Introduction:Reimbursement systems can create significant incentives for service delivery. From a theoretical perspective, the need for reform in reimbursement systems at the interface between outpatient and inpatient care is well established, but practical proposals are lacking. As part of the sekTOR-HF project, a concept for a bundled payment system was developed, and its feasibility in Germany was demonstrated. Methods:The framework for a bundled payment system was developed through a participatory design process. A retrospective analysis of statutory health insurance (GKV) claims data (2018-2019) was used to calculate bundle prices for patients with left-sided heart failure. Generalized linear models with a gamma distribution and link function were applied to estimate prices and identify cost drivers. Results:Four bundled payment scenarios based on NYHA classes were identified. Among 129,262 patients with left-sided heart failure analyzed, the annual reimbursement prices per patient for a bundled payment ranged from €1,928 (NYHA I) to €5,567 (NYHA IV). Several cost-increasing comorbidities ("bundle breakers"), such as renal failure, multiple myeloma, and cardiac arrest, were identified. Conclusion:We developed an initial proof of concept for implementing bundled payments in the German healthcare system. Our findings indicate that viable design options can be identified and that price estimation based on existing routine data is feasible.

The implementation of care-related guidelines can only be promising in the form of multi-project management. Such a project (Avenue-Pal), with the aim of improving the care situation of the dying by reducing unnecessary transfers, is described in its method and implementation (in two model institutions). It becomes clear that some of the risks that lead to relocations can only be overcome through organizational adjustments. This means that guideline implementation always becomes a management task. The principle of the Balanced Scorecard (BSC) is introduced and transferred to the specific case of action. Different structure, process and result indicators for the four BSC dimensions, both for the care facility and the hospital, are reported. Indicators that are suitable for operationalizing the "visionary goal" of the BSC and thus making it controllable. Even if the BSC was developed for the specific case of Avenue-Pal, it was found that the BSC principle is fundamentally to be assessed as a helpful instrument for management for more complex guideline implementations.

Heart failure (HF) is one of the most common hospital admissions diagnoses and causes of death in Germany. In the care of HF, there are false incentives owing to quantity-based remuneration and separate remuneration models for inpatient and outpatient care. The research project of RHÖN-KLINIKUM AG, ‘sekTOR-HF’, has been promoted by the German government’s innovation fund and is intended to ensure better care for HF patients in Germany with the help of optimal coordination of the cross-sectoral care process and new incentives in remuneration. Part 1 describes the initial situation and concept that paved the way for the project in 2020. Patient inclusion began in March 2021. After the project has been completed, in November 2023, a second part will present the project evaluation and the results.

ZusammenfassungDie Implementierung von versorgungsbezogenen Leitlinien kann aussichtsversprechend nur in Form eines Multiprojektmanagements betrieben werden. Solch ein Projekt, Avenue-Pal, mit dem Ziel, die Versorgungssituation Sterbender durch Reduktion nicht notwendiger Verlegungen zu verbessern, wird in dessen Methode und Durchführung in 2 Modelleinrichtungen beschrieben. Deutlich wird, dass zentrale Risiken, die zu Verlegungen führen, nur durch organisatorische Anpassungen überwunden werden können. Damit wird die Umsetzung einer Leitlinie immer auch zu einer Managementaufgabe. Die Methode der Balanced Scorecard (BSC) wird einführend vorgestellt und auf den konkreten Handlungsfall übertragen. Es werden unterschiedliche Struktur-, Prozess und Ergebnisindikatoren für die 4 BSC-Dimensionen, sowohl der Pflegeeinrichtung als auch des Krankenhauses, berichtet. Kennzahlen, die geeignet sind, das „visionäre Ziel“ mit Hilfe der BSC zu operationalisieren und steuerbar zu machen. Auch wenn die BSC für das Projekt Avenue-Pal entwickelt wurde, zeigte sich, dass die Anwendung des Verfahrens grundsätzlich als hilfreiches Instrument des Managements zu bewerten ist, wenn transsektorale Versorgungsleitlinien umgesetzt werden.

Introduction: Door-to-CT scan time (DCT) and door-to-needle time (DNT) are important process measures in acute ischemic stroke (AIS) patients undergoing intravenous thrombolysis (IVT). We examined the impact of a telemedical prenotification by emergency medical service (EMS) (called the “Stroke Angel” program) on DCT and DNT and IVT rate compared to standard of care. Patients and Methods: Two prospective observational studies including AIS patients admitted via EMS from 2011 to 2013 (cohort I; n = 496) and from January 1, 2015 to May 31, 2018 (cohort II; n = 349) were conducted. After cohort I, the 4-Item Stroke Scale and a digital thrombolysis protocol were added. Multivariable logistic and linear regression analysis was performed. Results: In cohort I, DCT was lower in the intervention group (13 vs. 26 min using standard of care; p < 0.001), but no significant difference in median DNT (35 vs. 39 min; p = 0.24) was observed. In cohort II, a reduction of DCT (8 vs. 15 min; p < 0.001) and DNT (25 vs. 29 min p = 0.003) was observed in the intervention group. Compared to standard of care, the likelihood of DCT ≤10 min or DNT ≤20 min in the intervention group was 2.7 (adjusted odds ratio [aOR] 2.7; 95% CI: 2.1–3.5) and 1.8 (aOR 1.8; 95% CI: 1.1–2.9), respectively. In cohort II, IVT rate was higher (aOR 1.4; 95% CI: 1.1–1.9) in the intervention group. Conclusion: Although the positive effects of Stroke Angel in AIS provided a rationale for implementation in routine care, larger studies of practice implementation will be needed. Using Stroke Angel in the prehospital management of AIS impacts on important process measures of IVT delivery.

BACKGROUND:The Ischemic Stroke System is a novel device designed to deliver stimulation to the sphenopalatine ganglion(SPG).The SPG sends parasympathetic innervations to the anterior cerebral circulation. In rat stroke models, SPG stimulation results in increased cerebral blood flow, reduced infarct volume, protects the blood brain barrier, and improved neurological outcome. We present here the results of a prospective, multinational, single-arm, feasibility study designed to assess the safety, tolerability, and potential benefit of SPG stimulation inpatients with acute ischemic stroke(AIS).METHODS:Patients with anterior AIS, baseline NIHSS 7-20 and ability to initiate treatment within 24h from stroke onset, were implanted and treated with the SPG stimulation. Patients were followed up for 90 days. Effect was assessed by comparing the patient outcome to a matched population from the NINDS rt-PA trial placebo patients.RESULTS:Ninety-eight patients were enrolled (mean age 57years, mean baseline NIHSS 12 and mean treatment time from stroke onset 19h). The observed mortality rate(12.2%), serious adverse events (SAE)incidence(23.5%) and nature of SAE were within the expected range for the population. The modified intention to treat cohort consisted of 84 patients who were compared to matched patients from the NINDS placebo arm. Patients treated with SPG stimulation had an average mRS lower by 0.76 than the historical controls(CMH test p = 0.001).CONCLUSION:The implantation procedure and the SPG stimulation, initiated within 24hr from stroke onset, are feasible, safe, and tolerable. The results call for a follow-up randomized trial (funded by BrainsGate; clinicaltrials.gov number, NCT03733236).

Changes in healthcare are needed, particularly in order to address the consequences of demographic developments. A centralised and integrated healthcare provider, following economic and qualitative aspects and providing both a broad spectrum and highly specialised medicine, could be one solution. The campus-concept used by RHÖN-KLINIKUM-AG is based on the concept of networked medicine. Its primary element is patient navigation, which aims to exploit the assumed potential for efficiency. In the discussion on quality, patients should be not only targets but actors whose needs are taken into account. Patient-reported outcome measures (PROMs), which measure the quality of health care from a patient perspective, should play a major role in the German healthcare system. Forms follow function.

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Für den Ausbau der ambulant-stationären Vernetzung sind sowohl die internen Strukturen in Krankenhäusern durchgängig zu digitalisieren als auch sichere und flexible Plattformen zum Austausch zu etablieren. Hierfür hat die RHÖN-KLINIKUM AG mit KAS 4.0 und WebEPA+ 2 Ansätze entwickelt, die im Sinne der Netzwerkmedizin patientenorientierte Behandlungsprozesse fördern.

Alle 3 Minuten kommt es in Deutschland zu einem Schlaganfall – alle 9 Minuten stirbt jemand an den Folgen [1]. Je früher ein Patient behandelt wird, desto besser sein Outcome – ganz nach dem Motto: „time isbrain“. Daher ist es wichtig, dass Sie die Symptome sofort erkennen und den Patienten so schnell wie möglich in die richtige Klinik bringen.

Objective: To examine whether the use of a shoulder joint functional orthosis over four weeks can mitigate the development or progression of the shoulder–hand syndrome in patients with shoulder joint subluxation after stroke. Design: Two-armed randomized controlled trial. Setting: Rehabilitation unit of a neurological hospital, single centre. Subjects: Forty-one patients with caudal subluxation of the glenohumeral joint and hemiparesis of the upper extremity after ischaemic brain stroke. Interventions: Support by functional orthosis Neuro-Lux (Sporlastic, Nürtingen, Germany) on top of usual care according to current guidelines (experimental, n = 20) versus usual care alone (control, n = 21). Main measures: Weekly shoulder–hand syndrome scores (severity of clinical symptoms ranging from 0 to 14), discomfort caused by the orthosis, and its usage rate. The primary outcome was the average shoulder–hand syndrome score on days 14, 21 and 28, adjusted for the baseline shoulder–hand syndrome score. Results: The adjusted mean shoulder–hand syndrome score was lower by 3.1 in the intervention compared to the control subjects (95% confidence interval 1.9 to 4.3, P < 0.0001). Marginal or no discomfort from treatment with the orthosis was reported in 15 patients (75%), and only a single patient (5%) felt severe discomfort during the entire treatment. Use of the orthosis during the prescribed time was 89%. Conclusions: The orthosis examined in this trial has been successfully shown to reduce and prevent the development of clinical symptoms of shoulder–hand syndrome. Timing and duration of application of the orthosis as well as its combination with other therapeutic measures should be investigated in future clinical trials.

Der Schlaganfall ist ein zeitkritischer Notfall und muss umgehend in eine Klinik mit Expertise in der Schlaganfallbehandlung.

Objectives: The aim of the study was to evaluate the role of anatomical completeness of the circle of Willis for sufficient brain perfusion during unilateral cerebral perfusion and the methodology of the preoperative and intraoperative functional assessments of adequate cross-perfusion. Methods: This prospective observational study included all elective patients (99) who underwent elective open arch surgery (hemiarch in 74 and arch replacement in 25 patients, respectively) at our institution between September 2004 and September 2006. Preoperative neuro-vascular evaluation included color-coded duplexsonography of the extracranial arteries, cranial CTangiography, and transcranial sonography. A functional test of cerebral cross-perfusion was performed during cross-clamping of the common carotid artery during cannulation by transcranial Doppler, electroencephatography and measurement of somatosensory evoked potentials. These examinations, which were completed through measurement of arterial pressure in both radial arteries, also served as an intraoperative assessment of cerebral perfusion during surgery. During mild hypothermic (30 degrees C) circulatory arrest with a mean duration of 18 min (range, 7-70) brain protection using unilateral cerebral perfusion was performed in all patients. Results: As assessed in preoperative CTangiography, the circle of Willis was complete in only 59 patients. Eighteen patients showed a singular abnormal location within the circle of Willis, 13 patients presented with abnormalities within the posterior communicating arteries on both sides, and 9 patients within the anterior and posterior communicating arteries. Nevertheless, functional tests during carotid artery cross-clamping as well as intraoperative cerebral monitoring including transcranial Doppler showed no pathology in any patient, and only one patient with severe aortic valve calcification suffered from embolic minor stroke after surgery. Conclusions: The anatomical status of the circle of Willis assessed with cranial CTangiography does not correlate with functional and intraoperative tests examining the cerebral cross-perfusion. The authors do not recommend cranial CT angiography as a preoperative standard examination before open arch surgery in which unilateral cerebral perfusion is scheduled. (c) 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Pervasive Computing is developing fast and is presenting new opportunities for medical care. Unfortunately, technology selection and adoption in the healthcare sector and by physicians is typically an intricate process. Exemplified by Multiple Sclerosis (MS) this paper describes the assessment of a dedicated PC technology with respect to medical usefulness in real life applicability. MS is a chronic disease that typically affects the patient’s mobility and quality of life. Tri-axial accelerometers can be used to gain more information about the particular state of the disability. This technology can provide medical staff with objective and more comprehensive information. We present the design of a real life experiment and how the evaluation is designed to analyse the technology’s developmental status, its acceptance, and its medical usefulness.

OBJECTIVE:Presentation of typical imaging findings and diagnostic approaches in patients suspected of moyamoya disease.MATERIAL AND METHODS:Two female patients (24 resp. 44 years old) presenting with equivocal neurological symptoms (headache, recurrent monoparesis, choreiformic ataxia, grand mal seizure) were examined by means of colour-coded ultrasound, selective catheter-based angiography (DSA), CT and MRI including MR angiography.RESULTS:Cranial CT and MRI showed normal findings in one patient, and focal cerebral infarctions of different age in the other. In both cases, colour-coded ultrasound was indicative in detecting occlusive disease of the internal carotid arteries. Both, MR angiography as well as catheter-based angiography revealed the pathology of the culprid vessel, in addition catheter-based angiography was more accurate in depicting moyamoya collaterals at the skull base.CONCLUSION:In moyamoya disease colour-coded ultrasound is diagnostic for the lesion of the internal carotid artery, MRI resp. MRA depict the vascular and parenchymal lesion, whereas catheter-based DSA by providing information about the main vessel and collateral system allows the staging of the disease.