Surgical reorganization during the COVID-19 pandemic and impact on case-mix and surgical site infections: A multicenter cohort study in Italy.

BACKGROUND: The coronavirus 2019 (COVID-19) pandemic led to major disruptions in surgical activity, particularly in the first year (2020). The objective of this study was to assess the impact of surgical reorganization on surgical outcomes in Northern Italy in 2020 and 2021. METHODS: A retrospective cohort study was conducted among 30 hospitals participating in the surveillance system for surgical site infections (SSIs). Abdominal surgery procedures performed between 2018 and 2021 were considered. Predicted SSI rates for 2020 and 2021 were estimated based on 2018-2019 data and compared with observed rates. Independent predictors for SSI were investigated using logistic regression, including procedure year. RESULTS: 7605 procedures were included. Significant differences in case-mix were found comparing the three time periods. Observed SSI rates among all patients in 2020 were significantly lower than expected based on 2018-2019 SSI rates (p 0.0465). Patients undergoing procedures other than cancer surgery in 2020 had significantly lower odds for SSI (odds ratio, OR 0.52, 95 % confidence interval, CI 0.3-0.89, p 0.018) and patients undergoing surgery in 2021 had significantly higher odds for SSI (OR 1.49, 95 % CI 1.07-2.09, p 0.019) compared to 2018-2019. CONCLUSIONS: Enhanced infection prevention and control (IPC) measures could explain the reduced SSI risk during the first pandemic year. IPC practices should continue to be reinforced beyond the pandemic context.

Based on knowledge capital value for disease cost accounting of diagnosis related groups.

Background: The National Health Commission and the other relevant departments in China have initiated testing of the Diagnosis Related Groups (DRGs) system in 30 pilot locations since 2019. In the process of DRG payment reform, accounting for the costs of diseases has become a highly challenging issue. The traditional method of disease accounting method overlooks the compensation for the knowledge capital value of medical personnel. Objective: The primary objective of this study is to analyze the cost accounting scheme of China's Diagnosis Related Groups (C-DRG), focusing on the value of knowledge capital. Methods: The study initially proposes a measurement index system for the value of knowledge-based capital, including the difficulty of disease treatment, labor intensity of disease treatment, risk of disease treatment, and operation/treatment time for diseases. The Analytic Hierarchy Process (AHP) is then utilized to weigh the features of medical workers' knowledge capital value. First, pairwise comparisons are conducted in this stage to develop a two-pair judgment matrix of the primary indicators. Second, the eigenvectors corresponding to the maximum eigenvalues of the matrix are calculated to generate the weight coefficient of each feature. The consistency test is carried out after this stage. An empirical analysis is conducted by collecting data, including the full costs of treating three types of diseases-hip replacement, acute simple appendicitis, and heart bypass surgery-from one public medical institution. Results: The empirical analysis examines whether this DRG costing accounting can address the issue of neglecting the value of medical workers' knowledge capital. The methods reconfigure the positive incentive mechanism, stimulate the endogenous motivation of the medical service system, foster independent changes in medical behavior, and achieve the goals of reasonable cost control. Conclusion: In the cost accounting system of C-DRG, the value of medical workers' knowledge capital is acknowledged. This acknowledgment not only boosts the enthusiasm and creativity of medical workers in optimizing and standardizing the diagnosis and treatment process but also improves the transparency and authenticity of DRG pricing. This is particularly evident in the optimization and standardization of the diagnosis and treatment processes within medical institutions and in monitoring inadequate medical practices within these institutions.

Time trends in case-mix and risk of revision following hip and knee arthroplasty in public and private hospitals: a cross-sectional analysis based on 476,312 procedures from the Dutch Arthroplasty Register.

BACKGROUND AND PURPOSE: This study aims to assess time trends in case-mix and to evaluate the risk of revision and causes following primary THA, TKA, and UKA in private and public hospitals in the Netherlands. METHODS: We retrospectively analyzed 476,312 primary arthroplasties (public: n = 413,560 and private n = 62,752) implanted between 2014 and 2023 using Dutch Arthroplasty Register data. We explored patient demographics, procedure details, trends over time, and revisions per hospital type. Adjusted revision risk was calculated for comparable subgroups (ASA I/II, age ≤ 75, BMI ≤ 30, osteoarthritis diagnosis, and moderate-high socioeconomic status (SES). RESULTS: The volume of THAs and TKAs in private hospitals increased from 4% and 9% in 2014, to 18% and 21% in 2022. Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES compared with public hospital patients. In private hospitals, age and ASA II proportion increased over time. Multivariable Cox regression demonstrated a lower revision risk for primary THA (HR 0.7, CI 0.7-0.8), TKA (HR 0.8, CI 0.7-0.9), and UKA (HR 0.8, CI 0.7-0.9) in private hospitals. After initial arthroplasty in private hospitals, 49% of THA and 37% of TKA revisions were performed in public hospitals. CONCLUSION: Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES com-pared with public hospital patients. The number of arthroplasties increased in private hospitals, with a lower revision risk compared with public hospitals.

[Impact Analysis of a new, Cross-sector Service Provision of Gastroenterologic Endoscopic Services in Accordance with 115f SGB V (Hybrid-DRG): Allocation Matrix and Cost Analysis]. / Auswirkungsanalyse einer neuen, sektorenübergreifenden Erbringung bisher stationärer endoskopischer gastroenterologischer Leistungen entsprechend §115f SGB V (Hybrid-DRG): Zuordnungsmatrix und Kostenanalyse.

BACKGROUND: With the introduction of §115f SGB V, the prerequisites for "sector-equal remuneration" ('Hybrid DRG') have been created. In an impact analysis, we assigned inpatient gastroenterological endoscopic (GAEN) cases in a matrix of future hybrid DRG versus outpatient surgery (AOP) or inpatient treatment. METHODS: In selected DRGs (G47B, G67A, G67B, G67C, G71Z, H41D, H41E) an allocation matrix of GAEN cases was created on medical grounds. For this purpose, service groups from the DGVS service catalog ('Leistungskatalog') were assigned to the groups: 'Hybrid-DRG', 'AOP' and 'Inpatient' by a group of experts based on the DGVS position paper. Cost data from the DGVS-DRG project for the 2022 data year from 36 InEK calculation hospitals with a total of 232,476 GAEN cases were evaluated. RESULTS: 26 service groups from the DGVS service catalog were assigned to a "Hybrid-DRG", 24 to the "inpatient" group, and 12 to the "AOP" group. 7 performance groups were splitted "depending on the OPS code" and classified at this level. Cases with additional fees were excluded from a hybrid DRG because these cannot be agreed there.The cost analysis shows that services that are already in the AOP have a similar cost level to services that have been classified as 'Hybrid-DRG'. With the cost calculation, a cost level could be presented for the hybrid DRGs formed. CONCLUSION: Based on clearly defined structural, procedural and personnel requirements, services from suitable DRGs can be transferred to a hybrid DRG. Assigning services without the involvement of clinical experts seems extremely difficult. Case assignment based on arbitrary contextual factors increases complexity without demonstrably increasing the quality of the assignment and needs to be further developed. A cost analysis can be derived from the known inpatient costs and must serve as the basis for the 2025 Hybrid DRG catalog.

Underfunding of German university-based high-performance medicine exemplified by the treatment of varices in cirrhosis.

Facing increasing economization in the health care sector, clinicians have to adapt not only to the ever-growing economic challenges, but also to a patient-oriented health care. Treatment costs are the most important variable for optimizing success when facing scarce human resources, increasing material- and infrastructure costs in general, as well as low revenue flexibility due to flat rates per case in Germany, the so-called Diagnosis-Related Groups (DRG). University hospitals treat many patients with particularly serious illnesses. Therefore, their share of complex and expensive treatments, such as liver cirrhosis, is significantly higher. The resulting costs are not adequately reflected in the DRG flat rate per case, which is based on an average calculation across all hospitals, which increases this economic pressure. Thus, the aim of this manuscript is to review cost and revenue structures of the management of varices in patients with cirrhosis at a university center with a focus on hepatology. For this monocentric study, the data of 851 patients, treated at the Gastroenterology Department of a University Hospital between 2016 and 2020, were evaluated retrospectively and anonymously. Medical services (e.g., endoscopy, radiology, laboratory diagnostics) were analyzed within the framework of activity-based-costing. As part of the cost unit accounting, the individual steps of the treatment pathways of the 851 patients were monetarily evaluated with corresponding applicable service catalogs and compared with the revenue shares of the cost center and cost element matrix of the German (G-) DRG system. This study examines whether university-based high-performance medicine is efficient and cost-covering within the framework of the G-DRG system. We demonstrate a dramatic underfunding of the management of varicose veins in cirrhosis in our university center. It is therefore generally questionable whether and to what extent an adequate care for this patient collective is reflected in the G-DRG system.

[Outpatient care in pulmonology - a scientific analysis and a position paper of the German Society of Respiratory Medicine (DGP)]. / Ambulantisierung in der Pneumologie ­ eine wissenschaftliche Analyse und ein Positionspapier der DGP.

INTRODUCTION: The ambulantization of patient care that were previously provided as inpatient service is one of the goals of the current reform in the German healthcare system. In pulmonology, this particularly applies to endoscopic procedures. However, the real costs of endoscopic services, which form the basis for the calculation of a future so called hybrid DRG or in the AOP catalog, are unclear. METHODS: After selection of use cases including endoscopic procedures which can be performed on an outpatient basis by a committee of experts the appropriate DRGs were identified from the §â€Š21-KHEntgG data for 2022 published by the Institute for the Hospital Remuneration System (InEK). The costs were calculated from the respective InEK cost matrix added by the calculated material costs. RESULTS: The use cases suitable for outpatient treatment were systematic endobronchial ultrasound (EBUS) with transbronchial needle aspiration (calculated costs €â€Š2,175.60 without or €â€Š3,315.60 including PET/CT), navigation-assisted bronchoscopy for peripheral lesions (depending on the methodology €â€Š2,870.23 to €4,120.23) and diagnostic (flexible) bronchoscopy (€â€Š1,121.02). CONCLUSION: Outpatient treatment of endoscopic procedures that were previously performed inpatient is possible and necessary, and the costs calculated in this publication can form a reliable basis for appropriate reimbursement. Together with a structural quality that has been transformed to outpatient service and cross-sector cooperation, continued high-quality care for pneumological patients can be ensured.

Assessment of Price Variation in Coronary Artery Bypass Surgery at US Hospitals.

BACKGROUND: Little is known about hospital pricing for coronary artery bypass grafting (CABG). Using new price transparency data, we assessed variation in CABG prices across US hospitals and the association between higher prices and hospital characteristics, including quality of care. METHODS AND RESULTS: Prices for diagnosis related group code 236 were obtained from the Turquoise database and linked by Medicare Facility ID to publicly available hospital characteristics. Univariate and multivariable analyses were performed to assess factors predictive of higher prices. Across 544 hospitals, median commercial and self-pay rates were 2.01 and 2.64 times the Medicare rate ($57 240 and $75 047, respectively, versus $28 398). Within hospitals, the 90th percentile insurer-negotiated price was 1.83 times the 10th percentile price. Across hospitals, the 90th percentile commercial rate was 2.91 times the 10th percentile hospital rate. Regional median hospital prices ranged from $35 624 in the East South Central to $84 080 in the Pacific. In univariate analysis, higher inpatient revenue, greater annual discharges, and major teaching status were significantly associated with higher prices. In multivariable analysis, major teaching and investor-owned status were associated with significantly higher prices (+$8653 and +$12 200, respectively). CABG prices were not related to death, readmissions, patient ratings, or overall Centers for Medicare and Medicaid Services hospital rating. CONCLUSIONS: There is significant variation in CABG pricing, with certain characteristics associated with higher rates, including major teaching status and investor ownership. Notably, higher CABG prices were not associated with better-quality care, suggesting a need for further investigation into drivers of pricing variation and the implications for health care spending and access.

How do hospitals respond to payment unbundling for diagnostic imaging of suspected cancer patients?

Payments for some diagnostic scans undertaken in outpatient settings were unbundled from Diagnosis Related Group based payments in England in April 2013 to address under-provision. Unbundled scans attracted additional payments of between £45 and £748 directly following the reform. We examined the effect on utilization of these scans for patients with suspected cancer. We also explored whether any detected effects represented real increases in use of scans or better coding of activity. We applied difference-in-differences regression to patient-level data from Hospital Episodes Statistics for 180 NHS hospital Trusts in England, between April 2010 and March 2018. We also explored heterogeneity in recorded use of scans before and after the unbundling at hospital Trust-level. Use of scans increased by 0.137 scans per patient following unbundling, a 134% relative increase. This increased annual national provider payments by £79.2 million. Over 15% of scans recorded after the unbundling were at providers that previously recorded no scans, suggesting some of the observed increase in activity reflected previous under-coding. Hospitals recorded substantial increases in diagnostic imaging for suspected cancer in response to payment unbundling. Results suggest that the reform also encouraged improvements in recording, so the real increase in testing is likely lower than detected.

Comprehensive evaluation of disease coding quality in gastroenterology and its impact on the diagnosis-related group system: a cross-sectional study.

OBJECTIVE: According to the diagnosis-related group (DRG) requirement, issues of diagnosis and procedure coding in the gastroenterology department of our hospital were analyzed and improvement plans were proposed to lay the foundation for effective implementation of DRGs. METHODS: The title page of case-history of 1600 patients admitted to the Department of Gastroenterology of this hospital from January 1, 2021 to December 31, 2021 was sampled as a data source, and the primary and other diagnostic codes, operation or procedure codes involved in the title page of case-history were categorized and statistically analyzed. RESULTS: Of the 531 cases treated with gastrointestinal endoscopy in our hospital in 2021, coding errors were identified in 66 cases and unsuccessful DRG enrollment in 35 cases, including 14 cases with incorrect coding of the primary diagnosis (8 cases with unsuccessful DRG enrollment), 37 cases with incorrect coding of the primary operation (23 cases with unsuccessful DRG enrollment), and 8 cases with incorrect coding of both the primary diagnosis and the primary operation (4 cases with unsuccessful DRG enrollment). Analysis of 66 inpatient cases with coding problems showed a total of 167 deficiencies, including 36 deficiencies in major diagnoses, 84 deficiencies in other diagnoses, and 47 deficiencies in surgery or operation coding. CONCLUSION: The accuracy of coding of disease diagnosis and surgical operation is the basis for the smooth implementation of DRGs. The medical staff of this hospital has poor cognition of DRGs coding and fails to recognize the important role of the title page of case-history quality to DRGs system, and their attention to DRGs and knowledge base of disease classification coding should be improved. In addition, the high incidence of coding errors, especially the omission of disease diagnosis, requires increased training of physicians and nurses on clinical knowledge and requirements for DRGs medical records, thereby improving the quality of medical cases and ensuring the accuracy of DRGs information.

[Skull base surgery in the German DRG system-New categorization of important procedures]. / Die Schädelbasischirurgie im deutschen DRG-System ­ Neue Zuordnung wichtiger Prozeduren.

Surgery of the skull base includes interventions between the nose or paranasal sinuses (anterior skull base) or ear/temporal bone (lateral skull base) and the intracranial space. As interventions at the anterior skull base almost exclusively involve complex pathologies in a demanding anatomical region, in many cases two experienced surgeons from different disciplines are required who should be experienced in operating together. The technical and time requirements are also considerable in many cases; however, for many procedures there are no specific skull base operational and procedural keys (OPS) codes that take the considerable personnel and structural effort into account. A change in the diagnosis-related groups (DRG) system, implemented since the beginning of 2023, now adjusts the remuneration of the abovementioned effort for malignant pathologies of the anterior and lateral skull base. The reallocation of procedures 5­015.0/1/3/4 and 5­016.0/2/4/6 results in a significant upgrade of anterior and lateral skull base surgery. Since the beginning of 2023 skull base surgery will no longer be charged under DRG D25C with a (former) relative weight of 1.893, but with DRG D25B with a current relative weight of 3.753 when a code of the aforementioned groups is used. Nevertheless, further adjustments are necessary, for example, in the available reconstructive steps in order to provide the Institute for the Remuneration System in Hospitals (InEK) with the most differentiated data possible on the procedural effort of the intervention and to achieve a more balanced distribution of the reimbursements of skull base surgery in the long term.

Reducing abnormal expenses in national health insurance based on a control chart and decision tree-driven define, measure, analyze, improve and control process.

This study examined the cost of medical insurance for "sepsis" treatment in Taiwan. We applied statistical tests, cost control charts, and C5.0 decision trees using the define, measure, analyze, improve and control (DMAIC) process to mine data on Diagnosis-Related Groups (DRGs) and clinics that reported expense anomalies and disposal costs. Analyzing 353 valid samples (application fees) from four DRGs, 70 clinics, and 15 input variables, abnormalities in application fees for adults (age ≧18 years old) with comorbidities or complications was significant (95% confidence interval) in one DRG and nine clinics. Four input variables (ward charge, treatment fee, laboratory fee, and pharmaceutical service charge) had a significant impact. Improvements or controls should be prioritized for three clinics (Nos. 49, 44, and 14) and two input variables (treatment and laboratory fees). This model can be replicated to ascertain excess medical expenditures and improve the efficiency of medical resource use.

Health Economic Aspects of Platelet Concentrates: Comparing Cost and Reimbursement of Pathogen Inactivated and Conventional Platelet Concentrates in a German Comprehensive Cancer Center.

INTRODUCTION: Pathogen inactivation (PI) utilizing amotosalen and UVA light (INTERCEPT® Blood System) is a well-established method for the production of safer platelet concentrates (PCs). While many studies describe clinical and logistical benefits of PI, the implications and potential challenges from a hospital management perspective have not yet been analyzed - health economic analyses considering reimbursement of PI are lacking. The objective of this analysis was to examine the real-life inpatient treatment costs from a hospital perspective and to assess the economic impact of PI-PC versus conventional PC (CONV-PC) administration in Germany. METHODS: Real-life cost data for inpatient cancer cases from 2020 of the University Hospital Cologne were identified by operating and procedure codes. The German diagnosis-related groups, extra fees, case mix index (CMI), length of stay (LOS), and average resource consumption of PC were evaluated from a micro-management perspective. The potential economic impact of implementing PI-treated PCs was modeled retrospectively. RESULTS: In total, 951 inpatient cases were analyzed (CMI [median 4.7-9.9], LOS [median 26 days], number of cases in intensive care units [38%]). The median DRG fee was between EUR 13,800 and EUR 26,400. According to our model, the use of PI-PC compared to CONV-PC would result in savings between EUR 184 and EUR 306 per case. CONCLUSION: From a hospital management perspective, oncological cases requiring PC transfusion are associated with a high CMI (reimbursement per DRG flat fee) and moderate costs with sufficient add-on payment for PI on a case level. Investment and process costs for PI implementation can be analyzed for site-specific scenarios.

Case mix-based changes in health status: A prospective study of elective surgery patients in Vancouver, Canada.

INTRODUCTION: Hospital activity is often measured using diagnosis-related groups, or case mix groups, but this information does not represent important aspects of patients' health outcomes. This study reports on case mix-based changes in health status of elective (planned) surgery patients in Vancouver, Canada. DATA AND METHODS: We used a prospectively recruited cohort of consecutive patients scheduled for planned inpatient or outpatient surgery in six acute care hospitals in Vancouver. All participants completed the EQ-5D(5L) preoperatively and 6 months postoperatively, collected from October 2015 to September 2020 and linked with hospital discharge data. The main outcome was whether patients' self-reported health status improved among different inpatient and outpatient case mix groups. RESULTS: The study included 1665 participants with completed EQ-5D(5L) preoperatively and postoperatively, representing a 44.8% participation rate across eight inpatient and outpatient surgical case mix categories. All case mix categories were associated with a statistically significant gain in health status (p < .01 or lower) as measured by the utility value and visual analogue scale score. Foot and ankle surgery patients had the lowest preoperative health status (mean utility value: 0.6103), while bariatric surgery patients reported the largest improvements in health status (mean gain in utility value: 0.1515). CONCLUSIONS: This study provides evidence that it was feasible to compare patient-reported outcomes across case mix categories of surgical patients in a consistent manner across a system of hospitals in one province in Canada. Reporting changes in health status of operative case mix categories identifies characteristics of patients more likely to experience significant gains in health.

Colonoscopy performance monitoring: do we need to adjust for case mix?

INTRODUCTION: Overall caecum intubation rate(oCIR) and overall polyp detection rate(oPDR) have been proposed as performance indicators, but varying complexity in case mix among endoscopists may potentially affect validity. The study aims to explore the effect of adjusting for case mix on individual endoscopist performance by calculating case mix-adjusted performance estimates (cmCIR and cmPDR) and comparing them to overall performance estimates (oCIR and oPDR). The study also provides an R program for case mix analysis. METHODS: Logistic regression associated endoscopist, colonoscopy indication, patient age and patient gender with the binary outcomes of cecum intubation and polyp detection. Case mix-adjusted performance indicators were calculated for each endoscopist based on logistic regression and bootstraps. Endoscopists were ranked from best to worst by overall and case mix-adjusted performance estimates, and differences were evaluated using percentage points(pp) and rank changes. RESULTS: The dataset consisted of 7376 colonoscopies performed by 47 endoscopists. The maximum rank change for an endoscopist comparing oCIR and cmCIR was eight positions, interquartile range (IQR 1-3). The maximum change in CIR was 1.95 percentage point (pp) (IQR 0.27-0.86). The maximum rank change in the oPDR versus cmPDR analysis was 17 positions (IQR 1.5-8.5). The maximum change in PDR was 11.21 pp (IQR 2.05-6.70). Three endoscopists improved their performance from significantly inferior to within the 95% confidence interval (CI) range of performance targets using case mix-adjusted estimates. CONCLUSIONS: The majority of endoscopists were unaffected by adjustment for case mix, but a few unfortunate endoscopists had an unfavourable case mix that could invite incorrect suspicion of inferior performance.

Cost and reimbursement analysis of end-of-life cancer inpatients. The case of the Greek public healthcare sector.

BACKGROUND: While hospital-based Palliative Care services are usually covered through the main funding healthcare framework, traditional reimbursement methods have been criticized for their appropriateness. The present study investigates for the first time the case of treating end-of-life cancer patients in a Greek public hospital in terms of cost and reimbursement. METHODS: This retrospective observational study used health administrative data of 135 deceased cancer patients who were hospitalized in the end of their lives. Following the cost estimation procedure, which indentified both the individual patient and overhead costs, we compared the relevant billing data and reimbursement requests to the estimated costs. RESULTS: The average total cost per patient per day was calculated to be 97 EUR, with equal participation of individual patient's and overhead costs. Length of stay was identified as the main cost driver. Reimbursement was performed either by per-diem fees or by Diagnosis Related Groups' (DRGs), which were correspondingly associated with under or over reimbursement risks. In the case of the combined use of the two available reimbursement alternatives a cross-subsidization phenomenon was described. CONCLUSION: Although the cost of end-of-life care proved to be quite low, the national per-diem rate fails to cover it. DRGs designed for acute care needs are rather unsuitable for such sub acute hospitalizations. POLICY SUMMARY: There is a concrete need for reconsidering the current reimbursement schemes for this group of patients as part of any national plan concerning the integration and reformation of Palliative Care services. Otherwise, there is a serious danger for public institutions' reluctance to admit them with a serious impact on access and equity of end-of-life cancer care.

Conversion Total Hip Arthroplasty in the Era of Bundled Care Payments: Impacts on Costs of Care.

BACKGROUND: Conversion hip arthroplasty is defined as a patient who has had prior open or arthroscopic hip surgery with or without retained hardware that is removed and replaced with arthroplasty components. Currently, it is classified under the same diagnosis-related group as primary total hip arthroplasty (THA); however, it frequently requires a higher cost of care. METHODS: A retrospective study of 228 conversion THA procedures in an orthopaedic specialty hospital was performed. Propensity score matching was used to compare the study group to a cohort of 510 primary THA patients by age, body mass index, sex, and American Society of Anesthesiologists score. These matched groups were compared based on total costs, implants used, operative times, length of stay (LOS), readmissions, and complications. RESULTS: Conversion THA incurred 25% more mean total costs compared to primary THA (P < .05), longer lengths of surgery (154 versus 122 minutes), and hospital LOS (2.1 versus 1.56 days). A subgroup analysis showed a 57% increased cost for cephalomedullary nail conversion, 34% increased cost for sliding hip screw, 33% for acetabular open reduction and internal fixation conversion, and 10% increased costs in closed reduction and percutaneous pinning conversions (all P < .05). There were 5 intraoperative complications in the conversion group versus none in the primary THA group (P < .01), with no statistically significant difference in readmissions. CONCLUSION: Conversion THA is significantly more costly than primary THA and has longer surgical times and greater LOS. Specifically, conversion THA with retained implants had the greatest impact on cost.

Insights on DRGs, guideline compliance and economic sustainability. The case of mastectomy with immediate breast reconstruction.

Background: Immediate breast reconstruction is recommended for eligible patients undergoing mastectomy, raising the issue of economic sustainability of both mastectomy and breast reconstruction performed within the same hospitalization, as opposed to two surgical procedures in two different hospitalizations. Study design: A retrospective analysis was conducted to compare economic sustainability of mastectomies with or without immediate breast reconstruction. Methods: Economic data on hospitalizations for mastectomy in a Teaching Hospital between 1 January 2019 and 31 March 2021 were analyzed to assess their sustainability. Results: 338 admissions were selected (63.9% with immediate breast reconstruction (CI 99%: 57.2% to 70.6%). Compared to mastectomy alone, mastectomy with immediate breast reconstruction had higher cost of € 2,245 (p < 0.001), with operating rooms and devices as main cost drivers. Current reimbursements rates (which are the same for mastectomy alone and for mastectomy with immediate breast reconstruction) led to an average loss of € 1,719 for each mastectomy with immediate breast reconstruction. Conclusion: Current DRGs reimbursement rates for hospital admissions for breast cancer surgery do not guarantee immediate breast reconstruction's economic sustainability. DRGs system should be revised, or other solutions as bundled payment should be implemented in the light of the costs of innovation in healthcare, considering mastectomy and breast reconstruction steps in a path of linked actions aimed at improving patients' health.

[The Usefulness of ERAS Concepts for Colorectal Resections - an Economic Analysis under DRG Conditions]. / Sinnhaftigkeit von ERAS-Konzepten bei kolorektalen Resektionen ­ eine ökonomische Analyse unter DRG-Bedingungen.

BACKGROUND: ERAS (Enhanced Recovery After Surgery) describes a multimodal, interdisciplinary and interprofessional treatment concept that optimizes the postoperative convalescence of the patient through the use of evidence-based measures. GOAL OF THE WORK: The aim of this article is to examine the economic feasibility of the concept in the German DRG system. MATERIAL AND METHODS: Since August 2019, patients have been treated in our clinic according to the later certified ERAS concept. The last 20 patients before ERAS implementation are compared below with 20 patients after ERAS implementation, who were identified using a matched pair analysis. In addition to the comparison of costs and revenues, the clinical outcome of the patients is also presented. RESULTS: The cases of the patients in the pre-ERAS cohort caused median costs of € 7432.83. BWR of 3.38 were billable. The resulting DRG revenue for the patients in this group amounted to € 11325.78. The proceeds generated in the end amounted to € 4575.14. The cases of patients in the ERAS cohort resulted in costs of € 5582.96. BWR of 2.84 could be billed. The DRG proceeds for the patients in this group therefore amounted to € 10014.18. The profit generated was thus € 4993.84. DISCUSSION: The cost reduction generated by ERAS was comparable to the "loss" caused by the BWR decrease. ERAS is therefore also possible to cover costs in the German DRG system.