Thomas Mansky

Nationwide In-hospital Mortality Following Pancreatic Surgery in Germany is Higher than Anticipated.

Objective: We aimed to determine the unbiased mortality rates for pancreatic surgery procedures at the national level through a comprehensive analysis of every inpatient case in Germany. Summary of Background Data: Several studies have proclaimed a general improvement of perioperative outcomes following pancreatic surgery. These results are challenged by recent analyses of large US databases that found strong volume-outcome relationships, with high mortality in low-volume facilities. Methods: All inpatient cases with a pancreatic surgery procedure code in Germany from 2009 to 2013 were identified from nationwide administrative hospital data. We determined the absolute number of patients and the in-hospital death rate for crucial subcategories such as medical indications and types of surgical procedure. Results: A total of 58,003 inpatient episodes of pancreatic surgery were identified between 2009 and 2013. Annual case numbers increased significantly, which was primarily attributed to patients aged 70 years and older. The overall in-hospital mortality rate (10.1%) did not significantly change during the study period. Major pancreatic resections were associated with mortality ranging from 7.3% (distal pancreatectomy) to 22.9% (total pancreatectomy). Postoperative interventions indicative of severe complications were documented frequently (eg, more than 6 blood transfusions in 20% of all patients and relaparotomy in 16%). Their occurrence was associated with a dramatic increase in mortality. Conclusion: At the national level in Germany, perioperative mortality is higher than anticipated from previous studies. The absence of a significant reduction in overall mortality challenges current health policies that aim to improve the outcomes of high-risk surgical procedures in Germany.

Hip and knee replacement in Germany and the USA: analysis of individual inpatient data from German and US hospitals for the years 2005 to 2011.

BACKGROUND The number of hip and knee replacement operations is rising in many industrialized countries. To evaluate the current situation in Germany, we analyzed the frequency of procedures in Germany compared to the USA, with the aid of similar case definitions and taking demographic differences into account. METHODS We used individual inpatient data from Germany (DRG statistics) and the USA (Nationwide Inpatient Sample) to study differences in the age- and sex-adjusted rates of hip and knee replacement surgery and the determinants of trends in case numbers over the years 2005 to 2011. RESULTS In 2011, hip replacement surgery was performed 1.4 times as frequently in Germany as in the USA (284 vs. 204 cases per 100 000 population per year; the American figures have been adjusted to the age and sex structure of the German population). On the other hand, knee replacement surgery was performed 1.5 times as frequently in the USA as in Germany (304 [standardized] vs. 206 cases per 100,000 population per year). Over the period of observation, the rates of both procedures increased in both countries. The number of elective primary hip replacement operations in Germany grew by 11%, from 140,000 to 155 300 (from 170 to 190 per 100,000 persons); after correction for demographic changes, a 3% increase remained. At the same time, the rate of elective primary hip replacement surgery in the USA rose by 28%, from 79 to 96 per 100 000 population, with a 13% increase remaining after correction for demographic changes. CONCLUSION There are major differences between Germany and the USA in the frequency of these operations. The observed upward trend in elective primary hip replacement operations was mostly due to demographic changes in Germany; non-demographic factors exerted a stronger influence in the USA than in Germany. With respect to primary knee replacement surgery, non-demographic factors exerted a comparably strong influence in both countries.

Effect of Hospital Volume on In-hospital Morbidity and Mortality Following Pancreatic Surgery in Germany

Objective: We aimed to determine the effect of hospital volume on in-hospital mortality, and failure to rescue following major pancreatic resections using hospital discharge data of every inpatient case in Germany. Summary Background Data: Several studies have found strong volume–outcome relationships in pancreatic surgery, with high mortality in low-volume facilities. However, their datasets were only based on portions of national populations. In addition, these studies did not assess the effect of hospital volume according to other crucial variables such as medical indications, postoperative complications, and failure to rescue. Methods: We studied all inpatient cases of major pancreatic surgery (n = 60,858) in Germany from 2009 to 2014, using national hospital discharge data. We evaluated the association between hospital volume and in-hospital mortality following major pancreatic resections by using multivariate regression methods. In addition, we analyzed rates of major complications and failure to rescue across hospital volume quintiles. Results: Risk-adjusted in-hospital mortality varied widely across hospital volume quintiles, from 6.5% (95% CI 6.0–7.0) in very high volume hospitals to 11.5% (95% CI 10.9–12.1) in very low volume hospitals (OR 0.47, 95% CI 0.41–0.54). Rates of postoperative interventions necessary for complications and failure to rescue were lower in higher volume hospitals [eg, mortality following septic complications in very high volume hospitals: 24.2% (95% CI 22.4–26.1) vs. very low volume hospitals: 36.8% (34.9–38.7)]. Moreover, we estimated that centralization of surgical care to the minimum volume and mortality risk of the medium volume quintile could prevent at least 94 deaths per year. Conclusions: In Germany, patients who are undergoing major pancreatic resections have improved outcomes if they are admitted to higher volume hospitals. As current health policies failed to centralize pancreatic surgery procedures in Germany, new strategies to initiate a sufficient centralization process in the field of pancreatic surgery are needed.

Quality Measurement Combined With Peer Review Improved German In-Hospital Mortality Rates For Four Diseases

Mortality rates during hospital stays for common diseases show considerable variation at the hospital level, which suggests that there is potential for outcome improvement. We studied changes in mortality after an intervention that aimed to improve medical outcomes through quality measurement combined with peer review. We examined eighteen acute care hospitals purchased by the Helios Hospital Group in Germany from one year before to three years after the start of the intervention. In-hospital mortality for myocardial infarction, heart failure, ischemic stroke, and pneumonia was stratified by initial hospital performance and compared to the German average. Following the intervention, hospitals whose performance was initially subpar significantly reduced in-hospital mortality for all four diseases. In hospitals that initially performed well, no significant changes in mortality were observed. The observational nonrandomized data suggest that the quality management approach was associated with improved outcomes in initially subpar hospitals. Disease-specific measures of mortality, combined with peer reviews, can be used to direct actions to areas of potential improvement.

Achieving minimum caseload requirements--an analysis of hospital discharge data from 2005-2011.

BACKGROUND The German Federal Joint Committee (the highest decision-making body of physicians and health insurance funds in Germany) has established minimum caseload requirements with the goal of improving patient care. Such requirements have been in place for five types of surgical procedure since 2004 and were introduced for total knee endoprosthesis surgery in 2006 and for the care of low-birth-weight neonates (weighing less than 1250 g) in 2010. METHOD We analyzed data from German nationwide DRG statistics (DRG = diagnosis-related groups) for the years 2005-2011. The procedures that were performed were identified on the basis of their operation and procedure codes, and the low-birth-weight neonates on the basis of their birth weight and age. The treating facilities were distinguished from one another by their institutional identifying numbers, which were contained in the DRG database. RESULTS In 2011, there were 172 838 hospitalizations to which minimum caseload requirements were applicable. 4.5% of these took place in institutions that did not meet the minimum requirement for the procedure in question. The percentage of institutions that did not meet the minimum caseload requirement for complex pancreatic surgery fell significantly from 64.6% in 2006 to 48.7% in 2011, and the percentage of pancreatic surgery cases treated in such institutions fell over the same period from 19.0% to 11.4%. A significant reduction in the number of institutions treating low-birth-weight neonates was already evident before minimum caseload requirements were introduced. For all other types of procedure subject to minimum caseload requirements, there has been no significant change either in the percentage of institutions meeting the requirements or in the percentage of cases treated in such institutions. CONCLUSION After taking account of the potential bias due to the identification of institutions by their institutional identifying numbers, we found no discernible effect of minimum caseload requirements on care structures over the seven-year period of observation, with the possible exception of a mild effect on pancreatic procedures.

Mindestmengen und Krankenhaussterblichkeit – Beobachtungsstudie mit deutschlandweiten Krankenhausabrechnungsdaten von 2006 bis 2013

Background: In order to improve hospital care, minimum caseload requirements for certain elective hospital treatments have been defined by law in Germany. This study analyses retrospectively if adherence to this regulation is associated with the outcome of hospital treatment. Differences in in-hospital mortality were analyzed for complex esophageal and pancreatic surgery, liver and kidney transplantation, stem cell transplantation and total knee replacement. Methods: Within individual inpatient data of the nationwide German hospital discharge data (DRG statistics) all inpatient episodes subject to the minimum volume requirements were identified and annual caseloads per hospital were calculated. Inpatient episodes were assigned to 2 groups: Patients treated in hospitals with a caseload equal to or greater than the minimum caseload (≥ MC) and patients treated in hospitals with a caseload below the minimum caseload (< MC). Logistic regression was used to calculate adjusted in-hospital mortality. Results: In total, 28 931 esophageal surgeries, 78 879 pancreatic surgeries, 7 984 liver transplantations, 21 773 kidney transplantations, 51 064 stem cell transplantations and 1 093 296 total knee replacements were analyzed. Adjusted in-hospital mortality in hospitals with a caseload≥MC was significantly lower than in hospitals with a caseload<MC for esophageal surgery (9.2% [95% KI 8.8-9,6] vs. 12.1% [11.4-12.9]), pancreatic surgery (8.6% [8.3-8.8] vs. 11.8% [11.2-12.5]), kidney transplantation (1.7% [1.4-1.8] vs. 3.3% [2.1-5.0]) and total knee replacement (0.13% [0.12-0.14] vs. 0.18% [0.14-0.23]). For liver transplantation, no significant difference in adjusted mortality was found (15.5% [14.7-16.5] vs. 15.9% [12.9-19.3]). For stem cell transplantation mortality in hospitals with a caseload≥MC was significantly higher than in hospital with a caseload<MC (6.0% [5.7-6.2] vs. 4.0% [3.2-4.9]). Conclusion: For 4 of the 6 studied treatments, a significantly lower risk of in-hospital death was observed in hospitals that adhere to the minimum caseload requirement. This implies that, for those treatments, full implementation of the minimum caseload regulation could improve the quality of hospital care in Germany.

Hospital volume and mortality for 25 types of inpatient treatment in German hospitals: observational study using complete national data from 2009 to 2014

Objectives To explore the existence and strength of a relationship between hospital volume and mortality, to estimate minimum volume thresholds and to assess the potential benefit of centralisation of services. Design Observational population-based study using complete German hospital discharge data (Diagnosis-Related Group Statistics (DRG Statistics)). Setting All acute care hospitals in Germany. Participants All adult patients hospitalised for 1 out of 25 common or medically important types of inpatient treatment from 2009 to 2014. Main outcome measure Risk-adjusted inhospital mortality. Results Lower inhospital mortality in association with higher hospital volume was observed in 20 out of the 25 studied types of treatment when volume was categorised in quintiles and persisted in 17 types of treatment when volume was analysed as a continuous variable. Such a relationship was found in some of the studied emergency conditions and low-risk procedures. It was more consistently present regarding complex surgical procedures. For example, about 22 000 patients receiving open repair of abdominal aortic aneurysm were analysed. In very high-volume hospitals, risk-adjusted mortality was 4.7% (95% CI 4.1 to 5.4) compared with 7.8% (7.1 to 8.7) in very low volume hospitals. The minimum volume above which risk of death would fall below the average mortality was estimated as 18 cases per year. If all hospitals providing this service would perform at least 18 cases per year, one death among 104 (76 to 166) patients could potentially be prevented. Conclusions Based on complete national hospital discharge data, the results confirmed volume–outcome relationships for many complex surgical procedures, as well as for some emergency conditions and low-risk procedures. Following these findings, the study identified areas where centralisation would provide a benefit for patients undergoing the specific type of treatment in German hospitals and quantified the possible impact of centralisation efforts.

Komplikationen und Folgeeingriffe nach koronaren Prozeduren in der klinischen Routine

BACKGROUND Data on 1-year complication and follow-up intervention rates after coronary angiography (CA) and percutaneous coronary intervention (PCI) in German clinical routine are sparse. This analysis aims to determine these rates. METHODS The analysis uses 2009 AOK claims data. Patients were divided into 3 groups (CA, without cardiac surgery and without acute myocardial infarction (AMI) n=116.071; PCI with stenting, without AMI: n=36.685; PCI with stenting and with AMI: n=32.707). The frequency of the endpoints MACCE (mortality, AMI, stroke, TIA), CABG, PCI and CA was recorded for up to one year. RESULTS 1-year MACCE rates were 8.1 % (CA), 9.9 % (PCI without AMI) and 17.9 % (PCI with AMI). Quality-relevant follow-up intervention rates in the CA group were 2.5 % for CABG (after 31-365 days), 1.7 % for PCI within 90 days and 3.5 % for follow-up CA within 1 year. In the PCI groups, the frequencies were 1.6 % (without AMI) and 2.7 % (with AMI) for CABG (after 31-365 days), and 10.2 % (without AMI) and 10.1 % (with AMI) for PCI after 91-365 days. CONCLUSION This is the first cross-sectoral routine analysis of cardiac catheters and sequential events up to one year in Germany. The actual medical care situation revealed information particularly with regard to the second and follow-up inventions, which cannot be derived directly from medical guidelines. Beyond clinical trials, knowledge can be gained which is important both for medicine as well as the politics of health services.

Medizinische Qualitätsmessung im Krankenhaus – Worauf kommt es an?

In Germany, the aims of hospital quality measurement have evolved from intra-professional quality assurance via organisational quality improvement to public reporting. Recently, quality-based purchasing is also discussed as a political option. These developments lead to new requirements for quality measurement which have gained little attention so far. Quality indicators have to become more comprehensive, more outcome-related, and more tamper-resistant. Furthermore statistical limitations of quality measurement related to low case numbers may impair quality assessment and therefore have to be considered in political discussions. In many cases the use of administrative data allows for the measurement of meaningful endpoints and is less prone to manipulation than separate data collections. Also, it allows for the extension of quality measurements to other medical conditions without causing additional effort. Bearing costs and benefits in mind, the use of administrative data might be the only way to establish nationwide long-term outcome measurements. Using administrative data also enables the advancement of provider-independent quality measurement. This may cause political controversies. Irrespective of future political regulations, new outcome-related quality measurements already have been shown to contribute to improving hospital care, if used in internal quality management systems.

Improving outcomes using German Inpatient Quality Indicators in conjunction with peer review procedures.

Some hospital comparisons seem to generate confusion because different methods of outcome comparisons lead to different results in hospital rankings. This article questions the concept of overall comparisons of hospitals, which are multiproduct enterprises and may have specialties that provide good results in some areas despite having worse outcomes in others. Therefore, the authors argue for a disease specific view of outcome measurement. The concept of the German Inpatient Quality Indicators is explained. These indicators cover volume, mortality, and other information by a disease specific approach, which includes information for potential patients as well as specific feedback to the physicians responsible for the respective specialty. This article focuses on the feedback to the hospitals and explains how these indicators can be used for improvement in conjunction with a peer review process. The indicators provide information to the hospitals regarding their relative position because German reference values are available for all indicators. Thus, the indicators can serve as a trigger instrument for identifying possible quality problems. Based on these indications, peer review can be used to analyze the treatment processes and to eventually verify weaknesses and define actions for improvement. The first studies indicate that the use of this approach within hospital quality management can largely improve hospital outcomes in hospitals with subpar results compared to the German average.