Failure In Germany Research Articles

The Failure of Germany's Memory Culture

ABSTRACT: In the months since October 7, people around the world have looked on in horror as Germany has wielded the memory of the Holocaust to silence criticism of Israel's war on Gaza. The German government's response to the conflict itself has not been all that different from that of the United States: both have increased their supply of weapons to Israel and supported Israel against South Africa in the International Court of Justice. But Germany has gone much further than the United States in persecuting protesters, artists, and intellectuals expressing sympathy for and solidarity with the Palestinian people. It wields its responsibility for a barely distant genocide as a kind of moral authority.

Impact of the COVID-19 pandemic on implementation of novel guideline-directed medical therapies for heart failure in Germany: a nationwide retrospective analysis.

Guideline-directed medical therapy (GDMT) is the cornerstone in the treatment of patients with heart failure and reduced ejection fraction (HFrEF) and novel substances such as sacubitril/valsartan (S/V) and sodium-glucose co-transporter-2 inhibitors (SGLT2i) have demonstrated marked clinical benefits. We investigated their implementation into real-world HF care in Germany before, during, and after the COVID-19 pandemic period. The IQVIA LRx data set is based on ∼80% of 73 million people covered by the German statutory health insurance. Prescriptions of S/V were used as a proxy for HFrEF. Time trends were analysed between Q1/2016 and Q2/2023 for prescriptions for S/V alone and in combination therapy with SGLT2i. The number of patients treated with S/V increased from 5260 in Q1/2016 to 351,262 in Q2/2023. The share of patients with combination therapy grew from 0.6% (29 of 5260) to 14.2% (31,128 of 219,762) in Q2/2021, and then showed a steep surge up to 54.8% (192,429 of 351,262) in Q2/2023, coinciding with the release of the European Society of Cardiology (ESC) guidelines for HF in Q3/2021. Women and patients aged >80 years were treated less often with combined therapy than men and younger patients. With the start of the COVID-19 pandemic, the number of patients with new S/V prescriptions dropped by 17.5% within one quarter, i.e., from 26,855 in Q1/2020 to 22,145 in Q2/2020, and returned to pre-pandemic levels only in Q1/2021. The COVID-19 pandemic was associated with a 12-month deceleration of S/V uptake in Germany. Following the release of the ESC HF guidelines, the combined prescription of S/V and SGLT2i was readily adopted. Further efforts are needed to fully implement GDMT and strengthen the resilience of healthcare systems during public health crises. Supported by Novartis Pharma GmbH, Nuremberg, Germany.

Organization and quality of care in patient-sharing networks

Healthcare systems seek to provide continuous and coordinated care of high quality. However, patient pathways in the ambulatory sector may differ and result in various provider units. Our aim was to analyze whether health outcomes and the quality of care differ between different types of patient-sharing physician networks. We analyzed administrative data on patients with diagnosed heart failure in Germany. We investigated distinct networks of ambulatory physicians by using a modular-based optimization algorithm and characterized each network as having either a key physician at its center or some other kind of configuration. We subsequently conducted multilevel regression analyses to estimate the impact a network's configuration has on hospitalization rates and guideline-based process indicators. We identified 1,847 networks, of which 27% had a key physician at their center. Compared to physician networks with other configurations, networks that had a key physician at their center were associated in our regression analysis with (a) somewhat lower hospitalization rates, and (b) heart failure treatment that was more frequently in concordance with the German national treatment guideline. Organizing healthcare for people with chronic disease into units that have a key physician at their center and include the relevant specialists may foster treatment that is effective and of higher quality.

Nemačka u multipolarnom svetu i strateške opcije Srbije

The paper analyzes the position of the Federal Republic of Germany in international relations today and based on that policy, possible guidelines for the Republic of Serbia in its strategic actions in the upcoming period are given. The first goal of the research was to consider the relationship of official Berlin to the European Union, the United States, Russia, China and the rest of the world. Berlin's tendency to further strengthen the institutions, monetary, foreign and defense policy of the European Union has been present for decades. However, since 2008, that policy has been going through constant challenges. The Greek debt crisis, Brexit, the migrant crisis, the recession, a new wave of debts by European countries due to the Covid-19 pandemic and the war in Ukraine have put the authorities in Berlin in a difficult position. The failure of Germany and France to establish a unified EU security policy, the impossibility of peace initiatives around Ukraine and the consistent monitoring of Washington's policy have limited the EU ability to project power in other parts of the world. In addition to Russia, it is also obvious that the growing antagonism towards the People's Republic of China has been noticed recently, which threatens to affect very good economic relations The second goal of the paper is to offer Serbia's strategic options based on global trends, and in the context of German policy towards the Western Balkans. The Serbian focus on the European integration and the proclaimed policy of neutrality with a strong commitment to the European peace can be an incentive for joint affairs of the two countries. Particularly problematic is Berlin's attitude towards the self-proclaimed independence of the interim institutions in Prishtina. The opposing positions of Germany and Serbia, however, can be attributed to various regional initiatives such as the Berlin Process and particularly the Open Balkans. The attempts to further escalate the conflict or confrontation of Serbia towards the environment would adversely affect the position of Serbs in the surrounding countries and would also weaken economic exchange, which is traditionally oriented towards the European countries. However, official Belgrade should also work on strengthening internal capacities, primarily defensive, economic, administrative and demographic, so that it can have a high level of readiness in case of possible challenges.

Impact of cardiac amyloidosis on outcomes of patients hospitalized with heart failure in Germany

Abstract Background Amyloidosis is a multi-systemic disease resulting from deposition of misfolded proteins as insoluble fibrils in the interstitium of affected organs including the heart, subsequently leading to organ failure. Cardiac involvement is predominantly observed in light chain (AL) amyloidosis and wild-type transthyretin (ATTRwt) amyloidosis. Purpose We aimed to investigate prevalence and prognostic implications of cardiac amyloidosis of any etiology on outcomes of hospitalized patients with heart failure (HF) in Germany. Methods We analyzed data of the German nationwide inpatient sample (2005–2018) of patients hospitalized for HF (including myocarditis with HF and heart transplantation with HF). HF patients with amyloidosis (defined as cardiac amyloidosis [CA]) were compared with those HF patients without amyloidosis and impact of CA on outcomes was assessed (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2018, and own calculations). Results During this fourteen-year observational period 5,478,835 hospitalizations of HF patients were analyzed. Amyloidosis was coded in 5,407 hospitalizations of HF patients (0.1%). Prevalence of CA was 1.87 hospitalizations per 100,000 German population. CA patients were younger (75.0 [IQR 67.0/80.0] vs. 79.0 [72.0–85.0] years, p<0.001), predominantly male (68.9%) and had a higher prevalence of cancer (14.8% vs. 3.6%, P<0.001) compared with HF without amyloidosis. Although patients without amyloidosis had a pronounced cardiovascular risk profile -especially arterial hypertension (45.4% vs. 35.6%; p<0.001) and diabetes mellitus (38.9% vs. 18.5%; p<0.001)- and a higher prevalence of concomitant coronary artery disease (40.5% vs. 34.5%; p<0.001) and chronic obstructive pulmonary disease (17.1% vs. 9.4%; p<0.001), adverse in-hospital events including necessity of transfusions of blood constituents (7.1% vs. 5.4%, p<0.001) and cardio-pulmonary resuscitation (CPR, 2.7% vs. 1.4%; p<0.001) were more frequent in CA. CA was independently associated with acute kidney failure (OR 1.40 [95% CI 1.28–1.52], p<0.001), CPR (OR 1.58 [95% CI 1.34–1.86], p<0.001), intracerebral bleeding (OR 3.13 [95% CI 1.68–5.83], p<0.001) and in-hospital mortality in the 6th and 8th decade of life (6thdecade: OR 1.40 [95% CI 1.01–1.94], p=0.042; 8thdecade: OR 1.18 [95% CI 1.03–1.35], p=0.02). Conclusions CA was identified as an independent risk factor for complications and in-hospital mortality in HF patients. Physicians should be aware of this issue concerning treatments and monitoring of CA-patients. Funding Acknowledgement Type of funding sources: None.

Impact of a telemonitoring intervention in patients with chronic heart failure in Germany: A difference-in-difference matching approach using real-world data

Introduction The aim of this study was to evaluate the effects of a non-invasive telemonitoring intervention on mortality, healthcare costs, and hospital and pharmaceutical utilisation in patients with chronic heart failure (CHF) of a large statutory health insurer in Germany. Methods In a retrospective observational cohort study using real-world data, we assessed differences between 635 patients who received a telemonitoring intervention versus 635 receiving usual care covering 36 months after intervention. We used propensity score matching on a set of 102 parameters collected in the 24-month pre-intervention period to correct for observed differences, as well as difference-in-difference (DiD) estimators to account for unobserved differences. We analysed the effect of the intervention for up to three years on (i) all-cause mortality; (ii) costs (i.e. inpatient stays, ambulatory care, pharmaceuticals, and medical aids and appliances); and (iii) healthcare utilisation (i.e. length and number of hospital stays, number of prescriptions). Results DiD estimates suggest lower inpatient costs of the telemonitoring group of up to €1160 (95% confidence interval (CI): –2253 to –69) in year three. Ambulatory care costs increased significantly in all three years up to €316 (95% CI: 1267 to 505) per year. Telemonitoring had a positive effect on survival (hazard ratio = 0.71; 95% CI: 0.51 to 0.99) and increased the number of prescriptions for diuretics. Effects were more prominent for patients with severe CHF. Discussion The study suggests that the telemonitoring intervention led to a significant decrease in mortality and a shift in costs from the inpatient to the ambulatory care sector 36 months after intervention.

Translation and Psychometric Evaluation of the German Version of the Thirst Distress Scale for Patients With Heart Failure.

In patients with chronic heart failure, thirst can be perceived as an intensive and burdensome symptom, which may have a negative impact on patients' quality of life. To initiate thirst-relieving interventions, assessment of thirst and its related distress is essential. At the time of this study, no instrument was available to evaluate thirst distress in patients with heart failure in Germany. The aims of this study were to translate the "Thirst Distress Scale for patients with Heart Failure" (TDS-HF) from English into German and to test validity and reliability of the scale. The English version of the TDS-HF was translated into German. A linguistically and culturally sensitive forward-and-backward translation was performed. Psychometric evaluation included confirmatory factor analysis, reliability in terms of internal consistency, and concurrent validity. Eighty-four hospitalized patients (mean age, 72 ± 10 years; 29% female; mean left ventricular ejection fraction, 36% ± 12%; 62% New York Heart Association functional classes III-IV, 45% on fluid restriction) from an acute care hospital were involved in the study. The item-total correlation ranged from 0.58 to 0.78. Interitem correlations varied between 0.37 and 0.79. Internal consistency was high, with a Cronbach α of 0.89. There was a high correlation between the total score of the TDS-HF and the visual analog scale to assess thirst intensity (r = 0.72, P ≤ .001), and a low correlation with fluid restriction (r = 0.35, P = .002). The evaluation of the German TDS-HF showed satisfactory psychometric properties in this sample. The instrument is usable for further research and additional psychometric testing.

Temporal trends, sex-differences and outcomes of patients hospitalized for heart failure in Germany

Abstract Background Despite remarkable improvements in treatment of cardiovascular disease, heart failure (HF) is still characterized by a high mortality rate. Sex-specific differences in HF have been described, but underlying reasons are widely unexplored. Thus, we aimed to investigate sex differences of patients hospitalized for HF in a nationwide cohort. Methods The nationwide German inpatient sample (2005–2016) was used for this sex-specific analyses. Temporal trends on hospitalizations, mortality, and treatments were analyzed and independent predictors of adverse outcomes identified. Results The present analysis comprises 4,538,977 hospitalizations due to HF (52.0%women) in Germany (2005–2016). Although women were older (median 82 (IQR75–87) vs. 76 (69–82), P<0.001), coronary artery disease (CAD, 50.3% vs. 30.7%, P<0.001) was more prevalent in men, who were more often treated with PCI (3.4% vs. 1.4%, P<0.001) and implantable cardioverter-defibrillator (2.2% vs. 0.5%, P<0.001). In-hospital mortality was significantly lower in men than in women (8.9% vs. 10.2, P=0.001) and was reduced in patients who received PCI or implantation of an ICD. While total numbers of hospitalizations between 2005 and 2016 increased in both men (β-estimate 7185.71 (95% CI 6502.23 to 7869.18), P<0.001) and women (β-estimate 5297.60 (95% CI 4557.37 to 6037.83), P<0.001) as well as almost all comorbid co-conditions, in-hospital mortality rate decreased more distinctly in women (β-estimate −0.41 (95% CI: −0.42 to −0.39), P<0.001) compared to men (β-estimate −0.29 (95% CI: −0.30 to −0.27), P<0.001). Conclusions Interventional treatments of HF were associated with improved outcomes and equally beneficial for both sexes. However, they were more often used in male HF patients, in which CAD is significantly more frequent than in female HF patients. This may explain the higher case fatality rate of HF in females. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Federal Ministry of Education and Research (BMBF)

Healthcare experiences of patients with chronic heart failure in Germany: a scoping review

ObjectivesTo review systematically the past 10 years of research activity into the healthcare experiences (HCX) of patients with chronic heart failure (CHF) in Germany, in order to identify research foci...

No perfect storm for crop yield failure in Germany

Large-scale crop yield failures are increasingly associated with food price spikes and food insecurity and are a large source of income risk for farmers. While the evidence linking extreme weather to yield failures is clear, consensus on the broader set of weather drivers and conditions responsible for recent yield failures is lacking. We investigate this for the case of four major crops in Germany over the past 20 years using a combination of machine learning and process-based modelling. Our results confirm that years associated with widespread yield failures across crops were generally associated with severe drought, such as in 2018 and to a lesser extent 2003. However, for years with more localized yield failures and large differences in spatial patterns of yield failures between crops, no single driver or combination of drivers was identified. Relatively large residuals of unexplained variation likely indicate the importance of non-weather related factors, such as management (pest, weed and nutrient management and possible interactions with weather) explaining yield failures. Models to inform adaptation planning at farm, market or policy levels are here suggested to require consideration of cumulative resource capture and use, as well as effects of extreme events, the latter largely missing in process-based models. However, increasingly novel combinations of weather events under climate change may limit the extent to which data driven methods can replace process-based models in risk assessments.

In-hospital mortality in heart failure in Germany during the Covid-19 pandemic.

AimsThe Covid‐19 pandemic affects care for cardiovascular conditions, but data on heart failure (HF) are scarce. This study aims to analyse HF care and in‐hospital outcomes during the pandemic in Germany.Methods and resultsA total of 9452 HF admissions were studied using claims data of 65 Helios hospitals; 1979 in the study period (13 March 30 April 2020) and 4691 and 2782 in two control periods (13 March to 30 April 2019 and 1 January to 12 March 2020). HF admissions declined compared with both control periods by 29–38%. Cardiac resynchronization therapy was implanted in 0.55% during the study period, 0.32% [odds ratio (OR) 1.66, 95% confidence interval (CI) 0.68–4.04, P = 0.27] in the previous year and 0.43% (OR 1.35, 95% CI 0.64–2.84, P = 0.43) in the same year control. Intensive care treatment was 6.22% during the study period, 4.49% in the previous year (OR 1.46, 95% CI 1.13–1.89, P < 0.01), and 5.27% in the same year control (OR 1.19, 95% CI 0.96–1.49, P = 0.12). Length of hospital stay was 7.0 ± 5.0 days in the study and 7.8 ± 5.6 (P < 0.01) and 7.3 ± 5.1 days (P = 0.07) in the control periods. In‐hospital mortality was 7.0% in the study and 5.5% in both control periods (P < 0.05).ConclusionsDuring the early phase of the Covid‐19 pandemic in Germany, HF treatment pathways seem not to be affected, but hospital stay shortened and in‐hospital mortality increased. As the pandemic continues, this early signal demands close monitoring and further investigation of potential causes.

Temporal trends and predictors of inhospital death in patients hospitalised for heart failure in Germany.

We investigated trends in incidence, case fatality rate, patient characteristics and adverse inhospital events of patients hospitalised for heart failure in Germany. The German nationwide inpatient sample (2005-2016) was used for this analysis. Patients hospitalised due to heart failure were selected for analysis. Temporal trends in the incidence of hospitalisations, case fatality rate and treatments were analysed and predictors of inhospital death were identified. The analysis comprised a total number of 4,539,140 hospitalisations (52.0% women, 81.0% aged ≥70 years) due to heart failure. Although hospitalisations increased from 381 (2005) to 539 per 100,000 population (2016) (β estimate 0.06, 95% confidence interval (CI) 0.06 to 0.07, P < 0.001) in parallel with median age and prevalence of comorbidities, the inhospital case fatality rate decreased from 11.1% to 8.1% (β estimate -0.36, 95% CI -0.37 to -0.35, P < 0.001) and the rate of major adverse cardiovascular and cerebrovascular events (β estimate -0.24, 95% CI -0.25 to -0.23, P < 0.001) decreased from 12.7% to 10.3%. Age 70 years and older (odds ratio (OR) 2.60, 95% CI 2.57 to 2.63, P < 0.001) and cancer (OR 1.93, 95% CI 1.91 to 1.96, P < 0.001) were independent predictors of inhospital death. Hospitalisations for heart failure increased in Germany from 2005 to 2016, whereas the major adverse cardiovascular and cerebrovascular event rate and inhospital case fatality rate decreased during this period despite higher patient age and increasing prevalence of comorbidities.

Cardiac Resynchronisation Therapy in Patients with Moderate to Severe Heart Failure in Germany: A Cost-Utility Analysis of the Additional Defibrillator

BackgroundCardiac resynchronisation therapy (CRT) is a well-established form of treatment for patients with heart failure and cardiac dyssynchrony. There are two different types of CRT devices: the biventricular pacemaker (CRT-P) and the biventricular defibrillator (CRT-D). The latter is more complex but also more expensive. For the majority of patients who are eligible for CRT, both devices are appropriate according to current guidelines. The purpose of this study was to conduct a cost-utility analysis for CRT-D compared to CRT-P from a German payer’s perspective.MethodsA cohort Markov-model was developed to assess average costs and quality-adjusted life-years (QALY) for CRT-D and CRT-P. The model consisted of six stages: one for the device implementation, one for the absorbing state death, and two stages (“Stable” and “Hospital”) for either a CRT device or medical therapy. The time horizon was 20 years. Deterministic and probabilistic sensitivity analyses and scenario analyses were conducted.ResultsThe incremental cost-effectiveness ratio (ICER) of CRT-D compared with CRT-P was €24,659 per additional QALY gained. In deterministic sensitivity analysis, the survival advantage of CRT-D to CRT-P was the most influential input parameter. In the probabilistic sensitivity analysis 96% of the simulated cases were more effective but also more costly.ConclusionsTherapy with CRT-D compared to CRT-P resulted in an additional gain of QALYs, but was more expensive. In addition, the ICER was subject to uncertainty, especially due to the uncertainty in the survival benefit. A randomised controlled trial and subgroup analyses would be desirable to further inform decision making.Electronic supplementary materialThe online version of this article (10.1007/s40258-020-00571-y) contains supplementary material, which is available to authorized users.

Permanent Implantable Cardiac Support Systems

Nearly 1000 permanent ventricular assist devices (VADs) are implanted in patients with severe congestive heart failure in Germany each year. VADs are miniaturized centrifugal pumps that generate continuous blood flow; they are powered and controlled through a cable that passes through the skin. Para- corporeal systems are only rarely implanted, usually in children. In this selective review of the literature, including guidelines and registry data, we discuss the indications, therapeutic effects, and complications of permanently implantable cardiac support systems. The optimal time for VAD implantation cannot be precisely defined. A comparative assessment of the various available systems is not possible, as no randomized trials have been performed on this topic. Registry data indicate that 69% to 81% of patients survive one year after VAD implantation, which is signifi- cantly better than the natural course of (conservatively treated) severe congestive heart failure. The distance patients are able to walk is 129 to 220 m longer at six months, depending on the system implanted. Scores on the EQ-5D health status questionnaire are 28 to 37 points better at six months. The potential severe compli- cations include infection, right-heart failure, hemorrhage, pump thrombosis, stroke, and death. A VAD system can be implanted as an alternative to cardiac transplan- tation or as a bridging treatment until the patient can be listed for transplantation and receive the transplant. Because of the organ s , only a minority of VAD patients ever receive a transplant.

Strategies for Improving Influenza Vaccination Rates in Patients with Chronic Renal Disease.

The influenza vaccination rate among older and chronically ill patients in Germany has declined in the past decade in spite of vaccination campaigns. The influenza vaccination rate among persons with chronic renal disease was studied with the aid of billing data from various Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen, ASHIPs) in Germany. It was tested in a randomized controlled trial whether a written vaccination appeal, sent by physicians to patients, led to an increase in the vaccination rate. It was tested in a further such trial whether the vaccination rate among patients with renal disease could be improved by an appeal for vaccination that was sent by the ASHIPs to the treating nephrologists. Finally, it was also tested in a prospective interventional study whether the vaccination rate could be improved by an appeal for vaccination sent by a health- insurance carrier directly to the patients. In 2012-2017, the vaccination rate among persons with chronically impaired renal function ranged from 41.1% to 46.9%; it ranged from 31.7% to 33.7% in kidney transplant recipients and from 42.7% to 44.7% in dialysis patients. An appeal for vaccination that was sent from physicians to patients raised the vaccination rate by 8.3% in the intervention group compared to the control group (p = 0.03; number needed to treat [NNT]: 13). On the other hand, an appeal for vaccination that was sent to the nephrologists lowered the vaccination rate by 0.8% in the intervention group compared to the control group. Finally, an appeal for vaccination that was sent by the health-insurance fund to the patients raised the vaccination rate by 3.2% (p<0.001; NNT: 32). Fewer than half of all patients with chronic renal failure in Germany are vaccinated against influenza. The vaccination rate was found to be increased only after an appeal for vaccination that was sent directly to the patients. A letter sent to the treating physicians had no positive effect at all.

Can telehealth reduce health care expenditure? A lesson from German health insurance data.

This study analyzes a telemedical program for chronic heart failure in Germany with respect to economic and treatment indicators. The program entails a routine data-based preselection of the insured and specific treatment intensities for low- and high-risk patients. This study complements previous research by considering differentiated end points such as mortality and rehospitalization as well as ambulatory, outpatient, and medication costs to account for potential cost shifts. In addition, different time frames and regional characteristics are dealt with. A difference-in-differences approach accounts for potential self-selection into the voluntary program. Our results challenge the current paradigm of program-induced cost shifting between hospital and ambulatory care. Except for a short-term effect in the lower-risk group, the program is associated with raising hospital admission rates as well as higher costs in all categories, while mortality is significantly reduced. The findings are robust as to various sensitivity checks.

An early analysis of cost-utility of baroreflex activation therapy in advanced chronic heart failure in Germany

BackgroundThis study aimed to evaluate cost-utility of baroreflex activation therapy (BAT) using the Barostim neo™ device (CVRx Inc., Minneapolis, MN, USA) compared with optimized medical management in patients with advanced chronic heart failure (NYHA class III) who were not eligible for treatment with cardiac resynchronization therapy, from a statutory health insurance perspective in Germany over a lifetime horizon.MethodsA decision analytic model was developed using the combination of a decision tree and the Markov process. The model included transitions between New York Heart Association (NYHA) health states, each of which is associated with a risk of mortality, hospitalization, cost, and quality of life. The effectiveness of BAT was projected through relative risks for mortality (obtained by application of patient-level data to the Meta-analysis Global Group in Chronic Heart Failure risk prediction model) and hospitalization owing to worsening of heart failure (obtained from BAT Randomized Clinical Trial). All patients were in NYHA class III at baseline.ResultsBAT led to an incremental cost of €33,185 (95% credible interval [CI] €24,561–38,637) and incremental benefits of 1.78 [95% CI 0.45–2.71] life-years and 1.19 [95% CI 0.30–1.81] quality-adjusted life-years (QALYs). This resulted in an incremental cost-effectiveness ratio of €27,951/QALY (95% CI €21,357–82,970). BAT had a 59% probability of being cost-effective at a willingness-to-pay threshold of €35,000/QALY (but 84% at a threshold of €52,000/QALY).ConclusionsBAT can be cost-effective in European settings in those not eligible for cardiac resynchronization therapy among patients with advanced heart failure.

The Right to Punishment for International Crimes

On October 1, 2002, Magnus Gafgen was taken into custody by the Frankfurt police in connection with the kidnapping of a young boy held for ransom. The police threatened Gafgen with various forms of torture unless he divulged the location of the boy. Gafgen quickly relented and led the police to the boy, who was already dead. Gafgen was convicted of murder and the police were convicted of coercion. However, the district court concluded that the police, though culpable, were not appropriate subjects of punishment. Gafgen, unhappy that his torturers were not punished, filed a case against Germany at the European Court of Human Rights (ECHR), arguing that Germany's failure to punish his torturers violated his human rights. The ECHR concluded that Gafgen was right--the German government was obligated to punish perpetrators of torture, and by failing to do so adequately, Germany violated Gafgen's human rights. The goal of this chapter is to show that the argument in Gafgen is generalizable to other contexts. Although the case arose from a particular procedural posture, there is little reason to suspect that the arguments in Gafgen will not hold for other crimes as well. At the very least, these arguments can be extended, without logical disruption, to other international crimes that states are under a legal obligation to criminalize, such as war crimes, crimes against humanity, and genocide. Moreover, if the structure of these arguments is conceptually sound, in theory they should apply outside of the European context, unless the argument is based on a particular right that is only protected by the European Convention and not by international law. This subtle change in emphasis -- moving from punishment as a license to punishment as a legal requirement -- has profound consequences for the operation of international criminal justice. States and international tribunals are required to punish perpetrators as a matter of human rights law, and their failure to follow through on this obligation violates not just some vague or inchoate ergo omnes obligation, it also violates an obligation owed directly to the victims of that particular atrocity. This applies not just when the perpetrators are not punished at all but also when the perpetrators, like in Gafgen's case, are not punished severely enough.

Treatment of chronic heart failure in Germany: a retrospective database study

BackgroundAdherence to treatment guidelines affects outcomes in patients with chronic heart failure (HF). We investigated patient pathways and treatment patterns for HF in Germany.MethodsThis retrospective study used anonymous healthcare claims data from the German Health Risk Institute on individuals with statutory health insurance. Patients with uninterrupted data from 1 January 2009 to 31 December 2013 or death (whichever occurred first), and ≥2 recorded HF-related diagnoses in 2011, were included. Patients with newly diagnosed HF were identified. Use of treatment patterns recommended by the European Society of Cardiology (2008) and German Nationale VersorgungsLeitlinien (2011) guidelines was evaluated.ResultsOf 123,925 patients with HF, 21.3% were newly diagnosed. Overall, 63.2% of new HF diagnoses were made in the ambulatory setting; 61.6% of these were made by family practitioners and 14.8% by cardiologists. In the ambulatory setting, family practitioners were primarily responsible for treatment; specialists in internal medicine (70.3% cardiologists) were mainly responsible for performing HF-related technical diagnostics. One-fifth (20.9%) of patients received a New York Heart Association (NYHA) classification; 45.1% of these received a guideline-based treatment pattern. Application of the recommended treatment pattern decreased with advancing disease severity (NYHA class IV: 21.1% application) and older age (≥90 years: 28.3% application).ConclusionsFamily practitioners play a key role in the diagnosis and initial treatment of HF in Germany. A substantial proportion of patients do not receive guideline-recommended pharmacotherapy. These findings should be reflected in the planning of national disease management programmes.

PCV4 - High Risk of Depression In Patients with Heart Failure in Germany

PCV4 - High Risk of Depression In Patients with Heart Failure in Germany