Holger Bunzemeier

Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence

AIMS Only few and historic studies reported a bad prognosis of peripheral arterial disease (PAD) and critical limb ischaemia (CLI). The contemporary state of treatment and outcomes should be assessed. METHODS AND RESULTS From the largest public health insurance in Germany, all in- and outpatient diagnosis and procedural data were retrospectively obtained from a cohort of 41 882 patients hospitalized due to PAD during 2009-2011, including a follow-up until 2013. Patients were classified in Rutherford categories 1-3 (n = 21 197), 4 (n = 5353), 5 (n = 6916), and 6 (n = 8416). The proportions of patients with classical risk factors such as hypertension, dyslipidaemia, and smoking declined with higher Rutherford categories (each P < 0.001) while diabetes, chronic kidney disease, and chronic heart failure increased (each P < 0.001). Angiographies and revascularizations were performed less often in advanced PAD (each P < 0.001). In-hospital amputations increased continuously from 0.5% in Rutherford 1-3 to 42% in Rutherford 6, as also myocardial infarctions, strokes, and deaths (each P < 0.001). Among 4298 amputated patients with CLI, 37% had not received any angiography or revascularization neither during index hospitalization nor the 24 months before. During follow-up (mean 1144 days), 7825 patients were amputated and 10 880 died. Kaplan-Meier models projected 4-year mortality risks of 18.9, 37.7, 52.2, and 63.5% in Rutherford 1-3, 4, 5, and 6, and for amputation of 4.6, 12.1, 35.3, and 67.3%, respectively. In multivariable Cox regression models, PAD categories were significant predictors of death, amputation, myocardial infarction, and stroke (each P < 0.001). Length of in-hospital stay (5.8 ± 6.7 days, 10.7 ± 11.1days, 15.2 ± 13.8 days and 22.1 ± 20.3 days; P < 0.001) and mean case costs (3662 ± 3186 €, 5316 ± 6139 €, 6021 ± 4892 €, and 8461 ± 8515 €; P < 0.001) increased continuously in Rutherford 1-3, 4, 5, and 6. While only 49% of the patients suffered from CLI, these produced 65% of in-hospital costs (141 million €), and 56% during follow-up (336 million €). CONCLUSION Regardless of recent advances in PAD treatment, current outcomes remain poor especially in CLI. Despite overwhelming evidence for reduction of limb loss by revascularization, CLI patients still received significantly less angiographies and revascularizations.

Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: a nationwide population-based analysis

AIMS The prevalence of peripheral arterial disease (PAD) and especially of critical limb ischaemia (CLI) is announced to rise dramatically worldwide, with a considerable impact on the health care and socio-economic systems. We aimed to characterize the recent trends in morbidity and in-hospital outcome of PAD among all hospitalized patients in the entire German population between 2005 and 2009. METHODS AND RESULTS Nationwide data of all hospitalizations in Germany in 2005, 2007, and 2009 were analysed regarding the prevalence of PAD, comorbidities, endovascular (EVR) and surgical revascularizations (SR), major and minor amputations, in-hospital mortality, and associated costs. From 2005 to 2009, total PAD cases increased by 20.7% (from 400 928 to 483 961), with an increase of CLI subset from 40.6 to 43.5%. Total EVR increased by 46%, while thromb-embolectomy, endarterectomy, and patch plastic increased by 67, 42, and 21%, respectively. Peripheral bypasses decreased by 2%. Major amputation decreased from 4.6 to 3.5%, while minor amputation slightly increased from 4.98 to 5.11%. The crude overall in-hospital mortality remained unchanged in claudicants (2.2%), while it decreased from 9.8 to 8.4% in CLI patients. However, mortality rate according to the Poisson model (n/1000 hospital residence days) increased significantly in claudicants (P < 0.001). Total reimbursement costs for PAD in-patient care increased by 21% with an average per case costs in 2009 of €4506 in a claudicant and €6791 in a CLI patient. CONCLUSION This population-based analysis documents the significant rise of PAD, particularly of the CLI subset, and highlights the malign prognosis associated with PAD as indicated by high amputation and in-hospital mortality rates.

CKD and Acute and Long-Term Outcome of Patients with Peripheral Artery Disease and Critical Limb Ischemia

BACKGROUND AND OBJECTIVES Despite the many studies showing an association between CKD and a high risk of ischemic events and mortality, the association of CKD with peripheral arterial disease (PAD) still has not been well described. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This large cohort study assessed the association of CKD, even in the earlier stages, with morbidity, short- and long-term outcome, and costs among patients with PAD. RESULTS We identified 41,882 patients with PAD who had an index hospitalization between January 1, 2009, and December 31, 2011. Of these, 8470 (20.2%) also had CKD (CKD stage 2: n=2158 [26%]; stage 3: n=3941 [47%]; stage 4: n=935 [11%]; stage 5: n=1436 [17%]). The ratio of women to men was 1:1.2. Compared with patients without known CKD, those with CKD had higher frequencies of coronary artery disease (1.8-fold higher; P<0.001), chronic heart failure (3.3-fold higher; P<0.001), and Rutherford PAD categories 5 and 6 (1.8-fold higher; P<0.001); underwent significantly fewer revascularizations (0.9-fold fewer; P<0.001); had a nearly two-fold higher amputation rate (P<0.001); had higher frequencies of in-hospital infections (2.1-fold higher; P<0.001), acute renal failure (2.8-fold higher; P<0.001), and sepsis (1.9-fold higher; P<0.001); had a 2.5-fold higher frequency of myocardial infarction (P<0.001); and had a nearly three-fold higher in-hospital mortality rate (P<0.001). In an adjusted multivariable Cox regression model, CKD remained a significant predictor of long-term outcome of patients with PAD during follow-up for up to 4 years (until December 31, 2012; median, 775 days; 25th-75th percentiles, 469-1120 days); the hazard ratio was 2.59 (95% confidence interval, 2.21 to 2.78; P<0.001). The projected mortality rates after 4 years were 27% in patients without known CKD and 46%, 52%, 72%, and 78% in those with CKD stages 2, 3, 4, and 5, respectively. Lengths of hospital stay and reimbursement costs were on average nearly 1.4-fold higher (P<0.001) in patients who also had CKD. CONCLUSIONS This analysis illustrates the significant and important association of CKD with in-hospital and long-term mortality, morbidity, amputation rates, duration and costs of hospitalization, in-hospital treatment, and complications in patients with PAD.

Retrospective Analysis of the Blood Component Utilization in a University Hospital of Maximum Medical Care

Background: Demographic data illustrate clearly that people in highly developed countries get older, and the elderly need more blood transfusions than younger patients. Additionally, special extensive therapies result in an increased consumption of blood components. Beyond that the aging of the population reduces the total number of preferably young and healthy blood donors. Therefore, Patient Blood Management will become more and more important in order to secure an increasing blood supply under fair-minded conditions. Methods: At the University Hospital of Münster (UKM) a comprehensive retrospective analysis of the utilization of all conventional blood components was performed including all medical and surgical disciplines. In parallel, a new medical reporting system was installed to provide a monthly analysis of the transfusional treatments in the whole infirmary, in every department, and in special blood-consuming cases of interest, as well. Results: The study refers to all UKM in-patient cases from 2009 to 2011. It clearly demonstrates that older patients (>60 years, 35.2–35.7% of all cases, but 49.4–52.6% of all cases with red blood cell (RBC) transfusions, 36.4–41. 6% of all cases with platelet (PTL, apheresis only) transfusions, 45.2– 48.0% of all cases with fresh frozen plasma (FFP) transfusions) need more blood products than younger patients. Male patients (54.4–63.9% of all cases with transfusions) are more susceptible to blood transfusions than female patients (36.1–45.6% of all cases with transfusions). Most blood components are used in cardiac, visceral, and orthopedic surgery (49.3–55.9% of all RBC units, 45.8–61.0% of all FFP units). When regarding medical disciplines, most transfusions are administered to hematologic and oncologic patients (12.9–17.7% of all RBC units, 9.2– 12.0% of all FFP units). The consumption of PTL in this special patient cohort (40.6–50.9% of all PTL units) is more pronounced than in all other surgical or in non-surgical disciplines. Conclusion: The results obtained from our retrospective analysis may help to further optimize the responsible and medical indication-related utilization of blood transfusions as well as the recruitment of blood donors and their timing. It may be also a helpful tool in order to avoid needless transfusions and transfusion-associated adverse events.

DRGs in der Dermatologie: Erlösoptimierung durch Sicherung der Kodierqualität

Hintergrund: Die sachgerechte Abbildung der Behandlungsfälle im DRG‐System stellt die Grundlage der Vergütung für die durchgeführte Behandlung in deutschen Krankenhäusern dar. Dies kann nur über eine ausreichend gute Kodierung der medizinischen Daten ermöglicht werden. Ziel der vorliegenden Studie war, den Einfluß einer kontrollierten Leistungsdokumentation auf die klinischen Patientendaten zu untersuchen und die Auswirkungen einer verbesserten Kodierqualität auf die theoretischen Ertragsvolumina im australischen AR‐DRG‐System zu ermitteln.

Krankenhausfinanzierung unter DRG-Bedingungen

BACKGROUND Intensive care medicine is extremely heterogeneous, expensive and can only be partially planned and controlled. A correct and fair representation of intensive care medicine in the G-DRG system is an essential requirement for the use as a pricing system. From the perspective of intensive care medicine, pertinent changes of the DRG structure and differentiation of relevant parameters have been established within the G-DRG systems 2003-2010. METHODS Analysis of relevant diagnoses, medical procedures, co-payment structures and G-DRGs in the versions 2003-2010 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS Since the first G-DRG system version 2003, numerous measures improved quality of case allocation of intensive care medicine. Highly relevant to the system version 2010 are duration of mechanical ventilation, the intensive care treatment complex and complicating constellations. The number of G-DRGs relevant to intensive medical care increased from n = 3 (2003) to n = 58 (2010). CONCLUSION For standard cases, quality of case allocation and G-DRG reimbursement are adequate in 2010. The G-DRG system gained complexity again. High demands are made on correct and complete coding of complex cases. Nevertheless, further adjustments of the G-DRG system especially for cases with extremely high costs are necessary. Where the G-DRG system is unable to cover extremely high-cost cases, reimbursement solutions beyond the G-DRG structure should be taken into account.ZusammenfassungHintergrund:Intensivmedizinische Maßnahmen sind äußerst heterogen, kostenintensiv und nur bedingt plan- und steuerbar. Eine sach- und leistungsgerechte Abbildung der Intensivmedizin im G-DRG-System ist eine wesentliche Voraussetzung für den Einsatz als Preissystem. Das deutsche DRG-System wurde im Rahmen der jährlichen Weiterentwicklungen von 2003 bis 2010 mit erheblicher Relevanz für die Intensivmedizin umstrukturiert.Methodik:Analyse der relevanten Diagnosen, Prozeduren und DRGs in den Systemversionen 2003–2010 anhand der durch das Institut für das Entgeltsystem im Krankenhaus (InEK) und das Deutsche Institut für Medizinische Dokumentation und Information (DIMDI) publizierten Informationen.Ergebnisse:Seit der G-DRG-Systemversion 2003 wurden zahlreiche Maßnahmen im Sinne einer Verbesserung der Abbildungsqualität intensivmedizinischer Maßnahmen umgesetzt. Hierbei waren bis zur Systemversion 2010 die Dauer der maschinellen Beatmung, die intensivmedizinische Komplexbehandlung und komplizierende Konstellationen besonders relevant. Die Anzahl der G-DRGs zur Abbildung intensivmedizinischer Maßnahmen hat sich seit der Systemversion 2003 von n = 3 auf n = 58 in der Version 2010 erhöht.Schlussfolgerung:Die intensive Weiterentwicklung des G-DRG-Systems hat seit der Systemversion 2003 zu einer erheblichen Verbesserung der Abbildungsqualität aller medizinischen Bereiche, aber insbesondere der Intensivmedizin geführt. Eine beträchtliche Anzahl an Fallkonstellationen von Extremkostenfällen konnte demaskiert werden. Der Preis für ein sach- und leistungsgerechtes G-DRG-System sind sehr hohe Anforderungen an die Dokumentations- und Kodierqualität sowie eine deutliche Zunahme der Systemkomplexität.AbstractBackground:Intensive care medicine is extremely heterogeneous, expensive and can only be partially planned and controlled. A correct and fair representation of intensive care medicine in the G-DRG system is an essential requirement for the use as a pricing system. From the perspective of intensive care medicine, pertinent changes of the DRG structure and differentiation of relevant parameters have been established within the G-DRG systems 2003–2010.Methods:Analysis of relevant diagnoses, medical procedures, co-payment structures and G-DRGs in the versions 2003–2010 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI).Results:Since the first G-DRG system version 2003, numerous measures improved quality of case allocation of intensive care medicine. Highly relevant to the system version 2010 are duration of mechanical ventilation, the intensive care treatment complex and complicating constellations. The number of G-DRGs relevant to intensive medical care increased from n = 3 (2003) to n = 58 (2010).Conclusion:For standard cases, quality of case allocation and G-DRG reimbursement are adequate in 2010. The G-DRG system gained complexity again. High demands are made on correct and complete coding of complex cases. Nevertheless, further adjustments of the G-DRG system especially for cases with extremely high costs are necessary. Where the G-DRG system is unable to cover extremely high-cost cases, reimbursement solutions beyond the G-DRG structure should be taken into account.

DRG-System 2008 – Überblick aus internistischer Sicht

jedoch dazu, dass gerade die Erbringung dieser Leistungen einem besonders hohen Optimierungsdruck im Wettbewerb unterliegt. Die für die Verweildauer beschriebene Entwicklung wird auch bei der Vergütung (Bewertungsrelationen) nachgezeichnet. Während Maximalversorgungsleistungen (mehrzeitige Eingriffe, Extremkostenfälle etc.) durch zunehmend sachgerechtere Abbildung immer besser vergütet werden, ist im Bereich von Routineleistungen eher ein Rückgang der Vergütung zu sehen. Zur Beurteilung des Einflusses der Katalogveränderungen auf die jeweils eigene Fachabteilung muss eine DRG-Gruppierung der eigenen Behandlungsfälle der Vorjahre nach dem System 2008 erfolgen. Die in den letzten Jahren zunehmende Orientierung des Systems an Prozeduren setzt sich auch für 2008 fort. Sie drückt sich sowohl in der höheren Zahl von Zusatzentgelten als auch in den für das DRG-System vorgenommenen Anpassungen des Operationenund Prozedurenschlüssels (OPS) und deren Berücksichtigung bei den Definitionen von DRG-Fallgruppen aus. Da in der Art der durchgeführten Leistung bzw. teilweise sogar in der Art der verwendeten Materialien (z.B. Art der Beschichtung eines Koronarstents) ein kostenbeeinflussender Faktor liegt, ist eine immer detailliertere Kodierung der erbrachten Leistung notwendig. Damit werden aber Z 1. 1. 2008 tritt das G-DRGSystem 2008 als Abrechnungsgrundlage im stationären Bereich in Kraft. Wie in den Vorjahren erfolgten bei der Entwicklung des Systems kalkulatorische und inhaltliche Anpassungen, um zum Ende der Konvergenzphase (2009) eine sachgerechte Finanzierung auf Basis von Fallpauschalen sicherzustellen [1]. Dieser Beitrag fasst grundlegende Tendenzen in der Weiterentwicklung des Fallpauschalensystems zusammen. Änderungen in einzelnen Fachbereichen werden in den kommenden Monaten an dieser Stelle dargestellt.

Utilisation of Blood Components in Trauma Surgery: A Single-Centre, Retrospective Analysis before and after the Implementation of an Educative PBM Initiative.

Background: The aim of our single-centre retrospective study presented here is to further analyse the utilisation of allogeneic blood components within a 5-year observation period (2009-2013) in trauma surgery (15,457 patients) under the measures of an educational patient blood management (PBM) initiative. Methods: After the implementation of the PBM initiative in January 2012, the Institute of Transfusion Medicine und Transplantation Immunology educates surgeons and nurses at the Department of Trauma Surgery to avoid unnecessary blood transfusions. A standardised reporting system was used to document the utilisation of blood components carefully for the most frequent diagnoses and surgical interventions in trauma surgery. These measures served as basis for the implementation of an interdisciplinary systematic exchange of information to foster decision-making processes in favour of patient blood management. Results: Since January 2012, the proportion of patients who received a transfusion as well as the number of transfused red blood cell (RBC) (7.3%/6.4%; p = 0.02), fresh frozen plasma (FFP) (1.7%/1.3%; p < 0.05) and platelet (PLT) (1.0%/0.5%; p < 0.001) units were reduced as a result of our PBM initiative. However, among the transfused patients, the number of administered RBC, FFP and PLT units did not decrease significantly. Overall, patients who did not receive transfusions were younger than transfused patients (p = 0.001). The subgroup with the highest probability of blood transfusion administered included patients with intensive care and long-term ventilation (before/after implementation of PBM: RBC 81.5%/75.9%; FFP 33.3%/20.4%; PLT 24.1%/13.0%). Only a total of 60 patients of 531 patients suffering multiple traumas were massively transfused (before/after implementation of PBM: RBC 55.6%/49.8%; FFP 28.4%/20.4%; PLT 17.6%/8.9%). Conclusion: According to our educational PBM initiative, at least the proportion of trauma patients who received allogeneic blood transfusions could be reduced significantly. However, in case of blood transfusions, the total consumption of RBC, FFP and PLT units remained stable in both time periods. This phenomenon might indicate that the actual need of blood transfusions rather depends on the severity of trauma-related blood loss, the coagulopathy rates or the complexity of the surgical intervention which mainly determines the intra-operative blood loss. Taken together, educational training sessions and systematic reporting systems are suitable measures to avoid unnecessary allogeneic blood transfusions and to continuously improve their restrictive application.

[The German DRG system 2003-2010 from the perspective of intensive care medicine].

BACKGROUND Intensive care medicine is extremely heterogeneous, expensive and can only be partially planned and controlled. A correct and fair representation of intensive care medicine in the G-DRG system is an essential requirement for the use as a pricing system. From the perspective of intensive care medicine, pertinent changes of the DRG structure and differentiation of relevant parameters have been established within the G-DRG systems 2003-2010. METHODS Analysis of relevant diagnoses, medical procedures, co-payment structures and G-DRGs in the versions 2003-2010 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS Since the first G-DRG system version 2003, numerous measures improved quality of case allocation of intensive care medicine. Highly relevant to the system version 2010 are duration of mechanical ventilation, the intensive care treatment complex and complicating constellations. The number of G-DRGs relevant to intensive medical care increased from n = 3 (2003) to n = 58 (2010). CONCLUSION For standard cases, quality of case allocation and G-DRG reimbursement are adequate in 2010. The G-DRG system gained complexity again. High demands are made on correct and complete coding of complex cases. Nevertheless, further adjustments of the G-DRG system especially for cases with extremely high costs are necessary. Where the G-DRG system is unable to cover extremely high-cost cases, reimbursement solutions beyond the G-DRG structure should be taken into account.ZusammenfassungHintergrund:Intensivmedizinische Maßnahmen sind äußerst heterogen, kostenintensiv und nur bedingt plan- und steuerbar. Eine sach- und leistungsgerechte Abbildung der Intensivmedizin im G-DRG-System ist eine wesentliche Voraussetzung für den Einsatz als Preissystem. Das deutsche DRG-System wurde im Rahmen der jährlichen Weiterentwicklungen von 2003 bis 2010 mit erheblicher Relevanz für die Intensivmedizin umstrukturiert.Methodik:Analyse der relevanten Diagnosen, Prozeduren und DRGs in den Systemversionen 2003–2010 anhand der durch das Institut für das Entgeltsystem im Krankenhaus (InEK) und das Deutsche Institut für Medizinische Dokumentation und Information (DIMDI) publizierten Informationen.Ergebnisse:Seit der G-DRG-Systemversion 2003 wurden zahlreiche Maßnahmen im Sinne einer Verbesserung der Abbildungsqualität intensivmedizinischer Maßnahmen umgesetzt. Hierbei waren bis zur Systemversion 2010 die Dauer der maschinellen Beatmung, die intensivmedizinische Komplexbehandlung und komplizierende Konstellationen besonders relevant. Die Anzahl der G-DRGs zur Abbildung intensivmedizinischer Maßnahmen hat sich seit der Systemversion 2003 von n = 3 auf n = 58 in der Version 2010 erhöht.Schlussfolgerung:Die intensive Weiterentwicklung des G-DRG-Systems hat seit der Systemversion 2003 zu einer erheblichen Verbesserung der Abbildungsqualität aller medizinischen Bereiche, aber insbesondere der Intensivmedizin geführt. Eine beträchtliche Anzahl an Fallkonstellationen von Extremkostenfällen konnte demaskiert werden. Der Preis für ein sach- und leistungsgerechtes G-DRG-System sind sehr hohe Anforderungen an die Dokumentations- und Kodierqualität sowie eine deutliche Zunahme der Systemkomplexität.AbstractBackground:Intensive care medicine is extremely heterogeneous, expensive and can only be partially planned and controlled. A correct and fair representation of intensive care medicine in the G-DRG system is an essential requirement for the use as a pricing system. From the perspective of intensive care medicine, pertinent changes of the DRG structure and differentiation of relevant parameters have been established within the G-DRG systems 2003–2010.Methods:Analysis of relevant diagnoses, medical procedures, co-payment structures and G-DRGs in the versions 2003–2010 based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI).Results:Since the first G-DRG system version 2003, numerous measures improved quality of case allocation of intensive care medicine. Highly relevant to the system version 2010 are duration of mechanical ventilation, the intensive care treatment complex and complicating constellations. The number of G-DRGs relevant to intensive medical care increased from n = 3 (2003) to n = 58 (2010).Conclusion:For standard cases, quality of case allocation and G-DRG reimbursement are adequate in 2010. The G-DRG system gained complexity again. High demands are made on correct and complete coding of complex cases. Nevertheless, further adjustments of the G-DRG system especially for cases with extremely high costs are necessary. Where the G-DRG system is unable to cover extremely high-cost cases, reimbursement solutions beyond the G-DRG structure should be taken into account.

Herzchirurgie im G-DRG-System 2008

ZusammenfasungDas vor 5 Jahren eingeführte Fallpauschalensystem zur Vergütung stationärer Behandlungsfälle (G-DRG-System) wird durch eine jährliche Überarbeitung an die Behandlungswirklichkeit in Deutschland angepasst. Im vorliegenden Artikel werden die auf die Herzchirurgie bezogenen Änderungen des G-DRG-Systems für das Jahr 2008 beschrieben. Da sich Anzahl und Definition der für die Herzchirurgie relevanten G-DRG beim Systemwechsel 2007/2008 als inzwischen weitestgehend stabil erweisen, lassen sich die Kriterien, die in den einzelnen Bereichen ausschlaggebend für eine DRG-Zuordnung der Behandlungsfälle sind (gruppierungsrelevante Kriterien), mittlerweile zusammenfassend darstellen. Die Struktur des G-DRG-Systems muss auch deshalb besonders genau betrachtet werden, da es sich bei herzchirurgischen Fachabteilungen in der Regel um umsatzstarke Bereiche handelt, deren hohen DRG-Erlösen aber auch ein entsprechender Ressourcenverbrauch insbesondere in den Bereichen OP und Intensivstation gegenübersteht.AbstractThe system of capitation payments (G-DRG-System) for hospital inpatient services was introduced in Germany 5 years ago. Changes in the G-DRG algorithm for the year 2008 relating to cardiac surgery are described in this article. After 5 steps of further improvements, the G-DRG-System is meanwhile relatively stabile. Thus, it is possible to summarize the relevant criteria for the allocation process of patient episodes to diagnosis related groups (DRGs). Knowledge of these criteria is important since departments of cardiac surgery have substantial turnover which is accompanied by high costs especially in the intensive care unit and operating room.