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Stolberg-Stolberg J, Köppe J, Rischen R, Freistühler M, Faldum A, Katthagen JC, Raschke MJ. [Influence of complications and comorbidities on length of hospital stay and costs for surgical treatment of proximal humeral fractures]. Chirurg 2021; 92:907-915. [PMID: 34533598 PMCID: PMC8463392 DOI: 10.1007/s00104-021-01491-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2021] [Indexed: 11/30/2022]
Abstract
Nach proximaler Humerusfraktur beim alten Patienten stellen die winkelstabile Plattenosteosynthese und die inverse Schulterendoprothese zwei konkurrierende Operationsverfahren dar. Auch wenn erste klinische Studien auf eine funktionelle Überlegenheit der inversen Schulterendoprothese hindeuten, fehlt ein gesundheitsökonomischer Vergleich in der Literatur. Krankenkassendaten von 55.070 Patienten ab einem Alter von 65 Jahren, welche nach proximaler Humerusfraktur mittels inverser Schulterendoprothese oder winkelstabiler Plattenosteosynthese versorgt worden sind, wurden auf Kosten und Liegedauer untersucht. Multivariable lineare Regressionsmodelle wurden zur Beurteilung von Komplikationen und Komorbiditäten gerechnet. Die Liegedauer nach inverser Schulterendoprothese war mit 20,0 (±13,5) Tagen statistisch auffällig länger als nach winkelstabiler Plattenosteosynthese mit 14,6 (±11,4) Tagen (p < 0,001). Die Kosten pro Fall unterschieden sich mit 11.165,70 (±5884,36) EUR für die inverser Prothese und 7030,11 (±5532,02) EUR für die Plattenosteosynthese deutlich (p < 0,001). Statistisch auffällige Kostensteigerungen durch Komplikationen und Komorbiditäten unterstreichen den Bedarf an spezialisierten geriatrischen Traumazentren.
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Affiliation(s)
- Josef Stolberg-Stolberg
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland.
| | - Jeanette Köppe
- Institut für Biometrie und Klinische Forschung, Westfälische Wilhelms-Universität Münster, Schmeddingstraße 56, 48149, Münster, Deutschland
| | - Robert Rischen
- Klinik für Radiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Moritz Freistühler
- Geschäftsbereich Medizinisches Management-Medizincontrolling, Universitätsklinikum Münster, Niels-Stensen-Straße 8, 48149, Münster, Deutschland
| | - Andreas Faldum
- Institut für Biometrie und Klinische Forschung, Westfälische Wilhelms-Universität Münster, Schmeddingstraße 56, 48149, Münster, Deutschland
| | - J Christoph Katthagen
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - Michael J Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
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Abstract
BACKGROUND AND OBJECTIVES Estimated treatment costs of severely injured patients were often added to registry-based analyses. In the past, the TraumaRegister DGU® used a modular cost estimator for this purpose. A recent research project initiated by the German Trauma Society (DGU) evaluated the reimbursement of severely injured patients in the German DRG system. This project also allowed the generation of an improved update of the registry's cost estimator. METHODS Detailed cost data for the acute therapy of severely injured patients were available from 10 hospitals that also participate in the TraumaRegister DGU®. Cost and registry data were matched using hospital code, date of admission, age, sex, and length of stay. A multivariate regression analysis with hospital costs as dependent variable included patients with an injury severity score (ISS) ≥ 9 points who stayed in hospital at least three days. All injuries were coded using the abbreviated injury scale (AIS). A total of 1002 patients treated in 2007 and 2008 were successfully matched. Cost data was collected for each case according to the method of calculation provided by the German DRG Institute (InEK). RESULTS The mean age was 44 years and 73 % were males; the mean ISS was 27 points. The following aspects were significantly associated with the overall hospital costs: length of stay on the intensive care unit (ICU) (1152 € per day); length on intubation/ventilation (568 € per day); length of stay on normal ward (531 € per day); number of blood products (packed red blood cells; fresh frozen plasma) transfused until ICU admission (258 € per unit); a serious abdominal injury (AIS ≥3; 2849 €); an instable pelvic fracture with relevant blood loss (AIS 5; 7505 €); and a serious injury of the extremities (AIS 3-4; 2418 €). The estimated overall treatment costs calculated by the above mentioned formula averaged 22,138 € per case. The deviation from the measured real costs (21,546 € per case) was less than 3 %. CONCLUSION Using only key data available for all patients in the registry, a valid cost estimator for acute care costs is now available in the TraumaRegister DGU®.
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Affiliation(s)
- R Lefering
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke, Ostmerheimer Str. 200, 51109, Köln, Deutschland.
| | - L Mahlke
- Klinik für Unfallchirurgie und Orthopädie, St. Vincenz-Krankenhaus, Paderborn, Deutschland
| | - D Franz
- Medizinisches Management - Medizincontrolling/DRG-Research Group, Universitätsklinikum Münster, Münster, Deutschland
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St-Louis E, Paradis T, Landry T, Poenaru D. Factors contributing to successful trauma registry implementation in low- and middle-income countries: A systematic review. Injury 2018; 49:2100-2110. [PMID: 30333086 DOI: 10.1016/j.injury.2018.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 08/05/2018] [Accepted: 10/05/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trauma registries (TR) provide invaluable data, informing resource allocation and quality improvement. The purpose of this systematic review was to identify factors promoting and inhibiting successful TR implementation in low- and middle-income countries (LMICs). METHODS The protocol was registered a priori (CRD42017058586). With librarian oversight, a peer-reviewed search strategy was developed. Adhering to PRISMA guidelines, two independent reviewers performed first-screen and full-text screening. Studies describing implementation of a TR in LMICs or reviewed the experience of registry users/implementers were included. Extracted data, focusing on publication, institution, registry and data factors, was summarized using descriptive statistics and subjected to thematic qualitative analysis. RESULTS Out of 3842 screened references, 40 articles were included for analysis. Most registries were paper-based, implemented in single publicly-funded institutions within LMICs, benefited from funding, and were run by untrained house-staff with other clinical responsibilities. Constituent variables, injury scoring, outcome assessment, and quality assurance practices were very diverse. Principal obstacles to successful implementation were lack of funding, significant missing data, and insufficient resources. CONCLUSIONS This work may contribute to the planning of future efforts towards TR implementation in LMICs, where better injury data has the potential to alleviate the morbidity and mortality associated with trauma through advocacy and quality-improvement.
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Affiliation(s)
- Etienne St-Louis
- Montreal Children's Hospital, Division of Pediatric General and Thoracic Surgery, Canada; McGill University Health Centre, Centre for Global Surgery, Canada.
| | - Tiffany Paradis
- McGill University Health Centre, Centre for Global Surgery, Canada.
| | - Tara Landry
- McGill University Health Centre, Patient Resource Centre, Canada.
| | - Dan Poenaru
- Montreal Children's Hospital, Division of Pediatric General and Thoracic Surgery, Canada; McGill University Health Centre, Centre for Global Surgery, Canada.
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Paradis T, St-Louis E, Landry T, Poenaru D. Strategies for successful trauma registry implementation in low- and middle-income countries-protocol for a systematic review. Syst Rev 2018; 7:33. [PMID: 29467037 PMCID: PMC5822522 DOI: 10.1186/s13643-018-0700-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 02/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The benefits of trauma registries have been well described. The crucial data they provide may guide injury prevention strategies, inform resource allocation, and support advocacy and policy. This has been shown to reduce trauma-related mortality in various settings. Trauma remains a leading cause of mortality in low- and middle-income countries (LMICs). However, the implementation of trauma registries in LMICs can be challenging due to lack of funding, specialized personnel, and infrastructure. This study explores strategies for successful trauma registry implementation in LMICs. METHODS The protocol was registered a priori (CRD42017058586). A peer-reviewed search strategy of multiple databases will be developed with a senior librarian. As per PRISMA guidelines, first screen of references based on abstract and title and subsequent full-text review will be conducted by two independent reviewers. Disagreements that cannot be resolved by discussion between reviewers shall be arbitrated by the principal investigator. Data extraction will be performed using a pre-defined data extraction sheet. Finally, bibliographies of included articles will be hand-searched. Studies of any design will be included if they describe or review development and implementation of a trauma registry in LMICs. No language or period restrictions will be applied. Summary statistics and qualitative meta-narrative analyses will be performed. DISCUSSION The significant burden of trauma in LMIC environments presents unique challenges and limitations. Adapted strategies for deployment and maintenance of sustainable trauma registries are needed. Our methodology will systematically identify recommendations and strategies for successful trauma registry implementation in LMICs and describe threats and barriers to this endeavor. SYSTEMATIC REVIEW REGISTRATION The protocol was registered on the PROSPERO international prospective register of systematic reviews ( CRD42017058586 ).
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Affiliation(s)
- Tiffany Paradis
- McGill University, 3655 Promenade Sir William Osler, Montreal, QC H3A 1A3 Canada
| | - Etienne St-Louis
- McGill University Health Centre, 1001 Decarie Boulevard, Montreal, QC H4A 3J1 Canada
| | - Tara Landry
- McGill University Health Centre, 1001 Decarie Boulevard, Montreal, QC H4A 3J1 Canada
| | - Dan Poenaru
- McGill University Health Centre, 1001 Decarie Boulevard, Montreal, QC H4A 3J1 Canada
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A model-based cost-effectiveness analysis of Patient Blood Management. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018. [PMID: 29517965 DOI: 10.2450/2018.0213-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patient blood management (PBM) is a multidisciplinary concept focused on the management of anaemia, minimisation of iatrogenic blood loss and rational use of allogeneic blood products. The aims of this study were: (i) to analyse post-operative outcome in patients with liberal vs restrictive exposure to allogeneic blood products and (ii) to evaluate the cost-effectiveness of PBM in patients undergoing surgery. MATERIALS AND METHODS A systematic literature review and meta-analysis were performed to compare post-operative complications in predominantly non-transfused patients (restrictive transfusion group) and patients who received one to three units of red blood cells (liberal transfusion group). Outcome measures included sepsis with/without pneumonia, acute renal failure, acute myocardial infarction and acute stroke. In a second step, a health economic model was developed to calculate cost-effectiveness of PBM (PBM-arm vs control-arm) for simulated cohorts of 10,000 cardiac and non-cardiac surgical patients based on the results of the meta-analysis and costs. RESULTS Out of 478 search results, 22 studies were analysed in the meta-analysis. The pooled relative risk of any complication in the restrictive transfusion group was 0.43 for non-cardiac and 0.34 for cardiac surgical patients. In the simulation model, PBM was related to reduced complications (1,768 vs 1,245) and complication-related deaths (411 vs 304) compared to standard care. PBM-related costs of therapy exceeded costs of the control arm by € 150 per patient. However, total costs, including hospitalisation, were higher in the control-arm for both non-cardiac (€ 2,885.11) and cardiac surgery patients (€ 1,760.69). The incremental cost-effectiveness ratio including hospitalisation showed savings of € 30,458 (non-cardiac and cardiac surgery patients) for preventing one complication and € 128,023 (non-cardiac and cardiac surgery patients) for prevention of one complication-related death in the PBM-arm. DISCUSSION Our results indicate that PBM may be associated with fewer adverse clinical outcomes compared to control management and may, thereby, be cost-effective.
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Kostenanalyse von Schockraumpatienten im DRG-System. Unfallchirurg 2014; 117:716-22. [DOI: 10.1007/s00113-013-2405-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mahlke L, Lefering R, Siebert H, Windolf J, Roeder N, Franz D. [Description of the severely injured in the DRG system: is treatment of the severely injured still affordable?]. Chirurg 2014; 84:978-86. [PMID: 23512224 DOI: 10.1007/s00104-013-2490-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Due to the heterogeneity of severely injured patients (multiple trauma) it is difficult to assign them to homogeneic diagnosis-related groups (DRG). In recent years this has led to a systematic underfunding in the German reimbursement system (G-DRG) for cases of multiply injured patients. This project aimed to improve the reimbursement by modifying the case allocation algorithms of multiply injured patients within the G-DRG system. METHODS A retrospective analysis of standardized G-DRG data according to §21 of the Hospital Reimbursement Act (§ 21 KHEntgG) including case-related cost data from 3,362 critically injured patients from 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals was carried out. For 1,241 cases complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of multiply injured patients within the G-DRG system. Analysis of coding and grouping, performance of case allocation and the homogeneity of costs in the G-DRG versions 2008-2012 was carried out. RESULTS The results showed systematic underfunding of trauma patients in the G-DRG version 2008 but adequate cost covering in the majority of cases with the G-DRG versions 2011 and 2012. Cost coverage was foundfor multiply injured patients from the clinical viewpoint who were identified as multiple trauma by the G-DRG system. Some of the overfunded trauma patients had high intensive care costs. Also there was underfunding for multiple injured patients not identified as such in the G-DRG system. CONCLUSIONS Specific modifications of the G-DRG allocation structures could increase the appropriateness of reimbursement of multiply injured patients. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical specialist societies.
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Affiliation(s)
- L Mahlke
- Klinik für Unfallchirurgie und Orthopädie, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098, Paderborn, Deutschland,
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Anders B, Ommen O, Pfaff H, Lüngen M, Lefering R, Thüm S, Janssen C. Direct, indirect, and intangible costs after severe trauma up to occupational reintegration - an empirical analysis of 113 seriously injured patients. PSYCHO-SOCIAL MEDICINE 2013; 10:Doc02. [PMID: 23798979 PMCID: PMC3687242 DOI: 10.3205/psm000092] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Although seriously injured patients account for a high medical as well as socioeconomic burden of disease in the German health care system, there are only very few data describing the costs that arise between the days of accident and occupational reintegration. With this study, a comprehensive cost model is developed that describes the direct, indirect and intangible costs of an accident and their relationship with socioeconomic background of the patients. METHODS This study included 113 patients who each had at least two injuries and a total Abbreviated Injury Scale (AIS) greater than or equal to five. We calculated the direct, indirect and intangible costs that arose between the day of the accident and occupational reintegration. Direct costs were the treatment costs at hospitals and rehabilitation centers. Indirect costs were calculated using the human capital approach on the basis of the work days lost due to injury, including sickness allowance benefits. Intangible costs were assessed using the Short Form Survey (SF-36) and represented in non-monetary form. Following univariate analysis, a bivariate analysis of the above costs and the patients' sociodemographic and socioeconomic characteristics was performed. RESULTS At an average Injury Severity Score (ISS) of 19.2, the average direct cost per patient were €35,661. An average of 185.2 work days were lost, resulting in indirect costs of €17,205. The resulting total costs per patient were €50,431. A bivariate analysis showed that the costs for hospital treatment were 58% higher in patients who graduated from lower secondary school [Hauptschule] (ISS 19.5) than in patients with qualification for university admission [Abitur] (ISS 19.4). CONCLUSIONS The direct costs of treating trauma patients at the hospital appear to be lower in patients with a higher level of education than in the comparison group with a lower educational level. Because of missing data, the calculated indirect costs can merely represent a general trend, so that the bivariate analysis can only be seen as a starting point for further studies.
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Affiliation(s)
- Benjamin Anders
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Germany
| | - Oliver Ommen
- Federal Center for Health Education (BZgA), Cologne, Germany
| | - Holger Pfaff
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Germany
| | - Markus Lüngen
- Faculty of Business Management and Social Sciences, University of Applied Sciences Osnabrück, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Private University of Witten/Herdecke, Cologne, Germany
| | - Sonja Thüm
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Germany
| | - Christian Janssen
- Faculty of Applied Social Sciences, University of Applied Sciences Munich, Germany
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Topp T, Müller T, Kiriazidis I, Lefering R, Ruchholtz S, Kühne CA. Multiple blunt trauma after suicidal attempt: an analysis of 4,754 multiple severely injured patients. Eur J Trauma Emerg Surg 2011; 38:19-24. [PMID: 26815668 DOI: 10.1007/s00068-011-0114-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 04/26/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE The suicidal attempt is a significant cause for multiple severe injuries in Germany. The aim of the present study was to obtain information regarding injury patterns, clinical treatment, and outcome. METHODS We analyzed the data of 4,754 patients of the Trauma Registry of the German Trauma Society (1993-2007) with an Injury Severity Score (ISS) ≥9 after a suicidal jump from a height (SUICIDE) and after an accidental fall from a height (ACCIDENT). RESULTS Comparing the data of 3,682 patients with accidental fall versus those with intentional fall/jump (n = 1,072), we found that male patients were predominant in the ACCIDENT group (84.9 vs. 52.2%). The SUICIDE group had more severe injuries (ISS: 31.8 vs. 26.4). The ACCIDENT group suffered more severe head injuries (51.1 vs. 36.6%). Mortality (21.4 vs. 14.2%), length of stay in hospital (29.5 vs. 26.5 days), and costs (€34,833 vs. €24,701) were higher in the SUICIDE group. CONCLUSIONS Falls from a height are a common cause of injury among severely injured patients. The resulting trauma composes a particular form of blunt trauma with severe and multiple injuries, which depends on the fact of whether the free fall from a height was caused by an accident or as a result of a suicidal attempt. Taking the injury severity into consideration, there is no difference in the prognosis of the patients.
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Affiliation(s)
- T Topp
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Gießen and Marburg, Baldingerstraße 1, 35033, Marburg, Germany.
| | - T Müller
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Gießen and Marburg, Baldingerstraße 1, 35033, Marburg, Germany
| | - I Kiriazidis
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Gießen and Marburg, Baldingerstraße 1, 35033, Marburg, Germany
| | - R Lefering
- Faculty of Medicine, Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
| | - S Ruchholtz
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Gießen and Marburg, Baldingerstraße 1, 35033, Marburg, Germany
| | - C A Kühne
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Gießen and Marburg, Baldingerstraße 1, 35033, Marburg, Germany
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Stübig T, Mommsen P, Krettek C, Probst C, Frink M, Zeckey C, Andruszkow H, Hildebrand F. [Comparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple trauma with femoral shaft fractures: benefit and costs]. Unfallchirurg 2011; 113:923-30. [PMID: 20960146 DOI: 10.1007/s00113-010-1887-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Femoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC). PATIENTS AND METHODS In a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects. RESULTS In the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group. CONCLUSION From an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).
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Affiliation(s)
- T Stübig
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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Probst C, Schaefer O, Hildebrand F, Krettek C, Mahlke L. [The economic challenges of polytrauma care]. Unfallchirurg 2010; 112:975-80. [PMID: 19669721 DOI: 10.1007/s00113-009-1684-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- C Probst
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover.
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Juhra C, Franz D, Roeder N, Vordemvenne T, Raschke MJ. [Classification of severely injured patients in the G-DRG System 2008]. Unfallchirurg 2009; 112:525-32. [PMID: 19288071 DOI: 10.1007/s00113-009-1570-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND 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. METHOD 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. RESULTS 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. DISCUSSION 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.
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Affiliation(s)
- C Juhra
- Klinik und Poliklinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Germany.
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Probst C, Richter M, Haasper C, Lefering R, Otte D, Oestern HJ, Krettek C, Hüfner T. [Trauma and accident documentation in Germany compared with elsewhere in Europe]. Chirurg 2008; 79:650-6. [PMID: 18351306 DOI: 10.1007/s00104-008-1498-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The role of trauma documentation has grown continuously since the 1970s. Prevention and management of injuries were adapted according to the results of many analyses. Since 1993 there have been two different trauma databases in Germany: the German trauma registry (TR) and the database of the Accident Research Unit (UFO). Modern computer applications improved the data processing. Our study analysed the pros and cons of each system and compared them with those of our European neighbours. METHODS We compared the TR and the UFO databases with respect to aims and goals, advantages and disadvantages, and current status. Results were reported as means +/- standard errors of the mean. The level of significance was set at P<0.05. RESULTS There were differences between the two databases concerning number and types of items, aims and goals, and demographics. The TR documents care for severely injured patients and the clinical course of different types of accidents. The UFO describes traffic accidents, accident conditions, and interrelations. The German and British systems are similar, and the French system shows interesting differences. DISCUSSION The German trauma documentation systems focus on different points. Therefore both can be used for substantiated analyses of different hypotheses. Certain intersections of both databases may help to answer very special questions in the future.
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Affiliation(s)
- C Probst
- Unfallchirurgische Klinik, Medizinischen Hochschule, Carl-Neuberg-Strasse 1, Hannover, Germany.
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Cost-Drivers in Acute Treatment of Severe Trauma in Europe: A Systematic Review of Literature. Eur J Trauma Emerg Surg 2008; 35:61-6. [PMID: 26814534 DOI: 10.1007/s00068-008-8013-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Accepted: 04/02/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Throughout the world, trauma is a leading cause of morbidity and mortality in the young and most active group of society. While specialist trauma centers play a critical role in the survival after severe trauma, the assessment of trauma-related costs, budgeting for adequate trauma capacity, and determining the cost-effectiveness of interventions in critical care are fraught with difficulties. Through a systematic review of the European literature on severe trauma, we aimed to identify the key elements that drive the costs of acute trauma care. METHODS A PubMed/MEDLINE search for articles relating the costs and economics of trauma was performed for the period January 1995 to July 2007. One hundred and seventy-three European publications were identified. Twelve publications were retrieved for complete review that provided original cost data, a breakdown of costs according to the different elements of trauma care, and focused on severe adult polytrauma. The identified publications presented studies from the UK (3), Germany (6), Italy (2), and Switzerland (1). RESULTS In all publications reviewed, length of stay in the intensive care unit (ICU; 60%) and requirements for surgical interventions (≤ 25%) were the key drivers of hospital costs. The cost of transfusion during the initial rescue therapy can also be substantial, and in fact represented a significant portion of the overall cost of emergency and ICU care. Multiple injuries often require multiple surgical interventions, and prolonged ICU and hospital stay, and across all studies a clear relationship was observed between the severity of polytrauma injuries observed and overall treatment costs. While significant differences existed in the absolute costs of trauma care across countries, the key drivers of costs were remarkably similar. CONCLUSIONS Irrespective of the idiosyncrasies of the national healthcare systems in Europe, severity of injury, length of stay in ICU, surgical interventions and transfusion requirements represent the key drivers of acute trauma care for severe injury.
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McRoberts RJ, Beard D, Walsh TS. A study of blood product use in patients with major trauma in Scotland: analysis of a major trauma database. Emerg Med J 2007; 24:325-9. [PMID: 17452697 PMCID: PMC2658474 DOI: 10.1136/emj.2006.044198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES (1) To define blood product requirements in patients with trauma whose underlying injuries are consistent with major blood loss; (2) to use these data to estimate the annual number of patients in Scotland who sustain significant trauma and require substantial blood product replacement; and (3) to place these data in the context of recent findings concerning the efficacy of recombinant factor VIIa in patients with major trauma. METHODS A retrospective case note review study was conducted for patients who presented with trauma at each of four Scottish hospitals. The four sites were selected from the 26 hospitals that were the source of data for the Scottish Trauma Audit Group (STAG) database. Collected between 1991 and 2002, STAG encompasses approximately 53 000 patients. 129 patients whose trauma codes were likely to be linked to injuries associated with major blood loss were selected. Data on the use of blood products for each patient were collected and analysed for three periods: (1) time spent in the emergency department (ED); (2) time from leaving the ED to the end of the first 24 h; and (3) time from the end of the first 24 h to 7 days. Blood product use for each period and for the entire first week of care was described for all patients and for blunt and penetrating injury subgroups. Using national population data estimates, the incidence of major trauma requiring blood transfusion was calculated for Scotland. RESULTS Among the patients with trauma codes predicting significant blood loss, the proportion of patients requiring any blood transfusion within the first 7 days was 53.9%. 27.4% of patients received > or =8 units of red cell concentrate (RCC) within the first 24 h of hospitalisation. By direct extrapolation, we estimated that the annual number of Scotland's patients (aged >13 years) with a significant blood transfusion requirement secondary to traumatic injury was 67. Of these, 35 patients would require > or =8 units of RCC within the first 24 h. CONCLUSION In summary, this study estimates that approximately 67 patients annually in Scotland, above the age of 13 years, require blood transfusion as a direct result of significant traumatic injury. Of these 67 patients, an estimated 35 patients (28 of whom had a blunt form of trauma) require > or =8 units of RCC during the first 24 h in hospital. On the basis of the current limited trial evidence, the potential benefit in using recombinant factor VIIa in such patients, in Scotland, is small-approximately seven patients per million population aged >13 years, per year.
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Affiliation(s)
- Randal J McRoberts
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Little France, Edinburgh, UK.
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Janssen C, Ommen O, Neugebauer E, Lefering R, Pfaff H. How to improve satisfaction with hospital stay of severely injured patients. Langenbecks Arch Surg 2007; 392:747-60. [PMID: 17384957 DOI: 10.1007/s00423-007-0186-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Accepted: 02/23/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND In the context of medical quality assurance, patient satisfaction with medical and organisational aspects of health care service is considered to be a relevant outcome of patient surveys after a stay in hospital. Within quality research, it is assumed that assessments of patient satisfaction represent a direct measure of the quality of health care received. Furthermore, there is evidence that satisfied patients demonstrate higher levels of compliance for the course of their treatment and that the probability of successful treatment completion thus considerably increases. The present analysis aims to identify determinants of satisfaction of seriously injured patients with regard to their acute hospitalisation. MATERIALS AND METHODS One hundred twenty-one seriously injured survivors of work-related or traffic-related accidents treated in two hospitals in Cologne during the years 1996 to 2001 were sent a survey questionnaire. In addition to socio-demographic details, the survey covered the subjective evaluation of organisational and structural aspects of the acute hospitalisation and the psychosocial care provided by the medical staff. RESULTS Employing the "tailored design method", a response rate of 74.4% (n = 90) was obtained. Three highly significant factors influencing the satisfaction of seriously injured patients were identified by means of logistic regression: (1) patients' perception of being involved in treatment, (2) patients' feeling of being neglected by physicians and (3) patients' perception of trust in physicians. CONCLUSIONS In the present study, the perceived quality of psychosocial care proved to have a significant effect on patients' satisfaction with their hospital stay. Results of the current analysis thus indicate that psychosocial aspects of physician-patient interaction are of considerable importance in the medical care of seriously injured patients. Although this study is mainly based on subjective patient reported outcome, there is evidence that the subjective view of a patient is relevant in many aspects of medical treatment and outcome. These results already gave the motivation to develop a prospective interventional study with a training programme of communication skills to improve subjective and objective outcome parameters of severely injured patients.
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Affiliation(s)
- C Janssen
- Department of Medical Sociology, Institute and Polyclinic for Occupational and Social Medicine, School of Medicine and Dentistry, University of Cologne, Eupener Strasse 129, 50933 Cologne, Germany.
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Ommen O, Janssen C, Neugebauer E, Rehm K, Boullion B, Bouillon B, Pfaff H. Patienten- und krankenhausspezifische Einflussfaktoren auf die Zufriedenheit mit dem Krankenhausaufenthalt schwerverletzter Patienten. Unfallchirurg 2006; 109:628-39. [PMID: 16897026 DOI: 10.1007/s00113-006-1091-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND General political and legal changes in the German health care system will increase the importance of patient surveys. Patient satisfaction with medical and organizational care during their stay in a hospital is a relevant outcome of quality assurance. Satisfied patients also show a higher compliance with treatment and therefore increase the probability of a successful outcome. The objective of this analysis was to identify determinants of satisfaction with hospital stay of severely injured patients. METHODS A written questionnaire was sent to 121 severely injured patients, who were predominantly hurt by traffic or work-related accidents and were treated between 1996 and 2001 in two hospitals in Cologne (response rate=74.4%, n=90). The questionnaire used in this study contained questions about psychosocial care of physicians and nurses in and organizational and structural characteristics of the hospital. RESULTS Logistic regressions identified two significant predictors for satisfaction with hospital stay: (1) subjective evaluation of psychosocial quality of care by physicians and (2) patients' perception of active integration in treatment decisions. CONCLUSION The results of this analysis confirm the importance of soft science in medical education also for surgeons. Medical education should integrate knowledge about psychosocial aspects of medicine. The quality of psychosocial care of physicians seems to be a predictor of patient satisfaction. The probability of dissatisfaction increases with deficits in communication, information, and time as well as no active integration in treatment. The results of this analysis confirm the vital importance of psychosocial aspects in physician-patient interactions with severely injured patients for satisfaction with stay in hospital.
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Affiliation(s)
- O Ommen
- Zentrum für Versorgungsforschung Köln, Medizinische Fakultät der Universität zu Köln im Technologie Park, Eupener Strasse 129, 50933 Köln.
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Polinder S, Meerding WJ, van Baar ME, Toet H, Mulder S, van Beeck EF. Cost estimation of injury-related hospital admissions in 10 European countries. ACTA ACUST UNITED AC 2006; 59:1283-90; discussion 1290-1. [PMID: 16394898 DOI: 10.1097/01.ta.0000195998.11304.5b] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Injuries are a major cause of total health care costs. Cost estimations may help identify injuries and high risk-groups to be considered for potential intervention. METHODS Hospital discharge registers of 10 European countries were used to estimate injury incidence. Consensus was reached between the participating countries about methodology, definition, classification, cost measurements, and valuation to maximize cross-national comparability of outcomes. The data of the countries were also used to give an estimate of the costs per capita by age, sex, type of injury, and external cause in Europe. RESULTS Large international differences were observed in injury incidence and associated costs related to hospital admissions, with relatively high costs per capita for Austria, followed by Denmark and Norway. In Greece, Italy, Ireland, and Wales, intermediate costs per capita were found, but these costs were relatively low for Spain, England, and the Netherlands. The patterns of costs by age, sex, injury type, and external cause are quite similar between the countries. For all countries, costs per capita increase exponentially in older age groups (age > or =65 years), due to the combined effect of high incidence and high costs per patient. The elderly females account for almost triple costs compared with same age males. Young children and male adolescents are also high-cost groups. Highest costs were found for hip fractures, fractures of the knee/lower leg, superficial injuries, skull-brain injuries, and spinal cord injuries. Home and leisure injuries (including sport injuries) and occupational injuries combined make a major contribution (86%) to the hospital costs of injury. CONCLUSION Elderly patients aged 65 years and older, especially women, consume a disproportionate share of hospital resources for trauma care, mainly caused by hip fractures and fractures of the knee/lower leg, which indicates the importance of prevention and investing in trauma care for this specific patient group.
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Affiliation(s)
- Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands.
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Strohm PC, Südkamp NP, Zwingmann J, El Saman A, Köstler W. Polytrauma bei Fahrradfahrern. Unfallchirurg 2005; 108:1022-4, 1026-8. [PMID: 16032368 DOI: 10.1007/s00113-005-0975-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In our region we have noticed an increasing number of cyclists and consequently a rise in bicycle-related accidents in recent years. A large number of our polytraumatized patients are victims of bicycle-related accidents. MATERIAL AND METHODS Retrospectively we analyzed the data of our polytraumatized patients recorded between May 2003 and June 2004 for bicycle-related injuries. Of 153 polytraumatized patients treated in our emergency room 32 were cyclists (21%). The average age of our polytraumatized cyclist was 42 years, and the male-to-female ratio was 1:1. RESULTS The median score on the Glasgow Coma Scale (GCS) after the accident was 8 (min. 3, max. 15), the median Injury Severity Score (ISS) was 24 (min. 18, max. 41), and the median Polytrauma Score (PTS) was 23 (min. 14, max. 51). A total of 30 patients (94%) suffered a head injury; in 28 patients (88%) the head injury was the leading diagnosis. The median score on the Abbreviated Injury Scale (AIS) Head was 4 (min. 1, max. 5), the AIS Thorax 3 (min. 2, max. 4), and the AIS Extremities 3 (min, 2, max. 5). Our data were also compared with the official injury statistics of the region and the current literature. CONCLUSION The most frequent and most severe injury was the head injury (94%). Of the 32 polytraumatized cyclists 30 did not wear a helmet. Successful prevention could possibly be practiced if all cyclists wear helmets.
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Affiliation(s)
- P C Strohm
- Department für Orthopädie und Traumatologie, Klinikum der Albert-Ludwigs-Universität Freiburg.
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Grotz M, Schwermann T, Lefering R, Ruchholtz S, Graf v d Schulenburg JM, Krettek C, Pape HC. [DRG reimbursement for multiple trauma patients -- a comparison with the comprehensive hospital costs using the German trauma registry]. Unfallchirurg 2004; 107:68-75. [PMID: 14749855 DOI: 10.1007/s00113-003-0715-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
UNLABELLED The introduction of diagnosis related groups (DRG) will radically change the payment system for German hospitals. In 2002 the values for most DRG's were published for the german system (G-DRG). The polytrauma working group of the German Trauma Society developed a calculating algorithm to estimate the comprehensive hospital costs for every patient in the German trauma registry. The aim of this study was to compare these costs with the reimbursement according the the G-DRG's for a standardized population of polytrauma patients. MATERIAL AND METHODS For polytrauma patients treated at Hannover Medical School in 2000 and 2001 the reimbursement according to the G-DRG's was calculated using a base value of 2900 euro. In the same patients the total cost of inpatient treatment was calculated according to the algorithm developed by the polytrauma working group of the German Trauma Society. The difference between these values represents the economic result. This was calculated as an overall result, but also for specific subgroups of patients (injury severity, mortality, G-DRG grouping). RESULTS Datasets of 103 polytrauma patients were included. The following G-DRG's were most frequently occuring: A06Z (n=41), A07Z (n=16), W01Z (n=13). All other G-DRG's were documented less than 3 times. The mean reimbursement according to the G-DRG was 21.380+/-12.300 euro for a polytrauma patient. However, the mean hospital cost accounted to 34.274+/-22.501 euro, which resulted in a mean deficit of 12.893+/-15.534 euro. Analysis of subgroups revealed, that an ISS of more than 35 points, patients with a prolonged hospital stay and patients of the G-DRG group A06Z show a particularly negative result. CONCLUSION The comprehensive hospital costs for treating polytrauma patients are on average 12.893 euro higher than the reimbursement according the G-DRG's. For hospitals to be fully reimbursed G-DRG values have to be reconfigured according to the German health care system. Thus, inclusion criteria to specific G-DRG have to be changed and a specific G-DRG group for very severely injured patients needs to be established.
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Affiliation(s)
- M Grotz
- Unfallchirurgische Klinik, MHH, Hannover.
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