Medicine faces significant cost pressure in most developed countries. Health economists recommend QALYs as a key instrument for allocating scarce health care resources. However, many European countries (e.g., Italy, Spain, Belgium, Germany, and others) have a natural-law-based constitution, which makes it questionable whether QALY-based rationing is legal. Taking Germany as a typical example for a natural-law-based constitution, we performed a multidisciplinary systematic literature review, retrieving 54 relevant sources from five scientific databases. There are legal boundaries to QALY-based rationing (QBR) in health care, mostly found in Articles 1 and 2 GG (“Grundgesetz”, German constitution). A rationing process that is based on calculation of lifetime and its quality (QALYs) is likely to be unconstitutional because it violates the guarantee of human dignity. Article 2 could also pose a limitation to rationing, at least if it violates a certain existential minimum. Despite the primacy of the QALY concept in health economic sciences, few authors evaluated its legal feasibility in countries with a natural-law based constitution. It seems highly unlikely QBR would be legally admissible under the GG if used for rationing in health care. La médecine fait face à une pression importante sur les coûts dans la plupart des pays développés. Les économistes de la santé recommandent les QALY comme instrument pour l’allocation de ressources limitées en soins de santé. Cependant, de nombreux pays européens (par exemple l’Italie, l’Espagne, la Belgique, l’Allemagne et d’autres) ont une constitution fondée sur le droit naturel, ce qui permet de se demander si le rationnement basé sur la QALY est légal. En prenant l’Allemagne comme exemple typique d’une constitution basée sur le droit naturel, nous avons effectué une revue de littérature systématique multidisciplinaire, en récupérant 54 sources pertinentes dans cinq bases de données scientifiques. Il existe des limites légales au rationnement basé sur la QALY dans les soins de santé, principalement dans les articles 1 et 2 GG (« Grundgesetz », constitution allemande). Un processus de rationnement basé sur le calcul de la durée de vie et de sa qualité (QALY) est susceptible d’être inconstitutionnel, car il viole la garantie de la dignité humaine. L’article 2 pourrait également limiter le rationnement, du moins s’il viole un certain minimum existentiel. Malgré la primauté du concept QALY dans les sciences économiques de la santé, peu d’auteurs ont évalué sa faisabilité juridique dans les pays dotés d’une constitution fondée sur le droit naturel. Il semble hautement improbable que le QALY-rationnement soit légalement admissible en vertu du droit naturel.

In 2011, a new legislation in Germany (AMNOG) aimed both at introducing value based pricing as well as massively reducing pharmaceutical costs in a scientifically sound and socially viable way, basically creating a natural experiment on drug cost containment. This paper analyses strength and weaknesses of the approach. While parts of the process are very transparent and can be analysed with simple literature analysis, others - mainly the negotiation process - are not. Therefore, over 20 in-depth interviews with participants from both pharmaceutical and social health insurance companies were conducted. The first part of the AMNOG – the benefit assessment – process works well. There are two major shortcomings in the AMNOG process: (i) there is no clear algorithm that leads from additional benefit to price; and (ii), the demand side lacks negotiation power. In addition, the negotiation process itself does not follow a scientific and structured procedure – rather, it can be described as a “bazaar”. According to our findings, it seems very difficult to combine the principle of providing innovative pharmaceuticals to everyone paid for by a social security system with the idea of achieving 'reasonable' prices through negotiations between payers and pharmaceutical companies. While some basic ideas of AMNOG are still valid, the negotiation process needs to be changed.

Introduction and Aims: Although some guidelines recommend salt restriction, few studies have examined the association between salt restriction and clinical outcomes in hemodialysis (HD) patients.Methods: We conducted a retrospective cohort study of 88,115 adult patients enrolled in the Japanese Society for Dialysis Therapy (JSDT) registry ( 2008) who had received HD for at least two years and were considered anuric.The primary outcome measure was all-cause mortality at one year, and the secondary outcome was cardiovascular (CV) mortality.Estimated salt intake was the main predictor, and was calculated from interdialytic weight gain and pre-and postdialysis serum sodium levels according to the validated method of Kimura and Ramdeen.Nonlinear logistic regression was used to determine the association of salt intake with mortality, adjusting for age, gender, body mass index, vintage of HD, dialysis time, Kt/V, protein catabolic rate normalized to body weight, comorbid conditions, type of vascular access, serum potassium, phosphate, calcium, CRP level, and endotoxin level in dialysate.Cubic splines were plotted and the reference was median salt intake.Salt consumption was categorized by intake levels of 2 g per day and the association with mortality examined.Results: Median [25th-75th percentile] salt intake at baseline was 6.4 [4.6-8.3]g per day.At one year, all-cause mortality occurred in 1,845 (2.1%) patients, including cardiovascular mortality in 821 (0.9%).We observed an association between low salt intake and clinical outcomes (all-cause and CV mortality) (Fig. 1).We observed the highest all-cause mortality in the low salt group (<6g/day) (Fig. 2), and no association between all-cause mortality and high salt intake.Further, we observed similar associations between salt intake and CV mortality.Conclusions: Low salt intake is associated with all-cause and CV mortality.These findings do not support current clinical guidelines, which recommend restricting salt intake to less than 6g per day.

Quality management (QM) will soon become mandatory for private practice physicians in Germany. We aimed to assess the knowledge about and state of implementation of QM in German private practices. In cooperation with the Stiftung Gesundheit (Foundation for Health), Hamburg, a stratified sample of 15,383 physicians was requested via e-mail in 2006 to participate in the online survey. The survey covered sources of information and experiences with QM, cost of implementing QM, and general attitudes towards QM in private health care. A total of 787 doctors (5.1% response rate) rendered useful data sets; 16% of doctors had not yet familiarized themselves with QM. The DIN-ISO QM System is by far the best-known system, with 86% of doctors having heard about it. All other systems are known by only 30% or less of the physicians. Only about 20% of private practices have already implemented QM or are about to have it implemented. The cost of QM depends heavily on the system used with DIN-ISO (5600 euros) and EFQM (2800 euros) being the more expensive, while EPA (1800 euros) and QEP (850 euros) are much less costly. All QM systems require roughly the same amount of time from staff to be implemented and maintained. Two thirds of all doctors have not yet decided which QM system to use and contacts during seminars and recommendations from colleagues are most important when selecting a system. The level of satisfaction with QM service providers is generally high. In general, the study revealed a very heterogeneous picture. As with other new technologies or organizational changes there is a group of enthusiastic "early adopters," but we also found a substantial number of physicians (about 25%) who are highly skeptical about implementing QM. They posed a challenge for health policy and service providers alike and careful market segmentation will be needed to cater for the different needs of the different groups of doctors. Moreover, the still rather technical approach towards QM might not be helpful in convincing the clinical and patient-oriented doctors of the need to install systematic and organization-based quality systems.

Qualitätsmanagement (QM) ist für niedergelassene Ärzte gesetzlich vorgeschrieben – der gemeinsame Bundesausschuss hat detaillierte Richtlinien dazu veröffentlicht. Wie sind die Kenntnisse und Stand der Durchführung in den Praxen?

The health policy debate about rationing is often confused by dealing with several different issues concurrently. This contribution introduces a typology and matrix that separates two of the most important of these issues in order to improve the clarity of the debate. The first of these issues, the mode of rationing, concerns how the responsible parties allocate scarce resources. This can be achieved non-systematically, for example, via ad hoc clinical bedside reasoning, or systematically with the aid of rigorously developed and tested algorithms, possibly including elucidated public preferences which trade-off efficiency and equity. The second issue, the transparency of the debate, concerns how the debate is presented, should it happen tacitly being left to the parties involved (hidden) or should it be open to public scrutiny (open)? Thinking about mode and transparency separately may lend more clarity to the rationing debate. The paper also discusses possible implications resulting from such a separation.

Summary form only given. Various applications of all-optical signal processing, e.g, demultiplexing in optical time-division multiplexing (OTDM) systems or optical sampling, can be accomplished by all-optical switches based on semiconductor optical amplifiers (SOAs) in interferometric configurations. To optimize such switching devices, it is useful to have a model which describes the temporal characteristics of the switches accurately. The SOA model, which we present, takes the pulse propagation and the gain dynamics into account. The gain dynamics is determined by carrier density modulation (also called carrier density pulsation, CDP) and carrier heating (CH), calculated in separate rate equations.

The turn-on jitter of zero-biased nearly single-mode vertical-cavity surface-emitting lasers (VCSEL's) is experimentally investigated. Since during the turn-on event both the dominant and the suppressed polarization are exited, an analytical expression describing the probability density function of the turn-on delay for a single-mode VCSEL is derived, which accounts for both polarizations. The measurement results and the theory are in good agreement as long as the VCSEL is transversal single-mode.

□ Rationierung in der Medizin ist unvermeidlich. Dieser ökonomische Terminus beschreibt wertneutral die Beschränkung der zuteilung von Gütern und Dienstleistungen angesichts knapper Mittel. Ursachen für den zunehmenden Rationierungsdruck in der Medizin sind der sich ändernde Altersaufbau der Bevölkerung, zunehmende Erwartungshaltung von Patienten und Angehörigen sowie der medizinisch-technische Fortschritt; Entwicklungen, die wenn überhaupt, nur teilweise beeinflußbar sind.

Genitale Chlamydien werden heute als die Haupterreger aszendierender Infektionen und ihrer Folgeschäden angesehen. Wegen des besonderen Vermehrungszyklus verlaufen ca. 90% der Infektionen asymptomatisch oder symptomarm. Im ersten Teil werden Häufigkeit, Bedeutung und Stand der Diagnostik der genitalen Chlamydieninfektionen dargestellt. Im zweiten Teil wird durch eine Kosten-Nutzen-Analyse gezeigt, daß nur durch Verwendung der snsitiveren Amplifikationsmethoden und durch ein großzügigeres Screening als das derzeitige Schwangerschaftsscreening Folgeschäden und Folgekosten dieser Infektion zu senken sind.

The turn-on jitter of zero-biased, polarization controlled single-mode VSCELs is investigated experimentally. It is found that during the turn-on event, both the suppressed polarization and transverse higher modes are existent yielding a reduction of the turn-on jitter. On the other hand, when the transmission link contains polarizations sensitive elements or spatial filtering this means that the turn-on jitter is significantly enhanced

Genital Chlamydiae are now considered to be the principal cause of ascending infections and their sequels. Due to their unique, obligately intracellular developmental cycle approximately 90 per cent of these infections progress asymptomatically or with only few and/or mild symptoms. In the first part of this article the incidence, significance and update diagnostics of genital chlamydiae infections are presented. The second part demonstrates by means of a cost-benefit analysis that the sequelae of this infection in respect of damage and cost can be reduced only by means of a screening procedure that is more elaborate and extensive than the presentely practised pregnancy screening method.

Summary form only given. We solved the nonlinear integral equation for the carrier density by the method of fixed-point iteration for different SOA lengths. We also investigated the reduction in the gain recovery time due to the saturation caused by ASE, which is important for both linear and nonlinear applications. The spontaneous carrier lifetime can be reduced by approximately a factor of 10 when sufficiently long SOAs are used.

We compare the performance of dispersion-managed 4/spl times/40, 16/spl times/10, and 16/spl times/40 Gb/s wavelength-division-multiplexed transmission over 1000-km standard single-mode fiber operating at 1.55 /spl mu/m. It is shown, that for N/spl times/40 Gb/s, the system performance is mainly limited by the degradations of each single channel. No significant additional degradation due to cross-phase modulation or four-wave mixing could be observed. Moreover, it is shown that focusing on the total fiber-input power, both transmission schemes, 4/spl times/40 Gb/s at 100-GHz channel spacing and 16/spl times/10 Gb/s at 25-GHz channel spacing, yielding the same total bandwidth show almost identical performance.