Neue Krankenhausfinanzierung - Experiment mit ungewissem Ausgang: Zur geplanten Umstellung auf ein DRG-basiertes Fallpauschalensystem

Im Rahmen der GKV-Gesundheitsreform 2000 wurde die Umstellung der Krankenhausfinanzierung auf ein vollständiges Fallpauschalensystem beschlossen. Das erst vor wenigen Jahren eingeführte Mischsystem aus Basis- und Abteilungspflegesätzen sowie Fallpauschalen und Sonderentgelten soll zum 1.1.2003 durch ein Fallpauschalensystem ersetzt werden, das sich an den ursprünglich in den USA entwickelten Diagnosis Related Groups (DRG) orientiert. Das vorliegende Papier setzt sich kritisch mit dem Reformvorhaben auseinander und arbeitet eine Reihe von gravierenden Mängeln heraus. Bei der Verwirklichung des Vorhabens würde es sich um ein international einmaliges Experiment handeln, das mit erheblichen Risiken für die bedarfsgerechte Krankenhausversorgung verbunden wäre. Keines der als Vorlage in Frage kommenden DRG-Systeme wurde bislang in einem Staat flächendeckend für alle Krankenhauspatienten eingesetzt und der im Gesetz vorgegebene Zeitplan läßt eine sorgfältige Vorbereitung der Umstellung nicht zu. Auch wenn ein verstärkter Abbau von Kapazitäten angesichts des Fortbestandes der staatlichen Krankenhausplanung nicht wahrscheinlich ist, so besitzt die geplante Umstellung doch das Potential für tiefgreifende Veränderungen im Krankenhausbereich. Neben internen Verteilungskonflikten in den Krankenhäusern und einer primär an Rentabilitätsgesichtspunkten orientierten Reorganisation von Abteilungen und Leistungsspektren ist vor allem der massive Anreiz zur ökonomisch motivierten Patientenselektion zu nennen. Diese Veröffentlichung entstand im Rahmen des Forschungsprojektes „Anpassungsprozesse der Krankenhäuser an die prospektive Finanzierung und ihre Auswirkungen auf die Patientenorientierung“. Das Projekt wird im Rahmen des Berliner Zentrums Public Health aus Mitteln des Bundesministeriums für Bildung und Forschung gefördert (FKZ 01EG9525/8).

Intervention for organizational innovation: a case study

This article is intended to report an intervention in a SME of the IT sector, aiming at an organizational change process towards a greater proactivity of employees. The presentation of the case includes the diagnosis, intervention, and the beginning of the implementation of innovation projects, based on an adapted model of third generation large-group organizational change methods. In addition to the steps followed, small-world analysis techniques were used, with the intention of determining the existing communication networks; also, a content analysis of collected success stories was made, in order to suggest strong points for a future organizational culture. The results clarified the desirable characteristics of an intervention method with large groups, adapted to Portuguese companies, and effective in organizational innovation project design. The analysis of the success stories helped to determine the strengths of an orientation for the future, while the use of measures of small-world networks allowed us to analyze the existing informal organization. Although this study does not include the completion of the projects, due to difficulties in the company, it can provide a solid basis for application in future interventions.

Proposta de modelo de interação da Universidade Federal do Rio Grande do Norte e empresas do setor de petróleo

Operational procedures may negatively interfere in negotiation and execution regarding universities and business companies. In some cases it may even derail business interaction. Thus, aiming to overcome this and other barriers a university-industry interaction model was structured. The model enhances the appropriation of technological solutions on behalf of enterprises, as well as aim to improve the quality of teaching and research done at the university. In order to conduct a case study, sampling considering the Federal University of Rio Grande do Norte (UFRN) was made as well as the Oil and Gas sector. For data collection questionnaires, classroom observation, document analysis, semi-structured interviews were used. The study describes the companies as well as the internal organization of UFRN in their interaction context. The diagnosis related to past interactions as well as the expectations of the companies and the university s internal subjects regarding the university-industry relationship were also studied. Thus, specific questionnaires were applied for the three types of groups: researchers, managers and business companies. These subjects pointed out that the great deal of barriers they identified were related to issues regarding the university internal management. Given these barriers, the critical factors were then identified in order to overcome this reality. Among the nine critical factors only one belongs to the macro environment, while the remaining factors are related to organizational issues present in the university context. It was possible to formulate a university-business interaction model one the researched focused on the case study results and contribution from a theoretical framework that was enabled trough literature review. The model considers all business collaboration mechanisms; it focuses on a particular strategic productive sector and provides a co-evolution vision over time, according to the sector´s development strategy. The need for institutionalizing the relationship with the companies involved is pointed out. The proposed model considers all the critical factors identified by the research; it aims long-term relationship with the company and integrates teaching, research and extension actions. The model implementation was also considered. It was seen that it must be done in three phases. The phases will be defined by the level of maturity in the relationship between the university and the companies. Thus, a framework was developed in order to assess the interaction level regarding company institutionalization. Whilst structuring the model was a concern with replication came up. It was pointed out that this model should not only serve to this specific case study situation. So the final result is a model of university-industry relationship appropriate in the first instance, for UFRN, but has applicability, in general, to any Brazilian university

African 2, a clonal complex of Mycobacterium bovis epidemiologically important in East Africa

We have identified a clonal complex of Mycobacterium bovis isolated at high frequency from cattle in Uganda, Burundi, Tanzania, and Ethiopia. We have named this related group of M. bovis strains the African 2 (Af2) clonal complex of M. bovis. Af2 strains are defined by a specific chromosomal deletion (RDAf2) and can be identified by the absence of spacers 3 to 7 in their spoligotype patterns. Deletion analysis of M. bovis isolates from Algeria, Mali, Chad, Nigeria, Cameroon, South Africa, and Mozambique did not identify any strains of the Af2 clonal complex, suggesting that this clonal complex of M. bovis is localized in East Africa. The specific spoligotype pattern of the Af2 clonal complex was rarely identified among isolates from outside Africa, and the few isolates that were found and tested were intact at the RDAf2 locus. We conclude that the Af2 clonal complex is localized to cattle in East Africa. We found that strains of the Af2 clonal complex of M. bovis have, in general, four or more copies of the insertion sequence IS6110, in contrast to the majority of M. bovis strains isolated from cattle, which are thought to carry only one or a few copies.

Desenvolvimento de um sistema de Data Warehousing para a consolidação da informação num grupo empresarial

Pretende-se desenvolver um Data Warehouse para um grupo empresarial constituído por quatro empresas, tendo como objectivo primordial a consolidação de informação. A consolidação da informação é de extrema utilidade, uma vez que as empresas podem ter dados comuns, tais como, produtos ou clientes. O principal objectivo dos sistemas analíticos é permitir analisar os dados dos sistemas transacionais da organização, fazendo com que os utilizadores que nada percebem destes sistemas consigam ter apoio nas tomadas decisão de uma forma simples e eficaz. A utilização do Data Warehouse é útil no apoio a decisões, uma vez que torna os utilizadores autónomos na realização de análises. Os utilizadores deixam de estar dependentes de especialistas em informática para efectuar as suas consultas e passam a ser eles próprios a realizá-las. Por conseguinte, o tempo de execução de uma consulta através do Data Warehouse é de poucos segundos, ao contrário das consultas criadas anteriormente pelos especialistas que por vezes demoravam horas a ser executadas. __ ABSTRACT: lt is intended to develop a Data Warehouse for a business related group of four companies, having by main goal the information consolidation. This information consolidation is of extreme usefulness since the companies can have common data, such as products or customers. The main goal of the analytical systems is to allow analyze data from the organization transactional systems, making that the users that do not understand anything of these systems may have support in a simple and effective way in every process of taking decisions. Using the Data Warehouse is useful to support decisions, once it will allow users to become autonomous in carrying out analysis. Users will no longer depend on computer experts to make their own queries and they can do it themselves. Therefore, the time of a query through the Data Warehouse takes only a few seconds, unlike the earlier queries created previously by experts that sometimes took hours to run.

Diagnostic value of soluble CD14 subtype (sCD14-ST) presepsin for the postmortem diagnosis of sepsis-related fatalities.

The first aim of this study was to assess the diagnostic performance of presepsin (sCD14-ST) in postmortem serum from femoral blood compared to procalcitonin (PCT) to detect sepsis-related fatalities. The second aim was to compare sCD14-ST levels found in postmortem serum to the values in pericardial fluid to investigate the usefulness of the latter as an alternative biological fluid. Two study groups were formed, a sepsis-related fatalities group and a control group. Radiology (unenhanced CT scans and postmortem angiographies), autopsies, histology, neuropathology, and toxicology as well as other postmortem biochemistry investigations were performed in all cases. Microbiological investigations on right cardiac blood were carried out exclusively in septic cases. The results of this study indicated that postmortem serum PCT and sCD14-ST levels, individually considered, allowed septic cases to be identified. Even though increases in both PCT and sCD14-ST concentrations were observed in the control cases, coherent PCT and sCD14-ST results in cases with suspected sepsis allowed the diagnosis to be confirmed. Conversely, no relevant correlation was identified between postmortem serum and pericardial fluid sCD14-ST levels in either the septic or control groups.

How many diagnosis fields are needed to capture safety events in administrative data? Findings and recommendations from the WHO ICD-11 Topic Advisory Group on Quality and Safety

OBJECTIVE: As part of the WHO ICD-11 development initiative, the Topic Advisory Group on Quality and Safety explores meta-features of morbidity data sets, such as the optimal number of secondary diagnosis fields. DESIGN: The Health Care Quality Indicators Project of the Organization for Economic Co-Operation and Development collected Patient Safety Indicator (PSI) information from administrative hospital data of 19-20 countries in 2009 and 2011. We investigated whether three countries that expanded their data systems to include more secondary diagnosis fields showed increased PSI rates compared with six countries that did not. Furthermore, administrative hospital data from six of these countries and two American states, California (2011) and Florida (2010), were analysed for distributions of coded patient safety events across diagnosis fields. RESULTS: Among the participating countries, increasing the number of diagnosis fields was not associated with any overall increase in PSI rates. However, high proportions of PSI-related diagnoses appeared beyond the sixth secondary diagnosis field. The distribution of three PSI-related ICD codes was similar in California and Florida: 89-90% of central venous catheter infections and 97-99% of retained foreign bodies and accidental punctures or lacerations were captured within 15 secondary diagnosis fields. CONCLUSIONS: Six to nine secondary diagnosis fields are inadequate for comparing complication rates using hospital administrative data; at least 15 (and perhaps more with ICD-11) are recommended to fully characterize clinical outcomes. Increasing the number of fields should improve the international and intra-national comparability of data for epidemiologic and health services research, utilization analyses and quality of care assessment.

Health-related quality of life in patients with dual diagnosis: clinical correlates

Background: Although the studies published so far have found an affectation in the Health Related Quality of Life (HRQOL) in both psychiatric and substance use dependence disorders, very few studies have applied HRQOL as an assessment measure in patients suffering both comorbid conditions, or Dual Diagnosis. The aim of the current study was to assess HRQOL in a group of patients with Dual Diagnosis compared to two other non-comorbid groups and to determine what clinical factors are related to HRQOL. Methods: Cross-sectional assessment of three experimental groups was made through the Short Form 36 Item Health Survey (SF-36). The sample consisted of a group with Dual Diagnosis (DD; N=35), one with Severe Mental Illness alone (SMI; N=35) and another one with Substance Use Dependence alone (SUD; N=35). The sample was composed only by males. To assess the clinical correlates of SF-36 HRQOL, lineal regression analyses were carried out. Results: The DD group showed lower scores in most of the subscales, and in the mental health domain. The group with SUD showed in general a better state in the HRQOL while the group with SMI held an intermediate position with respect to the other two groups. Daily medication, suicidal attempts and daily number of coffees were significantly associated to HRQOL, especially in the DD group. Conclusions: The DD group showed lower self-reported mental health quality of life. Assessment of HRQOL in dual patients allows to identify specific needs in this population, and may help to establish therapeutic goals to improve interventions.

The impact of late diagnosis on the survival of patients following their first AIDS-related hospitalization in Belo Horizonte, Brazil

The purpose of this study is to estimate the survival probability of patients following their first admission for the treatment of AIDS to an infectious disease reference hospital in Belo Horizonte, Brazil, during 2005. Study subjects were monitored during a 12-month period to identify factors associated with survival probability. Late diagnosis was recorded among many of the 250 study subjects: almost half (44.8%) were diagnosed less than 30 days prior to or during their hospitalization. A high mortality rate was also detected: 39.6% of the subjects died during the 12 months of monitoring. The cumulative survival probability of the cohort group was estimated at 68.0% after 3 months and at 61.2% after 12 months. However, certain patient subgroups analyzed had even lower cumulative survival probabilities after 12 months of monitoring: if diagnosed during hospitalization, it was estimated at only 48.0% and those with no record of antiretroviral treatment had a 48.5% cumulative survival probability. Patients with severe anemia had the lowest survival probability, similar among the two lymphocyte count groups (<1000 mm(3) and >= 1000 mm(3)), the former with a 45.5% survival probability and the latter with a 46.7% one. The proportional death risk was 2.5-fold higher for men residing in other area than the capital city of the State of Minas Gerais and greater metropolitan region when compared with women residing there. The findings of this study highlight the importance of early diagnosis for predicting patient survival and reinforce the necessity off acilitating HIV diagnosis.

A rapid ELISA for the diagnosis of intravascular catheter related sepsis caused by coagulase negative staphylococci

Aim: To develop and evaluate a rapid enzyme linked immunosorbent assay (ELISA) for the diagnosis of intravascular catheter related sepsis caused by coagulase negative staphylococci. Methods: Forty patients with a clinical and microbiological diagnosis of intravascular catheter related sepsis and positive blood cultures, caused by coagulase negative staphylococci, and 40 control patients requiring a central venous catheter as part of their clinical management were recruited into the study. Serum IgG responses to a previously undetected exocellular antigen produced by coagulase negative staphylococci, termed lipid S, were determined in the patient groups by a rapid ELISA. Results: There was a significant difference (p = < 0.0001) in serum IgG to lipid S between patients with catheter related sepsis and controls. The mean antibody titre in patients with sepsis caused by coagulase negative staphylococci was 10 429 (range, no detectable serum IgG antibody to 99 939), whereas serum IgG was not detected in the control group of patients. Conclusions: The rapid ELISA offers a simple, economical, and rapid diagnostic test for suspected intravascular catheter related sepsis caused by coagulase negative staphylococci, which can be difficult to diagnose clinically. This may facilitate treatment with appropriate antimicrobials and may help prevent the unnecessary removal of intravascular catheters.

National Institutes Of Health Consensus Development Project On Criteria For Clinical Trials In Chronic Graft-versus-host Disease: I. The 2014 Diagnosis And Staging Working Group Report.

The 2005 National Institutes of Health (NIH) Consensus Conference proposed new criteria for diagnosing and scoring the severity of chronic graft-versus-host disease (GVHD). The 2014 NIH consensus maintains the framework of the prior consensus with further refinement based on new evidence. Revisions have been made to address areas of controversy or confusion, such as the overlap chronic GVHD subcategory and the distinction between active disease and past tissue damage. Diagnostic criteria for involvement of mouth, eyes, genitalia, and lungs have been revised. Categories of chronic GVHD should be defined in ways that indicate prognosis, guide treatment, and define eligibility for clinical trials. Revisions have been made to focus attention on the causes of organ-specific abnormalities. Attribution of organ-specific abnormalities to chronic GVHD has been addressed. This paradigm shift provides greater specificity and more accurately measures the global burden of disease attributed to GVHD, and it will facilitate biomarker association studies.

Transcutaneous Tibial Nerve Stimulation In The Treatment Of Lower Urinary Tract Symptoms And Its Impact On Health-related Quality Of Life In Patients With Parkinson Disease: A Randomized Controlled Trial.

A randomized controlled trial study was performed to evaluate the efficacy of transcutaneous tibial nerve stimulation (TTNS) and sham TTNS, in patients with Parkinson disease (PD) with lower urinary tract symptoms (LUTS). Randomized controlled trial. Thirteen patients with a diagnosis of PD and bothersome LUTS were randomly allocated to one of the following groups: Group I: TTNS group (n = 8) and group II: Sham group (n = 5). Both groups attended twice a week during 5 weeks; each session lasted 30 minutes. Eight patients received TTNS treatment and 5 subjects allocated to group II were managed with sham surface electrodes that delivered no electrical stimulation. Assessments were performed before and after the treatment; they included a 3-day bladder diary, Overactive Bladder Questionnaire (OAB-V8), and the International Consultation on Incontinence Quality of Life Questionnaire Short Form (ICIQ-SF), and urodynamic evaluation. Following 5 weeks of treatment, patients allocated to TTNS demonstrated statistically significant reductions in the number of urgency episodes (P = .004) and reductions in nocturia episodes (P < .01). Participants allocated to active treatment also showed better results after treatment in the OAB-V8 and ICIQ-SF scores (P < .01, respectively). Urodynamic testing revealed that patients in the active treatment group showed improvements in intravesical volume at strong desire to void (P < .05) and volume at urgency (P < .01) when compared to subjects in the sham treatment group. These findings suggest that TTNS is effective in the treatment of LUTS in patients with PD, reducing urgency and nocturia episodes and improving urodynamic parameters as well as symptom scores measured by the OAB-V8 and health-related quality-of-life scores measured by the ICIQ-SF.

Novel Spotted Fever Group Rickettsiosis, Brazil

We report a clinical case of spotted fever group rickettsiosis acquired in Sao Paulo, Brazil, Definitive diagnosis was supported by seroconversion between acute-phase and convalescent-phase serum samples. Molecular analysis of skin samples indicated the agent was a novel spotted fever group strain closely related to Rickettsia africae, R. parked, and R. sibirica.

Gender-related symptoms and correlates of alcohol dependence among men and women with a lifetime diagnosis of alcohol use disorders

This study explored gender-related symptoms and correlates of alcohol dependence in a cross-sectional study of 150 men and 150 women with a lifetime diagnosis of alcohol use disorders (AUD). Participants were recruited in equal numbers from treatment settings, correctional centres and the general community. Standardized measures were used to determine participants' use of substances, history of psychiatric disorders and psychosocial stress, their sensation seeking and family history of substance use and mental health disorders. Multivariate analyses were used to detect patterns of variables associated with gender and the lifetime severity of AUD. Men had a longer history of severe AUD than women. Women had similar levels of alcohol dependence and medical and psychological sequelae as men, despite 6 fewer years of AUD. More women than men had a history of severe psychosocial stress, severe dependence on other substances and antecedent mental health problems, especially mood and anxiety disorders. There were differences in family history of alcohol-related problems approximating same-gender aggregation. The severity of a lifetime AUD was predicted by its earlier age at onset and the occurrence of other disorders, especially anxiety, among both men and women. The limitations in the generalizability of these findings due to sample idiosyncrasies are discussed.

A prognostic score for AIDS-related diffuse large B-cell lymphoma in Brazil

The aim of this study was to evaluate a prognostic score for aids-related lymphoma (ARL). A retrospective study of 104 patients with ARL treated between January 1999 and December 2007 was conducted. Diffuse large B-cell lymphoma (DLBC) was the most observed histological type (79.8%). The median CD4 lymphocyte count at lymphoma diagnosis was 125 cells per microliter. Treatment response could be evaluated in 83 (79.8%) patients, and 38 (45.8%) reached complete remission (CR); overall response rate was 51.8% (95 CI = 38.5-65.1%). After a median follow-up of 48 months, the 4-year overall survival (OS) rate among all patients was 35.8%, with a median survival time of 9.7 months (95% CI = 5.5-13.9 months). The survival risk factors observed in multivariate analysis (previous AIDS and high-intermediate/high international prognostic index (IPI)) were combined to construct a risk score, which divided the whole patient population in three distinct groups as low, intermediate, and high risk. When this score was applied to DLBC patients, a clear distinction in response rates and in OS could be demonstrated. Median disease-free survival (DFS) for patients that achieved CR was not reached, and DFS in 4 years was 83.0%. Our results show that the reduced OS observed could be explained by poor immune status with advanced stage of disease seen in our population of HIV-positive patients. Further studies will be needed to clarify the role of different treatment approaches for ARL in the setting of marked immunosuppression and to identify a group of patients to whom intensive therapy could be performed with a curative intent.