[The cost estimator in the TraumaRegister DGU]. / Der Kostenschätzer im TraumaRegister DGU®.

BACKGROUND AND OBJECTIVES: Estimated treatment costs of severely injured patients were often added to registry-based analyses. In the past, the TraumaRegister DGU® used a modular cost estimator for this purpose. A recent research project initiated by the German Trauma Society (DGU) evaluated the reimbursement of severely injured patients in the German DRG system. This project also allowed the generation of an improved update of the registry's cost estimator. METHODS: Detailed cost data for the acute therapy of severely injured patients were available from 10 hospitals that also participate in the TraumaRegister DGU®. Cost and registry data were matched using hospital code, date of admission, age, sex, and length of stay. A multivariate regression analysis with hospital costs as dependent variable included patients with an injury severity score (ISS) ≥ 9 points who stayed in hospital at least three days. All injuries were coded using the abbreviated injury scale (AIS). A total of 1002 patients treated in 2007 and 2008 were successfully matched. Cost data was collected for each case according to the method of calculation provided by the German DRG Institute (InEK). RESULTS: The mean age was 44 years and 73 % were males; the mean ISS was 27 points. The following aspects were significantly associated with the overall hospital costs: length of stay on the intensive care unit (ICU) (1152 € per day); length on intubation/ventilation (568 € per day); length of stay on normal ward (531 € per day); number of blood products (packed red blood cells; fresh frozen plasma) transfused until ICU admission (258 € per unit); a serious abdominal injury (AIS ≥3; 2849 €); an instable pelvic fracture with relevant blood loss (AIS 5; 7505 €); and a serious injury of the extremities (AIS 3-4; 2418 €). The estimated overall treatment costs calculated by the above mentioned formula averaged 22,138 € per case. The deviation from the measured real costs (21,546 € per case) was less than 3 %. CONCLUSION: Using only key data available for all patients in the registry, a valid cost estimator for acute care costs is now available in the TraumaRegister DGU®.

[Quality of case allocation of orthopedics and trauma surgery in the 2004 and 2014 versions of the German DRG system. An interim assessment of the development process]. / Abbildung orthopädisch-unfallchirurgischer Leistungen in den G-DRG-Systemversionen 2004 und 2014. Eine Zwischenbilanz des Weiterentwicklungsprozesses.

BACKGROUND: Since 2004 the German diagnosis-related groups (DRG) system has been applied nationwide in all German somatic hospitals. The G-DRG system is updated annually in order to increase the quality of case allocation. What developments have occurred since 2004 from the perspective of orthopedics and trauma surgery? This article takes stock of the developments between 2004 and 2014. METHODS: Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2004 and 2014 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: The number of G-DRGs in the whole system increased by 45.1 % between 2004 and 2014. The number of G-DRGs in the major diagnostic category (MDC) 08 that contains the majority of orthopedic and trauma surgery categories increased in the same period by 61.6 %. The reduction of variance of inlier costs in the MDC 08 category, a statistical measure of the performance of the G-DRG system, was below the corresponding value of the total system in 2004 as well in 2014. However, the reduction of variance of inlier costs in MDC 08 (+ 30.0 %) rose more from 2004 to 2014 than the corresponding value of the overall system (+ 21.5 %). CONCLUSION: Many modifications of the classification systems of diagnoses (ICD-10-GM) and medical procedures (OPS) and the structures of the G-DRG system could significantly improve the quality of case allocation from the perspective of orthopedics and trauma surgery between 2004 and 2014. Th assignment of cases could be differentiated so that complex cases with more utilization of resources were allocated to higher rated G-DRGs and vice versa. However, further improvements of the G-DRG system are necessary. Only correct and complete documentation and coding can provide a high quality of calculation of costs as a basis for a correct case allocation in future G-DRG systems.

[The challenge of adequate reimbursement for the seriously injured patient in the German DRG system]. / Die Herausforderung der sachgerechten Vergütung von Schwerverletzten im deutschen DRG-System.

BACKGROUND: Critically injured patients are a very heterogeneous group, medically and economically. Their treatment is a major challenge for both the medical care and the appropriate financial reimbursement. Systematic underfunding can have a significant impact on the quality of patient care. In 2009 the German Trauma Society and the DRG-Research Group of the University Hospital Muenster initialised a DRG evaluation project to analyse the validity of case allocation of critically injured patients within the German DRG system versions 2008 and 2011 with additional consideration of clinical data from the trauma registry of the German Trauma Society. Severe deficits within the G-DRG structure were identified and specific solutions were designed and realised. METHODS: A retrospective analysis was undertaken of standardised G-DRG data (§ 21 KHEntgG) including case-related cost data from 3 362 critically injured patients in the periods 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals. For 1 241 cases of the sample, complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of critically injured patients within the G-DRG system. Analyses of coding and grouping, performance of case allocation, and the homogeneity of costs in the G-DRG versions 2008 and 2011 were done. RESULTS: The following situations were found: (i) systematic underfunding of trauma patients in the G-DRG-Version 2008, especially trauma patients with acute paraplegia; (ii) participation in the official G-DRG development for 2011 with 13 proposals which were largely realised; (ii) the majority of cases with cost-covering in the G-DRG version 2011; (iv) significant improvements in the quality of statistical criteria; (v) overfunded trauma patients with high intensive care costs; (vi) underfunding for clinically relevant critically injured patients not identified in the G-DRG system. CONCLUSION: The quality of the G-DRG system is measured by the ability to obtain adequate case allocations for highly complex and heterogeneous cases. Specific modifications of the G-DRG structures could increase the appropriateness of case allocation of critically injured patients. Additional consideration of the ISS clinical data must be further evaluated. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical societies in this process.

[Orthopedic and trauma surgery in the German DRG system. Recent developments]. / Orthopädie und Unfallchirurgie im deutschen DRG-System. Aktuelle Entwicklungen.

BACKGROUND: Orthopedics and trauma surgery are subject to continuous medical advancement. The correct and performance-based case allocation by German diagnosis-related groups (G-DRG) is a major challenge. This article analyzes and assesses current developments in orthopedics and trauma surgery in the areas of coding of diagnoses and medical procedures and the development of the 2012 G-DRG system. METHODS: The relevant diagnoses, medical procedures and G-DRGs in the versions 2011 and 2012 were analyzed based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: Changes were made for the International Classification of Diseases (ICD) coding of complex cases with medical complications, the procedure coding for spinal surgery and for hand and foot surgery. The G-DRG structures were modified for endoprosthetic surgery on ankle, shoulder and elbow joints. The definition of modular structured endoprostheses was clarified. CONCLUSION: The G-DRG system for orthopedic and trauma surgery appears to be largely consolidated. The current phase of the evolution of the G-DRG system is primarily aimed at developing most exact descriptions and definitions of the content and mutual delimitation of operation and procedures coding (OPS). This is an essential prerequisite for a correct and performance-based case allocation in the G-DRG system.

[Financing of inpatient orthopaedics and trauma surgery in the 2011 G-DRG System]. / Finanzierung der stationären Orthopädie und Unfallchirurgie im G-DRG-System 2011.

BACKGROUND: The German DRG system forms the basis for billing inpatient hospital services. It includes not only the case groups (G-DRGs), but also copayments. This paper analyses and evaluates the relevant developments of the 2011 G-DRG system for orthopaedics and traumatology from the medical and classificatory perspective. METHODS: An analysis was performed of relevant diagnoses, medical procedures and G-DRGs in the 2010 and 2011 versions based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: A number of codes for surgical measures have been newly established or modified - above all in foot surgery, arthroscopic surgery and wound surgery. Here, the identification and the correct and performance-based mapping of complex and elaborate scenarios was again the focus of the restructuring of the G-DRG system. The G-DRG structure in orthopaedics and traumatology is changed, especially for polytraumata. CONCLUSION: The allocation of common cases with a standardized treatment pattern appears to be appropriate and the reimbursement adequate. For the less common and more complex cases the 2011 G-DRG system still shows need for further modification (e.g. polytraumata, joint replacement, spine surgery). The proper integration of the modified OPS classification for foot surgery to the appropriate G-DRGs will be essential to maintain the high quality of the reimbursement structure for the future.

Femur ultrasound (FemUS)--first clinical results on hip fracture discrimination and estimation of femoral BMD.

SUMMARY: A quantitative ultrasound (QUS) device for measurements at the proximal femur was developed and tested in vivo (Femur Ultrasound Scanner, FemUS). Hip fracture discrimination was as good as for DXA, and a high correlation with hip BMD was achieved. Our results show promise for enhanced QUS-based assessment of osteoporosis. INTRODUCTION: Dual X-ray absorptiometry (DXA) at the femur is the best predictor of hip fractures, better than DXA measurements at other sites. Calcaneal quantitative ultrasound (QUS) can be used to estimate the general osteoporotic fracture risk, but no femoral QUS measurement has been introduced yet. We developed a QUS scanner for measurements at the femur (Femur Ultrasound Scanner, FemUS) and tested its in vivo performance. METHODS: Using the FemUS device, we obtained femoral QUS and DXA on 32 women with recent hip fractures and 30 controls. Fracture discrimination and the correlation with femur bone mineral density (BMD) were assessed. RESULTS: Hip fracture discrimination using the FemUS device was at least as good as with hip DXA and calcaneal QUS. Significant correlations with total hip bone mineral density were found with a correlation coefficient R (2) up to 0.72 and a residual error of about one half of a T-score in BMD. CONCLUSIONS: QUS measurements at the proximal femur are feasible and show a good performance for hip fracture discrimination. Given the promising results, this laboratory prototype should be reengineered to a clinical applicable instrument. Our results show promise for further enhancement of QUS-based assessment of osteoporosis.

[Financing of inpatient orthopedics and trauma surgery in the G-DRG system 2010]. / Finanzierung der stationären Orthopädie und Unfallchirurgie im G-DRG-System 2010.

BACKGROUND: The German DRG (diagnosis-related groups) system forms the basis for billing inpatient hospital services. It includes not only the case groups (G-DRGs), but also additional and innovation payments. This paper analyzes and evaluates the relevant developments of the G-DRG System 2010 for orthopedics and traumatology from the medical and classification perspectives. METHODS: Analyses of relevant diagnoses, medical procedures and G-DRGs in the versions 2009 and 2010 based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI) were carried out. RESULTS: The DRG catalog is has grown from 8 to 1,200 G-DRGs. A number of codes for surgical measures have been newly established or modified. Here, the identification and the correct and performance-based mapping of complex and elaborate scenarios was again the focus of the restructuring of the G-DRG system. The G-DRG structure in orthopedics and traumatology has been changed, especially in the areas of spinal surgery and surgery of the upper and lower extremities. The actual impact of the changes may vary depending on the individual hospital services. CONCLUSION: For the first time since the introduction of the G-DRG system, the pure numerical changes at the level of DRGs themselves are so marginal that only part of the DRG users in the hospitals will register them. The changes implemented not only a high selectivity between complex and less complex scenarios, but partly also unintended and unjustified revaluation of less complex measures. The G-DRG system has gained complexity again. Especially the G-DRG allocation of spinal surgery and multiple surgical interventions of the upper and/or lower extremities have reached such a complexity that only a few DRG users can follow them.

[Six years of Advanced Trauma Life Support (ATLS) in Germany: the 100th provider course in Hamburg]. / Sechs Jahre Advanced Trauma Life Support (ATLS) in Deutschland: 100. Providerkurs in Hamburg.

With over 1 million certified physicians in more than 50 countries worldwide, the Advanced Trauma Life Support (ATLS) concept is one of the most successful international education programs. The concept is simple, priority-orientated (ABCDE scheme) and assesses the situation of the trauma patient on the basis of vital signs to treat the life-threatening injuries immediately. With over 100 ATLS provider courses and 10 instruction courses accomplished in less than 6 years, no other land in the world has successfully established this concept in such a short time as Germany. Meanwhile nearly 1,600 colleagues have been trained and certified. Evaluation of the first 100 ATLS courses in Germany supports this concept. The total evaluation of all courses is 1.36 (1.06-1.8, n=100). The individual parts of the course were marked as followed: presentations 1.6 (1.0-2.81, n=100), practical skills stations 1.46 (1.0-2.4, n=100) and surgical skills stations 1.38 (1.0-2.38, n=100). In 2009 a total of 47 ATLS courses were accomplished which will clearly increase in 2010. Other ATLS formats, such as ATCN (Advanced Trauma Care for Nurses) and refresher courses are planned for the beginning of 2010.

[Prophylactic ventilation of severely injured patients with thoracic trauma--does it always make sense?]. / Prophylaktische Beatmung des Schwerverletzten mit Thoraxtrauma--immer sinnvoll?

For therapy of blunt thoracic trauma in multiple injured patients, some studies have recommended prophylactic ventilation with kinetic therapy for 3-5 days. In contrast other clinics prefer to reduce the time of ventilation and to extubate as soon as possible. In this retrospective study our patient collective was investigated to find out if early extubation is linked to a higher complication rate. A total of 26 ventilated patients with severe thoracic trauma and an abbreviated injury scale score (AIS thorax) >3 were included in the study. The mean time of ventilation was 98.4 h and in patients without head injury 71.3 h. Out of 22 patients 4 had to be reintubated which had to be repeated for 2 patients. Of the patients 3 developed pneumonia but no cases of adult respiratory distress syndrome (ARDS) were observed. Of the patients 4 died due to other injuries. The mean stay on the intensive care unit was 6.3 days and the mean stay in hospital 22.6 days. Our findings indicate that even with early and aggressive weaning from a respirator with extensive lung contusions an adequate therapy of thorax trauma is possible without having a higher incidence of complications.

[The economic challenges of polytrauma care]. / Wirtschaftliche Herausforderungen der Polytraumaversorgung.

Following the introduction of DRGs ("diagnosis-related groups") in Germany, reimbursements changed from a per diem rate to a flat charge per patient. DRGs are defined by the German Institute for the Hospital Remuneration System (InEK, Institut für das Entgeltsystem im Krankenhaus) along with the respective reimbursement. The revenues are set according to the diagnoses and procedures. In complex cases like serious injury this applies for the average diagnoses and procedures. As a result, several groups reported costs of polytrauma care as high as 70,000 euro with losses as high as 20,000 euro. In the USA, a similar constellation has lead to the closure of trauma centers. The main reasons for the financial deficit are heterogeneity of polytrauma patients and contingency costs. Both are difficult to transfer to a case-based compensation system. Since the German DRG system was designed to learn during introduction, there were adjustments to reimbursements for polytrauma care in the initial phase. However, in recent years, no further improvements in the care of severely injured patients have been seen. The deficit per seriously injured patient currently runs at approx. 5000 euro. A renewed joint effort is required in order to avoid an economy-related reduction in quality of care.

[Distribution planning of injured persons in mass disasters or catastrophes. Structuring of hospital capacities exemplified by the catastrophe network of the German Society for Trauma Surgery (DGU)]. / Verteilungsplanung von Verletzten beim MANV oder Katastrophenfall. Strukturierung der Krankenhauskapazitäten am Beispiel des Katastrophennetzwerks der DGU.

Relevant changes have occurred in disaster management in Germany due to legal alterations and the introduction of the diagnosis-related groups (DRG) system. This has resulted in a reduction in bed capacities and an increase in bed utilization. In addition to the preclinical deployment strategy the provisional aspects of disaster medicine with the problem of the emergency service/hospital interface will be described. A suggestion for a solution for optimization of patient allocation in mass disasters or catastrophes will be demonstrated with the catastrophe network of the German Society for Trauma Surgery (DGU).

Comparison of intraoperative flat panel imaging and postoperative plain radiography for the detection of intraarticular screw displacement in volar distal radius plate ostheosynthesis.

OBJECTIVES: To investigate if intraoperative 3D flat panel imaging improves the detection of radiocarpal intraarticular screw misplacement (RCSM) in comparison to standard postoperative x-ray. METHODS: In a study on cadaver specimens, we evaluated the sensitivity and specificity to detect RCSM using X-ray, intraoperative 3D-fluoroscopy as well as the digital volume tomography. The gold standard reference was computed tomography. RESULTS: Sensitivity for the detection of RCSM for X-ray was 58% and specificity 88%. For DVT, the sensitivity to detect RCSM was 88% and the specificity 53%. For 3D-fluoroscopy, the sensitivity for RCSM was 68% and specificity 95%. When combining the methods, the best performance was found, when combining the two intraoperative imaging methods, with a resulting sensitivity of 88% and a specificity of 73%. CONCLUSIONS: Intraoperative 3D fluoroscopy and digital volume tomography appear to be at least as sensitive and specific to detect RCSM than the regular postoperative radiography in two planes. However, especially discrete screw misplacements can be missed with either method. LEVEL OF EVIDENCE: Level IV. Diagnostic device study.

[Description of the severely injured in the DRG system: is treatment of the severely injured still affordable?]. / Abbildung von Schwerverletzten im DRG-System : Wird die Schwerverletztenversorgung doch bezahlbar?

BACKGROUND: Due to the heterogeneity of severely injured patients (multiple trauma) it is difficult to assign them to homogeneic diagnosis-related groups (DRG). In recent years this has led to a systematic underfunding in the German reimbursement system (G-DRG) for cases of multiply injured patients. This project aimed to improve the reimbursement by modifying the case allocation algorithms of multiply injured patients within the G-DRG system. METHODS: A retrospective analysis of standardized G-DRG data according to §21 of the Hospital Reimbursement Act (§ 21 KHEntgG) including case-related cost data from 3,362 critically injured patients from 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals was carried out. For 1,241 cases complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of multiply injured patients within the G-DRG system. Analysis of coding and grouping, performance of case allocation and the homogeneity of costs in the G-DRG versions 2008-2012 was carried out. RESULTS: The results showed systematic underfunding of trauma patients in the G-DRG version 2008 but adequate cost covering in the majority of cases with the G-DRG versions 2011 and 2012. Cost coverage was foundfor multiply injured patients from the clinical viewpoint who were identified as multiple trauma by the G-DRG system. Some of the overfunded trauma patients had high intensive care costs. Also there was underfunding for multiple injured patients not identified as such in the G-DRG system. CONCLUSIONS: Specific modifications of the G-DRG allocation structures could increase the appropriateness of reimbursement of multiply injured patients. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical specialist societies.

Does ATLS trauma training fit into Western countries: evaluation of the first 8 years of ATLS in Germany.

BACKGROUND: With over 2 million certified physicians worldwide, the Advanced Trauma Life Support (ATLS) program is one of the most successful international medical education programs. Germany joined the ATLS program in 2003. Before implementation of the program, there was a controversial discussion as to whether a country like Germany with a long history of trauma care needed ATLS at all. 197 courses with nearly 3,000 providers were performed until December 2010. AIM: We assessed the course evaluations since the implementation of ATLS in Germany using the participants' systematic feedback. METHOD: During the course, each participant evaluated each presentation, skill station, and simulation on a rating scale from 1 to 4 (1 being the best, 4 being the worst). The participants completed the evaluation forms during the course and before they received their results. The course coordinator made sure that all forms were returned. The feedback forms were collected anonymously and were entered into a database. Statistical analysis was performed using frequencies and mean values. RESULTS: The cumulative evaluation of all courses revealed an average performance score of 1.39 (1.06-1.86; n = 197). The lectures, skill stations, and simulations were individually evaluated as follows: lectures 1.61 (1.00-2.81; n = 197), skill stations 1.40 (1.00-2.40; n = 197), and surgical skill stations 1.35 (1.00-2.38; n = 197). Practical skills simulation (case scenarios) received the highest grade of 1.24 (1.00-1.57; n = 197). There were no significant changes during the time concerning the results of the evaluation. CONCLUSION: The overall assessment showed constantly good and excellent evaluations by the participants over the years. In general, skill stations and simulations performed better than lectures. According to these results, the course format is well accepted by the participants and, therefore, can be recommended to all physicians treating trauma patients. Our results also underline the value of such a course format in an industrial country with an already established trauma system.

[Diaphyseal pseudarthroses. Epidemiology and outcome]. / Diaphysäre Pseudarthrosen. Epidemiologie und Outcome.

From 1971 to 1993, a total of 759 cases of nonunion of both the upper and lower extremities were treated. In recent years the frequency of these cases of nonunion has clearly declined. Analysis of patient data shows a positive trend particularly for nonunion in the lower arm and leg while at the same time nonunion in the upper arm and leg remained essentially constant. Moreover, the proportion of aseptic to septic manifestations has shifted towards the aseptic forms in a ratio of 1:0.5. The treatment results of a representative, randomly chosen group (n = 107 out of a total of 392) from 1981 to 1993 are satisfactory with little statistical deviation for the upper extremity. The least pleasing results were seen in nonunion of the lower leg, which differed from the somewhat better results for the upper leg on the OLERUD score, with a statistical significance of P < 0.05. This study shows a very interesting development in clinical results.

[Preoperative nutritional status of neurosurgery patients]. / Präoperativer Ernährungszustand neurochirurgischer Patienten.

In a prospective trial anthropometric and biochemical data of 24 neurosurgical patients with primary intracranial tumors were measured to assess preoperative malnutrition in this special group of patients. In spite of starving because of invasive diagnostic procedures, high-dose dexamethasone therapy of peritumoral edema, and changes in food intake because of psychical alterations and repeated vomiting resulting from elevated intracranial pressure no abnormalities were found in the data measured. The authors conclude that in general preoperative malnutrition is absent in neurosurgical patients and preoperative nutrition to improve postoperative outcome is not indicated in this group.

[Navigated Iso-C(3D)-based drilling of a osteochondral lesion of the talus]. / Navigierte Iso-C(3D)-basierte Anbohrung einer osteochondralen Läsion des Talus.

Retrograde drilling of osteochondral lesions has obtained acceptable results in the initial stage. Intraoperatively not all lesions are accessible with the arthroscopic technique, despite being readily identifiable with modern imaging preoperatively. As an alternative, open surgical treatment is recommended to achieve good results. The use of computer-assisted navigated retrograde drilling of osteochondral lesions has been described with promising results as a new technique. Computed tomography (CT)- and fluoroscopy-based navigation systems in current use are limited in their flexibility. The drawbacks of fluoroscopy are lack of three-dimensional imaging intraoperatively. CT-based navigation still requires intraoperative cumbersome registration, extra preoperative planning, and imaging with further technical resources. In the current case report, we describe a patient with an osteochondral lesion of the posteromedial talus. In addition to the current method of arthroscopic evaluation and treatment, we also introduce an alternative technique of using Iso-C(3D)-based navigation-assisted retrograde drilling of the lesion. The advantages of this technique are an actual intraoperative three-dimensional imaging for the use of navigation without the need for anatomical registration and an immediate postoperative control of surgical treatment. The results of this case report demonstrate accurately navigated drilling with the described system. The accuracy was confirmed with immediate intraoperative Iso-C(3D) and postoperative CT scans. Our results indicate that the use of an Iso-C(3D) navigation system is a possible alternative to arthroscopic or open drilling for osteochondral lesions of the talus. To provide further evidence for the use of Iso-C (3D)-based drilling, current studies will start at our institution.