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The shortage of specialists in SHI-accredited medical care is increasingly affecting medical assistants (MFA) in medical practices and Medical Care Center (MVZ). Training can mitigate the associated problems in the future, but currently only 42% of practices provide training. A survey of a sample of large ophthalmic centers was conducted to test the hypothesis that larger practices and MVZs provide disproportionate training. In addition, an interaction between ownership (physician-owned (äE); third-party owned (F)) and training engagement was evaluated. In a questionnaire-based complete survey (2022) of large ophthalmic centers of different ownerships organized in a network, the training rate by main operating site (HBS), the number of MFA trainees (MFA-A) per HBS, staffing problems and planned change in training commitment were collected. The distribution measures of the quantitative data were analyzed overall and separately by sponsoring organization and tested for significance.Results were compared to data from a representative survey (2020/2021) of all practices and MVZs. In order to determine the proportion of all ophthalmic MFA-A accounted for by the sample, their total number was determined in an extrapolation. The training rate of the total of 100 HBS of the 14 surveyed centers (11 äE, 3 F) of the sample was 82% (äE: 93%, F: 79%), which was higher than the representative survey (41%). In the sample, there were on average 5.9 MFA-A per HBS (äE: 5.6, F: 7.1), in the comparative survey 1.5. 50% of the centers in the sample reported staffing problems, 25% wanted to expand their training commitment; the comparative values of the representative survey were 11% for both parameters. Stratified by sponsorship, neither training rate nor MFA-A per HBS showed significant differences. According to projections, there were nearly 1,966 MFA-A working in ophthalmology in 2021, of which 19.5% were at centers in the study population. Of all the MFA-A in the sample, 71% were at the significantly larger centers by number of HBS owned by third-party. The survey confirms the positive correlation between the size of practices and MVZ and commitment to training. There are no significant differences according to the ownership of organization., Competing Interests: Frau PD Dr. U. Hahn ist Geschäftsführerin des OcuNet Verbunds, Herr Prof. Dr. U. Kellner ist Mitglied im Aufsichtsrat des OcuNet Verbunds und leitender Arzt eines Zentrums, das Mitglied im OcuNet Verbund ist., (Thieme. All rights reserved.)

Background The importance of evaluating real-life data is constantly increasing. Currently available computer systems better allow for analyses of data, as more and more data is available in a digital form. Before a project for real-life data analyses is started, technical considerations and staff, legal, and data protection procedures need to be addressed. In this manuscript, experiences made at the University Eye Hospital in Munich will be shared. Materials and Methods Legal requirements, as found in laws and guidelines governing documentation and data privacy, are highlighted. Technical requirements for information technology infrastructure and software are defined. A survey conducted by the German Ophthalmological Society, among German eye hospitals investigating the current state of digitalization, was conducted. Also, staff requirements are outlined. Results A database comprising results of 330,801 patients was set up. It includes all diagnoses, procedures, clinical findings and results from diagnostic devices. This database was approved by the local data protection officer. In less than half of German eye hospitals (n = 21) that participated in the survey (n = 54), a complete electronic documentation is done. Fourteen institutions are completely paper-based, and the remainder of the hospitals used a mixed system. Conclusion In this work, we examined the framework that is required to develop a comprehensive database containing real-life data from clinics. In future, these databases will become increasingly important as more and more innovation are made in decision support systems. The base for this is comprehensive and well-curated databases., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Due to demographic change and societal transformation the number of elderly persons living in retirement homes is growing in Germany. Access to health care is more complicated in the setting of nursing homes. Different regional studies suggest unmet ophthalmological health care needs in institutionalized elderly people. This study assessed the current ophthalmological health care structure and supply status in nursing homes in Germany., Methods: This prospective, multicenter cross-sectional study was conducted by 14 study centers in Germany. Elderly people living in 32 nursing homes were included after approval by the local institutional review boards. A standardized examination was performed which included a detailed medical and ocular history, refraction, visual acuity testing, tonometry, biomicroscopy and dilated funduscopy. Unmet ophthalmological health care needs were documented and the data were analyzed descriptively and via logistic regression modelling., Results: A total of 600 participants (434 women and 166 men) aged 50-104 years were examined of which 368 (61%) had ophthalmological conditions requiring treatment. The most prevalent findings were cataracts (315; 53%), disorders of the eyelids (127; 21%), dry eye disease (57; 10%) and posterior capsule opacification (43; 7%). In 63 (11%) of the participants glaucoma was suspected and 55 (9%) of the examined population had a known diagnosis of glaucoma, of whom one third was not on any or on insufficient anti-glaucomatous therapy. 236 (39%) showed signs of age-related macular degeneration (AMD). Only 52% of the examined cohort had been examined by an ophthalmologist within the last 5 years and 39% stated that they would currently not be able to consult an ophthalmologist. Reported barriers were mainly transport and lack of support., Conclusion: This study demonstrates considerable unmet ophthalmological health care needs of the institutionalized elderly in Germany. Novel and reformed models of specialist care provision have to be developed.

Background: Technical efficiency of hospital services is debated since performance has been heterogeneous. Staff time represents the main resource in patient care and its inappropriate allocation has been identified as a key factor of inefficiency. The aim of this study was to analyse the utilisation of physicians' work time stratified by staff groups, tasks and places of work. A further aim was to use these data to estimate resource use per unit of output., Methods: A self-reporting work-sampling study was carried during 14-days at a University Eye Hospital. Staff costs of physicians per unit of output were calculated at the wards, the operating rooms and the outpatient unit., Results: Forty per cent of total work time was spent in contact with the patient. Thirty per cent was spent with documentation tasks. Time spent with documentation tasks declined monotonically with increasing seniority of staff. Unit costs were 56 € per patient day at the wards, 77 € and 20 € per intervention at the operating rooms for inpatients and outpatients, respectively, and 33 € per contact at the outpatient unit. Substantial differences in resources directly dedicated to the patient were found between these locations., Conclusion: The presented data provide unprecedented units costs in inpatient Ophthalmology. Future research should focus on analysing factors that influence differences in time allocation, such as types of patients, organisation of care processes and composition of staff.

Introduction: Individual health services (ihs) have gained importance in the German health-care system. This article describes the economic impact and the daily practice of individual health services from the perspective of ophthalmologists., Methods: An online survey to examine the role of individual health services in ophthalmology was sent to the members of the German Ophthalmological Society (DOG) and the Professional Association of Ophthalmologists in Germany (BVA). 1,361 ophthalmologists (one fifth of all ophthalmologists in Germany) responded to the poll., Results: 87.5 % of the ophthalmologists agree that the quality of ophthalmic care could suffer if the necessary individual health services were not performed. 78.9 % consider individual health services to be financially feasible for the patient. 65.6 % responded to be hardly able to survive economically without individual health services. For approximately half of the ophthalmologists, individual health services represent more than 10 % of their overall income. 57.5 % wish to abolish individual health services and to extend the service catalogue of the statutory health insurances., Discussion: In contrast to official reports about the benefit from individual health services, the ophthalmologists do see a medical need for individual health services. Obviously there is a discrepancy in the perspective between health insurers and ophthalmologists., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Eye diseases that are relevant regarding their macroeconomic costs and their impact on society include cataract, diabetic retinopathy, age-related maculopathy, glaucoma and refractive errors., Objectives: The aim of this article is to provide a comprehensive overview of direct and indirect costs for major eye disease categories for Germany, based on existing literature and data sources., Methods: A semi-structured literature search was performed in the databases Medline and Embase and in the search machine Google for relevant original papers and reviews on costs of eye diseases with relevance for or transferability to Germany (last research date October 2013). In addition, manual searching was performed in important national databases and information sources, such as the Federal Office of Statistics and scientific societies., Results: The direct costs for these diseases add up to approximately 2.6 billion Euros yearly for the Federal Republic of Germany, including out of the pocket payments from patients but excluding optical aids (e.g. glasses). In addition to those direct costs there are also indirect costs which are caused e.g. by loss of employment or productivity or by a reduction in health-related quality of life. These indirect costs can only be roughly estimated. Including the indirect costs for the eye diseases investigated, a total yearly macroeconomic cost ranging between 4 and 12 billion Euros is estimated for Germany., Conclusion: The costs for the eye diseases cataract, diabetic retinopathy, age-related maculopathy, glaucoma and refractive errors have a macroeconomic relevant dimension. Based on the predicted demographic changes with an ageing society an increase of the prevalence and thus also an increase of costs for eye diseases is expected in the future.

Background: Demographic change not only affects patients with ophthalmological diseases but also ophthalmologists., Objectives: The aim of this article is to evaluate the consequences of an aging society on health care provision. How can these challenges be overcome?, Material and Methods: Evaluation of publications from the German Federal Statistical Office about the current and projected population, analysis of own studies about health care provision, utilization, and delivery as well as the presentation and discussion of regulatory and organizational conditions., Results: There is a continuous increase in chronic and age-related diseases. At the same time the prevalence of multimorbidity and the number of patients dependent on long-term care is rising, leading to an increase in the demand for ophthalmological care. Regarding health care providers we observed a cutback in qualified ophthalmological personnel, especially for remote areas thus causing difficulties in providing adequate eye care to the population., Conclusion: To deliver health care to a growing number of patients with a decreasing number of medical professionals is the major challenge of demographic change. This will have an enormous impact on ophthalmological health care in terms of maintaining high quality health services covering a nationwide area.

Purpose: To identify and describe the most relevant obstacles to carrying out ophthalmic research in Germany., Methods: Two research methods were used to assess current problems in ophthalmic research. First, 55 expert interviews were conducted with major stakeholders in ophthalmic research, and key problems were identified. An online questionnaire was then sent to 3,080 German ophthalmologists, of whom 927 responded by evaluating the current research situation within ophthalmology in Germany. We devised a score to rank areas of concern by multiplying the responders' rate, ranging between -3 ('I disagree completely') and +3 ('I fully agree'), with the percentage of response frequencies. The maximum possible score was 300., Results: The lack of opportunities to combine clinical work and research (score: 231.8) as well as unattractive career perspectives (175.7) were identified as the most relevant problems. Further barriers were difficulties in acquiring research funds (155.7), organizational problems at the local level (143.7) and a lack of support for women (24.1; among women: 122.3). Potential improvement was expected in particular from exemption from clinical work for scientific purposes; this was found to be more appealing than more prestigious awards for research achievements. A widely held position was that research projects should focus more closely on common eye diseases, and that vision research needs a more prominent profile among politicians and in the public arena., Conclusion: Our findings may help to initiate improvements in both research performance and outcomes.

Background: The increasing number of patients taking action for medical malpractice (MM) is a burden for the medical practitioners accused. After the assessment through an arbitration committee, which is free of cost for the patients,a large number of lawsuits can be avoided. Discussion of patient complaints and analyzing cases of MM is an important concern for the medical community in order to reduce errors in treatment and to contribute to patient safety., Material and Methods: The patient applications to the arbitration committee of the medical association of North-Rhine ("Gutachterkommission Nordrhein") for review of MM in the field of ophthalmology in the years 1999-2010 were analyzed statistically., Results: In the years 1999-2010 a total of 583 cases were related to ophthalmology (3% of all cases) and in 122 cases (21%) MM was recognized by the committee. In 61% of the cases MM was caused by errors in diagnosis, in 24% by errors in processes and in 15% by errors in surgical procedures., Conclusions: The proportion of ophthalmological cases in the total number of MM cases is low. Most errors in diagnosis are caused by the lack of basic diagnostic on examination procedures. Errors in processes are caused by instrumental errors and deficient communication. An important reason for errors in surgical procedures is a deficient management of complications. A standardized workflow of medical examinations and a quality management can help to avoid MM.

Background: Over the last decade inpatient treatment has been reduced in favor of outpatient care or markedly shortened inpatient stays in most organ-specific surgical specialties such as ophthalmology in Germany., Methods: Data from the federal statistics agency on the international classification of disease (ICD), diagnosis-related groups (DRG) and performed operations and procedures from 2000 to 2010 as well as data from the Institute for Reimbursements of Hospitals (InEK) on average costs per DRG in every German DRG (G-DRG) version from 2004 to 2010 were analyzed for ophthalmology., Results: From 2000 to 2010, the number of cases with a main ophthalmological diagnosis decreased (-19 %), which was mostly due to a reduction in the number of cataract inpatients (-56 %). All subspecialties such as glaucoma (+82 %) and retina (+68 %) with the exception of primary strabismus diagnoses (-15 %) gained in number of cases. Inpatient cataract surgery was the most common surgery in 2004 but numbers decreased to 2010 (-9 %). The most often performed inpatient procedure was vitreoretinal surgery in 2007 and 2010 (increase 2004-2010 + 46 %). Average hospital stay decreased between 2005 and 2010 from 3.9 to 3.4 days and the average cost per case increased by 3.6 % overall and by 13.4 % for surgical cases., Conclusion: Ophthalmic healthcare provided as inpatient services decreased with a trend towards more complex cases being treated as inpatients from 2000 to 2010.

Background: Analysis of willingness for postmortem cornea donation by professionals in ophthalmology and their motives in favor of or against donation., Patients and Methods: 3887 members of the German Ophthalmological Society received an anonymous questionnaire concerning sociodemographic background, physical health, experiences with organ explantation and their former engagement and motives concerning organ and cornea donation., Results: 722 of the questionnaires were partially and 533 completely answered with an average willingness for cornea donation of 79.4%. Significant parameters for cornea donation were gender, former experience with organ explantation, ophthalmological health and fear of false diagnosis of brain death, worse medical treatment or organ commercialization. Of the participants 53.9% suggested the internet as a favorite source of information in this matter., Conclusion: The factors which had a significant impact on cornea donation in this survey seem to be mainly a result of insufficient information. Detailed information regarding this topic should preferentially be presented on internet pages of professional societies and could probably increase donation approval of DOG members.

Background and Purpose: Data on the epidemiology of glaucoma are sparse for Germany. Case registries from the Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung) can be used to estimate disease prevalence rates for different types of glaucoma and to illustrate the utilization of glaucoma healthcare., Methods: Analysis of healthcare data for suspected glaucoma cases and open angle, angle closure, secondary and other types of glaucoma was carried on the basis of case registries from the Association of Statutory Health Insurance Physicians in Rhineland-Palatine for the year 2010. Glaucoma cases were registered quarterly according to the ICD-10 classification for different glaucoma types (H40.0-H40.9). For the purpose of calculating the prevalence data were adjusted to the population size and compared in different age strata., Results: The estimated prevalence of suspected glaucoma, open angle, angle closure, secondary and other types of glaucoma were 0.55%, 0.97%, 0.06%, 0.10% and 0.64%, respectively, with a higher prevalence in older age groups and women. Most glaucoma cases were diagnosed in the age group between 70 and 79 years and up to 15% of the population within this age group sought glaucoma care. In more than 50% of the glaucoma cases unspecific types of glaucoma diagnosis (suspected glaucoma /other glaucoma) were used., Conclusions: The data from the Association of Statutory Health Insurance Physicians can provide information about the utilization of ophthalmic healthcare and allow estimation of the underlying glaucoma prevalence in the population. The data illustrate weaknesses in the practice of glaucoma diagnosis and indicate the lack of a widely accepted glaucoma definition.

Background: The prognosis of functional improvement after vision loss in the non-amblyopic eye in adulthood is important for counselling of the patients, but uncertain for a number of reasons. Our study focuses on two aspects. Firstly, a questionnaire was developed asking ophthalmologists and orthoptists for their opinion about the chances of significant spontaneous improvement; secondly, patient data were analysed with respect to acuity data acquisition and documentation as reasons for uncertainty concerning the prognosis., Materials and Methods: In the context of a project about age limits of amblyopia treatment, a questionnaire was developed which comprised also an item about the estimation of the prognosis after loss of vision in the non-amblyopic eye. It was distributed to ophthalmologists and orthoptists, and the answers were analysed in connection with two large, published studies about this topic . Furthermore, acuity data of three adult amblyopes were analysed after loss of function in the non-amblyopic eye., Results: The questionnaire was answered by 109 ophthalmologists and 128 orthoptists, all working in Germany. Almost 50% of the answers concerning the chances of spontaneous improvement were in agreement with the data of the two published studies, which stated that the chances of spontaneous improvement were 10% or 17.4%, respectively. More than 25% of the answers underestimated the chances for spontaneous improvement (answer: 0 to 5%). On the other hand, a number of orthoptists and ophthalmologists estimated the chances much too optimistically, some anticipating more than a 60% chance of spontaneous improvement. The analysis of the patient data showed that both acquisition and documentation of acuity data gave reasons for uncertainties concerning the prognosis for visual acuity., Conclusions: In addition to new ways of assessing treatment compliance and quality of life, knowledge about the opinion of the treating personnel concerning various aspects of a disease may lead to more evidence-based treatment. In amblyopic patients, the inclusion of certain details into the documentation (type and separation of the optotypes, optical correction) may be essential., (Georg Thieme Verlag KG Stuttgart.New York.)

Background/purpose: Ocular toxoplasmosis is the most frequent cause of posterior uveitis in Germany. The purpose of this survey was to evaluate current strategies in the management of ocular toxoplasmosis by uveitis specialists in Germany., Methods: An itemized questionnaire including clinical case reports with authentic photographs was distributed to physician members (n=40) of the German Uveitis Society. In addition, members were categorized regarding their clinical background, professional affiliation and experience with ocular toxoplasmosis., Results: The completed questionnaire was returned by 72% (29/40) of the members. According to the answers, the majority (70%) of responders base their diagnosis of ocular toxoplasmosis on clinical examination and serological findings. Although a positive IgM titre or increasing IgG titres support the diagnosis only in cases of recently acquired disease, these are reported to support the diagnosis by 58 and 41%, respectively. Invasive procedures such as aqueous humour analysis are performed by 59% of colleagues to establish the diagnosis in selected patients. A total of six antimicrobial agents were reported for treatment in different regimens for typical clinical conditions in patients with recurrent toxoplasmic retinochoroiditis. The combination of pyrimethamine and sulfadiazine is the most commonly used (48%), followed by clindamycin (38%)., Conclusions: Our survey indicates the lack of a "gold standard" for diagnosis and medical treatment in ocular toxoplasmosis. Further efforts have to be undertaken towards a better distribution of available information and to determine strategies for providing standards of continuously updated diagnostic and therapeutic recommendations for routine clinical practice.

Purpose: The use of serum eye drops has become more common for treating ocular surface diseases such as persistent epithelial defect and dry eye. For the production and use of blood products, regulatory restrictions apply. We surveyed the practice of production and application of serum eyedrops among the members of the Cornea Section of the German Ophthalmological Society (DOG) in Germany., Methods: A questionnaire concerning the application of topical blood-derived therapeutic agents for use in the eye was sent to 103 institutions in 2005 and 2007. The questionnaire included 14 groups of questions., Results: The rate of response was 49% in 2005 and 55% in 2007. Sixty-five percent (2005: 48%) of the institutions used blood-derived products as therapeutic agents in the eye (in 96%, serum eye drops). In 2007, 17% of the centers stated that they had a license to produce serum eye drops according to the official regulations (2005: 10%). Three hospitals stopped using serum eyedrops for regulatory reasons. In 2007 1,237 patients were treated (2005: 1,389); 36% of the ophthalmic departments produced the serum eye drops themselves (2005: 55%) and 43% produced them in cooperation together with or exclusively in another institution. Quality controls (e.g., virus serology and sterility checks) were performed in 47% (2005: 24%). In 2005, one corneal fibrin deposit was described. In 2007, no complication was reported., Conclusion: Although fewer patients were treated in total in 2007, the number of centers using serum eye drops increased between 2005 and 2007. Serious complications were not described. Some hospitals stopped the production and use of serum eye drops because of regulatory reasons or had the drops produced by nonophthalmic institutions with a license to produce blood-derived products. In view of prospective randomized clinical trials showing that autologous serum support ocular surface wound healing, this therapy should be accepted as a standard of care.

In an overview new data from the literature regarding alternative/complementary medicine are presented. Naturopathy, acupuncture and homeopathy as well as new findings in placebo-research and their correlation to alternative medicine are discussed. In addition, as a synthesis a patient-orientated so-called anthropologic medicine is recommended to make alternative/complementary medicine unnecessary.

Background: The objective of the study was to illustrate the effect of the extensive changes of the German DRG System on reimbursement of clinical ophthalmology during the years 2003, 2004 and 2005., Methods: All ophthalmologic patients treated as in-patients at the Department of Ophthalmology at the University Munich during the year 2003 served as a reference data basis. By means of appropriate software those cases were then re-grouped according to the G-DRG classification of the years 2003, 2004 and 2005. This resulted in different reimbursements caused only by system changes for an exemplary hospital of maximum medical care. In addition, the same calculations were performed for four virtual, typical clinics based on the calculation data of the "Institut für Entgeltsysteme (InEK)". For those four clinics it was assumed that 80 % of the cases came from one of the subspecialties retina, glaucoma, cataract or strabismus surgery., Results: Changes in the G-DRG system caused the sample hospital of maximum care to loose 8.5 % case mix index (CMI) during the period of 2003 to 2005. For three of the four virtual, typical ophthalmological clinics the theoretic reimbursement conditions also deteriorated: retina surgery -- 10.6 %, glaucoma surgery - 15.8 % and cataract surgery -- 17.9 % CMI. Only strabismus surgery showed an increase of + 5.6 % in CMI during the period examined., Conclusion: Over the years 2003 to 2005 the CMI clearly deteriorated for many ophthalmological subspecialties given otherwise identical conditions. To calculate the changes specifically for an individual hospital, the individual base rates have to be considered.

Background: Evidence-based medicine requires careful appraisal of published data derived from experimental and clinical studies. Based on classification of biomedical research reports, evidence levels can be determined and recommendations for therapeutic decisions can be made., Methods: A classification system for clinical studies was developed. It was evaluated in classifying the reports published in Der Ophthalmologe during 2003-2004 (study design: descriptive cross-sectional study, case series)., Results: In the 2-year interval, 70 longitudinal and 95 cross-sectional studies were published. The vast majority of the longitudinal studies were interventional cohort studies. Not considering case reports, 73% of the original articles were longitudinal prospective studies, 1% were retrospective (case-control) studies, and 26% were cross-sectional studies., Conclusions: The study design of all published articles could be classified using the classification system. This classification system proves to be applicable in the context of clinical studies in ophthalmology and may be helpful in the process of critical appraisal of the literature and synthesis of clinical evidence and an evidence-based recommendation.