German Diagnosis-related Groups System Research Articles

In-Hospital Pulmonary Arterial Embolism after Catheter Ablation of Over 45,000 Cardiac Arrhythmias: Individualized Case Analysis of Multicentric Data.

Data on incidence of in-hospital pulmonary embolisms (PE) after catheter ablation (CA) are scarce. To gain further insights, we sought to provide new findings through case-based analyses of administrative data. Incidences of PE after CA of supraventricular tachycardias (SVT), atrial fibrillation (AF), atrial flutter (AFlu), and ventricular tachycardias (VT) in three German tertiary centers between 2005 and 2020 were determined and coded by the G-DRG (German Diagnosis Related Groups System) and OPS (German Operation and Procedure Classification) systems. An administrative search was performed with a consecutive case-based analysis. Overall, 47,344 ablations were analyzed (10,037 SVT; 28,048 AF; 6,252 AFlu; 3,007 VT). PE occurred in 14 (0.03%) predominantly female (n = 9; 64.3%) patients with a mean age of 55.3 ± 16.9 years, body mass index 26.2 ± 5.1 kg/m2, and left ventricular ejection fraction of 56 ± 13.6%. PE incidences were 0.05% (n = 5) for SVT, 0.02% (n = 5) for AF, and 0.13% (n = 4) for VT ablations. No patient suffered PE after AFlu ablation. Five patients (35.7%) with PE after CA had no prior indication for oral anticoagulation (OAC). Preprocedural international normalized ratio in PE patients was 1.2 ± 0.5. Most patients with PE following CA presented with symptoms the day after the procedure (n = 9) after intraprocedural heparin application of 12,943.2 ± 5,415.5 IU. PE treatment included anticoagulation with either phenprocoumon (n = 5) or non-vitamin K-dependent OAC (n = 9). Two patients with PE died after VT/AF ablation, respectively. The remaining patients were discharged without sequels. Over a 15-year period, incidence of PE after ablation is low, particularly low in patients with ablation for AF/AFlu. This is most likely due to stricter anticoagulation management in these patients compared with those receiving SVT/VT ablation procedures and could argue for continuation of OAC prior to ablation. Optimizing periprocedural anticoagulation management should be subject of further prospective trials.

Cost-efficiency of ascites treatment in the G-DRG system

In Germany, around 1,000,000 people are affected by cirrhosis of the liver, with ascites being a common consequence. Hospitals are caught between the opposing aims of profitability and patient-centered treatment as a result of the increasing compression of services in hospitals and the increasing economization in the healthcare sector. Treatment costs are a crucial starting point for optimizing success and the optimal use of resources, given the restricted revenue flexibility due to established flat charges per case. The goal of this study is to examine the exact cost and income structures for ascites therapy at a university hospital that specializes in liver diseases. The treatment data of 778 patients admitted to the University Hospital Aachen's Department of Internal Medicine III between 2016 and 2019 were retrospectively and anonymously evaluated for this study. The revenue shares of the matrix of cost centers and cost types of the German Diagnosis-Related Groups (G-DRG) system were compared to the revenue shares of the specified services in the context of activity-based costing. Inadequate refinancing was discovered in every area of the therapy process that was investigated. As a result, the treatment of ascites in cirrhosis is currently underrepresented in the DRG system. This is owing to the fact that patients treated at the university hospital have a greater case severity.

The usefulness of Enhanced Recovery After Surgery concepts for colorectal resections: an economic analysis under DRG conditions.

PurposeERAS® (Enhanced Recovery After Surgery) describes a multimodal, interdisciplinary, and interprofessional treatment concept that optimizes the postoperative convalescence of the patient through the use of evidence-based measures.Goal of the work.The aim of this article is to examine the economic feasibility of the ERAS® concept in the German DRG (diagnosis-related groups) system.Material and methodsSince August 2019, patients have been treated in our clinic according to the later certified ERAS® concept. The last 50 patients before ERAS® implementation are compared below with 50 patients after ERAS® implementation, who were identified using a matched pair analysis. In addition to the comparison of costs and revenues, the clinical outcome of the patients is also presented.ResultsThe cases of the patients in the pre-ERAS® cohort caused median costs of € 7432.83. BWR (valuation ratio) of 3.38 were billable. The resulting DRG revenue for the patients in this group amounted to € 11,325.78. The proceeds generated in the end amounted to € 4575.14. The cases of patients in the ERAS® cohort resulted in costs of € 5582.96. BWR of 2.84 could be billed. The DRG proceeds for the patients in this group therefore amounted to € 10,014.18. The profit generated was thus € 4993.84.ConclusionThe cost reduction generated by ERAS® was more pronounced than the “loss” due to the decrease in BWR. ERAS® is therefore also possible in the German DRG system at absolutely cost-covering levels.

Advances in Neurocardiology: Focus on Atrial Fibrillation.

Advances in Neurocardiology: Focus on Atrial Fibrillation.

Depiction of cardiovascular surgery in the current modified German DRG system 2021

EinleitungDas Jahr 2020 wird immer im Schatten der durch die „coronavirus disease 2019“ (COVID-19) ausgelösten Pandemie stehen. Die ersten 3 Quartale 2020 waren geprägt von einem beispiellosen Herunterfahren der elektiven stationären Leistungserbringung und einem Freihalten von Intensivkapazitäten für die Behandlung von COVID-19-Patienten. Auch für die Herzchirurgie resultierten dadurch deutliche Auswirkungen auf die Leistungserbringung. Die Akteure in den Kliniken waren im Jahresverlauf zusätzlich mit einer Fülle von Änderungen der gesetzlichen Rahmenbedingungen konfrontiert. Dennoch wurde das aG-DRG-System 2021 durch das Institut für das Entgeltsystem im Krankenhaus (InEK) kalkuliert. Dieser Beitrag beschreibt und bewertet die wesentlichen Veränderungen des aG-DRG-Systems 2021 für die Herz-Thorax- und Gefäßchirurgie.MethodikAnalyse der relevanten Diagnosen, Prozeduren und G‑DRG-Strukturen in den Systemversionen 2020 und 2021 anhand der durch InEK und das Bundesinsitut für Arzneimittel und Medizinprodukte (BfArM) publizierten Informationen.ErgebnisseErweiterungen der relevanten Klassifikationssysteme für Diagnosen (ICD-10-GM 2021) und Prozeduren (OPS 2021) führen zu einer Zunahme spezifischerer Kodierungen von wesentlichen Interventionen und Operationen der Herz- und Gefäßchirurgie. Im Rahmen der Anpassung der G‑DRG-Strukturen sind besonders die Kondensation der bisherigen Fallpauschalen für die Herztransplantation zur aG-DRG A05Z und Abwertungen koronarer Bypassoperationen und rekonstruktiver Gefäßeingriffe zu nennen.SchlussfolgerungFür die Herz- und Gefäßchirurgie finden sich vielfältige Veränderungen mit z. T. erheblichen Auswirkungen auf die Fallerlöse. Hinzu kommt, dass die Auswirkungen der „Coronapandemie“ für viele deutsche Kliniken noch nicht abschließend absehbar sind. Ein weiterer, immer dringlicherer insbesondere die Gefäßmedizin betreffende Einflussfaktor ist der zunehmende Druck zur Ambulantisierung von Leistungen. Hier wird der im Jahre 2022 erwartete und voraussichtlich deutlich erweiterte Katalog für Ambulantes Operieren im Krankenhaus (AOP-Katalog) den Zwang zur ambulanten Erbringung bisher noch stationär erbrachter Leistungen sicher noch einmal deutlich erhöhen.

Performance Pay in Hospitals: An Experiment on Bonus-Malus Incentives.

Recent policy reforms in Germany require the introduction of a performance pay component with bonus–malus incentives in the inpatient care sector. We conduct a controlled online experiment with real hospital physicians from public hospitals and medical students in Germany, in which we investigate the effects of introducing a performance pay component with bonus–malus incentives to a simplified version of the German Diagnosis Related Groups (DRG) system using a sequential design with stylized routine cases. In both parts, participants choose between the patient optimal and profit maximizing treatment option for the same eight stylized routine cases. We find that the introduction of bonus–malus incentives only statistically significantly increases hospital physicians’ proportion of patient optimal choices for cases with high monetary baseline DRG incentives to choose the profit maximizing option. Medical students behave qualitatively similar. However, they are statistically significantly less patient oriented than real hospital physicians, and statistically significantly increase their patient optimal decisions with the introduction of bonus–malus incentives in all stylized routine cases. Overall, our results indicate that whether the introduction of a performance pay component with bonus–malus incentives to the (German) DRG system has a positive effect on the quality of care or not particularly depends on the monetary incentives implemented in the DRG system as well as the type of participants and their initial level of patient orientation.

Reimbursement After Congenital Heart Surgery in Germany: Impact of Early Postoperative Extubation.

Duration of mechanical ventilation is an important variable used by German Diagnosis-Related Groups (G-DRG) system to establish cost weight values for reimbursement after congenital heart surgery. Infants are commonly ventilated after open heart surgery. As of year 2015, we strived to achieve early postoperative extubation. This work studies how this approach impacted reimbursement after infant open heart surgery. Data of infants who underwent surgery on cardiopulmonary bypass (CPB) from 2014 to 2018 were reviewed. Successful early extubation was defined as end of mechanical ventilation within 24 hours postoperatively, without reintubation at a later point. Mean cost weight values (case mix index [CMI]) of achieved DRGs were used for estimation of reimbursement. Evolutions over years of early extubation and of reimbursement were compared. A total of 521 infants underwent operations on CPB. Of these, 161 (31%) procedures were of higher risk Society of Thoracic Surgery and the European Association for Cardio-Thoracic Surgery (STAT) categories 3 and 4. Early extubation was achieved in 205 (39%) patients. The rate increased from 14% (year 2014) to 57% (year 2018). Case mix index amounted to 8.87 ± 7.00 after early extubation, and 12.37 ± 7.85 after late extubation: P value <.0001. It was 8.77 ± 6.09 after early extubation in patients undergoing lower risk STAT categories 1 and 2 operations, and 8.09 ± 2.95 when categories 3 and 4 procedures were performed (P = .18). An overall 14.4% decrease in hospital reimbursement per patient was observed. Early extubation could be progressively obtained in the majority of infants. This resulted in lower reimbursement. Surgical complexity was disregarded. The current G-DRG system appears to favor longer mechanical ventilation durations after infant open heart surgery.

Inpatient treatment costs, cost-driving factors and potential reimbursement problems due to epileptic seizure-related injuries and fractures

HintergrundDie Analyse krankheitsspezifischer Kosten gewinnt in einem zunehmend ökonomisch ausgerichteten Gesundheitssystem an Relevanz, wobei vor allem chronische Erkrankungen aufgrund der langen Krankheitsdauer sowie häufiger Hospitalisierung und Arztbesuche von besonderem Interesse sind. Epilepsien stellen eine häufige neurologische Erkrankung dar, welche mit paroxysmal auftretenden epileptischen Anfällen und häufig hiermit assoziierten Verletzungen einhergeht und alle Altersgruppen betrifft.ZielZiel der Arbeit ist die Aufarbeitung der stationären Behandlungskosten anfallsbedingter Verletzungen sowie die Analyse hinsichtlich relevanter kostenverursachender Faktoren. Mittels alternativer Kalkulation der Versorgungskosten soll zusätzlich der Frage nach potenziellen Vergütungsproblemen im aktuellen DRG-System („diagnosis related groups“) nachgegangen werden.MethodenGrundlage dieser monozentrischen, retrospektiven Analyse ist der tatsächliche Erlös der stationären Behandlung von 62 Patienten, die zwischen 01/2010 und 01/2018 im Universitätsklinikum Frankfurt aufgrund von Verletzungen im Rahmen epileptischer Anfälle erfolgte. Die Analyse potenzieller kostenverursachender Faktoren bezog sich auf relevante soziodemographische und klinische Aspekte, die alternative Kalkulation der Versorgungskosten wurde mit gängigen gesundheitsökonomischen Methoden durchgeführt.ErgebnisseDer mittlere DRG-Erlös betrug 7408 € (±8993 €, Median 5086 €, Spanne 563–44.519 €), die mittleren kalkulierten Kosten 9423 € (±11.113 €, 5626 €, Spanne 587–49.830 €). Als signifikant kostenverursachender Faktor konnte eine Liegedauer ≥7 Tage (p = 0,014) identifiziert werden. Aufgrund des signifikanten Unterschieds (p < 0,001) zwischen Erlös und kalkulierten Kosten erfolgte eine Analyse nach Faktoren für potenzielle Vergütungsprobleme, welche für eine Aufenthaltsdauer von ≥7 Tagen (p = 0,014) sowie für eine Behandlung auf Intensivstation (p = 0,019) signifikant verblieb.SchlussfolgerungDie stationären Versorgungskosten von Patienten mit Frakturen aufgrund epileptischer Anfälle sind hoch und daher gesundheitsökonomisch relevant. Generell scheint die auf Fallpauschalen basierende Vergütung nach G‑DRG die tatsächlichen Kosten zu decken, bei Patienten mit einer langen Liegedauer oder einen Aufenthalt auf Intensivstation können jedoch Vergütungsprobleme bestehen.

Implementation of new technologies in the DRG system under economic aspects

The implementation of technological innovations in surgery, such as robotic-assisted procedures, novel implants, navigation or modern visualization techniques, pose an economic challenge for institutions, as they are rarely cost-covering per se. In the German diagnosis-related groups (DRG) system, the costs of numerous novel technologies and innovations in surgery are not or not sufficiently covered in the short term and even less in the middle and long term. This review article describes the economic aspects of surgical innovations and outlines possible ways for hospitals to cover costs. Asimulated case study illustrates the extent to which the current German DRG tariff system reflects the costs of minimally invasive techniques (laparoscopic, robot-assisted) in the context of an elective sigmoid colon resection with benign indications.

Reduced Revenues after Introduction of the G-DRG System due to Poor Coding Quality? Qualification of Coding Staff at 177 German Children's Hospitals

Pediatrics are often regarded as a "victim" of the German Diagnosis related Groups (G-DRG) system because the economic situation of many pediatric hospitals has deteriorated since the introduction of the G-DRG system in 2004. This is often attributed to an insufficient case mix of pediatric diagnoses. It is unknown if revenues are lost due to an insufficient qualification of coding staff. All members of the German Society of Pediatric Hospitals and Departments (GKinD) were invited to an online survey by e-mail. 177 (52%) of the 340 german children's hospitals delivered complete questionnaires. 52% of the hospitals employed codings staff that had no additional clinical duties. Coding staff had no specific professional training and did not undergo specific ongoing education in 47 and 32% of the hospitals, respectively. During absence, 35% of coding staff a no substitute or a non-pediatric substitute. 2,8% of the senior physicians judged the established structures as "bad" or "very bad". In many german children's hospitals, diagnoses are documented by coding staff with an insufficient qualification. This is associated with the risk of inaccurate or incomplete coding and can threaten the economic success of the hospital. The senior physicians are satisfied with the established coding structures, thus they might be unaware of the great economic potenzial of improvements of the coding quality. The economic situation of german children's hospitals could be significantly improved by recruitment of qualified, full-time coding staff.

Elektive Versorgung von Leistenhernien in der universitären Chirurgie – eine ökonomische Herausforderung

Elective and emergency inguinal hernia surgery is acentral task for general and abdominal surgeons. As astandard procedure it is regarded as having a relatively low income in the German diagnosis-related groups (DRG) system. This can lead to an economic imbalance, especially in acost-intensive environment of auniversity hospital. The aim of this analysis was to investigate the influence of clinical factors on costs and the contribution margin as well as the overall economic evaluation of elective inguinal hernia surgery at auniversity hospital. All patients undergoing elective inguinal hernia surgery at two locations of the Charité University Medicine Berlin in 2014 and 2015 were included in the analysis. The influence of clinical, patient and surgical factors on the economic outcome of the cases was evaluated. Atotal of 419 patients were included, mostly after a Lichtenstein operation (44.9%) and laparoscopic transabdominal preperitoneal (TAPP) surgery (53.9%). The greatest impact on the economic outcome was the occurrence of postoperative complications. Also, apatient clinical complexity level (PCCL) value of >1, more than 8 encoded secondary diagnoses and aduration of hospital stay of less than 2days had asignificantly negative impact on the contribution margin. Overall, elective inguinal hernia surgery led to anegative contribution margin of € 651 per case. Elective inguinal hernia surgery in the environment of auniversity hospital has a high financial deficit; however, since acomplete discontinuation of this treatment is not an alternative multifactorial approaches are required to improve the economic outcome.

Which Reimbursement System Fits Inpatient Palliative Care? A Qualitative Interview Study on Clinicians' and Financing Experts' Experiences and Views.

Context: Internationally, a variety of reimbursement systems exists for palliative care (PC). In Germany, PC units (PCUs) may choose between per-diem rates and diagnosis-related groups (DRGs). Both systems are controversially discussed. Objectives: To explore the experiences and views of German PCU clinicians and experts for PCU financing regarding per-diem rates and DRGs as reimbursement systems with a focus on (1) cost coverage, (2) strengths and weaknesses of both financing systems, and (3) options for further development of funding PCUs. Design: Qualitative semistructured interviews with PCU clinicians and experts for PCU financing, analyzed by thematic analysis using the Framework approach. Setting/Subjects/Measurements: Ten clinicians and 13 experts for financing were interviewed June-October 2015 on both reimbursement systems for PCU. Results: Interviewees had divergent experiences with both reimbursement systems regarding cost coverage. A described strength of per-diem rates was the perceived possibility of individual care without direct financial pressure. The nationwide variation of per-diem rates and the lack of quality standards were named as weaknesses. DRGs were criticized for incentives perceived as perverse and inadequate representation of PC-specific procedures. However, the quality standards for PCUs required within the German DRG system were described as important strength. Suggestions for improvement of the funding system pointed toward a combination of per-diem rates with a grading according to disease severity/complexity of care. Conclusions: Expert opinions suggest that neither current DRGs nor per-diem rates are ideal for funding of PCUs. Suggested improvements regarding adequate funding of PCUs resemble and supplement international developments.

PDB45 - COSTS OF PREVENTION, MONITORING AND TREATMENT OF IODINE DEFICIENCY DISORDERS IN GERMANY

Iodine deficiency can lead to impaired thyroid function and other so called iodine deficiency disorders (IDD). In Germany, more than 30 percent of the population is considered to be mildly to moderately iodine deficient. The economic burden of IDD management is still unclear. The purpose of our study was to compile costs for prevention, monitoring and treatment of IDDs in Germany. We assessed costs for the medical management of IDDs from the German societal perspective (index year 2018). Resource utilization was based on published evidence. Outpatient costs were based on the ‘Uniform Value Scale of the National Association of Statutory Health Insurance Physicians ' and the ‘German Medical Fee Index'. Inpatient costs were based on the 'case fees' of the German Diagnosis Related Groups System. Medication costs are calculated according to reimbursement rules. Indirect costs were based on productivity loss occurring due to disease-related absence from work. Published data and additional expert opinion were used to estimate resource utilization and costs for IDD prevention and monitoring. Annual average costs per case were EUR 20,792 for intellectual disability; EUR 2,541 for goiter and/or benign thyroid nodules; EUR 4,204 for hyperthyroidism; EUR 2,549 for hypothyroidism; and EUR 10,624 for thyroid cancer. Average costs for miscarriage were EUR 2,182The annual per-person costs in the German population for an IDD prevention program including costs for monitoring, salt iodization, information campaigns and administering and enforcing an iodine fortification program were approximately EUR 0.10. Cost for the management of disorders related to iodine deficiency range from EUR 2,182 per case to EUR 20,792 annually. In contrast, prevention costs are low. For recommendations regarding the implementation of an IDD prevention program, effectiveness and epidemiological data needs to be considered in addition in a full economic evaluation, for example, by applying a decision-analytic model.

Center formation, registries, and quality assurance : Economic impact on training and quality of care

The increasing tendency toward formation of centers and expansion of quality assurance has had a clear effect on medical education and quality of care in Germany in recent years. On the background of the German diagnosis-related groups (DRG) system and the significant devaluation of DRG codes, this issue should be addressed, particularly in the field of orthopedic endoprostheses. The effects of center formation and quality assurance on education and quality of care were evaluated based on a middle-sized clinic. In particular, we highlighted the number of training interventions in recent years on the background of the EndoCert initiative. The costs of complete certification of a hospital according to the KTQ or ISO standard, the expenses for the EndoCert certifications and the EPRD, as well as the continuously increasing personnel demands for registries, quality assurance, and education centers represent an immense economic burden. An improvement in the quality of care can be assumed for the EndoCert Initiative, but this remains without consequence for the revenues situation of the respective cases. In light of the lack of medical students and in terms of the quality of care in Germany, it must be discussed as to what extent a training-adapted remuneration of clinics is possible. We stress that medical training doesn't only take place in the operating theater and, up until now, has often not been awarded a high priority in the everyday practice of middle-sized clinics across Germany. Since refinancing is not available in the DRG system, in the absence of remuneration of medical education and the different medical center systems, we can expect that affected clinics, particularly those under economic strain, will no longer be able to meet the high demands of modern initiatives.

Redefining diagnosis-related groups (DRGs) for palliative care \u2013 a cross-sectional study in two German centres

BackgroundHospital costs and cost drivers in palliative care are poorly analysed. It remains unknown whether current German Diagnosis-Related Groups, mainly relying on main diagnosis or procedure, reproduce costs adequately. The aim of this study was therefore to analyse costs and reimbursement for inpatient palliative care and to identify relevant cost drivers.MethodsTwo-center, standardised micro-costing approach with patient-level cost calculations and analysis of the reimbursement situation for patients receiving palliative care at two German hospitals (7/2012–12/2013). Data were analysed for the total group receiving hospital care covering, but not exclusively, palliative care (group A) and the subgroup receiving palliative care only (group B). Patient and care characteristics predictive of inpatient costs of palliative care were derived by generalised linear models and investigated by classification and regression tree analysis.ResultsBetween 7/2012 and 12/2013, 2151 patients received care in the two hospitals including, but not exclusively, on the PCUs (group A). In 2013, 784 patients received care on the two PCUs only (group B). Mean total costs per case were € 7392 (SD 7897) (group A) and € 5763 (SD 3664) (group B), mean total reimbursement per case € 5155 (SD 6347) (group A) and € 4278 (SD 2194) (group B). For group A/B on the ward, 58%/67% of the overall costs and 48%/53%, 65%/82% and 64%/72% of costs for nursing, physicians and infrastructure were reimbursed, respectively. Main diagnosis did not significantly influence costs. However, duration of palliative care and total length of stay were (related to the cost calculation method) identified as significant cost drivers.ConclusionsRelated to the cost calculation method, total length of stay and duration of palliative care were identified as significant cost drivers. In contrast, main diagnosis did not reflect costs. In addition, results show that reimbursement within the German Diagnosis-Related Groups system does not reproduce the costs adequately, but causes a financing gap for inpatient palliative care.

Economy of Standards: European Association of Urology Guideline Changes Influence Treatment Costs in Stage I Testicular Cancer Patients

Objective: The study aimed to calculate direct medical costs (DMC) during the first year of diagnosis and to evaluate the impact of guideline changes on treatment costs in clinical stage (CS) I testicular germ cell tumor (TGCT) patients in a German healthcare system. Materials and Methods: Healthcare expenditures as DMC during the first year of diagnosis for 307 TGCT patients in CS I treated at our institution from 1987 to 2013 were calculated from the statutory health insurance perspective using patient level data. Three periods were defined referring to the first European Association of Urology (EAU) guideline in 2001 as well as to subsequent major guideline changes in 2005 and 2010. Data source for cost calculations were the German Diagnosis Related Groups system for inpatient stays (version 2014) and the German system for reimbursement of outpatient care (EBM – Einheitlicher Bewertungsmaßstab, edition 2014). Results: During our 25 years of study period, mean DMC in the first year after diagnosis for the entire cohort of TGCT patients in CS I almost halved from EUR 13.000 to EUR 6.900 (p < 0.001). From 1987 to 2001, DMC for CS I seminomatous germ cell tumor (SGCT) patients were EUR 13.790 ± 4.700. From 2002 to 2010, mean costs were EUR 10.900 ± 5.990, and from 2011 to 2013, mean costs were EUR 5.190 ± 3.700. For CS I non-seminomatous germ cell tumor (NSGCT) patients, from 1987 to 2001, mean DMC were EUR 11.650 ± 5.690. From 2002 to 2010, mean costs were EUR 11.230 ± 5.990, and from 2011 to 2013, mean costs were EUR 11.170 ± 7.390. Follow-up examinations became less frequent over time, which caused a significant cost reduction for NSGCT (p = 0.042) while costs remained stable for SGCT. When adding costs of relapse treatment, active surveillance (AS) was the most cost-effective adjuvant treatment option in CS I NSGCT whereas one course carboplatin or AS caused similar expenditures in SGCT patients. Conclusion: The introduction of the EAU guidelines in 2001 caused a decrease in DMC in CS I seminoma patients. This cost reduction mainly took place due to the declining importance of radiation therapy. No substantial changes were seen in patients with CS I NSGCT. Costs for follow-up care also diminished, but to a lesser degree. Even when considering expenditures for relapse treatment, AS remained cost-effective in CS I TCGT patients. Our data show that evidence-based medicine in TGCT can reduce DMC in the first year after diagnosis.

Structure of Neurological Departments in Germany: Results of the 12th Survey by the German Neurological Society

AbstractThe German Neurological Society has conducted a survey of the structure of neurological in-patient care every other year. The present survey covers the year 2015. With a response rate of 62% in mind, the questionnaire allowed meaningful comparisons to former surveys covering the years 2013 and 2011.Only a minority of departments maintains intensive care units of their own. In contrast, 24/7 presence of neurological physicians has become standard in interdisciplinary emergency rooms. Stroke management has made neurology increasingly involved in emergency care. Since 2015, thrombectomy has been recognized as state-of-the-art therapy for a subgroup of stroke patients, raising special demands for the availability of CT and MRI on a 24/7 basis. However, infrastructure did not improve as compared to former surveys.Number of beds, total procedures and average procedures per case proceeds (case mix, case mix index) has remained roughly unchanged. However, case numbers increased, and average length of stay robustly decreased within 2 years by 17% to 5.4 days.Staff structures were heterogeneous and were involved in various duties apart from inpatient care covered by the German Diagnosis-Related Groups (DRG) system. Departments did not succeed in differentiating expenditures related to the DRG system from other procedures. Shortage of nursing staff forced 22% of departments to temporally reduce services, 6% of departments did so because of a shortage of physicians, and in 2% of departments, both occurred. Departments were confident of certifications as means of quality management, and a few suggestions were provided for more meaningful parameters for outcome-oriented quality management in the future.

Generalizable items of quantitative and qualitative cornerstones for personnel requirement of physicians in anesthesia.

Anesthesiologists perform a broad spectrum of tasks. However, in many countries, there is no legal basis for personnel staffing of physicians in anesthesia. Also, the German diagnosis related groups system for refunding does not deliver such a basis. Thus, in 2006 a new calculation base for the personnel requirement that included an Excel calculation sheet was introduced by the German Board of Anesthesiologists (BDA) and the German Society of Anesthesiology and Intensive Care Medicine (DGAI), and updated in 2009 and 2015. Oriented primarily to organizational needs, in 2015, BDA/DGAI defined quantitative and qualitative cornerstones for personnel requirement of physicians in anesthesia, especially reflecting recent laws governing physician’s working conditions and competence in the field of anesthesia, as well as demands of strengthened legal rights of patients, patient care and safety. We present a workload-oriented model, integrating core working hours, shift work or standby duty, quality of care, efficiency of processes, legal, educational, controlling, local, organizational and economic aspects for calculating personnel demands. Auxiliary tables enable physicians to calculate personnel demands due to differing employee workload, non-patient oriented tasks and reimbursement of full-equivalents due to parental leave, prohibition of employment, or long-term illness. After 10 years of experience with the first calculation tool, we report the generalizable key aspects and items of a necessary calculation tool which may help physicians to justify realistic workload-oriented personnel staffing demands in anesthesia. A modular, flexible nature of a calculation tool should allow adaption to the respective legal and organizational demands of different countries.

PHP165 - Extra Budgetary Reimbursement Options For Innovations In The German Hospital Sector

The compensation in the German hospital sector takes place on a performance-based, continuous and generalized compensation system - the G-DRG (German Diagnosis Related Groups). ICD-10-GM and OPS are foundations of this system. The annual adjustment to classifications allows innovations to be included in the G-DRG catalog. For appropriate compensation NUB services=Neue Untersuchungs- und Behandlungsmethoden [new treatment and examination methods]) can be integrated in the DRG system via additional supplementary payments (Zusatzentgelte=ZE) or inclusion in the OPS (Operations- and procedure code). The objective of this analysis is to provide an overview of applications for NUB and additional supplementary payments and to evaluate for which pharmaceutical indications these tools are used. The German DRG database issued by InEK is used to analyse NUB subgroups sorted according to key therapeutic indications for the year 2016. In addition the NUB services which were provided with Status 1 (NUB meets the criteria) or 4 (required criteria aren’t sufficient illustrated) in 2015, and were integrated into the G-DRG system 2016, are analyzed. This overview list is also provided by InEK. Changes in the OPS system are assessed by monitoring the information provided on DIMDI website. An overall increase of 7% compared to 2015 were observed concerning NUB submissions. (710 in 2016 vs. 670 in 2015). Out of 710 NUB submissions 167 (23.5%) are classified as drugs in 2016. Oncology and anti-inflammatory/immunology pharmaceuticals were identified as leading therapeutic areas for pharmaceutical applications. New ZEs for 2016 were also for pharmaceuticals in these two indications. An increase in extra budgetary reimbursement options were recognized. As it may take up to three years until a new procedure/pharmaceutical is included in the DRG system, NUBs represent a key method and are increasingly used to achieve reimbursement for innovative, cost-intensive drugs, medical products/procedures in in-patient setting.

Pain - a neglected neurological issue

Chronic pain represents a great challenge; according to epidemiological data increasing numbers of patients should be expected. Based on recent advances, a better understanding of the pathophysiology of chronic pain has been achieved and neurologists have made a major contribution to this understanding. Chronic pain is accompanied by substantial maladaptive plastic alterations in both the peripheral and central nervous systems; therefore, neurological knowledge is of paramount importance for pain therapists but this contrasts with the current treatment situation of pain patients in Germany. There are basically too few departments and practices undertaking treatment, and neurologists are an exception in most pain centers. Furthermore, due to economic reasons neurological hospitals are currently experiencing a dearth of inpatients suffering from chronic pain. Diagnostic and/or treatment procedures for neurological pain entities (e.g. headaches or neuropathic pain) are insufficiently represented in the German diagnosis-related groups (DRG) reimbursement system and the obstacles for an efficient pain therapy in neurological practices are too high. Finally, there are too few academic positions for pain medicine in neurological hospitals; therefore, career opportunities for motivated young neurologists with an interest in pain are lacking. In order to address the unmet therapeutic needs of patients with chronic pain there is a high demand for (i) establishment of departments for neurological pain medicine, (ii) modification of the German DRG system and (iii) education of young neurologists with expertise in pain. Pain medicine in particular should be especially appealing to neurologists .