[Influence of minimum volumes on the structure of inpatient care]

Impact of suspending minimum volume requirements for knee arthroplasty on hospitals in Germany: an uncontrolled before-after study

Background

In 2004, the Federal Joint Committee, supreme decision-making body in German healthcare, introduced minimum volume requirements (MVRQs) as a quality instrument. Since then, MVRQs were implemented for seven hospital procedures. This study evaluates the effect of a system-wide intermission of MVRQ for total knee arthroplasty (TKA), demanding 50 annual cases per hospital.

Methods

An uncontrolled before–after study based on federal-level data including the number of hospitals performing TKA, and TKA cases from the external hospital quality assurance programme in Germany (2004–2017). Bi- and multivariate analyses based on hospital-level secondary data of TKA cases and TKA quality indicators extracted from hospital quality reports in Germany (2006–2014).

Results

The number of TKAs performed in Germany decreased by 11% after suspending the TKA-MVRQ in 2011, and rose by 13% after its reintroduction in 2015. The number of hospitals with less than 50 cases rose from 10 to 25% and their case share from 2 to 5.5% during suspension. Change in hospital volume after the suspension of TKA-MVRQ was not associated with hospital size, ownership, or region. All four evaluable quality indicators increased significantly in the year after their first public reporting. Compared to hospitals meeting the TKA-MVRQ, three indicators show slight but statistically significant better quality in hospitals below the TKA-MVRQ.

Conclusions

In Germany, TKA-MVRQs seem to induce in-hospital caseload adjustments rather than foster regional inter-hospital case transfers as intended.

Volume-outcome relationship and minimum volume regulations in the German hospital sector - evidence from nationwide administrative hospital data for the years 2005-2007

BACKGROUND

This paper analyses the volume-outcome relationship and the effects of minimum volume regulations in the German hospital sector.

METHODS

We use a full sample of administrative data from the unselected, complete German hospital population for the years 2005 to 2007. We apply regression methods to analyze the association between volume and hospital quality. We measure hospital quality with a binary variable, which indicates whether the patient has died in hospital. Using simulation techniques we examine the impact of the minimum volume regulations on the accessibility of hospital services.

RESULTS

We find a highly significant negative relationship between case volume and mortality for complex interventions at the pancreas and oesophagus as well as for knee replacement. For liver, kidney and stem cell transplantation as well as for CABG we could not find a strong association between volume and quality. Access to hospital care is only moderately affected by minimum volume regulations.

CONCLUSION

The effectiveness of minimum volume regulations depends on the type of intervention. Depending on the type of intervention, quality gains can be expected at the cost of slightly decreased access to care.

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.

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

BACKGROUND

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.

METHOD

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.

RESULTS

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.

CONCLUSION

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.

Implementation and effects of Germany's minimum volume regulations: results of the accompanying research

INTRODUCTION

Since 2004, Germany has had legal minimum volumes for five surgical interventions (kidney, liver, and stem cell transplantations and complex pancreatic and esophageal interventions). In 2006, minimum volumes for total knee replacement were added. On behalf of the Federal Joint Committee we evaluated the implementation of the minimum volumes and their effects on health service structure, hospitals, and outcome quality.

METHODS

We analyzed hospital surveys and secondary data from quality reports for 2004, the Institute for the Hospital Remuneration System, and the Federal Agency for Quality Assurance.

RESULTS

In 2006, the minimum volume regulations affected about half of all acute-care hospitals and about 146 000 hospital cases. Depending on the intervention, 10% to 60% of the hospitals with 1% to 31% of the patients performed the procedures yet failed to attain the minimum volumes. The number of hospitals providing the services did not change between 2004 and 2006, so nationwide coverage remained virtually unchanged. Regarding outcomes, only data for total knee replacement were available. One of three analyzed indicators of outcome, wound infections, showed the introduction of the minimum volumes to be associated with better results for higher numbers of cases.

DISCUSSION

To date, the minimum volumes have affected health care only marginally. Further monitoring of the effects of the minimum volumes requires prospective definition of essential indicators of outcome and access.