[Discussion paper for a hospital financing reform in Germany from the perspective of intensive care medicine]. / Diskussionspapier für eine Reform der Krankenhausfinanzierung in Deutschland aus der Perspektive der Intensivmedizin.

In Germany, there are currently many voices calling for a reform of hospital planning and reimbursement to correct some aberrations of the last decades and to enable the system to cope with future challenges. Some recent political decisions to change the structures of emergency medical services as well as the introduction of mandatory nurse-to-patient ratios and the exclusion of the cost for nursing from the case-based hospital reimbursement represent first steps of a reform, which also affects intensive care and emergency medicine. In this discussion paper a group of intensivists, emergency physicians, medical controllers, and representatives of nurses suggest more far-reaching changes, which can be summarized in 5 points: (1) General hospitals with intensive care units (ICU) and emergency departments (ED) which are part of the emergency medical system should be considered as an element of public service and be planned accordingly. (2) The planning of the intensive care infrastructure should be based on the three levels of emergency medical services to identify hospitals that are system relevant and to define appropriate criteria for structure and quality measures. (3) Hospital reimbursement should consist of a base amount (covering costs for hospital staff, infrastructure plus investments) and case-based fees (covering material costs). (4) To determine the requirements for nurses, physicians, and other medical staff, adequate tools for ICU and ED should be applied. (5) For these purposes as well as for quality management and optimal medical care, hospitals should be provided with a substantially improved IT-infrastructure.

Hospitalization and Intensive Therapy at the End of Life.

BACKGROUND: Germany has more intensive care unit (ICU) beds per capita than the USA, but the utilization of these resources at the end of life is unknown. METHODS: Retrospective observational study using nationwide German hospital discharge data (DRG statistics; DRG, diag- nosis-related groups) from 2007 to 2015. We investigated hospital deaths and use of intensive care services during terminal hospitalizations. Population-based incidences were standardized to the age and sex distribution of the German population. RESULTS: Standardized hospital admission rates increased by 0.8% annually (from 201.9 to 214.6 per 1000 population), while hospital admissions involving ICU care increased by 3.0% annually (from 6.5 to 8.2 per 1000 population). Among all deaths in the German population, the proportion of hospital deaths with ICU care increased by 2.3% annually (from 9.8% to 11.8%). Among all hospital deaths, the proportion involving ICU care increased by 2.8% annually from 20.6% (2007) to 25.6% (2015). In patients aged 65 and older, the use of intensive care services during terminal hospitalizations increased 3 times faster than hospital deaths. CONCLUSION: Use of intensive care services during terminal hospitalizations increased across all age groups, particularly the elderly. The increased need for end-of-life care in the ICU calls for improvements in educational, policy, and reimbursement strategies. It is unclear whether ICU care was appropriate and compliant with patient preferences.

Comparing the validity of different ICD coding abstraction strategies for sepsis case identification in German claims data.

INTRODUCTION: Administrative data are used to generate estimates of sepsis epidemiology and can serve as source for quality indicators. Aim was to compare estimates on sepsis incidence and mortality based on different ICD-code abstraction strategies and to assess their validity for sepsis case identification based on a patient sample not pre-selected for presence of sepsis codes. MATERIALS AND METHODS: We used the national DRG-statistics for assessment of population-level sepsis incidence and mortality. Cases were identified by three previously published International Statistical Classification of Diseases (ICD) coding strategies for sepsis based on primary and secondary discharge diagnoses (clinical sepsis codes (R-codes), explicit coding (all sepsis codes) and implicit coding (combined infection and organ dysfunction codes)). For the validation study, a stratified sample of 1120 adult patients admitted to a German academic medical center between 2007-2013 was selected. Administrative diagnoses were compared to a gold standard of clinical sepsis diagnoses based on manual chart review. RESULTS: In the validation study, 151/937 patients had sepsis. Explicit coding strategies performed better regarding sensitivity compared to R-codes, but had lower PPV. The implicit approach was the most sensitive for severe sepsis; however, it yielded a considerable number of false positives. R-codes and explicit strategies underestimate sepsis incidence by up to 3.5-fold. Between 2007-2013, national sepsis incidence ranged between 231-1006/100,000 person-years depending on the coding strategy. CONCLUSIONS: In the sample of a large tertiary care hospital, ICD-coding strategies for sepsis differ in their accuracy. Estimates using R-codes are likely to underestimate the true sepsis incidence, whereas implicit coding overestimates sepsis cases. Further multi-center evaluation is needed to gain better understanding on the validity of sepsis coding in Germany.

Hospital Incidence and Mortality Rates of Sepsis.

BACKGROUND: Sepsis, the most severe manifestation of acute infection, poses a major challenge to health care systems around the world. To date, adequate data on the incidence and mortality of sepsis in Germany have been lacking. METHODS: Nationwide case-related hospital DRG statistics for the years 2007-2013 were used to determine the in-hospital incidence and mortality of sepsis. Cases were identified on the basis of the clinical and pathogen-based ICD-10 codes for sepsis. The statistical evaluation was standardized for age and sex and carried out separately for each age group. RESULTS: The number of cases of sepsis rose by an average of 5.7% per year, from 200 535 in 2007 to 279 530 in 2013, corresponding to an increase in the adjusted in-hospital incidence from 256 to 335 cases per 100 000 persons per year. The percentage of patients with severe sepsis rose from 27% to 41%. The in-hospital mortality of sepsis fell over the same period by 2.7%, to 24.3%. In 2013, 67 849 persons died of sepsis in German hospitals (or died of another disease, but also had sepsis). The incidence was highest in the youngest and oldest age groups, and the in-hospital mortality rose nearly linearly with age from age 40 onward. CONCLUSION: Sepsis and death from sepsis are markedly more common in Germany than previously assumed, and they are on the rise. Sepsis statistics should become a standard component of federal statistical reports on public health, as well as of hospital statistics. Preventive measures and evidencebased treatment should be implemented across the nation.

Patient-relevant endpoints in inflammatory bowel diseases--have changes occurred in Germany over the past twelve years?

BACKGROUND AND AIMS: Inflammatory bowel diseases (IBDs) are gaining increasing medical as well as economic significance. Improving medical treatment options can have a positive effect on number of hospitalized patients, necessary operations and the inability to work. METHODS: To understand patient-relevant endpoints in IBDs, the data for 2000-12 published by the Federal Statistical Office and the data for 2012 according to Article 21 of the Hospital Reimbursement Act in Germany were assessed. In addition, data records held by a public health insurance company on the medication of IBD patients were evaluated. RESULTS: During 2000-12, the number of hospitalized IBD patients (ICD 10 K50, K51) rose from 38533 to 43452 (+12.7%). The necessity of surgical intervention increased during the period under review. The number of people unable to work increased differently for Crohn's disease (CD) and ulcerative colitis (UC), by 2.1 and 9.5%, respectively. Entry of persons into the statutory pension insurance system did not decline from 2000 to 2012. The number of potential years of life lost (PYLL) in patients with IBD also remained constant during the period under review (2017 in 2000-02 versus 2011 in 2010-012). From 2009 to 2013 the percentage of patients treated with an anti-TNF-antibodies rose (2009, 4.3% for CD and 1.4% for UC; 2013, 8.4% for CD and 3.2% for UC). CONCLUSIONS: An improvement in patient-relevant endpoints was not observed between 2000 and 2012 in IBD patients in Germany. Improvements can only be achieved through structured and interdisciplinary treatment concepts involving all healthcare providers.