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Hintergrund
Die chronische Nierenkrankheit (CKD) ist eine häufige Erkrankung, insbesondere im höheren Alter. Um der Progression der Erkrankung und deren Komplikationen vorzubeugen, ist eine leitliniengerechte ambulante Versorgung von Patient:innen mit CKD anzustreben. Zur Messung und Bewertung der Versorgungsqualität können Qualitätsindikatoren (QI) genutzt werden. In Deutschland existieren bisher keine QI für CKD. Ziel der Arbeit war die Entwicklung von QI für die Qualitätsüberprüfung der ambulanten Versorgung von Patient:innen über 70 Jahren mit nichtdialysepflichtiger CKD.
Material und Methoden
Auf Grundlage der nationalen S3-Leitlinie CKD und eines Reviews internationaler QI wurde eine Liste von QI erstellt. Die ausgewählten QI wurden in 2 Sets eingeteilt: basierend auf Routinedaten (z. B. Abrechnungsdaten der Krankenkassen) und auf Datenerhebung in der Praxis (Chart-Review). Expert:innen verschiedener Fachrichtungen sowie ein Patient:innenvertreter bewerteten diese in einem Delphi-Verfahren mit 2‑stufiger Onlinebefragung im Oktober 2021 und Januar 2022 und abschließender Konsensuskonferenz im März 2022. Zusätzlich wurden Ranglisten der wichtigsten QI von jedem Set erstellt.
Ergebnisse
Ein Inzidenz- und ein Prävalenzindikator wurden a priori festgelegt und standen nicht zur Abstimmung. Weitere 21 QI standen zur Abstimmung durch die Expert:innen. Für jedes QI-Set wurden die 7 wichtigsten Indikatoren ausgewählt. Nur 1 QI wurde von dem Expert:innenpanel für den zusätzlichen Einsatz bei Erwachsenen unter 70 Jahren als nicht geeignet eingestuft.
Diskussion
Die QI sollen es ermöglichen, die Qualität der ambulanten Versorgung von Patient:innen mit CKD zu untersuchen, mit dem Ziel, die leitlinienkonforme ambulante Versorgung zu optimieren.
The structure and content of the training phase following completion of medical school, referred to in most countries as postgraduate medical training, varies between countries. The purpose of this article is to give national and international readers an overview of the organisation and structure of postgraduate medical training in Germany.
The content and duration of postgraduate training in Germany are stipulated by state medical boards, officially termed associations (Landesärztekammer). In a periodically updated decree, the federal German medical association (Bundesärztekammer) provides a template for postgraduate medical training structure (Musterweiterbildungsordnung), which is adapted by the state medical associations. Admission to postgraduate medical training in Germany takes place by way of open, free-market selection. Based on the traditional assumption that junior doctors acquire all necessary clinical skills “on the job”, formal education in the form of seminars, lectures, or preorganised, detailed rotation plans through various specialties or wards is largely absent. Requirements for postgraduate medical training focus on the fulfilment of broad categories of rotations rather than specific content or gaining competencies. With few exceptions, no structured educational programs with curricular learning objectives exist. Limited funding impedes program development and expansion. Junior doctors bear the primary organisational responsibility in their training, which often results in extended training times and dissatisfaction. Structured training programs which prioritise skill-building and formal education are needed to support junior doctors and ensure their competence in primary and specialty care.
ObjectiveWhole-body MRI (wb-MRI) is increasingly used in research and screening but little is known about the effects of incidental findings (IFs) on health service utilisation and costs. Such effects are particularly critical in an observational study. Our principal research question was therefore how participation in a wb-MRI examination with its resemblance to a population-based health screening is associated with outpatient service costs.DesignProspective cohort study.SettingGeneral population Mecklenburg-Vorpommern, Germany.ParticipantsAnalyses included 5019 participants of the Study of Health in Pomerania with statutory health insurance data. 2969 took part in a wb-MRI examination in addition to a clinical examination programme that was administered to all participants. MRI non-participants served as a quasi-experimental control group with propensity score weighting to account for baseline differences.Primary and secondary outcome measuresOutpatient costs (total healthcare usage, primary care, specialist care, laboratory tests, imaging) during 24 months after the examination were retrieved from claims data. Two-part models were used to compute treatment effects.ResultsIn total, 1366 potentially relevant IFs were disclosed to 948 MRI participants (32% of all participants); most concerned masses and lesions (769 participants, 81%). Costs for outpatient care during the 2-year observation period amounted to an average of €2547 (95% CI 2424 to 2671) for MRI non-participants and to €2839 (95% CI 2741 to 2936) for MRI participants, indicating an increase of €295 (95% CI 134 to 456) per participant which corresponds to 11.6% (95% CI 5.2% to 17.9%). The cost increase was sustained rather than being a short-term spike. Imaging and specialist care related costs were the main contributors to the increase in costs.ConclusionsCommunicated findings from population-based wb-MRI substantially impacted health service utilisation and costs. This introduced bias into the natural course of healthcare utilisation and should be taken care for in any longitudinal analyses.
Frequency of biopsies after the disclosure of incidental findings from whole-body research MRI
(2021)
Large-scale, population-based cohort studies gather a range of data from participants over extended periods of time with the goal of providing researchers with information regarding the health status, prevalence of disease, and risk factors in a regional population. Examinations conducted in the context of population-based studies include imaging and laboratory testing and may yield abnormal results, also called incidental findings. According to predetermined disclosure policies, incidental findings may be disclosed to study participants. Evidence shows that the disclosure of incidental findings results in medical follow-up as research participants and their physicians seek to clarify the significance of findings.
This work examined the effect of disclosing incidental findings from whole-body MRI (wb-MRI) on the frequency and organ system of biopsies in participants in the Study of Health in Pomerania (SHIP), a population-based cohort study in Mecklenburg-West Pomerania. As most of the incidental wb-MRI findings involved unclear masses and lesions, we hypothesized that the disclosure of wb-MRI findings would lead to an increase in diagnostic biopsies. Based on current data showing that the outcomes of incidental imaging findings are frequently clinically irrelevant, we further hypothesized that an increase in biopsies would not translate to a clinically relevant increase in diagnoses of malignancies. We also took disclosed laboratory findings into account, as they were disclosed to all SHIP participants and may play a role in the decision to pursue a biopsy.
We found that the rate of biopsies increased after participation in SHIP and disclosure of incidental MRI and laboratory findings. Overall, most biopsies showed nonmalignant findings, indicating likely overdiagnosis and overtesting resulting from the disclosure of incidental findings in our cohort. However, subgroups of participants with disclosed MRI findings had a higher proportion of biopsies revealing premalignant or malignant diagnoses after SHIP, indicating that the applied decision rules for disclosure of MRI findings led to the identification of individuals with an elevated risk for premalignant or malignant diagnoses. The clinical relevance of these diagnoses is unclear and overdiagnosis cannot be ruled out.
In summary, we recommend more restrictive disclosure policies for incidental imaging findings in research to protect research participants from overtesting and to reduce bias. Further studies regarding the long-term morbidity and mortality of participants are needed to better understand the therapeutic impact of the disclosure of incidental wb-MRI findings in the research setting.