[Structure of hospital care for COVID-19 patients up to July 2020 in Germany]. / Stationäre und intensivmedizinische Versorgungsstrukturen von COVID-19-Patienten bis Juli 2020.

BACKGROUND: Hospitalized coronavirus disease 2019 (COVID-19) patients have a high morbidity and mortality and are often dependent on intensive care, especially mechanical ventilation. Little is as yet known about COVID-19 patient allocation. OBJECTIVES: Analysis of the structures of German hospital care for COVID-19 patients up to July 2020 in terms of number of beds and previous ventilation experience. DATA AND METHODS: For the analysis of the care structures, only completed COVID-19 cases in which the virus was detected by a PCR test were evaluated. Claims data from the German Local Health Care Funds (Allgemeine Ortskrankenkassen, AOK) were analysed. The sample includes 17,094 COVID-19 cases that were treated in 1082 hospitals. RESULTS: A total of 77% of all hospitals participated in the treatment COVID-19 patients and 48% of all hospitals provided intensive care for these patients. One half of the hospitals that treated COVID-19 cases cared for 88% of all cases. Although this suggests a centralization effect of COVID-19 cases in specific hospitals, the remaining 12% of the cases were distributed among many hospitals with often very small numbers of cases. Furthermore, 23% of the ventilated COVID-19 cases were treated in hospitals with below-average ventilation experience. CONCLUSIONS: In the context of increasing numbers of infections, it is both necessary to improve the allocation of hospitalized, and therefore potentially ventilated, COVID-19 cases by means of clearly defined and centrally controlled pyramid-type concepts and to continue to care for patients without COVID-19. For Germany, a comprehensive pyramid-type concept with a greater concentration in the best-qualified hospitals seems reasonable for the care of these patients with complex diseases.

[The S2k guideline: Indications for knee endoprosthesis : Evidence and consent-based indications for total knee arthroplasty]. / S2k-Leitlinie: Indikation Knieendoprothese : Evidenz- und konsensbasierte Indikationsstellung in der Knie-Endoprothetik (EKIT-Knie).

Total knee arthroplasty (TKA) is one of the most frequent surgical procedures in orthopaedic surgery. Until now there have not been any standardized indication criteria, which might contribute to the large geographical differences in the frequency of TKA. This guideline aims to consent minimal requirements (main criteria), additional important aspects (minor criteria), as well as relative and absolute contraindications for TKA. The following main criteria have been consented: knee pain, radiological confirmation of osteoarthritis or osteonecrosis, inadequate response to conservative treatment, adverse impact of knee disease on the patient's quality of life and the burden of suffering due to the knee disease. Relative contraindications have been consented as severe general disease with reduced life expectancy and a BMI ≥40; absolute contraindications are an active infection and if the patient is not able to undergo major surgery.

[Influence of surgeon experience in total hip arthroplasty. Dependence on operating time and complication risk]. / Einfluss der Erfahrung des Operateurs in der Hüftendoprothetik. Abhängigkeit von Operationsdauer und Komplikationsrisiko.

BACKGROUND: As a consequence of limited personnel and financial resources, the increase in total hip arthroplasties places higher demands on orthopedic surgeons. OBJECTIVES: In order to maintain high quality treatment, the correlation between surgical experience, duration of surgery and risk of complications was examined. MATERIAL AND METHODS: The surgery time and, if applicable, complications (until discharge from hospital) of 1129 total hip arthroplasties over a period of 4 years were evaluated retrospectively. RESULTS: The group of most experienced surgeons needed an average time of 53.2 ± 17.6 min for each implantation, followed by moderately experienced surgeons (74.5 ± 25.5 min) and less experienced surgeons (80.8 ± 21.9 min). Of all included cases, a total of 41 complications until discharge from hospital occurred. The number of complications increased with duration of surgery, whereby the risk of complications was significantly lower for shorter surgery times conducted by the most experienced surgeons as well as moderately experienced surgeons. The complication risk of less experienced surgeons remained constant independent of surgery duration. CONCLUSION: These results underline the recommendations of the German Endocert system, which determine a minimum number of total joint arthroplasties as a quality indicator not only for hospitals but also for individual surgeons.

[Conservative and operative treatment of working age patients with gonarthritis. Economic considerations]. / Konservative und operative Behandlung von Gonarthrosepatienten im Erwerbsalter. Ökonomische Betrachtung.

BACKGROUND: The development of the overall achievements for hospital performance since the introduction in Germany of the diagnosis-related groups (DRG) system in 2003 is the subject of healthcare political discussion. The field of prosthetics is often at the center of considerations. PROBLEM: After consideration of the development of achievements with international and regional earnings, the question was investigated how the average expenditure for patients with gonarthritis developed in a time period of 1 year before and after implantation of total knee prostheses. MATERIAL AND METHODS: The study was based on individual patient data from the accounting data of the AOK (General Regional Healthcare Insurance) from the categories, inpatient care, panel physician treatment, pharmaceuticals and medicines as well as disability leave periods. The data include the average expenditure and disability times calculated by the AOK for individual patients 12 months before and 12 months after implantation of a total knee prosthesis. The methods were selected because the international classification of diseases (ICD) coding does not allow a differentiation in the degree of severity and, therefore, a comparison of patients who were only conservatively treated within the scope of panel physicians which would have led to problems in risk adjustment. Due to a lack of coding guidelines for treatment by panel physicians, the accuracy of the diagnosis is also limited in comparison to inpatient treatment data. RESULTS: The expenditure and the average disability leave for gonarthritis patients were higher in the year following implantation of total knee prostheses than in the year prior to implantation. DISCUSSION: No conclusions can be drawn from the provision of service data with respect to the quality of life of the patients. Investigations over a longer time period seem to be necessary.

[Re-evaluation of the AOK hospital navigator with a focus on total knee replacement]. / Re-Evaluation des Krankenhausnavigators der AOK für das "QSR-Verfahren" unter besonderer Berücksichtigung des Themenschwerpunkts Knieendoprothetik.

BACKGROUND: One of the biggest health insurance companies in Germany (AOK, Allgemeine Ortskrankenkasse) has published new results focussing on process quality of total knee replacement in 2010. These results were published in the online portal "Weiße Liste", which is based on health insurance routine data. The German Association of Orthopeadic Surgery questions the credibility of the rating system of the "Weiße Liste". To prove the system an interdisciplinary task force was created. MATERIAL AND METHODS: The task force identified patient-specific parameters, which influence the outcome of total knee replacement based on the literature and expert opinions. Out of 907 orthopaedic departments, 4 above average and four below average were identified. The AOK was asked to provide 80 data sets for each department. These anonymised data sets could be converted into patient-specific data sets in the identified departments. Statistical analysis was performed to answer the question of whether there are differences between the below and the above average groups. RESULTS: 625 cases could be investigated. We found an increased rate of postoperative complications in the below average group. There are differences between both groups in terms of factors influencing the procedure. In the below average group an increased rate of patients with one or more comorbidities and a preoperative extension lag of over 10° was found. The above average group has a higher rate of operations before the knee replacement. CONCLUSION: The results need to be proven on a larger scale. Further, prospective investigations are planned.

[Complication rates and secondary interventions after coronary procedures in clinical routine: 1-year follow-up based on routine data of a German health insurance company]. / Komplikationen und Folgeeingriffe nach koronaren Prozeduren in der klinischen Routine.

BACKGROUND: Data on 1-year complication and follow-up intervention rates after coronary angiography (CA) and percutaneous coronary intervention (PCI) in German clinical routine are sparse. This analysis aims to determine these rates. METHODS: The analysis uses 2009 AOK claims data. Patients were divided into 3 groups (CA, without cardiac surgery and without acute myocardial infarction (AMI) n=116.071; PCI with stenting, without AMI: n=36.685; PCI with stenting and with AMI: n=32.707). The frequency of the endpoints MACCE (mortality, AMI, stroke, TIA), CABG, PCI and CA was recorded for up to one year. RESULTS: 1-year MACCE rates were 8.1 % (CA), 9.9 % (PCI without AMI) and 17.9 % (PCI with AMI). Quality-relevant follow-up intervention rates in the CA group were 2.5 % for CABG (after 31-365 days), 1.7 % for PCI within 90 days and 3.5 % for follow-up CA within 1 year. In the PCI groups, the frequencies were 1.6 % (without AMI) and 2.7 % (with AMI) for CABG (after 31-365 days), and 10.2 % (without AMI) and 10.1 % (with AMI) for PCI after 91-365 days. CONCLUSION: This is the first cross-sectoral routine analysis of cardiac catheters and sequential events up to one year in Germany. The actual medical care situation revealed information particularly with regard to the second and follow-up inventions, which cannot be derived directly from medical guidelines. Beyond clinical trials, knowledge can be gained which is important both for medicine as well as the politics of health services.

Trends and geographical variation of primary hip and knee joint replacement in Germany.

OBJECTIVE: Considerable variation in total hip replacement and total knee replacement (THR/TKR) between regions has been described. The aim of this study was to explore geographical variation in THR and TKR in Germany and to analyse potentially explanatory variables. METHOD: We used data of Germany's largest statutory health insurer. Between 2005 and 2009 451,108 THR and 335,022 TKR were performed. Age-standardised joint replacement rates were calculated for 16 federal states and 407 counties. We performed cluster (Moran's I) and spatial error regression analyses including regional deprivation, osteoarthritis rate, urbanity and number of orthopaedic specialists as dependent variables on county level. RESULTS: In 2009 the overall age-standardised and crude rates were 148.9 (95% CI (confidence interval) 147.6-151.1) and 290.2 for THR, and 132.5 (95% CI 131.3-133.6) and 232.7 for TKR. Between counties THR rates differed by factor 2 (106.1-215.8) and showed significant clusters with high utilisation in South and Northwest Germany. TKR rates differed by factor 3.2 (69.1-219.5) and were also high in South Germany whereas almost all areas in East Germany showed low replacement rates. Differences were pronounced when restricting the analysis to cases with an indication of osteoarthritis. All tested predictors could be identified as significant explanatory variables (each P < 0.001). CONCLUSION: This study proofed considerable and consistent geographic variation of THR and TKR in Germany. Thereby relevant explanatory factors were identified. These results may foster the discussion and future research in health services which should include areas of patients' and doctors' expectation, financial aspects and an outcome-based definition of appropriate supply.