostic and therapeutic co-operation need to be examined. In the present study, 130 general practitioners were asked in regard to four typical primary care indication groups whether they prefer to diagnose and treat the patients on their own or in co-operation with colleagues. This self-assessment was validated using the data from 2,069 physician-patient contacts: physicians preferring therapy in co-operation actually referred patients three times more often. Concerning both gastro-intestinal and rheumatic disorders, physicians' preferences for diagnostic and therapeutic co-operation are highly correlated (phi = 0.491 and 0.528 respectively); preferences for diagnostic and therapeutic co-operation across indications are not as strongly correlated (phi = 0.334 and 0.397 respectively). However, there is no general indication-independent attitude towards co-operation for individual physicians: Indication and type of services are two factors which--probably in addition to others--affect co-operation independently. We confirm earlier conclusions that the detailed analysis of provider and patient characteristics together with the actual patient management on a case by case basis is a powerful tool for health services research.

Diagnostic Techniques and Procedures↗
PubMed1998

Approaches to the denominator in practice-based epidemiology: a critical overview.

OBJECTIVES: An accurate knowledge of the population at risk is a fundamental requirement for determining rates and making comparisons in epidemiological research. The major obstacle of studying the epidemiology of sentinel practice networks is the determination of population at risk, in this case, the reference population of medical practices. This article is intended to give a brief overview of major denominator approaches used in practice based epidemiology today, to discuss their underlying assumptions, their strengths and limitations. DESIGN: The literature used in this paper was searched from Medline databases of 1970-1997 using the logical expression "denominator and practice". More literature was identified from the references cited in those articles and from research reports that were available to the authors. MAIN RESULTS: There are various approaches to the denominator at different levels of complexity, which were presented akin to the well known "iceberg phenomenon": with only a small portion of the iceberg visible above the surface, inference as to the size of the invisible part may still be made under certain assumptions. Crude numbers of cases may still reflect trends in the true epidemiology of disease and may be useful for time-series analyses. Differences in the number of network participants over time and across region may be controlled for by using the number of sentinel practices as a denominator. The number of consultations is a first step towards a population-based denominator, reflecting characteristics of both patients and the network. The yearly or quarterly contact group is a true person-based denominator, yet disregarding the population not consulting. The population in practices' catchment areas can be either determined from patient lists or estimated using mathematical models. The ideal denominator is the total population in a geographically defined area, though this information can be directly related to medical practices only in very few countries. CONCLUSIONS: Although a person, or ideally a population-based denominator is desirable, even "lower-level" denominators may be suitable for certain research topics. In countries without patient registration, the estimation of incidences and prevalences has many methodological uncertainties that limit the use of sentinel practice systems. Assuming representativeness, valid analytical or time-series studies, however, can still be carried out even if there is very little information on the population at risk covered by particular medical practices.

Bias↗
PubMed1998

Contamination of human breast milk with organochlorine residues: a comparison between East and West Germany through sentinel practice networks.

STUDY OBJECTIVE: The aim of the study was to assess and compare the contamination of human breast milk with organochlorine residues through two sentinel practice networks in Lower Saxony, a state of former West Germany, and Saxony-Anhalt, a state of former East Germany. DESIGN: Eligible women were enrolled in this cross sectional study by a network of 51 paediatric practices in Lower Saxony and 44 in Saxony-Anhalt when bringing their babies for a regular screening examination four to six weeks after delivery. Sociodemographic, lifestyle, and exposure factors were determined by questionnaire. Milk samples were analysed for hexachlorocyclohexane (HCH), hexachlorbenzole (HCB), DDT, dieldrin, polychlorinated biphenyls (PCB), and heptachlorepoxid (HCE); half the samples were also analysed for dioxin. Analytic statistics were computed using multiple logistic regression. SETTING: The study was conducted in Lower Saxony, Germany, from July 1992 to June 1993, and in Saxony-Anhalt, Germany, from January to June 1995. PARTICIPANTS: 156 primiparous, breast-feeding women from Lower Saxony and 113 from Saxony-Anhalt were studied, who either were born and raised in former West or East Germany, respectively. MAIN RESULT: Mean age of mothers and children differed significantly between the two study groups. In Lower Saxony all but two milk samples were well below the tolerable concentrations established by the German Research Council (Deutsche Forschungsgemeinschaft (DFG)). In Saxony-Anhalt no participant had concentrations above those recommended by the DFG. After adjustment for age of mother and child, occupational and non-occupational pesticide contact, DDT and beta-HCH concentrations were significantly lower in Lower Saxony; HCE and dieldrin concentrations were lower in Saxony-Anhalt. No differences between the two states were found for PCB, HCB, gamma-HCH, and dioxin. CONCLUSIONS: Breast milk contamination levels in former East German Saxony-Anhalt exceeded the contamination in Lower Saxony only for DDT and beta-HCH.

Adult↗
PubMed1998

Sentinel practices in evaluating longer periods of care: quality of life and drug therapy of terminally ill persons in Lower Saxony (Germany).

STUDY OBJECTIVES: (1) To study the feasibility of using sentinel practice networks to evaluate longer periods of care. (2) To assess the quality of life and drug therapy of community dwelling terminally ill persons. DESIGN: Prospective longitudinal design with GPs in an existing sentinel practice network identifying "terminally ill" persons and recording the following data: age, sex, diagnoses, and ongoing drug therapy initially, time, place, duration, services, and drug changes for every contact, quality of life (HRCA-QL Index, Spitzer Index, uniscale), pain intensity and frequency on a weekly basis, and time and circumstances of death. SETTING: 26 GP practices in Lower Saxony, Germany. PATIENTS: 47 patients (age: mean 76 years, range 31 to 98; sex: 21 male, 26 female; diagnosis: 35 with cancer) with 582 contacts. Mean of recorded time before death was 70 days (median 50). MAIN RESULTS: Average number of physician-patient contacts increased from 0.7 a week three months before death to 2.4 in the final week. Quality of life decreased during that period (HRCA-QL Index: 5.1 to 0.8; Spitzer: 4.4 to 0.8; uniscale: 37 to 9). In the last week of life, no person was free of pain; analgetic therapy was "successful" in 57% of cases. CONCLUSIONS: (1) The sentinel practice approach is feasible for evaluating longer periods of care. The generalisibility, however, may be limited to certain subgroups. (2) The observed trends in quality of life, pain, and analgetic treatment should be compared with those in other settings and countries to identify the scope of care improvement.

Adult↗
PubMed1997

Financing reforms in the German hospital sector: from full cost cover principle to prospective case fees.

OBJECTIVES: The authors provide an overview of the hospital sector in Germany with a focus on the impact of recent reform legislation on this sector. METHODS: Data from the Federal Statistics Office, the Ministry of Health, and the Federal Association of Physicians are synthesized with information obtained from a general review of the literature. RESULTS: Before the implementation of recent health-care reforms, the German health-care system has been sharply divided into inpatient and ambulatory care sectors, resulting in a fragmented system of care delivery. All hospital operating costs were fully covered through per diem charges. The 1992 Health Care Structure Act and subsequent pieces of legislation have introduced new mechanisms to improve cost efficiency in the hospital sector and increase coordination between the inpatient and outpatient care. These measures notably include implementing an inpatient prospective payment system and permitting ambulatory surgery and care services to be offered in inpatient settings. CONCLUSIONS: Whereas prospective payments have greatly reduced the length of stay, hospitals were reluctant to offer ambulatory surgery due to budgetary constraints and the high level of ambulatory surgery by office-based physicians. The reforms passed have not yielded substantial cost savings. These reforms offer a natural experiment that could benefit from national and international studies on the impact of hospital sector redesign on management, financing, and patient outcomes.

Financial Management, Hospital↗
PubMed1997

Hospital outcomes research in Germany: results from a retrospective survey among sickness fund beneficiaries.

OBJECTIVES: The authors assess the feasibility of using retrospective, indication-specific patient surveys to conduct hospital outcomes research in Germany. Surgical outcome and patient satisfaction were examined in patients who underwent common elective surgical procedures. METHODS: Using the International Classification of Diseases Ninth Revision coding available in the Schwäbisch Gmünd health insurance data base, all patients for a defined period of time with one of the three following diagnoses were selected and questioned retrospectively using an indication-specific survey instrument: (1) varicose veins of the lower extremity; (2) nasal septum deviation; and (3) inner knee joint damage limited to patients undergoing arthroscopic meniscus repair. Survey content focused on preoperative conditions, pre- and postoperative symptoms, postoperative complications, the nature and duration of postoperative follow-up, and satisfaction with surgical outcome. RESULTS: Significant postoperative improvement of preoperative symptoms was found for all three groups. Complete freedom from symptoms was found in 29.7% of patients treated for varicose veins, 24.1% of patients with meniscus repair, and in only 10.6% of patients with nasal septum deviation. Multivariate analyses indicated that postoperative impairment was the decisive variable governing patient satisfaction for all three groups. CONCLUSIONS: The use of retrospective, indication-specific patient surveys constitutes a time-efficient, cost-effective, and patient-focused option for the systematic acquisition and evaluation of health outcomes in Germany. This methodology holds promise for international and domestic efforts to demonstrate the consequences of restructuring activities in the inpatient sector.

Adult↗
PubMed1997

[Observations on social medicine in public health transition].

In spite of the growing criticism of the social welfare principles, the social health insurance model is remarkably stable in Europe. Key features of this model are even implemented in more market oriented models (as in Switzerland) and in national health systems as in the United Kingdom. In Germany, however, the discussion is almost solely centred around the argument of globalisation of capital and labour and, subsequently, the high additional costs on labour. This endangers social security which is financed through wages. If the social welfare system in Germany would be abolished de facto and not intelligently adapted, this would be a dramatic signal against social principles all over Europe. Consequences for social medicine as a scientific discipline are: Social medicine as a public health discipline with the goal of equality in health care must get involved in health politics. Social medicine as an empirical science has to evaluate- and refute, if necessary-existing myths and prejudices. Social medicine needs a stable network for research, teaching and practice-this is the growing field of "public health".

Cost Control↗
PubMed1997

[General practice management and therapy of terminally ill patients--a longitudinal study].

Since most persons in Germany die outside a hospital, the aim of the study was to quantify GP and nursing services for persons in the ten weeks prior to death. GPs were asked to document patients they considered to be terminal, using a set of different documentation sheets: 1. age, sex, living situation, and diagnoses, 2. time, place, duration, services, and nursing intensity for every contact and 3. circumstances of death. GPs were told to expect three-month periods to be documented. Twenty-six practices participated, documenting 47 patients and 582 contacts. Mean age of the deceased was 76 years (31 to 98); 21 were male and 26 female. Patients were classified as "terminal" on average 70 days prior to death (median 50 days). Average number of doctor-patient contacts increased from 0.7/week to 1.6 in the third and second last week and 2.4 in the final week. Average number of hospital days were around 1.1/week for the whole period. Nursing hours by relatives increased to over 13 h/day in the final week. Professional home nursing services were available for 80% in the final week, but only for 3 h/day. Thirty-two patients (68%) died at home, 7 (15%) in a nursing home and 8 (17%) in hospital (after a mean of 6 days as in-patients). The results document the large amount of time needed by physicians, relatives and nurses in the last weeks of life for persons who die at home.

Adult↗