German DRG Research Articles

Recombinant human TSH versus hypo thyroidism

SummaryThe primary aim of this study was to compare pharmacoeconomic effects of hypothyroidism secondary to hormone withdrawal (THW) and recombinant human TSH (rhTSH) for followup WBS in patients with differentiated thyroid cancer (DTC). The second aim was to determine patients' preference for one procedure or the other. Patients, methods: This retrospective survey included 327 patients with DTC who underwent at least one in-hospital WBS with rhTSH between 1999 and 2006. They had also undergone THW for WBS. Patients received a two-page questionnaire via mail addressing five symptoms and ten items regarding managing their daily life which was answered by 61.6%. The responder group did not differ from the entire group. The medical and societal cost of both procedures for diagnostic WBS was calculated including direct and all ascertainable indirect cost for the reference year 2005. A sensitivity analysis included the German DRG system of 2007 and 2010. Results: After THW, 94% of patients reported hypothyroid symptoms. Using rhTSH, symptoms occurred significantly less. As a result, 97% of patients favored rhTSH over THW. Mean absence from salaried work was 12.3 days after THW compared to 4 days with rhTSH. Family members of salaried employees missed 3 and 0.7 workdays after THW and rhTSH, respectively. Almost twice as often, medical attention was sought after THW (36%) compared to rhTSH (19 %). Undergoing THW, 48% of patients still used their car while hypothyroid. Our cost calculation revealed a slight benefit of about 89.00 Euro in favour of rhTSH stimulation. Conclusion: Hypothyroidism after THW causes significant morbidity and safety risks. The clinical and societal benefits associated with rhTSH are roughly gained at equivalent overall cost to that of THW.

Costs of dialysis--a regional population-based analysis

Population-based estimates of costs of renal replacement therapy are scarce in the literature. The aim of our study was to calculate the costs of long-term dialysis in 2006 on the basis of patient-specific data from a well-defined population in a region in western Germany (n = 310,757). Cost estimation was performed from the perspective of the statutory health insurance. All dialysis patients from the study region (n = 344, 54% male, mean age (+/-SD) 69 +/- 13 years, 42% diabetic) were assessed for the costs of the dialysis procedures, dialysis-related hospital admissions, outpatient contacts outside of our dialysis center, dialysis-related medication, patient transportation and related costs (e.g. reimbursement fees on the basis of the German diagnosis-related group system, price scales). We estimated the cumulative cost per patient year in 2006 (in Euros), along with the 10th and 90th percentiles and the 95% confidence intervals (CI) by using bootstrapping procedures. The mean total dialysis-related cost in 2006 was 54,777 Euros (95% CI, 51,445-65,705) per patient year. The largest part of the costs (55%) was caused by the dialysis procedures, followed by the costs of medication (22%), hospitalization (14%) and transportation (8%). The total cost increased significantly with increasing age. No significant association was found between total cost and sex, dialysis strategy, end-stage renal disease duration and diabetes. We present for the first time a cost estimation of dialysis in Germany on the basis of patient-level data in a population-based sample. Except age, patient characteristics were not significantly associated with costs. The largest part of the costs was caused by the dialysis procedures themselves; however, other dialysis-specific health care utilization also strongly contributed to the total cost.

DRG für die Nierentransplantation

Renal transplantation is a cost-effective form of renal replacement therapy which prolongs life and improves the quality of life. The representation in the German DRG system is, however, not cost-covering in all cases. Cost-effectiveness must also be considered in view of long-term transplant survival which relates to overall costs to the health care system and goes beyond hospital costs.

Erlöszuordnung von Zusatzentgelten in der Intensivmedizin

In patient care several clinical departments are often involved in the treatment of a single case. Due to this shared work and internal patient transfer between departments the respective departments have to share the single reimbursement sum which is granted for each hospital case in the German DRG system. The intensive care unit in particular, at least if maintained as an independent department, has a high rate of internal transfers and most of the patients will be transferred back to the original department prior to discharge from hospital. Different models have been suggested regarding the splitting of DRG reimbursement between clinical departments, however, no research has been done on the splitting of supplemental revenues. The allocation of supplemental revenues is especially complex for revenues generated over many days of hospital care or for clustered revenues. In most cases the supplemental revenues are simply allocated to the department from which the patient is ultimately discharged. This would lead to a significant economic risk for the intensive care unit, as a considerable proportion of medical services which are eligible for triggering supplemental revenues are applied there. In this study all cases treated in two intensive care units in a university hospital in 2007 were analyzed in which supplemental revenue-related medical services were performed over a longer period of time or graduated according to different amounts. In a total of 385 cases, 691 supplemental revenues were analyzed. Three different methods of supplemental revenues allocation were analyzed regarding the financial impact on the intensive care unit: allocation to the department from which the patient is discharged, allocation according to the length of stay in a particular department (in this case the intensive care unit) and allocation based on actually documented medical services eligible for supplemental revenues. The supplemental revenues take up a considerable share of the total reimbursement for intensive care. Based on the first 2 allocation methods the intensive care unit would receive 20% less supplemental revenues compared to the third allocation method, which supposedly reflects best the actual costs.

Kostenanalyse zur Navigation in der Knieendoprothetik

Total knee arthroplasty (TKA) is one of the most frequent procedures in orthopaedic surgery. The outcome depends on a range of factors including alignment of the leg and the positioning of the implant in addition to patient-associated factors. Computer-assisted navigation systems can improve the restoration of a neutral leg alignment. This procedure has been established especially in Europe and North America. The additional expenses are not reimbursed in the German DRG system (Diagnosis Related Groups). In the present study a cost analysis of computer-assisted TKA compared to the conventional technique was performed. The acquisition expenses of various navigation systems (5 and 10 year depreciation), annual costs for maintenance and software updates as well as the accompanying costs per operation (consumables, additional operating time) were considered. The additional operating time was determined on the basis of a meta-analysis according to the current literature. Situations with 25, 50, 100, 200 and 500 computer-assisted TKAs per year were simulated. The amount of the incremental costs of the computer-assisted TKA depends mainly on the annual volume and the additional operating time. A relevant decrease of the incremental costs was detected between 50 and 100 procedures per year. In a model with 100 computer-assisted TKAs per year an additional operating time of 14 mins and a 10 year depreciation of the investment costs, the incremental expenses amount to <euro> 300-395 depending on the navigation system. Computer-assisted TKA is associated with additional costs. From an economical point of view an amount of more than 50 procedures per year appears to be favourable. The cost-effectiveness could be estimated if long-term results will show a reduction of revisions or a better clinical outcome.

Wirtschaftliche Herausforderungen der Polytraumaversorgung

Following the introduction of DRGs ("diagnosis-related groups") in Germany, reimbursements changed from a per diem rate to a flat charge per patient. DRGs are defined by the German Institute for the Hospital Remuneration System (InEK, Institut für das Entgeltsystem im Krankenhaus) along with the respective reimbursement. The revenues are set according to the diagnoses and procedures. In complex cases like serious injury this applies for the average diagnoses and procedures. As a result, several groups reported costs of polytrauma care as high as 70,000 euro with losses as high as 20,000 euro. In the USA, a similar constellation has lead to the closure of trauma centers. The main reasons for the financial deficit are heterogeneity of polytrauma patients and contingency costs. Both are difficult to transfer to a case-based compensation system. Since the German DRG system was designed to learn during introduction, there were adjustments to reimbursements for polytrauma care in the initial phase. However, in recent years, no further improvements in the care of severely injured patients have been seen. The deficit per seriously injured patient currently runs at approx. 5000 euro. A renewed joint effort is required in order to avoid an economy-related reduction in quality of care.

Minimizing procedural cost in diagnosing small bowel bleeding: comparison of a strategy based on initial capsule endoscopy versus initial double-balloon enteroscopy

Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) detect small bowel bleeding with equal diagnostic yield. We aimed to detect factors that influence procedural cost of CE and DBE in diagnosing and treating small bowel bleeding, and to compare them with reimbursement. A cost model analysed procedural cost for diagnostic CE versus diagnostic, unidirectional DBE(scenario 1) and CE plus directed therapeutic DBE(positive findings in CE) versus unidirectional diagnostic plus therapeutic DBE (scenario 2). The frequency of investigations per annum (p.a.) at which cost per procedure is equalized (break-even point) was determined for CE versus DBE. A retrospectively collected cohort of patients was used to validate the cost model and to compare procedural costs with reimbursement (German diagnosis related groups, G-DRG). The break-even point at which cost per procedure is equalized for CE versus DBE was reached at 100 procedures p.a. in scenario 1 and 79 in scenario 2 for a rate of therapeutic enteroscopy of 14%, and 27 for a therapeutic enteroscopy rate of 30%. Personnel cost, procedure time,procedures p.a. and the rate of therapeutic enteroscopy had a major influence on procedural cost. In this patient cohort, the 'CE-first' and the 'DBE-first' strategies produced procedural costs of pound sterling 830 and pound sterling 1,076 per patient to attain a diagnosis, and pound sterling 1,042 versus pound sterling 1,181 to achieve therapeutic enteroscopy, respectively. For this cohort, potential reimbursement was pound sterling 2,320 and pound sterling 3,047 for the 'CE-first' and the 'DBE-first' strategies, respectively (G-DRG). Workflow management of CE versus DBE should consider frequency of investigations p.a. and probability for therapeutic enteroscopy to minimize procedural costs. The cost of DBE increases with less frequent or time-consuming investigations; CE is more robust with regard to these factors. From a third-party payer perspective, a strategy incorporating CE seems to minimize costs in G-DRG.

G-DRG-Systemanpassung 2009

The 2009 version of the German DRG system brought significant changes for urology concerning coding of diagnoses, medical procedures and the DRG structure. In view of the political situation and considerable economic pressure, a critical analysis of the 2009 German DRG system is warranted. Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2008 and 2009 based on the publications of the German DRG-institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). The relevant diagnoses, medical procedures and German DRGs in the versions 2008 and 2009 were analysed based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). Changes for 2009 focus on the development of the DRG structure, DRG validation and codes for medical procedures to be used for very complex cases. The outcome of these changes for German hospitals may vary depending in the range of activities. The German DRG system again gained complexity. High demands are made on correct and complete coding of complex urology cases. The quality of case allocation in the German DRG system was improved. On the one hand some of the old problems (e.g. enterostomata) still persist, while on the other hand new problems evolved out of the attempt to improve the case allocation of highly complex and expensive cases. Time will tell whether the increase in highly specialized DRG with low case numbers will continue to endure and reach acceptable rates of annual fluctuations.

G-DRG Version 2009: New Developments

The update of the G-DRG system for the year 2009 has been successfully negotiated. Like in the past years, changes are minimal and not dramatic, but they significantly enhance the quality of the DRG system. Once again, the German DRG system demonstrates its versatility and reliability for clinical reimbursement purposes. In the field of dermatology, several improvements or enhancements can be identified; the average case mix index that declined in the past years should now rise by 0.5 percent for 2009. Oncology cases are affected especially by this increase. Some refinements advanced for several years by the German Dermatologic Society (DDG) have been recognized --complex therapies like vacuum wound therapy, isolation due to multi-resistant infections and multiple primary tumors now have better cost weights. Although there still remain some minor problems like reimbursement of cost-intensive treatments, German dermatology is in summary very well prepared for the year 2009.

Abbildung des schwer verletzten Patienten im G-DRG-System 2008

Since the introduction of a per-case reimbursement system in Germany (German Diagnosis-Related Groups, G-DRG), the correct reimbursement for the treatment of severely injured patients has been much debated. While the classification of a patient in a polytrauma DRG follows different rules than the usual clinical definition, leading to a high number of patients not grouped as severely injured by the system, the system was also criticized in 2005 for its shortcomings in financing the treatment of severely injured patients. The development of financial reimbursement will be discussed in this paper. 167 patients treated in 2006 and 2007 due to a severe injury at the University-Hospital Münster and grouped into a polytrauma-DRG were included in this study. For each patient, cost-equivalents were estimated. For those patients treated in 2007 (n=110), exact costs were calculated following the InEK cost-calculation method. The reimbursement was calculated using the G-DRG-Systems of 2007, 2008 and 2009. Cost-equivalents/costs and clinical parameters were correlated. A total of 167 patients treated in 2006 and 2007 for a severe injury at the Münster University Hospital and grouped into a polytrauma DRG were included in this study. Cost equivalents were estimated for each patient. For those patients treated in 2007 (n=110), exact costs were calculated following the InEK (Institute for the Hospital Remuneration System) cost calculation method. Reimbursement was calculated using the G-DRG systems of 2007, 2008 and 2009. Cost equivalents/costs and clinical parameters were correlated. With the ongoing development of the G-DRG system, reimbursement for the treatment of severely injured patient has improved, but the amount of underfinancing remains substantial. As treatment of severely injured patients must be reimbursed using the G-DRG system, this system must be further adapted to better meet the needs of severely injured patients. Parameters such as total surgery time, injury severity score (ISS) and LOS in ICU could be used for this purpose. In future, data obtained in trauma networks can help optimize reimbursement for the treatment of these patients.

Frührehabilitation und OPS 8-552

The German DRG system recognises and reimburses cases of intensive early neurological rehabilitation on the basis of the fulfilment of a specific combination of qualifications, services and the provision of more than 300 minutes of therapy per day. There is no agreement yet as to how these features are to be documented, which results in conflicts between the hospitals and the Medical Service of the Statutory Health Insurances. The problem is described in this article and ways of solution are demonstrated.

Finanzierbarkeit der modernen Skoliosechirurgie unter den Bedingungen des DRG-Systems

In the German health system the payment of a hospital stay is standardised. The common basis is the G-DRG System (German diagnosis-related groups) in which every stay is paid by a lump sum. Scoliosis correction in our times means pedicle screw-based multilevel double rod instrumentation or anterior plate-rod instrumentation with primary stability. The outcome of those methods has improved the results of correction and decreased the complication rate but also means high costs due to the implants. Scoliosis correction is covered by DRG I06. Due to constant efforts a general improvement took place in the assessment of DRG I06. That is the reason why the losses incurred in DRG I06C could be lowered to 38% and in I06D to 22% in 2008. For an appropriate assessment further improvements are required.

Intravaskuläre Brachytherapie bei peripherer arterieller Verschlusskrankheit: Systematische Übersicht zur medizinischen Wirksamkeit und gesundheitsökonomische Modellierung

Percutaneous transluminal angioplasties (PTA) using balloon dilatation with or without stenting are performed to treat peripheral arterial occlusive disease (PAOD). Intravascular brachytherapy (IB) after PTA promises to reduce the restenosis rates. The present article addresses questions concerning medical efficacy and cost-effectiveness of IB in PAOD patients.A systematic literature search for randomized controlled studies evaluating IB in PAOD was conducted in August 2007. Information synthesis was conducted using meta-analysis. Health economic modelling was performed on the basis of clinical assumptions derived from the meta-analysis and economical assumptions derived from the German Diagnosis Related Groups (G-DRG) 2007.Twelve publications covering seven studies about IB vs. no IB were included in the evaluation. IB after successful balloon dilatation showed a significant reduction in the rate of restenosis at six and/or twelve months (relative risk 0.62; 95% confidence interval: 0.46 to 0.84) and a significant delay in the time to recurrence of restenosis (17.5 vs. 7.4 months, p < 0.01). IB after stenting did not lead to significant results regarding the restenosis rates, but was more often associated with early and late occlusive thromboses. The incremental cost-effectiveness ratio per restenosis avoided for IB vs. no IB after successful balloon dilatation was--depending on the G-DRG used-Euro 8,484 and Euro 9,058, respectively. In the comparison of IB vs. no IB after stenting IB was demonstrated to be inferior to no IB.IB after successful balloon dilatation in PAOD can be recommended from a medical point of view. From the health economic perspective the answer is not yet clear. IB after stenting in PAOD cannot be recommended.

Übertragbarkeit von Studienergebnissen in die Praxis: Beispiele aus der Pädiatrie

Since 2000 there has been sufficient evidence that chest X-rays are unnecessary in infants and children with uncomplicated lower respiratory tract infection. The reason is that neither the diagnosis nor the first therapeutic decisions will be influenced by the result of this procedure, and especially so if children have been infected with the respiratory syncytial virus. However, epidemiological studies in Germany reveal an ongoing use of chest X-ray in these cases. This might suggest that the X-ray images are taken as "proof" of pneumonia, which indeed pays off in the German DRG (Diagnosis Related Groups) system since hospitals receive a higher reimbursement for RSV pneumonia than for RSV bronchiolitis.

Clinical benefit and cost effectiveness of total knee arthroplasty in the older patient

PurposeTotal knee arthroplasty (TKA) is an effective, but also cost-intensive health care procedure for the elderly. Furthermore, bearing demographic changes in Western Europe in mind, TKA-associated financial investment for health care insurers will increase notably and thereby catalyze discussions on ressource allocation to Orthopedic surgery. To derive a quantitative rationale for such discussions within Western Europe's health care systems, a prospective assessment of both the benefit of TKA from a patient's perspective as well as its cost effectiveness from a health care insurer's perspective was implemented.MethodsA prospective cost effectiveness trial recruited a total of 65 patients (60% females), who underwent TKA in 2006; median age of patients was 66 years (interquartile range 61 - 74 years). Before and three months after surgery patients were interviewed by means of the EuroQol-5D and the WOMAC questionnaires to assess their individual benefit due to TKA and the subsequent inpatient rehabilitation. Both questionnaires' benefit estimates were transformed into the number of gained quality adjusted life years [QALYs]. Total direct cost estimates for the overall care were based on German DRG and rehabilitation cost rates [€]. The primary clinical endpoint of the investigation was the individual number of QALYs gained by TKA based on the WOMAC interview; the primary health economic endpoint was the marginal cost effectiveness ratio (MCER) relating the costs to the associated gain in quality of life [€/QALY].ResultsTotal direct costs for the overall procedure were estimed 9549 € in median. The WOMAC based interview revealed an overall gain of 4.59 QALYs (interquartile range 2.39 - 6.21 QALYs), resulting in marginal costs of 1795 €/QALY (1488 - 3288 €/QALY). The corresponding EuroQol based estimates were 2.93 QALYs (1.75 - 5.59 QALYs) and 3063 €/QALY (1613 - 5291 €/QALY). Logistic regression modelling identified the patients' age as the primary determinant of cost effectiveness (Likelihood Ratio p = 0.006): patients younger than 60 years showed a median gain of 6.45 QALYs and median marginal costs of 1463 €/QALY, patients between 60 - 70 years 5.47 QALYs and 1744 €/QALY, patients older than 70 years 2.76 QALYs and 3186 €/QALY.ConclusionTKA was proven to be cost effective from a health care insurer's perspective, although its marginal costs notably increased with increasing age. Note, however, that this age-related gradient in marginal cost effectiveness is of comparable order as the changes in cost effectiveness due to variation of the underlying assessment instrument.

Bewertung von Ressourcenverbräuchen im deutschen Gesundheitswesen aus Sicht der Gesetzlichen Krankenversicherung

This paper gives a systematic overview of resource use that is relevant within the German health-care system from the perspective of the statutory health insurance and how these resource uses should be priced in economic analyses. This includes all relevant cost domains from ambulatory and inpatient care as well as a detailed description of relevant data resulting from drug usage. For prescriptions the legal framework (e.g., reference pricing) is applied to list all relevant co-payments or discounts (e.g., for pharmaceutical companies) which have to be considered in patented as well as off-patent drugs. The same method is applied for ambulatory services [taking the universal remuneration scheme (EBM) into account] as well as for inpatient stays (discussing certain characteristics of the German DRG system). As a result, for the first time, a pragmatic as well as a practical approach is presented to value resource usage within the German health care system in future studies from the perspective of the statutory health insurance or, in other words, the sickness funds.

Minimally Invasive, Minimally Reimbursed? Anesthesia for Endoscopic Cardiac Surgery Is Not Reflected Adequately in the German Diagnosis-Related Group System

In the German diagnosis-related group (G-DRG) system, hospital reimbursement for anesthesia is linked to specific surgical procedures, irrespective of case duration. Accordingly, costs of innovative procedures, such as endoscopic cardiac surgery, may be underreimbursed. The authors assessed to what extent anesthesia costs for endoscopic cardiac surgery are reimbursed with the G-DRG system. Retrospective analysis. University hospital. Eighty-four patients were studied undergoing general anesthesia for minimally invasive endoscopic port-access intracardiac surgery (n = 42) or conventional "open" surgery (n = 42) for similar indications. None. The authors measured anesthesia staffing time, costs, and reimbursement for endoscopic cardiac surgery and compared results with data from a matched group undergoing conventional surgery. Endoscopic surgery increased anesthesia staffing time per case by 521 minutes (977 minutes +/- 177 v 456 +/- 92, mean +/- standard deviation, p = 0.0001) and costs by approximately 200%. Anesthesia duration increased by 152 minutes (503 minutes +/- 89 v 351 +/- 69, p = 0.0001). In contrast, staffing reimbursement did not increase at the time of the patient's surgery (euro500/case [446-569] v 492 [452-508], p = 0.75, median [interquartile range]) or with the 2007 G-DRG matrix (euro548/case [463-559] v 503 [503-568], p = 0.48). Cost recovery was only 66% +/- 17.4% and 72.7 +/- 38.9 in the 2007 G-DRG matrix, respectively. It was shown that (1) endoscopic cardiac surgery consumed more anesthesia resources and was underreimbursed both relative to actual costs and to conventional surgery, (2) costs for such anesthesia services were inappropriately reflected in the G-DRG system, and (3) a DRG system's inability to adapt timely to innovative procedures may adversely affect anesthesia departments and medical progress.

Fast-track concepts in routine pediatric surgery: a prospective study in 436 infants and children

The aim of this study was to investigate fast-track concepts in routine pediatric surgery in a university clinic over 1 year. Fast-track concepts were established for procedures requiring hospital admission in patients up to 15 years of age. Patients were studied prospectively from June 2006 to June 2007. Out of a total of 436 potentially suitable patients, 155 (36%) were finally treated following the protocols. The mean intensity of pain in children younger than 4 years (CHIPPS, 0-10) was 1.3 +/- 1.5 the evening of the operation day and decreased to <1 at all other time points. The initial postoperative mean pain intensity in older children (Smiley/VAS, 1-10) was 3.7 +/- 2.2 and decreased constantly thereafter. The mean hospital stay of fast-track patients was significantly shorter compared with German diagnosis-related group data (4.6 +/- 2.9 versus 9.7 +/- 3.8, p < 0.01). There were four (3%) readmissions for minor complications. At follow-up after 2 weeks, 95% of patients and parents judged fast-track care as excellent. Fast-track concepts are feasible in one third of pediatric patients undergoing routine in-hospital surgery. Fast-track pediatric surgery achieves accelerated convalescence, minimal hospital stay, and high patient and parent satisfaction.

The data collection process established for the German DRG system over the last six years with focus on data quality

A key aspect of developing a successful DRG system is the quality of the underlying data. In Germany, about 18 million patient data and four million detailed patient cost data are collected annually to obtain an accurate and up-to-date basis. Though routines are established in the collection process, the process has been developed and refined over the years (2002 to 2007). This leads to a continuous upgrading of data validation. An overview of the process of data collection is given with focus on the following questions: - What happens to data in order to analyse it successfully and apply the results in the further development of the G-DRG system? - How can improvement of data quality be achieved? How can it be measured? - How are approximately 18 million cases collected every year (data flow)? - Which results are published to guarantee transparency? There is an obligation for nearly all German hospitals (about 1,800) to transfer patient data according to a certain law of hospital remuneration. In addition, detailed patient cost data and augmentative patient data are provided by nearly 270 hospitals that participate voluntarily in a partial census. The collection of hospital data in Germany runs annually through a standardised technical process including several quality checks. The data collection process from hospital into the relational databases of the German DRG Institute (InEK) is described, and details about the communication process and data security are given.

Wie differenziert und vergütet das G-DRG-System bei vitreoretinalen Eingriffen an Diabetikern?

The German DRG system (G-DRG system) is required to assign medical cases with similar costs correctly into a particular group, each case within the group receiving the same amount of reimbursement. At the same time the system should allow all-inclusive reimbursement, not necessarily reflecting the exact costs of each case. These opposite goals and the so far limited calculation basis raise the question of how the G-DRG system actually processes and reimburses empirically collected in-hospital treatment data. In 2005, 112 patients were admitted to the University Eye Hospital, University of the Saarland. All patients had diabetic retinopathy and required at least one vitreoretinal procedure. Demographic and clinical data were collected by using the hospital information system and the coding software KODIP. For statistic evaluation, principal diagnoses, ancillary diagnoses and procedures were each reassigned to particular groups. Reimbursement was calculated based on the case data of the year 2005. Also, the case data were reassigned with respect to calculation of reimbursement for the years 2006 and 2007. The results were compared with federal G-DRG calculation data. Mean age of the patients was 65.8 +/- 11.1 years, length of stay in-hospital was 9.3 +/- 3.2 days. In the 66 patients requiring general anaesthesia the cumulative length of stay in the operation room was 148.4 +/- 39.5 minutes, the cumulative duration of surgery was 86.3 +/- 34.1 minutes. In the 50 patients requiring local anaesthesia the cumulative length of stay in the operation room was 137.8 +/- 51.8 minutes, the cumulative duration of surgery was 81.6 +/- 43.6 minutes. The patients had 1.9 +/- 0.8 principal diagnoses, 14.4 +/- 5.8 ancillary diagnoses and 3.4 +/- 1.6 procedures. Twenty-five of 112 patients (22.3 %) were assigned to DRG C 03Z (1), 82 of 112 patients (73.2 %) were assigned to DRG C 17Z (2). Five patients were assigned to other DRG. Compared with the federal calculation data, our own data for 2005, 2006 and 2007 showed more high primary clinical complexity levels and a longer duration of in-hospital stay. For each of the three years the amount of reimbursement was equal in about two thirds of the own patients. Reimbursement was only differentiated for outliers beyond the trim point of the duration of in-hospital stay. The demographic and clinical G-DRG data of the included patients showed substantial cost-effective inhomogeneities. These inhomogeneities were not sufficiently considered for reimbursement based upon Z-DRG. Specialised departments with higher numbers of difficult cases may be discriminated. Wrong incentives may result in the selection of "low-risk cases".