Mindestmengen

Minimum volume standards in German hospitals: do they get along with procedure centralization? A retrospective longitudinal data analysis

BACKGROUND

Compliance with minimum volume standards for specific procedures serves as a criterion for high-quality patient care. International experiences report a centralization of the respective procedures. In Germany, minimum volume standards for hospitals were introduced in 2004 for 5 procedures (complex esophageal and pancreatic interventions; liver, kidney and stem cell transplantations), in 2006 total knee replacement was added. This study explores whether any centralization is discernible for these procedures in Germany.

METHODS

A retrospective longitudinal analysis of secondary data serves to determine a possible centralization of procedures from the system perspective. Centralization means that over time, fewer hospitals perform the respective procedure, the case volume in high-volume hospitals increases together with their percentage of the annual total case volume, and the case volume in low-volume hospitals decreases together with their percentage of the annual total case volume. Using data from the mandatory hospital quality reports for the years 2006, 2008 and 2010 we performed Kruskal Wallis and chi-square tests to evaluate potential centralization effects.

RESULTS

No centralization was found for any of the six types of interventions over the period from 2006 to 2010. The annual case volume and the number of hospitals performing interventions rose at differing rates over the 5-year period depending on the type of intervention. Seven percent of esophagectomies and 14% of pancreatectomies are still performed in hospitals with less than 10 interventions per year.

CONCLUSIONS

For the purpose of further centralization of interventions it will be necessary to first analyze and then appropriately address the reasons for non-compliance from the hospital and patient perspective.

[Biliary fistulas and biliary congestion after hepatopancreaticobiliary surgery]

Biliary complications after hepatopancreaticobiliary surgery can have severe consequences for the long-term quality of life of patients. Adequate and timely diagnosis of the underlying problem by an experienced surgeon is essential. Ultrasonography, computed tomography, contrast-enhanced fluoroscopy of drains and endoscopic retrograde cholangiopancreatography (ERCP) are helpful examinations that can be employed in a step-wise approach. Early re-do surgery is indicated in the initial postoperative course. Interventional methods, such as ERCP and percutaneous transhepatic cholangiodrainage ( PTCD, plus stents and drains) offer a variety of additional therapeutic options that should be used by the experienced interventionalist in a patient-tailored interdisciplinary fashion.

Early detection of cervical carcinomas: finding an overall approach

BACKGROUND

Infection with human papillomavirus (HPV) is a necessary, but not sufficient condition for the emergence of cervical cancer. Cervical cancer develops over several years through a series of precursor lesions that can be detected by cytological screening. The majority of these lesions, however, regress spontaneously. The challenge of cancer screening is to detect those patients who are at high risk of tumor progression.

METHODS

Selective literature review on cervical cancer screening in light of current guidelines and recommendations.

RESULTS AND CONCLUSION

Since the recently introduced vaccination against HPV does not provide full protection against cervical cancer, screening programs must continue. HPV vaccination and early detection of cervical carcinomas should be organized into a combined prevention program with systematic documentation, quality control, and active invitation to participate. It is assumed that the reduction in prevalence of precancerous lesions as a result of vaccination will have a negative impact on the efficiency of cytological early detection. Therefore, the existing screening procedures should be optimized and complemented by new techniques. Already available for screening is the detection of HPV DNA. Further promising biomarkers are currently being investigated in international studies, but no conclusions on their potential efficacy can yet be drawn.