Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2018-11-26T11:12:22Z No. of bitstreams: 1 Carolina Campos Machado Marques Horta.pdf: 13050055 bytes, checksum: d05c55aa48de89c384578ec4803c576e (MD5) / Made available in DSpace on 2018-11-26T11:12:22Z (GMT). No. of bitstreams: 1 Carolina Campos Machado Marques Horta.pdf: 13050055 bytes, checksum: d05c55aa48de89c384578ec4803c576e (MD5) Previous issue date: 2018-08-15 / Treatment adherence has become a recurrent debate and research topic during the last 40 years. Poor adhesion is one of the main reasons for unsatisfactory results in the treatment of a disease. One of the main problems found by health professionals in the area of hip orthopedy is the poor adhesion to the preoperative and postoperative protocols for the total hip joint replacement arthroplasty, which reduce the patient's quality of life and waste health resources. This study aimed to develop and evaluate a behavioral intervention to increase the adhesion to the preoperative and postoperative protocols for the total hip joint replacement arthroplasty addressed to a patient which presented poor adhesion to the protocol in his first surgery. We used: (a) two surveys: one to evaluate the adhesion of the patient to the protocols, and the other to verify if the patient knew how to detect and describe relevant signals that should be reported to health professionals after the surgery; (b) two logs: one to evaluate the answers given by the patient in face-to-face meetings, and the other to evaluate the verbal report about his behavior in the last 24 hours in phone interviews; (c) an educational booklet with written instructions and images to guide the patient on the appropriate behavior before and after the surgery; and (d) three videos with examples of the exercises that should be executed before and after the surgery and appropriate movements of the body. In the initial meeting with the patient, we evaluated whether he fulfilled all the criteria to participate in the study. Before the intervention the researcher evaluated which behaviors were already a part of the patient's behavioral repertoire. During the intervention, the researcher used several strategies to increase the probability of adhesion to the surgical protocol, including shaping, modeling, instructions and positive reinforcement, in face-to-face meetings and in telephone interviews. After the intervention, the researcher repeated the same steps carried in before the intervention, besides phone interviews. During this phase the patient also filled a survey similar to the one used in the initial meeting. The results showed that the intervention produced a positive effect on patient's adherence to the surgical protocols. After the study, the patient presented a more complete adhesion to the items in the protocol to which adhesion was initially only partial / A adesão ao tratamento tornou-se objeto de intensas investigações e debates nos últimos 40 anos. Um dos grandes problemas encontrados pelos profissionais de saúde, na área da ortopedia do quadril, é a pobre adesão ao protocolo pré e pós-operatório da artroplastia de substituição total do quadril (ATQ), o que causa prejuízos à qualidade de vida e à saúde do paciente e desperdiça recursos de saúde. O presente estudo teve como objetivo desenvolver e avaliar uma intervenção comportamental para aumentar a adesão ao protocolo cirúrgico da revisão da artroplastia de substituição total da articulação do quadril (ARQ) por um paciente que apresentou pobre adesão ao protocolo na primeira cirurgia. Foram utilizados (a) dois questionários, um para avaliar a adesão do participante ao protocolo cirúrgico, e outro para avaliar a identificação e descrição de sinais relevantes que devem ser descritos à equipe de saúde após a cirurgia, utilizado nas fases Pré-Intervenção, Intervenção e Seguimento; (b) duas folhas de registro, uma para avaliar as respostas apresentadas pelo participante em encontros presenciais com a pesquisadora, outra para avaliar o relato sobre a ocorrência de adesão apresentada pelo participante nas últimas 24 horas em entrevistas por telefone; (c) um livreto educativo com instruções escritas e imagens relacionadas à cirurgia para orientar o participante sobre os comportamentos que devem ser apresentados no pré e no pós-operatório da ARQ e (d) três vídeos para oferecer modelos dos exercícios que devem ser executados no pré-operatório, dos movimentos apropriados após a cirurgia e dos exercícios que devem ser praticados no pós-operatório. No Encontro Inicial avaliou-se se o participante preenchia os critérios para participação no estudo. Na Pré-intervenção, a pesquisadora avaliou os comportamentos de adesão que já faziam parte do repertório comportamental do participante. Na fase Intervenção, a pesquisadora utilizou estratégias para aumentar a probabilidade de ocorrência de comportamentos de adesão ao protocolo cirúrgico, a saber, modelagem, modelação, instruções e reforçamento positivo, em encontros presenciais e em entrevistas por telefone. No seguimento a pesquisadora repetiu o mesmo procedimento da fase Pré-intervenção acrescido de entrevistas por telefone utilizadas na Intervenção e do Questionário de adesão ao protocolo cirúrgico utilizado no Encontro Inicial. Os resultados mostraram que a intervenção produziu um efeito positivo sobre a adesão do participante ao protocolo cirúrgico. Ao final do estudo o participante passou a apresentar uma adesão mais completa aos itens do tratamento para os quais a adesão era inicialmente apenas parcial

Made available in DSpace on 2016-01-26T12:51:09Z (GMT). No. of bitstreams: 1 cristianebonvicine_dissert.pdf: 1983528 bytes, checksum: 28b368ace7fce3a0702c933b45454b76 (MD5) Previous issue date: 2006-08-29 / The loss of hip mobility, spontaneous or surgical, is an important and frequent functional impairment. In the evolvement of operative techniques of the muscoskeletal system, the cemented total hip replacement is pointed out since it improves the patients quality of life. Physiotherapy is an important resource in the patients care after Total Hip Replacement (THR) to aid their functional return. Objective: to analyze the physiotherapy intervention in the improvement of pain, gait, mobility and quality of life in the postoperative period of patients who have undergone THR, moreover, comparing the physiotherapic ambulatory rehabilitation with orientations and self-care guide.Casuistics and Method: This is a randomized clinical trial and double blinded study, in which patients with osteoarthritis submitted to THR in the period of May to October 2005 were evaluated. They were objectively evaluated either for pain, gait or mobility, according to D´Aubigné and Postel´s criteria in the preoperative, with 1 month and 3 months of postoperative, respectively. Life quality was evaluated by means of the questionnaire SF-36. The patients were randomly divide into two groups: the study group and the control group. The patients of the study group were submitted to a protocol of physiotherapic treatment during twelve weeks, with two-week sessions. The control group did not receive the guide of instructions related to postoperative cares. Mood´s median test was used to evaluate the results for the non-parametric values to compare the results between the groups. Wilcoxon´s test was used to compare the evolution of the groups. A level of significance of p=0.05, with a confidence interval (CI) of 95% was used. Results: Twenty patients, 10 from the study group and 10, the control group, finished the study. In the first evaluation, there was a significance just regarding the general state of health. This showed a smaller median in the study group (p=0.025), In the second, at the 30th PO period, there was statistical significance in relation to the study group regarding both the gait (p=0.007) and the mobility (p=0.001). In the third, there was a statistical significance after three months of postoperative, and at the end of the physiotherapeutic intervention in the study group: in the functional capacity (p<0.0005), in the physical aspects (p=0,002), in the pain (p=0,019), in the vitality (p=0,025), in the emotional aspects (p<0.0005), in the gait (p=0.001) and in the mobility (p=0.010). Regarding the evolution, after three months of postoperative period, a greater median was observed in the study group according to the physical capacity (p=0.006), physical aspects (p=0,002), general state of health (p<0,0005), vitality (p=0,025) and emotional aspects (p=0,001). Conclusion: Early physiotherapy procedures can improve the rehabilitation process of patient´s submitted to THR. / A perda de mobilidade do quadril, espontânea ou cirúrgica, é um comprometimento funcional importante e freqüente. Na evolução das técnicas operatórias do aparelho locomotor, destacam-se as relacionadas com a substituição da articulação do quadril por uma prótese total de quadril cimentada que melhora a qualidade de vida dos pacientes. A fisioterapia é um importante recurso nos cuidados de pacientes após a Artroplastia Total de Quadril (ATQ) para auxiliar o retorno funcional. Objetivos: analisar a intervenção da fisioterapia na melhora da dor, marcha, mobilidade e qualidade de vida no pós-operatório de pacientes que realizaram ATQ cimentada, além de comparar a reabilitação fisioterapêutica ambulatorial com um guia de orientações e auto-cuidados. Casuística e Método: Trata-se de um ensaio clínico aleatorizado, mono-cego, no qual foram avaliados os pacientes portadores de osteoartrose submetidos a ATQ no período de maio a outubro de 2005. Os pacientes foram avaliados objetivamente quanto à dor, marcha e mobilidade, de acordo com os critérios estabelecidos por DAubigné e Postel no pré-operatório, com 1 mês e 3 meses de pós-operatório, respectivamente.A qualidade de vida foi avaliada por meio do questionário SF-36. Os pacientes foram divididos, de forma aleatória em dois grupos - o grupo de estudo e o grupo controle. Os pacientes do grupo de estudo foram submetidos a um protocolo de tratamento fisioterapêutico durante doze semanas, com duas sessões semanais. O grupo controle não recebeu intervenção fisioterapêutica padronizada precocemente, tendo recebido apenas o guia de instruções quanto aos cuidados pós-operatórios. Os resultados foram avaliados pelo teste de Mediana de Mood para valores não paramétricos a fim de comparar os resultados entre os grupos. Nota de Resumo A evolução dos grupos foi comparada utilizando-se o teste estatístico de Wilcoxon. Adotou-se um nível de significância de p= 0,05, com intervalo de confiança (IC) de 95%. Resultados: 20 pacientes terminaram o estudo, 10 pertenciam ao grupo de estudo e 10 ao grupo controle. Na avaliação inicial, houve significância apenas com relação ao estado geral de saúde, que demonstrou uma menor mediana no grupo de estudo (p=0.025).Na segunda avaliação, realizada no 30 PO, houve significância a favor do grupo de estudo com relação à marcha (p=0,007) e com relação à mobilidade (p=0,001). Na terceira avaliação, realizada após três meses de pós-operatório e ao término da intervenção fisioterápica no grupo de estudo, houve significância na capacidade funcional (p<0,0005), nos aspectos físicos (p=0,002), na dor (p=0,019), na vitalidade (p=0,025), nos aspectos emocionais (p<0,0005), na marcha (p=0,001) e na mobilidade (p=0,010). Quanto à evolução, após três meses de pós operatório, percebeu-se uma maior mediana no grupo de estudo quanto à capacidade física (p=0,006), aspectos físicos (p=0,002), estado geral de saúde (p<0,0005), vitalidade (p=0,025) e aspectos emocionais (p=0,001). Conclusão: A fisioterapia precoce auxilia no processo de recuperação dos pacientes submetidos a ATQ.

No description available.

This project attempts to quantify the integrity of the fixation of total hip arthro- T plasties (THAs) by observing vibration signal features. The aim of this thesis is, therefore, to find the signal differences between firm and loose prosthesis. These difference will be expressed in different transformed domains with the expectation that a certain domain will provide superior results. Once the signal differences have been determined they will be examined for their ability to quantify the looseness. Initially, a new definition of progressive, femoral component loosening was created, based on the application of mechanical fit, involving four general conditions. In order of increasing looseness the conditions (with their equivalent engineering associations) are listed as, firm (adherence), firm (interference), micro-loose (transition) and macro-loose (clearance). These conditions were then used to aid in the development and evaluation of a simple mathematical model based on an ordinary differential equation. Several possible parameters well suited to quantification such as gap displacement, cement/interface stiffness and apparent mass were the identified from the model. In addition, the development of this model provided a solution to the problem of unifying early and late loosening mentioned in the literature by Li et al. in 1995 and 1996. This unification permitted early (micro loose) and late (macro loose) loosening to be quantified, if necessary, with the same parameter. The quantification problem was posed as a detection problem by utilising a varying amplitude input. A set of detection techniques were developed to detect the quantity of a critical value, in this case a force. The detection techniques include deviation measures of the instantaneous frequency of the impulse response of the system (accuracy of 100%), linearity of the systems response to Gaussian input (total accuracy of 97.9% over all realisations) and observed resonant frequency linearity with respect to displacement magnitude (accuracy of 100%). Note, that as these techniques were developed with the model in mind their simulated performance was, therefore, considerably high. This critical value found by the detector was then fed into the model and a quantified output was calculated. The quantification techniques using the critical value approach include, ramped amplitude input resonant analysis (experimental accuracy of 94%) and ramped amplitude input stochastic analysis (experimental accuracy of 90%). These techniques were based on analysing the response of the system in the time-frequency domain and with respect to its short-time statistical moments to a ramping amplitude input force, respectively. In addition, other mechanically sound forms of analysis, were then applied to the output of the nonlinear model with the aim of quantifying the looseness or the integrity of fixation of the THA. The cement/interface stiffness and apparent mass techniques, inspired by the work of Chung et.al. in 1979, attempt to assess the integrity of fixation of the THA by tracking the mechanical behaviour of the components of the THA, using the frequency and magnitude of the raw transducer data. This technique has been developed fron the theory of Chung etal but with a differing perspective and provides accuracies of 82% in experimentation and 71% in simulation for the apparent mass and interface stiffness techniques, respectively. Theses techniques do not quantify all forms of clinical loosening, as clinical loosening can exist in many different forms, but they do quantify mechanical loosening or the mechanical functionality of the femoral component through related parameters that observe reduction in mechanical mass, stiffness and the amount of rattle generated by a select ghap betweent he bone/cement or prosthesis/cement interface. This form of mechanical loosening in currently extremely difficult to detect using radiographs. It is envisaged that a vibration test be used in conjunction with radiographs to provide a more complete picture of the integrity of fixation of the THA.

La prothèse totale de la hanche (PTH) avec cupule acétabulaire monobloc et articulation de grand diamètre (LDH) offre une amplitude articulaire supraphysiologique et une stabilité accrue. Reposant sur une fixation primaire par press-fit, l’implantation de ces prothèses sur des cotyles atypiques peut représenter un défi technique. L’objectif principal de ce mémoire est d’évaluer la stabilité de la fixation primaire et secondaire de ces implants lorsqu’utilisés dans un cotyle atypique en première intention ou en révision prothétique. Comme objectif secondaire, nous évaluerons les résultats fonctionnels rapportés par le patient (PROMs) à l’aide de scores validés. Deux séries de cas consécutifs de PTHs LDH monoblocs sur cotyles atypiques ont été évaluées : 125 PTHs primaires et 47 révisions de PTH (rPTH). La mesure d’efficacité primaire était la révision acétabulaire pour toutes causes aseptiques. Les PROMs ont été évalués au dernier suivi avec les scores de Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Forgotten Joint Score (FJS) et Patient’s Joint Perception (PJP). Une évaluation radiologique à la recherche de signes de descellement aseptique a été complétée au dernier suivi. En PTH primaire, après un suivi moyen de 9,2 ans (2,2-15,8), aucun descellement aseptique de la cupule n’a été identifié. Il y a eu 13 (10,4%) révisions sans lien avec la fixation acétabulaire. En rPTH, après un suivi moyen de 4,5 ans (2,0-13,7), il y a eu 5 (10,6%) ré-révision de la cupule incluant 2 pertes de fixation primaire. Le taux de luxation fut de 0% en PTH primaire et de 8,5% (4/47) en rPTH. Les résultats fonctionnels moyens en PTH primaire et rPTH étaient un WOMAC de 9,2 et 19,5 ainsi qu’un FJS de 80,9 et 57,3, respectivement. Quant au PJP en PTH primaire et en rPTH, respectivement, 49,4% et 8,8% des patients percevaient leurs hanches comme naturelle, 19,1% et 23,5% comme une articulation artificielle sans restriction tandis que 31,5% et 67,7% rapportaient un certain degré de restriction. Lorsqu’utilisés par des opérateurs expérimentés sur cotyles présentant un défi de fixation primaire, les cupules monoblocs LDH sont des options intéressantes offrant un faible taux de révision et de complication ainsi que d’excellents résultats cliniques à moyen terme. / Total hip arthroplasty (THA) with monobloc acetabular cup with large diameter bearing (LDH) offers supraphysiologic range of motion and increased stability. Relying on primary press-fit fixation, implantation of these prostheses on atypical acetabula can represent a technical challenge. The main objective of this thesis is to evaluate the stability of primary and secondary fixation of these implants on atypical acetabula in first intention or prosthetic revision. As a secondary objective, we will assess the mid-term clinical results using validated patient-reported outcome measures (PROMs). Two consecutive case series of monobloc LDH THA with atypical acetabula were evaluated: 125 THAs and 47 revisions THA (rTHA). The primary efficacy measure was acetabular revision for all aseptic causes. PROMs were assessed at last follow-up with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Forgotten Joint Score (FJS) and Patient’s Joint Perception question (PJP). A radiological evaluation assessing for signs of aseptic loosening was completed at last follow-up. In primary THA, after a mean follow-up of 9,2 years (2,2-15,8), no aseptic loosening of the acetabular cup was identified. There were 13 (10,4%) revisions unrelated to acetabular fixation. In rTHA, after a mean follow-up of 4,5 years (2,0-13,7), there were 5 (10,6%) cup re-revisions: 2 loss of primary fixation and 3 recurrent instabilities. The dislocation rate in primary THA was 0% and 8,5% (4/47) in rTHA. The average functional scores in primary THA and rTHA were a WOMAC of 9,2 and 19,5 and a FJS of 80,9 and 57,3, respectively. As for PJP in primary THA and rTHA, respectively, 49,4% and 8,8% of patients perceived their hip as natural, 19,1% and 23,5% as an unrestricted artificial joint while 31,5% and 67,7% reported some degree of restriction. When used by experienced operators on acetabula presenting a technical challenge for primary fixation, LDH monoblocs cups are attractive options offering low revision and complication rates and excellent mid-term clinical results.

No description available.

No description available.

Knie- und Hüftgelenkersatz zählt weltweit zu den erfolgreichsten und häufigsten Operationen, wenngleich 3-24% der Patienten unzufrieden sind. Der OECD-Ländervergleich ergab 2014 für Deutschland die höchste Durchführungsrate an Hüft-TEP und die zweithöchste an Knie-TEP. Erhebungen der Patientenzufriedenheit und Rückkehrbereitschaft können zur Prozessoptimierung und Qualitätsverbesserung genutzt werden und zugleich eine Steigerung der Zufriedenheit und Kundenbindung fördern. Mit der erstmaligen Aufnahme eines P4P-Ansatzes im KHSG, sind zukünftig qualitätsbezogene Zuschlagszahlungen an ein Krankenhaus unter Berücksichtigung der Patientenzufriedenheit denkbar. Damit gewinnen Erwartungen der Patienten an ein Krankenhaus zunehmend an Bedeutung, da deren Erfüllung Einfluss auf die Erlösrechnung haben kann. Parallel kann eine Anpassung der Versorgungsstruktur dazu führen, dass verstärkt Behandlungszentren entstehen und operative Eingriffe bei geringer Fallzahl in abgeschiedenen, ländlichen Regionen nicht mehr erbracht werden. Diese Studie befasste sich mit medizinischen und servicebezogenen Parametern sowie Krankenhausdaten, die signifikant mit der Zufriedenheit bei Patienten nach Knie- und Hüft-TEP assoziiert waren und die Bereitschaft in dasselbe Krankenhaus zurückzukehren beeinflussen. Neben der Frage, ob unterschiedliche Parameter Einfluss auf die Gesamtzufriedenheit und Rückkehrbereitschaft haben, wurde untersucht, inwiefern potentielle Einflussgrößen zwischen Knie- und Hüft-TEP-Patienten variieren. Zudem wurde die Relevanz verschiedener Kriterien erhoben, die aus Patientensicht Einfluss auf die Wahl eines zukünftigen Krankenhausaufenthalts haben kann. Die Daten der Studie wurden über eine schriftliche Befragung von Knie- und Hüft-TEP-Patienten gewonnen, die zwischen 2010 und 2011 in sächsischen Krankenhäusern in den Direktionsbezirken Dresden und Chemnitz behandelt wurden. Zufriedenheit und Rückkehrbereitschaft waren jeweils abhängige Variablen in mehreren logistischen Regressionsanalysen. Gemeinsam mit den unabhängigen Variablen wurden diese über einen validierten, mehrdimensionalen Fragebogen anhand 6-stufiger Skalen abgefragt und zusammen mit Routinedaten der Krankenhäuser bivariat und multivariat ausgewertet. Die Krankenhausdaten wurden den strukturierten Qualitätsberichten der Krankenhäuser entnommen. In die Analyse wurden 856 Fragebögen von Knie-TEP-Patienten und 810 Fragebögen von Hüft-TEP-Patienten eingeschlossen, was einer Rücklaufquote von 12,04% bzw. 11,89% entsprach. Bei beiden Behandlungsgruppen war im Ergebnis der multivariaten Analyse das subjektive Behandlungsergebnis sowohl mit der Gesamtzufriedenheit als auch mit der Rückkehrbereitschaft assoziiert. Postoperative Komplikationen waren jeweils nur mit der Rückkehrbereitschaft verknüpft. Einfluss auf die Rückkehrbereitschaft hatte bei Knie-TEP-Patienten zudem die Freundlichkeit des Pflegepersonals, die Organisation und der Ablauf von Untersuchungen sowie die Zimmerausstattung. Letztere wies zusammen mit der Qualität des Essens einen Zusammenhang zur Gesamtzufriedenheit bei dieser Patientengruppe auf. Bei den Hüft-TEP-Patienten war die Einschätzung der Aufenthaltsdauer, die verständliche Beantwortung von Patientenfragen durch Ärzte, die Sauberkeit und die verständliche Aufklärung über die Operation sowie die Wahrung der Privatsphäre bei Untersuchungen auch mit der Rückkehrbereitschaft assoziiert. Ein weiterer Zusammenhang zur Gesamtzufriedenheit zeigte sich dagegen bei der Einschätzung der ärztlichen Betreuung und der Einschätzung der Aufenthaltsdauer für Hüft-TEP-Patienten. Den Krankenhausparametern Behandlungsfallzahl, postoperative Beweglichkeit und Reoperation lag kein Zusammenhang gegenüber den abhängigen Variablen zugrunde. Die Befragten beider Behandlungsgruppen gaben gleichermaßen an, dass die Qualität der Behandlung bei der zukünftigen Wahl eines Krankenhauses am wichtigsten ist. Demgegenüber waren die Entfernung der Klinik zum Wohnort sowie die Größe des Krankenhauses im unteren Bereich der Bewertung angesiedelt. Es konnten verschiedene Interventionsmaßnahmen aufgezeigt werden, die auf der Makro-, Meso- und Mikroebene einzuordnen waren und in ihren Auswirkungen den einzelnen Patienten ebenso wie Entscheidungsträger im Gesundheitswesen ansprechen. Die relevanten Einflussfaktoren aus Patientensicht zeigten, dass Zufriedenheit und Rückkehrbereitschaft differenziert bewertet werden und auch zwischen Knie- und Hüft-TEP-Patienten variieren. Die Ergebnisse liefern krankenhausübergreifend wertvolle Informationen und unterstützen das medizinische Fachpersonal, Erwartungen von Knie- und Hüft-TEP-Patienten gerecht zu werden, die sich unter anderem auf die Bereiche Personalentwicklung, Patientenaufklärung und Catering erstreckten. Patientenzufriedenheit kann sich auf die Compliance auswirken, womit ein verbessertes Behandlungsergebnis erreicht werden kann. Infolge einer gezielten Steigerung der Patientenzufriedenheit sind Einsparungen durch eine kürzere Krankenhausverweildauer oder seltenere Komplikationen denkbar. Somit konnte die Präsenz der Patientenzufriedenheit im Rahmen aktueller DRG-Abrechnungsverfahren und zukünftig unter Berücksichtigung des P4P-Ansatzes aufgezeigt werden, die neben einer Erlössteigerung für das einzelne Krankenhaus zugleich Einsparungen auf der Gesundheitssystemebene bewirken kann. In Betracht an den im Aufbau befindlichen P4P-Ansatz, können die Ergebnisse als Grundlage dienen, um die Wirksamkeit der Patientenzufriedenheit als einem von vier möglichen Leistungszielen statistisch auf deren Wirksamkeit zu überprüfen. Die Bewertung verschiedener Parameter bei der zukünftigen Wahl eines Krankenhauses deutet darauf hin, dass sich weitere Anfahrtswege infolge der im Wandel befindlichen Versorgungsstruktur aus Patientensicht nicht nachteilig auswirken werden. / Knee and hip joint replacements are among the most successful and frequent operations conducted worldwide, with 3-24% of all patients being dissatisfied. In 2014, an OECD country comparison showed that Germany had the highest implementation rate for total hip replacement and the second highest for total knee replacement. Surveys of patient satisfaction and willingness to return can be used to optimize processes and improve quality while at the same time encouraging an increase in satisfaction and customer loyalty. With the first-time inclusion of a P4P approach in the German Hospital Structures Act (Krankenhausstrukturgesetz (KHSG)), quality-related supplementary payments to a hospital may be feasible in the future, taking patient satisfaction into account. In this way, patients' expectations of a hospital increasingly gain in importance, since their fulfilment can have an impact on the revenue calculation. At the same time, an adjustment of the care structure may lead to the increasing emergence of treatment centers and that surgical intervention will no longer be provided in isolated, rural regions with a sparse number of cases. This study looked at medical and services-related parameters as well as hospital data significantly associated with satisfaction in patients after total knee and hip endoprosthesis and affecting their willingness to return to the same hospital. In addition to the question whether different parameters have an influence on the overall satisfaction and willingness to return, the extent was examined to which potential influencing variables vary between the total knee and hip endoprosthesis patients. In addition, the relevance of different criteria was assessed, which from the view of a patient may have an influence on the choice of a future hospital stay. The data of the study were obtained through a written survey of total knee and hip endoprosthesis patients treated between 2010 and 2011 in Saxon hospitals of the directorate districts of Dresden and Chemnitz. In several logistic regression analyses, the dependent variables were satisfaction and returnability, respectively. These were obtained together with the independent variables on the basis of 6-step scales by way of a validated, multidimensional questionnaire and were evaluated in bivariate and multivariate manner together with the routine data of the hospitals. The hospital data were retrieved from the structured quality reports of the hospitals. The analysis included 856 questionnaires of total knee endoprosthesis patients and 810 questionnaires of total hip endoprosthesis patients, which corresponded to a return rate of 12.04% and 11.89%, respectively. In the result of the multivariate analysis, the subjective outcomes of the treatment for both treatment groups were associated with overall satisfaction as well as with the readiness to return. Postoperative complications were in each case only associated with the willingness to return. In the case of total knee endoprosthesis patients, the friendliness of the nurses, the organization, and the course of examinations as well as the room equipment had an influence on the willingness to return. The latter, together with the quality of the food, was related to the overall satisfaction in this patient group. In the total hip endoprosthesis patients, the readiness to return was also associated with assessing the duration of stay, the clarity of the doctors’ answers to patients, the cleanliness, and clear information provided of the operation as well as the maintenance of privacy during examinations. A further link to the overall satisfaction of total hip endoprosthesis patients was found, however, in the assessment of medical care and the assessment of the duration of stay. The hospital parameters of the number of patients treated, postoperative mobility, and reoperation were not related to the dependent variables. Respondents of both treatment groups also stated in equal measure that the quality of treatment is most important in their future choice of a hospital. On the other hand, the distance from the hospital to the place of residence, as well as the size of the hospital, was located in the lower segment of the evaluation. Various interventions could be identified, which could be categorized on the macro, meso, and micro level and of which their impacts are addressed to the individual patient as well as the decision makers in the healthcare system. The relevant influencing factors from the patient's view showed that satisfaction and the willingness to return are assessed differently and also vary between the knee and the hip endoprosthesis patients. The results provide valuable comprehensive information for hospitals and help medical professionals meet the expectations of knee and hip endoprosthesis patients, including personnel development, patient education, and catering. Patient satisfaction can affect compliance, resulting in an improved treatment outcome. As a result of a targeted increase in patient satisfaction, savings are possible due to a shorter hospital stay or more infrequent complications. Thus, the presence of patient satisfaction could be demonstrated within current DRG billing procedures and, in the future, taking into account the P4P approach, which in addition to an increase in revenue for the individual hospital at the same time can bring about savings on the health care system level. Considering the ongoing P4P approach, the results can serve as a basis to statistically assess the efficacy of patient satisfaction as one of four possible performance targets. The assessment of various parameters in the future choice of a hospital suggests that further access routes will not be disadvantageous from the patient's perspective due to the changing care structure.

Submitted Diploma thesis deals with stress-strain analysis of deformation proximal end of femur with applied total hip joint endoprosthesis (replacement) – shortcut type. To identify deformation and tensity (stress) was used computational simulation by method of final elements. Have been created two computational models TEP- type Santori and type DePuy Proxima. Geometry model Santori was created on low level model geometry through the use of X-ray photograph. Principle of geometry model type DePuy Proxima was real Femoral stem endoprosthesis which was scanned on scanner ATOS. Geometry of both these replacements were set up in program Rhinoceros 4.0 and then execute in program CatiaV5R17. Data for geometry model of femur were gained from CT chains. Material model of femur have been crated in two variants. The first one looks at structure bone tissues and the second one were created by Gruen´s zones. Femoral Stem was weighted by static equivalent resultant force acting in hip joint. Computational model of system and self solution, including depiction results, was done by ANSYS Workbench 11.0 for four model variants.

This diploma thesis deals with hip endoprothesis, primarily with endoprothesis conservative Mayo. A part of this paper considers a study aimed at an anatomy, types and modern trends in endoprothetic. On the basis of this study, gained CT data and the help of systems Ansys Workbench, Rhino Ceros and Catia there was made a model of proximal part of femur and TEP Conservative Mayo. A computational model was build up afterwards, which was used for a stress-train analysis.