[Influence of the general data protection regulation on data quality in registry data collection : Selection bias due to data protection requirements and the impact on key indicators for measuring the quality of care in a level 1 trauma center]. / Einfluss der Datenschutz-Grundverordnung auf die Datenqualität bei der Erhebung von Registerdaten : Selektionsbias aufgrund datenschutzrechtlicher Anforderungen und dessen Auswirkungen auf Kennzahlen zur Messung der Versorgungsqualität am Beispiel eines überregionalen Traumazentrums.

BACKGROUND: Due to the new general data protection regulations (GDPR), the requirements for correct patient information on the documentation of pseudonymized data in a registry have increased enormously. In particular, written consent applies to the TraumaRegister DGU® as it is not always possible to get written permission from severely injured patients in acute situations. Therefore, the study aimed to investigate the influence of undocumented cases due to a lack of clarification on the standardized mortality rate (SMR). MATERIAL AND METHODS: In 2019, 274 patients meeting the criteria of the baseline dataset were retrospectively recorded. In the remaining 197 patients, the RISC II score could be calculated in all cases. In addition, due to state-specific law, all deceased patients were documented in our trauma center. RESULTS: In this study with 197 primary care patients (72% male), 147 (74,6%) were informed and gave permission or died and were subsequently documented. The predicted mortality, actual mortality and SMR were 18.5%, 19.0% and 1.03, respectively. For patients who were not informed (n = 50), the predicted mortality, actual mortality, and SMR were 7.0%, 0% and 0. When these cases are included, the SMR is significantly more favorable at 0.93. CONCLUSION: Due to the lack of written consent from surviving patients, only about 75% of all patients at Leipzig University Hospital could be documented for the TraumaRegister DGU®. On the other hand, since the local legal situation permits registry documentation of deceased patients, this has a detrimental effect on the standardized mortality rate (SMR), which is about 10% higher in our collective than it actually is.

[Cost coverage for complex paediatric spinal deformities with preoperative halo traction-an economic problem?] / Kostendeckung bei komplexen pädiatrischen Wirbelsäulendeformitäten mit präoperativer Halotraktion ­ ein wirtschaftliches Problem?

BACKGROUND: Spinal surgery is largely reimbursed in a differentiated manner via the DRG system. For treatments of complex paediatric deformities with increased pre and postoperative effort due to special treatment approaches, it seems that the costs for the treatment are not fully covered. MATERIALS AND METHODS: All paediatric cases with surgical treatment of the spine that were treated in a single spine centre from 2018-2020 were considered. The subgroup of patients with inpatient halo-gravity traction (halo group) before surgery was compared with all other cases treated in terms of economic and demographic factors. RESULTS: There were 86 cases that were treated surgically without halo traction and 6 cases with halo traction. The groups did not differ significantly in age (p = 0.41) or Patient Clinical Complexity Level (PCCL, p = 0.76). The average length of hospital stay in the halo group was significantly longer than in the other cases (84.2 ± 40.1 d vs. 11.0 ± 6.4 d; p = 0.001). Due to DRG grouping and long-stay surcharges, the mean revenue per case was significantly higher in the halo group than in the other cases (€ 63,615 ± 45,138 vs. € 16,836 ± 9356) (p = 0.003). The contribution margin for the period of the long-term surcharges varied between 11,394 and 9766 €. The high additional costs due to the necessary medical devices of halo traction were not sufficiently reflected in the reimbursement. CONCLUSION: Paediatric spine surgery can be challenging in special cases. In particular, severe deformities of the spine may require additional procedures. The subgroup of patients requiring preoperative halo traction is not adequately compensated by the DRG system.

[Seasonal variation in surgical diseases : Is an economic resource management necessary?] / Saisonale Verteilung chirurgischer Krankheitsbilder : Ist eine Ressourcenverteilung erforderlich?

BACKGROUND: The registration of diagnoses and diagnose-related groups (DRG) allows conclusions to be drawn about the distribution over the course of the year. Seasonal variations can be recognized and used to plan further resource management. METHODS: From 2006 to 2016 a total of 30,999 main diagnoses and DRGs were registered at the hospital for visceral surgery of the University Medical Hospital in Leipzig. The data were sorted on a monthly and seasonal basis and compared to meteorological data received from the German Meteorological Service. Furthermore, epidemiological information about the patients was recorded. RESULTS: The most frequently registered main diagnosis was malignant neoplasms of the liver and intrahepatic bile ducts with 1589 cases (C22), followed by acute appendicitis with 1557 cases (K35). There was a significant seasonal and monthly variation for cholelithiasis (K80) with 1013 cases (p = 0.002++), inguinal hernia (K40), 887 cases (p = 0.002++), ventral hernia (K43), 696 cases (p < 0.001++) and varices of the lower limbs (I83), 352 cases (p < 0.001++). A similar correlation could be shown for daily sunshine hours and case numbers for patients with the main diagnosis groups I83 (r = -0.12, p = 0.036+) and K43 (r = -0.08, p = 0.041+). Another significant correlation was observed between patients' epidemiological information and medical data: patient-related clinical severity (PCCL) ~ age (r = 0.27, p < 0.001++), length of hospital stay ~ age (r = 0.25, p < 0.001++), duration of ventilation ~ age (r = 0.07, p < 0.001++) and mortality ~ age (r = 0.09, p < 0.001++). CONCLUSION: A seasonal variation in case numbers for individual main diagnoses could be registered and elective and therefore plannable surgeries were mostly affected. An adequate resource management can reveal economic benefits. Older patients consume a high amount of resources and should be given a higher priority.

[Seasonal distribution of clinical case codes (DOC study)]. / Saisonale Verteilung klinischer Kennzahlen (DOC-Study).

OBJECTIVES: The German diagnosis-related groups remuneration system (G-DRG) was implemented in 2004 and patient-related diagnoses and procedures lead to allocation to specific DRGs. This system includes several codes, such as case mix (CM), case mix index (CMI) and number of cases. Seasonal distribution of these codes as well as distribution of diagnoses and DRGs may lead to logistical consequences for clinical management. METHODS: From 2004 to 2013 all the main diagnoses and DRGs for inpatients were recorded. Monthly and seasonal distributions were analyzed using ANOVA. RESULTS: The average monthly number of cases was 265 ± 25 cases, the average CM was 388.50 ± 51.75 and the average CMI was 1.46 ± 0.15 with no significant seasonal differences (p > 0.1). Concussion was the most frequently occurring main diagnosis (3739 cases) followed by fractures of the humeral head (699). Significant distribution differences could be shown for humeral head fractures in monthly (p = 0.018) and seasonal comparisons (p = 0.006) with a maximum in winter. Radius (p = 0.01) and ankle fractures (p ≤ 0.001) also occurred most frequently in winter. Non-bony lesions of the shoulder were significantly less in spring (p = 0.04). The DRGs showed no evidence of a monthly or seasonal clustering (p > 0.1). CONCLUSION: The significant clustering of injuries in specific months and seasons should lead to logistic consequences (e.g. operating room slots, availability of nursing and anesthesia staff). For a needs assessment the analysis of main diagnoses is more appropriate than DRGs.

[Economic aspects of oncological esophageal surgery : Centralization is essential]. / Ökonomische Aspekte der onkologischen Ösophaguschirurgie : Zentralisierung ist essenziell.

The incidence of esophageal carcinoma has increased in recent years in Germany. The aim of this article is a discussion of the economic aspects of oncological esophageal surgery within the German diagnosis-related groups (DRG) system focusing on the association between minimum caseload requirements and outcome quality as well as costs. The margins for the DRG classification G03A are low and quickly exhausted if complications determine the postoperative course. A current study using nationwide German hospital discharge data proved a significant difference in hospital mortality between clinics with and without achieving the minimum caseload requirements for esophagectomy. Data from the USA clearly showed that besides patient-relevant parameters, the caseload of a surgeon is relevant for the cost of treatment. Such cost-related analyses do not exist in Germany at present. Scientific validation of reliable minimum caseload numbers for oncological esophagectomy is desirable in the future.

[Implementation of a department of plastic surgery in a university clinic for trauma surgery]. / Implementierung einer universitären Abteilung für Plastische Chirurgie in eine Klinik für Unfallchirurgie.

BACKGROUND: Since May 2012 plastic surgery for trauma patients at the University Hospital Leipzig is provided by an autonomous department. OBJECTIVES: This study analyzed the effect of plastic surgery on the changes in diagnosis-related groups (DRG) at a clinic for trauma surgery. MATERIALS AND METHODS: Within the first 2 years 37 patients (29 male and 8 female of which 38 were inpatient cases) were admitted to the clinic for trauma surgery and additionally received plastic surgery treatment. The appropriate DRG assignment as well as associated codes and revenues were recorded and compared with and without plastic surgery. RESULTS: A total of 261 operations were performed on these patients of which 71 were performed by the department of plastic surgery. The mean revenue was 22,156.44 EUR±20,578.22 EUR with a mean cost weighting of 7.2±6.7. Excluding plastic surgery treatment the mean revenue was 19,378.44 EUR±20,688.40 EUR and the mean cost weighting was 6.3±6.7. Thus, additional proceeds by the plastic surgery treatment were 2778.00 EUR±3857.01 EUR per case. The mean increase of the cost weighting was 0.9±1.3. A change of the DRG grouping occurred in 20 out of 38 cases treated. The mean length of stay (LoS) was 40.2±26.6 days. In the first year this was 17.9±22.4 days more than the mean national LoS of the appropriate DRG and 10.9±19.3 days in the second year. This means an average cost reduction of 4774.59 EUR per case. CONCLUSION: The implementation of a department for plastic surgery increased the revenues. Additional profits should be achieved by process enhancement and not by prolonged LoS.

[Multiplanar reconstruction with mobile 3D image intensifier. Surgical treatment of proximal humerus fractures]. / Multiplanare Rekonstruktion mit mobilem 3D-Bildwandler. Operative Versorgung proximaler Humerusfrakturen.

PURPOSE: The aim of this study was to analyze the applicability and advantages of the intraoperative use of a mobile 3D C-arm with multiplanar imaging for surgery of acute proximal humerus fractures. MATERIALS AND METHODS: In this study 20 patients (11 female, 9 male, median age 70 years, range 35-91 years) with dislocated proximal humerus fractures (6 with 2 segments, 10 with 3 segments and 4 with 4 segments) were included. Preoperatively 3D scanning was performed and a reevaluation of the fracture in comparison to the plain radiographs was performed. After operative treatment another scan was performed to evaluate technical complications. RESULTS: In comparison to the multiplanar reconstructions fracture morphology could not be correctly detected in 5 out of the 20 cases with plain radiographs. The preoperative image quality of the multiplanar reconstructions showed a significantly better assessment in comparison to the image quality with osteosynthesis (p < 0.05). The screws had to be replaced in 5 of the 20 patients. CONCLUSION: Intraoperative 3D imaging with mobile image intensifier enables an accurate analysis of fracture morphology. Furthermore a quasi real time preoperative planning, evaluation of reduction and implant position with immediate operative relevance can be realized.

[Is distal femoral replacement an adequate therapeutic option after complex fractures of the distal femur?]. / Ist der distale Femurersatz als extremitätenerhaltendes Verfahren nach komplexen Frakturen am distalen Femur geeignet?

BACKGROUND: Modular distal femur replacements originally were developed for reconstructing a full weight-bearing and functional extremity after resection of primary bone tumours with large bony defects located in proximity to joints. The aim of this study was to examine the use of the modular distal femur replacements for complex fractures and severe post-traumatic sequelae of the distal femur in context to comparable studies. PATIENTS AND METHODS: Fourteen patients with complex fractures or post-traumatic sequelae and extensive bone defects requiring distal femur replacement were analysed retrospectively. Median age of the patients at the time of distal femoral replacement was 77 years and median follow-up interval was 27 months. Median follow-up was 27.0 (IQB 13.5-37.5) months (range 10-49 months). RESULTS: The indication for distal femur replacement was a periprosthetic fracture in three cases. Three further periprosthetic fractures were treated with a megaendoprosthesis after failure of osteosynthesis. In eight patients a megaendoprosthesis was implanted due to complications following ostheosynthesis for distal femoral fractures. Distal femoral arthroplasty was performed as a two-stage procedure in five patients with implant-associated infections. A lateral approach was used in six patients and a medial arthrotomy was conducted in eight patients. The median Knee Society score (KSS) improved significantly from 20.0 (IQB 7.5-30.0) points preoperatively to 80.0 (IQB 62.3-89.0) points at follow-up (p < 0.001). Complications requiring surgical intervention were documented in seven of 14 patients (50 %). In two patients wound-healing disorders and superficial infections necessitated surgery. In one patient a rupture of the patellar tendon was diagnosed. This patient subsequently also sustained a periprosthetic fracture. Another patient developed early aseptic loosening of the femoral component. The most common complication was a periprosthetic fracture in four patients. Three patients died for reasons not related to distal femoral replacement. CONCLUSION: Distal femoral replacement is an important option in reconstituting a full weight-bearing and functional lower extremity after complex fractures and post-traumatic sequelae with massive bone destruction. Particularly elderly patients regain ambulatory ability in the vast majority of cases. The relatively high complication rate demands very thorough preoperative planning as well as prompt allocation of extensive surgical procedures in the case of an adverse event.

[Clinical and radiological mid-term results after autologous osteochondral transplantation under consideration of quality of life]. / Mittelfristige klinische und radiologische Ergebnisse nach autologer osteochondraler Transplantation unter Berücksichtigung der Lebensqualität.

BACKGROUND: Treatment of full-thickness cartilage defects remains a challenge in musculoskeletal surgery. Autologous osteochondral transplantation represents a possible solution for the repair of affected areas. However, some problems like degenerative changes of the transplanted cylinders and the surrounding cartilage or lack of cylinder integration to the surrounding cartilage arise with this method. Thus mid-term results respecting the quality of life are useful for assessment of the method. PATIENTS/MATERIAL AND METHODS: We investigated 22 patients with a mean follow-up of 88 ± 14.5 months after autologous osteochondral transplantation due to a full-thickness cartilage defect of the medial femoral condyle. Beside clinical scores we assessed at follow-up the quality of life using the SF-36 health survey and the EQ-5D. Furthermore, radiological changes were detected and MRI was performed in 21 patients. A control group of 19 patients, treated with microfracture, was matched in terms of BMI, gender and age. Exclusion criteria for this group were tibial kissing lesion, ligament instability, arthrosis and malalignment. RESULTS: In a longitudinal comparison with results 13.5 months after operation, no difference in Lysholm score was found. In plain radiographs higher degrees of arthritic changes in the medial compartment compared to the unaffected knee were observed. MRI revealed a mean modified MOCART score of 41.2 ± 7.7 for the OAT group and of 39.4 ± 16.1 for the microfracture group, without being significant. For OAT patients all cylinders showed an osseous integration. However, cylinder oedema was found in 9 patients. Those patients had a higher intensity of pain on a visual analogue scale. Quality of life was better for OAT patients in the physical scale of SF-36, but not in the mental scale. CONCLUSION: Autologous osteochondral transplantation has an unaltered significance in treating full-thickness cartilage defects and leads to satisfying mid-term results. The development of early arthritic changes might not be preventable by this method. Oedema of the transplanted cylinders is attended by higher pain intensity and might be an indirect sign of cartilage degeneration.

[Total knee arthroplasty in post-traumatic osteoarthritis]. / Knieendoprothetik bei posttraumatischer Arthrose.

BACKGROUND: This study aims to analyse the outcome and the complications after total knee arthroplasty in post-traumatic osteoarthritis in comparison to TKA in patients with degenerative osteoarthritis. PATIENTS AND METHODS: In a period of six years 43 patients with a post-traumatic osteoarthritis were treated with a total knee arthroplasty (group PT). 38 (88 %) patients (age median 55 years, 22 female, 16 male) were investigated clinically and radiologically after an average follow-up time of 2.7 years. The OKS (Oxford Knee Score, max. 48 points), the Knee Society Scores "function" (max. 100 points) and "knee" (max. 100 points) as well as the visual analogue scale (VAS, 0 to 10 points) were recorded preoperatively and at follow-up. For comparison we chose a matched-pair selection of patients with degenerative osteoarthritis and TKA (group DO, age median 63 years, 22 female, 16 male). For statistical analysis we used common parametric tests (Wilcoxon and U test) and a level of significance of 0.05. RESULTS: In 19 patients (50 %) of the group PT the osteoarthritis was caused by a bone injury. Furthermore in 19 patients a meniscal and/or ligamentous injury led to osteoarthritis. Out of all patients of group PT, 10 patients showed a preoperative valgus malalignment higher than 10°. KSS knee and KSS function added up to 76.9 and 84.9 points. So they are significantly less than in the matched group (DO, knee: 86.1; function: 94.4). Similarly, the OKS is significantly less in group PT after follow-up (PT: 32.3; DO: 38.4, p ≤ 0.05) although the preoperative values are equal in both groups. The VAS value decreased significantly in both groups. Initial level of pain was significantly higher in the group DO compared to the group PT. Patients with osteoarthritis after trauma showed complications in 17 cases (^ = 44.7 %) that led to 28 revision operations (^ = 0.7 operations per knee). The group with valgus malalignment had a revision rate of 1.4 operations per knee. In the group DO 8 complications occurred (^ = 21,1 %) that led to 11 revision operations (^=0.3 per knee). The deviation from the "ideal" leg axis could be reduced from 3.8° varus to 1.7° varus in the group DO and from 1.3° valgus auf 1.2° valgus in the group PT. Patients with a preoperative valgus deviation > 10° were reduced from 13.6° (± 3.9°) valgus to 0.5° (± 9.2°) varus. CONCLUSION: Patients after TKA because of post-traumatic osteoarthritis show worse results concerning function and condition compared to patients with degenerative osteoarthritis. Heterogeneous pathogenesis and high rates of revision operations underline the complexity of this group of patients. The treatment has to be adjusted to the patient's requirements as well to the pathoanatomy.

[Seasonal distribution of diagnoses and DRG in trauma surgery]. / Saisonale Verteilung von Diagnosen und DRG in der Unfallchirurgie.

BACKGROUND: Recording DRGs and diagnoses allows their distribution to be shown over the course of the year. Thus, cumulative seasonal occurrence of diseases can be detected. PATIENTS AND METHODS: From 2004 to 2010 we recorded 22,293 main diagnoses and DRGs at the clinic for trauma surgery. Injuries with the same localization and treatment were pooled. RESULTS: The most frequent injuries were concussion, followed by spinal and lower leg fractures. They showed no seasonal accumulation. Proximal fractures of the humerus occurred approx. 25% more often in winter and ankle fractures about 33% more frequently. The diagnosis of osteoarthritis of the knee is twice as high in the winter as in the summer. CONCLUSION: It has to be verified if logistic conclusions of these results can lead to more efficiency in a hospital. The underlying analysis is applicable for every hospital and poses a valid controlling tool.

[Examples of erroneous coding in trauma surgery]. / Beispiele für fehlerhafte Kodierung in der Unfallchirurgie.

The G-DRG-System is complex, mistakes in accounting are common. Therefore diagnosis with CCL-value are important because of the possibility of increasing revenues. Also procedures may lead to DRGs with a higher cost weight. So their acquisition is mandatory. The exact medical documentation is essential. High revenues have to be understood according to unvoidable expenditures.