[Costs of potentially outpatient endoscopic procedures in cases with a 1-day hospital stay versus a longer stay]. / Kosten potenziell ambulant erbringbarer endoskopischer Leistungen in Fällen mit 1-Tages-Verweildauer gegenüber einer längeren Verweildauer.

INTRODUCTION: The transfer of patient care and medical interventions that was previously provided on an inpatient basis to outpatient settings is a stated goal of health politics. It is unclear to what extent costs of an endoscopic procedure and the disease severity depend on the duration of inpatient treatment. We therefore examined whether endoscopic services for cases with a one-day length of stay (VWD) are comparably expensive to cases with a longer VWD. METHODS: Outpatient services were selected from the DGVS service catalog. Day cases with exactly one such gastroenterological endoscopic (GAEN) service were compared with cases with VWD>1 day regarding their patient clinical complexity levels (PCCL) and mean costs. Data from the DGVS-DRG project with §21-KHEntgG cost data from a total of 57 hospitals from 2018 and 2019 served as the basis. Endoscopic costs were taken from cost center group 8 of the InEK cost matrix and plausibility checked. RESULTS: A total of 122,514 cases with exactly one GAEN service were identified. Statistically equal costs were shown in 30 of 47 service groups. In 10 groups, the cost difference was not relevant (<10%). Cost differences >10% existed only for EGD with variceal therapy, insertion of a self-expanding prosthesis, dilatation/bougienage/exchange with PTC/PTCD in place, non-extensive ERCP, endoscopic ultrasound in the upper gastrointestinal tract, and colonoscopy with submucosal or full thickness resection, or foreign object removal. PCCL differed in all but one group. CONCLUSION: Gastroenterology endoscopy services provided as part of inpatient care but potentially performable on an outpatient basis are predominantly equally expensive for day cases as for patients with a length of stay greater than one day. The disease severity is lower. Calculated §21-KHEntgG cost data thus form a reliable basis for the calculation of appropriate reimbursement for hospital services to be provided as outpatient services under the AOP in the future.

[Limits of the G-DRG system to reflect Complexity in German University Hospitals]. / Die Grenzen des G-DRG-Systems bei der Abbildung von Komplexität in der Universitätsmedizin.

Since the introduction of the G-DRG-system in Germany for the reimbursement of in-hospital patients in 2003 the Institute for the Hospital Remuneration System (InEK) annually determines case reimbursements for currently 1300 individual diagnosis-related groups (DRGs). These are based on the cost documentation of 200 representative hospitals, coopted by InEK (§â€Š21-KHEntG-dataset). Since DRGs represent cost averages, one half of German hospitals would be expected to report an annual income surplus, the other half a deficit. In spite of sustained cost reductions two thirds of public University Hospitals, but only 29 % of non-University hospitals, report annual deficits. The German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) has obtained the §â€Š21-cost-dataset from 74 InEK-hospitals and 7 Mio anonymized cases since 2012 in order to appeal for individual DRG-corrections to InEK. In the current project this database was used to investigate whether the cost of care at University Hospitals is appropriately reflected in three representative DRGs and OPS codes (operation and procedure codes): Liver cirrhosis with hepatic encephalopathy, endoscopic procedure-tiers, and an endoscopic intervention after patient transfer from one hospital to another. The analysis reveals that the higher patient complexity, severity and cost at University Hospitals cannot be corrected by modification or further differentiation of individual DRGs within the existing G-DRG-system. Even in DRGs for which a differentiation would be possible and economically appropriate it is often not permitted. A further rise of the systematic deficit of German University Hospitals (currently 300 Mio. Euro annually) can only be prevented by introducing either a case-based DRG-System-Surcharge for University Hospitals or by separation of a University Hospital U-DRG-System from the general G-DRG-System.

[Prognostic significance and economic burden of hepatic encephalopathy in liver cirrhosis in German hospitals based on G-DRG data]. / Mortalität und ökonomische Auswirkungen der hepatischen Enzephalopathie bei Leberzirrhose in deutschen Krankenhäusern auf der Basis von G-DRG-Kostendaten.

INTRODUCTION: Hepatic encephalopathy (HE) represents a frequent complication of liver cirrhosis with negative effects on patients' lives. The prevalence of clinical HE is estimated to be between 30-45 %. Regardless of its clinical and prognostic relevance HE is considered to be underdiagnosed. METHODS: Beyond a systematic analysis of mortality of HE, we investigated the economic impact and reimbursement situation for HE in patients with liver cirrhosis in Germany. For the retrospective analysis, anonymized data (2011-2015) concerning expenses and diagnoses (§â€Š21-4 KHEntgG) were obtained from 74 participating hospitals of the Diagnosis Related Groups (DRG) Project of the German Gastroenterological Association (DGVS). Furthermore, results were compared with case data from all German hospitals provided by the German Federal Authority on Statistics (Statistische Bundesamt (Destatis), Wiesbaden). RESULTS: In participating hospitals 59 093 cases with liver cirrhosis were identified of which 14.6 % were coded as having HE. Hospital mortality was threefold increased compared to cirrhosis-patients without HE (20.9 versus 7.5 %). Cases with cirrhosis as well as the proportion with HE increased over time. Compared to all patients with cirrhosis, reimbursement for HE patients produced a deficit (of up to 634 € for HE grade 4). DISCUSSION: Mortality is threefold increased in patients with cirrhosis when an additional HE is diagnosed. Hospitals participating in the DGVS-DRG-project coded 2 % more HE cases among their cirrhosis cases than the rest of hospitals either because of a selection bias for greater disease severity or because of better coding quality. At present, reimbursement for HE patients on the basis of F-DRG-system produced a deficit.

[Cost assessment for endoscopic procedures in the German diagnosis-related-group (DRG) system - 5 year cost data analysis of the German Society of Gastroenterology project]. / Kosten endoskopischer Leistungen der Gastroenterologie im deutschen DRG-System ­ 5-Jahres-Kostendatenanalyse des DGVS-Projekts.

Background In the German hospital reimbursement system (G-DRG) endoscopic procedures are listed in cost center 8. For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e. g. DKG-NT, GOÄ) have remained in use. We have assessed the cost for endoscopic procedures in the G-DRG-system. Methods To assess the cost of endoscopic procedures 74 hospitals, annual providers of cost-data to the Institute for the Hospital Remuneration System (InEK) made their data (2011 - 2015; §â€Š21 KHEntgG) available to the German-Society-of-Gastroenterology (DGVS) in anonymized form (4873 809 case-data-sets). Using cases with exactly one endoscopic procedure (n = 274 186) average costs over 5 years were calculated for 46 endoscopic procedure-tiers. Results Robust mean endoscopy costs ranged from 230.56 € for gastroscopy (144 666 cases), 276.23 € (n = 32 294) for a simple colonoscopy, to 844.07 € (n = 10 150) for ERCP with papillotomy and plastic stent insertion and 1602.37 € (n = 967) for ERCP with a self-expanding metal stent. Higher costs, specifically for complex procedures, were identified for University Hospitals. Discussion For the first time this catalogue for endoscopic procedure-tiers, based on §â€Š21 KHEntgG data-sets from 74 InEK-calculating hospitals, permits a realistic assessment of endoscopy costs in German hospitals. The higher costs in university hospitals are likely due to referral bias for complex cases and emergency interventions. For 46 endoscopic procedure-tiers an objective cost-allocation within the G-DRG system is now possible. By international comparison the costs of endoscopic procedures in Germany are low, due to either greater efficiency, lower personnel allocation or incomplete documentation of the real expenses.

Qualitative Assessment of the Symptoms and Impact of Pancreatic Exocrine Insufficiency (PEI) to Inform the Development of a Patient-Reported Outcome (PRO) Instrument.

BACKGROUND: Pancreatic exocrine insufficiency (PEI) affects patients with chronic pancreatitis (CP) and cystic fibrosis (CF) who produce insufficient digestive pancreatic enzymes. Common symptoms include steatorrhoea, diarrhea, and abdominal pain. OBJECTIVE: The objective of the study was to develop and test the content validity of a patient-reported outcome (PRO) instrument assessing PEI symptoms and their impact on health-related quality of life. METHODS: Instrument development was supported by a literature review, expert physician interviews (n = 10: Germany 4, UK 3, France 3), and exploratory, qualitative, concept-elicitation interviews with patients with CF and CP with PEI (n = 61: UK 29, Germany 18, France 14) and expert physicians (n = 10). Cognitive debriefing of the draft instrument was then performed with patients with PEI (n = 37: UK 24, Germany 8, France 5), and feasibility was assessed with physicians (n = 3). For all interviews, verbatim transcripts were qualitatively analysed using thematic analysis methods and Atlas.ti computerized qualitative software. All themes were data driven rather than a priori. RESULTS: Patient interviews elicited symptoms and impacts not reported in the literature. Six symptom concepts emerged: pain, bloating, bowel symptoms, nausea/vomiting, eating problems, and tiredness/fatigue. Six impact domains were also identified. A 45-item instrument was developed in English, French, and German for testing in cognitive debriefing patient interviews. Following cognitive debriefing, 18 items were deleted. CONCLUSION: Rigorous qualitative patient research and expert clinical input supported development of a PEI-specific PRO with the potential to aid management and monitoring of unmet needs among patients with PEI. The next step is to perform psychometric evaluation of the resulting instrument.

Physical Activity, Energy Expenditure, Nutritional Habits, Quality of Sleep and Stress Levels in Shift-Working Health Care Personnel.

BACKGROUND: Among health care personnel working regular hours or rotating shifts can affect parameters of general health and nutrition. We have investigated physical activity, sleep quality, metabolic activity and stress levels in health care workers from both groups. METHODS: We prospectively recruited 46 volunteer participants from the workforce of a University Medical Department of which 23 worked in rotating shifts (all nursing) and 21 non-shift regular hours (10 nursing, 13 clerical staff). All were investigated over 7 days by multisensory accelerometer (SenseWear Bodymedia® armband) and kept a detailed food diary. Physical activity and resting energy expenditure (REE) were measured in metabolic equivalents of task (METs). Quality of sleep was assessed as Pittsburgh Sleeping Quality Index and stress load using the Trier Inventory for Chronic Stress questionnaire (TICS). RESULTS: No significant differences were found for overall physical activity, steps per minute, time of exceeding the 3 METs level or sleep quality. A significant difference for physical activity during working hours was found between shift-workers vs. non-shift-workers (p<0.01) and for shift-working nurses (median = 2.1 METs SE = 0.1) vs. non-shift-working clerical personnel (median = 1.5 METs SE = 0.07, p<0.05). Non-shift-working nurses had a significantly lower REE than the other groups (p<0.05). The proportion of fat in the diet was significantly higher (p<0.05) in the office worker group (median = 42% SE = 1.2) whereas shift-working nurses consumed significantly more carbohydrates (median = 46% SE = 1.4) than clerical staff (median = 41% SE = 1.7). Stress assessment by TICS confirmed a significantly higher level of social overload in the shift working group (p<0.05). CONCLUSION: In this prospective cohort study shift-working had no influence on overall physical activity. Lower physical activity during working hours appears to be compensated for during off-hours. Differences in nutritional habits and stress load warrant larger scale trials to determine the effect on implicit health-associated conditions.

Evaluation of a non-invasive multisensor accelerometer for calculating energy expenditure in ventilated intensive care patients compared to indirect calorimetry and predictive equations.

Continuous measurement of resting energy expenditure (REE) in critically ill patients remains challenging but is required to prevent malnutrition. SenseWear Pro 3 Armband (SWA) is a research grade accelerometer for assessment of REE with the advantage of easy handling. In a prospective study we compared SWA with indirect calorimetry (IC) and predictive equations in critically ill, ventilated patients. REE was measured by SWA, IC and calculated by predictive formulas. Potential confounding factors that influence REE were also recorded. Results of SenseWear Armband and indirect calorimetry were compared using the Bland-Altman method. 34 ICU patients were investigated. SWA underestimated resting energy expenditure compared to IC with a mean bias of ΔREE = -253.6 ± 333.2 kcal, equivalent to -11.7 % (p = 0.025). This underestimation was seen in both, medical (-14.9 %) and surgical (-12.9 %) patients and the bias was greater in patients with fever (-19.0 %), tachycardia (-18.7 %) or tachypnea (-26.2 %). Differences were also noted when SWA was compared to predictive formulas. At present, SWA cannot be regarded as an alternative to indirect calorimetry. Individual measurements are often inaccurate and should be used with caution until improved algorithms, based on the results of this study, have been implemented.

The Clinical and Socio-Economic Relevance of Increased IPMN Detection Rates and Management Choices.

BACKGROUND: Increased usage of computed tomography and magnetic resonance imaging has led to a large increase in identified pancreatic cysts of up to 25% in population-based studies. The clinical and economic relevance of identifying so many cystic lesions has not been established. Compared to other organs such as liver or kidney, dysontogenetic pancreatic cysts are rare. Pancreatic cysts comprise a variety of benign, premalignant or malignant lesions; however, precise diagnosis before resection has an accuracy of only 80%. The focus of recent research was the malignant potential of intraductal papillary mucinous neoplasms (IPMN) with the aim of establishing clinical pathways addressing risk of malignancy, age and comorbidity, treatment-related morbidity and mortality as well as cost-effectiveness of treatment and surveillance. The focus of this review is to analyze the clinical and socio-economic relevance as well as the cost-benefit relation for IPMNs. METHODS: For analysis, the following MESH terms were used to identify original articles, reviews, and guidelines in PubMed: ('intraductal papillary mucinous neoplasm' OR 'pancreatic cysts') and (incidence OR relevance OR socio-economic OR economic OR cost-effectiveness OR cost-benefit). The retrieved publications were reviewed with a focus on clinical and socio-economic relevance in relation to the increasing incidence of IPMN. RESULTS: Addressing the increasing prevalence of pancreatic cystic lesions, recent consensus guidelines suggested criteria for risk stratification according to 'worrisome features' and 'high-risk stigmata'. Recent prospective cohort studies evaluated whether these can be applied in clinical practice. Evaluation of three different clinical scenarios with regard to costs and quality-adjusted life years suggested a better effectiveness of surveillance after initial risk stratification by endoscopic ultrasound-guided fine-needle aspiration with cyst fluid analysis compared with immediate resection or follow-up without further intervention. Of interest, the 'immediate surgery' strategy was lowest for cost-effectiveness. CONCLUSIONS: The increasing incidence of identified pancreatic cysts requires an improved strategy for non-invasive risk stratification based on advanced imaging strategies. In light of a malignancy risk of 2% for branch-duct IPMN, the socio-economic necessity of a balance between surveillance and resection has to be agreed on.

Development, external validation, and comparative assessment of a new diagnostic score for hepatic steatosis.

OBJECTIVES: We used data from population-based studies to determine the accuracy of the Fatty Liver Index (FLI) and the Hepatic Steatosis Index (HSI) in determining individual risk of hepatic steatosis. We also developed a new risk scoring system and validated all three indices using external data. METHODS: We used data from the Study of Health in Pomerania (SHIP; n=4,222), conducted in North-eastern Germany, to validate the existing scoring systems and to develop our own index. Data from the South German Echinococcus Multilocularis and Internal Diseases in Leutkirch (EMIL) study (n=2,177) were used as an external validation data set. Diagnostic performance was evaluated in terms of discrimination (area under the receiver operating characteristic curve (AUC)) and calibration plots. We applied boosting for generalized linear models to select relevant diagnostic separators. RESULTS: The FLI accurately discriminated patients with fatty liver disease from those without (AUC=0.817) but had poor calibration, in that predicted risks differed considerably from observed risks, based on SHIP data. The FLI performed well in discrimination and calibration in the analysis of EMIL data (AUC=0.890). The HSI performed worse than the FLI in analysis of both data sets (SHIP: AUC=0.782 and EMIL: AUC=0.841), showing an extremely skewed calibration. Our newly developed risk score had a good performance in the development data set (SHIP: AUC=0.860) and also good discrimination ability in the validation data (EMIL: AUC=0.876), but it had low calibration based on the validation data set. CONCLUSIONS: We compared the ability of the FLI, HSI, and our own scoring system to determine the risk of hepatic steatosis using two population-based data sets (one for the development of our own system and one for validation). In the development and independent replication data set, all three indices discriminated well between patients with and without hepatic steatosis, but the predicted risks did not match well with the observed risks, when applied to external data. Scoring systems for fatty liver disease could depend on methodological standardization of ultrasound diagnosis and laboratory measurements.

Secretin-stimulated MRCP in volunteers: assessment of safety, duct visualization, and pancreatic exocrine function.

OBJECTIVE: The objective of our study was to investigate secretin-stimulated MRCP in terms of the safety of secretin, improvement of duct visualization, and assessment of pancreatic exocrine function. MATERIALS AND METHODS: Eight hundred sixteen volunteers (370 women and 446 men; mean age, 49.7 ± 13.1 [SD] years) underwent 3D MRCP before and after secretin stimulation (1 U/kg of body weight) at 1.5 T. For the first 2 hours after secretin injection, subjects were evaluated for adverse reactions. Improvement of duct visualization after secretin stimulation was subjectively evaluated by two readers and was quantified by duct diameter measurements. Pancreatic exocrine function was evaluated subjectively by two readers according to the duodenal filling and was quantified using calibrated volumetric measurements of total excreted volume and pancreatic flow output. RESULTS: Two subjects (0.2%) showed flushing (minor adverse reaction). Duct visualization after secretin injection was improved for reader 1 in 468 (57.4%) and for reader 2 in 478 (58.6%) subjects, was unchanged for reader 1 in 324 (39.7%) and for reader 2 in 315 (38.6%) subjects, and was worse for reader 1 in 24 (2.9%) and reader 2 in 23 (2.8%) subjects (interrater agreement, κ = 0.925). Main pancreatic duct diameters increased significantly after secretin stimulation: pancreatic head, 10.5% (mean); body, 12.5%; and tail, 7.7%. Pancreatic exocrine function evaluated according to assessment of duodenal filling was as follows: grade 0 (restricted function) in 0.7% of subjects by both readers, grade 1 (reduced function) in 4.8% of subjects by reader 1 and 4.5% of subjects by reader 2, grade 2 (low-grade reduced function) in 31.1% of subjects by reader 1 and 26.5% of subjects by reader 2, and grade 3 (physiologic function) in 63.4% of subjects by reader 1 and 68.3% of subjects by reader 2 (interrater agreement, κ = 0.838). The mean total excreted volume was 111.8 ± 49.8 (SD) mL, and the mean pancreatic flow output was 9.6 ± 4.2 mL/min. CONCLUSION: Secretin-stimulated MRCP moderately improves main pancreatic duct visualization and allows noninvasive quantification of pancreatic exocrine function with a negligible risk of side effects.

Recent advances in autoimmune pancreatitis: type 1 and type 2.

Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis characterised clinically by frequent presentation with obstructive jaundice, histologically by a lymphoplasmacytic infiltrate with fibrosis, and therapeutically by a dramatic response to steroids. When so defined, AIP can be sub-classified into two subtypes, 1 and 2. Recent international consensus diagnostic criteria for AIP have been developed for diagnosis of both forms of AIP. Type 1 AIP is the pancreatic manifestation of a multiorgan disease, recently named IgG4-related disease. Little is known about the pathogenesis of either form of AIP. Despite frequent association of type 1 AIP with elevated serum IgG4 levels and infiltration with IgG4-positive plasma cells, it is unlikely that IgG4 plays a pathogenic role in AIP. Type 1 AIP responds to steroids, but there needs to be consensus on treatment regimens for induction and therapeutic end points. Relapses are common, but can be reduced by long-term use of low-dose steroids. Recent reports suggest that immunomodulators (azathioprine, 6-mercaptopurine and mycophenolate mofetil), as well biological agents (the antibody to CD20, rituximab) may have a role in maintaining remission in relapsing type 1 AIP. Future studies should clarify the best management options for treatment of relapses and maintenance of remission. Type 2 AIP is a pancreas-specific disorder not associated with IgG4. It presents in younger individuals equally with obstructive jaundice and pancreatitis. The inflammatory process responds to steroid therapy; relapses are uncommon. The clinical spectrum and long-term outcomes of medically treated type 2 AIP are still being evaluated.