Association between hospital onset of infection and outcomes in sepsis patients - A propensity score matched cohort study based on health claims data in Germany.

BACKGROUND: Hospital-acquired infections are a common source of sepsis. Hospital onset of sepsis was found to be associated with higher acute mortality and hospital costs, yet its impact on long-term patient-relevant outcomes and costs is unknown. OBJECTIVE: We aimed to assess the association between sepsis origin and acute and long-term outcomes based on a nationwide population-based cohort of sepsis patients in Germany. METHODS: This retrospective cohort study used nationwide health claims data from 23 million health insurance beneficiaries. Sepsis patients with hospital-acquired infections (HAI) were identified by ICD-10-codes in a cohort of adult patients with hospital-treated sepsis between 2013 and 2014. Cases without these ICD-10-codes were considered as sepsis cases with community-acquired infection (CAI) and were matched with HAI sepsis patients by propensity score matching. Outcomes included in-hospital/12-month mortality and costs, as well as readmissions and nursing care dependency until 12 months postsepsis. RESULTS: We matched 33,110 HAI sepsis patients with 28,614 CAI sepsis patients and 22,234 HAI sepsis hospital survivors with 19,364 CAI sepsis hospital survivors. HAI sepsis patients had a higher hospital mortality than CAI sepsis patients (32.8% vs. 25.4%, RR 1.3, p < .001). Similarly, 12-months postacute mortality was higher (37.2% vs. 30.1%, RR=1.2, p < .001). Hospital and 12-month health care costs were 178% and 22% higher in HAI patients than in CAI patients, respectively. Twelve months postsepsis, HAI sepsis survivors were more often newly dependent on nursing care (33.4% vs. 24.0%, RR=1.4, p < .001) and experienced 5% more hospital readmissions (mean number of readmissions: 2.1 vs. 2.0, p < .001). CONCLUSIONS: HAI sepsis patients face an increased risk of adverse outcomes both during the acute sepsis episode and in the long-term. Measures to prevent HAI and its progression into sepsis may be an opportunity to mitigate the burden of long-term impairments and costs of sepsis, e.g., by early detection of HAI progressing into sepsis, particularly in normal wards; adequate sepsis management and adherence to sepsis bundles in hospital-acquired sepsis; and an improved infection prevention and control.

Assessing the Use of German Claims Data Vocabularies for Research in the Observational Medical Outcomes Partnership Common Data Model: Development and Evaluation Study.

Background: National classifications and terminologies already routinely used for documentation within patient care settings enable the unambiguous representation of clinical information. However, the diversity of different vocabularies across health care institutions and countries is a barrier to achieving semantic interoperability and exchanging data across sites. The Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) enables the standardization of structure and medical terminology. It allows the mapping of national vocabularies into so-called standard concepts, representing normative expressions for international analyses and research. Within our project "Hybrid Quality Indicators Using Machine Learning Methods" (Hybrid-QI), we aim to harmonize source codes used in German claims data vocabularies that are currently unavailable in the OMOP CDM. Objective: This study aims to increase the coverage of German vocabularies in the OMOP CDM. We aim to completely transform the source codes used in German claims data into the OMOP CDM without data loss and make German claims data usable for OMOP CDM-based research. Methods: To prepare the missing German vocabularies for the OMOP CDM, we defined a vocabulary preparation approach consisting of the identification of all codes of the corresponding vocabularies, their assembly into machine-readable tables, and the translation of German designations into English. Furthermore, we used 2 proposed approaches for OMOP-compliant vocabulary preparation: the mapping to standard concepts using the Observational Health Data Sciences and Informatics (OHDSI) tool Usagi and the preparation of new 2-billion concepts (ie, concept_id >2 billion). Finally, we evaluated the prepared vocabularies regarding completeness and correctness using synthetic German claims data and calculated the coverage of German claims data vocabularies in the OMOP CDM. Results: Our vocabulary preparation approach was able to map 3 missing German vocabularies to standard concepts and prepare 8 vocabularies as new 2-billion concepts. The completeness evaluation showed that the prepared vocabularies cover 44.3% (3288/7417) of the source codes contained in German claims data. The correctness evaluation revealed that the specified validity periods in the OMOP CDM are compliant for the majority (705,531/706,032, 99.9%) of source codes and associated dates in German claims data. The calculation of the vocabulary coverage showed a noticeable decrease of missing vocabularies from 55% (11/20) to 10% (2/20) due to our preparation approach. Conclusions: By preparing 10 vocabularies, we showed that our approach is applicable to any type of vocabulary used in a source data set. The prepared vocabularies are currently limited to German vocabularies, which can only be used in national OMOP CDM research projects, because the mapping of new 2-billion concepts to standard concepts is missing. To participate in international OHDSI network studies with German claims data, future work is required to map the prepared 2-billion concepts to standard concepts.

Return to work after sepsis-a German population-based health claims study.

Background: Long-term impairments after sepsis can impede the return to work in survivors. We aimed to describe rates of return to work 6 and 12 months postsepsis. Methods: This retrospective, population-based cohort study was based on health claims data of the German AOK health insurance of 23.0 million beneficiaries. We included 12-months survivors after hospital-treated sepsis in 2013/2014, who were ≤60 years at the time of the admission and were working in the year presepsis. We assessed the prevalence of return to work (RTW), persistent inability to work and early retirement. Results: Among 7,370 working age sepsis survivors, 69.2% returned to work at 6 months postsepsis, while 22.8% were on sick leave and 8.0% retired early. At 12 months postsepsis, the RTW rate increased to 76.9%, whereas 9.8% were still on sick leave and 13.3% retired early. Survivors who returned to work had a mean of 70 (SD 93) sick leave days in the 12 months presepsis (median 28 days, IQR 108 days). Conclusion: One out of four working age sepsis survivors does not resume work in the year postsepsis. Specific rehabilitation and targeted aftercare may be opportunities to reduce barriers to RTW after sepsis.

Urban-Rural Disparities in Case Fatality of Community-Acquired Sepsis in Germany: A Retrospective Cohort Study.

BACKGROUND: We aimed to examine urban-rural disparities in sepsis case fatality rates among patients with community-acquired sepsis in Germany. METHODS: Retrospective cohort study using de-identified data of the nationwide statutory health insurance AOK, covering approx. 30% of the German population. We compared in-hospital- and 12-month case fatality between rural and urban sepsis patients. We calculated odds ratios (OR) with 95% confidence intervals and the estimated adjusted odds ratio (ORadj) using logistic regression models to account for potential differences in the distribution of age, comorbidities, and sepsis characteristics between rural and urban citizens. RESULTS: We identified 118,893 hospitalized patients with community-acquired sepsis in 2013-2014 with direct hospital admittance. Sepsis patients from rural areas had lower in-hospital case fatality rates compared to their urban counterparts (23.7% vs. 25.5%, p < 0.001, Odds Ratio (OR) = 0.91 (95% CI 0.88, 0.94), ORadj = 0.89 (95% CI 0.86, 0.92)). Similar differences were observable for 12-month case fatalities (45.8% rural vs. 47.0% urban 12-month case fatality, p < 0.001, OR = 0.95 (95% CI 0.93, 0.98), ORadj = 0.92 (95% CI 0.89, 0.94)). Survival benefits were also observable in rural patients with severe community-acquired sepsis or patients admitted as emergencies. Rural patients of <40 years had half the odds of dying in hospital compared to urban patients in this age bracket (ORadj = 0.49 (95% CI 0.23, 0.75), p = 0.002). CONCLUSION: Rural residence is associated with short- and long-term survival benefits in patients with community-acquired sepsis. Further research on patient, community, and health-care system factors is needed to understand the causative mechanisms of these disparities.

German Claims Data for Real-World Research: Content Coverage Evaluation in OMOP CDM.

Research on real-world data is becoming increasingly important. The current restriction to clinical data in Germany limits the view of the patient. To gain comprehensive insights, claims data can be added to the existing knowledge. However, standardized transfer of German claims data into OMOP CDM is currently not possible. In this paper, we conducted an evaluation regarding the coverage of source vocabularies and data elements of German claims data in OMOP CDM. We point out the need to extend vocabularies and mappings to support research on German claims data.

The Effects of Postacute Rehabilitation on Mortality, Chronic Care Dependency, Health Care Use, and Costs in Sepsis Survivors.

Rationale: Sepsis often leads to long-term functional deficits and increased mortality in survivors. Postacute rehabilitation can decrease long-term sepsis mortality, but its impact on nursing care dependency, health care use, and costs is insufficiently understood. Objectives: To assess the short-term (7-12 months postdischarge) and long-term (13-36 months postdischarge) effect of inpatient rehabilitation within 6 months after hospitalization on mortality, nursing care dependency, health care use, and costs. Methods: An observational cohort study used health claims data from the health insurer AOK (Allgemeine Ortskrankenkasse). Among 23.0 million AOK beneficiaries, adult beneficiaries hospitalized with sepsis in 2013-2014 were identified by explicit codes from the International Classification of Diseases, Tenth Revision. The study included patients who were nonemployed presepsis, for whom rehabilitation is reimbursed by the AOK and thus included in the dataset, and who survived at least 6 months postdischarge. The effect of rehabilitation was estimated by statistical comparisons of patients with rehabilitation (treatment group) and those without (reference group). Possible differential effects were investigated for the subgroup of ICU-treated sepsis survivors. The study used inverse probability of treatment weighting based on propensity scores to adjust for differences in relevant covariates. Costs for rehabilitation in the 6 months postsepsis were not included in the cost analysis. Results: Among 41,918 6-month sepsis survivors, 17.2% (n = 7,224) received rehabilitation. There was no significant difference in short-term survival between survivors with and without rehabilitation. Long-term survival rates were significantly higher in the rehabilitation group (90.4% vs. 88.7%; odds ratio [OR] = 1.2; 95% confidence interval [95% CI] = 1.1-1.3; P = 0.003). Survivors with rehabilitation had a higher mean number of hospital readmissions (7-12 months after sepsis: 0.82 vs. 0.76; P = 0.014) and were more frequently dependent on nursing care (7-12 months after sepsis: 47.8% vs. 42.3%; OR = 1.2; 95% CI = 1.2-1.3; P < 0.001; 13-36 months after sepsis: 52.5% vs. 47.5%; OR = 1.2; 95% CI = 1.1-1.3; P < 0.001) compared with those without rehabilitation, whereas total health care costs at 7-36 months after sepsis did not differ between groups. ICU-treated sepsis patients with rehabilitation had higher short- and long-term survival rates (short-term: 93.5% vs. 90.9%; OR = 1.5; 95% CI = 1.2-1.7; P < 0.001; long-term: 89.1% vs. 86.3%; OR = 1.3; 95% CI = 1.1-1.5; P < 0.001) than ICU-treated sepsis patients without rehabilitation. Conclusions: Rehabilitation within the first 6 months after ICU- and non-ICU-treated sepsis is associated with increased long-term survival within 3 years after sepsis without added total health care costs. Future work should aim to confirm and explain these exploratory findings.

Occurrence and Risk Factors for New Dependency on Chronic Care, Respiratory Support, Dialysis and Mortality in the First Year After Sepsis.

Sepsis survival is associated with adverse outcomes. Knowledge about risk factors for adverse outcomes is lacking. We performed a population-based cohort study of 116,507 survivors of hospital-treated sepsis identified in health claims data of a German health insurance provider. We determined the development and risk factors for long-term adverse events: new dependency on chronic care, chronic dialysis, long-term respiratory support, and 12-month mortality. At-risk patients were defined by absence of these conditions prior to sepsis. Risk factors were identified using simple and multivariable logistic regression analyses. In the first year post-sepsis, 48.9% (56,957) of survivors had one or more adverse outcome, including new dependency on chronic care (31.9%), dialysis (2.8%) or respiratory support (1.6%), and death (30.7%). While pre-existing comorbidities adversely affected all studied outcomes (>4 comorbidities: OR 3.2 for chronic care, OR 4.9 for dialysis, OR 2.7 for respiratory support, OR 4.7 for 12-month mortality), increased age increased the odds for chronic care dependency and 12-month mortality, but not for dialysis or respiratory support. Hospital-acquired and multi-resistant infections were associated with increased risk of chronic care dependency, dialysis, and 12-month mortality. Multi-resistant infections also increased the odds of respiratory support. Urinary or respiratory infections or organ dysfunction increased the odds of new dialysis or respiratory support, respectively. Central nervous system infection and organ dysfunction had the highest OR for chronic care dependency among all infections and organ dysfunctions. Our results imply that patient- and infection-related factors have a differential impact on adverse life changing outcomes after sepsis. There is an urgent need for targeted interventions to reduce the risk.

Collateral Effects and Mortality of Kidney Transplant Recipients during the COVID-19 Pandemic.

Background: Collateral effects and consequences of the coronavirus disease 19 (COVID-19) pandemic on kidney transplant recipients remain widely unknown. Methods: This retrospective cohort study examined changes in admission rates, incidences of diseases leading to hospitalization, in-patient procedures, and maintenance medication in long-term kidney transplant recipients with functioning graft during the early COVID-19 pandemic in Germany. Data were derived from a nationwide health insurance database. Analysis was performed from March 15 to September 30 and compared the years 2019 and 2020. Effects on mortality and adverse allograft events were compared with COVID-19-attributed effects. Results: A total of 7725 patients were included in the final analysis. Admissions declined in 2020 by 17%, with the main dip during a 3-month lockdown (-31%) but without a subsequent rebound. Incidences for hospitalization did not increase for any investigated disease entities, whereas decreasing trends were noted for non-COVID-19 pulmonary and urogenital infections (incidence rate ratio 0.8, 95% CI, 0.62 to 1.03, and 0.82, 95% CI, 0.65 to 1.04, respectively). Non-COVID-19 hospital stays were 0.6 days shorter (P=0.03) and not complicated by increased dialysis, ventilation, or intensive care treatment rates. In-hospital and 90-day mortality remained stable. Incidences of severe COVID-19 requiring hospitalization was 0.09 per 1000 patient-days, and in-hospital mortality was 9%. A third (31%) of patients with calcineurin-inhibitor medication and without being hospitalized for COVID-19 reduced doses by at least 25%, which was associated with an increased allograft rejection risk (adjusted hazard ratio 1.29, 95% CI, 1.02 to 1.63). COVID-19 caused 17% of all deaths but had no significant association with allograft rejections. All-cause mortality remained stable (incidence rate ratio 1.15, 95% CI, 0.91 to 1.46), also when restricting analysis to patients with no or outpatient-treated COVID-19 (0.97, 95% CI, 0.76 to 1.25). Conclusion: Despite significant collateral effects, mortality remained unchanged during the early COVID-19 pandemic. Considerable temporary reductions in admissions are safe, whereas reducing immunosuppression results in increased allograft rejection risk.

Development and validation of risk-adjusted quality indicators for the long-term outcome of acute sepsis care in German hospitals based on health claims data.

Background: Methods for assessing long-term outcome quality of acute care for sepsis are lacking. We investigated a method for measuring long-term outcome quality based on health claims data in Germany. Materials and methods: Analyses were based on data of the largest German health insurer, covering 32% of the population. Cases (aged 15 years and older) with ICD-10-codes for severe sepsis or septic shock according to sepsis-1-definitions hospitalized in 2014 were included. Short-term outcome was assessed by 90-day mortality; long-term outcome was assessed by a composite endpoint defined by 1-year mortality or increased dependency on chronic care. Risk factors were identified by logistic regressions with backward selection. Hierarchical generalized linear models were used to correct for clustering of cases in hospitals. Predictive validity of the models was assessed by internal validation using bootstrap-sampling. Risk-standardized mortality rates (RSMR) were calculated with and without reliability adjustment and their univariate and bivariate distributions were described. Results: Among 35,552 included patients, 53.2% died within 90 days after admission; 39.8% of 90-day survivors died within the first year or had an increased dependency on chronic care. Both risk-models showed a sufficient predictive validity regarding discrimination [AUC = 0.748 (95% CI: 0.742; 0.752) for 90-day mortality; AUC = 0.675 (95% CI: 0.665; 0.685) for the 1-year composite outcome, respectively], calibration (Brier Score of 0.203 and 0.220; calibration slope of 1.094 and 0.978), and explained variance (R 2 = 0.242 and R 2 = 0.111). Because of a small case-volume per hospital, applying reliability adjustment to the RSMR led to a great decrease in variability across hospitals [from median (1st quartile, 3rd quartile) 54.2% (44.3%, 65.5%) to 53.2% (50.7%, 55.9%) for 90-day mortality; from 39.2% (27.8%, 51.1%) to 39.9% (39.5%, 40.4%) for the 1-year composite endpoint]. There was no substantial correlation between the two endpoints at hospital level (observed rates: ρ = 0, p = 0.99; RSMR: ρ = 0.017, p = 0.56; reliability-adjusted RSMR: ρ = 0.067; p = 0.026). Conclusion: Quality assurance and epidemiological surveillance of sepsis care should include indicators of long-term mortality and morbidity. Claims-based risk-adjustment models for quality indicators of acute sepsis care showed satisfactory predictive validity. To increase reliability of measurement, data sources should cover the full population and hospitals need to improve ICD-10-coding of sepsis.

Epidemiology and Costs of Postsepsis Morbidity, Nursing Care Dependency, and Mortality in Germany, 2013 to 2017.

Importance: Sepsis survivorship is associated with postsepsis morbidity, but epidemiological data from population-based cohorts are lacking. Objective: To quantify the frequency and co-occurrence of new diagnoses consistent with postsepsis morbidity and mortality as well as new nursing care dependency and total health care costs after sepsis. Design, Setting, and Participants: This retrospective cohort study based on nationwide health claims data included a population-based cohort of 23.0 million beneficiaries of a large German health insurance provider. Patients aged 15 years and older with incident hospital-treated sepsis in 2013 to 2014 were included. Data were analyzed from January 2009 to December 2017. Exposures: Sepsis, identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) hospital discharge codes. Main Outcomes and Measures: New medical, psychological, and cognitive diagnoses; long-term mortality; dependency on nursing care; and overall health care costs in survivors at 1 to 12, 13 to 24, and 25 to 36 months after hospital discharge. Results: Among 23.0 million eligible individuals, we identified 159 684 patients hospitalized with sepsis in 2013 to 2014. The mean (SD) age was 73.8 (12.8) years, and 75 809 (47.5%; 95% CI, 47.2%-47.7%) were female patients. In-hospital mortality was 27.0% (43 177 patients; 95% CI, 26.8%-27.3%). Among 116 507 hospital survivors, 86 578 (74.3%; 95% CI, 74.1%-74.6%) had a new diagnosis in the first year post sepsis; 28 405 (24.4%; 95% CI, 24.1%-24.6%) had diagnoses co-occurring in medical, psychological, or cognitive domains; and 23 572 of 74 878 survivors (31.5%; 95% CI, 31.1%-31.8%) without prior nursing care dependency were newly dependent on nursing care. In total, 35 765 survivors (30.7%; 95% CI, 30.4%-31.0%) died within the first year. In the second and third year, 53 089 (65.8%; 95% CI, 65.4%-66.1%) and 40 959 (59.4%; 95% CI, 59.0%-59.8%) had new diagnoses, respectively. Health care costs for sepsis hospital survivors for 3 years post sepsis totaled a mean of €29 088/patient ($32 868/patient) (SD, €44 195 [$49 938]). New postsepsis morbidity (>1 new diagnosis) was more common in survivors of severe sepsis (75.6% [95% CI, 75.1%-76.0%]) than nonsevere sepsis (73.7% [95% CI, 73.4%-74.0%]; P < .001) and more common in survivors treated in the intensive care unit (78.3% [95% CI, 77.8%-78.7%]) than in those not treated in the intensive care unit (72.8% [95% CI, 72.5%-73.1%]; P < .001). Postsepsis morbidity was 68.5% (95% CI, 67.5%-69.5%) among survivors without prior morbidity and 56.1% (95% CI, 54.2%-57.9%) in survivors younger than 40 years. Conclusions and Relevance: In this study, new medical, psychological, and cognitive diagnoses consistent with postsepsis morbidity were common after sepsis, including among patients with less severe sepsis, no prior diagnoses, and younger age. This calls for more efforts to elucidate the underlying mechanisms, define optimal screening for common new diagnoses, and test interventions to prevent and treat postsepsis morbidity.

6-month mortality and readmissions of hospitalized COVID-19 patients: A nationwide cohort study of 8,679 patients in Germany.

BACKGROUND: COVID-19 frequently necessitates in-patient treatment and in-patient mortality is high. Less is known about the long-term outcomes in terms of mortality and readmissions following in-patient treatment. AIM: The aim of this paper is to provide a detailed account of hospitalized COVID-19 patients up to 180 days after their initial hospital admission. METHODS: An observational study with claims data from the German Local Health Care Funds of adult patients hospitalized in Germany between February 1 and April 30, 2020, with PCR-confirmed COVID-19 and a related principal diagnosis, for whom 6-month all-cause mortality and readmission rates for 180 days after admission or until death were available. A multivariable logistic regression model identified independent risk factors for 180-day all-cause mortality in this cohort. RESULTS: Of the 8,679 patients with a median age of 72 years, 2,161 (24.9%) died during the index hospitalization. The 30-day all-cause mortality rate was 23.9% (2,073/8,679), the 90-day rate was 27.9% (2,425/8,679), and the 180-day rate, 29.6% (2,566/8,679). The latter was 52.3% (1,472/2,817) for patients aged ≥80 years 23.6% (1,621/6,865) if not ventilated during index hospitalization, but 53.0% in case of those ventilated invasively (853/1,608). Risk factors for the 180-day all-cause mortality included coagulopathy, BMI ≥ 40, and age, while the female sex was a protective factor beyond a fewer prevalence of comorbidities. Of the 6,235 patients discharged alive, 1,668 were readmitted a total of 2,551 times within 180 days, resulting in an overall readmission rate of 26.8%. CONCLUSIONS: The 180-day follow-up data of hospitalized COVID-19 patients in a nationwide cohort representing almost one-third of the German population show significant long-term, all-cause mortality and readmission rates, especially among patients with coagulopathy, whereas women have a profoundly better and long-lasting clinical outcome compared to men.

[Definition of Variables in Hospital Discharge Data: Pitfalls and Proposed Solutions]. / Variablendefinition in fallbezogenen Krankenhausabrechnungsdaten ­ Fallstricke und Lösungsmöglichkeiten.

In Germany, the Diagnosis-Related Group Statistics (DRG Statistics) supply full coverage of inpatient episodes in acute care hospitals. The Research Data Centres of the Federal Statistical Office and the Statistical Offices of the Federal States provide the microdata of the DRG Statistics, namely hospital discharge files of each inpatient case, for scientific research. Hospital discharge data are generated for administrative purposes. As well as other data sources, they have specific features and characteristics, which should be considered in planning and designing research studies. A key challenge is the appropriate and sophisticated operationalization of units of analysis, targets variables, and other study variables. The methodological approach should consider, among other factors, differing coding behaviour between hospitals in order to minimize the risk of bias. This contribution shows by practical examples what should be incorporated in variable definition to ensure that the risk of bias by coding behaviour or other factors is minimized to the greatest possible degree. First of all, the features and characteristics of the German hospital discharge data are outlined. Based on the authors' experiences, basic steps and challenges in observational health services research studies are described. Examples are illustrated by our own calculations, derived from previous studies based on the microdata of the DRG Statistics. The reliability and validity of analyses based on hospital discharge data are crucially dependent on the appropriateness of variable definition. To minimize the risk of bias and misinterpretation, extensive preliminary considerations are required which involve clinical aspects, as well as the context of data collection and technical classification opportunities. Hopefully, there will be greater acceptance of research based on hospital discharge data, so that these valuable data will be used more frequently for research purposes in the future.

Correction to: Amputation rates of the lower limb by amputation level - observational study using German national hospital discharge data from 2005 to 2015.

In the original publication of this article [1], some numbers in the below sentence errors in the Results section of the Abstract.

[Lower Extremity Amputation in Germany: Regional Analysis using Nationwide Hospital Discharge Data 2011-2015]. / Amputationen der unteren Extremität in Deutschland ­ Regionale Analyse mit Krankenhausabrechnungsdaten von 2011 bis 2015.

OBJECTIVES: Amputations reduce irreversibly the quality of life. Health care always aims at avoiding amputations, and the quality of such care provided nationwide should be the same. This study aims to display rates of amputations at the county level and to uncover differences in health care. METHODS: Using German nationwide hospital discharge data, amputations between 2011 and 2015 were identified. Regional variation is displayed using raw and risk-standardized rates per 100,000 persons. Furthermore, the Systematic Component of Variation (SCV) was computed and Funnel Plots display the Standardized Morbidity Ratio (SMR). RESULTS: The median amputation rate during the observation period was 67 cases per 100,000 persons with a 6-fold variation between counties. Variation between counties remained independent of demographic differences. Higher rates got visible especially within counties in the East and Southeast. The highest systematic variation was seen in amputation heights toe/foot ray (SCV 11.8) and foot complete and mid-/forefoot (SCV 11.7). CONCLUSION: In Germany, there are significant regional variations of amputation rates at the county level. The systematic variation is strongest within peripheral amputation heights. Especially in the East and Southeast of Germany, clusters of high amputation rates give insights in the potential regional need for improvement.

Amputation rates of the lower limb by amputation level - observational study using German national hospital discharge data from 2005 to 2015.

BACKGROUND: In international comparisons, rates of amputations of the lower limb are relatively high in Germany. This study aims to analyze trends in lower limb amputations over time, as well as outcomes of care concerning in-hospital mortality and reamputation rates during the same hospital stay which might indicate the quality of surgical and perioperative health care processes. METHODS: This work is an observational population-based study using complete national hospital discharge data (Diagnosis-Related Group Statistics (DRG Statistics)) from 2005 to 2015. All inpatient cases with lower limb amputation were identified and stratified by eight amputation levels. Time trends of case numbers and in-hospital mortality were studied age-sex standardized. For inpatient cases with reamputation during the same hospital stay, first and last amputation levels were cross tabulated. RESULTS: A total of 55,595 amputations of the lower limb in 2015 (52,096 in 2005) were identified. After age-sex standardization to the demographic structure of 2005, a relative decrease of - 11.1% was revealed (men - 2.6%, women - 25.0%). The stratified analysis by amputation levels showed that the decreases were induced by higher amputation levels, whereas the amputation levels of toe/foot ray after standardization still showed a relative increase of + 12.8%. In-hospital mortality of all cases with lower limb amputation fell from 11.2% in 2005 to 7.7% in 2015 (SMR 0.89 [95% CI 0.86; 0.92]). The percentage of reamputations during the same hospital stay declined from 13.2 to 10.2%. CONCLUSIONS: The number of lower limb amputations declined in Germany, however distinctly stronger in women than in men. The observed decreases of in-hospital mortality as well as of reamputation rates point to improvements in perioperative health care. Despite these indications of improvements, the distinct increase in case numbers at the level of toe/foot ray calls for additional targeted prevention efforts, especially for patients with diabetes.

[Volume Growth of Inpatient Treatments for Spinal Disease - Analysis of German Nationwide Hospital Discharge Data from 2005 to 2014]. / Mengenentwicklung stationärer Behandlungen bei Erkrankungen der Wirbelsäule ­ Analyse der deutschlandweiten Krankenhausabrechnungsdaten von 2005 bis 2014.

BACKGROUND: Marked volume growth of inpatient treatments for spinal disease has been observed since diagnosis related groups (DRG) were introduced as payment for inpatient services in Germany. This study aims to analyse this increase by population and stratified by types of treatment. MATERIAL AND METHODS: Using German nationwide hospital discharge data (DRG statistics), inpatient treatments for spinal disease with or without surgery were identified. Trends in case numbers were analysed from 2005 to 2014 with consideration of demographic changes, in order to explore which age groups and which types of treatment are affected by volume growth. RESULTS: In 2014 (2005), 289 000 (177 000) inpatient treatments with surgery and 463 000 (287 000) treatments without surgery were identified. After adjusting for demographic factors, treatments with and without surgery exhibited a relative volume growth of + 50%. This increase affected higher age groups and women, in particular. Depending on the type of treatment, very different degrees of volume growth were observed. For example, disc surgeries adjusted for demographic change increased by about + 5%, whereas spinal fusion and vertebral replacement surgeries, kypho-/vertebroplasties and decompression of the spine more than doubled. Within the non-surgically treated cases, local pain therapies of the spine increased after adjustment for demographic changes by about + 142%. The conservatively treated cases showed a demographically adjusted increase of + 22%. CONCLUSION: Apart from demographic changes, this analysis cannot resolve the underlying causes of volume growth in treatments for spinal disease. However, the stratified analysis of various subgroups may help to classify these developments in a more differentiated manner. The results may support a more targeted debate about potential over- or misallocation of inpatient services in this area.

Reported Energy Intake Accuracy Compared to Doubly Labeled Water and Usability of the Mobile Food Record among Community Dwelling Adults.

The mobile Food Record (mFR) is an image-based dietary assessment method for mobile devices. The study primary aim was to test the accuracy of the mFR by comparing reported energy intake (rEI) to total energy expenditure (TEE) using the doubly labeled water (DLW) method. Usability of the mFR was assessed by questionnaires before and after the study. Participants were 45 community dwelling men and women, 21-65 years. They were provided pack-out meals and snacks and encouraged to supplement with usual foods and beverages not provided. After being dosed with DLW, participants were instructed to record all eating occasions over a 7.5 days period using the mFR. Three trained analysts estimated rEI from the images sent to a secure server. rEI and TEE correlated significantly (Spearman correlation coefficient of 0.58, p < 0.0001). The mean percentage of underreporting below the lower 95% confidence interval of the ratio of rEI to TEE was 12% for men (standard deviation (SD) ± 11%) and 10% for women (SD ± 10%). The results demonstrate the accuracy of the mFR is comparable to traditional dietary records and other image-based methods. No systematic biases could be found. The mFR was received well by the participants and usability was rated as easy.