Skip to main content
SpringerLink
Log in

Versorgungsforschung

Bedeutung, Methoden und Herausforderungen in der Unfallchirurgie

Outcomes research

Definitions, methods and challenges in trauma and orthopaedic surgery

  • In der Diskussion
  • Published:
Der Unfallchirurg Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Versorgungsforschung („outcomes research“ und „health services research“) stellt nach grundlagen-, krankheits- und patientenorientierter Forschung die 4. Säule des Gesundheitssystems dar. Sie untersucht die günstigen und unerwünschten Effekte medizinischer und operativer Interventionen unter Alltagsbedingungen.

Methode

Im klinischen Experiment und unter kontrollierten Studienbedingungen beobachtete Wirkungen (efficacy) sind aufgrund strenger Ein- und Ausschlusskriterien und dem Spektrum von Begleiterkrankungen häufig nur eingeschränkt auf die üblicherweise behandelte Patientenpopulation zu übertragen. Eine nützliche und wertvolle, damit auch solidarisch zu finanzierende diagnostische oder therapeutische Maßnahme sollte auch in der klinischen Praxis noch nachweisbar wirksam sein (effectiveness). Es erfordert anspruchsvolle Studiendesigns, um diese Wirksamkeit modellieren und von systematischen Fehlern und anderen Störfaktoren trennen zu können.

Ergebnisse

Für die Etablierung einer fachspezifischen Versorgungsforschung in Unfallchirurgie und Orthopädie bieten sich Register und pragmatische randomisierte Studien an. Gute Beispiele für Interventionen, deren Wirksamkeit noch geprüft werden muss, sind u. a. Kyphoplastie und Vertebroplastie, navigierte Operationen, Damage-control-Konzepte, winkelstabile Implantate und Knochenwachstumsfaktoren. Die Aufdeckung von Über- und Unterversorgung, die Generierung von Negativlisten und die Einbindung von Patientinnen und Patienten als Co-Therapeuten können nur durch enge Vernetzung von Kliniken und Praxen gelingen.

Schlussfolgerung

Versorgungsforschung ist eine gesellschaftliche Notwendigkeit. Ihre Entwicklung und Finanzierung erfordert die konzertierte Aktion aller Anbieter und Kostenträger von Gesundheitsleistungen.

Abstract

Background

Besides basic, illness- and patient-oriented research, outcomes research is regarded as the fourth pillar of modern health care systems. Outcomes research investigates both the desirable and adverse effects of medical and surgical interventions under day-to-day conditions.

Method

Because of rigorous entry criteria and selection of eligible subjects, the efficacy of a certain treatment derived from clinical experiments (i.e. classic randomized trials) may not necessarily be transferred to common patient populations or clinical settings. Apart from efficacy, a valuable (thus reimbursable) diagnostic or therapeutic procedure must prove its effectiveness in clinical practice as well. Demanding study designs are necessary to model effectiveness and to separate the observed intervention-related effects from bias and confounding.

Results

Registries and pragmatic randomized trials may represent the most appropriate modalities to establish outcomes research in trauma and orthopaedic surgery. Good examples for interventions still needing proof of effectiveness are kyphoplasty and vertebroplasty, navigated surgery, damage control, interlocking implants and bone growth factors. Revealing over- and undersupply, generating negative lists (i.e. interventions of questionable or almost nil effectiveness) and integrating patients as co-therapists requires networking between hospitals and private practitioners.

Concusion

Also, since outcomes research is a societal need, its development and funding must be ensured by all providers and payers of health care services.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Literatur

  1. Aarts MC, Hogen Esch TT, Terhaard CH et al. (2005) Guidelines in head and neck oncology compliance and consequences of deviations from the standard protocol for tongue and floor of mouth squamous carcinoma. Clin Otolaryngol 30: 444–450

    Article  PubMed  CAS  Google Scholar 

  2. Arbeitskreis „Versorgungsforschung“ beim Wissenschaftlichen Beirat der Bundesärztekammer (2004) Definition und Abgrenzung der Versorgungsforschung. http://www.bundesaerztekammer.de/30/Versorgungsforschung/10Definition/Definition.pdf

  3. Bachmann LM, Kolb E, Koller MT et al. (2003) Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ 326: 417

    Article  PubMed  Google Scholar 

  4. Bartlett C, Doyal L, Ebrahim S et al. (2005) The causes and effects of socio-demographic exclusions from clinical trials. Health Technol Assess 9: 1–171

    Google Scholar 

  5. Bledsoe BE, Wesley AK, Eckstein M et al. (2006) Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis. J Trauma 60: 1257–1266

    Article  PubMed  Google Scholar 

  6. Bryan S, Weatherburn G, Bungay H et al. (2001) The cost-effectiveness of magnetic resonance imaging for investigation of the knee joint. Health Technol Assess 5: 1–95

    CAS  Google Scholar 

  7. Clancy CM, Eisenberg JM (1998) Outcomes research: measuring the end results of health care. Science 282: 245–246

    Article  PubMed  CAS  Google Scholar 

  8. Crawford JR, Khan RJ, Varley GW (2004) Early management and outcome following soft tissue injuries of the neck-a randomised controlled trial. Injury 35: 891–895

    Article  PubMed  Google Scholar 

  9. De Maeseneer JM, Dril M van, Green LA, Weel C van (2003) The need for research in primary care. Lancet 262: 1314–1319

    Google Scholar 

  10. Deutsche Forschungsgemeinschaft (1999) Klinische Forschung. Denkschrift. Wiley-VCH, Weinheim

  11. Ellwood PM (1966) Quantitative measurement of patient care quality: 1. Measures of care. Hospitals 40: 42–45

    PubMed  Google Scholar 

  12. Ellwood PM (1966) Quantitative measurement of patient care quality: 2. A system for identifying meaningful factors. Hospitals 40: 59–63

    PubMed  Google Scholar 

  13. Ellwood PM (1988) Shattuck lecture–outcomes management. A technology of patient experience. N Engl J Med 318: 1549–1556

    Article  PubMed  CAS  Google Scholar 

  14. Endsley S, Magill MK, Godfrey MM (2006) Creating a lean practice. Fam Pract Manag 13: 34–38

    PubMed  Google Scholar 

  15. Ferrari R, Obelieniene D, Russell A et al. (2002) Laypersons‘ expectation of the sequelae of whiplash injury. A cross-cultural comparative study between Canada and Lithuania. Med Sci Monit 8: 728–734

    Google Scholar 

  16. Ferrari R, Constantoyannis C, Papadakis N (2003) Laypersons‘ expectation of the sequelae of whiplash injury: a cross-cultural comparative study between Canada and Greece. Med Sci Monit 9: 120–124

    Google Scholar 

  17. Godwin M, Ruhland L, Casson I et al. (2003) Pragmatic controlled clinical trials in primary care: the struggle between external and internal validity. BMC Medical Research Methodology 3: 28

    Article  PubMed  Google Scholar 

  18. Guller U (2006) Surgical outcomes research based on administrative data: inferior or complementary to prospective randomized clinical trials? World J Surg 30: 255–266

    Article  PubMed  Google Scholar 

  19. Hallstrom A, Rea TD, Sayre MR et al. (2006) Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest: a randomized trial. JAMA 295: 2620–2628

    Article  PubMed  CAS  Google Scholar 

  20. Hurley RE (1999) Qualitative research and the profound grasp of the obvious. Health Serv Res 34: 1119–1136

    PubMed  CAS  Google Scholar 

  21. Jencks SF, Cuerdon T, Burwen DR et al. (2000) Quality of medical care delivered to medicare beneficiaries a profile at state and national levels. JAMA 284: 1670–1676

    Article  PubMed  CAS  Google Scholar 

  22. Jones DT, Filochowski J (2006) Lean healthcare. Think yourself thin. Health Serv J 116(Suppl): 6–7

    PubMed  Google Scholar 

  23. King M, Nazareth I, Lampe F et al. (2005) Conceptual framework and systematic review of the effects of participants‘ and professionals‘ preferences in randomised controlled trials. Health Technol Assess 9: 1–186

    PubMed  CAS  Google Scholar 

  24. Kipnis K, King NM, Nelson RM (2006) An open letter to institutional review boards considering Northfield Laboratories‘ PolyHeme trial. Am J Bioeth 6: 18–21

    Article  PubMed  Google Scholar 

  25. Nathens AB, Jurkovich GJ, Maier RV et al. (2001) Relationship between trauma center volume and outcomes JAMA 285: 1164–1171

  26. Peterson ED, Roe MT, Mulgund J et al. (2006) Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA 295: 1912–1920

    Article  PubMed  CAS  Google Scholar 

  27. Pijnenburg ACM, Bogaard K, Krips R et al. (2003) Treatment of ruptures of the lateral ankle ligaments: a meta-analysis. J Bone Joint Surg Br 82: 761–773

    Google Scholar 

  28. Pirente N, Ottlik Y, Lefering R et al. (2006) Quality of life in multiply injured patients. Development of the Trauma Outcome Profile as part of the Polytrauma Outcome (POLO) Chart. Eur J Trauma 32: 44–62

    Article  Google Scholar 

  29. Pitetti R, Davis PJ, Redlinger R et al. (2006) Effect on hospital-wide sedation practices after implementation of the 2001 JCAHO procedural sedation and analgesia guidelines. Arch Pediatr Adolesc Med 160: 211–216

    Article  PubMed  Google Scholar 

  30. Righini M, Paris S, Le Gal G et al. (2006) Clinical relevance of distal deep vein thrombosis. Review of literature data. Thromb Haemost 95: 56–64

    PubMed  CAS  Google Scholar 

  31. Rosenfeld M, Seferiadis A, Carlsson J, Gunnarsson R (2003) Active intervention in patients with whiplash-associated disorders improves long-term prognosis: a randomized controlled clinical trial. Spine 28: 2491–2498

    Article  PubMed  Google Scholar 

  32. Rothwell PM (2005) External validity of randomized controlled trials: „To whom do the results of this trial apply?“ Lancet 365: 82–93

    Google Scholar 

  33. Schaapveld M, Vries EG de, Otter R et al. (2005) Guideline adherence for early breast cancer before and after introduction of the sentinel node biopsy. Br J Cancer 93: 520–528

    Article  PubMed  CAS  Google Scholar 

  34. Schneider A, Rosemann T, Wensing M, Szecsenyi J (2005) Physicians perceived usefulness of high-cost diagnostic imaging studies: results of a referral study in a German medical quality network. BMC Fam Pract 6: 22

    Article  PubMed  Google Scholar 

  35. Schnabel M, Ferrari R, Vassiliou T, Kaluza G (2004) Randomised, controlled outcome study of active mobilisation compared with collar therapy for whiplash injury. Emerg Med J 21: 306–310

    Article  PubMed  CAS  Google Scholar 

  36. Smith J, Lynch J, Sugrue M et al. (2005) An evaluation of compliance with practice guidelines on interhospital trauma transfer. Injury 36: 1051–1057

    Article  PubMed  Google Scholar 

  37. Schrappe M, Glaeske G, Gottwik M et al. für die Ständige Kongresskommission Versorgungsforschung (2005) Konzeptionelle, methodische und strukturelle Voraussetzungen der Versorgungsforschung. Dtsch Med Wochenschr 130: 2918–2922

    Google Scholar 

  38. Tunis SR, Stryer DB, Clancy CM (2003) Practical clinical trials. JAMA 290: 1624–1632

    Article  PubMed  CAS  Google Scholar 

  39. Truog RD, Robinson W, Randolph A, Morris A (1999) Is informed consent always necessary for randomized controlled trials? N Engl J Med 340: 804–807

    Article  PubMed  CAS  Google Scholar 

  40. Vargas RB, Landon BE, Shapiro MF (2000) The future of health services research in academic medicine. Am J Med 116: 503–507

    Article  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Zentrum für Klinische Forschung, Klinik für Unfallchirurgie und Orthopädie, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Deutschland

    D. Stengel

  2. Institut für Forschung in der Operativen Medizin, Private Universität Witten/Herdecke gGmbH, Witten/Herdecke, Deutschland

    E.A. Neugebauer

  3. Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland

    N.M. Meenen

Authors
  1. D. Stengel
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. E.A. Neugebauer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. N.M. Meenen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to D. Stengel.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Stengel, D., Neugebauer, E. & Meenen, N. Versorgungsforschung. Unfallchirurg 110, 792–796 (2007). https://doi.org/10.1007/s00113-007-1317-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00113-007-1317-4

Schlüsselwörter

Keywords

Search

Navigation