[How does the German DRG system differentiate and reimburse vitreoretinal surgery in diabetic patients?]. / Wie differenziert und vergütet das G-DRG-System bei vitreoretinalen Eingriffen an Diabetikern?

INTRODUCTION: The German DRG system (G-DRG system) is required to assign medical cases with similar costs correctly into a particular group, each case within the group receiving the same amount of reimbursement. At the same time the system should allow all-inclusive reimbursement, not necessarily reflecting the exact costs of each case. These opposite goals and the so far limited calculation basis raise the question of how the G-DRG system actually processes and reimburses empirically collected in-hospital treatment data. PATIENTS AND METHODS: In 2005, 112 patients were admitted to the University Eye Hospital, University of the Saarland. All patients had diabetic retinopathy and required at least one vitreoretinal procedure. Demographic and clinical data were collected by using the hospital information system and the coding software KODIP. For statistic evaluation, principal diagnoses, ancillary diagnoses and procedures were each reassigned to particular groups. Reimbursement was calculated based on the case data of the year 2005. Also, the case data were reassigned with respect to calculation of reimbursement for the years 2006 and 2007. The results were compared with federal G-DRG calculation data. RESULTS: Mean age of the patients was 65.8 +/- 11.1 years, length of stay in-hospital was 9.3 +/- 3.2 days. In the 66 patients requiring general anaesthesia the cumulative length of stay in the operation room was 148.4 +/- 39.5 minutes, the cumulative duration of surgery was 86.3 +/- 34.1 minutes. In the 50 patients requiring local anaesthesia the cumulative length of stay in the operation room was 137.8 +/- 51.8 minutes, the cumulative duration of surgery was 81.6 +/- 43.6 minutes. The patients had 1.9 +/- 0.8 principal diagnoses, 14.4 +/- 5.8 ancillary diagnoses and 3.4 +/- 1.6 procedures. Twenty-five of 112 patients (22.3 %) were assigned to DRG C 03Z (1), 82 of 112 patients (73.2 %) were assigned to DRG C 17Z (2). Five patients were assigned to other DRG. Compared with the federal calculation data, our own data for 2005, 2006 and 2007 showed more high primary clinical complexity levels and a longer duration of in-hospital stay. For each of the three years the amount of reimbursement was equal in about two thirds of the own patients. Reimbursement was only differentiated for outliers beyond the trim point of the duration of in-hospital stay. CONCLUSIONS: The demographic and clinical G-DRG data of the included patients showed substantial cost-effective inhomogeneities. These inhomogeneities were not sufficiently considered for reimbursement based upon Z-DRG. Specialised departments with higher numbers of difficult cases may be discriminated. Wrong incentives may result in the selection of "low-risk cases".

Interdisciplinary pain therapy: an innovative therapeutic but pre-DRG Economical Center of Medical Excellence.

OBJECTIVE: After the implementation of the G-DRG system in Germany, doubts arose whether and how interdisciplinary pain therapy centers should be restructured to remain profitable and maintain medical excellence for patients with a long ordeal of malaise. METHODS: To reveal structural deficits, we performed a detailed economic analysis of all patients treated at an interdisciplinary pain therapy center of a German University hospital in 2004. RESULTS: 3,672 patients were treated: 2,163 outpatients, 753 at the daycare clinic, 619 as consults and 132 inpatients. The costs for personnel were euro 736,645, consumables euro 105,061, and infrastructure euro 277,762. We calculated fixed costs of euro 236, and consumables of euro 24 per patient. The costs for surgery were euro 1,595, and for a neuroradiological examination euro 245 per patient. Overall treatment costs were euro 319 per patient. We calculated an overall loss of euro 476,752 or euro 109.19 per patient. Outpatients caused a total loss of euro 456,665.83 or euro 211 per patient, consults a total loss of euro 161 683.16 or euro 261.20 per patient, daycare patients a slight profit of euro 30,370 or euro 40 per patient and inpatients a total profit of euro 111,225 or euro 135 per day. CONCLUSION: Managerial optimization can yield considerable cost reductions in the G-DRG coding system, without any change in treatment strategies, selection of profitable patients or dismissal of personnel. Inversely, additional personnel are needed to accomplish the implementation process. Board certification was unveiled to constitute the key structural implementation that ensures the economic survival of the department and continuing medical excellence for the patients.

[New communication platforms in gynecology exemplified by the Professional Group for Information Processing in Gynecology and Obstetrics and the German IVF Registry]. / Neue Kommunikationsplattformen in der Frauenheilkunde am Beispiel der Arbeitsgemeinschaft für Informationsverarbeitung in der Gynäkologie und Geburtshilfe (AIG) und des Deutschen IVF-Registers (DIR).

Main reason for acceptance and distribution of the internet is the possibility to present information in a reasonable and contemporary way. Therefore the internet changed the way of decision making techniques in medicine. Two different information platforms for gynecological and reproductive topics have been created. The German Register for In-Vitro-Fertilization (DIR) collect data for quality assessment in reproductive medicine. The Work Group for Information Technologies in Gynecology and Obstetrics (AIG) will establish methods and new techniques to support treatments and science.

Effects of androgen deprivation prior to radical prostatectomy in 375 patients.

The effects of pharmacotherapeutic complete androgen deprivation treatment for 2 months before radical retropubic prostatectomy (RRP) were investigated in an open study in 375 patients. Prostate volume, tumor staging and prostatespecific antigen (PSA) were investigated as clinical parameters. The RRP specimens were analyzed particularly in terms of tumor cell regressions, pathological tumor staging and grading. Before neoadjuvant therapy (NAT) the 375 patients were classified according to stage: 36 (9.6%) were T1B; 137 (46.1%) were T2, and 166 (44.3%) were T3 stage. After NAT, the clinical investigation (digital rectal examination + transrectal ultrasonography) gave an impression of a T0 stage in 11% of the T2 patients, and a T2 tumor stage in 39% of the T3 patients. The histopathological analysis of the initial T1B and T2 cases did not reveal any tumor in the RRP specimen in 11 (3.8%) cases, a pT2 tumor in 153 (73%) cases, and a pT3 tumor in 48 (23.5%) cases. In the patients initially classified as T3, a tumor was no longer found in 1 (0.6%) case, and a pT2 tumor was found in 48 (29.3%) cases and a pT3 tumor in 113 (67.7%) cases. Under NAT, the prostate volume fell by 34% in T3 tumors and by 24% in T2 tumors. The fall in PSA averaged 85% without significant differences in the individual tumor stages. A statistically significant correlation could not be demonstrated between the fall of PSA and the definitive pathological tumor stage. Tumor cell regressions were found in all preparations. The degree of regression was predominantly RII. These results document the direct effect on tumor cells of an inductive androgen-ablative pharmacotherapy. Regression and volume reduction of the tumor might lead to an improvement of the local surgical control. A final clinical evaluation of NAT will only be possible after long-term analysis of ongoing prospective, randomized studies.

[Endosonography in the assessment of pancreatic tumors. A comparison of the endosonographic findings of carcinomas and segmental inflammatory changes]. / Endosonographie in der Dignitätsbeurteilung von Pankreastumoren. Ein Vergleich endosonographischer Befunde von Karzinomen und segmentalen entzündlichen Veränderungen.

AIM OF STUDY: To examine the value of endoscopic ultrasonography in distinguishing malignant and benign tumours of the pancreas. PATIENTS AND METHODS: Endoscopic ultrasonography (EUS) was performed on 130 consecutive patients (35 women and 95 men; mean age 56.6 [38-71] years), 61 with carcinoma of the pancreas (CP), 69 with segmental inflammatory (pseudotumorous) lesions of the pancreas (SILP). The diagnosis was confirmed by histology in 41 cases of CP, by autopsy in 4, by clinical follow-up (4-56 weeks, mean of 7 months) in 16. It was confirmed histologically in 39 cases of SILP, by clinical follow-up in 30 (12-93 weeks, mean of 12 months). All EUS findings were performed and recorded according to a standardized protocol and subsequently compared. RESULTS: There were no significant differences in EUS findings between CP and SILP. Statistical analysis between the two groups revealed any differential diagnostic relevance only with regard to some individual findings: coarse echo-dense deposits were seen by EUS in 16 of SILP cases (23%), but in only 4 of those with CP (7%), and then only in the face of similar changes in the rest of the organ or if there was additional chronic pancreatitis. Absence of demarcation from the duodenal or gastric wall was recorded in 18 cases of CP (30%), but in only 5 of SILP (7%). Lack of demarcation from the portal vein, splenic vein or coeliac artery was noted in 17 cases of CP (28%) and 6 of SILP (9%). Extension of tumour into vessel lumens was seen only in CP, but even here in only 7 cases (11%). CONCLUSION: Despite the high resolution of EUS it does not provide reliable differentiation of benign and malignant lesions of the pancreas in the individual case.

Multi-dimensional visualisation of laboratory findings and functional test results for analysing the clinical course of disease in medicine.

The illustration of a patient's history by a graphical primitive is discussed. Illustration technology is presented which simultaneously represents quantitative examination findings (e.g., laboratory values) and qualitative findings (e.g., from function diagnostics) by a single geometrical figure. Depending on the medical results, this figure takes on characteristic forms which can be identified as patterns typical for a specific disease. The procedure developed is integrated in a user interface which is implemented in the form of a computerized medical record for use on a pentop computer. This portable computer assists the physician during ward rounds, supplies additional, intelligence-based information, serves quality control, and streamlines working procedures making them more efficient.

Endosonography in chronic pancreatitis--a comparison between endoscopic retrograde pancreatography and endoscopic ultrasonography.

Endoscopic ultrasonography (EUS) and endoscopic retrograde pancreatography (ERP) were prospectively performed in 114 patients, 94 of whom (62 men, mean age 53 years) had inflammatory pancreatic disease, either chronic pancreatitis or status post acute edematous pancreatitis. Twenty patients (14 men, mean age 54 years) who were examined for other reasons and who had a normal ERP served as controls. EUS was performed in most cases with the knowledge of ERP results which had been classified according to the Cambridge classification system of chronic pancreatitis as being grade 0 (normal) or 1-3 (inflammatory changes). Parenchymal and ductal changes on EUS were correlated with the ERP changes. Abnormal EUS features were found in all patients with grade 2 and 3 chronic pancreatitis, in 88% with stage 1, and in 63% of cases with a normal ERP as well. These changes were, however, not detectable in any of the 20 control cases. Among the EUS features of chronic pancreatitis, diffuse changes predominated (stage 1: 75%, 2: 88%, 3: 96%) and consisted mainly of alternating echopoor and echorich areas and of a lobulated parenchymal pattern. In 80% of patients, these findings were combined with an irregular pancreatic margin. Changes of the main pancreatic duct were found in stages 2 and 3 in 81% and 96%, respectively; isolated side branch alterations, as detected mainly in stage 1 chronic pancreatitis on ERP, escaped endosonographic visualization. We conclude that EUS shows inflammatory changes in almost all patients in whom ERP suggests chronic pancreatitis. EUS, however, is also positive in a considerable number of cases with normal ERP but who have a clinical episode of pancreatic inflammation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Endosonography in chronic pancreatitis. A comparative study of endoscopic retrograde pancreatography and endoscopic sonography]. / Endosonographie bei chronischer Pankreatitis. Eine vergleichende Studie zwischen endoskopisch-retrograder Pankreatikographie und endoskopischer Sonographie.

EUS and ERP were performed in 114 patients. 94 patients (32 women, 62 men; mean age 53 years; range 29-78 years) had inflammatory pancreatic disease while 20 patients (6 women, 14 men; mean age 54 years; range 28-78 years) without disease of the pancreas served as controls. ERP-findings served as the gold standard and were classified into stages I-III according to the Cambridge classification. On ERP 51 patients had duct changes typical of chronic pancreatitis (CP). Control cases always displayed a homogeneous echo pattern and a regular outer margin of the pancreas. Abnormal EUS findings were present in all patients with ERP-stages II and III and in 88% of patients with ERP-stage I. 63% of patients with a normal pancreatogram, i.e. ERP-stage 0 showed pathological alterations on EUS examination. Diffuse alterations of the echopattern were seen in 75% of CP patients with stage I, in 88% with stage II and in 96% with stage III. Alternating echo-poor/echo-dense areas were present in 50% of stage I, in 88% of stage II, and in 81% of stage III cases, respectively. 38% of stage I, 56% of stage II, and 27% of stage III cases displayed a lobulated appearance of pancreatic parenchyma. In 80% of the patients these findings were combined with an irregularly lined pancreatic surface. This same combination of EUS-findings in proven CP was also present in 30% of patients with completely normal pancreatic ducts, i.e. ERP-stage 0. Changes of the main pancreatic duct in stages II and III were also seen with EUS in 81% and 96%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Endoscopic implantation of balloon expandable endoprostheses (Strecker stents) in extrahepatic bile duct stenoses]. / Endoskopische Implantation von ballonexpandierbaren Endoprothesen (Strecker-Stents) bei extrahepatischen Gallengangsstenosen.

22 balloon expandable wire Strecker-stents were implanted endoscopically in 20 patients (eleven women, nine men, mean age 68.3 [44 to 86] years) with malignant (n = 19) and benign (n = 1) bile duct obstruction. In all cases an effective biliary drainage was obtained. To achieve complete drainage repeated balloon dilatation of the inserted stent was often performed. In two cases stent dislocation occurred immediately after implantation. Additional complications were not observed during the first 30 days. During the observation period of maximally 15 months one patient developed an incomplete occlusion of the stent due to tumor compression that could be reversed endoscopically. In a further patient biliary stones caused relapse of cholestatic jaundice. Four patients died from their malignant disease without evidence of stent occlusion. 15 patients continue to live without renewed jaundice. With the mean observation period of 5.5 months (median five months) this corresponds to a patency rate of 95%. The estimated survival rate according to Kaplan-Meier was 87.7% and the estimated mean survival time 11.7 months. These results demonstrate that in patients with extrahepatic bile duct obstruction an effective biliary drainage can be achieved with balloon expandable wire stents. They represent a further progress in the palliative treatment of patients with extrahepatic obstructive jaundice.