[Hip Fractures in Adults - Contemporary Clinical Management Based on International Standards]. / Zur hüftgelenknahen Femurfraktur des erwachsenen Menschen ­ Zeitgemäßes klinisches Management auf der Basis internationaler Standards.

BACKGROUND: Patients with hip fractures, often of advanced age and with multimorbidity-trauma, require early surgery and interdisciplinary treatment in order to avoid complications and reduce morbidity and mortality. "Time to surgery" is a sensitive quality indicator (QI) for the treatment process, reflecting multiple factors. Due to persistently noticeable problems in relation to this QI in external inpatient quality assurance in Germany, a special need for action was identified by the Federal Joint Committee (Gemeinsamer Bundesausschuss - G-BA). OBJECTIVES: Identification of methodologically particular reliable recommendations to establish structural and procedural standards to ensure adequate clinical care. METHODS: Systematic international web-based research and analysis of relevant guidelines for domain 3 of the AGREE II instrument; extraction of distinct, methodologically well-founded recommendations; supplementing the guideline analysis with an assessment of regulations with structure and process requirements or criteria for quality and care standards. RESULTS: Out of 66 identified, context-relevant guidelines, 15 were of "high methodological quality". Out of these 15, particular reliable recommendations could be extracted-among others - regarding surgical technique, combined orthogeriatric treatment, antibiotics, pressure ulcers and thromboembolic prophylaxis, time to surgery, anesthetics, physiotherapy, postoperative management and delirium. Further structural and procedural specifications could be extracted from nine other sets of rules. CONCLUSIONS: Surgery as early as possible and adequate care can be assured through a consistent, multifactorial, interdisciplinary and coordinated team approach in well structured and adequately staffed facilities of appropriate quality.

[The MDK as an Institution for Quality Assurance in the German Health System: A Practice Report on Quality Audits Based on the Guideline on Minimally Invasive Heart Valve Interventions of the G-BA]. / Der MDK als Institution der Qualitätssicherung im deutschen Gesundheitssystem: Qualitätsprüfungen auf Basis der Richtlinie zu minimalinvasiven Herzklappeninterventionen des G-BA ­ ein Praxisbericht.

INTRODUCTION: In 2015, the Federal Joint Committee (G-BA) adopted a guideline on minimally invasive heart valve interventions (MHI-RL). Every year, hospitals have to declare compliance with the quality requirements of the guideline in the form of checklists vis-à-vis the social service providers, who can have the data checked by the medical service of the health insurance (MDK) on site. Here we report on the experience with these tests in Hessian hospitals. METHODS: At the MDK Hessen, after being commissioned by the social service providers and announcement to this effect, examinations are carried out by two specialist medical assessors as part of on-site inspections in the hospitals. RESULTS: Since the MHI-RL took effect, a total of 33 quality audits for transcatheter aortic valve implantations (TAVI) and/or transcatheter mitral valve repairs (TMVR/"MitraClip®") have been performed in 12 Hessian hospitals. As part of a first review, 87.5% of hospitals performing TAVI and TMVR and 50.0% of TMVR-only hospitals confirmed compliance with the checklists. Following the initial assessment, all hospitals that had not yet complied fulfilled the requirement within the period agreed upon with the social service providers. By the deadline of 21.03.2017, 11 of the 12 hospitals examined fulfilled the requirements of the MHI-RL and since March 2018, all 12 hospitals did so. CONCLUSION: Since the MHI-RL took effect, the MDK Hessen has been commissioned as an independent and impartial socio-medical expert institution within the statutory health insurance system. With the quality checks, it makes an important contribution to the quality assurance of specialized inpatient care in Hesse. This has led to fulfillment of the quality requirements of the MHI-RL throughout Hessen. Based on these experiences, the MDK Hessen is well prepared for the challenges of the future MDK quality control guideline/MDK-QK-RL.

[Quality Controls in Hospitals by MDK Hessen: A Practice Report of Experiences and Outlook]. / Qualitätsprüfungen in Krankenhäusern durch den MDK Hessen: Erfahrungen und Ausblick - ein Praxisbericht.

INTRODUCTION: The Hospital Structure Act introduced § 275a SGB V into the German Social Code. It specifies and expands the legal requirements for future quality controls in hospitals performed by the Medical Review Board of the Statutory Health Insurance Funds (MDK). These controls are intended to ensure high-quality, patient-centered and needs-based medical care of the population. Based on 10 years of experience of the Hessian MDK, the practicability of the quality controls is to be demonstrated. METHODS: The hospital quality controls carried out so far concern either the examination of the structural quality according to the regulations of the Federal Joint Committee (G-BA) for the quality assurance of special care complexes/procedures or the specifications of the German Institute of Medical Documentation and Information (DIMDI) for complex procedures. All quality controls in the Hessian hospitals are performed as on-site inspections by a specialized MDK-team of 2 medical examiners. The quality controls involve the responsible medical staff as well as members of the hospital management. RESULTS: From 2006-2016 a total of 357 quality controls were carried out according to the regulations of the G-BA for 10 different special care complexes/procedures. In about 20% of cases, the requirements were not fulfilled. During the same period, 1624 quality controls were carried out according to the specifications of the DIMDI for 33 different complex procedures. In about 40% of cases the required standards were not fulfilled. CONCLUSION: The deficits revealed demonstrate the need for quality control by an independent and qualified body. The quality controls contribute to quality assurance and thus to the quality of structures, processes and outcomes in hospitals. The quality control practice established by the Hessian MDK is transferable to nationwide quality controls to be performed in future.

Time to Surgery and Outcome in the Treatment of Proximal Femoral Fractures.

BACKGROUND: It has not been conclusively established whether, or to what extent, the time to surgery affects mortality and the risk of complications after the surgical treatment of proximal femoral fractures. METHODS: Data on 106 187 hospitalizations over the period 2015-2017 involving insurees of the German AOK health insurance company aged 20 and above were drawn from pseudonymized billing data and stratified in three subgroups: osteosynthesis for pertrochanteric fracture (PTF-OS: N = 52 358), osteosynthesis for femoral neck fracture (FNF-OS: N = 7970), and endoprosthesis for femoral neck fracture (FNF-EP: N = 45 859). Multivariate regression models were used to analyze the relation between preoperative in-hospital stay (time to surgery, TTS: 0 days [reference category], 1, 2, 3, 4-7 days) and mortality and general complications within 90 days, with risk adjustment for fracture site, operative method, age, sex, accompanying illnesses, and antithrombotic medication in the preceding year. RESULTS: Mortality was significantly elevated only with PTF-OS, and only with a TTS of 2 days (odds ratio: 1.12 [95% confidence interval: (1.02; 1.23)]). General complications in relation to TTS were significantly elevated in the following situations: PTF-OS: 2 days: OR 1.24 [1.13; 1.37], 3 days: OR 1.33 [1.11; 1.60], 4-7 days: OR 1.47 [1.21; 1.78]; FNF-EP: 3 days: OR 1.21 [1.06; 1.37], 4-7 days: OR 1.42 [1.25; 1.62]; FNF-OS: 4-7 days: OR 1.86 [1.26; 2.73]. CONCLUSION: A prolonged time to surgery is associated with an elevated general complication risk depending on the site of the fracture and the type of surgical procedure used.