Shaping the System - The DRG Evaluation Project of the German Society for Gynaecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG).

Introduction: The German DRG system is annually adapted to the changing services provided. For the further development, the self-governing body and its DRG Institute (InEK) depend on participation of the users. Methods: For one of the DRG evaluation projects initiated by DGGG, cost and performance data for the year 2011 from 16 hospitals were available. After plausibility checks and corrections, analyses for service and cost homogeneity were performed. In cases of inadequate DRG-representation attributes were sought that would make an appropriate reimbursement possible. Conspicuities and potential solutions were checked for clinical plausibility. Results: 44 concrete modification proposals for further development of the G-DRG system were formulated and submitted in due time to the InEK. In addition, 3 modification proposals were addressed to the German Institute for Medical Documentation and Information (Deutsches Institut für Medizinische Dokumentation und Information, DIMDI) for further development of the diagnosis classification ICD-10-GM. For all modification proposals care was taken to minimise misdirected incentives and to reduce the potential for disputes with the cost bearers and their auditors services in settlements. Discussion: The publication of the G-DRG system 2014 shows which modification proposals have been realised. Essentially, an appropriate redistribution of the resources among the gynaecological and obstetrics departments is to be expected. The financial pressure that is caused by the generally inadequate financing of hospitals will not be reduced by a further development of the G-DRG system.

[Patient selection in tertiary hospitals based on economic data: exemplified by visceral surgery]. / Patientenauswahl in Krankenhäusern der Maximalversorgung auf Basis ökonomischer Daten: Beispiel Viszeralchirurgie.

BACKGROUND: With respect to economic aspects it remains questionable if tertiary hospitals should focus on operations with high complexity or if surgery for benign diseases should be performed as well. MATERIAL AND METHODS: Data from the Institute for Reimbursement in hospitals (InEK) were analyzed for esophageal and pancreatic surgery and for appendectomy, cholezystectomy and thyroid surgery. RESULTS: Operations with a high complexity showed a slightly better revenue-cost relation. Earnings in esophageal and pancreatic surgery varied between 590 EUR and 1,977 EUR, while in operations for benign diseases it ranged from 492 EUR to 1,648 EUR. In patients with a longer hospital stay this advantage diminished. The cost-revenue ratio was much more stable for patients with appendectomy, cholezystectomy or thyroid resection. CONCLUSIONS: For economic reasons tertiary hospitals need to treat not only oncology patients but also patients with benign diseases. The focus on surgery for malignant diseases is economically not recommended because the revenues may be drained by the costs particularly in patients with a longer hospital stay due to complications.

[Costs and revenues for a birth in Germany]. / Kosten und Erlöse für eine Geburt in Deutschland.

UNLABELLED: INTRODUCTION Based on the data of the Institut für das Entgeltsystem im Krankenhaus (InEK) cost and revenue data for deliveries in Germany can be compared. The InEK calculates the cost data for each individual diagnosis-related group (DRG) on the basis of those hospitals that deliver their individual cost data, so-called "Kalkulationshäuser". The InEK only publishes data for patients with standard lengths of stay. It does not deliver data for short- and long-stay patients. Beside these cost data, the InEK publishes the nationwide case volume for each DRG. Having a knowledge of the individual base rate (Landesbasisfallwert), which differs from province (Bundesland) to province and, in addition, the nationwide case weight for each DRG, the average revenues for deliveries in general, vaginal deliveries, and Cesarean sections can be calculated. These revenue data differ not only from province to province, but from hospital to hospital because of the individual hospital-specific base rates. MATERIALS AND METHODS: The average costs for a delivery in general, a vaginal delivery, and a Cesarean section were calculated on the basis of the DRG Report Browsers 2005/2007-2007/2009 published by the InEK. The costs for short- and long-stay patients were estimated on the basis of a scenario technique. The revenues were calculated on the basis of the published DRG catalogues, which supply individual case weights, and the county-wide base rate. Short- and long-stay revenues again had to be estimated by a scenario technique. In every DRG the cost data create the basis for the case weight two years later. RESULTS: In relation to the average base rate over all provinces the 2005 costs are higher than the revenues in each province. Even in Rhineland-Palatinate, the county with the highest base rate, costs and revenues are at par. Only the declining costs from 2005-2007 balance the costs and revenues nationwide. But in provinces with low base rates the revenues stay lower than costs. These data demonstrate the pressure of rationalisation on German perinatal medicine and their hospitals. Cost and revenue comparisons with other countries are of lesser interest. Most countries have totally different systems for financing hospitals. In Germany, the published data show only the running costs financed by public and private health-care insurances. Infrastructure costs are financed by the government. In other countries not only the running costs but also the investment costs must be financed by running revenues too.

[Immunoblastic highly malignant lymphoma of the uterine cervix]. / Immunoblastisches hochmalignes Lymphom der cervix uteri.

Report on a case of a highly malignant solitary lymphoma of the cervix uteri in a 51-year-old patient. The only noticeable finding leading to the diagnosis was the pathological result of the routine cervical smear. Solitary malignant lymphomas of the cervix must be seen as systemic diseases. They should therefore be treated by local surgical intervention and consecutive systemical chemotherapy in an interdisciplinary conception.

[Double umbilical cord knot in mono-amniotic twin pregnancy as the cause of intrauterine fetal death of both twins]. / Doppelter Nabelschnurknoten bei monoamniotischer Geminigravidität als Ursache des intrauterinen Fruchttods beider Zwillinge.

In cases of rare monoamniotic-monochronic geminie pregnancies there is a high risk of complications by real umbilical cord knots, including the cords of both gemini. In these cases fetal mortality is very high. Modern examination techniques (Colour doppler sonography) are able to detect such cord knots in monoamniotic twins. Therefore it is necessary in all twin pregnancies, especially following fertility treatment, to examine precisely by a routine examinator the question of mono - or diamniotic pregnancy. In monoamniotic pregnancy there should be a look for real knots of umbilical cord in regular intervals. In such a case, if a knot is present, the pregnant woman had to be supervised by CTG, to react immediately at first signs of hypoxia.

[Forensic aspects of bladder and ureteral injuries in standard gynecologic operations]. / Forensische Aspekte von Blasen- und Harnleiterverletzungen bei gynäkologischen Standardoperationen.

Damage to the efferent urinary passages during abdominal or vaginal hysterectomy cannot always be prevented no matter how carefully one may proceed preoperatively and intraoperatively. However, all possibilities of avoiding complications or at least of recognising and eliminating them before surgery, must be explored. Nevertheless, formation of vesicovaginal or ureterovaginal fistulas or of a congested ureter will be rare. In such cases, one cannot jump to the conclusion of mismanagement or a therapeutic error from the mere occurrence of damage. In each individual case, there must be an expertise and a legal judgment as to whether there has been any infringement of the legal requirement to exercise all possible medical care lege artis. Claims for damages are justified only if the conditions of an individual case show, on close examination, that such care had not been exercised.

[Definition and etiologic factors of hypotonic urethra in relation to urinary stress incontinence in the female]. / Definition und ätiologische Faktoren der hypotonen Urethra in Verbindung mit der Stressharninkontinenz der Frau.

In 555 stress-induced urinary incontinent and 119 continent women patients, we studied the history, clinical and urodynamic investigations to define the hypotonic urethra and to find out important etiological factors of the low urethral closure pressure. The linear depression of the urethral pressure and the urethral closure pressure at rest--well known from literature--has been confirmed in this study. With hypotonic urethra, closure pressure values were found to be below the simple standard deviation from a norm-curve. Also, in cases of stress urinary incontinence, we found a nearly linear depression of closure pressure. The stress incontinent patients could be divided in two groups: 46% with hypotonic urethra, 54% with nearly normal closure pressure. History of former incontinence surgery, but also of other operations such as simple abdominal or vaginal hysterectomy, is correlated with low urethral closure pressure. The degree of closure pressure is correlated with shortening of the functional urethral length. The maximum closure pressure shifts distally. Women, who, despite hypotonic urethras, are continent, build up a positive closure pressure throughout a broad zone of the functional urethral length. Contrarily, in the case of incontinent patients, even a weak coughing spasm, which does not even break through the bladder sphincter in maximum closure, can cause opening of the urethra and establishment of pressure equilibration between bladder and urethra.

[Beta-endorphin in premature labor and in mature newborn infants following vaginal and abdominal delivery]. / beta-Endorphin bei Frühgeburten und reifen Neugeborenen nach vaginaler und abdominaler Entbindung.

Umbilical venous plasma concentrations of beta-endorphin in 20 premature and 30 mature newborn infants after vaginal delivery or elective caesarean section were determined by specific RIA. In the premature infants the beta-endorphin levels after vaginal and abdominal delivery were significantly higher than in mature newborns. Our data indicate that for premature infants the delivery is more stressful and therefore most likely the release of beta-endorphin from the pituitary is more pronounced. Since high opioid levels can cause respiratory and circulatory difficulties, premature infants are exposed to risk of these problems.

[Is there a correlation between the degree of proliferation of vaginal and urethral epithelium and the incidence of stress incontinence? A contribution to estrogen therapy in stress incontinence]. / Besteht ein Zusammenhang zwischen Proliferationsgrad des Vaginal- und Urethralepithels und der Häufigkeit der Stressinkontinenz? Ein Beitrag zur Ostrogentherapie bei Stressharninkontinenz.

The extent of proliferation of the vaginal and urethral epithelium, as well as urodynamic parameters, were studied in 232 patients in order to determine whether there is a relation between the development of stress incontinence and hormone-related epithelial proliferation. A higher build-up of vaginal than of urethral epithelium was found in 74% of the patients. Even in post-menopause patients, epithelial atrophy in the vagina was only found in 29.3%, while in the urethra it was found in 61.3%. Therefore, the vaginal epithelium cannot with confidence be taken as a basis for conclusions concerning the condition of the urethral epithelium. In the group of 145 patients with urinary stress incontinence no link could be established between the extent of proliferation of the urethral epithelium, the urethral occlusion pressure and the functional length of the urethra: The occurrence of an age-related excessively low urethral occlusion pressure (hypotonic urethra) is independent of the extent of proliferation of the vaginal or urethral epithelium. Sedimentation phenomena are also seen equally frequently in cases with atrophic and eutrophic epithelium. Owing to the high percentage of overweight women among those with stress incontinence, the extent of proliferation of the vaginal and urethral epithelium often corresponds to premenopausal cell pictures even in perimenopausal and postmenopausal women; this is a consequence of increased estrogen production in the peripheral fatty tissue. Therefore, estrogen therapy is unsuccessful in women with pure urinary stress incontinence. However, the efficacy of an equivalent therapy, e.g., with estriol, has been confirmed in cases of active and combined incontinence.