Improvements In Care Of People Research Articles

The prevalence of vascular and metabolic complications after lung transplant in people with cystic fibrosis in a Dutch cohort

BackgroundWith improvements in care for people with Cystic Fibrosis (pwCF), total survival after Lung Transplantation (LTx) will be longer. Therefore, this population's up-to-date analysis of late-onset post-transplant metabolic and vascular complications will be more relevant in current clinical practice. MethodsWe studied 100 pwCF who underwent an LTx between 2001 and 2020 at the University Medical Centre Utrecht, the Netherlands. The median age at transplant was 31 years and 55 percent was male. We assessed survival, the prevalence of metabolic complications (diabetes, renal damage, dyslipidemia, and metabolic syndrome), and vascular complications (hypertension, heart rhythm disease, micro-, and macrovascular disease). In addition, differences in risks for developing complications based on sex and overall survival were analyzed. ResultsThe prevalence of macrovascular disease raised to 15.9 percent 15 years post-LTx. The prevalence of diabetes increased from 63 percent at LTx to over 90 percent 15 years post-LTx and the prevalence of dyslipidemia increased from 21 percent to over 80 percent. Survival 1-, 2-, 5-, and 10 years post-transplant were 84, 80, 76, and 58 percent respectively. No significant differences were found based on sex. ConclusionThis study shows that the prevalence of cardiovascular risk factors increases after LTx for CF, potentially leading to major complications. These data emphasize the necessity of regular check-ups for metabolic and vascular complications after LTx with specific attention to renal damage. Early recognition of these complications is crucial and will lead to earlier intervention, which could lead to improved prognosis after lung transplantation.

ANDA-Evaluating Facilitated Feedback Enhancement - a Cluster randomised Trial (ANDA-EFFECT): protocol for a cluster randomised trial of audit feedback augmented with education and support, compared to feedback alone, on acceptability, utility and health outcomes in diabetes centres in Australia

BackgroundPeople living with diabetes must manage a range of factors for optimal control of glycaemia and to minimise the risk of diabetes-related complications. Diabetes practitioners are expected to follow guidelines for the key process of care and clinical outcomes, to help people living with diabetes achieve clinical targets. In Australia, the performance of diabetes centres against guidelines is evaluated by the Australian National Diabetes Audit, an annual clinical audit and feedback activity. Previous work has identified areas for improvement in the feedback provided to participating diabetes centres and suggested additional educational and support resources to assist in using audit feedback for the development of quality improvement activities. This cluster randomised trial will test the acceptability, utility and impact on selected clinical outcomes of the developed study intervention (audit feedback and a tailored educational and peer support cointervention).MethodsTwo-armed cluster randomised trial with Australian Diabetes Centres that participated in the Australian National Diabetes Audit in 2021 as the clusters, stratified by location and type of centre. We aim to recruit 35 diabetes centres in each arm. Both the intervention and control arms will receive an augmented feedback report, accompanied by a partially pre-populated slide deck. In addition, the intervention arm will receive a tailored theory-based intervention designed to address identified, modifiable barriers to utilising and implementing the recommendations from diabetes audit feedback. The co-primary outcomes are (1) HbA1c at the patient level, measured at 6 months after delivery of the intervention, and (2) the acceptability and utility of the augmented feedback and cointerventions at the practitioner level, measured at 3 months after delivery of the intervention.DiscussionThis trial aims to test the effects of systematic development and implementation of theory and evidence-informed changes to the audit feedback delivered to diabetes centres participating in an established national clinical diabetes audit. Potential benefits of improved audit feedback include more optimal engagement with the feedback by end clinical users which, ultimately, may lead to improvements in care for people living with diabetes.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12621000765820. Prospectively registered on June 21, 2021

Epilepsy research in Africa: A scoping review by the ILAE Pediatric Commission Research Advocacy Task Force.

Despite the high prevalence of epilepsy in Africa, evaluation of epilepsy research trends on the continent is lacking. Without establishing effective research, improvement in care for people with epilepsy cannot be effectively strategized or targeted. A scoping review of the peer-reviewed literature on epilepsy from Africa (1989-2019) was conducted. The aim was to understand from this what areas are well researched versus underresearched based on published epilepsy topics. A total of 1227 publications were identified and assessed. A significant increase in publications occurred over the 30 years assessed. African author leadership was evident in most reports. Nine countries had >50 publications identified; the remaining 45 countries had <50 or no publications. Research studies were typically of lower quality (case series and observational studies). Research themes were more focused on clinical epilepsy (descriptive observational studies) and social aspects (qualitative surveys). However, there were a number of unique and strong themes, specifically for neurocysticercosis and nodding syndrome, where strong research collaborations were evident, basic science understandings were explored, and interventional models were established. Despite Africa being the continent with the most countries, it is lacking in the quantity, quality, and for some areas, relevance of research on epilepsy. Targeted approaches are needed to upskill the strength of research undertaken with more basic science, interventional, and randomized controlled studies. Themes of research need to promote those with unique African content but also to align with current international research areas that have impact on care delivery, such as epilepsy surgery and epilepsy genetics. For this to be possible, it is important to strengthen research hubs with collaborations that empower Africa to own its epilepsy research journey.

Severe obesity in a specialist type 2 diabetes outpatient clinic: an Australian retrospective cohort study

BackgroundObesity is a major risk factor for the development of type 2 diabetes (T2DM) and its complications. Significant weight loss has been shown to improve glycaemia in people with T2DM and obesity. National and international guidelines recommend considering bariatric surgery for body mass index (BMI) ≥ 35 kg/m2. We assessed the proportion of people with T2DM meeting criteria for surgery, how many had been offered a bariatric/obesity service referral, and compared the characteristics of people with BMI ≥ 35 kg/m2 and BMI < 35 kg/m2.MethodsRetrospective data were collected for all people with T2DM aged ≥18 years, attending a hospital specialist diabetes outpatient service over three calendar years, 2017–2019.ResultsOf 700 people seen in the service, 291 (42%) had BMI ≥ 35 kg/m2 (the “BMI ≥ 35 group”) and met criteria for bariatric surgery, but only 54 (19%) of them were offered referral to an obesity service. The BMI ≥ 35 group was younger than those with a BMI < 35 kg/m2 (56.1 ± 14.8 vs 61.4 ± 14.6 years, p < 0.001) (mean ± SD), with similar diabetes duration (11.0 ± 9.0 vs 12.3 ± 8.9 years, p = 0.078), and there was no significant difference in initial HbA1c (75 ± 27 vs 72 ± 26 mmol/mol, p = 0.118) (9.0 ± 2.5 vs 8.7 ± 2.4%) or proportion treated with insulin (62% vs 58%). There was more GLP1 agonist use in the BMI ≥ 35 group (13% vs 7%, p = 0.003) but similar rates of SGLT2 inhibitor use (25% vs 21%, p = 0.202). The BMI ≥ 35 group received more new medication and/or dose adjustments (74% vs 66%, p = 0.016). Only 29% in the BMI ≥ 35 kg group achieved HbA1c < 53 mmol/mol (7.0%).ConclusionsIn spite of frequently meeting the criteria for bariatric surgery and not achieving glycaemic targets, people with T2DM in this specialist clinic received limited medical or surgical management of their obesity. This study suggests opportunities for improvement in care of people with T2DM at several levels including increased referrals from T2DM services to weight management/bariatric services, as well as an increased use of GLP1 agonists and SGLT2 inhibitors where appropriate. Our data support the need to prioritise obesity management in the treatment of type 2 diabetes.

Impetus to change: a multi-site qualitative exploration of the national audit of dementia

BackgroundNational audit is a key strategy used to improve care for patients with dementia. Audit and feedback has been shown to be effective, but with variation in how much it improves care. Both evidence and theory identify active ingredients associated with effectiveness of audit and feedback. It is unclear to what extent national audit is consistent with evidence- and theory-based audit and feedback best practice.MethodsWe explored how the national audit of dementia is undertaken in order to identify opportunities to enhance its impact upon the improvement of care for people with dementia. We undertook a multi-method qualitative exploration of the national audit of dementia at six hospitals within four diverse English National Health Service organisations. Inductive framework analysis of 32 semi-structured interviews, documentary analysis (n = 39) and 44 h of observations (n = 36) was undertaken. Findings were presented iteratively to a stakeholder group until a stable description of the audit and feedback process was produced.ResultsEach organisation invested considerable resources in the audit. The audit results were dependent upon the interpretation by case note reviewers who extracted the data. The national report was read by a small number of people in each organisation, who translated it into an internal report and action plan. The internal report was presented at specialty- and organisation-level committees. The internal report did not include information that was important to how committee members collectively decided whether and how to improve performance. Participants reported that the national audit findings may not reach clinicians who were not part of the specialty or organisation-level committees.ConclusionsThere is considerable organisational commitment to the national audit of dementia. We describe potential evidence- and theory-informed enhancements to the enactment of the audit to improve the local response to performance feedback in the national audit. The enhancements relate to the content and delivery of the feedback from the national audit provider, support for the clinicians leading the organisational response to the feedback, and the feedback provided within the organisation.

416-P: Change in Extent of Coronary Artery Disease in People with and without Diabetes Undergoing Coronary Angiography

Objective: To assess whether improvements in preventative care for people with diabetes have resulted in a relative decrease in the burden of coronary artery disease (CAD) compared to people without diabetes. Methods: All patient-level linked coronary angiography and hospital separation data at a large Australian tertiary referral hospital between 2013 and 2019 were obtained. Indication for angiography and extent of CAD were based on original classification by treating cardiologists, classified as no disease, mild, moderate or severe. Propensity scores were estimated to match people with and without diabetes on a 1:1 ratio. Ordinal logistic regression models were fitted to assess trends in CAD severity in people with and without diabetes over time with adjusted odds ratios (adjOR) reported. Results: For 3,016 people identified in the coronary angiography database and matched using propensity scores, 1508(50%) were diagnosed with diabetes. Angiographic evidence of CAD was detected in 1155(77%) and 1257(83%) people without and with diabetes. For people with diabetes there was an increased risk of more extensive CAD in 2018 compared to 2013 (adjOR: 2.02 95% C.I. 1.36, 2.99). This risk appears to have been attenuated in 2019 with no significant change in CAD burden between 2013 and 2019 (adjOR: 1.33 95% C.I. 0.90, 1.98). In contrast, there was no effect of time on CAD burden in people without diabetes. Conclusions: The initial increase in severity of disease burden seen in our study for people with diabetes compared to those without diabetes may represent improved CAD screening rather than suboptimal application of preventative therapies. Possibly, greater recent use of newer glucose lowering medications with cardiovascular protective effects accounts for the attenuation of CAD burden in 2019 for people with diabetes. These findings highlight the importance of aggressive risk factor modification for people with diabetes to minimize the development and progression of CAD. Disclosure K.V. Kiburg: None. A.I. MacIsaac: None. V. Sundararajan: None. R. MacIsaac: None.

Using data to improve the care of people with diabetes across Oxfordshire

AbstractData from GP practices and hospital trusts have long been used to understand the quality of care received by people with diabetes. However, annual data collection is too infrequent to see what difference rapid changes in practice make to diabetes care. We developed a diabetes dashboard modelled on the National Diabetes Audit (NDA), which provided monthly updates on key care components. The data were displayed at both individual GP level as well as at a Locality level (now called primary care network [PCN] level) and clinical commissioning group (CCG) level. Discussion about the dashboard was incorporated into regular GP practice visits by diabetes consultants and community diabetes specialist nurses which occurred twice a year to nearly every GP practice in the CCG. Twice‐yearly Locality meetings also reviewed the data at Locality level and provided a forum for sharing ‘best practice’. Over the last two years significant improvements have been seen, particularly in the achievement of the eight key care processes and the attendance at structured education within one year of diagnosis.The diabetes dashboard has been integral in the improvement of care for people with diabetes in Oxfordshire. It continues to evolve with data now displayed at PCN level and ongoing work to align the dashboard with the NDA coding. The dashboard was most effective when used within the context of supportive clinical engagement.

MyStoma - putting phenomenology into practice

In this paper I will use an example of a person-centered approach to healthcare in action gained from my own experience of coping with serious illness. My overall endeavour will be to show how a philosophical position, based on the phenomenological work of Heidegger and Gadamer, can be effective in the practice of commissioning and providing healthcare and conversely how, in the practice of person-centered healthcare, this philosophical ground is made manifest. First, I give an account of the MyStoma project in East Kent as an example of person-centered care in practice which has led to improvements in care for people with a stoma. The project gives a voice to people who have a stoma and ensures that the care that they receive reflects their own needs as expressed by the service users themselves. The aim of MyStoma is to change the way that people who have a stoma are involved in the development of the services provided to them and to put their needs and expectations at the heart of all decisions made about stoma care services.This is followed by a discussion of how the insights gained from MyStoma can provide lessons for those seeking to engage patients in the development and improvement of services by suggesting that they listen to the first hand accounts, or stories, of those who are ill and use what they hear in the development of Service User Agenda, which can then be used as the basis for service development.Finally I will argue that the success of MyStoma and the primacy it gives to the first hand lived experience of those who are receiving care, rests on a reading of Heidegger’s affirmation of Being-with-Others and his notion of authentic solicitude. By the conclusion of this paper it will be clear that the understanding of the philosophical roots of MyStoma offers the opportunity to extend this successful approach to other care communities based on the understanding of our relationship with Others, like ourselves, as constitutive of our own Being.

Analysis of Casuistry and Results of the Implementation of a Care Programme in Ten Sub-Acute Care Units in Catalonia

Introduction : Several studies show that a high percentage of people admitted to acute care hospitals could be treated in alternative care facilities of less intensity. The hospitalisation of fragile elderly people or people with chronic illnesses can give rise to various complications, as well as represent a high cost in terms of healthcare. In recent years, as an alternative to conventional hospitalisation, a number of new specific units have been set up in intermediate care hospitals in Catalonia: sub-acute care units. Their goal is to guarantee the care continuum with a geriatric rehabilitation approach from the outset, for those multi-pathological elderly patients with decompensation, who call for treatment and control of their pathologies. Sub-acute care becomes an alternative to conventional hospitalisation, with the contribution of interdisciplinary treatment plans to the complex needs of patients with chronic illnesses. They are people that call for patient-centred care, over and above managing the illness. In this setting, the rehabilitation therapies they need can be applied, with an integrated care focus and at a lower cost, in order to achieve improved health outcomes, more rapid functional improvement and with a care continuum process that is better adapted to their needs. Objective : To appraise the improvement in care for people with complex chronic illnesses, in the context of comprehensive and integrated care, through on-going care and an adaptation of resources tailored to patient needs, through the implementation of sub-acute care units in the realm of intermediate care. A sample of 591 cases admitted to eleven sub-acute care units across Catalonia were collected in a defined period of time, from February to March 2015. The care process and its outcomes, as well as their adjustment to the standards established for this resource, were analysed. Methodology : A statistical analysis of the sample endeavours to classify it into different areas that allow us to identify the socio-demographic and epidemiological profile of treated patients, as well as characteristics of the care process and its results. An emphasis has been placed on the analysis of readmissions, the level of dependence upon admission and release (Barthel) and mortality during admission and at six months of care, among other elements. Results : The analysis of the sample has identified that the average age of treated patients is 86 years of age, 63% of whom are women. Thirty-seven per cent of treated patients are complex chronic patients, and 17% are patients with advanced chronic illness. Eighty-two per cent of patients originate from emergency services, 8% from primary healthcare and 6% from nursing homes. The average length of stay is ten days. The most prevalent diagnosis, 55% of cases, involves respiratory illnesses, and 20% account for circulatory system illnesses. The number of readmissions a month after release stands at approximately 20%. The rate of mortality upon release is 18%, and 30% after six months. Conclusions : Sub-acute care units are an alternative to conventional hospitalisation that offer a specific and agile care system for geriatric patients with decompensation treated in emergency services or detected in primary care. Care becomes personalised, treating their many pathologies and their personal and context-based determining factors, which do not require cutting-edge diagnosis or therapy, but rather a stay in a facility with an interdisciplinary, person-centred approach, and where the possibility for functional recovery appropriate for the geriatric patient is offered, which allows them to return to their usual environment in the same or similar functional conditions they had previous to the acute decompensation of their chronic disease.

PWE-030 The Inflammatory Bowel Disease (IBD) Audit Programme at The Royal College of Physcians Reports on 10 Years of Achievements and Demonstrates Improvements in Care Of People with IBD

Introduction The IBD audit programme, first established in 2004 has conducted several rounds of audit. The programme’s aim is to improve the care of people with IBD by; facilitating the collection of key aspects of data on patient care and organisational services, analysing and disseminating the results, providing recommendations for improvements based on the key findings in the analyses. Methods Since 2006 the programme has facilitated up to 4 rounds of data collection on adults and children for inpatient care, organisation of IBD services and administration of biological therapies. We also collected data on patients experiences of care and the provision of care in primary care services. In 2015 the programme team hosted 8 regional workshops and proactively helped hospital IBD teams to develop action plans on key aspects of care that required improvements in their local areas. Results Over the 10 years of the programme’s work - a high level of participation in the audit has been achieved, >90% participation rate from IBD hospital teams across the UK. There have been many improvements in patient care, the most notable since 2006 to date, are a reduction in mortality during admissions, reduction in unplanned surgery, increased patient contact with an IBD nurse, improved rates of prescribing heparin and bone protection. From the biological therapies audit, results clearly demonstrate biological therapies for IBD are effective and safe treatments. Patterns of prescribing are changing with earlier use in patients with less severe disease suggesting doctors have become more familiar with the treatment. Despite the positive improvements, the most recent audit, reported in 2014, identified that there were still aspects of care requiring improvements including treatment of anaemia, access to dietetic support and management of people attending out patient care. Also, the two audits on patient experience between 2010 and 2012 showed no improvements in patient’s experiences of care. The 8 regional workshops hosted in 2015 across the UK proved to be a successful initiative. They were attended by 84 trusts and healthcare boards. 74% of delegates surveyed at 6 months agreed that these had helped them to improve their service. Conclusion 10 years of intensive working and engagement with the IBD community, the programme could not boast of its achievements without acknowledging the support of the community. However further and continued improvements in patient care for people with IBD are necessary. In 2016 the IBD audit programme will be transitioning to the UK IBD Registry. There will be a continued emphasis to help hospital teams to make continued improvements in the quality of care of people with IBD through a number of initiatives. Disclosure of Interest None Declared

Perception of AIDS among health professionals who experienced the epidemic while caring for people with the disease in Florianópolis in the state of Santa Catarina, Brazil (1986-2006)

The scope of this study is to ascertain how the health professionals of a Reference Hospital for Infectious diseases experienced the AIDS epidemic while caring for people with the disease between 1986 and 2006. It involved a qualitative study with a socio-historical approach that used oral history to collect data from twenty-three health professionals. The following categories emerged from the content analysis: a change in profile of the AIDS epidemic; the improvement of care for people with HIV/AIDS; and an improvement in working conditions. The health professionals who experienced the epidemic while caring for patients with the disease perceived how much public health policies on AIDS, with advances and research, led to the consolidation of many laws. It also led to the coordination of health programs aimed at the improvement of services, assistance to people with the disease and ensuring a safer and less tiring work environment.

Doença renal crônica e estado nutricional [Editorial

DOI: http://dx.doi.org/10.15448/1980-6108.2014.1.17317 The support of a multidisciplinary team and the education for healthier habits can increase the ability of patients with chronic kidney disease to cope with the disease and to comply with a hemodialysis program, improving their motivation to adhere to necessary therapeutic and lifestyle interventions. The strategies of the multidisciplinary team should be directed to the needs of patients and must adapt to the resources of the health system in each country; the systematic implementation of these programs can contribute to the improvement in care for people with chronic kidney disease.

Improving care for people living with chronic diseases: Innovative examples from Spain

PurposeMany countries around the world have been undertaking initiatives to promote the improvement of care for people with chronic diseases. The purpose of this article is to showcase some of the innovations developed in Spain, with emphasis on the societal burden of chronicity and the emergent challenge of polypathology.MethodsThe database of the Observatory of Innovative Practices on Complex Chronic Disease Management (known in Spanish as OPIMEC and available at www.opimec.org) was used to identify innovations in Spain. Those that met five requirements were selected for this article. The person in charge of each innovation selected was contacted and asked to provide further information. All data gathered were organized in a similar way to facilitate a better understanding.FindingsSix out of 45 potentially eligible innovations were selected. The innovations are related to strategies, predictive tools, case management, home care and patient education.ConclusionThe innovations showed in this article are breaking ground in the Spanish National Health System. They appear to be improving chronic disease management, while transforming current healthcare delivery models.

Service inequalities remain ‘significant and avoidable’

Report identifies only modest improvements in care for people with learning disabilities, writes Erin Dean

Public health surveillance and data collection: general principles and impact on hemophilia care

Public health surveillance is the ongoing collection, analysis, and dissemination of health related data to provide information that can be used to monitor and improve the health of populations. Such surveillance systems can be established in many settings to study a variety of populations and conditions. The most effective systems are designed around specific, well-defined objectives, collect data in a standardized fashion, analyze the data frequently, and disseminate the results to those who need to know the information. Surveillance has been used to determine the occurrence rates of hemophilia and to characterize the population affected by this rare but potentially serious congenital disorder. Data from surveillance systems have been used to identify risk factors for complications that, once identified, have been modified through public health interventions. The effectiveness of these interventions can be assessed by continued surveillance, thereby assuring improvement in care of people affected by hemophilia around the world.

Quality of after-hours primary care in the Netherlands: adherence to national guidelines

ObjectiveTo assess the quality of after-hours clinical care as delivered by general practitioner (GP) cooperatives in the Netherlands.MethodsA cross-sectional analysis was undertaken of patient health records of five GP cooperatives...

Haemophilia B: impact on patients and economic burden of disease

Worldwide, haemophilia is the most common hereditary bleeding disorder. The incidence of haemophilia B, however, is considerably less than haemophilia A and consequently appears to have received less attention in the research literature. This article aims to summarise the available evidence documenting the patient and economic burden associated with haemophilia B and current methods of disease management. Both the immediate and long-term clinical consequences of haemophilia B can have significant implications for patients in terms of functional limitations and diminished health-related quality of life (HRQOL). Evidence demonstrates that primary prophylaxis is the optimal strategy for replacing missing clotting factor IX (FIX) and managing haemophilia B. Use of recombinant FIX (rFIX) over plasma-derived FIX (pd-FIX) is also generally preferred for safety reasons. Prophylaxis using currently available rFIX products, however, requires a demanding regimen of intravenous infusions 2-3 times a week which may have significant implications for adherence and ultimately the long-term efficacy of such regimens. Only limited assessments of the cost-effectiveness of prophylactic versus on-demand FIX treatment regimens have been conducted to date. Prophylaxis, however, is generally more costly as greater quantities of FIX are consumed. Any reduction in FIX replacement dosing frequency is expected to improve patient adherence and contribute to improved clinical outcomes, further supporting the cost-effectiveness of such interventions. Although a rare disease, as economic constraints for healthcare increase, generating further information regarding the key clinical, patient and economic outcomes associated with haemophilia B will be essential for supporting improvements in care for people with haemophilia B.

The German plan for rare diseases: a development in progress

In the year 2008, the German Federal Ministry of Health initiated a comprehensive study on the topic, “Activities for the improvement of health care for people with Rare Diseases”. The study was motivated by recommendations on Rare Diseases by the European Council of Health Ministers. One important aim of the Council is to develop strategies and plans to improve the situation for patients with Rare Diseases at a national level. In summer 2009, we published the aforementioned study about the situation of people with Rare Diseases in Germany, in which we made recommendations to improve their health care and life situation. One major conclusion was the creation of an institution working on a national plan for Rare Diseases in Germany. In consideration of this result, the German Federal Government announced the foundation of NAMSE (National coalition for people with Rare Diseases) in March 2010. The main purpose of NAMSE is to finalise a German plan for Rare Diseases until the year 2013. Other goals are to concentrate current initiatives and to encourage pilot projects in the field of Rare Diseases. In order to secure the implementation of different perspectives and point of views, NAMSE’s members are the most important stakeholders of the German health care system. This helps to ensure the feasibility of the national plan for Rare Diseases. The constituent meeting will take place in summer 2010. NAMSE is separated into a steering committee, which is the decision and controlling board, and working groups, which provide functional and continual work on particular questions. The activities of NAMSE are patient information/transfer of knowledge, diagnostics and therapy (including development of guidelines), health care and quality assurance, national and European networks of Reference and Expertise Centres, research as well as topics, suggested by the steering committee.

Subjective well-being and ‘male depression’ in male adolescents

Background The concept of male depression is based on the hypothesis that typical symptoms of depression in men often seem to be masked by non-typical male distress symptoms not considered in common depression inventories. Although there is a large amount of clinical evidence, scientific evidence is still lacking. The study aims at further validating the concept of male depression, by obtaining information on symptoms reported by males, and analyzing the dimensional structure of the Gotland Scale of Male Depression [Rutz, W., 1999. Improvement of care for people suffering from depression: The need for comprehensive education. International Clinical Psychopharmacology 14, 27–33.]. Methods A community sample of male adolescents aged 18 ( n = 1004) was asked to complete the WHO-5 Well-being Index [Bech, P., 1998. Quality of life in the psychiatric patient. London: Mosby-Wolfe.] and the Gotland Scale of Male Depression [Rutz, W., 1999. Improvement of care for people suffering from depression: The need for comprehensive education. International Clinical Psychopharmacology 14, 27–33.]. Principal component analysis with promax rotation was calculated to analyze the dimensional structure of the Gotland Scale. Cluster center analyses were used to classify the sample according to the symptoms' characteristics. Results General well-being was rather reduced, and 22% of the respondents were seen to be at risk of male depression. There was no evidence for the hypothesis that young males tend to mask their depressive symptoms with distress symptoms. Depressive and male distress symptoms appeared to be mixed in a dominant factor, while male distress symptoms constitute an additional minor factor. A cluster of 38% of those at risk for depression could be identified who reported significantly elevated male distress symptoms. Irritability turned out to be the single item of the Gotland Scale with the highest item-total correlation. Limitations Risk of depression was not assessed by an additional depression scale or evaluated by a clinical rating. Conclusions Male distress symptoms should be considered when diagnosing depression in men. Further research is needed with respect to comorbidity and differential diagnoses, which should also include bipolar depression.

Gesundheitsökonomische Bewertung von Disease-Management-Programmen

Disease management has become an important element in the improvement of care for people with chronic illnesses and has become embedded in the discussion on health policy in recent years. The approach has been introduced very differently to the health systems worldwide. Since 1 January 2003 accredited disease management programs (DMPs) have been a part of the risk structure compensation scheme of the German statutory health insurance. This is seen as the first step to a morbidity orientation of the risk structure compensation. DMPs have to be evaluated according the German Social Law, especially whether the objectives of the programs and the criteria for inclusion of the patients have been met and the quality of care for the patients is insured. The criteria for evaluation are threefold: medical issues, economic issues and subjective quality of life of the patients. Due to the immense amounts of data which can be expected the evaluation of the German DMPs is a huge logistical challenge. Until now not very much is known about the data quality. The evaluation is focused on the perspective of the sickness funds as e.g. information about indirect cost is not collected. In the article the methods for evaluation are described and critically discussed.