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.DFG, 325093850, Open Access Publizieren 2017 - 2018 / Technische Universität Berli

A-IQI : Austrian Inpatient Quality Indicators

Zugleich gedruckt erschienen im Universitätsverlag der TU Berlin unter der ISBN 978-3-7983-2249-3.Qualitätsmanagement baut auf den Säulen Struktur-, Prozess- und Ergebnisqualität auf. In Niederösterreich wie auch in Gesamtösterreich wurde das Augenmerk im Krankenhausbereich bisher vorrangig auf Strukturen und Prozesse gelegt. Mittlerweile sind Strukturvorgaben flächendeckend erfüllt und die Abläufe liegen im Verantwortungsbereich der leitenden Personen in den Abteilungen. Doch wie sich die Patientenversorgung bei bestimmten Behandlungen oder Erkrankungen darstellt, wissen die wenigsten Leistungserbringer. Der nächste Schritt in Österreich muss nun die Ergebnismessung sein. Seit 2008 beschäftigt sich die Niederösterreichische Landeskliniken-Holding mit dem Thema medizinische Qualität messbar zu machen. Ziel war und ist anhand von bereits vorhandenen Routinedaten darzustellen, wo ein Leistungserbringer steht. Nur wenn Qualität gemessen wird, kann man sich vergleichen, einordnen und wenn nötig Verbesserungsmaßnahmen ergreifen. Die Qualitätsmessung ist in Österreich noch sehr neu. Es gibt bereits einige Qualitätsregister die detailliertere Informationen liefern als die Routinedaten. Die Eingabe ist jedoch zeitaufwändig und die Datenqualität hängt sehr stark von der Compliance der Leistungserbringer ab. Das vorliegende Dokument ist durch die Zusammenarbeit der Niederösterreichischen Landeskliniken-Holding mit dem deutschen Klinikenträger HELIOS, dem Schweizer Bundesamt für Gesundheit und dem Fachgebiet Strukturentwicklung und Qualitätsmanagement im Gesundheitswesen an der Technischen Universität Berlin entstanden. Es beinhaltet die in Deutschland entwickelten und auch in der Schweiz eingesetzten Indikatoren aus dem HELIOS-System (G-IQI, German Inpatient Quality Indicators, Mansky et al. 2010), die an die Kodierverfahren des österreichischen Dokumentations- und Abrechnungssystems angepasst wurden. Was wird gemessen? ■ Mortalität ■ Mengen für bestimmte Behandlungen, Operationen ■ Wahl der Operationstechnik, des Behandlungsverfahrens ■ Intensivhäufigkeit bei bestimmten Operationen ■ Elemente des Behandlungsprozesses ■ Wiederaufnahmen ■ Komplikationen, Re-Eingriffe Die Grundlagen dieses Indikatorensystems, wie Berechnungslogik oder Risikoadjustierung, sowie die genauen Indikatorendefinitionen der Austrian Inpatient Quality Indicators mit Diagnosen, medizinischen Einzelleistungen und demographischen Daten werden in diesem Band erläutert und sind somit frei zugänglich. Die Qualitätsmessung schafft Bewusstsein bei allen Beteiligten und zeigt Abweichungen strukturiert auf, der Grund für diese bleibt jedoch unklar. Um einen kontinuierlichen Verbesserungsprozess zu erreichen, stellt das Peer Review Verfahren einen zentralen Punkt und das Herzstück dieses Qualitätsmanagementsystems dar. Erst wenn bei Auffälligkeiten auf Ebene der Krankengeschichten strukturiert von Experten analysiert wird, kann beurteilt werden, ob Verbesserungspotential besteht, die Datenqualität schlecht ist oder das Ergebnis „berechtigterweise“ nicht im Zielbereich liegt. Einem österreichweiten Benchmarking steht nun nichts mehr im Wege

G-IQI – German Inpatient Quality Indicators Version 5.4

The German Inpatient Quality Indicators (G-IQI) are the most comprehensive system of quality indicators based on administrative data. G-IQI allow a disease-specific monitoring of inpatient care in acute care hospitals. On the one hand, the indicators are designed to provide medically meaningful figures on hospital performance and outcomes for external users. On the other hand, the indicators serve as a tool for internal quality management and quality improvement in hospital care. The indicators may help hospitals to identify potential for improvement by comparing their own results with national figures. The indicators serve as triggers for peer reviews or morbidity and mortality conferences. Thus, the use of the indicators is essential to detect medical errors and to improve quality of care. The present working paper contains the German national reference values of the year 2020 for the G-IQI version 5.4. Reference values were calculated by using the microdata of the national hospital statistics database (DRG statistics) and are displayed for each indicator. The technical specifications of the indicators are attached in the appendix of this paper and refer to the German coding systems valid in 2022. The G-IQI version 5.4 represents a modification and expansion of the previous version 5.3. In the year of analysis 2020, the present G-IQI version 5.4 captures 56.9% of all inpatient cases and 82.5% of all in-hospital deaths. Thereby, the G-IQI version 5.4 achieves one of the highest coverages among available quality indicator systems. The national reference values of the indicators help hospitals to assess their own results as compared to national figures. Beyond that, the national reference values provide a comprehensive analysis of inpatient care in German acute care hospitals. In addition to the complete national indicator results, the age-and-sex specific mortality figures that are used to calculate expected deaths at the hospital level are displayed. Furthermore, distribution of case volume among hospitals is illustrated for selected indicators. By this means, the present working paper covers various figures which are not published by any other statistics and, thus, complements other systems of health care reporting

G-IQI – German Inpatient Quality Indicators Version 5.4

The German Inpatient Quality Indicators (G-IQI) are the most comprehensive system of quality indicators based on administrative data. G-IQI allow a disease-specific monitoring of inpatient care in acute care hospitals. On the one hand, the indicators are designed to provide medically meaningful figures on hospital performance and outcomes for external users. On the other hand, the indicators serve as a tool for internal quality management and quality improvement in hospital care. The indicators may help hospitals to identify potential for improvement by comparing their own results with national figures. The indicators serve as triggers for peer reviews or morbidity and mortality conferences. Thus, the use of the indicators is essential to detect medical errors and to improve quality of care. The present working paper contains the German national reference values of the year 2020 for the G-IQI version 5.4. Reference values were calculated by using the microdata of the national hospital statistics database (DRG statistics) and are displayed for each indicator. The technical specifications of the indicators are attached in the appendix of this paper and refer to the German coding systems valid in 2022. The G-IQI version 5.4 represents a modification and expansion of the previous version 5.3. In the year of analysis 2020, the present G-IQI version 5.4 captures 56.9% of all inpatient cases and 82.5% of all in-hospital deaths. Thereby, the G-IQI version 5.4 achieves one of the highest coverages among available quality indicator systems. The national reference values of the indicators help hospitals to assess their own results as compared to national figures. Beyond that, the national reference values provide a comprehensive analysis of inpatient care in German acute care hospitals. In addition to the complete national indicator results, the age-and-sex specific mortality figures that are used to calculate expected deaths at the hospital level are displayed. Furthermore, distribution of case volume among hospitals is illustrated for selected indicators. By this means, the present working paper covers various figures which are not published by any other statistics and, thus, complements other systems of health care reporting

Volume Growth of Inpatient Treatments for Spinal Disease – Analysis of German Nationwide Hospital Discharge Data from 2005 to 2014

Hintergrund Seit der Einführung der Diagnosis related Groups (DRG) zur Vergütung akutstationärer Krankenhausleistungen wurden Anstiege der stationären Fallzahlen zur Behandlung von Erkrankungen der Wirbelsäule beobachtet. Ziel dieser Arbeit ist, diese Mengenentwicklung bevölkerungsbezogen und nach Behandlungsarten differenziert darzustellen. Material und Methode In den deutschlandweiten Krankenhausabrechnungsdaten (DRG-Statistik) wurden Behandlungsfälle mit operativer sowie nicht operativer Versorgung von Wirbelsäulenerkrankungen identifiziert. Unter Berücksichtigung der demografischen Entwicklung wurde analysiert, in welchem Umfang sich die Fallzahlen im Zeitraum von 2005 bis 2014 verändert haben und in welchen Altersgruppen und bei welchen Eingriffs- bzw. Behandlungsarten Anstiege zu verzeichnen sind. Ergebnisse Im Jahr 2014 (2005) wurden 289 000 (177 000) operativ versorgte und 463 000 (287 000) nicht operativ versorgte Behandlungsfälle identifiziert. Nach Bereinigung um demografische Faktoren wurden sowohl bei operativen als auch bei nicht operativen Behandlungen relative Fallzahlanstiege um jeweils ca. 50% beobachtet, die in höheren Altersgruppen und bei Frauen besonders ausgeprägt waren. Die Mengenentwicklung fiel je nach Art des Eingriffs bzw. der Behandlung sehr unterschiedlich aus. Bei den operativ versorgten Behandlungsfällen hat sich die Anzahl der Bandscheibenoperationen demografiebereinigt nur um + 5% erhöht während sich Wirbelkörperversteifungs- und -ersatzeingriffe, Kypho- und Vertebroplastien und alleinige Dekompressionen der Wirbelsäule mehr als verdoppelt haben. Bei den nicht operativ versorgten Behandlungsfällen wurde bei Behandlungen mit lokaler Schmerztherapie der Wirbelsäule ein demografiebereinigter Anstieg von + 142% beobachtet. Bei rein konservativen Behandlungen lag der demografiebereinigte Anstieg bei + 22%. Schlussfolgerung Welche Ursachen den nicht demografiebedingten Fallzahlanstiegen zugrunde liegen, kann diese Untersuchung nicht direkt klären. Die stratifizierte Betrachtung der Fallzahlen in den verschiedenen Untergruppen kann aber dazu beitragen, die Entwicklungen differenziert einzuordnen und damit die Diskussion um eine mögliche Über- oder Fehlversorgung zielgerichteter als bisher zu führen.Background Marked volume growth of inpatient treatments for spinal disease has been observed since diagnosis related groups (DRG) were introduced as payment for inpatient services in Germany. This study aims to analyse this increase by population and stratified by types of treatment. Material and Methods Using German nationwide hospital discharge data (DRG statistics), inpatient treatments for spinal disease with or without surgery were identified. Trends in case numbers were analysed from 2005 to 2014 with consideration of demographic changes, in order to explore which age groups and which types of treatment are affected by volume growth. Results In 2014 (2005), 289 000 (177 000) inpatient treatments with surgery and 463 000 (287 000) treatments without surgery were identified. After adjusting for demographic factors, treatments with and without surgery exhibited a relative volume growth of + 50%. This increase affected higher age groups and women, in particular. Depending on the type of treatment, very different degrees of volume growth were observed. For example, disc surgeries adjusted for demographic change increased by about + 5%, whereas spinal fusion and vertebral replacement surgeries, kypho-/vertebroplasties and decompression of the spine more than doubled. Within the non-surgically treated cases, local pain therapies of the spine increased after adjustment for demographic changes by about + 142%. The conservatively treated cases showed a demographically adjusted increase of + 22%. Conclusion Apart from demographic changes, this analysis cannot resolve the underlying causes of volume growth in treatments for spinal disease. However, the stratified analysis of various subgroups may help to classify these developments in a more differentiated manner. The results may support a more targeted debate about potential over- or misallocation of inpatient services in this area

a 1-year follow-up analysis based on German health insurance administrative data from 2008 to 2014

Objectives To describe the use of drug-eluting stents (DESs) in the largest population of statutory health insurance members in Germany, including newly developed bio-resorbable vascular scaffolds (BVSs), and to evaluate 1-year complication rates of DES as compared with bare metal stents (BMSs) in this cohort. Design Routine data analysis of statutory health insurance claims data from the years 2008 to 2014. Setting The German healthcare insurance Allgemeine Ortskrankenkasse covers approximately 30% of the German population and is the largest nationwide provider of statutory healthcare insurance in Germany. Participants and interventions We included all patients with a claims record for a percutaneous coronary intervention (PCI) with either DES or BMS and additionally, from 2013, BVS. Patients with acute myocardial infarction (AMI) were excluded. Main outcome measure: major adverse cerebrovascular and cardiovascular event (MACCE, defined as mortality, AMI, stroke and transient ischaemic attack), bypass surgery, PCI and coronary angiography) at 1 year after the intervention. Results A total of 243 581 PCI cases were included (DES excluding BVS: 143 765; BVS: 1440; BMS: 98 376). The 1-year MACCE rate was 7.42% in the DES subgroup excluding BVS and 11.29% in the BMS subgroup. The adjusted OR for MACCE was 0.72 (95% CI 0.70 to 0.75) in patients with DES excluding BVS as compared with patients with BMS. In the BVS group, the proportion of 1-year MACCE was 5.0%. Conclusion The analyses demonstrate a lower MACCE rate for PCI with DES. BVSs are used in clinical routine in selected cases and seem to provide a high degree of safety, but data are still sparse

MRP8 and MRP14, phagocyte-specific danger signals, are sensitive biomarkers of disease activity in cryopyrin-associated periodic syndromes

To assess the sensitivity of the phagocyte-specific molecules myeloid-related protein (MRP) 8 and MRP14 (calprotectin) for monitoring disease activity during anti-interleukin (IL)-1 therapies in patients with cryopyrin-associated periodic syndromes (CAPS), including familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS) and chronic infantile neurological, cutaneous and articular (CINCA) syndrome

Alterations in peripheral blood memory B cells in patients with active rheumatoid arthritis are dependent on the action of tumour necrosis factor

INTRODUCTION: Disturbances in peripheral blood memory B cell subpopulations have been observed in various autoimmune diseases, but have not been fully delineated in rheumatoid arthritis (RA). Additionally, the possible role of tumour necrosis factor (TNF) in regulating changes in specific peripheral blood memory B cell subsets in RA is still unclear. METHODS: The frequency and distribution of B cell subsets in the peripheral blood and synovial membrane of active RA patients with long-standing disease have been analysed. Additionally, the possible role of TNF in causing disturbances in memory B cell subsets in RA patients was assessed in a clinical trial with the specific TNF-neutralising antibody, infliximab. RESULTS: RA patients, independent of disease duration, have a significantly lower frequency of peripheral blood pre-switch IgD+CD27+ memory B cells than healthy individuals, whereas post-switch IgD-CD27+ accumulate with increased disease duration. Notably, both pre-switch IgD+CD27+ and post-switch IgD-CD27+ memory B cells accumulate in the synovial membrane of RA patients. Finally, anti-TNF therapy increased the frequency of pre-switch IgD+CD27 memory B cells in the peripheral blood. CONCLUSIONS: The data suggest that decreases in peripheral blood IgD+CD27+ pre-switch memory B cells in RA reflect their accumulation in the synovial tissue. Moreover, the significant increase in the peripheral blood pre-switch memory B cells in patients who underwent specific TNF-blockade with infliximab indicates that trafficking of memory B cells into inflamed tissue in RA patients is regulated by TNF and can be corrected by neutralising TN

In vivo regulation of interleukin 1β in patients with cryopyrin-associated periodic syndromes

The investigation of interleukin 1β (IL-1β) in human inflammatory diseases is hampered by the fact that it is virtually undetectable in human plasma. We demonstrate that by administering the anti–human IL-1β antibody canakinumab (ACZ885) to humans, the resulting formation of IL-1β–antibody complexes allowed the detection of in vivo–produced IL-1β. A two-compartment mathematical model was generated that predicted a constitutive production rate of 6 ng/d IL-1β in healthy subjects. In contrast, patients with cryopyrin-associated periodic syndromes (CAPS), a rare monogenetic disease driven by uncontrolled caspase-1 activity and IL-1 production, produced a mean of 31 ng/d. Treatment with canakinumab not only induced long-lasting complete clinical response but also reduced the production rate of IL-1β to normal levels within 8 wk of treatment, suggesting that IL-1β production in these patients was mainly IL-1β driven. The model further indicated that IL-1β is the only cytokine driving disease severity and duration of response to canakinumab. A correction for natural IL-1 antagonists was not required to fit the data. Together, the study allowed new insights into the production and regulation of IL-1β in man. It also indicated that CAPS is entirely mediated by IL-1β and that canakinumab treatment restores physiological IL-1β production

Comparison of Classifier Fusion Methods for Predicting Response to Anti HIV-1 Therapy

BACKGROUND: Analysis of the viral genome for drug resistance mutations is state-of-the-art for guiding treatment selection for human immunodeficiency virus type 1 (HIV-1)-infected patients. These mutations alter the structure of viral target proteins and reduce or in the worst case completely inhibit the effect of antiretroviral compounds while maintaining the ability for effective replication. Modern anti-HIV-1 regimens comprise multiple drugs in order to prevent or at least delay the development of resistance mutations. However, commonly used HIV-1 genotype interpretation systems provide only classifications for single drugs. The EuResist initiative has collected data from about 18,500 patients to train three classifiers for predicting response to combination antiretroviral therapy, given the viral genotype and further information. In this work we compare different classifier fusion methods for combining the individual classifiers. PRINCIPAL FINDINGS: The individual classifiers yielded similar performance, and all the combination approaches considered performed equally well. The gain in performance due to combining methods did not reach statistical significance compared to the single best individual classifier on the complete training set. However, on smaller training set sizes (200 to 1,600 instances compared to 2,700) the combination significantly outperformed the individual classifiers (p<0.01; paired one-sided Wilcoxon test). Together with a consistent reduction of the standard deviation compared to the individual prediction engines this shows a more robust behavior of the combined system. Moreover, using the combined system we were able to identify a class of therapy courses that led to a consistent underestimation (about 0.05 AUC) of the system performance. Discovery of these therapy courses is a further hint for the robustness of the combined system. CONCLUSION: The combined EuResist prediction engine is freely available at http://engine.euresist.org