[Analysis of Efficency, Cost Structure and Revenues of ALT Free Flaps in Extremity Reconstruction]. / Analyse der Effizienz, Kostenstruktur und Erlössituation von freien ALT-Lappenplastiken zur Extremitätenrekonstruktion.

Microvascular reconstructions can be lengthy procedures lasting the entire day. As a result of unforeseeable events, the standardization of these procedures can be challenging. Moreover, the length of these procedures varies strongly, which impedes adequate scheduling and, therefore, optimal capacity utilization. Within the years 2018-2020, the duration of ALT free flap extremity reconstructions was correlated with the experience of the microsurgeon (category 1:<50 free flaps life-time experience, category 2: 50-200, category 3:>200) and comorbidities. The resulting costs were compared with the matrix of the German DRG Institute InEK. The surgical experience of the microsurgeon had a significant impact on the duration of surgery in extremity reconstruction. In due consideration of potential complications, category 2 microsurgeons were 45 minutes faster and category 3 microsurgeons were 167 minutes faster than category 1 microsurgeons. Comorbidities, by contrast, did not have a significant impact on procedure duration. Cost analysis revealed deficits for these procedures in relation to the InEK matrix. However, an additional analysis showed that the duration of surgery was within the German average while costs for personnel/OR minute were slightly below the average. According to this calculation, costs for microsurgical training were approximately 1000€/case. The reimbursement for flaps in extremity reconstruction is not entirely mapped in the German DRG system. Given the longer procedure times, microsurgical training is associated with higher costs. Defining the duration of microsurgery based on the level of expertise should result in improved adherence to schedule and more efficient utilization of the valuable operating room time.

Spinal infection with intraspinal abscess or empyema and acute myelopathy: comparative analysis of diagnostics, therapy, complications and outcome in primary care.

INTRODUCTION: This study on pyogenic spinal infections with intraspinal epidural involvement (PSI +) compared the outcome of patients with spinal cord injury (SCI) to those without (noSCI) taking diagnostic algorithm, therapy, and complications into account. METHODS: Patients were enrolled in an ambispective study (2012-2017). Diagnostic and therapeutic algorithms, complications, and neurological outcome were analyzed descriptively. Survival was analyzed applying Kaplan-Meier method and Cox regression. RESULTS: In total, 134 patients with a median (IQR) age of 72 (61-79) years were analyzed. Baseline characteristics were similar between the SCI (n = 55) and noSCI (n = 79). A higher percentage of endocarditis (9% vs. 0%; p = 0.03) was detected in the noSCI group. The majority (81%) received combinatorial therapy including spinal surgery and antibiotic treatment. The surgery complication rate was 16%. At discharge, improvement in neurologic function was present in 27% of the SCI patients. Length of stay, duration of ventilation and the burden of disease-associated complications were significantly higher in the SCI group (e.g., urinary tract infection, pressure ulcers). Lethality risk factors were age (HR 1.09, 95% CI 1.02-1.16, p = 0.014), and empyema/abscess extension (≥ 3 infected spinal segments, HR 4.72, 95% CI 1.57-14.20, p = 0.006), dominating over additional effects of Charlson comorbidity index, SCI, and type of treatment. The overall lethality rate was 11%. CONCLUSION: PSI + are associated with higher in-hospital mortality, particularly when multiple spinal segments are involved. However, survival is similar with (SCI) or without myelopathy (noSCI). If SCI develops, the rate of disease complications is higher and early specialized SCI care might be substantial to reduce complication rates.

The Berlin Acute Trauma Care Instrument Set (BATMIN) - A Selected Combination of Surgical Instruments for Damage Control and Hemostasis Surgery in Severe Acute Trauma.

A lack of sterile surgical instrument sets for damage control surgeries of severely injured patients became evident in a series of in-hospital mass casualty trainings in the German capital of Berlin. Moreover, the existing instrument trays contained mostly specialized instruments for elective interventions and were not well composed for the treatment of poly-traumatized patients. After a literature search on the most common injury patterns in Mass Casualty Incidents (MCIs), an expert group of surgeons from different disciplines designed an optimized instrument set. A set of 194 instruments was assembled and distributed into two containers. These 2 sets were subjected to a 6-month trial phase in our hospital, and the evaluation of usability was subsequently analyzed through feedback forms administered to the staff. After analysis of the feedback sheets, only minor alterations had to be incorporated. The Berlin Acute Trauma Care Instrument Set (BATMIN) was then made available by the state of Berlin to Berlin Hospitals providing acute trauma care. Out of the need to be prepared for mass casualties, we created an instrument set suitable for the damage control surgery of severely injured patients in individual care and MCIs.

Cervical Spine Injuries with Acute Traumatic Spinal Cord Injury: Spinal Surgery Adverse Events and Their Association with Neurological and Functional Outcome.

STUDY DESIGN: Monocenter case-control study. OBJECTIVE: Effects of spinal surgical adverse events (SSAE) on clinical and functional outcome, length of stay, and treatment costs after traumatic cervical spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA: Traumatic SCI is a challenge for primary care centers because of the emergency setting and complex injury patterns. SSAE rates of up to 15% are reported for spine fractures without SCI. Little is known about SSAE after traumatic SCI and their outcome relevance. METHODS: Acute traumatic cervical SCI patients were enrolled from 2011 to 2017. Cases with and without SSAE were compared regarding neurological recovery, functional outcome, secondary complications, mortality, length of stay, and treatment costs. Adjusted logistic regression and generalized estimating equation models were calculated for the endpoints ASIA impairment scale (AIS)-conversion and dysphagia. All analyses were run in the total and in a propensity score matched sample. RESULTS: At least one SSAE occurred in 37 of 165 patients (22.4%). Mechanical instability and insufficient spinal decompression were the most frequent SSAE with 13 (7.9%) or 11 (6.7%) cases, respectively. The regression models adjusted for demographic, injury, and surgery characteristics demonstrated a reduced probability for AIS-conversion related to SSAE (OR [95% CI] 0.14 [0.03-0.74]) and additionally to single-sided ventral or dorsal surgical approach (0.12 [0.02-0.69]) in the matched sample. Furthermore, SSAE were associated with higher risk for dysphagia in the matched (4.77 [1.31-17.38]) and the total sample (5.96 [2.07-17.18]). Primary care costs were higher in cases with SSAE (median (interquartile range) 97,300 [78,200-112,300]) EUR compared with cases without SSAE (52,300 [26,700-91,200]) EUR. CONCLUSION: SSAE are an important risk factor after acute traumatic cervical SCI with impact on neurological recovery, functional outcome, and healthcare costs. Reducing SSAE is a viable means to protect the limited intrinsic capacity for recovery from SCI.Level of Evidence: 4.

Association of age with the timing of acute spine surgery-effects on neurological outcome after traumatic spinal cord injury.

PURPOSE: To investigate the association of age with delay in spine surgery and the effects on neurological outcome after traumatic spinal cord injury (SCI). METHODS: Ambispective cohort study (2011-2017) in n = 213 patients consecutively enrolled in a Level I trauma center with SCI care in a metropolitan region in Germany. Age-related differences in the injury to surgery interval and conditions associated with its delay (> 12 h after SCI) were explored using age categories or continuous variables and natural cubic splines. Effects of delayed surgery or age with outcome were analyzed using multiple logistic regression. RESULTS: The median age of the study population was 58.8 years (42.0-74.6 IQR). Older age (≥ 75y) was associated with a prolonged injury to surgery interval of 22.8 h (7.2-121.3) compared to 6.6 h (4.4-47.9) in younger patients (≤ 44y). Main reasons for delayed surgery in older individuals were secondary referrals and multimorbidity. Shorter time span to surgery (≤ 12 h) was associated with higher rates of ASIA impairment scale (AIS) conversion (OR 4.22, 95%CI 1.85-9.65), as mirrored by adjusted spline curves (< 20 h 20-25%, 20-60 h 10-20%, > 60 h < 10% probability of AIS conversion). In incomplete SCI, the probability of AIS conversion was lower in older patients [e.g., OR 0.09 (0.02-0.44) for'45-59y' vs.' ≤ 44y'], as confirmed by spline curves (< 40y 20-80%, ≥ 40y 5-20% probability). CONCLUSION: Older patient age complexifies surgical SCI care and research. Tackling secondary referral to Level I trauma centers and delayed spine surgery imposes as tangible opportunity to improve the outcome of older SCI patients.

[The revenue from finger replantation and revision amputation: Is it cost-covering?] / Fingeramputationen und -replantationen bei unterschiedlichen Kostenträgern: Ist die Vergütung kostendeckend?

BACKGROUND: Finger amputation injuries are frequently treated conditions in occupational accident hospitals. They are either treated by replantation or revision amputation. The costs of these two treatment options differ significantly. This study aims to determine if the revenue generated from the treatment of finger amputation injuries in the German DRG system is cost-covering and if there are differences depending on the type of health insurance. METHODS: Based on our hospital's cost data from the years 2014 and 2015, we performed an analysis of the revenue generated from finger replantation and finger revision amputation and compared it with the cost data of the nationwide calculation hospitals in Germany. In addition, we compared the revenue generated from patients with statutory health insurance with the revenue from patients with workers' compensation insurance. RESULTS: During the study period, a total of 90 patients were treated for finger amputation. For primary finger revision amputation, the actual costs were lower compared to the cost data of the nationwide calculation hospitals (€ 3551 vs. € 3809, p = 0.442). After deduction of all costs, the revenue was 1,008 Euros for patients with statutory health insurance and 688 Euros for patients with workers' compensation insurance (p = 0.578). In contrast, the costs of complex finger reconstruction procedures were considerably underestimated. In cases of primary finger replantation or secondary finger revision amputation, losses of 260 Euros were recorded for patients with statutory health insurance. In patients with workers' compensation insurance, the revenue of complex finger reconstruction procedures after deduction of all costs was cost-covering (€ 900, p = 0.403). CONCLUSIONS: In the German DRG system, the reimbursement for the treatment of finger amputation depends on the type of health insurance. In patients with workers' compensation insurance, cost-covering revenue is generated from both finger revision amputation and finger replantation, whereas in patients with statutory health insurance, only the revenue of primary finger revision amputation appears to be cost-covering. Hence for finger amputation injuries with subsequent complex reconstruction procedures, a revision of the cost calculation is required to avoid inappropriate incentives in patient care.

[The German Statutory Accident Insurance: A successful example of a value-based healthcare structure]. / Die Gesetzliche Unfallversicherung in Deutschland als erfolgreiches Beispiel einer Value-based- Healthcare-Struktur.

In the mid-1920s Porter and others developed a reform approach for existing health care systems, aiming at a patient-focused, value-based orientation. Improving patient outcomes by attaining, preserving and restoring good health is inherently less costly than dealing with poor health. The authors of the present article will outline that the German statutory accident insurance system, which was already introduced in1884 and is of an evolving nature, reflects key elements of Porter's efficient value-based health care system. The German accident insurance system with its statutory mandate limited to the prevention and rehabilitation of work-related damage to one's health can also serve as a model for other larger health care insurance systems. Prevention and rehabilitation is pursued using all appropriate means to achieve the set goals of protecting and restoring individual health. In line with these objectives, the statutory health insurance controls the process in terms of the required care quality. The components of a complex health care system, usually managed by a variety of different institutions, are consolidated. Thus it can be ensured that in both prevention and rehabilitation all services that are necessary to keep focussing the value "individual health" rather than indemnities are applied.

Cost-effectiveness and economic impact of the KineSpring ® Knee Implant System in the treatment for knee osteoarthritis.

PURPOSE: To investigate the cost-effectiveness and economic impact of the KineSpring System in the treatment for knee osteoarthritis in Germany. METHODS: Functional outcome scores of the general German population and knee osteoarthritis (OA) patients under surgical treatments (HTO, UKA and TKA), conservative treatments and treatment with the KineSpring System were used to derive the utility scores for each group. Quality-adjusted life years (QALYs) of each group were estimated using the utility scores. Finally, cost-utility analysis was performed using cost and QALYs data. The economic impact of knee OA in Germany was assessed in terms of annual total direct cost and indirect cost, total diseased population and potential QALYs saved with the KineSpring System. RESULTS: Assuming the durability of 10 years, the cost-utility ratio of the KineSpring System, surgical treatments and conservative treatments compared to no treatment in 2012 was euro>3,402/QALY, euro 4,899/QALY and euro 9,996/QALY, respectively. With even a lesser durability of 5 years, the cost-utility ratio of the KineSpring System maintained superiority over surgical treatments and conservative treatments (euro 7,327/QALY, euro 9,706/QALY and euro 10,467/QALY, respectively). The KineSpring System is a highly cost-effective alternative for knee osteoarthritis compared with the current accepted cost-effective threshold (willingness to pay) of $50,000 US/QALY gained. Our models suggest KineSpring System, if adapted widely could save up to 2.0 ± 0.07 million QALY assuming it has a 5-year durability and save up to 3.9 ± 0.1 million QALY assuming it has a 10-year durability. CONCLUSION: An economic advantage for using the KineSpring System over other surgical and conservative treatments in knee OA patients in Germany is suggested by our model. According to currently accepted cost-effectiveness guidelines, the KineSpring Knee Implant System for knee OA is a cost-effective strategy.