[Economics of operating room use at a university eye hospital]. / Wirtschaftlichkeit der Operationssaalnutzung an einer Universitäts-Augenklinik.

BACKGROUND: In ophthalmologic surgery, there are usually short operation times and thus many changes between the individual operations, which are not subject to remuneration. As in maximum care hospitals consecutive different operations with different durations are often performed, emergency operations have to be inserted and further training of colleagues is practiced, it is particularly important to generate the shortest possible transfer times in order to have both sufficient operation time and to be able to treat as many cases as possible. The aim of this work is to evaluate the efficiency of the surgical performance of a university eye hospital. MATERIAL AND METHOD: The surgeries performed in 2021 at the MHH Eye Clinic were evaluated with respect to the spectrum, number, surgery duration, transfer times and process times. In terms of personnel, each operating room was staffed with one assistant anesthesiologist, one nurse anesthetist, two operating room nurses, one surgeon, and 20% senior anesthesiologist supervision. Based on a theoretical concept, which provides an increased staffing ratio while maintaining the same infrastructure, it was calculated how many more surgeries could be performed if the transfer time was halved and whether the additional financial expense could be compensated. RESULTS: With a total of n = 2712 surgeries performed during regular duty hours (244 working days) in 2 operating rooms (average daily n = 11.1; weekly n = 53.6 and monthly n = 237.1), the average surgery duration was 37 min and the transition time 43 min. This means that the operating rooms were used for surgery for 51% of the total operating time. Main procedures were vitrectomy with n = 1350 and cataract surgery with n = 1308. The new personnel concept provided one additional operating room nurse per operating room and one additional anesthesiologist for both operating rooms. The additional costs for this personnel expenditure were calculated at approx. 300,000 € per year. The halving of the transfer time from 43 min to about 21 min through possible overlapping induction and parallel work, which was not possible until now, results in an additional operation time of about 100 min per operating room, so that at least 4 additional operations can be planned and performed. In this way, with stringent implementation and the same spatial structures with stable fixed costs, n = 976 more operations could be performed, which, minus the personnel costs, the additional material costs for surgery and anesthesia of 557,042 € and the inpatient hotel costs of 600,663 €, with an average length of stay of 2.8 days, would result in an additional revenue of about 2.4 times the additional personnel costs at the current flat rate of 3739.40 € and an average case mix index of the MHH Eye Hospital of 0.649 (total revenue: 2,155,449 €; profit margin II: 701,389 €) for the considered surgical patient collective in 2021. CONCLUSION: An increase of the personnel expenditure in the operating room for surgical subjects such as ophthalmology with shorter interventions and many changes is economically worthwhile also for a large hospital in order to enable and optimize overlapping transfers of anesthesia and surgical care. This should therefore also be considered separately, contrary to standardized staffing of the overall hospital, in order to use existing resources with their fixed costs as optimally as possible.

[Performance and cost calculation for a university ophthalmological outpatient clinic]. / Leistungs- und Kostenkalkulation für eine universitäre, augenheilkundliche Hochschulambulanz.

BACKGROUND: Outpatient procedures at a university hospital are generally considered to be unprofitable. In the present publication we evaluate the turnover and costs of the university eye outpatient department of the Hannover Medical School (MHH) in terms of a cost unit accounting as well as providing a summary of the workload. MATERIAL AND METHOD: Given the data of the hospital information system (IS-H/i.s.h.med from SAP) and a proprietary software (TimeElement), all patient contacts in the year 2019 were evaluated. The latter software is applied in a standardized manner to record the patient flow of our outpatient service in real time electronically. The total costs consist of personnel, material and room costs including infrastructure of the MHH and are compared to the flat-rate revenues according to the university outpatient contract (HSA) as well as further revenues from internal referral services, self-pay patients, outpatient surgery and cooperation contracts for intravitreal injections (IVOM). RESULTS: With an average full-time equivalent (FTE) headcount of 10.63 assistant physicians, 3.6 specialist physicians, and 21 nonphysicians (plus 4 Federal Volunteer Service, BUFDI) in our policlinic, we have determined €â€¯2,927,022 in personnel costs, including overheads, for the entire year. Including infrastructure (€â€¯524,942), material and equipment costs with overheads and internal cost allocation of €â€¯258.657, the total costs in 2019 resulted in €â€¯3,710,621. In contrast, the total income in 2019 was €â€¯3,524,737 generated through the abovementioned patient segments, resulting in a deficit of €â€¯-185,884 (5%). Our data provide evidence that regular outpatient revenues are insufficient and are mainly balanced by outpatient surgery, IVOMs and self-pay patients. In total, there were 19,453 patient contacts during regular office hours (with 17,305 billable cases). At n = 9943, the majority of the contacts were HSA visits; however, only 82% of the cases could effectively be charged due to multiple visits per quarter. The median total patient attendance was 3.21 h (mean 3.38 h). On average, 78 patient contacts were counted per working day. The analysis with TimeElement unveiled a median of n = 2 physician contacts per patient (mean n = 1.91). The median duration per interaction with a physician was 17.98 min (mean 23.23 min). For diagnostics, we counted a median of n = 2 interactions per patient (mean n = 2.31), with an entire interaction lasting a median of 18.30 min (mean 22.60 min). In total n = 37,363 individual diagnostic procedures were recorded in 2019, with SD-OCT being the primary procedure at n = 10,888. CONCLUSION: The cost/turnover calculation showed a marginal financial loss through our ophthalmological outpatient department. Thus, the costs of a university eye outpatient department in Lower Saxony do not seem to be sufficiently covered by direct outpatient revenues. Maintaining quarterly flat rates for all cases of the outpatient department would require a fee of about €â€¯214 in our setting to remain cost neutral. Currently, the lower flat rates in the HSA area are compensated by other areas. Obviously, the high content-related workload in our setting requires a high personnel expenditure with a considerable personnel cost contribution of nearly 80%.

[Influence of COVID-19 shutdown on the workload of a university eye clinic]. / Einfluss des COVID-19-Shutdowns auf die Arbeitsleistung einer Universitäts-Augenpoliklinik.

BACKGROUND: The outbreak of the novel coronavirus disease 2019 (COVID-19) has led to a significant reduction in the number of patients treated in elective medicine in hospitals in spring 2020. Up until now, there are no corresponding data for university policlinics. MATERIAL AND METHODS: With the help of the data of the clinic's electronic medical record system (IS-H/i.s.h.med from SAP, Cerner Corporation, North Kansas City, MO, United States of America and SAP SE, Walldorf, Germany) and the time recording and management software TimeElement (Hannover Medical School, Hannover, Germany), which was codeveloped at our clinic, all patient contacts of the COVID-19 shutdown were evaluated over a period of approximately 7 weeks from 18 March 2020 to 8 May 2020 and compared with the same period in 2019. In addition, quarterly revenues for the first and second quarters of 2019 and 2020 were put into perspective via SAP. RESULTS: During the COVID-19 period the total number of patient contacts was reduced by 59.5% compared to the previous year. The number of lockdown period cases decreased by 74.8% compared to the same period in 2019. In particular, the university outpatient/self-paying sector recorded the largest number of lost patient contacts with a reduction to 17.2% of the 2019 baseline. The reduced patient contacts and case numbers resulted in a significant financial loss of at least €â€¯218,000. Via TimeElement there was a 69.4% decrease in all special diagnostic services, with visual field examinations in particular also reduced by 75.3%. Optical coherence tomography (OCT) measurements recorded a decrease of 60.3%. Patient tracking revealed a reduction of average patient attendance times by approximately 23% (COVID 19: 145.8 ± 88.8 min versus 189.6 ± 97.2 min in 2019). DISCUSSION: The COVID-19 shutdown caused the work performance of our policlinic to drop to only about 40% of patient contacts and that of functional diagnostic examinations to only about 30%, compared to the performance in 2019; however, the reduction in the number of patients also led to a significant reduction in the time patients were present at the clinic compared to the regular workload. The associated financial losses are considerable and obviously not compensated by legally regulated compensation payments as in the inpatient sector.

[Cost unit accounting of strabismus surgery at a university eye hospital]. / Kostenträgerrechnungen von strabologischen Operationen an einer Universitäts-Augenklinik.

BACKGROUND: Strabismus surgery is frequently carried out in university centers. The aim of this work was to calculate the costs of strabismus surgery at a university hospital and to assess the remuneration of costs for outpatient procedures. MATERIAL AND METHODS: Of all strabismus surgeries at the Hanover Medical School in the years 2018 and 2019, relevant surgical data, such as patient age, number of muscles operated on, incision to suture time, attendance time of the surgeons and anesthetists as well as the nursing staff, were evaluated based on the clinics own information system. During this process, the costs for personnel, material, room rental charges and overheads were computed applying cost unit accounting. RESULTS: A total of 302 operations (inpatient proportion 92.1%) were carried out in most cases with the patient under general anesthesia. The mean patient age was 31 years (median 26 years), with 33 patients being children under 6 years of age. On average 1.84 muscles were treated per intervention. The mean incision to suture time was 51.5 min, mean anesthesia time was 85 min, the attendance time of surgical as well as anesthesia nursing staff each accounted for 104 min, the additional time in the postanesthesia care unit added 66 min. Average personnel costs originating from the overall process amounted to 642.14 €, with the addition of 109.23 € for material and medication (surgery and anesthesia) and costs for cleaning and room rental (including overheads) of 178.71 €. Therefore, the overall costs of an average strabismus surgery in our collective added up to 930.08 € (minimum 491.01 €, maximum 1729.29 €). Cost accounting of subgroups yielded substantially higher costs for anesthesia in children as well as for higher numbers of muscles operated on due to different treatment duration (37 min for 1 muscle to 72 min for 3 muscles) and anesthesia time, especially in children <6 years of age (on average 22 min longer than adults and children >5 years; the differences being 11 min for 1 muscle, 25 min for 2 muscles and 30 min for 3 or more muscles). The pure costs of a strabismus surgery at this clinic seem on average to exceed the revenues for strabismus surgery in the outpatient sector calculated by the German uniform evaluation benchmark (EBM) by about a factor of 2. CONCLUSION: It could be shown that the purely economically calculated costs for strabismus surgery at a university clinic are significantly higher than the revenues achieved in the outpatient sector according to paragraph 115b, section 1, of the Social Security Act V (SGB V). Under these circumstances, such operations cannot be performed in a cost-effective manner.

Socioeconomic status amplifies genetic effects in middle childhood in a large German twin sample.

The Scarr-Rowe hypothesis predicts that the heritability of cognitive abilities is higher in more privileged socioeconomic conditions, meaning that genetic potential can be more fully expressed in environments characterized by high socioeconomic status (SES) compared to low SES. This gene × SES interaction, however, has been replicated mostly in the United States, but not in other Western nations like the United Kingdom. In the current study, we tested the interaction between childhood SES and the heritability of cognitive ability in 3,074 German twin pairs comprising three age cohorts at different developmental stages (mean ages of 11, 17, and 23 years). Higher SES was associated with significantly higher mean cognitive ability scores in the two younger cohorts, with reduced variances at higher SES levels. Results further support the Scarr-Rowe hypothesis in middle childhood, and to some degree in adolescence, but not in adulthood. This indicates that the role of family SES as a moderator of the heritability of cognitive ability changes as children grow older. Moreover, children's shared experiences appear to be explain more variance in cognitive ability at the lower end of the SES distribution in middle childhood and adolescence.