Quality of Service im Internet: Eine ökonomische Analyse (German Edition)

This encompasses not only the mastery of operating techniques, but also a comprehensive knowledge of the interdisciplinary treatment of patients with breast cancer. A further urgent problem in advanced clinical training is the distribution by gender.

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This problem is particularly acute in relation to gynaecology. In a survey carried out by the DGGG involving responses, the cause was revealed to be the lack of scope for harmonising family and work life e. Consequently, the majority of female clinicians prefer to work in general practice The fact is that education, advanced training and ongoing training in our discipline needs to be improved and stepped up, as we shall otherwise be faced with a huge lack of specialists — both in terms of numbers and in terms of quality. Besides the campaigning of the professional association for better funding new, resource-saving concepts for communicating knowledge and skills need to be developed and evaluated in the context of health services research.

In the field of oncological care and quality assurance much has changed in recent years. These changes, such as care in certified structures, an expansion of quality assurance measures, the development of guidelines, etc. Below, these changes will be explained using the example of patients with breast cancer to show which changes are transferrable to the structures of other organ entities.

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Although the incidence of breast cancer has risen significantly in the last few decades and continues to do so, mortality rates have fallen. This can only be convincinly presented, however, if data from clinical and epidemiological cancer registers are made available and sufficient levels of follow-up are possible, as patients can be lost to follow-up, especially those in remission, and therefore this may indicate a poorer quality of treatment and not in fact reflect reality Consequently, causes for these developments can be analysed and positive influencing factors stepped up — this is a significant, if not in fact the most important, aspect of health services research.

The use of hormone replacement therapy in recent years and improved early detection are regarded as possible reasons for the upward trend. This will only be measurable, however, if the implementation of these new structures and innovations is accompanied by health services research-related projects. Guideline-compliant treatment, however, also requires compliance on the part of the patient. The patient needs to play her part in every recommended treatment option.

Consequently, the adequate communication of information and shared decision-making are essential. Patients are also the most important factor when it comes to establishing certified centres. An awareness of the role — as well as the presence — of a certified centre is a key requirement for their implementation.

This can be evaluated through health services research. In a study involving patients, no fewer than Compared to obstetric patients, receiving treatment in a specialist centre was seven times more important for oncology patients — a highly significant figure. Incidence of and mortality from breast cancer, trend from to , number of diagnoses and deaths in A further reduction in mortality, as well as optimisation of the care of oncology patients, can be expected from the introduction of the National Cancer Plan Fig.

In view of the high incidence of breast cancer, this subject plays a key role in shaping the care of women with cancer and therefore the National Cancer Plan. Areas of focus in this context include the further development of oncology care in certified structures, along with a clear definition of these Fig.

The objective here is to define organ-specific such as the breast or ovary but also multi-organ such as psycho-oncology, supportive measures, palliative medicine and pain management approaches in order to implement transparent standards of care and also to further develop existing guidelines. An informative oncology quality reporting system is also being promoted for service providers, decision makers and patients, with particular support for clinical cancer registers.

Adequate documentation systems will ensure a high quality of documentation and data, which on the one hand will relieve the pressure on certified organ cancer centres which expend considerable staffing resources to achieve the figures required in the survey sheets and which, on the other hand, will comprehensively stratify the progress of the disease not only in terms of mortality, but also in terms of such parameters as recurrence and metastatic disease. Proving the benefit of certified structures based on outcome quality will enable a determination of the cost effectiveness of these structures and funding then requested on the basis of adequate data.

Until now there has been no definitive evidence that a certified breast centre is able to achieve a better outcome quality independently of other influencing factors or propose an independent parameter for the prognosis of breast cancer. It is here that health services research can help.

Recently, the highly significant proof of mortality figures in relation to an improvement in mortality figures was published in Middle Franconia The data from patients with breast cancer from three certified centres and 18 further non-certified treatment units was examined with the help of the Erlangen-Nuremberg Tumour Centre to determine whether care in a certified breast centre offers a better survival prognosis. National Cancer Plan Definition of cancer centres Aftercare is an important topic, not least in relation to oncology care.

The optimisation of aftercare, in particular compliance with participation in recommended investigatory procedures, remains a challenge Health services research can also help here In the control group, higher QALYs were achieved 1. This means that the more intensive system was definitely not cost effective and therefore cannot be recommended. These data emphasise the need for health economics evaluations for the case of more intensive support programmes, as not every approach is necessarily effective.

Drug therapies in particular are associated with enormous costs and are therefore ideal for health economics evaluations. The financial pressure is also underscored by the new law on the restructuring of the medicines market AMNOG Oncology preparations, such as anti-hormone treatments, chemotherapies, targeted therapies and supportive medications, account for a significant part of these costs.

Rarely, however, are these integrated into health services research and health economics, although this could be of considerable benefit As an example, we mention drug therapy for patients with breast cancer. One key element of health economics considerations concerns the endocrine therapies employed in adjuvant therapy for patients with hormone receptor-positive breast cancer The five-year prevalence of all women with breast cancer over the age of 50, i.

This corresponds to nearly half a per cent of the female population over the age of In view of the high proportion of women and taking account of the long duration of endocrine therapy at least five years and including extended adjuvants up to 10 years , it is perfectly understandable that the benefits of endocrine therapy need to be weighed against the risks and costs from the perspective of the healthcare system The benefits of aromatase inhibitor therapy are well documented and are also supported by current publications, such as the effectiveness of letrozole in accordance with the results of the BIG study Health economics is useful for weighing advantages and costs, including quality of life, in the equation.

In the Health Technology Assessment HTA programme published a meta-analysis of the available economic analyses of the aromatase inhibitors letrozole, anastrozole and exemestane compared with tamoxifen. Aromatase inhibitors were consequently evaluated as cost-effective therapy. This is also reflected in the prescribing behaviour in Germany. Regional differences were only slight. A significantly higher incidence of gynaecological events was found with tamoxifen Endocrine therapies are only as good as the manner in which they are used.

As a result, investigating compliance with drug therapies is an important element of health services research. During follow-up therapy, a detailed investigation of the issue of compliance with endocrine therapies is required, bearing in mind the predictors described above, while possible reasons for early discontinuation, e.

Compliance also needs to be improved by prescribing larger package sizes as well as a reduction in contributions from patients with chronic diseases through cost bearers which, given the possible economic damage caused by follow-on costs, are marginal for the company involved. One major deficit for health economics analyses is the lack of data in respect of costs in metastasis situations, which can generally only be estimated.

Using a retrospective health economics analysis, women were identified with a median age of The highest costs occurred in the outpatient sector. It is clear that endocrine therapies must be given priority as long as possible and wherever available — not just in light of the quality of life they bring, but also in view of their relevance to the health economy. A significant rise in costs is also seen with the increasing use of targeted therapies. The development of targeted therapies for patients with a triple-negative breast cancer is also of scientific interest An interesting meta-analysis of 75 pharmaco-economic studies of targeted therapies e.

The studies, which were financed by pharmaceutical companies, showed a significantly more frequent cost-effective result 87 vs. Even the alleged conflicts of interests of the authors were associated with a positive outcome 78 vs. As with all types of studies, it is necessary to examine the funding of the project, even in the case of health economics studies. Whereas modern supportive therapies may in some cases be associated with high costs, the prevention of side effects, along with their associated cost-intensive management, can save resources.

The personalisation of supportive therapy, for example anti-emetics, may also increase its cost effectiveness,. A cost saving of Health services research and health economics evaluations focus on structural issues or drug therapies which are mostly, by their very nature, very cost-intensive. This is also apparent from the new law on prescribing drugs AMNOG , which particularly deals with the approval of drug therapies Research into surgical treatment tends to be neglected.

Abstract (Deutsch)

This is regrettable, as major surgical procedures require the provision of high levels of personnel and material resources and enormous potential exists for optimising cost effectiveness. Internationally, interesting work is being carried out in this field. In a multi-centre, randomised study involving 21 Dutch hospitals, laparoscopic hysterectomy TLH was compared with open abdominal hysterectomy TAH in relation to complication rates and the associated costs in patients with endometrial adenocarcinoma of the uterus stage I or complex atypical hyperplasia The TLH had a lower complication rate 2.

On this basis, they concluded that the TLH was a safe and, in particular, cost-effective option for patients with early-stage endometrial carcinoma from the perspective of the healthcare industry. Health economics studies are also available from Germany. In this case, not only were personnel and material costs taken into account, but the services of other institutions were also documented and included into the calculation. The staffing costs alone accounted for one third of the total costs. Although the inpatient stay was shorter for laparoscopic operations 5. Added to this are the costs of procedure-specific, specialist endoscopic instruments e.

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