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

Abstract

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. 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. 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]). 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.

Influence of Hospital Volume Effects and Minimum Caseload Requirements on Quality of Care in Pancreatic Surgery in Germany

“…An analysis of German hospital discharge data from 2006 to 2011 also revealed that a large proportion of hospitals perform pancreatic surgeries without achieving minimum caseload requirements and that a substantial number of pancreatic surgery inpatients was treated in such facilities [12]. This study found a mild trend towards a concentration of care structures within the field of pancreatic surgery from 2005 through 2011 (percentage of hospitals with caseload below minimum caseload requirements: 64.1 to 48.7%; percentage of pancreatic surgery cases in hospitals below minimum caseload requirements: 19.4 to 11.4%, respectively), which seemed to stop between 2011 and 2013 [9]. Another study assessed volume-outcome relationships related to pancreatic surgery using hospital discharge data from Germany's largest provider of statutory health insurance [13].…”

“…After screening of titles and abstracts, 51 articles were excluded and of the remaining 6, 4 publications were suitable for inclusion in the present study [9,[11][12][13].…”

“…Nonetheless, the German Federal Joint Committee (G-BA) has established minimum caseload requirements for pancreatic surgery (10 procedures per year) with the goal to improve patient care. This regulation has been formally binding for all hospitals that are permitted to charge the German statutory health insurance carriers for their services since 2004 [9]. However, the regulation also provides certain general exceptions that may compromise its desired effect of centralization of care structures.…”

Minimum Volume Standards in Surgery - Are We There Yet

“…The experience in Germany is not much different [1,19]. Through such analyses, reliable knowledge can also be acquired for health and distribution policy discussions.…”

“…Many hospitals still fail to meet these targets and still maintain their patient care offer in this area. However, mortality in hospitals that do not comply with the Mm-R is clearly higher; a strict implementation of the Mm-R and a further specialization of hospitals for certain elective interventions could clearly improve quality of care with fewer complications and deaths [1,2]. The question posed in the title would therefore be clearly rejected.…”