Treating Anemia in the Preanesthesia Assessment Clinic: Results of a Retrospective Evaluation.

BACKGROUND: Perioperative anemia is challenging during hospital stay because anemia and red blood cell (RBC) transfusions are associated with an increased morbidity and mortality. With the implementation of patient blood management (PBM), a preanesthesia assessment clinic to screen and treat anemia before elective surgery was institutionalized at Muenster University Hospital, Germany. The main objective of this study was to evaluate the association between treating preoperative anemic patients with intravenous iron (IVI) and (primarily) presurgical hemoglobin levels and (secondarily) use of RBCs and mortality. METHODS: Between April 1, 2014, and July 4, 2016, patients scheduled for elective surgery with a risk for RBC transfusions >10% in 2013 were screened for preoperative anemia and, if indicated, treated with IVI. Patients' data, time span between visit in the anesthesia/PBM clinic and surgery, demographic data, type of surgery, the difference of hemoglobin levels between visit and surgery, RBC transfusion, infectious-related International Classification of Disease codes during hospital stay, and 1-year survival were determined retrospectively by screening electronic data files. In addition, patients were interviewed about adverse events, health-related events, and infections via telephone 30, 90, and 365 days after visiting the anesthesia/PBM clinic. RESULTS: A total of 1101 patients were seen in the anesthesia/PBM clinic between days -28 and -1 (median [Q1-Q3], -3 days [-1, -9 days]) before elective surgery. Approximately 29% of patients presented with anemia, 46.8% of these anemic patients were treated with ferric carboxymaltose (500-1000 mg).In the primary analysis, hemoglobin levels at median were associated with a reduction between the visit in the anesthesia/PBM clinic and the surgery in all nonanemic patients on beginning of medical treatment (nonanemic patients at median -2.8 g/dL [-4, -0.9 g/dL], while anemic patients without IVI presented with median differences of -0.8 g/dL [-2, 0 g/dL] and anemic patients with IVI of 0 g/dL [-1.0, 0.5 g/dL]). Hemoglobin levels raised best at substitution 22-28 days before surgery (0.95 g/dL [-0.35, 1.18 g/dL]). Due to the selection criteria, transfusion rates were high in the cohort. Overall, there was no association between IVI treatment and the use of RBC transfusions (odds ratio for use of RBCs in anemic patients, no IVI versus IVI: 1.14; 95% confidence interval, 0.72-1.82). Patients treated with or without IVI presented a comparable range of International Classification of Disease codes related to infections. Telephone interviews indicated similar adverse events, health-related events, and infections. Cox regression analysis showed an association between anemia and reduced survival, regardless of IVI. CONCLUSIONS: An anemia clinic within the preanesthesia assessment clinic is a feasible and effective approach to treat preoperative anemia. The IVI supplementation was safe but was associated with decreased RBC transfusions in gynecology/obstetric patients only. The conclusions from this retrospective analysis have to be tested in prospective, controlled trials.

Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence.

AIMS: Only few and historic studies reported a bad prognosis of peripheral arterial disease (PAD) and critical limb ischaemia (CLI). The contemporary state of treatment and outcomes should be assessed. METHODS AND RESULTS: From the largest public health insurance in Germany, all in- and outpatient diagnosis and procedural data were retrospectively obtained from a cohort of 41 882 patients hospitalized due to PAD during 2009-2011, including a follow-up until 2013. Patients were classified in Rutherford categories 1-3 (n = 21 197), 4 (n = 5353), 5 (n = 6916), and 6 (n = 8416). The proportions of patients with classical risk factors such as hypertension, dyslipidaemia, and smoking declined with higher Rutherford categories (each P < 0.001) while diabetes, chronic kidney disease, and chronic heart failure increased (each P < 0.001). Angiographies and revascularizations were performed less often in advanced PAD (each P < 0.001). In-hospital amputations increased continuously from 0.5% in Rutherford 1-3 to 42% in Rutherford 6, as also myocardial infarctions, strokes, and deaths (each P < 0.001). Among 4298 amputated patients with CLI, 37% had not received any angiography or revascularization neither during index hospitalization nor the 24 months before. During follow-up (mean 1144 days), 7825 patients were amputated and 10 880 died. Kaplan-Meier models projected 4-year mortality risks of 18.9, 37.7, 52.2, and 63.5% in Rutherford 1-3, 4, 5, and 6, and for amputation of 4.6, 12.1, 35.3, and 67.3%, respectively. In multivariable Cox regression models, PAD categories were significant predictors of death, amputation, myocardial infarction, and stroke (each P < 0.001). Length of in-hospital stay (5.8 ± 6.7 days, 10.7 ± 11.1days, 15.2 ± 13.8 days and 22.1 ± 20.3 days; P < 0.001) and mean case costs (3662 ± 3186 €, 5316 ± 6139 €, 6021 ± 4892 €, and 8461 ± 8515 €; P < 0.001) increased continuously in Rutherford 1-3, 4, 5, and 6. While only 49% of the patients suffered from CLI, these produced 65% of in-hospital costs (141 million €), and 56% during follow-up (336 million €). CONCLUSION: Regardless of recent advances in PAD treatment, current outcomes remain poor especially in CLI. Despite overwhelming evidence for reduction of limb loss by revascularization, CLI patients still received significantly less angiographies and revascularizations.

Utilisation of blood components in cardiac surgery: a single-centre retrospective analysis with regard to diagnosis-related procedures.

BACKGROUND: More blood components are required in cardiac surgery than in most other medical disciplines. The overall blood demand may increase as a function of the total number of cardiothoracic and vascular surgical interventions and their level of complexity, and also when considering the demographic ageing. Awareness has grown with respect to adverse events, such as transfusion-related immunomodulation by allogeneic blood supply, which can contribute to morbidity and mortality. Therefore, programmes of patient blood management (PBM) have been implemented to avoid unnecessary blood transfusions and to standardise the indication of blood transfusions more strictly with aim to improve patients' overall outcomes. METHODS: A comprehensive retrospective analysis of the utilisation of blood components in the Department of Cardiac Surgery at the University Hospital of Münster (UKM) was performed over a 4-year period. Based on a medical reporting system of all medical disciplines, which was established as part of a PBM initiative, all transfused patients in cardiac surgery and their blood components were identified in a diagnosis- and medical procedure-related system, which allows the precise allocation of blood consumption to interventional procedures in cardiac surgery, such as coronary or valve surgery. RESULTS: This retrospective single centre study included all in-patients in cardiac surgery at the UKM from 2009 to 2012, corresponding to a total of 1,405-1,644 cases per year. A blood supply was provided for 55.6-61.9% of the cardiac surgery patients, whereas approximately 9% of all in-patients at the UKM required blood transfusions. Most of the blood units were applied during cardiac valve surgery and during coronary surgery. Further surgical activities with considerable use of blood components included thoracic surgery, aortic surgery, heart transplantations and the use of artificial hearts. Under the measures of PBM in 2012 a noticeable decrease in the number of transfused cases was observed compared to the period from 2009 to 2011 before implementation of the PBM initiative (red blood cells p < 0.002; fresh frozen plasma p < 0.0006; platelets p < 0.00006). CONCLUSION: Until now, cardiac surgery comes along with a significant blood supply. By using a case-related data evaluation programme, the consumption of each blood component can be linked to clinical performance groups and, if necessary, to individual patients. Based on the results obtained from this retrospective analysis, prospective studies are underway to begin conducting target / actual performance comparisons to better understand the individual decision-making by the attending physicians with respect to transfusions.

Utilisation of Blood Components in Trauma Surgery: A Single-Centre, Retrospective Analysis before and after the Implementation of an Educative PBM Initiative.

BACKGROUND: The aim of our single-centre retrospective study presented here is to further analyse the utilisation of allogeneic blood components within a 5-year observation period (2009-2013) in trauma surgery (15,457 patients) under the measures of an educational patient blood management (PBM) initiative. METHODS: After the implementation of the PBM initiative in January 2012, the Institute of Transfusion Medicine und Transplantation Immunology educates surgeons and nurses at the Department of Trauma Surgery to avoid unnecessary blood transfusions. A standardised reporting system was used to document the utilisation of blood components carefully for the most frequent diagnoses and surgical interventions in trauma surgery. These measures served as basis for the implementation of an interdisciplinary systematic exchange of information to foster decision-making processes in favour of patient blood management. RESULTS: Since January 2012, the proportion of patients who received a transfusion as well as the number of transfused red blood cell (RBC) (7.3%/6.4%; p = 0.02), fresh frozen plasma (FFP) (1.7%/1.3%; p < 0.05) and platelet (PLT) (1.0%/0.5%; p < 0.001) units were reduced as a result of our PBM initiative. However, among the transfused patients, the number of administered RBC, FFP and PLT units did not decrease significantly. Overall, patients who did not receive transfusions were younger than transfused patients (p = 0.001). The subgroup with the highest probability of blood transfusion administered included patients with intensive care and long-term ventilation (before/after implementation of PBM: RBC 81.5%/75.9%; FFP 33.3%/20.4%; PLT 24.1%/13.0%). Only a total of 60 patients of 531 patients suffering multiple traumas were massively transfused (before/after implementation of PBM: RBC 55.6%/49.8%; FFP 28.4%/20.4%; PLT 17.6%/8.9%). CONCLUSION: According to our educational PBM initiative, at least the proportion of trauma patients who received allogeneic blood transfusions could be reduced significantly. However, in case of blood transfusions, the total consumption of RBC, FFP and PLT units remained stable in both time periods. This phenomenon might indicate that the actual need of blood transfusions rather depends on the severity of trauma-related blood loss, the coagulopathy rates or the complexity of the surgical intervention which mainly determines the intra-operative blood loss. Taken together, educational training sessions and systematic reporting systems are suitable measures to avoid unnecessary allogeneic blood transfusions and to continuously improve their restrictive application.

Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: a nationwide population-based analysis.

AIMS: The prevalence of peripheral arterial disease (PAD) and especially of critical limb ischaemia (CLI) is announced to rise dramatically worldwide, with a considerable impact on the health care and socio-economic systems. We aimed to characterize the recent trends in morbidity and in-hospital outcome of PAD among all hospitalized patients in the entire German population between 2005 and 2009. METHODS AND RESULTS: Nationwide data of all hospitalizations in Germany in 2005, 2007, and 2009 were analysed regarding the prevalence of PAD, comorbidities, endovascular (EVR) and surgical revascularizations (SR), major and minor amputations, in-hospital mortality, and associated costs. From 2005 to 2009, total PAD cases increased by 20.7% (from 400 928 to 483 961), with an increase of CLI subset from 40.6 to 43.5%. Total EVR increased by 46%, while thromb-embolectomy, endarterectomy, and patch plastic increased by 67, 42, and 21%, respectively. Peripheral bypasses decreased by 2%. Major amputation decreased from 4.6 to 3.5%, while minor amputation slightly increased from 4.98 to 5.11%. The crude overall in-hospital mortality remained unchanged in claudicants (2.2%), while it decreased from 9.8 to 8.4% in CLI patients. However, mortality rate according to the Poisson model (n/1000 hospital residence days) increased significantly in claudicants (P < 0.001). Total reimbursement costs for PAD in-patient care increased by 21% with an average per case costs in 2009 of €4506 in a claudicant and €6791 in a CLI patient. CONCLUSION: This population-based analysis documents the significant rise of PAD, particularly of the CLI subset, and highlights the malign prognosis associated with PAD as indicated by high amputation and in-hospital mortality rates.

[The significance of the principal diagnosis in Germany's new payment system for inpatient treatment of mental disorders]. / Die Bedeutung der Hauptdiagnose im Pauschalierenden Entgeltssystem Psychiatrie Psychosomatik (PEPP) - Bedeutung und Konsequenzen.

In 2013 Germany implemented a new payment system for the inpatient treatment of mental disorders. Besides perpetuating a per-diem payment, the payment system sets up a classification system that groups cases with comparable costs per diem. The first release of the system reveals the principal diagnosis to be the main grouping variable. Especially in psychosomatic and psychotherapy this approach seems to be at least questionable. Because of the insufficiently precise definition of the assignment of the principal diagnosis in the coding standards - and therefore the expected conflicts between clinics and health insurance funds - this paper discusses the difficulties involved in defining the principal diagnosis. It also formulates recommendations of how the principal diagnosis should be assigned.

[Reorientation of the hospital planning in NRW-Importance for cardiovascular medicine and thoracic surgery]. / Neuausrichtung der NRW-Krankenhausplanung ­ Bedeutung für die Herz-Kreislauf-Medizin und die Thoraxchirurgie.

The year 2022 will mark the beginning of a new era for hospitals in North Rhine-Westphalia. With the reorganization of hospital planning in NRW to an allocation of treatment assignments via specialized medical service groups with personnel and infrastructural structural quality requirements specific for this purpose instead of via specialized departments and beds, a new form of hospital planning and structuring is implemented. This method is now proposed by the "government commission for a modern and needs-based hospital treatment" implemented by the Minister of Health Lauterbach as a structurization option for the whole of Germany in combination with hospital treatment levels. Therefore, it would be advisable to become acquainted with the possible effects on cardiovascular medicine in a timely manner, in order to anticipate possible alterations in the treatment assignments of one's own hospital as well as other hospitals with repercussions for cooperations with cardiac surgery.

Retrospective Analysis of the Blood Component Utilization in a University Hospital of Maximum Medical Care.

BACKGROUND: Demographic data illustrate clearly that people in highly developed countries get older, and the elderly need more blood transfusions than younger patients. Additionally, special extensive therapies result in an increased consumption of blood components. Beyond that the aging of the population reduces the total number of preferably young and healthy blood donors. Therefore, Patient Blood Management will become more and more important in order to secure an increasing blood supply under fair-minded conditions. METHODS: At the University Hospital of Münster (UKM) a comprehensive retrospective analysis of the utilization of all conventional blood components was performed including all medical and surgical disciplines. In parallel, a new medical reporting system was installed to provide a monthly analysis of the transfusional treatments in the whole infirmary, in every department, and in special blood-consuming cases of interest, as well. RESULTS: The study refers to all UKM in-patient cases from 2009 to 2011. It clearly demonstrates that older patients (>60 years, 35.2-35.7% of all cases, but 49.4-52.6% of all cases with red blood cell (RBC) transfusions, 36.4-41. 6% of all cases with platelet (PTL, apheresis only) transfusions, 45.2-48.0% of all cases with fresh frozen plasma (FFP) transfusions) need more blood products than younger patients. Male patients (54.4-63.9% of all cases with transfusions) are more susceptible to blood transfusions than female patients (36.1-45.6% of all cases with transfusions). Most blood components are used in cardiac, visceral, and orthopedic surgery (49.3-55.9% of all RBC units, 45.8-61.0% of all FFP units). When regarding medical disciplines, most transfusions are administered to hematologic and oncologic patients (12.9-17.7% of all RBC units, 9.2-12.0% of all FFP units). The consumption of PTL in this special patient cohort (40.6-50.9% of all PTL units) is more pronounced than in all other surgical or in non-surgical disciplines. CONCLUSION: The results obtained from our retrospective analysis may help to further optimize the responsible and medical indication-related utilization of blood transfusions as well as the recruitment of blood donors and their timing. It may be also a helpful tool in order to avoid needless transfusions and transfusionassociated adverse events.

The impact of map and data resolution on the determination of the agricultural utilisation of organic soils in Germany.

Due to its nature, agricultural land use depends on local site characteristics such as production potential, costs and external effects. To assess the relevance of the modifying areal unit problem (MAUP), we investigated as to how a change in the data resolution regarding both soil and land use data influences the results obtained for different land use indicators. For the assessment we use the example of the greenhouse gas (GHG) emissions from agriculturally used organic soils (mainly fens and bogs). Although less than 5 % of the German agricultural area in use is located on organic soils, the drainage of these areas to enable their agricultural utilization causes roughly 37 % of the GHG emissions of the German agricultural sector. The abandonment of the cultivation and rewetting of organic soils would be an effective policy to reduce national GHG emissions. To assess the abatement costs, it is essential to know which commodities, and at what quantities, are actually produced on this land. Furthermore, in order to limit windfall profits, information on the differences of the profitability among farms are needed. However, high-resolution data regarding land use and soil characteristics are often not available, and their generation is costly or the access is strictly limited because of legal constraints. Therefore, in this paper, we analyse how indicators for land use on organic soils respond to changes in the spatial aggregation of the data. In Germany, organic soils are predominantly used for forage cropping. Marked differences between the various regions of Germany are apparent with respect to the dynamics and the intensity of land use. Data resolution mainly impairs the derived extent of agriculturally used peatland and the observed intensity gradient, while its impact on the average value for the investigated set of land-use indicators is generally minor.

[Depiction of cardiovascular surgery in the current modified German DRG system 2021]. / Abbildung der Herz- und Gefäßchirurgie im aktuellen aG-DRG-System 2021.

INTRODUCTION: The year 2020 will always stand in the shadow of the pandemic triggered by the coronavirus 2019 (COVID-19). The first three quarter years of 2020 were characterized by an unprecedented reduction of elective inpatient services and a prioritization of intensive care capacity for the treatment of COVID-19 patients. This also resulted in clear consequences for the services provided in cardiac surgery. In addition, during the course of the year the personnel in hospitals were confronted with a plethora of amendments in the legal framework conditions. Nevertheless, the modified German diagnosis-related groups (G-DRG) system 2021 was calculated by the Institute for the Remuneration System in Hospitals (InEK). This article describes and assesses the most important amendments of the modified G­DRG system 2021 for cardiac, thoracic and vascular surgery. METHODS: Analysis of the relevant diagnoses, procedures and G­DRG structures in the system versions for 2020 and 2021 based on the information published by the InEK and the German Federal Institute for Drugs and Medical Devices (BfArM). RESULTS: Expansions of the relevant classification systems for diagnoses (ICD-10-GM 2021) and procedures (OPS 2021) lead to an increase in specific coding of essential interventions and operations in cardiovascular surgery. Within the framework of the adaptation of the G­DRG structures, the condensation of the previous fixed rates for heart transplantation to G­DRG A05Z and devaluation of coronary bypass operations and reconstructive vascular interventions are particularly important. CONCLUSION: For cardiovascular surgery there are manifold amendments with sometimes substantial repercussions for the case proceeds. Additionally, for many German hospitals the effects of the corona pandemic are not yet finally foreseeable. A further increasingly more urgent influencing factor particularly affecting vascular medicine is the increasing pressure to promote outpatient treatment. In this respect, the catalogue for outpatient operations in hospitals (AOP), which is expected in 2022 and will presumably be much expanded, will once again clearly increase the enforcement of outpatient performance of services that were previously performed as inpatient treatment.

G-DRG Version 2009: new developments.

The update of the G-DRG system for the year 2009 has been successfully negotiated. Like in the past years, changes are minimal and not dramatic, but they significantly enhance the quality of the DRG system. Once again, the German DRG system demonstrates its versatility and reliability for clinical reimbursement purposes. In the field of dermatology, several improvements or enhancements can be identified; the average case mix index that declined in the past years should now rise by 0.5 percent for 2009. Oncology cases are affected especially by this increase. Some refinements advanced for several years by the German Dermatologic Society (DDG) have been recognized --complex therapies like vacuum wound therapy, isolation due to multi-resistant infections and multiple primary tumors now have better cost weights. Although there still remain some minor problems like reimbursement of cost-intensive treatments, German dermatology is in summary very well prepared for the year 2009.

Impact of different stages of chronic kidney disease on in-hospital costs in patients with coronary heart disease.

BACKGROUND: Chronic kidney disease (CKD) is associated with markedly increased in-hospital morbidity and mortality. Its effect on in-hospital costs for the treatment of coronary heart disease (CHD) has not been assessed that, although it is of interest due to the exponential increase in its prevalence. METHODS: Clinical and costing data were retrospectively assessed from 765 consecutive patients who suffered from CHD requiring percutaneous coronary interventions. Based on their estimated glomerular filtration rate (eGFR), patients were classified in accordance with the National Kidney Foundation. Patient-level in-hospital costs for this single hospitalization were thoroughly calculated from precise in-house assessments for the national DRG database. RESULTS: In univariate analysis, the average total in-hospital costs increased with each stage of CKD [euro2926; euro3466; euro4208; euro9687 (stages 4 and 5 combined), P < 0.0001]. Treating patients with CKD stages 4 and 5 utilized markedly more resources than patients with ST-elevation myocardial infarction (euro4916), coronary three-vessel disease (euro4659), severely impaired left ventricular function (euro6072) or diabetes (euro4495). Multivariate analyses identified, even after adjustment for confounding comorbidities, that CKD was a significant and independent predictor of in-hospital costs; with each loss of 1 ml/min in the eGFR, the expenses for this hospitalization increased by euro18 (95% CI euro13-23). CONCLUSIONS: Although the absolute amount of costs may vary between different countries, this work showed, for the first time, that in all stages of CKD, there is a significant increase of in-hospital costs when treating patients with both CHD and CKD.

[G-DRG version 2007: a short overview]. / G-DRG Version 2007: Ein kurzer Uberblick.

Just as in the year before, the structure and regulations of the new GDRG version 2007 was successfully agreed on a mutual basis by the national self-governing bodies in the German health care system. Although some problems in high-specialized medicine or day clinic care will remain, the current developments demonstrate once more the learning aptitude of the G-DRG-system. Some beneficial and major changes have been made in 2007, but most of them do not touch dermatology. Additional procedure-based payments have been introduced in 2007 including the parenteral administration of such expensive agents as etanercept and itraconazole. A statistical analysis of cost weights of the year 2006 versus 2007 for two university clinics suggests that in dermatology, the increasing complexity of the G-DRG system partly leads to lower cost weights. Overall in 2007 a remarkable increase of complexity and differentiation throughout the DRG-system can be identified as well as a careful expansion of procedure-based payments.

[Representation of Internal Medicine in G-DRG System - Analysis of Reasons for Prolonged Length of Stay]. / Innere Medizin im G-DRG-System.

Background There is an ongoing discussion within the German Society of Internal Medicine (DGIM) and the Professional Association of German Internists (BDI) about the appropriate depiction and remuneration of internal medicine in the G-DRG. Method Therefore, cases with a significantly prolonged length of stay were analyzed in a multicenter study. 124 cases from 6 hospitals were collected for evaluation. Results The results show that the observed prolongation of hospitalization was mainly due to medical reasons. Discussion Thus, patients with unclear symptoms and consequently need for a thorough workup could not be identified to cause longer inpatient stay. Instead, treatment complications and comorbidities led to extended hospitalization. The results also reveal prolonged hospitalization as a consequence of unsettled or delayed postdischarge care e. g. in rehabilitation facilities.

Quality Indicators in Cranial Neurosurgery: Which Are Presently Substantiated? A Systematic Review.

BACKGROUND: Owing to the rising costs of health care delivery, the quality of delivered care has become a central issue across all medical specialties. Consequently, there is increasing pressure to create standardized frameworks for measuring quality of care. In the field of cranial neurosurgery, health care administrators have begun applying quality measures that are easily available but might be inaccurate in measuring the quality of care. METHODS: We performed a systematic literature review on quality indicators (QIs) that are presently used in this field, aiming to elucidate which QIs are scientifically founded and thus potentially justifiable as measures of quality. We found a total of 8 QIs, and methodologically evaluated published studies according to the AIRE (Appraisal of Indicators through Research and Evaluation) criteria. These criteria include length of hospital stay, all-cause readmission rate, and unplanned reoperation rate. RESULTS: Our review indicates that these presently used or proposed QIs for neurosurgery lack scientific rigor and are restricted to rudimentary measures, and that further research is necessary. CONCLUSIONS: Neurosurgeons need to define their own QIs and actively participate in the validation of these QIs to provide the best possible patient outcomes. More reliable clinical registries, obligatory for all neurosurgical services, should be established as a basis for establishing such indicators, with risk adjustment being an important element of any such indicators.

[Evaluation of flat-rate payment in radiation oncology. German experience with disease-related groups for inpatient funding in radiation oncology]. / Evaluation von Fallpauschalen in der Radioonkologie: Abbildungsqualität radioonkologischer stationärer Therapien und Anpassung der G-DRG-Systeme 2003-2006.

PURPOSE: In Germany a new casemix-related reimbursement system with "diagnosis related groups" (DRGs) for inpatient treatment was started in 2003. The first German system G-DRG 1.0 was developed on the basis of the Australian AR-DRG version 4.1. German inpatient treatment in radiation oncology was not specifically represented in this system due to the very different health care systems. As the DRG system was planned as a pricing system with severe effects on the funding of radiation oncology departments, an adjustment was urgently needed. For the modification, national data about pattern of care and economic relevance were needed. METHODS: For 3,689 cases treated in radiation oncology departments from eleven hospitals data were collected prospectively concerning diagnosis, length of stay, procedures and high-cost drugs and treatments. The DRGs were analyzed for homogeneity in length of stay and costs. Readmission frequency and interval were analyzed and the relevance of existing reimbursement regulations for this situation was evaluated. RESULTS: It could be shown, that radiation therapy implicated additional expenses for oncologic inpatients. These additional costs were not represented in the G-DRG 1.0 reimbursement system. Chemotherapy was an additional cause for economically inhomogeneous oncologic DRGs. The complex sequence of cases for the same patient could be shown, and that the rules for reimbursement of readmissions have to take these sequential treatments into account. Based on these data, modifications of the reimbursement system were suggested. In the following G-DRG version for the year 2004, 21 DRGs were designed for patients receiving radiation therapy. The regulations concerning the readmission of oncologic patients were modified. The correlation between the number of radiation therapy fractions and the total expense was acknowledged in the following year (G-DRG system 2005) and resulted in 35 DRGs. The version for 2006 showed the solidity of these solutions with almost unchanged definitions of these DRGs. CONCLUSION: This evaluation revealed the deficits in the G-DRG system 1.0 (and the AR-DRG system 4.1) related to the inpatient treatment in radiation oncology departments. Modifications could be proposed for following years. In 2004-2006, the regulatory boards adopted several implications of these data for the improvement of the German casemix-based hospital-financing system.

CKD and Acute and Long-Term Outcome of Patients with Peripheral Artery Disease and Critical Limb Ischemia.

BACKGROUND AND OBJECTIVES: Despite the many studies showing an association between CKD and a high risk of ischemic events and mortality, the association of CKD with peripheral arterial disease (PAD) still has not been well described. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This large cohort study assessed the association of CKD, even in the earlier stages, with morbidity, short- and long-term outcome, and costs among patients with PAD. RESULTS: We identified 41,882 patients with PAD who had an index hospitalization between January 1, 2009, and December 31, 2011. Of these, 8470 (20.2%) also had CKD (CKD stage 2: n=2158 [26%]; stage 3: n=3941 [47%]; stage 4: n=935 [11%]; stage 5: n=1436 [17%]). The ratio of women to men was 1:1.2. Compared with patients without known CKD, those with CKD had higher frequencies of coronary artery disease (1.8-fold higher; P<0.001), chronic heart failure (3.3-fold higher; P<0.001), and Rutherford PAD categories 5 and 6 (1.8-fold higher; P<0.001); underwent significantly fewer revascularizations (0.9-fold fewer; P<0.001); had a nearly two-fold higher amputation rate (P<0.001); had higher frequencies of in-hospital infections (2.1-fold higher; P<0.001), acute renal failure (2.8-fold higher; P<0.001), and sepsis (1.9-fold higher; P<0.001); had a 2.5-fold higher frequency of myocardial infarction (P<0.001); and had a nearly three-fold higher in-hospital mortality rate (P<0.001). In an adjusted multivariable Cox regression model, CKD remained a significant predictor of long-term outcome of patients with PAD during follow-up for up to 4 years (until December 31, 2012; median, 775 days; 25th-75th percentiles, 469-1120 days); the hazard ratio was 2.59 (95% confidence interval, 2.21 to 2.78; P<0.001). The projected mortality rates after 4 years were 27% in patients without known CKD and 46%, 52%, 72%, and 78% in those with CKD stages 2, 3, 4, and 5, respectively. Lengths of hospital stay and reimbursement costs were on average nearly 1.4-fold higher (P<0.001) in patients who also had CKD. CONCLUSIONS: This analysis illustrates the significant and important association of CKD with in-hospital and long-term mortality, morbidity, amputation rates, duration and costs of hospitalization, in-hospital treatment, and complications in patients with PAD.

[Introduction of quality management with the EFQM Self-Assessment method. Implementation and experience in a university department of dermatology]. / Einstieg ins Qualitäts- management mit der EFQM-Selbstbewertung Anwendung und Erfahrung in einer dermatologischen Universitätsklinik.

In the near future, the German legislative and health insurance agencies will increasingly demand proof of quality in hospital health care. The role of quality management in hospitals is emphasized by the introduction of per-case payment (DRG) in Germany. The implementation of internal quality management at an early stage sets the course of a systematic and continuous quality improvement process, with the goal to increase performance and results by efficient utilization of resources. The decision for or against one or another quality management model appears to be difficult, since the possible impacts of the quality management system can hardly be foreseen. As this article shows, the Self-Assessment method of the European Foundation for Quality Management (EFQM) provides a valuable and efficient tool to introduce quality management in a hospital environment. The Self-Assessment method enables a systematic survey of levels of performance and outcome of the hospital. Furthermore, it provides an appropriate basis to identify areas of strengths and weaknesses. A high degree of motivation of the personnel is fostered by the creation of a local guidance circle, a coordinating group, and several Self-Assessment teams. However, formulation and deployment of improvement actions are necessary for the long-term implementation of quality management. The application of Self-Assessment in quality management appears a suitable tool to promote excellence.

The diagnosis related groups enhanced electronic medical record.

PROBLEM: The introduction of Diagnosis Related Groups as a basis for hospital payment in Germany announced essential changes in the hospital reimbursement practice. A hospital's economical survival will depend vitally on the accuracy and completeness of the documentation of DRG relevant data like diagnosis and procedure codes. In order to enhance physicians' coding compliance, an easy-to-use interface integrating coding tasks seamlessly into clinical routine had to be developed. A generic approach should access coding and clinical guidelines from different information sources. METHODS: Within the Electronic Medical Record (EMR) a user interface ('DRG Control Center') for all DRG relevant clinical and administrative data has been built. A comprehensive DRG-related web site gives online access to DRG grouping software and an electronic coding expert. Both components are linked together using an application supporting bi-directional communication. Other web based services like a guideline search engine can be integrated as well. RESULTS: With the proposed method, the clinician gains quick access to context sensitive clinical guidelines for appropriate treatment of his/her patient and administrative guidelines for the adequate coding of the diagnoses and procedures. This paper describes the design and current implementation and discusses our experiences.

[The DRG law--planning gone wrong? The conversion from the physician's point of view]. / Fallpauschalengesetz (FPG)--Falsche Planung Gemacht? Die Umsetzung der DRG-Einführung aus ärztlicher Sicht.

With the Health Care Reform Act of 2000 the German government initiated the introduction of a new hospital funding system based on an internationally used Diagnosis Related Group (DRG) system. In June 2000, the medical self-governing bodies (consisting of representatives of the German Hospital Federation, the German Statutory Health Insurance Funds and the Association of Private Health Insurances) commissioned for the execution of this project decided to use the Australian Refined DRG system, version 4.1 (AR DRG) as the basis for the future German (Refined) DRG system (G-DRG). It is planned for voluntary hospitals to replace the previous German hospital reimbursement system by the new DRG-based hospital funding system in January 2003. From January 2004, the change of the reimbursement system will be mandatory for all hospitals with the exception of psychiatric, psychosomatic and psychotherapeutic hospitals or units. The new reimbursement system is not only intended to cover acute hospital care but also parts of early rehabilitation, palliative and sub-acute care. Due to its economic incentives the effects of introducing the DRG system in Germany will not only affect the hospital sector but ambulatory care, nursing and rehabilitation as well.