Background Nationwide, unbiased, and unselected data of hospitalised patients with COVID-19 are scarce. Our aim was to provide a detailed account of case characteristics, resource use, and outcomes of hospitalised patients with COVID-19 in Germany, where the health-care system has not been overwhelmed by the pandemic. Methods In this observational study, adult patients with a confirmed COVID-19 diagnosis, who were admitted to hospital in Germany between Feb 26 and April 19, 2020, and for whom a complete hospital course was available (ie, the patient was discharged or died in hospital) were included in the study cohort. Claims data from the German Local Health Care Funds were analysed. The data set included detailed information on patient characteristics, duration of hospital stay, type and duration of ventilation, and survival status. Patients with adjacent completed hospital stays were grouped into one case. Patients were grouped according to whether or not they had received any form of mechanical ventilation. To account for comorbidities, we used the Charlson comorbidity index. Findings Of 10 021 hospitalised patients being treated in 920 different hospitals, 1727 (17%) received mechanical ventilation (of whom 422 [24%] were aged 18–59 years, 382 [22%] were aged 60–69 years, 535 [31%] were aged 70–79 years, and 388 [23%] were aged ≥80 years). The median age was 72 years (IQR 57–82). Men and women were equally represented in the non-ventilated group, whereas twice as many men than women were in the ventilated group. The likelihood of being ventilated was 12% for women (580 of 4822) and 22% for men (1147 of 5199). The most common comorbidities were hypertension (5575 [56%] of 10 021), diabetes (2791 [28%]), cardiac arrhythmia (2699 [27%]), renal failure (2287 [23%]), heart failure (1963 [20%]), and chronic pulmonary disease (1358 [14%]). Dialysis was required in 599 (6%) of all patients and in 469 (27%) of 1727 ventilated patients. The Charlson comorbidity index was 0 for 3237 (39%) of 8294 patients without ventilation, but only 374 (22%) of 1727 ventilated patients. The mean duration of ventilation was 13·5 days (SD 12·1). In-hospital mortality was 22% overall (2229 of 10 021), with wide variation between patients without ventilation (1323 [16%] of 8294) and with ventilation (906 [53%] of 1727; 65 [45%] of 145 for non-invasive ventilation only, 70 [50%] of 141 for non-invasive ventilation failure, and 696 [53%] of 1318 for invasive mechanical ventilation). In-hospital mortality in ventilated patients requiring dialysis was 73% (342 of 469). In-hospital mortality for patients with ventilation by age ranged from 28% (117 of 422) in patients aged 18–59 years to 72% (280 of 388) in patients aged 80 years or older. Interpretation In the German health-care system, in which hospital capacities have not been overwhelmed by the COVID-19 pandemic, mortality has been high for patients receiving mechanical ventilation, p...

Objective. To examine the causal effect of a hospital's experience with treating hip fractures (volume) on patient treatment outcomes. Data Sources. We use a full sample of administrative data from German hospitals for 2007. The data provide detailed information on patients and hospitals. We also reference the hospitals' addresses and the zip codes of patients' place of residence. Study Design. We apply an instrumental variable approach to address endogeneity concerns due to reverse causality and unobserved patient heterogeneity. As instruments for case volume, we use the number of potential patients and number of other hospitals in the region surrounding each hospital. Principal Findings. Our results indicate that after applying an instrumental variables (IV) regression of volume on outcome, volume significantly increases quality. Conclusions. We provide evidence for the practice-makes-perfect hypothesis by showing that volume is a driving factor for quality. Key Words. Volume, hospital quality, mortality, instrumental variables Quality of (hospital) care is the result of interaction between many factors. It reflects, for example, the care provided by physicians, nurses, and other hospital staff. At the same time, it reflects the implementation of and adherence to treatment standards. It can also indicate the effective and efficient usage of specialist technical equipment (Mainz 2003). The case volume of a hospital is often used as a proxy for the mentioned structure and processes of care with the assumption of a positive correlation (Halm, Lee, and Chassin 2002). Hence, it is an indirect measure of quality and related to the interaction of several factors.Luft, Bunker, and Enthoven (1979) showed in their seminal paper that there is a correlation between volume and outcome quality in 10 of 12 procedures; that is, a higher case volume is associated with better outcomes. This correlation has been referred to as the volume-outcome relationship. The studies that followed have predominantly confirmed this correlation (Halm,

For decades, there is an ongoing discussion about the quality of hospital care leading i.a. to the introduction of minimum volume standards in various countries. In this paper, we analyze the volume-outcome relationship for patients with intact abdominal aortic aneurysm and hip fracture. We define hypothetical minimum volume standards in both conditions and assess consequences for access to hospital services in Germany. The results show clearly that patients treated in hospitals with a higher case volume have on average a significant lower probability of death in both conditions. Furthermore, we show that the hypothetical minimum volume standards do not compromise overall access measured with changes in travel times.

Background The role of non-invasive ventilation (NIV) in severe COVID-19 remains a matter of debate. Therefore, the utilization and outcome of NIV in COVID-19 in an unbiased cohort was determined. Aim The aim was to provide a detailed account of hospitalized COVID-19 patients requiring non-invasive ventilation during their hospital stay. Furthermore, differences of patients treated with NIV between the first and second wave are explored. Methods Confirmed COVID-19 cases of claims data of the Local Health Care Funds with non-invasive and/or invasive mechanical ventilation (MV) in the spring and autumn pandemic period in 2020 were comparable analysed. Results Nationwide cohort of 17.023 cases (median/IQR age 71/61–80 years, 64% male) 7235 (42.5%) patients primarily received IMV without NIV, 4469 (26.3%) patients received NIV without subsequent intubation, and 3472 (20.4%) patients had NIV failure (NIV-F), defined by subsequent endotracheal intubation. The proportion of patients who received invasive MV decreased from 75% to 37% during the second period. Accordingly, the proportion of patients with NIV exclusively increased from 9% to 30%, and those failing NIV increased from 9% to 23%. Median length of hospital stay decreased from 26 to 21 days, and duration of MV decreased from 11.9 to 7.3 days. The NIV failure rate decreased from 49% to 43%. Overall mortality increased from 51% versus 54%. Mortality was 44% with NIV-only, 54% with IMV and 66% with NIV-F with mortality rates steadily increasing from 62% in early NIV-F (day 1) to 72% in late NIV-F (>4 days). Conclusions Utilization of NIV rapidly increased during the autumn period, which was associated with a reduced duration of MV, but not with overall mortality. High NIV-F rates are associated with increased mortality, particularly in late NIV-F.

The correct definition of the product market and of the geographic market is a prerequisite for assessing market structures in antitrust cases. For hospital markets, both dimensions are controversially discussed in the literature. Using data for the German hospital market we aim at elaborating the need for differentiating the product market and at investigating the effects of different thresholds for the delineation of the geographic market based on patient flows. Thereby we contribute to the scarce empirical evidence on the structure of the German hospital market. We find that the German hospital sector is highly concentrated, confirming the results of a singular prior study. Furthermore, using a very general product market definition such as “acute in-patient care” averages out severe discrepancies that become visible when concentration is considered on the level of individual diagnoses. In contrast, varying thresholds for the definition of the geographic market has only impact on the level of concentration, while the correlation remains high. Our results underline the need for more empirical research concerning the definition of the product market for hospital services.

BackgroundThis paper analyses the volume-outcome relationship and the effects of minimum volume regulations in the German hospital sector.MethodsWe use a full sample of administrative data from the unselected, complete German hospital population for the years 2005 to 2007. We apply regression methods to analyze the association between volume and hospital quality. We measure hospital quality with a binary variable, which indicates whether the patient has died in hospital. Using simulation techniques we examine the impact of the minimum volume regulations on the accessibility of hospital services.ResultsWe find a highly significant negative relationship between case volume and mortality for complex interventions at the pancreas and oesophagus as well as for knee replacement. For liver, kidney and stem cell transplantation as well as for CABG we could not find a strong association between volume and quality. Access to hospital care is only moderately affected by minimum volume regulations.ConclusionThe effectiveness of minimum volume regulations depends on the type of intervention. Depending on the type of intervention, quality gains can be expected at the cost of slightly decreased access to care.

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Zusammenfassung Zusammenfassung Die Covid-19-Pandemie hat das stationäre Versorgungsgeschehen stark verändert. Der Beitrag beschreibt wesentliche durch die Pandemie bedingte Leistungsveränderungen. Des Weiteren werden die Charakteristika und Versorgungsstrukturen von Covid-19-Patienten dargestellt. Es zeigt sich ein deutlicher Rückgang der Krankenhausaufnahmen im Jahr 2020 im Vergleich zum Vorjahr, der in der ersten Pandemiewelle (März bis Mai) stärker ausfiel als in der zweiten Pandemiewelle (Oktober bis Dezember). Dies ging mit einer Verschiebung des Leistungsspektrums hin zu Fällen mit einer höheren Fallschwere einher. Bei den operativen Leistungen ist ein geringerer Rückgang zu verzeichnen als bei den übrigen Leistungen. Auch bei ausgewählten dringlichen Behandlungsanlässen kam es zu Fallzahlrückgängen. Noch stärkere Rückgänge wiesen die überwiegend verschiebbaren Behandlungsanlässe auf, bei denen sich auch während der Sommermonate keine Nachholeffekte abzeichneten. Dass es sich bei Covid-19 um eine sehr schwere Erkrankung handelt, verdeutlichen die hohen Sterblichkeitsraten der stationären Patienten sowie deren lange Verweil- und Beatmungsdauer.