[Cases and duration of mechanical ventilation in German hospitals : An analysis of DRG incentives and developments in respiratory medicine]

BACKGROUND

Diagnosis-related groups (DRGs) have been used to reimburse hospitals services in Germany since 2003/04. Like any other reimbursement system, DRGs offer specific incentives for hospitals that may lead to unintended consequences for patients. In the German context, specific procedures and their documentation are suspected to be primarily performed to increase hospital revenues. Mechanical ventilation of patients and particularly the duration of ventilation, which is an important variable for the DRG-classification, are often discussed to be among these procedures.

OBJECTIVES

The aim of this study was to examine incentives created by the German DRG-based payment system with regard to mechanical ventilation and to identify factors that explain the considerable increase of mechanically ventilated patients in recent years. Moreover, the assumption that hospitals perform mechanical ventilation in order to gain economic benefits was examined.

MATERIAL AND METHODS

In order to gain insights on the development of the number of mechanically ventilated patients, patient-level data provided by the German Federal Statistical Office and the German Institute for the Hospital Remuneration System were analyzed. The type of performed ventilation, the total number of ventilation hours, the age distribution, mortality and the DRG distribution for mechanical ventilation were calculated, using methods of descriptive and inferential statistics. Furthermore, changes in DRG-definitions and changes in respiratory medicine were compared for the years 2005-2012.

RESULTS

Since the introduction of the DRG-based payment system in Germany, the hours of ventilation and the number of mechanically ventilated patients have substantially increased, while mortality has decreased. During the same period there has been a switch to less invasive ventilation methods. The age distribution has shifted to higher age-groups. A ventilation duration determined by DRG definitions could not be found.

CONCLUSION

Due to advances in respiratory medicine, new ventilation methods have been introduced that are less prone to complications. This development has simultaneously improved survival rates. There was no evidence supporting the assumption that the duration of mechanical ventilation is influenced by the time intervals relevant for DRG grouping. However, presumably operational routines such as staff availability within early and late shifts of the hospital have a significant impact on the termination of mechanical ventilation.

Ultrastructure of reticulum cells in the bone marrow

In this study the attempt was made to classify the reticulum cells of the bone marrow on the basis of electron-microscopic findings. The basis of the differentiation was the ability of the cells to phagocytize substances or not. For two cell types the intracytoplasmic filaments were used as distinctive marks. The following classification resulted: (a) phagocytic reticulum cells, (b) undifferentiated reticulum cells, (c) fibrous reticulum cells of type I, which contain filaments of 4-8 nm diameter and are located near the blood sinus of the bone marrow, (d) fibrous reticulum cells of type II, which contain intracytoplasmic filaments of 10 nm diameter; since these cells contain neutral fat bodies, the possibility of a reversible conversion to fat cells has to be assumed and (e) fibroblasts, cells which synthesize the substance of the extracellular space. A connection of reticulum cells to haematopoietic functions or to stem cell functions could be found.

[Ultrastructure of erythroid cells in a case of congenital dyserythropoietic anaemia type II (author's transl)]

The ultrastructure of erythroblasts in a case of congenital dyserythropoietic anaemia type II with a negative serum-lysis test is described. The well known symptoms in electronmicroscopy in CDA type I and II are faced to our findings. Morphological changes of hypolemmal cisterns are described and their possible meaning is discussed.

PHA and endotoxin stimulation of human lymphocytes separated by albumin density gradient centrifugation

Venous blood from eight healthy subjects was divided into four fractions on a discontinuous albumin density gradient. The percentage recovery of lymphocytes was 82.3%; the purity of the lymphocyte fractions was 83.6%. The lymphocytes were cultured with PHA and Endotoxin, and the samples were analysed after 24, 48, and 72 hours. After PHA stimulation immunoblasts appeared up to 59.3% in the cultures from the 19-21% albumin fraction. After Endotoxin stimulation the maximum (75.8%) was reached in the heavy (25-27% albumin) fraction. Thus, it is concluded that the lymphocytes which can be stimulated with both the mitogens have different densities, the PHA-stimulable T lymphocytes being ligther than the Endotoxin-stimulable B lymphocytes. It is also concluded that as a mitogen Endotoxin is equal to PHA.