[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.

[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.

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.

[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.

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.

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.

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.

[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.

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.

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.

[The "outcome benchmarking in rheumatologic acute care" project of the Association of Rheumatologic Acute Care Clinics (VRA e.V.) in Germany]. / "Outcome Benchmarking in der rheumatologischen Akutversorgung (obra)" - Projekt des Verbandes Rheumatologischer Akutkliniken (VRA e.V.).

By initiating and taking part in the pilot project obra (outcome benchmarking in rheumatologic acute care), which was supported by the German Ministry of Health, the rheumatologic hospitals committed themselves to the continuous improvement of quality through a collective benchmarking and learning process. In addition to verifiable and concrete improvements in quality, the major achievements of the obra pilot project include a cultural change in the participating hospitals as well as the continuation of outcome benchmarking and its expansion to an increasing number of hospitals.

[The German DRG system 2003-2010 from the perspective of intensive care medicine]. / Krankenhausfinanzierung unter DRG-Bedingungen: Entwicklung der Abbildung der Intensivmedizin im deutschen DRG-System 2003-2010.

BACKGROUND: Intensive care medicine is extremely heterogeneous, expensive and can only be partially planned and controlled. A correct and fair representation of intensive care medicine in the G-DRG system is an essential requirement for the use as a pricing system. From the perspective of intensive care medicine, pertinent changes of the DRG structure and differentiation of relevant parameters have been established within the G-DRG systems 2003-2010. METHODS: Analysis of relevant diagnoses, medical procedures, co-payment structures and G-DRGs in the versions 2003-2010 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: Since the first G-DRG system version 2003, numerous measures improved quality of case allocation of intensive care medicine. Highly relevant to the system version 2010 are duration of mechanical ventilation, the intensive care treatment complex and complicating constellations. The number of G-DRGs relevant to intensive medical care increased from n = 3 (2003) to n = 58 (2010). CONCLUSION: For standard cases, quality of case allocation and G-DRG reimbursement are adequate in 2010. The G-DRG system gained complexity again. High demands are made on correct and complete coding of complex cases. Nevertheless, further adjustments of the G-DRG system especially for cases with extremely high costs are necessary. Where the G-DRG system is unable to cover extremely high-cost cases, reimbursement solutions beyond the G-DRG structure should be taken into account.

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.

Risk predictors for adverse outcomes after percutaneous coronary interventions and their related costs.

OBJECTIVES: During recent years, numerous clinical and procedural risk factors for adverse outcomes after percutaneous coronary interventions (PCI) have been identified. Due to the high economic pressure in many national health care systems, it is of some interest whether these predictors of clinical risks represent also the main cost drivers. METHODS: Data of 770 patients undergoing PCI were retrospectively analyzed. Risk factors for PCI as well as angiographic classifications were adopted from the ACC/AHA Guidelines. In-hospital costs for each patient were obtained from thoroughly performed calculations for the national Diagnosis Related Groups database in Germany. RESULTS: Creatinine >2 mg/dl (192% of average costs, P < 0.0001), EF