Minimum Caseload Requirements Research Articles

[Minimum case volumes from the perspective of university providers].

The association between patient volume and treatment quality has been sufficiently proven for certain surgical interventions (e.g., resections of the esophagus and pancreas). International experience shows that centralization of patient care in these fields leads to an improvement in outcome quality. If properly enforced, minimum caseload requirements can induce centralization effects in the hospital market. Overcapacities in the German hospital market and high nationwide in-hospital mortality rates (e.g., nationwide postoperative hospital mortality after esophageal and pancreatic resections) justify the current changes in the minimum caseload requirement regulation. Nevertheless, still open questions on volume-outcome relationships (e.g., additive volume effects of associated organ systems) have yet to be answered by scientific studies. In addition, the special role of university medical centers in the German healthcare system needs to be considered in the minimum caseload requirement regulation in order not to jeopardize the importance of university clinics in science, education and patient care through self-regulatory processes in the hospital market induced by minimum caseload requirements.

[Legal principles and decision making of the Federal Joint Committee on minimum caseloads in operative medicine].

Minimum caseload requirements represent aregulatory instrument of the Federal Joint Committee in order to improve patient safety for elective, highly complex procedures or treatments. Arelationship between case volume and quality of the outcome must be demonstrated within the scientific literature before minimum caseload requirements can be implemented. Furthermore, patients need to be allocated to hospitals which perform higher case volumes but without causing temporal and/or transport distress for them. The recent Health Care Development Act has opened up new opportunities to combine minimum caseload requirements with each other along with structure, process and outcome quality. The surgical community can provide acontribution to this structuring process.

Distribution of Care and Hospital Incidence of Carotid Endarterectomy and Carotid Artery Stenting: A Secondary Analysis of German Hospital Episode Data

This is a description of the German healthcare landscape regarding carotid artery disease, assessment of hospital incidence time courses for carotid endarterectomy (CEA) and carotid artery stenting (CAS), and simulation of potential effects of minimum hospital caseload requirements for CEA and CAS.

Editor's Choice – Distribution of Care and Hospital Incidence of Carotid Endarterectomy and Carotid Artery Stenting: A Secondary Analysis of German Hospital Episode Data

This is a description of the German healthcare landscape regarding carotid artery disease, assessment of hospital incidence time courses for carotid endarterectomy (CEA) and carotid artery stenting (CAS), and simulation of potential effects of minimum hospital caseload requirements for CEA and CAS. The study is a secondary data analysis of diagnosis related group statistics data (2005-2016), provided by the German Federal Statistical Office. Cases encoded by German operation procedure codes for CEA or CAS and by International Classification of Diseases (ICD-10) codes for carotid artery disease were included. Hospitals were categorised into quartiles according to annual caseloads. Linear distances to the closest hospital fulfilling hypothetical caseload requirements were calculated. A total of 132 411 and 33 709 patients treated with CEA and CAS from 2012 to 2016 were included. CEA patients had lower rates of myocardial infarction (1.4% vs. 1.8%) and death (1.2% vs. 4.0%), and CAS patients were more often treated after emergency admission (38.1% vs. 27.1%). Age standardised annual hospital incidences were 67.2 per 100 000 inhabitants for CEA and 16.3 per 100 000 inhabitants for CAS. The incidence for CEA declined from 2005 to 2016, with CAS rising again until 2016 after having declined from 2010 to 2013. Regarding distance from home to hospital, centres offering CEA are distributed more homogeneously across Germany, compared with those performing CAS. Hypothetical introduction of minimum annual caseloads (> 20 for CEA; > 10 for CAS) imply that 75% of the population would reach their hospital after travelling 45 km for CEA and 70 km for CAS. Differences in spatial distribution mean that statutory minimum annual caseloads would have a greater impact on CAS accessibility than CEA in Germany. Presumably because of a decline in carotid artery disease and a transition towards individualised therapy for asymptomatic patients, hospital incidence for CEA has been declining.

Are Esophagectomy Board Requirements Achievable? A Multi-Institutional Analysis

Duty-hour restrictions have implications on trainee operative exposure necessary to meet minimum case-volume requirements. We utilized a previously validated simulation model to evaluate the effect of program volume, trainee numbers and complement, and rotation schedule on the probability of achieving adequate esophagectomy case numbers for cardiothoracic surgery trainees. A ProModel simulator centered on probabilistic distributions of operative cases was utilized. Historical data from five 2-year cardiothoracic surgery training programs were obtained from 2016-2018 and used as inputs to the simulator that generated 10,000 "trainee 2-year periods" per program. Programs varied in annual average esophagectomy volume (12-91 per year), with 2-4 trainees graduating over a 2-year training period. If esophagectomy cases were distributed solely based on scheduling and institutional volume, only 60% of evaluated programs could adequately expose all trainees in esophagectomy to meet case requirements. The 3 programs with adequate esophagectomy volumes had averaged 3.3 times (range 3.0-3.6) the minimum number of board-required cases for their programs' trainees. The ability of programs to provide trainees with adequate esophagectomy volume is challenging based on institutional volume and scheduling. Through simulation, we demonstrate that programs need >2 times the expected minimum number of esophagectomies to ensure that >90% of trainees meet case-volume requirements. Programs may consider strategies such as allowing trainees to select cases based on personal need, train fewer fellows, or enable trainees to seek subspecialty exposure externally to achieve minimum esophagectomy case-load requirements.

The Effects of Minimum Caseload Requirements on Management and Outcome in Abdominal Aortic Aneurysm Repair.

The German quality assurance guideline on abdominal aortic aneurysm (AAA) was implemented by the Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA) in 2008. The aims of this study were to verify the association between hospital case volume and outcome and to assess the hypothetical effect of minimum caseload requirements. The German diagnosis-related groups statistics for the years 2012 to 2016 were scrutinized for AAA (ICD-10 GM I71.3/4) with procedure codes for endo - vascular or open surgical treatment. The primary endpoint was in-hospital mortality. Logistic regression models were used for risk adjustment, and odds ratios (OR) were calculated as a function of the annual hospital-level case volume of AAA. In a hypo - thetical approach, the linear distances for various minimum caseloads (MC) were evaluated to assess accessibility. The mortality of intact AAA (iAAA) was 2.7% (men [M] 2.4%, women [W] 4.2%); ruptured AAA (rAAA), 36.9% (M 36.9%, F 37.5%). An inverse relationship between annual hospital case volume of AAA and mortality was confirmed (iAAA/rAAA: from 3.9%/51% [<10 cases/year] through 3.3%/37% [30-39 cases/year] to 1.9%/28% [≥ 75 cases/year]). For a reference category of 30 AAA procedures/year, the following significant OR were found: 10 AAA cases/year, OR 1.21 (95% confidence interval [1.20; 1.21]); 20 cases, OR 1.09 [1.09; 1.09]; 50 cases, OR 0.89 [0.89; 0.89]; 75 cases, OR 0.82 [0.82; 0.82]. In a hypothetical centralization scenario with assumed MC of 30/year, 86% of the population would have to travel less than 100 km to the nearest hospital; with an MC of 40, this would apply to only 50% (without redistribution effects). In the observed period, a significant correlation was confirmed between high annual case volume and low in-hospital mortality. A minimum caseload requirement of 30 AAA operations/year seems reasonable in view of the accessibility of hospitals. Cite this.

Increasing access to breast reconstruction for women living in underserved non-metropolitan areas of Australia.

The potential quality of life benefits of breast reconstruction (BR) for women who have undergone mastectomy for breast cancer have long been recognised. While many women will not want to have BR, international best-practice guidance mandates that all should be given the choice. The aim of this article is to highlight potential policies to support patients' informed discussion of BR options and to improve access to BR for women living in underserved locations. Ninety semi-structured interviews were conducted from May 2015 to May 2017 with a convenience sample of 31 breast reconstructive surgeons, 37 breast cancer health professionals and a purposive sample of 22 women who underwent mastectomy as part of their breast cancer treatment. Breast, plastic reconstructive surgeons and health professionals based in major cities also provided information about how they cared for patients from more remote areas. Analysis of interview data revealed a range of barriers that were grouped into four major categories describing issues for women living outside major cities: population characteristics associated with lower socioeconomic status; locational barriers including limited health services resources and distance; administrative barriers such as hospital policies and inadequate support for women who need to travel; and surgical workforce recruitment barriers. Suggestions for potential solutions included the following: greater geographical centralisation of BR services within major cities; the creation of designated breast centres with minimum caseload requirements similar to the UK's system; and a buddy system, whereby smaller hospitals network with multidisciplinary teams based in larger hospitals.

Relationship between hospital or surgeon volume and outcomes in joint arthroplasty: protocol for a suite of systematic reviews and dose–response meta-analyses

IntroductionJoint arthroplasty is a particularly complex orthopaedic surgical procedure performed on joints, including the hip, knee, shoulder, ankle, elbow, wrist and even digit joints. Increasing evidence from volume–outcomes research supports...

[Minimum Caseload Requirements and In-hospital Mortality: Observational Study using Nationwide Hospital Discharge Data from 2006 to 2013].

Background: 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. Methods: 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. Results: 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]). Conclusion: 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.

Achieving minimum caseload requirements: an analysis of hospital quality control reports from 2004-2010.

Legally mandated minimum hospital caseload requirements for certain invasive procedures, including pancreatectomy, esophagectomy, and some types of organ transplantation, have been in effect in Germany since 2004. The goal of such requirements is to improve patient care by ensuring that patients undergo certain procedures only in hospitals that have met the corresponding minimum caseload requirement. We used the case numbers published in legally mandated hospital quality control reports to determine whether the hospitals actually met the stipulated requirements. We performed a secondary analysis of data supplied by hospitals in their quality control reports for the years 2004, 2006, 2008, and 2010 with respect to six procedures that have a minimum caseload requirement: complex interventions on the esophagus and pancreas, total knee replacement, and hepatic, renal, and stem-cell transplantation. The total case numbers for these six different procedures rose from 22 064 (0.1% of all procedures) in 2004 to 170 801 (0.9% of all procedures) in 2010. From 2006 onward, procedures to which minimum caseload requirements apply have been carried out in half of all hospitals studied. These procedures account for 0.9% of all inpatient cases in Germany. The percentage of hospitals that continue to perform certain procedures despite not having met the minimum caseload requirement ranged from 5% to 45%, depending on the type of procedure, and the percentage of cases carried out in such hospitals ranged from 1% to 15%. These values remained nearly constant for each of the six minimum caseload requirements over the 4 reporting years for which data were examined. The establishment of minimum caseload requirements in Germany in 2004 did not lessen the number of cases performed in violation of these requirements over the period 2004 to 2010.

Achieving minimum caseload requirements--an analysis of hospital discharge data from 2005-2011.

The German Federal Joint Committee (the highest decision-making body of physicians and health insurance funds in Germany) has established minimum caseload requirements with the goal of improving patient care. Such requirements have been in place for five types of surgical procedure since 2004 and were introduced for total knee endoprosthesis surgery in 2006 and for the care of low-birth-weight neonates (weighing less than 1250 g) in 2010. We analyzed data from German nationwide DRG statistics (DRG = diagnosis-related groups) for the years 2005-2011. The procedures that were performed were identified on the basis of their operation and procedure codes, and the low-birth-weight neonates on the basis of their birth weight and age. The treating facilities were distinguished from one another by their institutional identifying numbers, which were contained in the DRG database. In 2011, there were 172 838 hospitalizations to which minimum caseload requirements were applicable. 4.5% of these took place in institutions that did not meet the minimum requirement for the procedure in question. The percentage of institutions that did not meet the minimum caseload requirement for complex pancreatic surgery fell significantly from 64.6% in 2006 to 48.7% in 2011, and the percentage of pancreatic surgery cases treated in such institutions fell over the same period from 19.0% to 11.4%. A significant reduction in the number of institutions treating low-birth-weight neonates was already evident before minimum caseload requirements were introduced. For all other types of procedure subject to minimum caseload requirements, there has been no significant change either in the percentage of institutions meeting the requirements or in the percentage of cases treated in such institutions. After taking account of the potential bias due to the identification of institutions by their institutional identifying numbers, we found no discernible effect of minimum caseload requirements on care structures over the seven-year period of observation, with the possible exception of a mild effect on pancreatic procedures.

Has the Minimum Caseload Requirement Failed? Strategic Planning in the Hospital Sector Requires Input From Elected Political Representatives

All over the world, demographic changes and medical advances have given rise to concern over the future ability of society to pay for health care. Here in Germany, our health-care system is easily accessible to all and provides efficient and high-quality care in both the inpatient and the outpatient sectors. Changes in health-care law have been introduced at regular intervals since the 1970s to limit costs and raise efficiency. Each new regulation creates new incentives, some of which will be undesirable. Thus, laws and proposed laws must be critically analyzed, so that the necessary changes and adjustments can be discussed. As soon as the minimum caseload requirements were introduced in Germany, there was not only a lively debate about the questionable underlying evidence, particularly about threshold values, but also a fear that the new rules would create a false incentive toward increasing the quantity of care delivered.