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Hintergrund und Zielsetzung Kostenberechnungen sind ein wesentlicher Bestandteil gesundheitsökonomischer Evaluationen, weisen jedoch für den deutschen Versorgungskontext teilweise große Unterschiede im methodischen Vorgehen auf. Zielsetzung der vorliegenden Artikelserie ist es, einen konsentierten Vorschlag zu den Vorgehensweisen der Kostenberechnungen in verschiedenen Versorgungssektoren zu präsentieren und mit diesem einführenden Artikel allgemeine, Sektoren-unspezifische Aspekte in der Durchführung von Kostenberechnungen zu beschreiben. Methodik In der Arbeitsgruppe „Standardkosten“ des Ausschusses „Ökonomische Evaluation und Entscheidungsfindung“ haben sich Wissenschaftlerinnen und Wissenschaftler von Universitäten und Entscheidungsträgern im Gesundheitswesen zusammengeschlossen, um die bestehenden Probleme bei Kostenberechnungen im Rahmen gesundheitsökonomischer Forschungen zu diskutieren und ein einheitliches Vorgehen zu erarbeiten. Zur Entwicklung der Empfehlungen fanden drei Arbeitstreffen sowie weitere Telefonkonferenzen statt. Die vorläufigen Ergebnisse wurden auf der 11. Jahrestagung der dggö der Fachöffentlichkeit vorgestellt. Ergebnisse Im vorliegenden ersten Artikel einer zunächst fünf Artikel umfassenden Serie werden grundsätzliche Themen der Perspektivwahl, des Preis-Mengengerüstes, der Studienarten, der Kostenkomponenten, der Datenquellen, der Anpassung von Kostendaten über die Zeit oder über Ländergrenzen hinweg sowie der Umgang mit Unsicherheit behandelt und Empfehlungen zu diesen Themen gegeben. Des Weiteren wird die Gliederung von später folgenden vier Artikeln zu den Berechnungsmethoden in einzelnen Versorgungssektoren beschrieben., Background and aim Costing is a crucial component of health economic evaluations, but there is a wide variation in the approaches of calculating costs in the German health care system. This series of articles aims to propose unified costing methods for the different health care sectors while the current article is addressing overarching problems across all sectors. Methods The working group "Standardized Costing" within the committee "Economic Evaluation" of the German Society of Health Economics (dggo) discussed the current problems in the context of costing for health economic evaluation and developed agreed, unified costing approaches for the different health care sectors. The group consisted of researchers from universities and decision-makers in the German health care system and developed the recommendations at three personal meetings and additional telephone conferences. Preliminary results were presented at the 11th annual meeting of the dggo. Results The current paper presents the recommendations regarding perspective, price-resources framework, study types, cost components, data sources, adjustment of cost data over time or cross-country, and uncertainty in cost calculations. Additionally, the general structure of the four following articles on health care sector-specific costing is presented.

Internal rectal prolapse and rectocele are frequent clinical findings in patients with obstructed defecation syndrome (ODS). However, there is still no evidence whether stapled transanal rectal resection (STARR) provides a safe and effective surgical option. Therefore, the German STARR registry was initiated to assess safety, effectiveness, and quality of life.The German STARR registry was designed as an interventional, prospective, multicenter audit. Primary outcomes include safety (morbidity and adverse events), effectiveness (ODS, symptom severity, and incontinence scores), and quality of life (PAC-QoL and EQ-5D) documented at baseline and at 6 and 12 months. Statistical evaluation was performed by an independent research organization of clinical epidemiology.Complete data of 379 patients (78% females, mean age 57.8 years) were entered into the registry database. Mean operative time was 40 min, mean hospitalization was 5.5 days. A total of 103 complications and adverse events were reported in 80 patients (21.1%) including staple line complications (minor bleeding, infection, or partial dehiscence; 7.1%), major bleeding (2.9%), and postsurgical stenosis (2.1%). Comparisons of ODS and symptom severity scores (SSS) demonstrated a significant reduction in ODS score between baseline (mean 11.14) and 6 months (mean 6.43), which was maintained at 12 months (mean 6.45), and SSS at preoperative and at 6- and 12-month follow-up (13.02 vs. 7.34 vs. 6.59; paired t test, p0.001). Significant reduction in ODS symptoms was matched by an improvement in quality of life as judged by symptom-specific PAC-QoL and generic ED-5Q (utility and visual analog scale) scores and was not associated with an impairment of incontinence score following STARR (p0.05). However, 11 patients (2.9%) showed de novo incontinence, and new-onset symptoms of fecal urgency were observed in 25.3% of patients.These data indicate that STARR is a safe and effective procedure. However, conclusions are limited due to the selection and reporting bias of a registry. The problem of fecal urgency needs cautious reassessment.

Vaccination against measles and rubella has been included in national immunization programs worldwide for several decades. In this article, we present the evidence related to the effectiveness of measles and rubella vaccination based on published systematic reviews, and we describe the epidemiological and health economic effects of vaccination at a population level. Several observational studies demonstrate the high effectiveness ( 90 %) of both measles and rubella vaccination. The global measles mortality reduction and the dramatic decrease in rubella and measles incidences after introduction of routine immunization contribute to the very high quality of evidence. The countries of the Americas have proved that it is feasible to eliminate measles and rubella by strengthening infant immunization through routine vaccination services and by conducting supplemental immunization activities in other childhood age groups so as to close immunity gaps. An economic evaluation of measles and rubella vaccination specifically for the healthcare system in Germany does not exist. However, we conducted a systematic review and identified 11 health-economic studies from other industrialized countries and one for a hypothetical industrialized country. Results indicate that vaccination against measles and rubella had either a cost-effective or even a cost-saving potential, which could be assumed with some limitations also for the German setting. In conclusion, there is compelling evidence that the available vaccines are very effective and that measles and rubella elimination is feasible if adequate vaccination strategies are implemented. In Germany, catch-up vaccination programs are urgently needed for children, adolescents, and young adults specifically in the western federal states.

Fistelnde Veranderungen entstehen am haufigsten im Anorektalbereich auf dem Boden einer pyogenen Entzundung einer Proktodealdruse. Diese Drusen sind beim Menschen rudimentar angelegt. Sie munden immer in einer Krypte des Analkanals, meist an der hinteren Analkommissur (Abb. 1, 2). Seltener finden wir sie an der vorderen und kaum an der lateralen Wand des Analkanals. Die Drusenauslaufer verzweigen sich mit einem oder mehreren blinden Schlauchen in den Sphinkteren. Die Fisteln entstehen spontan oder es geht ihnen ein Abszes voraus.

Forty-eight patients with malignant stenoses of the esophagus and cardio-esophageal junction were submitted to endocavitary afterloading treatment after prior endoscopic recanalization with the laser. An intraluminal reduction in tumor mass, and rapid elimination of dysphagia proved possible. This technique represents an alternative to the endoscopic implantation of an endoprosthesis. The afterloading tube is placed endoscopically under direct vision. Using a 192Iridium radiation source, 7 Gy were applied at a distance from the tube of 1 cm. Dysphagia was permanently relieved in 77%, while re-stenosis occurred in 23%. The mean survival time was 5.9 months. This procedure is associated with a low incidence of complications, and can be employed on an outpatient basis, and in combination with percutaneous radiotherapy given as boost radiation.

In einer Zeit von 2,5 Jahren wurde bei 48 elektiven linksseitigen Coloneingriffen selbstheilende Coecalfisteln nach Stelzner (1970) angelegt. Von 16 Operateuren wurde folgende Operation durchgefuhrt: Hemicolektomie links 5, radikale Sigmaresektionen 24, anteriore Rectumresektionen 19, davon 13 Anastomosen unter 8 cm.Ergebnisse: Durchschnittlicher p. o. Krankenhausaufenthalt 25,3 Tage, keine klinisch-manifeste Anastomoseninsuffizienz, erste Stuhlpassage im Durchschnitt nach 8,5 Tagen. Letalitat 4,2% anastomosenunabhangig, Fistelverschlus spontan nach 42 Tagen (± 26). In 21 % traten lokale nicht lebensbedrohende Komplikationen auf.

In fourteen patients with food allergy, intragastral provocation under endoscopical control (IPEC) was performed. In all patients positive immediate-type reactions of the gastric mucosa were observed consisting of oedema, erythema and petechial bleeding. Microscopically, mast cell degranulation was observed and measured by mast cell counts using the o-phthaldialdehyde technique. Concomitantly, tissue histamine content in gastric mucosa decreased significantly after allergen provocation, while there was no change in normal volunteers. Plasma histamine concentration increased in most patients; the increases were most evident in four patients showing mild systemic reactions (urticaria and bronchospasm). The technique described might prove to be useful in establishing the diagnosis in doubtful cases of food allergy.

In a double blind crossover experiment in 16 healthy male volunteers, the effects of oral FPL 52694 and a matching placebo upon pentagastrin stimulated gastric acid secretion, gastric mucosal histamine content, and gastric mucosal mast cell count were compared. There was a significant increase in acid secretion, and a fall in tissue histamine and the mast cell count after treatment with the placebo. All these changes were inhibited by FPL 52694, and there was a significant difference between the effects of this compound and the placebo in all three parameters. It is concluded that FPL 52694 caused significant inhibition of acid secretion, and that the likely mechanism of action is by stabilisation of mast cells and inhibition of histamine release.

Beim inoperablen Oesophaguscarcinom wurde als neues Alternativverfahren gegenuber der Palliativresektion die intraluminale hochdosierte Afterloadingtherapie mit Iridium 192 angewandt. Voraussetzung fur dieses Verfahren, das im letzten Jahr bei 19 Patienten eingesetzt wurde, ist die vorhergehende laserendoskopische Passagewiederherstellung der Tumorstenose. In 2wochigen Abstanden wird bis zu 3mal endocavitar mit einer Dosis von 7 Gy bestrahlt. Bei kontinuierlicher endoskopischer Patientenuberwachung ist die Tubusimplantation bei besserer Lebensqualitat und vergleichbaren Uberlebenszeiten vermeidbar.

Funktionsstorungen des Oesophagus nach Sklerotherapie wurden bei 24 Patienten 4 ± 2 Monate nach Sklerotherapie untersucht. 9 Patienten gaben Dysphagie und/oder Refluxsymptome an; es fanden sich 2 Falle von Oesophagusstrikturen und 4 Falle von Oesophagitis. 14 Patienten wiesen manometrisch eine dekompensierte Kardiainsuffizienz auf, nur 7 Patienten hatten nach Behandlung noch eine kompetente Kardia. Es bestand ein signifikanter Unterschied bezuglich der Menge des Sklerosierungsmittels zwischen beiden Patientengruppen. In der tubularen Speiserohre traten 18 % nicht propulsive und in 7 % repetitive Kontraktionsstorungen auf. Langzeit-pHmetrisch wiesen alle Patienten einen gesteigerten gastroesophagealen Reflux auf.

A relatively simple method for the intra-vascular treatment of a carotid-cavernous fistula is described and illustrated in one case. It consists of proximal ligation of the internal carotid artery and occlusion of the carotid syphon with a balloon catheter above the fistula. In this way, the carotid segment with the fistula is isolated from the circulation and therefore undergoes thrombosis. Close co-operation between radiologist and surgeon is required.

In a clinical study the participation of histamine in the allergenic response of patients with food allergy was investigated. The resting levels of gastric tissue and plasma histamines of 10 patients were slightly higher than the respective values of normal volunteers. 5 minutes after local intragastral allergenic provocation a decline of the mucosal histamine content of the allergen-treated area was noticed. Parallel investigations on the mast cell content of the stomach mucosa revealed a parallel decrease of the o-phthaldialdehyde stained cells, whereas the number of toluidine blue stained cells remained unchanged. These data are in accordance with an antigen-induced IgE-dependent liberation of the mast cell histamine stores.

Palliative brachytherapy with 192iridium in high dose rate technique was applied until August 1985 in 44 patients: 40 suffering from an inoperable malignant stenoses of the esophagus or cardia, and 4 from bile duct carcinomas located in the upper part of the duct. The patients with malignant stenoses of the upper gastrointestinal tract underwent laser therapy until an endoscope could be passed beyond this stenoses. Then an after-loading tube was placed endoscopically and the stenoses irradiated endocavitarily (7/Gray/session in 1 cm distance). In the patients with malignant bile duct obstruction a PTCD-catheter served to guide the iridium wire up to the stenotic region.

Value and indication of computerized tomography in diagnostic procedures after trauma of the musculoskeletal system is shown analyzing the case material with CT in traumatized patients. In general CT is not to take place of conventional X-ray methods. We feel CT is indicated in evaluation of: intraarticular fragments, congruity of joints, lesions of the cruciate ligaments and osteocartilagineous fractures, if conventional X-ray procedures prove insufficient.

A relatively simple method for the intra-vascular treatment of a carotid-cavernous fistula is described and illustrated in one case. It consists of proximal ligation of the internal carotid artery and occlusion of the carotid syphon with a balloon catheter above the fistula. In this way, the carotid segment with the fistula is isolated from the circulation and therefore undergoes thrombosis. Close co-operation between radiologist and surgeon is required.

During a period of 15 months we performed a laser therapy of bronchi stenosis due to malignant tumors in 28 patients. We used a Neodym-YAG-Laser (MBB-AT, Munich), guided through a fiberbronchoscope (Olympus BF-1 TR). 59% of total-stenoses and 83% of the partly occluded bronchi could be opened sufficiently. During a follow-up period of 12 months (mean 4.7 m) 83% of the bronchi remained open. According to our experience, fractional tissue removal is the method of choice rather than all-at-once coagulation since tissue edema may cause bronchial occlusion 1 to 3 days after treatment. We think, if surgical treatment is ruled out, intrabronchial laser coagulation is an alternative with little impairment of the patient to prevent hypoventilation and repair functional conditions.

After analysing 28 cases of ingestion of corrosive agents a regimen was developed for handling cases with caustic burns of the upper GI-tract. Emergency surgery was found to be indicated, if endoscopy revealed second degree or transmural burn injuries. The type of resection procedure is related to the extent of damage to the organ walls when explored by laparotomy.

Stimulation tests (pentagastrin) induced significant changes in tissue histamine levels in the gastric mucosa within 30 minutes. Acid secretion and a decrease of histamine after application of antacids containing calcium could not be observed in our study; neither was application of antacids over a period of eight days followed by a change in gastric mucosal tissue histamine concentrations. Patients under non-steroidal antiphlogistic medication showed diminished histamine levels. Administration of antacids did not produce changes in histamine levels, but induced a rise of PGE2 levels in the fundal and corpus area of the stomach. This may be due to a cytoprotective effect of antacids containing calcium on the gastric mucosa.

One of the main problems encountered in cryosurgery is that of controlling the amount of tissue that is irreversibly destroyed by cooling. In vitro-experiments in which the homogeneous cooling of various substances, as well as "ice-ball" propagation within different tissues of animals via a cryotip were evaluated. In vivo experiments, on an anaesthetized pig, indicate CT to be a useful continuous-monitoring technique with a high spatial resolution. Using CT simultaneous localization of pathological tissue and measurement of temperature distribution is possible. The density changes induced by cooling were visualized on CT and the corresponding temperature changes were measured using thermocouples. The greatest decrease in density was observed as a change of phase took place. The speed of ice-ball propagation as well as the diameter of the ice ball generated varied considerably depending on the type of tissue. Construction of cryoprobes of a very small diameter could facilitate the percutaneous treatment of lesions within the body.

Die weite Verbreitung endoskopisch-diagnostischer und endoskopisch-therapeutischer Verfahren last auch die dieser Untersuchungstechnik eigenen Komplikationen ansteigen. Die Kenntnis der Komplikationsmoglichkeiten verhindert sie bereits zu einem Grosteil. Genauso fuhrt das Wissen um sie zu einer schnelleren Diagnose und adaquaten Therapie.

In inoperable esophageal carcinoma the intraluminal high dose afterloading therapy with Iridium 192 was employed as an alternative to the palliative resection. Prerequisite for this treatment, which was used in 19 patients during the last year, is the preceding passage restoration of the tumor stenosis by endoscopic laser therapy. Every two weeks the patients are endocavitarily irradiated up to 3 times with a dose of 7 Gy. Observing the patients by endoscopic means the implantation of a tubus is avoidable achieving better quality of life and comparable survival times.

Bereits 1910 entdeckten Ackermann [1], Barger u. Dale [2], das Histamin als Produkt von Histidindekarboxylierung in Bakterien entsteht. 1936 waren es Werle et al. sowie Holz u. Heine unabhangig voneinander, die die Histidindekarboxylase erstmals im tierischen Organismus nachwiesen, die Histidin zu Histamin decarbo- xyliert. In den letzten Jahren hat man sich vermehrt bemuht, medikamentos die Wirkung des Histamins zu beeinflussen. Wahrend Antihistaminika vom H1 und H2-Typ freigesetztes Histamin am Receptor blockieren, besteht ein anderer Weg zur Ausschaltung der Histaminwirkung: indem die Bildung gehemmt wird.

It is possible to undertake a free transplantation of the jejunum with a low rate of thrombosis by a microsurgical technique of vascular anastomosis. The animals could be nourished sufficiently via the interponate with pasty food. Peristalsis within the interponate was retained. Stenoses caused by a periluminar cicatrix are possible. After 1 year a transformation of connective tissue of the interponate was not observed.

The replacement of the esophagus using multiple-stage procedures and requiring a double cavitary approach has been burdened with a high post-operative lethality rate. A replacement of the esophagus using a free autogenous jejunal interponate by avoiding a double-cavitary approach has a lower lethality rate. The hitherto grafting procedures using macrosurgical vascular transplantation techniques were burdened with such a high thrombosis rate that no competitive alternative has ensued. Furthermore, different publications did not clarify whether or not the autogenous intestinal graft retained its peristaltic or, as Nakayama et al. (1964) reported, changed into a rigid and inflexible conduit composed of connective tissue. In a collective of 18 Beagles the esophagus was replaced using a autogenous jejunum graft. The vascular anastomoses between the interponate and neck vessels prepared using microsurgical techniques and the esophago-jejunal anastomoses were prepared using a one-row multiple layer suture. No animal died as a result of the operation. Necrosis of the interponate due to microthrombosis in the vascular anastomoses did not occur. The peristalsis began after opening the arterial vessel. Peristalsis remained even after one year. Histological investigations showed that the intestinal villi degenerate but the musculature and ganglion cells from the myenteric plexus remain intact. The interponate does not become fibrous. In approximately 1/3 of the cases, periluminal scar-tissue growth caused a stenosis of the interponate. This complication was resolved by surgical revision.

By using the literature important facts of the spontaneous course of ulcer bleeding are presented. Patient groups with a high risk for early rebleeding are characterized. The indication for operation is discussed regarding intensity and activity of bleeding and endoscopic findings. The operative technique of haemostasis in duodenal and gastric ulcer is described. The own cases are analysed with special respect to endoscopic haemostasis.

Functional disorders of the esophagus were evaluated in 24 patients 4 +/- 2 months after sclerotherapy following the first hemorrhage. The mean volume of polidocanol required per patient was 181 +/- 111 ml. 9 patients complained of dysphagia and/or reflux symptoms; strictures were found in two cases; 4 patients had esophagitis. Manometrically the lower esophageal sphincter was completely insufficient in 14 patients; only 7 patients still had a competent cardia. The first group had received significantly more polidocanol than the latter. Tubular motility was disturbed by nonpropulsive (18%) and repetitive (7%) contractions. By longterm-pH-metry the percentage of oesophageal reflux was elevated in all patients.

Nach Wie Vor Ist Der Ersatz Der Halsspeiserohre Problematisch, Was Sich Schon In Der Mannigfaltigen Anzahl Der Angegebenen Methoden ausert.

Palliative treatment of malignant stenoses of the upper gastrointestinal tract should be instituted only when, on the basis of previous staging and assessment of the risk involved, curative surgery is no longer possible. Resection of an esophageal carcinoma is contraindicated by infiltration of the growth into the trachea or other organs, as revealed by CT or magnetic resonance. Invasion of the bronchial system by the tumor can be detected with the aid of bronchoscopy. Distant metastasis, poor pulmonary function, and cirrhosis of the liver also militate against resection [13]. For this reason endoscopic implantation of an endoproth-esis should not be carried out without discussing the oncological situation with the surgeon. Since the implantation of a tube does not always satisfactorily improve the quality of the patient’s life [1, 3], in the past 18 months, as an alternative to endoscopic tube implantation, we have submitted 93 patients to intracavitary afterloading following prior laser therapy [2].

During a period of 2.5 years self-healing coecostomies according to Stelzner (1970) were applied in 48 elective procedures to the left colon. The following operations were done by 16 different surgeons: left side hemicolectomy 5, sigma resection 24, anterior resection of the rectum 19, 13 of which had anastomoses less than 8 cm.Mean postoperative hospital care 25.3 days, no clinical manifestation of anastomotic leaks, first passing of stool after a mean of 8.5 days. Lethality of 4.2% independent of anastomoses, spontaneous occlusion of fistulae after 42 +/- 26 days. 21% local not life-endangering complications occurred.

Systematic bone marrow examinations in patients with bronchial carcinoma (n equals 75) gave positive findings (identification of tumor cells) in 12% related to all types of tumors and in 32% of microcellular carcinoma. The information value of this method is relatively small with regard to the assessment of operability, because positive findings in stages I and II are extremely rare. Non-specific iliac crest biopsy provides therapeutically and prognostically important pointers in patients who are to be irradiated (tumor stage III and all microcellular tumors of stages I-III), because a positive bone marrow finding must be valued as stage IV.

An 18 Beagles wurde der Halsoesophagus durch ein freies, autologes Jejunumtransplantat ersetzt. Interponatsnekrosen durch Thrombosen an den Gefasanastomosen kamen wegen der mikrochirurgischen Technik nicht vor. Die Passage und Peristaltik blieb in allen Fallen erhalten. Viermal schrumpfte das Interponat durch periluminare Narben. Zu einer Fibrosicrung des Interponates selbst kam es nicht, die Ganglienzellen des Plexus myentericus sind auch nach 1 Jahr noch erhalten. Es handelt sich somit um ein risikoarmes Verfahren zum Ersatz der Halsspeiserohre.

56 Patienten mit einer transfusionspflichtigen Blutung (? 1000 ml/24 h) wurden einer primaren endoskopischen Lasertherapie zugefuhrt. 91% zeigten eine Blutungsintensitat Typ Forrest (F) 1,9% Typ F 2. Eine primare Blutstillung konnte in 89% erreicht werden. Bei guter Einstellbarkeit spielte die Lokalisation der Blutungsquelle keine Rolle. Die Blutungsintensitat ging auf den Lasererfolg direkt ein. F 1a (spritzende Blutungen) in 82%, F 1 b (sickernde Blutungen) in 93%. Die Blutungsrezidivrate nach Lasertherapie war 28%, bei F 1a 50%. Ergebnis: F 1a ist fur die Lasertherapie ungeeignet. F 1 b ist die beste Indikation.

Die Behandlungsrichtlinien fur ingestive Veratzungen basieren auf klinischen und endoskopischen Parametern: Gruppe 1 (bei endoskopisch negativem Befund): konservatives Vorgehen, Infusion, Antacida, Antibiotica; Gruppe 2 (Magenschleimhautverdtzung): Laparotomie mit „geschlossener Magenspulung”; Gruppe 3 (Veratzung von Magen alleine): Gastrektomie mit Oesophago-Jejunostomie; Gruppe 4 (Veratzung von Magen und distalem Oesophagus): Gastrektomie mit Verschlus des Oesophagus und Duodenalstumpfes (Jejunumerndhrungsfistel); Gruppe 5 (Schadigung des gesamten Oesophagus und Magens) Gastrektomie, Oesophagektomie (Jejunumerndhrungsfistel). Letalitat: konservativ (Gruppe 1: 0 %), operativ (Gruppe 2–5: 50%).