[Orthopedic and trauma surgery in the German DRG System 2007]

Safety, Effect and Feasibility of Percutaneous SI-Screw with and without Augmentation-A 15-Year Retrospective Analysis on over 640 Screws

BACKGROUND

Minimally invasive sacroiliac-screw (SI-screw) fixation of the pelvis is used in energy trauma (Arbeitsgemeinschaft für Osteosynthesefragen (AO) classified) and fragility fractures (Fragility Fracture of the Pelvis (FFP) classified). However, available clinical data are based on small case series and biomechanical data seem to be contradictory.

METHODS

The present single center retrospective cohort study investigated percutaneous SI-screw fixation and augmentation over 15 years. Groups were compared concerning the general epidemiological data, mobilization, complication rates, duration of stay, and safety of SI-screw insertion. Multivariable analyses were performed using logistic regression.

RESULTS

Between 2005 and March 2020, 448 patients with 642 inserted SI-screws were identified. Iatrogenic neurological impairment was documented in 2.47% and correlated with screw misplacement. There was an increased complication risk in patients with AO type C over patients with AO type B and in FFP II over FFP III/IV patients. Cement-augmented FFP patients showed a 25% reduced stay in hospital and a reduced complication risk. Cement-associated complications were seen in 22% without correlation to neurologic impairment.

CONCLUSIONS

The present study confirms the safety and usability of percutaneous SI-screw fixation, despite specific risks. Cement augmentation seems to reduce the complication risk in FFP patients and shorten hospital stay for some reasons, without increased specific complications or correlated neurological impairment.

[Economic impact of infected total hip arthroplasty in the German diagnosis-related groups system]

BACKGROUND

The treatment of an infected total hip arthroplasty is becoming an increasing economic problem. The additional costs of treatment are insufficiently represented in the diagnosis-related groups (DRG) categories. The aim of this study was to clarify whether the costs can be covered under the German DRG system and to identify the extent of the surplus or negative balance.

PATIENTS AND METHODS

A retrospective analysis of the treatment costs of total hip arthroplasty was carried out. Data from all patients treated at the orthopedic clinic of the University Hospital in Rostock were collected from patient records and from the hospital information system and calculation of the personnel and material costs using data from the central pharmacy and control centre of the University of Rostock.

RESULTS

In this study a total of 49 patients were included. The average treatment costs were 29,331.36 EUR per patient for an infected and 6,263.59 EUR for a primarily non-infected total hip arthroplasty. A comparison between the calculated and compensated costs resulted in an average deficit of 12,685.60 EUR per patient and an average surplus of 781.41 EUR per patient in the control group.

CONCLUSIONS

An economically viable treatment of infected total hip arthroplasty was not possible mostly due to the increased personnel and material costs but also to the lack of inclusion of the procedures in the DRG system. Further multicenter cost analysis studies and extensive quality assurance measures are necessary with respect to a comprehensive medical standard for a medically meaningful and economically reasonable treatment of periprosthetic infections.

Economic impact of infected total knee arthroplasty

Background. An enormous economic impact can be observed for infected total knee arthroplasties (TKA). The aim of the present study was to evaluate whether a cost covering treatment of infected TKA is feasible in the German DRG System. Patients and Methods. Average total treatment costs were evaluated for infected TKA and compared with a matched pair of primary TKA. Data was generated using the health record and the hospitals' health information system. Results were evaluated and compared regarding the total personnel and material costs with respect to the financial receipts. Results. A total of 28 patients diagnosed with an infected TKA were included. A significant increase in the average length of stay, use of medical supplies and third party medical examinations were found for the infected TKA. An average deficiency of 6,356€ per patient was observed for the infected TKA. An average profit of 927€ per patient was made performing primary TKA. Conclusions. A cost-effective treatment of infected TKA was not feasible with the receipts from the German DRG System. An adaption of the receipts has to be evaluated. Moreover, other measures have to be considered in order to achieve a comprehensive medical yet financial reasonable standard in the treatment of infected TKA and THA.

[The economic challenges of polytrauma care]

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.

[Orthopedic and trauma surgery in the German DRG system 2008]

BACKGROUND

The German DRG (diagnosis-related groups) system has been modified and updated into version 2008. For orthopedic and trauma surgery significant changes concerning coding of diagnoses, medical procedures and the DRG structure were made. The modified version has been analyzed in order to ascertain whether the DRG system is suitably qualified to fulfill the demands of the reimbursement system or whether further improvements are necessary.

METHODS

Analysis of the severity of relevant side-effect diagnoses, medical procedures and G-DRGs in the versions 2007 and 2008 was carried out based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI).

RESULTS

Changes for 2008 focused on the development of DRG structure, DRG validation and codes for medical procedures. The outcome of these changes for German hospitals may vary depending on the range of activities.

CONCLUSIONS

G-DRG system has become even more complex and the new regulations have also resulted in new problems associated with complications.. High demands are made on correct and complete coding of complex orthopedic and trauma surgery cases. Quality of case allocation within the G-DRG system has been improved. Nevertheless, further improvements of the G-DRG system are necessary, especially for cases with severe injuries.

[Hand surgery in the German DRG System 2007]

BACKGROUND

Hand surgery often needs only a short length of stay in hospital. Patients' comorbidity is low. Many hand surgery procedures do not need inpatient structures. Up until 2006 special procedures of hand surgery could not be coded. The DRG structure did not separate very complex and less complex operations. Specialized hospitals needed a proper case allocation of their patients within the G-DRG system.

RESULTS

The DRG structure concerning hand surgery increased in version 2007 of the G-DRG system. The main parameter of DRG splitting is the complexity of the operation. Furthermore additional criteria such as more than one significant OR procedure, the patients' age, or special diagnoses influence case allocation. A special OPS code for complex cases treated with hand surgery was implemented.

CONCLUSION

The changes in the DRG structure and the implementation of the new OPS code for complex cases establish a strong basis for the identification of different patient costs. Different case allocation leads to different economic impacts on departments of hand surgery. Whether the new OPS code becomes a DRG splitting parameter has to be calculated by the German DRG Institute for further DRG versions.