[Reimbursement of intensive care services in the German DRG system : Current problems and possible solutions]

Does the disclosure of medical insurance information affect patients' willingness to adopt the diagnosis related groups system

Introduction

Medical insurance information disclosure is not only a direct way for the public to understand and master social insurance information and resource use benefits, but also an important way for the public to participate in medical service governance and supervision. Some studies have shown that information disclosure can significantly reduce the risk perception of user groups, strengthen their trust and reduce the negative impact of information asymmetry.

Methods

Based on risk perception and trust perception theories, this paper focuses on the mechanisms influencing patients' attitudes in the process of implementing a Diagnosis Related Groups payment system. Using medical insurance information disclosure from a governance perspective as the research object, the impact of medical insurance information disclosure on patients' willingness to adopt the Diagnosis Related Groups payment system was analyzed by means of a questionnaire survey, Data analysis and hypothesis testing via SPSS while the mechanism of the impact of medical insurance information disclosure on patients' attitudes was explored in depth.

Results

It was found that medical insurance information disclosure had a significant positive effect on patients' trust perceptions and a significant negative effect on patients' risk perceptions. The more comprehensive information patients received, the stronger their trust and the lower their perceived risk.

Discussion

This paper conducts an empirical study from patients' perspective, broadens the scope of research on medical insurance Diagnosis related groups, enriches the application of risk perception and trust perception theories in the medical field, and provides management suggestions for medical institutions in the management of medical insurance information disclosure.

Einfluss der Arbeitsbedingungen und des Gehalts auf die Leiharbeit für Intermediate-Care- und Intensivstationen

Hintergrund

Leiharbeit in der Pflege wird als Arbeitsform verwendet, um offenen Personalstellen in Kliniken zu begegnen. Sowohl Krankenhausträger als auch Pflegekräfte sehen dies aus unterschiedlichen Gründen kritisch.

Ziel

Zweck dieser Untersuchung war es herauszufinden, welches persönliche Nettoeinkommen Pflegekräfte von deutschen Intensivstationen und Intermediate-Care-Stationen als „gerecht und ausreichend“ für ihre Tätigkeit empfinden und welchen Einfluss das Gehalt auf die Wechselwilligkeit in die Leih‑/Zeitarbeit bzw. wieder zurück in eine Festanstellung haben.

Methode

Von September bis Oktober 2020 wurde eine anonymisierte Onlineumfrage unter Pflegenden von Intermediate-Care-Stationen, Intensivstationen und Funktionsbereichen im deutschsprachigen Raum durchgeführt. Die Auswertung erfolgte mittels deskriptiver Statistik.

Ergebnis

Von 1203 Teilnehmer_innen (TN) konnten 1036 (86 %) in Deutschland Arbeitende ausgewertet werden. Die Frage nach dem persönlichen Nettoeinkommen wurde von 1032 (99 %) TN beantwortet. Der überwiegende Anteil der Befragten (n = 522) gibt an, über ein persönliches Nettoeinkommen von 2000–2999 €/Monat zu verfügen. Der Wunsch, in die Leiharbeit zu gehen, ist in der untersuchten Stichprobe geringer, je höher das persönliche Nettoeinkommen ist. Die TN in Festanstellung ohne Nebenerwerb empfinden ein persönliches Nettoeinkommen von 3200 €/Monat (Median 3200 €; IQR 2800–3800 €) als ausreichend und gerecht für ihre Tätigkeit. Von den Leiharbeiter_innen gaben 142 Personen an, dass ein persönliches Nettoeinkommen von 3200 €/Monat (Median 3200 €; Interquartilsabstand 3000–3950 €) ausreichend wäre, um von der Leiharbeit zurück in eine Festanstellung zu wechseln.

Schlussfolgerung

Die Intensivpflegenden dieser Umfrage empfinden ein Gehalt von 3200 €/Monat netto als ausreichend und gerecht für ihre Tätigkeit. Die Gehaltshöhe kann ein Parameter für die Entscheidung sein, in die Leiharbeit zu gehen, aber auch um wieder in die Festanstellung zu wechseln. Unabhängig vom Gehalt wurden bessere Arbeitsbedingungen für alle befragten Gruppen als essenzieller Bestandteil in Bezug auf die Arbeitszufriedenheit angegeben.

Hospitalisation costs and health related quality of life in delirious patients: a scoping review

INTRODUCTION

Delirium is a common condition of a global disturbance of cognition, triggered by underlying diseases. The objective of this study is to review the current evidence in the literature on direct healthcare costs and health-related quality of life (HRQOL) associated with delirium.

METHODS

A systematic search was conducted in PubMed and Embase for relevant studies published between January 1, 2010 and November 4, 2021. Studies for inclusion reported estimates on healthcare costs or HRQOL, adjusted for relevant confounding factors.

RESULTS

Fourteen studies on healthcare costs and eleven studies on HRQOL were included. Delirium resulted in (adjusted) increased costs ranging from $1,532 to $22,269 depending on included cost categories, the country and the type of hospital department. Increased length of stay for delirious patients ranged from 2.5 days to 10.4 days and had the largest contribution to overall, direct incremental costs. Heterogeneity was observed in HRQOL outcomes.

CONCLUSION

The analysis indicates that the presence of a delirium episode may lead to increased costs of hospitalisation. Changes in HRQOL due to delirium are not well demonstrated and more research is needed to determine the effect of delirium on HRQOL.

Does adherence to a quality indicator regarding early weaning from invasive ventilation improve economic outcome? A single-centre retrospective study

OBJECTIVES

To measure and assess the economic impact of adherence to a single quality indicator (QI) regarding weaning from invasive ventilation.

DESIGN

Retrospective observational single-centre study, based on electronic medical and administrative records.

SETTING

Intensive care unit (ICU) of a German university hospital, reference centre for acute respiratory distress syndrome.

PARTICIPANTS

Records of 3063 consecutive mechanically ventilated patients admitted to the ICU between 2012 and 2017 were extracted, of whom 583 were eligible adults for further analysis. Patients' weaning protocols were evaluated for daily adherence to quality standards until ICU discharge. Patients with <65% compliance were assigned to the low adherence group (LAG), patients with ≥65% to the high adherence group (HAG).

PRIMARY AND SECONDARY OUTCOME MEASURES

Economic healthcare costs, clinical outcomes and patients' characteristics.

RESULTS

The LAG consisted of 378 patients with a median negative economic results of -€3969, HAG of 205 (-€1030), respectively (p<0.001). Median duration of ventilation was 476 (248; 769) hours in the LAG and 389 (247; 608) hours in the HAG (p<0.001). Length of stay (LOS) in the LAG on ICU was 21 (12; 35) days and 16 (11; 25) days in the HAG (p<0.001). LOS in the hospital was 36 (22; 61) days in the LAG, and within the HAG, respectively, 26 (18; 48) days (p=0.001).

CONCLUSIONS

High adherence to this single QI is associated with better clinical outcome and improved economic returns. Therefore, the results support the adherence to QI. However, the examined QI does not influence economic outcome as the decisive factor.

Structure and concept of ICU rounds: the VIS-ITS survey

Objective

To gather data about structural and procedural characteristics of patient rounds in the intensive care unit (ICU) setting.

Design

A structured online survey was offered to members of two German intensive care medicine societies.

Measurements and main results

Intensivists representing 390 German ICUs participated in this study (university hospitals 25%, tertiary hospitals 23%, secondary hospitals 36%, primary hospitals 16%). In 90% of participating ICUs, rounds were reported to take place in the morning and cover an average of 12 intensive care beds and 6 intermediate care beds within 60 min. With an estimated bed occupancy of 80%, this averaged to 4.3 min spent per patient during rounds. In 96% of ICUs, rounds were stated to include a bedside visit. On weekdays, 86% of the respondents reported holding a second ICU round with the attendance of a qualified decision-maker (e.g. board-certified intensivist). On weekends, 79% of the ICUs performed at least one round with a decision-maker per day. In 18%, only one ICU round per weekend was reported, mostly on Sundays. The highest-qualified decision-maker present during rounds on most ICUs was an ICU attending (57%). Residents (96%) and intensive care nurses (87%) were stated to be always or usually present during rounds. In contrast, physiotherapists, respiratory therapists or medical specialists such as pharmacists or microbiologist were not regular members of the rounding team on most ICUs. In the majority of cases, the participants reported examining the medical chart directly before or during the bedside visit (84%). An electronic patient data management system (PDMS) was available on 31% of ICUs. Daily goals were always (55%) or usually (39%) set during rounds.

Conclusion

This survey gives a broad overview of the structure and processes of ICU rounds in different sized hospitals in Germany. Compared to other mostly Anglo-American studies, German ICU rounds appear to be shorter and less interdisciplinary.

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

BACKGROUND

The systematic analysis of disease-specific costs is becoming increasingly more relevant in an economically oriented healthcare system. Chronic diseases are of particular interest due to the long duration as well as frequent hospitalization and physician visits. Epilepsy is a frequent neurological disorder affecting all age groups with the clinical hallmark of paroxysmal epileptic seizures, which are often associated with injuries.

OBJECTIVE

The aim of this work was to process the inpatient treatment costs due to seizure-related injuries and fractures. Moreover, relevant cost-causing factors were addressed. Using an alternative calculation of the costs of care, the question of potential reimbursement problems in the current German diagnosis-related groups (G-DRG) system was additionally assessed.

METHODS

For this monocentric retrospective analysis the actual proceeds of 62 inpatients who were treated at the University Hospital Frankfurt between January 2010 and January 2018 for injuries and fractures due to epileptic seizures were used. The analysis of potential cost-causing factors was carried out with respect to relevant sociodemographic and clinical aspects. The alternative calculation of the costs of treatment was carried out using established health economic methods.

RESULTS

The average DRG revenue was 7408€ (±8993€, median 5086€, range 563-44,519€), the average calculated costs were 9423€ (±11,113€, 5626€, range 587-49,830€). A length of stay ≥7 days (p = 0.014) was identified as a significant cost-driving factor. Due to the significant difference (p < 0.001) between revenue and calculated costs, an analysis was made according to factors for potential reimbursement problems, which remained significant for a length of stay of ≥7 days (p = 0.014) and for treatment in the intensive care unit (p = 0.019).

CONCLUSION

The inpatient treatment costs for patients with injuries and fractures due to epileptic seizures are high and therefore relevant from a health economic perspective. In general, reimbursement according to the G‑DRG appears to cover the actual costs, but there may be reimbursement problems for patients with a long period of hospitalization or a stay in an intensive care ward.

[Overtreatment in intensive care medicine-recognition, designation, and avoidance : Position paper of the Ethics Section of the DIVI and the Ethics section of the DGIIN]

Ungeachtet der sozialgesetzlichen Vorgaben existieren im deutschen Gesundheitssystem in der Patientenversorgung nebeneinander Unter‑, Fehl- und Überversorgung. Überversorgung bezeichnet diagnostische und therapeutische Maßnahmen, die nicht angemessen sind, da sie die Lebensdauer oder Lebensqualität der Patienten nicht verbessern, mehr Schaden als Nutzen verursachen und/oder von den Patienten nicht gewollt werden. Daraus können hohe Belastungen für die Patienten, deren Familien, die Behandlungsteams und die Gesellschaft resultieren. Dieses Positionspapier erläutert Ursachen von Überversorgung in der Intensivmedizin und gibt differenzierte Empfehlungen zu ihrer Erkennung und Vermeidung. Zur Erkennung und Vermeidung von Überversorgung in der Intensivmedizin erfordert es Maßnahmen auf der Mikro‑, Meso- und Makroebene, insbesondere die folgenden: 1) regelmäßige Evaluierung des Therapieziels im Behandlungsteam unter Berücksichtigung des Patientenwillens und unter Begleitung von Patienten und Angehörigen; 2) Förderung einer patientenzentrierten Unternehmenskultur im Krankenhaus mit Vorrang einer qualitativ hochwertigen Patientenversorgung; 3) Minimierung von Fehlanreizen im Krankenhausfinanzierungssystem gestützt auf die notwendige Reformierung des fallpauschalbasierten Vergütungssystems; 4) Stärkung der interdisziplinären/interprofessionellen Zusammenarbeit in Aus‑, Fort- und Weiterbildung; 5) Initiierung und Begleitung eines gesellschaftlichen Diskurses zur Überversorgung.

The future development of intensive care quality indicators - a methods paper

Introduction: Medical quality indicators (QI) are important tools in the evaluation of medical quality. Their development is subject to specific methodological requirements, which include practical applicability. This is especially true for intensive care medicine with its complex processes and their interactions. This methods paper presents the status quo and shows necessary methodological developments for intensive care QI. For this purpose, a cooperation with the Association of the Scientific Medical Societies' Institute for Medical Knowledge Management (AWMF-IMWi) was established. Methodology: Review of published German manuals for QI development from guidelines and narrative review of quality indicators with a focus on evidence and consensus-based guideline recommendations. Future methodological adaptations of indicator development for improved operationalization, measurability and pilot testing are presented, and a development process is proposed. Results: The development of intensive care quality indicators in Germany is based on an established process. In the future, additional evaluation criteria (QUALIFY criteria) will be applied to assess the evidence base. In addition, a continuous exchange between the national steering committee of the DIVI responsible for QI development and guideline development groups involved in intensive care medicine is planned. Conclusion: Intensive care quality indicators will have to meet improved methodological requirements in the future by means of an improved development process. Future QI development is intended to improve the structure of the development process, with a focus on scientific evidence and a link to guideline projects. This is intended to achieve the goal of a broad application of QI and to further evaluate its relevance for patient outcome and performance of institutions.

[Agency work in intensive care : Impact of temporary contract work on patient care in intermediate care and intensive care units]

Hintergrund

Leiharbeiter werden, meist im Sinne einer Arbeitnehmerüberlassung, zur pflegerischen Versorgung von Intensivpatienten eingesetzt. Ob bzw. wie sich Leiharbeit in der Pflege auf die Patientenversorgung auswirkt, wurde bislang kaum untersucht.

Ziel

Zweck dieser systematischen Übersichtsarbeit ist es, die verfügbaren Forschungsergebnisse über den Einsatz von Leiharbeitern in der pflegerischen Versorgung auf Intensiv- und Überwachungsstationen zu beschreiben und die potenziellen Auswirkungen auf das Patientenoutcome zusammenzufassen.

Methode

Es wurde in sieben Datenbanken mit booleschen Operatoren systematisch nach englisch- und deutschsprachigen Studien recherchiert und in Anlehnung an das PRISMA-Schema ausgewertet. Referenzen der Studien wurden ebenfalls in die Suche inkludiert und die Qualität aller eingeschlossenen Studien nach Hawker-Kriterien bewertet.

Ergebnis

Von insgesamt N = 630 gesichteten Datensätzen konnten jeweils eine qualitative und zwei quantitative Studien identifiziert und in die Auswertung einbezogen werden. Die Ergebnisse der qualitativen Studien gaben nicht signifikant an, dass Leiharbeiter zu einem schlechteren Patientenoutcome beitragen können. Die Ergebnisse der quantitativen Studien zeigten, dass die Wahrscheinlichkeit für das Auftreten von katheterassoziierten Infektionen mit dem Einsatz von Leiharbeitern steigen kann, aber eher von der Stationsgröße anhängig ist: Je zusätzlichem Bett steigt die Wahrscheinlichkeit für eine VAP um 14,8 % (95 %-CI = 1,032–1,277, p = 0,011). Allerdings konnten Tendenzen für einen Rückgang der Sepsisrate, sobald weniger Leiharbeiter (Stunden/Patient) auf der Intensivstation eingesetzt wurden, nicht bestätigt werden.

Schlussfolgerung

In den wenigen auswertbaren Studien wurden keine Hinweise dafür gefunden, dass der Einsatz von Leiharbeitern auf Intensiv- (ITS) und Überwachungsstationen (IMC) einen signifikanten Einfluss auf das Patientenoutcome hat. Es wurden allerdings Hinweise gefunden, dass individuelle Qualifikationen und die Arbeitsbedingungen einen Einfluss auf das Outcome haben. Weitere Studien sollten betrachten, welches Verhältnis von Festangestellten zu Leiharbeitern als unkritisch anzusehen ist, welche Qualifikationen temporäre Mitarbeiter vorweisen sollten und inwieweit diese überprüft werden können.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00063-020-00753-5) enthält die vollständige Suchstrategie je Datenbank. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

[Discussion paper for a hospital financing reform in Germany from the perspective of intensive care medicine]

In Germany, there are currently many voices calling for a reform of hospital planning and reimbursement to correct some aberrations of the last decades and to enable the system to cope with future challenges. Some recent political decisions to change the structures of emergency medical services as well as the introduction of mandatory nurse-to-patient ratios and the exclusion of the cost for nursing from the case-based hospital reimbursement represent first steps of a reform, which also affects intensive care and emergency medicine. In this discussion paper a group of intensivists, emergency physicians, medical controllers, and representatives of nurses suggest more far-reaching changes, which can be summarized in 5 points: (1) General hospitals with intensive care units (ICU) and emergency departments (ED) which are part of the emergency medical system should be considered as an element of public service and be planned accordingly. (2) The planning of the intensive care infrastructure should be based on the three levels of emergency medical services to identify hospitals that are system relevant and to define appropriate criteria for structure and quality measures. (3) Hospital reimbursement should consist of a base amount (covering costs for hospital staff, infrastructure plus investments) and case-based fees (covering material costs). (4) To determine the requirements for nurses, physicians, and other medical staff, adequate tools for ICU and ED should be applied. (5) For these purposes as well as for quality management and optimal medical care, hospitals should be provided with a substantially improved IT-infrastructure.

Hospitalization and Intensive Therapy at the End of Life

BACKGROUND

Germany has more intensive care unit (ICU) beds per capita than the USA, but the utilization of these resources at the end of life is unknown.

METHODS

Retrospective observational study using nationwide German hospital discharge data (DRG statistics; DRG, diag- nosis-related groups) from 2007 to 2015. We investigated hospital deaths and use of intensive care services during terminal hospitalizations. Population-based incidences were standardized to the age and sex distribution of the German population.

RESULTS

Standardized hospital admission rates increased by 0.8% annually (from 201.9 to 214.6 per 1000 population), while hospital admissions involving ICU care increased by 3.0% annually (from 6.5 to 8.2 per 1000 population). Among all deaths in the German population, the proportion of hospital deaths with ICU care increased by 2.3% annually (from 9.8% to 11.8%). Among all hospital deaths, the proportion involving ICU care increased by 2.8% annually from 20.6% (2007) to 25.6% (2015). In patients aged 65 and older, the use of intensive care services during terminal hospitalizations increased 3 times faster than hospital deaths.

CONCLUSION

Use of intensive care services during terminal hospitalizations increased across all age groups, particularly the elderly. The increased need for end-of-life care in the ICU calls for improvements in educational, policy, and reimbursement strategies. It is unclear whether ICU care was appropriate and compliant with patient preferences.

[Impact of nursing staff shortage on intensive care medicine capacity in Germany]

BACKGROUND

Compared to other countries, Germany has the highest number of intensive care unit (ICU) beds, but, despite this, a shortage in ICU care is evident. Currently, little comprehensive data on ICU staffing and on subsequent closure of ICU beds are available. The current survey therefore aimed to systematically investigate the closure of ICU beds.

METHOD

A survey was performed among authorized professional trainers in ICU medicine.

RESULTS

Overall, a shortage of ICU beds following bed closure was evident in 76% of all ICU floors with 22% reporting daily ICU bed closure. In 47%, two ICU beds were not available. Emergency care was unrestricted in only 18%, while restrictions were reportedly frequent or even constant in 30%. The main reasons for ICU bed closure were the unavailability of ICU nurses (44%) and the co-existing unavailability of nurses and physicians (19%). On average, the nurse/patient ratio was 1:2.5 in the morning, 1:2.6 in the afternoon, and 1:3.1 in the night shift.

CONCLUSIONS

ICU bed closure regularly occurs in Germany. The underlying main reason has been identified to be the unavailability of ICU nursing staff. This is suggested to directly interfere with emergency care. For this reason, an action plan is urgently needed.

[Organ assist devices in the future : Limits and perspectives]

In the last decade, extracorporeal organ assist devices (extracorporeal membrane oxygenation [ECMO]) have been increasingly applied to treat the most severe forms of respiratory failure and cardiogenic shock, although the underlying scientific evidence is still limited and the methods carry a high risk of complications despite all technical improvements. The selection of those patients who most benefit from these devices is still a great challenge for intensivists and all other involved disciplines. Besides the severity of the acute organ failure, it is important to thoroughly evaluate etiology and treatment options of the underlying disease, comorbidities, and the functional status of the patients in an interdisciplinary team. This also includes ethical challenges. Because of the complexity of the treatment and the high organizational demands it is reasonable to concentrate ECMO treatments in specifically qualified centers and to promote a comprehensive scientific analysis of the treatment data.

[Reimbursement of intensive care services in Austria : Use of the LKF system]

In Austria, the reimbursement of intensive care services is based on a Diagnosis-Related Groups (DRG) system which has been adapted to the Austrian framework conditions. Compared to Germany where economic considerations had led to personnel cuts, mandatory targets outlined in both the LKF ("Leistungsorientierte Krankenanstaltenfinanzierung", Performance-oriented Hospital Financing) and ÖSG ("Österreichischer Strukturplan Gesundheit", Austrian Health Care Structure Plan) plans ensure a high level of medical and intensive care. A clearly defined minimal nurse-to-bed ratio should ensure adequate care of critically ill patients. However, such a staffing ratio is still lacking for intensive care unit physicians. The following article is meant to outline the fundamental structures of the Austrian intensive care units and provide consideration about further optimization of intensive care medicine provided in Austria to ensure the high level of care in the future.